Every finding on record at Spring Valley Health & Rehabilitation Center

Based on interview and record review, the facility failed to provide care per standards of practice and care plan when staff failed to document full follow-up assessments, including neurological checks, for 72-hours post fall, failed to provide all assessed information to the physician when reporting a change of condition post fall, and failed to transcribe physician orders post fall for one resident (Resident #1) who had multiple falls. The facility census was 157.Review of the facility policy titled Fall Management, dated 02/28/23, showed the following information:-Prior to moving the resident, the charge nurse will evaluate for injury;-Complete neurological evaluation as applicable;-If an injury is suspected, provide emergency first aid;-Notify the physician, resident representative, supervisor, and Director of Nursing (DON);-Document in the resident's medical record, complete an incident report, implement post-fall evaluations, and documentation for 72 hours. Review of the facility policy titled Physician Orders, dated 09/28/22, showed the following information:-Orders must be documented clearly in the medical record;-Physician order sheet (POS) will be maintained with current physician orders as new orders are received. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 04/15/24;-Diagnoses included dementia, unsteadiness on feet, repeated falls, and high blood pressure. Review of the resident's care plan, dated 04/25/26, showed the following information:-Anticipate and meet needs;-Ensure the call light is within reach and encourage the resident to use it for assistance;-Requires prompt assistance to all requests for assistance;-Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in the wheelchair;-Follow facility fall protocol. Review of the resident's late entry progress note dated 05/01/26, at 8:23 A.M., showed the following information:-Follow-up to the resident falling. Nurse and certified nursing assistant (CNA) thoroughly assessed the resident, including passive range of motion (PROM) of the residents upper and lower extremities;-The resident was confused but said he/she had pain in his/her left knee. The resident frequently complained of pain in this area;-Resident had a slight protrusion on forehead;-The nurse notified the physician and administered as needed (PRN) pain medication.(Staff did not document initiation of neurological checks.) Review of the resident's Fall Incident Audit Report, dated 05/01/26, showed the following:-At 6:15 P.M., the resident fell;-At 8:58 P.M., staff found the resident on the floor just outside of the bathroom, sitting on the floor with legs forward with knees slightly bent. The resident propped his/her chest up with arms. Staff gave tresident a quilt and pillow to prop him/herself up with so he/she could rest his/her arms. Staff completed a quick neurological and eye assessment (PERRLA) with resident at baseline. Resident was able to follow commands and alert and oriented x 1 (only knows own identity). Staff noted no bruising or contusions. Sensation intact all extremities. Right and left hand grasp were good. Good strength in BUE (both arms and hands). Resident complained of pain. Staff had already administered Tylenol. Staff notified the Nurse Practitioner (NP) and a new order for tramadol (opioid used for the management of moderate to moderately severe pain) was received. Vital Signs within normal levels. Staff assisted resident to bed;-At 9:04 P.M., staff notified the NP and family;-At 9:05 P.M., staff notified the Assistant Director of Nursing (ADON) and (DON);-At 9:34 P.M., when standing, the resident's shoulders were humped over. He/she was unable to walk two feet, gait unsteady, and drags left foot;-At 9:55, the care plan was reviewed.(Staff did not document regarding continued monitoring after the fall, including neurochecks.) Review of the resident's late entry progress note dated 05/01/26, at 6:56 P.M., showed the following information:-The resident complained of his/her hip hurting;-The resident had a history of osteoporosis (disease characterized by weak, porous bones that break easily);-Staff notified the NP and requested more pain medication.(Staff did not document regarding continued monitoring after the fall, including neurochecks.) Review of the resident's progress note dated 05/01/26, at 7:18 P.M., showed staff notified the resident's family member of the fall. Review of the resident's Fall Incident Audit Report showed the following:-On 05/01/26, at 9:40 P.M., the resident fell;-On 05/02/26, at 08:11 A.M., the resident was found on the floor in her bathroom. The resident was on his/her right side with his/her head laying on his/her arms. He/She had a small protrusion on his/her left forehead. Staff noted no abrasions, lacerations, or wounds. Resident had no bleeding or bumps on his/her head. Staff assisted resident back to bed. Staff will continue with neurological checks and vital signs. Injury on top of scalp. Resident was very confused. He/She was not able to acknowledge his/her fall or where he/she was at. Resident was ambulatory with assistance;-On 05/02/26, at 8:19 P.M., staff notified the physician;-On 05/02/26, at 8:23 P.M., staff notified the ADON and DON;-On 05/02/26, at 8:24 P.M., staff notified the family.(Staff did not document regarding continued monitoring after the fall, including neurochecks.) Review of the resident's late entry progress note dated 05/01/26, at 9:52 P.M., showed the following information:-At 9:15 P.M., the resident had an unwitnessed fall, landing on the floor, with his/her head touching the door frame;-The resident's blood pressure was elevated;-The resident had a small bump on the left side of his/her forehead and was unable to bear weight on the left leg. The resident was moaning;-The nurse notified the NP. Review of the resident's medical record showed staff did not document neurological checks initiated, assessment of range of motion, or any deformity present. Staff did not document regarding ongoing monitoring post-fall. Review of the resident's SBAR Communication Form (communication form used to report concerns to the physician) dated 05/01/26 at 10:18 P.M., showed the following:-The resident fell and was experiencing pain with no changes observed with resident's mental status;-The resident was declining and argued regarding medication administrations;-The physician responded and ordered blood tests, an x-ray, and medication changes.(Staff did not document related to fall evaluation, neurological checks, or inability of resident to bear weight.) Review of the resident's Physician Order Sheet (POS), dated 05/01/26, showed staff did not transcribe the physician's order for x-ray and blood test. Review of resident's progress notes dated 05/01/26, at 11:29 P.M., showed the following:-Resident had fallen twice during shift;-Staff were conducting neurological and vital checks;-Staff notified the physician, DON, and family;-The physician gave new orders. Review of the resident's SBAR communication form dated 05/01/26, at 11:34 P.M., showed the following information:-Concerns of falls, functional decline (worsening function and/or mobility), pain (uncontrolled), tired, weak, confused, or drowsy;-The resident experienced a fall and had increased confusion, physical and verbal aggression, and pain;-The resident was more confused and attempted to get up by his/herself and falls. He/she fell in the bathroom and by his/her bed;-Staff notified physician who adjusted medication.(Staff did not document related to fall evaluation, neurological checks, or inability of resident to bear weight.) Review of the resident's progress note dated 05/02/26, at 3:49 P.M., showed the following information:-The resident's family requested the resident be sent to the hospital;-Orders for stat (immediate) x-ray were given, but the family declined and wanted the resident to go to the hospital due to the resident's further decline;-The resident was lethargic and was having difficulties following simple commands. Staff put medication in the resident's mouth and had to repeat numerous times before resident would swallow. This was not baseline for the resident;-Staff notified the NP, ADON, and DON. Review of the resident's POS, dated 05/02/26, showed staff did not transcribe an order for an x-ray. Review of the resident's electronic medical record showed staff did not document continued neurological checks after the residents' falls. During an interview on 05/14/26, at 12:51 P.M., Registered Nurse (RN) A said the following:-If a resident falls, it is the expectation of staff to ensure the resident is safe, assess the resident's neurological status, obtain vital signs, and notify the resident's physician, family, and administration;-Fall follow-up documentation is expected to be completed for 72 hours and documented in the progress notes;-If a resident with confusion falls and has elevated vital signs, or guards a body part and/or grimaces with pain, he/she would notify the physician, administer PRN pain medication, and order an x-ray;-He/she was the nurse on duty when the resident fell twice;-He/she assessed the resident after the fall, including a pain assessment, but did not complete any range of motion (ROM) assessment;-He/she did not notice any shortening or rotation of the legs and/or any grimacing with pain;-The resident seemed worse after the second fall and was unable to walk;-He/she contacted the physician due to concerns with pain control; however an x-ray was not ordered after either fall;-It can be difficult to assess a dementia resident as they can be consistently dramatic;-The resident's family requested the resident be sent to the hospital the next day. He/she informed the family that he/she would obtain an x-ray order, but they wanted the resident to be assessed at the hospital. During an interview on 05/14/26, at 2:06 P.M., Certified Nursing Assistant (CNA) B said the following information:-He/she was on shift at the time of the resident's falls;-The resident appeared to be fine after the first fall. After the second fall, the resident experienced a lot of pain and had a change in mobility;-RN A completed the assessments after each fall;-If a resident falls, the CNA notifies the nurse and the nurse completes an assessment, notifies the family and physician, and documents accordingly. During an interview on 05/14/26, at 2:28 P.M., the ADON said the following:-Staff were to report falls to the nurse. The nurse should assess the resident to ensure safety and obtain vital signs;-Neurological checks should be initiated on unwitnessed falls;-After a resident falls, staff should conduct monitoring for 72 hours. The monitoring is documented in the progress notes and a change of condition (SBAR) form should be completed;-The physician, and family should be notified;-If a resident falls and shows signs of pain and decreased mobility, staff should notify the physician for an x-ray order and document the conversation in the progress notes. The x-ray order should be added to the POS;-If a resident had a change of condition, staff should intervene in a timely manner, which could include obtaining an order for an x-ray or other interventions;-The ADON was on shift during the first fall, and did not observe any changes;-If a resident experienced rotation and shortening of a leg, staff should assess and recognize the issue;-The day after the resident fell twice, his/her demeanor was different. The ADON told the nurse to contact the physician, however family arrived and wanted the resident sent to the hospital. During an interview on 05/14/26, at 3:21 P.M., the MDS Coordinator said the following:-If a resident falls, staff were instructed to not move the resident until the nurse completed their assessment and obtained the resident's vital signs;-If a resident had elevated vital signs, increased pain, and a change in mobility, she would call the doctor and have the resident sent to the hospital for evaluation;-After a fall, staff should assess for rotation and shortening as it is a sign of a fracture. During an interview on 05/14/26, at 3:21 P.M., the Director of Nursing (DON) said the following:-Staff were expected to notify a nurse if a resident falls;-The nurse should complete an assessment, obtain the resident's vital signs, assess the resident's neurological status, ensure the resident's safety, and notify the physician, family, and administration;-After a resident falls, staff should conduct monitoring for 72 hours and document in the progress notes;-If the resident experienced pain, medication should be administered as ordered;-The physician should be notified of resident pain, to determine if x-rays or a different pain medication needed to be ordered;-Staff should recognize signs of fractures such as rotation or shortening of the limb;-The DON received notification of the residents' falls on the night of 05/01/26. The ADON asked if an x-ray should be obtained. The resident slept through the night after medication was administered, therefore an x-ray was not warranted;-On 05/02/26, the resident's family requested the resident be sent to the hospital. During an interview on 05/14/26, at 4:00 P.M., the Administrator said the following:-If a resident falls, she expected staff to assess the resident, notify the physician, family, and administration;-If there is a concern after the fall, staff should notify the physician and follow their instructions. Staff should document any concerns and/or notifications in the progress notes;-Staff are expected to assess for signs of fractures and follow the facility's policy on fall protocol. Complaints #2993154, #2980667, #3001655, #3001683, and #3001699

Based on observation, interview, and record review the facility failed implement a complete and effective infection control program when staff failed to properly discard a blood contaminated glucose (sugar) test strip and sharps (any device with points or edges that can puncture or cut skin) in the designated sharps container for one resident (Resident #2). The facility census was 157.Review of the facility policy titled Standard Precautions, dated 10/25/22, showed the following information:-Place sharps in a puncture resistant container;-Follow procedures for disposal of regulated/infectious waste when items are saturated with blood and meet the definition of regulated infectious waste. Review of the SafeNeedleDisposal.org's What To Do with Used Sharps in Missouri, dated 10/23/25, showed the following: -Put sharps in a strong, plastic container;-Sharps should never be thrown loosely into the trash or toilet;-Sharps that retract after use, or are very small, should be disposed of like all other sharps. Review of the Centers for Disease Control and Prevention page Regulated Medical Waste, dated 01/08/24, showed the following: -Medical waste requires careful disposal and containment before collection and consolidation for treatment;-Puncture-resistant containers located at the point of use (e.g., sharps containers) are used as containment for discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 1. Review of the Resident's #2 face sheet (brief look at resident information) showed the following information:-admission date of 09/05/23;-Diagnoses include dementia, diabetes, and high blood pressure. Review of the resident's care plan, dated 09/19/23, showed administer diabetic medications as ordered. Review of the resident's most recent Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff) resident received injections seven times a week. Observation on 05/14/26, at 12:07 P.M., showed the following: -Licensed Practical Nurse (LPN) C obtained a blood glucose level on the resident;-After obtaining the level, LPN C placed the used alcohol swab, cotton swab, blood contaminated glucose strip, and contaminated lancet (a medical instrument/needle used for blood sampling) into a plastic cup, within a tray he/she was carrying around;-LPN C then entered the open-door nurses' station, placed the tray on top of the medication cart, took off his/her gloves and placed them into the plastic cup;-LPN C obtained the plastic cup full of contaminated supplies and threw it into the trash bin located on the side of the medication cart. During an interview on 05/14/26, at 12:15 P.M., LPN C said the following:-He/she discarded the blood contaminated test strip, lancet, alcohol swab, cotton swab, and gloves into the trash bin, on the side of the medication cart;-He/she usually discards blood contaminated test strips and lancets in regular trash bins. During an interview on 05/14/26, at 12:51 P.M., Registered Nurse (RN) A said the following:-Glucose test strips and lancets should be discarded in the sharps container;-Blood contaminated items and/or lancets should not be placed in the regular trash bins. During an interview on 05/14/26, at 2:06 P.M., Certified Nursing Assistant (CNA) B said the following:-Blood contaminated items, and/or lancets should be placed in a sharps container;-Sharps containers are located throughout the building, but specifically in the nurse's station on the unit and the shower room. During an interview on 05/15/26, at 9:30 A.M., the Infection Preventionist said the following:-Staff were to dispose of sharps in the sharps containers. The containers are located within all the medication carts;-Staff should discard any blood contaminated products in the sharps containers and/or a biohazard trash bag;-It is unacceptable to place lancets and/or blood contaminated products in the regular trash bins. During an interview on 05/14/26, at 2:28 P.M., the Assistant Director of Nursing (ADON) said the following:-Glucose test strips and lancets should be discarded in the sharps container;-It was unacceptable to place blood contaminated items and/or lancets in the regular trash bins. During an interview on 05/14/26, at 3:00 P.M., the Director of Nursing (DON) said the following information:-Glucose test strips and lancets should be discarded in the sharps container;-Blood contaminated items and/or lancets should not be placed in the regular trash bins. During an interview on 05/14/26, at 4:00 P.M., the Administrator said the following:-Glucose test strips and lancets should be discarded in the sharps container;-It is unacceptable to place blood contaminated items and/or lancets in the regular trash bins. Complaints #2993154, #3001683, and #3001699

Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for three residents (Resident #1, Resident #2, and Resident #3) after each resident sustained a fall with potential for head injury. The facility census was 156.Review of the facility policy titled, Fall Management, dated 02/08/23, showed the following:-Prior to moving the resident, the charge nurse will evaluate for injury;-Complete neurological evaluation post-fall on resident with potential head injury or unwitnessed fall;-Provide emergency first aide treatment as applicable;-Notify physician, resident representative, supervisor, Director of Nursing (DON), and Administrator when appropriate;-Investigate the circumstances and surrounding where the fall occurred and implement intervention to reduce further occurrences;-Document in resident's medical record;-Implement post-fall evaluation/documentation, all shift evaluation/documentation for 72 hours. Review of the facility policy titled, Neurological Evaluation, dated 03/28/23, showed the following:-The licensed nurse may perform the neurological evaluation without a physician's order when there is a concern over change in mental status/functioning or a gradual/immediate change in motor/sensory status;-A change in level of consciousness constitutes the most significant or early signs of neurological deterioration. If there is a decline in the level of alertness/orientation: charge nurse will complete a neurological evaluation;-The licensed nurse shall perform a neurological evaluation as followed for a 72-hour timeframe, unless otherwise ordered by the physician. The results will be recorded on the Neurological Evaluation Form every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for eight hours, every four hours for 12 hours, and every shift for 48 hours. 1. Review of Resident # 1's face sheet showed the following:-admission date of 09/18/25;-Diagnoses included of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a stroke that resulted in paralysis on left side of the body), lack of coordination, abnormalities of gait and mobility, chronic obstructive pulmonary disease (COPD-inflammatory lung disease that causes obstructed airflow, making it difficult to breathe), and major depressive disorder. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), modified 11/28/25, showed the following:-Cognitively intact;-Impaired on one side;-Resident ambulated independently in wheelchair;-Partial to moderate assistance with hygiene, dressing, and transfers;-No falls since admission. Review of the resident's care plan showed the following:-Activities of daily living self-care performance deficit due to stroke, impaired mobility, and balance;-Impaired cognitive function/dementia or impaired thought process due to stroke;-History of falls and a risk for falls. Review of the resident's progress note dated 01/28/26, at 4:18 P.M., showed nurse was called to nurses' station by staff. Staff said resident was outside at the assisted living entrance and came back in and slipped due to melting snow around shoes. Resident hit back of head and his/her bottom on the ground when he/she fell. Neuro-checks (neurological assessments) initiated with vitals and range of motion within normal limits. Staff to continue fall monitoring and neuro checks. Review of the resident's Neurological Evaluation Log, dated 01/28/26, showed the following:-Neurological checks initiated on 01/28/26, at 3:30 P.M., and completed every fifteen minutes for one hour, 3:45 P.M, 4:00 P.M., and 4:15 P.M.;-Neurological checks completed every 30 minutes for one hour, 4:45 P.M, 5:15 P.M, and 5:45 P.M.;-Neurological checks completed every hour for two hours, at 7:45 P.M. and 8:45 P.M.,-No neurological checks documented every two hours for 8 hours;-Neurological checks completed every four hours for twelve hours completed on 01/29/26 at 12:00 A.M. and at 4:00 A.M. only;-No neurological checks documented on 01/29/26, at 8:00 A.M. and 12:00 P.M.;-No documentation of neurological checks every shift for 48 hours (a neurological check should have occurred at shift change on 01/29/26, at 6:30 P.M. and on 01/30/26, at 6:30 A.M);-The resident incurred a new fall on 01/30/26, time unknown, and neurological checks were initiated at 3:00 P.M. During an interview on 02/03/26, at 12:00 P.M., Certified Medication Technician (CMT) B said nurses conducted neurological checks on the resident last week due to the resident hitting his/her head during a fall. During an interview on 02/03/26, at 12:10 P.M., Licensed Practical Nurse (LPN) C said the resident fell on Wednesday, 01/28/26. The resident denied hitting his/her head, but the nurse heard something hit and placed the resident on neurological checks. During shift change, LPN C advised the oncoming nurse of the neurological checks. During an interview on 02/03/26, at 12:30 P.M., LPN D said staff placed the resident on neurological checks last week because he/she fell and hit their head. LPN C believed the resident was toward the end of his/her neurological checks, as he/she only completed one set during his/her shift. During an interview on 02/03/26, at 12:51 P.M., CMT E said last week the resident fell and hit his/her head. CMT E believed neurological checks were initiated after the resident's fall. During an interview on 02/03/26, at 1:24 P.M., LPN F said the resident fell, but no injuries were noted. He/she did not believe neurological checks were initiated. During an interview on 02/03/26, at 1:35 P.M., LPN G said he/she started the resident's neurological checks but was unsure if they were complete. When he/she came back to work for his/her next shift, he/she believed the resident was still on neurological checks, but he/she could not find the sheet. He/she asked the other nurse on duty, and they said there were not aware the resident was on neurological checks. During an interview on 02/04/26, at 1:22 P.M., the Nurse Practitioner (NP) said the physician was notified of the resident's fall. The resident should have received neurological checks for 72 hours. During an interview on 02/04/26, at 2:10 P.M., the Assistant Director of Nursing (ADON) said he/she was unaware of the circumstances surrounding the resident's fall and was unsure if the resident was on neurological checks. During an interview on 02/04/26, at 3:20 P.M., the Administrator said the resident had a fall which required him/her to be placed on neurological checks. The Administrator believed staff missed a section on page two of the neurological evaluation form. 2. Review of Resident # 2's face sheet showed the following:-admission date of 08/09/24;-Diagnoses included of COPD, Type 2 diabetes (when the body cannot use insulin correctly and sugar builds up in the blood(, morbid obesity, unsteadiness on feet, and muscle weakness. Review of the resident's quarterly MDS, modified 01/26/26, showed the following:-Cognitively impaired;-Resident ambulates independently in wheelchair;-Substantial/maximal assistance with hygiene;-Supervision or touching assistance with transfers;-Two or more falls since prior assessment. Review of the resident's care plan showed the following:-Resident was at risk for falls as evidenced by deconditioning and gait/balance problems;-History of falls due to peripheral vascular disease (circulation disorder), venous wound (shallow, slow-healing open sores, usually on the lower leg or ankle, caused by chronic venous insufficiency where faulty vein valves lead to blood pooling, high pressure, and skin breakdown), and congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal suppl). Review of the resident's progress note dated 01/04/26, at 7:22 A.M., on 01/03/26, at 9:45 P.M., resident was discovered lying on the floor by his/her bed. Resident stated, I was coming back from the bathroom and fell over the cords - oxygen. Resident was using his/her walker and was wearing slipper socks. Resident further stated maybe he/she will call for help next time. Staff noted no injuries and with assistance of staff resident helped up and walked to his/her bed. Staff began neuros (neuro-checks). Review of the resident's Neurological Evaluation Log, dated 01/03/26, showed the following:-Neurological checks initiated on 01/03/26, at 9:45 P.M., and completed every fifteen minutes for one hour, 10:00 P.M, 10:15 P.M., and 10:30 P.M.;-Neurological checks completed every 30 minutes for one hour, 11:00 P.M. and 11:30 P.M.;-Neurological checks completed every hour for two hours, neurological checks completed on 01/04/26, at 12:30 A.M. and 1:30 A.M.,-Neurological checks completed every two hours for 8 hours had two checks documented as completed at 3:30 A.M. and 5:30 A.M.;-No documentation of neurological checks on 01/04/26, at 7:30 A.M. and 9:30 A.M.;-No documentation of neurological checks completed every four hours for twelve hours;-No documentation of neurological checks every shift for 48 hours (a neurological check should have occurred at shift change on 01/05/26, at 6:30 P.M.);-The resident incurred a new fall on 01/05/26, at 10:55 P.M., and neurological checks were initiated. Review of the resident's progress note dated 01/16/26, at 1:29 A.M., showed the resident noted to be on the floor next to his bed with call bell within reach and bed in lowest position. Urine noted to be all over the resident's bed and paints. Resident stated, I fell trying to get in my chair. Vital signs and neurological check within normal limit per resident's baseline. Staff assisted resident into wheelchair via 4-person manual lift. Staff cleaned resident and cleaned resident's bed. Staff applied fresh linens to resident's bed. Staff restarted neuro checks and notified the physician, DON, Assistant Director of Nursing (ADON), and Administrator. Review of the resident's medical record showed staff did not document any further progress note or fall follow up/neurological assessments on 01/16/26. Review of the resident Neurological Evaluation Log, dated 01/17/26, showed the following:-Neurological checks initiated on 01/17/26 at 7:30 P.M., and completed every fifteen minutes for one hour, 7:45 P.M, 8:00 P.M., and 8:15 P.M.;-Neurological checks completed every 30 minutes for one hour, 8:45 P.M. and 9:15 P.M.;-Neurological checks completed every hour for two hours, 10:15 P.M. and 11:15 P.M.;-Neurological checks completed every two hours for 8 hours documented as completed on 01/18/26, at 1:15 A.M., 3:15 A.M., 5:15 A.M.;-No neurological check documented on 01/18/26, at 7:15 A.M.;-Neurological checks completed every four hours for 12 hours, 11:15 A.M., 3:15 P.M, and 7:15 P.M.;-Neurological checks completed every shift for 48 hours, on 01/19/26, at 6:00 A.M., 6:00 P.M, on 01/20/26, at 6:00 A.M., 6:00 P.M., and on 01/21/26, at 6:00 A.M., and 6:00 P.M. Review of the resident's progress notes show no documentation of a fall on 01/17/26. Review of the resident's progress note dated 01/18/26, at 8:45 A.M., showed resident was coming out of bathroom when his/her grabber bar gave away with him/her. Resident had slipper socks on, but his/her wheelchair was unlocked. Staff checked resident for injuries and none noted. Staff assisted resident with use of Hoyer lift and resident transferred to his/her bed. Staff started neurological checks per protocol. The solution to help prevent falls were checking on the resident every two hours and call light should be in place where he/she can notify staff of his/her needs. Review of the resident's medical record showed no documentation of neurological assessments re-started on 01/18/25 after the resident's fall. Review of the resident's progress note dated 01/24/26, at 2:39 A.M., showed on 01/19/26, at 11:40 P.M., staff discovered resident sitting on floor in front of bathroom with no shoes or slipper socks on. The resident stated, I fell. Call light was in his/her bed and wheelchair was next to his/her bed. Staff assisted the resident with use of the Hoyer lift and transferred the resident to his/her bed. Staff began neurological checks on the resident. Review of the resident's Neurological Evaluation Log, dated 01/19/26, showed the following:-Neurological checks initiated on 01/20/26, at 12:30 A.M., and completed every fifteen minutes for one hour documented completed at 12:45 A.M. and 1:00 A.M.;-No neurological check documented on 01/20/26, at 1:15 A.M.;-Neurological checks completed every 30 minutes for one hour, 1:30 A.M., 2:00 A.M., and 2:30 A.M.;-Neurological checks completed every hour for two hours, 3:30 A.M., 4:30 A.M., and 5:30 A.M.;-Neurological checks completed every two hours for 8 hours, 7:30 A.M., 9:30 A.M., 11:30 A.M., and 1:30 P.M.;-Neurological checks completed every four hours for 12 hours documented completed at 5:30 P.M.;-No neurological check documented on 01/20/26, at 9:30 P.M., or on 01/21/26, at 3:30 A.M.;-Neurological checks completed every shift for 48 hours, check only completed on 01/20/26, at 6:00 A.M., 6:00 P.M., 01/22/26, at 6:00 P.M., and 01/23/26, at 6:00 P.M.;-No neurological check documented on 01/22/26, at 6:00 A.M., or on 01/23/26, at 6:00 A.M. Review of the resident's progress note dated 01/24/26, at 4:50 P.M., showed late entry for 01/21/26, at 7:00 P.M., of resident found on floor in his room, lying on his left side, bleeding from left foot. Staff assessed resident for further injury with none found, and neurological checks initiated, within normal limit. Staff assisted resident up into wheelchair. Staff noted skin tear to foot and cleaned foot and applied gauze dressing. Staff placed call light placed within easy reach. Resident stated, My legs gave out, I'm going to quit this job. Staff notified emergency contact notified by voicemail. Staff noted physician had been notified. Review of the resident's medical record showed staff did not complete documentation of neurological assessments re-started on 01/21/25 after the resident's fall. During an interview on 02/04/25, at 1:00 P.M., CMT I said the resident had falls and neurological checks have been completed. During an interview on 02/04/26, at 1:06 P.M., LPN J said the resident had frequent falls and had been placed on neurological checks. During an interview on 02/04/26, at 1:22 P.M., the NP said the resident had frequent falls, and he/she followed up with the resident after the falls. During an interview on 02/04/2, at 2:10 P.M., the ADON said the resident had fallen and neurological checks were complete. During an interview on 02/04/26, at 2:24 P.M, the DON said the resident had not had any falls in the last week. During an interview on 02/04/26, at 3:20 P.M., the Administrator said the resident had fallen which had required neurological checks to be completed by staff. 3. Review of Resident # 3's face sheet showed the following:-admission date of 01/14/26;-Diagnoses included of malignant neoplasm of the head, face, and neck (cancerous, fast-growing tissue), anxiety, major depressive disorder, esophageal (muscular tube connecting the throat to the stomach) obstruction, and chronic kidney disease. Review of the resident's comprehensive MDS, modified 01/26/26, showed the following:-Moderate cognitive impairment;-Resident ambulated independently in wheelchair;-Partial to moderate assistance with hygiene;-Supervision or touching assistance with dressing and transfers;-No falls since admission. Review of the resident's current care plan showed the following:-At risk for falls and unaware of safety needs;-History of falls;-Delayed reporting unwitnessed falls without notifying staff at the time of the fall. Review of resident's progress note dated 01/26/26, at 7:15 A.M., showed on 01/26/26, at 5:05 A.M., staff entered resident's room on normal round checks and resident verbalized at this time that he/she had fallen twice, but was at that time sitting on his/her walker seat without distress. Resident stated he/she did not hit his/her head but complained of right hip hurting. Resident was able to lift right leg in front of him/herself easily with no obvious displacement noted. Staff notified hospice and who gave verbal permission for right hip x-ray if physician ordered one. Staff contacted physician and gave update with new order received for right hip x-ray. Review of the resident's Neurological Evaluation Log, dated 01/26/26, showed the following:-Neurological checks initiated on 01/26/26, at 5:15 A.M., and completed every fifteen minutes for one hour, 5:30 A.M., 5:45 A.M., 6:00 A.M.;-Neurological checks completed every 30 minutes for one hour, 6:30 A.M. and 7:00 A.M.;-No neurological checks documented every hour for two hours;-No neurological checks completed every two hours for 8 hours;-Neurological check completed on 01/26/26, at 8:00 P.M.;-Neurological checks completed every four hours for 12 hours, checks completed on 01/27/26, at 12:00 A.M. and 4:00 A.M.;-No neurological check completed on 01/27/26, at 8:00 A.M.;-No neurological checks completed every shift for 48 hours. Review of resident's progress note dated 02/03/26, at 4:15 A.M., showed the resident requested for her as needed (PRN) pain medication due to left hip pain. The resident was sitting on the side of his/her bed when nurse entered the room. Resident wrote down in his/her notebook that he/she had fallen Sunday night, and she/he was given morphine and helped back into bed during that time. Review of the resident's progress notes show staff did not document a fall on 02/01/26 or 02/02/26. Review of the resident's Neurological Evaluation Log, dated 02/03/26, showed the following:-Neurological checks initiated on 02/03/26, at 5:00 A.M.;-No neurological checks documented every fifteen minutes for one hour, 5:15 A.M., 5:30 A.M., and 5:45 A.M.;-Neurological checks completed every 30 minutes for one hour, 6:20 A.M. and 6:50 A.M.;-Neurological checks completed every hour for two hours, 7:50 A.M., 8:50 A.M., and 9:50;-Neurological checks completed every two hours for 8 hours, 11:50 A.M.;-Neurological checks were still in progress while on site. During an interview on 02/03/26, at 11:49 A.M., Certified Nursing Assistant (CNA) A said he/she unaware of the resident currently being on neurological checks. During an interview on 02/03/26, at 12:00 P.M., CMT B said he/she believed the resident recently had a fall. During an interview on 02/03/26, at 12:10 P.M., LPN C said the resident fell on Sunday evening and was currently on neurological checks. During an interview on 02/03/26, at 12:30 P.M., LPN D said the resident was on neurological checks due to a fall. During an interview on 02/03/26, at 12:51 P.M., CMT E said he/she was unaware of the resident having any falls or being on neurological checks. During an interview on 02/04/26, at 12:15 A.M., the resident said he/she fell on Sunday night. During an interview on 02/04/26, at 12:50 P.M., the Unit Manager (UM) said the resident reported a fall and was currently on fall protocol, which included neurological checks. During an interview on 02/04/26, at 1:22 P.M., the NP said the resident has self-reported falls. The NP expected neurological checks to be complete on the resident for 72 hours as it was unwitnessed and unknown if he/she hit their head. During an interview on 02/04/26, at 2:24 P.M., the DON said the resident had self-reported falls. Staff should treat self-reported falls as unwitnessed falls, and neurological checks should be initiated. During an interview on 02/04/26, at 3:20 P.M., the Administrator said he/she was unaware of the resident having any falls. 4. During an interview on 02/03/26, at 11:49 A.M., CNA A said the following:-If a resident falls, staff notify the nurse, and the nurse will assess the resident prior to moving the resident;-Neurological checks were completed if the resident hit their head or if it was an unwitnessed fall;-Aides may complete neurological checks, which are complete every 15 minutes for an hour and then decrease in duration. There was a sheet that prompted staff on the time and duration the neurological checks that needed to be completed;-Staff notified the on-coming shift if a resident was receiving neurological checks;-Staff documented neurological checks on a sheet and give to the nurse when completed. During an interview on 02/03/26, at 12:00 P.M., CMT B said the following:-If a resident falls, staff obtain vitals and notify the nurse. The nurse will assess prior to moving the resident;-Neurological checks consist of checking vitals and eye movement, and are collected over a 24-hour period;-Staff notify the next shift, during report, if a resident was receiving neurological checks;-CNAs and CMTs may conduct neurological checks, but it was best if the nurse completed the checks;-Staff filled out the neurological check sheet and turned them into the nurse when completed. During an interview on 02/03/26, at 12:10 P.M., LPN C the following:-If a resident fell, he/she obtained vitals and assessed the resident for injuries and level of consciousness;-He/she conducted neurological checks if the resident hit his/her head, or if the fall was unwitnessed;-Staff completed neurological checks over a duration of three days;-Aides may complete neurological checks, but LPN C completed the first six sets;-Completed neurological check sheets were turned into medical records, the unit manager, or the ADON. During an interview on 02/03/26, at 12:30 P.M., LPN D said the following:-If a resident fell, the nurse on duty would assess the resident for injuries. Staff would obtain vitals will be prior to moving the resident;-If a resident had an unwitnessed fall or hit their head, neurological checks would be initiated;-Staff completed neurological checks for 72 hours;-Staff filled out a form every time a neurological check was completed. Completed neurological sheets were placed in a file box at the nurses' station;-Staff notified oncoming staff of any residents requiring neurological checks. During an interview on 02/03/26, at 12:51 P.M., CMT E said the following:-If a resident fell staff notified the nurse, who would assess the resident;-Staff initiated neurological checks if a resident hit their head or had an unwitnessed fall;-Staff completed neurological checks over a three-day period, decreasing in frequency;-Staff documented neurological checks on a form and gave completed forms to the nurse;-CNAs completed neurological checks;-Staff notify the oncoming shift if a resident was on neurological checks. During an interview on 02/03/26, at1:24 P.M., LPN F said the following:-If a resident fell, the nurse assessed the resident before they were moved;-If a fall was unwitnessed, or if the resident hit their head, neurological checks are initiated;-Staff documented neurological checks on paper and completed them for a duration of 72 hours. Staff turned in completed neurological check sheets to the UM;-CNA staff may obtain vitals, but nurses conduct the neurological assessment;-Staff notified the oncoming staff if a resident was on neurological checks. During an interview on 02/03/26, at 1:35 P.M., LPN G said the following:-Fall protocol consisted of a nurse assessing the resident for injury, prior to moving a resident;-Staff conducted neurological checks if a resident hit their head or had an unwitnessed fall;-Nurses completed neurological checks for a period of three days;-Staff notify oncoming staff if a resident was on neurological checks. During an interview on 02/04/26, at 12:15 P.M., CNA H said the following:-If a resident fell, aides would obtain vitals and have a nurse assess the resident;-Staff completed neurological checks if a resident fell while walking or fell out of bed. Staff did not complete neurological checks if a resident just scooted off their bed or wheelchair;-Staff documented neurological checks for a day and turned in completed neurological sheets to the nurse. During an interview on 02/04/26, at 1:06 P.M., LPN J said the following:-If resident fell, staff notified the nurse. The nurse would assess the resident and checked for injuries;-Aides completed vitals, and nurses completed the neurological assessment for three to four days if a resident has an unwitnessed fall or hit their head;-Neurological checks should always be completed for the full duration. Completed neurological check sheets were placed in the medical records basket;-Staff documented on the shift report sheet if a resident was receiving neurological checks. During an interview on 02/04/26, at 1:22 P.M., the NP said the following:-If a resident fell, staff obtained vital signs, and the nurse would assess the resident prior to moving the resident;-Staff conducted neurological checks if the resident hit their head or had an unwitnessed fall, for 72 hours, decreasing in frequency;-Nurses completed the neurological checks and filled out the neurological check sheet;-If the neurological check was not documented on the sheet, it probably was not complete;-Staff should complete neurological checks for the full 72 hours. During an interview on 02/04/26, at 2:10 P.M., the ADON said the following:-If a resident fell, staff should ensure safety, obtain vitals, and a nurse should assess the resident;-If a resident hit their head, or the fall was unwitnessed, neurological checks were initiated;-Staff filled out the neurological check sheet, which was broken down into how frequent the checks needed to be complete, for approximately two to three days;-If was the expectation of management for neurological checks to be complete for the full required duration. During an interview on 02/04/26, at 2:24 P.M., the DON said the following: -If a resident fell, staff notified the nurse immediately, and the nurse would assess the resident;-If the resident hit their head, or the fall was unwitnessed, neurological checks were initiated;-CNAs may obtain vitals, but nurses completed the neurological assessment;-Staff fill out the neurological evaluation sheet at the nurses' station;-Staff completed neurological checks for three days;-Management expected staff to conduct neurological checks in full and there should not be any blanks on the sheet.-Staff documented residents receiving neurological checks in the report book, but also verbally notified on-coming staff. During an interview on 02/04/26, at 3:20 P.M., the Administrator said the following:-If a resident fell, a nurse would assess the resident;-Staff completed neurological checks if the resident hit their head or it was an unwitnessed fall for a duration of two days;-CNAs may obtain vitals, but the nurse validated and entered on the neurological evaluation sheet;-Staff reported to on-coming staff at shift change if a resident was receiving neurological checks. The neurological evaluation sheet should be at the nurses' station, and a progress note should be in the resident's chart indicating they are receiving neurological checks;-Staff should complete neurological checks as the sheet dictates and should be completed in full;-Staff turn in completed neurological evaluation check sheets to the ADON for review. Complaint #2731424

Based on observation, interview, and record review, the facility failed to provide care per accepted standards of practice when staff failed to accurately document regarding administration, or lack of administration, of an ordered medication; failed to ensure the medication was available for administration; failed notify the physician of the missed doses in a timely fashion; and failed to care plan the use and/or refusals of the medication for one resident (Resident #1) out of a sample of four residents. The facility census was 156.Review of the facility's Medication Administration-General Guidelines Policy, revised October 2017, showed the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-The Medication Administration Record (MAR) is always employed during medication administration;-Residents may actively refuse medications;-Medication refusal must be reported to the prescriber based upon facility guidelines;-The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given;-If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of an antibiotic needed), the space provided on the front of the MAR for that dosage administration is initialed and circled;-An explanatory note is entered on the reverse side of the record;-If a vital medication is withheld, refused, or not available the physician is notified;-Nursing documents the notification and physician response;-If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. Review of the facility's Notification of a Change in Condition Policy, revised 02/06/25, showed the following:-The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations;-The guidelines for notification of physician/resident representative include, but is not limited to significant change in medical or cognitive baseline, accident/incident, abnormal laboratory results in conjunction with a change in condition, significant weight loss/gain as per Resident Assessment Instrument (RAI) guidelines or provider specific orders, refusal to take prescribed medications, and missing resident;-Document in the Interdisciplinary Team (IDT) notes the following: resident change in condition, physician/physician extender notification, and notification of resident representative. 1. Review of Resident #1's face sheet (basic information sheet) showed the following information:-admission date of 10/14/25;-Diagnoses included acute parametritis (the tissue between the uterus and pelvic wall) and pelvic cellulitis (an infection of the tissues surrounding the female reproductive organs, including the uterus, ovaries, and fallopian tubes), generalized muscle weakness, high blood pressure, lymphedema (tissue swelling caused by an accumulation of fluid usually drained by the body), not elsewhere classified, autoimmune hepatitis (a long-term liver disease where the body's immune system mistakenly attacks and damages healthy liver cells), menopausal and female climacteric states (a condition where a woman's reproductive function stops and causes hormonal changes), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to a widespread inflammation and organ damage, unspecified organism, and obesity. Review of the resident's comprehensive Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 10/21/25, showed the following:-Cognitively intact;-Used wheelchair and required partial assistance from staff with personal hygiene and showers. Review of the resident's hospital Discharge summary, dated [DATE], showed an order for boric acid (help promote a balance of acid in the vagina) 600 milligram (mg) vaginal suppository. Insert one suppository vaginally daily for eight days. Review of the resident's October 2025 Physician Order Sheet (POS) showed an order, dated 10/14/25, for boric acid vaginal suppository 600 mg. Insert one suppository vaginally one time a day for antifungal for eight days Review of the resident's October 2025 Medication Administration Record (MAR) showed the following:-An order, dated 10/14/25, for boric acid vaginal suppository 600 mg. Insert one suppository vaginally one time a day for antifungal for eight days;-Staff documented administering the medication on 10/15/25 and 10/16/25. Review of the resident's progress note, dated 10/16/25, showed the facility Nurse Practitioner (NP) noted the resident has candida vulvovaginitis (an inflammation of the vulva and vagina caused by an overgrowth of Candida fungus) and was receiving boric acid vaginal suppository until 10/23/25. Review of the resident's October 2025 MAR showed the following:-Staff documented the boric acid was on hold on 10/17/25;-Staff documented the resident refused the boric acid on 10/18/25, 10/19/25, and 10/20/25;-Staff documented administering the boric acid on 10/21/25. Review of the resident' October 2025 Progress Notes showed staff did not document regarding holding or refusal of the boric acid and did not document physician notification of missed doses on 10/17/25, 10/18/25, 10/19/25, and 10/20/25. Review of a handwritten physician order sheet, dated 10/21/25, showed please provide boric acid vaginal suppository over the counter (OTC). Pharmacy will not provide. Review of the resident's October 2025 Physician Order Sheet (POS) showed the following: -The order, dated 10/14/25, for boric acid vaginal suppository 600 mg was place on hold and then discontinued on 10/21/25;-An order, dated 10/22/25, for boric acid vaginal suppository 600 mg. Insert one suppository vaginally one time a day for antifungal for eight days. Review of the resident's October 2025 MAR showed the following:-An order, dated 10/22/25, for boric acid vaginal suppository 600 mg. Insert one suppository vaginally one time a day for antifungal for eight days;-Staff documented administering the boric acid on 10/22/25, 10/23/25, 10/24/25, 10/26/25, 10/27/25, and 10/28/25;-Staff documented the boric acid as not administered on 10/25/25;-Staff documented the resident out of the facility on 10/29/25. Review of the resident' October 2025 Progress Notes showed staff did not document regarding the missed dose or physician notification of the missed does on 10/25/25. Review of the resident's current care plan showed staff did not address the boric acid suppository on the care plan. During an interview on 10/31/25, at 3:23 P.M., Certified Medication Technician (CMT) F said the following:-He/she would notify the nurse if resident refused a medication;-He/she would notify the nurse and Director of Nursing (DON) if a resident refused a medication for a second time;-When staff enter a code for refusal of medication, a progress note automatically populates for documentation. During an interview on 11/03/25, at 1:30 P.M., Licensed Practical Nurse (LPN) D said the following:-He/She remembered the resident had an order for a boric acid vaginal suppository;-On 10/21/25, the resident self-administered the vaginal suppository after LPN D provided it to the resident. He/she was not in the room when it was self-administered. He/she only took it to the resident's room and provided the resident with privacy while the resident inserted the suppository; -The boric acid suppositories looked like a capsule rather than a suppository and he/she kept telling the central supply staff member that he/she ordered the wrong thing, but the central supply staff member said it was the correct medication;-He/She searched everywhere to find the boric acid suppository and it was in the med tech's cart when he/she found it on 10/21/25. It looked like an over-the-counter medication bottle;-He/she remembered the suppository was in a bottle with more than one dose;-He/she thought the suppository bottle may have had the resident's name on it, but he/she could not remember for sure;-The boric acid vaginal suppository got moved over to the med techs cart and a med tech figured out the resident had an unopened tampon applicator in the room that the resident could use to insert the suppository easier;-The resident may have had problems inserting the vaginal suppository far enough into the vagina without the use of the tampon applicator;-LPN D thinks he/she only provided the resident with one dose of the boric acid vaginal suppository.-The medication information comes up on the LPN/Registered Nurse (RN) MAR and that is how he/she knows when and what to give the resident;-If a medication is not on the med tech cart, he/she would go to the central supply staff member or to the unit nurse manager and let them know he/she could not find it;-If he/she was unable to administer a medication, he/she would document not administered (NA) on the MAR and let the unit nurse manager know and notify the physician;-He/She would also make a note in the resident's chart stating he/she was unable to administer the medication. During an interview on 11/03/25, at 3:20 P.M., LPN B said the following:-He/She remembered the resident, but he/she could not recall anything about a vaginal suppository, whether or not it was given, or whether or not there was an issue with the facility not having the suppository;-He/She does not recall the resident having a boric acid vaginal suppository order;-He/She does not recall documenting that resident refused the boric acid suppository on 10/18/25 and 10/19/25;-He/She administers medications off the electronic health record MAR and treatment administration record (TAR);-If a medication was not in the medication cart, he/she would see if it were in the long-term care pharmacy service;-If the medication was not available there, he/she would notify the physician and see if he/she can give something that is available;-If the medication that was unavailable was an over-the-counter medication, he/she would tell the central supply staff member and have him/her get it locally;-If he/she documented that a resident refused a medication he/she would notify the physician of the refusal;-He/She would not chart that a resident refused a medication for any other reason than a resident refusal;-If a resident refused a medication the expectation was for staff to mark refused on the MAR, notify the physician, and make a note in the electronic health record system explaining why the resident refused the medication;-He/She did not think there is a protocol to notify the Director of Nursing (DON) when a resident refused a medication. During an interview on 10/31/25, at 3:20 P.M., Registered Nurse (RN) A said the following:-He/She was not aware of the resident had been refusing the vaginal suppository;-There were a couple of days the RN could not find the vaginal suppository;-He/she documented on the MAR on 10/17/25 that the vaginal suppository was held and documented on 10/20/25 that the resident refused the vaginal suppository, even though the resident did not refuse the vaginal suppository. He/he did not make any additional notes regarding the reason the vaginal suppository was not administered those two days;-He/She should have documented the vaginal suppository was being held rather than refused due to the medication not being available for him/her to administer;-He/she recalled talking to the unit nurse manager and asking where the vaginal suppository was. The unit nurse manager's response was that he/she did not know where the missing medication was;-If a medication was not available and put on hold, he/she should make a progress note and notify the provider if not given for a period of time;-He/She did not investigate why he/she could not locate the vaginal suppository or how long it was not given;-He/She knew the physician should have been notified with each medication refusal;-If a medication was on hold because it cannot be located, he/she would notify the unit manager, which he/she did, but he/she did not document it in the resident's electronic record.-The facility expectation was for staff to administer all medications as ordered by the physician and document on the MAR;-If a nurse recognizes that a medication is not being administered by the CMT, the medication will be moved to the nurses' MAR for the nurse to administer;-If a resident refuses a medication for three consecutive days the physician should be notified;-If a resident refuses any medication, the staff have to contact the physician every time, not just when it is refused for three consecutive days;-Staff should document the refusal in a progress note next to the order in the MAR. The note should include information that the resident refused that medication and the provider was notified. There should also be a progress note made in the chart separate from the MAR.-Medication refusals should be passed on in report to other staff;-It should be care planned if a resident refused medications, but he/she was unsure who updates the care plans. During an interview on 11/03/25, at 3:45 P.M., LPN C/Unit Manager said the following:-He/She was not sure if the facility tried to obtain the resident's boric acid vaginal suppository from the pharmacy, but probably did;-Central supply was notified to order the vaginal suppository, and a second order was written to restart the medication;-He/She was not sure if his/her charted refusals for the resident's vaginal suppository were actual refusals or if the medication was not administered because it was not available;-He/She was not sure if the three doses of the suppositories were given as the MAR reflects. The entries could have been incorrect entries;-He/she could not remember if he/she gave the vaginal suppository or not or if the facility had any doses of the suppository in the facility when the first order was written;-The facility doctor honors discharge orders from the hospital;-The facility physician orders over-the-counter medications, and the facility obtains them from central supply;-Over-the-counter medications do not typically come from the pharmacy;-If central supply does not have a medication on hand, they order the medication online and will receive them pretty quick;-If a medication was refused by a resident, staff should enter a note showing the physician and family was notified of the refusal;-It was best to let the physician and family know about a medication refusal after each refusal, unless it was stated otherwise in the order;-The facility does not have a lot of residents that receive a vaginal suppository;-If the facility does not have an over-the-counter medication, the nursing staff would notify central supply and have more ordered. During an interview on 11/03/25, at 12:10 P.M., the Central Supply staff member said the following:-The facility did not have the boric acid vaginal suppository in their supply stock, so he/she ordered it from a mail order supplier at 4:00 P.M. on 10/21/25 and it arrived in the facility on 10/22/25;-The Administrator had the order form from when the vaginal suppository came into the facility;-Prior to him/her ordering the boric acid vaginal suppository for the resident, he/she had never heard of it;-The facility keeps over the counter medications in the facility and purchases them if they do not have something in stock that a resident needs;-If he/she cannot get the medication or supply through the supply company, he/she goes to a local retailer or orders it on-line. During an interview on 10/31/25, at 3:38 P.M., the Assistant Director of Nursing (ADON) said the following:-Residents who chronically refuse medication should have this information in the care plan;-The NP should be notified of any medication refusals and is updated daily on refusals;-CMT's should notify the nurse of any medication refusals;-Staff should make a corresponding progress note for resident refusals or any other reason medication is not administered;-OTC medications are available through the facility central supply, pharmacy, or local retail stores. During an interview on 11/03/25, at 4:31 P.M., the DON said the following:-He/She was not aware of a boric acid vaginal suppository order;-He/She did not know if the vaginal suppository was in supply at the facility when the resident was admitted ;-He/She was not sure if any other residents at the facility had an order for the boric acid vaginal suppository in the past;-If the vaginal suppository was not in stock at the facility it could be obtained quickly by letting the central supply staff member know;-For the resident, the physician did put the vaginal suppository on hold and said to stop the order until the facility received the medication;-The central supply staff ordered the boric acid suppository on 10/21/25 and the facility had the suppository in house on 10/22/25;-He/She did not know if the resident received any doses of the boric acid vaginal suppository prior to the arrival of the boric acid vaginal suppository to the facility on [DATE];-The unit nurse manager had the bottle of boric acid vaginal suppositories in his/her office and seven of the vaginal suppositories were administered out of the bottle;-If the facility received an order from the hospital for an over-the-counter medication, it would be a medication the facility would obtain from central supply;-The facility can buy over-the-counter medications in bulk online;-On the day of admission, the facility should know if they need a medication; however, it is typically the next day before some medications are available;-If central supply cannot get the medication, the facility will send someone to locally to purchase it;-Staff should let the physician know if they are not able to administer the medication;-Staff should be documenting medication administration accurately;-If a resident refuses a medication, staff should call the doctor and make a progress note in the resident's medical record showing the refusal;-Staff should not be documenting that a resident refused a medication if the medication is not available. During an interview on 11/03/25, at 5:13 P.M., the Administrator said the following:-The receipt provided to him/her from the central supply staff member shows the boric acid vaginal suppository was ordered on 10/21/25;-He/She was not sure if the facility had the vaginal suppository in the facility when the resident was admitted . He/she was not sure when the facility actually received it;-The pharmacy does not fill over the counter medications. The facility typically gets over the counter medications online or at a local retailer;-Staff have been educated on the process to document medication refusals by a resident as well as medications not administered due to the medication not being available or due to the resident being out of the facility;-The expectation is for staff to contact the primary care physician or physician on call and the family if a resident refuses a medication;-If staff report that they documented something wrong, that would be a clerical error, and they would need to complete a risk assessment to correct it. Complaint # 2650298

Based on observation, interview, and record review, the facility failed to ensure all residents with tube feedings received sufficient nutrition when staff failed to understand how to document tube feeding intake, failed to document when tube feedings amounts varied from the ordered amount, and failed to document physician notification when tube feeding amounts varied from the ordered amount for one resident (Resident #2), who was at nutritional risk, out of a sample of four residents. The facility census was 156.Review of the facility's Notification of a Change in Condition Policy, revised 02/06/25, showed the following:-The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations;-The guidelines for notification of physician/resident representative include, but is not limited to significant change in medical or cognitive baseline, accident/incident, abnormal laboratory results in conjunction with a change in condition, significant weight loss/gain as per Resident Assessment Instrument (RAI) guidelines or provider specific orders, refusal to take prescribed medications, and missing resident;-Document in the Interdisciplinary Team (IDT) notes the following: Resident change in condition, physician/physician extender notification, and notification of resident representative. Review of the facility's Tube Feeding Policy, reviewed 07/31/25, showed nursing will receive tube feeding order written by physician. 1. Review of Resident #2's face sheet (basic information sheet) showed the following information:-admission date of 06/06/24;-readmission date of 09/04/24;-Diagnoses included nontraumatic intracerebral hemorrhage (a stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue), unspecified. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by staff), dated 07/24/25, showed the following:-Cognitively intact;-Requires maximum assistance with toileting hygiene, dressing, transfers, and mobility;-Dependent on staff for eating and showering;-Resident had a feeding tube. Review of the resident's care plan, revised 07/28/25, showed the following:-Resident required alternative nutritional intake via tube feeding related to dysphagia (difficulty swallowing and inadequate intake history of stroke;-Malnutrition risk/history related to acute illness as evidenced by significant weight loss and inadequate oral intakes;-Need for night tube feeding to help ensure nutritional needs are met;-Resident will only eat food brought in by family;-Resident will maintain adequate nutritional and hydration status and weight stable with no signs or symptoms of malnutrition or dehydration through review date;-Resident will maintain/gain current weight of +/- 5 pounds through review date;-Resident wishes to gain weight. Weight prior to stroke was 160 pounds;-Assist with tube feeding and water flushes;-See physician orders for current feeding orders. Review of the resident's current Physician Orders (POS) showed the following:-An order, dated 11/07/24, to document tube feeding every night to document millimeters (ml/cc) given;-An order, dated 12/04/24, for tube feed of Jevity (therapeutic liquid food) 1.5 or comparable at 100 cubic centimeters (cc) per hour for 12 hours per day and a total volume to infuse of 1200 cc. Start at 6:00 P.M. and end at 6:00 A.M. to allow for stomach emptying/encourage hunger prior to breakfast with 100 ml water flushes four times a day for enteral feed one time a day for tube feeding related to unspecified protein-calorie malnutrition. Keep head of bed at 30 degrees while feeding is going on. May have 1200 cc to 1500 cc per resident request; Review of the resident's October 2025 Medication Administration Record (MAR) showed the following:-An order, dated 12/04/24, for tube feed Jevity 1.5 or comparable at 100 cc per hour for 12 hours per day and a total volume to infuse 1200 cc. Start at 6:00 P.M. and end at 6:00 A.M. to allow for stomach emptying/encourage hunger prior to breakfast with 100 ml water flushes four times a day for enteral feed one time a day for tube feeding related to unspecified protein-calorie malnutrition. Keep head of bed at 30 degrees while feeding is going on. May have 1200 to 1500 cc per resident request;-On 10/16/25, at 5:00 P.M., staff documented 0 mls consumed;-On 10/17/25, 10/18/25, and 10/19/25, at 8:00 A.M. staff documented 1100 mls consumed; and at 5:00 P.M., staff documented 240 mls consumed;-On 10/25/25, at 8:00 A.M., staff documented 2505 mls consumed;-On 10/26/25, at 5:00 P.M., staff documented 2200 mls consumed;-On 10/30/25, at 5:00 P.M., staff documented 600 mls consumed. Review of the resident's progress notes showed staff did not document regarding the documented tube feeding amounts that varied from the ordered amount or physician notification of the variances. During an interview on 10/31/25, at 3:20 P.M., Registered Nurse (RN) A said the following:-The staff offer the resident the amount of feeding the physician ordered, but the resident will sometimes say he/she wants the tube feeding stopped before the ordered amount is completely administered;-The resident always gets 1200 mls put in the feeding bag and the feeding pump is already programmed for the resident to receive 1200 mls;-RN A clears the feeding tube volume infused from the feeding pump every morning when he/she is working;-He/She supposes that he/she should document the difference in intake and output measurements for the resident, but there are three different places for him/her to document output, oral intake, and tube feeding intake in the MAR for the resident, which is confusing;-The resident has an order for a minimum of 1200 mls of tube feeding formula and if only 1050 mls of the ordered feeding was infused, he/she does not see the need to enter a note into the resident's record explaining the difference of how much was received compared to how much was ordered;-If the resident only received 240 mls of his/her 1200 ml ordered tube feeding, then he/she would call the physician or send a quick text to the nurse practitioner (NP);-He/She was usually the nurse that started the resident's tube feeding at 5:00 P.M.;-The resident sometimes complained about his/her stomach hurting, so he/she refused to eat regular food, and to be hooked up to his/her tube feeding;-He/she was not sure that the resident's tube feedings were being documented correctly on the MAR;-He/she did not contact the physician or nurse practitioner on 10/11/25 after documenting not applicable, 10/16/25 after documenting zero, 10/17/25 after documenting 240 mls, 10/26/25 after documenting 2200 mls, or on 10/30/25 after documenting 600 mls instead of the 1200 to1500 mls physician ordered tube feeding. He/she monitored the resident's weight and oral intake, and he/she did not have any concern with either, so he/she did not see a need to report the differing amounts to the physician;-When he/she documented not applicable on the 10/11/25, at 5:00 P.M., in tube feeding area on the MAR, which showed no tube feeding was to be administered that day, that documentation was not correct;-The 10/16/25, tube feeding documentation at 5:00 P.M. for the amount to be administered was recorded correctly as zero being administered, but he/she failed to make a progress note explaining why the resident did not receive the ordered tube feeding. He/she remembered that the resident refused the tube feeding that day due to nausea and vomiting;-He/she thinks his/her documentation of 240 mls on the [DATE]/17/25 at 5:00 P.M. was not documented correctly. He/she believed the resident received 1200 mls of his/her feeding that day and that he/she may have mistakenly documented the resident's oral intake in the MAR instead of the feeding tube amount to be administered. He/she was confused on the documentation process in the MAR and could not verify that for sure;-He/she thought his/her 10/26/25 MAR documentation showing the resident was supposed to receive 2200 mls of the tube feeding at 5:00 P.M. was not accurate. He/she believed the amount of feeding that was supposed to be administered should have been documented as 1200 mls because the resident normally receives 1200 mls as ordered;-He/she documented on the MAR on 10/30/25 that the resident was going to receive 600 mls of his/her tube feeding at 5:00 P.M. that day, but he/she believed that was an error in his/her documentation and the resident was set up to receive1200 mls as ordered;-Last week, the resident reported that the med tech would not bring him/her Mylanta for nausea. During that instance, the resident vomited and requested to have the tube feeding disconnected. He/she could not remember if he/she documented that information in a progress note;-He/She thought the tube feeding should be included in the resident's care plan, but he/she does not enter information into the care plan or even look at the care plan due to a lack of time;-He/she believes the tube feeding should be entered on the resident's MDS and that the facility may have an MDS coordinator, but he/she is not sure;-Nursing judgment wise, if there is a ridiculous amount of difference in the amount of tube feeding formula that a resident receives than what is ordered, he/she should enter a note in the resident's record explaining the difference;-He/she does not have time to enter a note into a resident's record every time the feeding tube amount administered is different than the amount ordered;-It is the responsibility of the RN or unit nurse manager to notify the physician of any problems or concerns with a resident's tube feeding;-The unit nurse manager or the physician should be notified if a resident does not receive any of the tube feeding or not all his/her tube feeding as ordered. During an interview on 11/03/25, at 1:30 P.M., Licensed Practical Nurse (LPN) D said the following:-At 5:00 P.M., he/she documents on the resident's MAR the amount of tube feeding formula that he/she planned to administer through the feeding bag, not the amount of feeding that was administered to the resident. The amount of feeding that is administered is documented at 8:00 A.M., not at 5:00 P.M.;-If staff give more than 1200 mls of the tube feeding formula to the resident, they will have to add the additional amount of formula to the feeding bag at a later time because the feeding bag will only hold 1200 mls at a time;-Residents on a fluid restriction only receive 240 mls of fluid with each meal, so maybe staff mistakenly documented 240 mls of intake on the resident's MAR on 10/17/25, 10/18/25, and 10/19/25 as if he/she was on a fluid restriction; -The 600 mls documented on the resident's MAR at 5:00 P.M. on 10/30/25 would make sense if the resident only wanted half of the 1200 ml feeding, but he/she was not sure if the resident only wanted or received 600 mls of his/her feeding;-He/She thinks the 2504 mls documented on the MAR as the amount of tube feeding administered at 8:00 A.M. on 10/25/25 could be from staff adding 1200 mls of water administration along with 1200 mls of tube feeding formula, with the amount of water administered during bolus water flushes;-LPN D thought staff were documenting on the resident's MAR wrong;-If the resident refused the 1200 mls tube feeding amount ordered, LPN D would put a nurses' note in the MAR documenting the refusal and notify the nurse practitioner, physician, or unit nurse manager of the refusal;-LPN D did not know why the feeding tube administration documentation was scheduled on the resident's MAR for 8:00 A.M. when the tube feeding ends at 6:00 A.M. The 8:00 A.M. documentation area on the MAR should really be scheduled for 6:00 A.M. to be correct with the time the tube feeding administration should end;-If only 1100 mls of the resident's ordered 1200 ml tube feeding was administered LPN D would not notify the physician, unless the resident only received 1100 mls of the feeding several days in a row. In that instance, he/she would inform the unit nurse manager and the nurse practitioner, and make a note in the resident's record;-On 10/21/25, at 8:00 A.M., LPN D documented that 1100 mls of the resident's tube feeding was administered because that was the actual amount that was infused. When he/she went into the resident's room to administer his/her medications he/she noticed some of the feeding formula was still in the feeding bag, but the feeding was no longer running. LPN D offered to give the resident an additional 100 ml bolus feeding to complete the 1200 mls that was ordered, but the resident refused. LPN D did not make a note regarding this in the resident's record because the amount administered was only 100 mls less than what the physician ordered;-On 10/26/25, when the resident's MAR documentation shows more feeding formula was going to be administered than what was ordered, it could be because staff included the amount of water that would be administered through the feeding tube as well;-At first, he/she did not know how to document the intake and output in the MAR for the resident. For the first few days of working at the facility he/she just let the intake and output documentation section go red on the MAR and he/she did not document anything because he/she did not know what to document because it was so confusing to him/her;-RN A told him/her to just document times three in the output section for the resident, so that is what he/she started documenting, but he/she did not know what times three meant. He/she assumed that times three was a code that administration used for something specific and that the administrative staff that reviews the documentation would know what times three meant;-When he/she started working he/she was never trained on the med-bridge (500 and 600 halls), where the resident resides, before he/she was assigned to work the med-bridge halls;-Tube feedings are not started and stopped at the exact same time each day, so it would be unrealistic for staff to document that a resident received 1200 mls of their tube feeding if they are reading the amount administered off the residents feeding pump. LPN D looks at the resident's feeding bag to determine the amount of feeding administered and what to document on the MAR rather than reading the amount infused off the feeding pump. He/she has observed the resident's feeding pump set on 1100 mls rather than 1200mls as ordered;-The amount of tube feeding formula administered to a resident should match what is entered into the MAR as the amount given. During an interview on 11/03/25, at 2:57 P.M., Licensed Practical Nurse (LPN) B said the following:-The intake amount for the resident is recorded everyday shift and every night shift;-For the resident, no staff has ever told him/her how much oral intake the resident took in, so he/she has not been documenting oral intake;-He/She just assumed the intake he/she was supposed to record on the MAR was the tube feeding and water that went into the resident's feeding tube;-He/She does not recall the physician's order stating the resident may receive1200 to1500 mls of formula per tube feeding;-If the resident said he/she was ill and he/she wanted the feeding pump turned off for half an hour then he/she would call the physician and let them know what happened;-He/She is not sure why the resident's tube feeding was scheduled on the MAR for 5:00 P.M. when the physician's order states it should be started at 6:00 P.M.;-He/She was confused by the 5:00 P.M. tube feeding documentation area on the MAR and he/she asked RN A why staff were supposed to document something before it was done;-Prior to discussing with RN A what should be documented at 5:00 P.M. on the resident's MAR, he/she guessed that the documentation at 5:00 P.M. was for flushing the feeding tube. It seemed to be an order that needed to be cleaned up and he/she does not know why it was on the MAR that way;-Most orders are put on the MAR for the time they are scheduled to be completed. He/she did not realize the resident had a 5:00 P.M. order where documentation needed to be completed on the MAR until he/she received a call this morning from the Assistant Director of Nursing (ADON);-He/She does not know who is entering the 5:00 P.M. MAR entry for the tube feeding amount that should be administered to the resident even though the MAR shows he/she made an entry on the resident's MAR at 5:00 P.M. on 10/18/25 and 10/19/25 showing that 240 mls of the 1200 mls ordered would be administered during the feeding both days. LPN B said he/she did not make those two MAR entries;-He/She does not recall documenting that the resident received only 1100 mls of his/her 1200 mls physician ordered tube feeding on 10/18/25 and 10/19/25. During an interview on 11/03/25, at 3:45 P.M., LPN C/Unit Manager said the following:-There was some confusion on the tube feeding order as written for the resident;-The start time for the tube feeding was ordered for 6:00 P.M. but the MAR shows a start time of 5:00 P.M.; -The end time for the tube feeding is scheduled for 6:00 A.M., but the documentation section for the tube feeding amount administered is on the MAR to be documented at 8:00 A.M.;-The 5:00 P.M. area on the resident's MAR is for staff to document the amount of tube feeding they are adding to the tube feeding bag and that they plan to administer;-The 8:00 A.M. area on the MAR is for staff to document the amount of tube feeding the resident actually received during the entire feeding;-It is very important for staff to pay attention to the resident's tube feeding order and to make sure the feeding pump is set to infuse 1200 mls;-Staff should notify the physician every time if the resident receives 1100 mls or less of his/her 1200 mls ordered tube feeding, whether it is because the resident refuses or for other reasons;-Typical intake and output orders include the same thing for all residents, but the resident's intake and output orders are vague;-The resident's intake is typically his/her tube feeding amount received;-Resident's output should be documented everyday shift at 6:30 A.M. and every night shift at 10:30 P.M.;-The resident's 10/11/25 intake amount of 1100 mls and 10/25/25 intake amount for 2504 mls should have had a progress note in the MAR showing the reason for the difference in what was administered and what was ordered. During an interview on 10/31/25, at 3:38 P.M., the ADON said the following:-Staff should administer tube feeding to a resident according to the physician orders;-Staff should document the reason why the ordered amount was not administered and should notify the provider;-The resident should receive between 1200 to 1500 mls of tube feeding and has a potential for weight loss if the ordered amount is not received During an interview on 11/03/25, at 4:31 P.M., the Director of Nursing (DON) said the following:-There was some confusion on the tube feeding order as it was written for the resident;-The tube feeding was ordered to start at 6:00 P.M. but the MAR shows a 5:00 P.M. start time;-The tube feeding was ordered to end at 6:00 A.M., but the intake documentation was scheduled on the MAR for 8:00 A.M.;-Nurses have a one-hour grace period before or after the time ordered on the MAR to administer medications, but the residents feeding start time should be based on 6:00 P.M. as ordered;-The resident's tube feeding start time needed to be fixed on the MAR to match the order;-At 5:00 P.M., staff are expected to document the amount of tube feeding that is anticipated to be given to the resident, not the amount that was actually administered;-At 8:00 A.M., staff should document the amount of the resident's tube feeding that was delivered to the resident when the feeding ended at 6:00 A.M.;-If the order reads to administer 1200 to1500 mls and the resident only received 1100 mls, staff should not contact the physician unless the 1100 mls administered is an everyday occurrence. He/she would expect staff to notify the physician if a lesser amount is administered more than two times per week;-He/She does not think staff are accurately documenting all of the resident's intake because his/her family brings him/her food every day;-If a tube feeding is stopped before the ordered amount is administered, staff should document the reason such as refused or nauseated in a progress note and, in the MAR. The progress note should also say that staff called the physician;-Staff should use the tube feeding pump settings to document the amount of tube feeding administered;-Staff should document accurately in a resident's record. During an interview on 11/03/25, at 5:13 P.M., the Administrator said the following:-Some days the resident does not want the tube feeding, but staff need to document why the feeding was not given.-Staff should have entered a progress note on 10/11/25 when they documented the resident received 1100 mls of his/her ordered tube feeding amount and on 10/25/25 when they documented the resident received 2504 mls instead of 1200 mls as ordered;-The registered dietician for the facility reviews the tube feeding orders and he/she looks to see if there needs to be a change in a resident's tube feeding;-He/She is not sure what intake amounts staff should document;-If a tube feeding is not given for any reason, staff should put a note in the residents MAR showing why the resident did not receive it. Complaint # 2650298

Based on observation, interview, and record review, the facility failed to ensure all food was protected from possible contamination during storage and preparation when staff failed to ensure the air gap for the ice machine had the required two-inch gap between the drain and the floor, when staff failed to wear a hairnet covering all exposed hair, when staff failed to clean the outside of the appliances, when staff failed to date and label opened food, and when staff failed to keep fans and vents above food items clean. The facility census was 149. Review of the facility's policy titled Nutritional Services Sanitation, dated 03/31/21, showed nutritional services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with federal, state and local governing food sanitation and safety.1. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.Review showed the facility did not provide a policy related to the air gap.During an observation on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed an ice machine located in the kitchen. The plastic drainpipe tubing from the ice machine rested directly on the floor next to the drain area and did not have the required two inch gap. During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said he/she doesn't know anything about the drain on ice machine, and whether it should have a gap.During an interview on 08/22/25, at 9:25 A.M., the Dietary Manager (DM) said he/she didn't know anything about the gap on the ice machine drain. He/she didn't know if it was supposed to have a one-inch gap from the drain. During an interview on 08/22/25, at 9:57 A.M., the Administrator said he/she wasn't aware of an issue with the drain outside of the ice machine and that it needed an one inch air gap.2. Review of the facility's policy titled, Nutritional Services Personal Hygiene and Appearance, dated 03/31/21, said hair nets or hair coverings shall be worn while in the kitchen or storage areas. Facial hair, except the eyebrows, shall be covered with a hairnet or beard cover.Review of the 2013 Food Code, issued by the Food and Drug Administration, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles.Observation on 08/17/25, at 3:46 P.M., showed DA Y in the kitchen folding silverware. DA Y had a mustache, and he/she was not wearing a net to cover. He/she also wore a ball cap, with two to three inches of hair that hung outside of the ball cap with no hair net. During an interview on 08/22/25, at 8:50 A.M., DA L said hair nets should cover all of staff's hair, including facial hair. They should be worn when staff are in the kitchen. If staff are wearing a hat, and hair is hanging out, that should be covered with a hair net. During an interview on 08/22/25, at 9:05 AM., DA M said hair nets should be worn at all times when in the kitchen. It should cover all the hair, facial or if there's hair sticking out of a cap.During an interview on 08/22/25, at 9:16 A.M., DA N said hair nets should be on as soon as staff come through door. The hair nets should cover all hair, including beards, mustache, and any hair hanging out of a ball cap.During an interview on 08/22/25, at 9:25 A.M., the DM said he/she expected staff to wear a hairnet as soon as they pass the line that's set up in the kitchen. The hair net should cover all hair, facial hair if it's over a 1/4 inch. If they have hair coming under a cap, it should be covered as well.During an interview on 08/22/25, at 9:57 A.M., the Administrator said staff should be wearing hair nets in the kitchen and they should cover all hair, including facial hair and any hair outside of the cap.3. Review of the 2013 Missouri Food Codes showed the following information:-Equipment food-contact surfaces and utensils shall be clean to sight and touch;-The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations;-The physical facilities shall be cleaned as often as necessary to keep them clean.Observations on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-The front of the stove had multiple pieces of food on the front;-Multiple streaks of white substance were on the front and sides of the stove;-The dehydrator had multiple white streaks down the sides and front. During an interview on 08/22/25, at 8:50 A.M., DA L said appliances are cleaned by the cooks and prep cooks. There should not be grease on or around the appliances. These should be wiped down morning and evening.During an interview on 08/22/25, at 9:05 AM., DA M said the appliances should be cleaned daily.During an interview on 08/22/25, at 9:25 A.M., the DM said appliances should be cleaned daily, wiped down, and there should not be streaks of stuff on them.During an interview on 08/22/25, at 9:57 A.M., the Administrator said the appliances should be wiped down daily. 4. Review of the Missouri Food Code, published 2013, regarding refrigerator food storage showed the following:-Refrigerated, ready-to-eat, potentially hazardous food, prepared and held in a food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of forty-one degrees Fahrenheit (F) or less for a maximum of seven days or when held at a temperature of forty-five degrees F or less for a maximum of four days;-Refrigerated, ready-to-eat, potentially hazardous food, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty four hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified:-The day the original container is opened in the food establishment shall be counted as day 1;-The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety.Observation on 08/17/25, at 3:46 P.M., showed the following:-One package of turkey lunchmeat, opened, in a Ziplock bag, with no date or label;-One large container of jelly, no label or use by date;-Two large containers of salad mix with no label or use by date;-One open bag of strawberries, in the original package, with an open top and no open or use by date.During an interview on 08/22/25, at 8:50 A.M., DA L said anything opened should be put in another container if needed, labeled, and staff write down the date it's opened so they know when to throw it out.During an interview on 08/22/25, at 9:05 AM., DA M said when opening a food item, there should be a date opened and if it needs to be put in another, it should be labeled.During an interview on 08/22/25, at 9:16 A.M., DA N said when foods are opened, such as lunchmeat, they should be put in another container and dated.During an interview on 08/22/25, at 9:25 A.M., the DM said when staff open food, they should cover it, or put in another container, label and date it.During an interview on 08/22/25, at 9:57 A.M., the Administrator said when staff open food, they should cover it, or put in another container, label and date it.5. Observation on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-Two fans located in the walk-in refrigerator with a black fuzzy substance on the fan covers (that could fall and contaminate food in the refrigerator);-Two fans located in the walk-in freezer with a black fuzzy substance on the fan covers (that could fall and contaminate food in the refrigerator). There were 13 cups of pudding, uncovered, sitting below the fans. During an interview on 08/22/25, at 8:50 A.M., DA L said the following:-Maintenance cleans the fans in the walk in freezer and refrigerator. He/she doesn't know how often. He/she knew there shouldn't be black, crusty stuff on them;-When there are issues in the kitchen, he/she tells the DM and the DM lets maintenance know of the issues. During an interview on 08/22/25, at 9:05 AM., DA M said the following:-Fans in the walk-in freezer or fridge should be clean and not have black fuzzy stuff, could get into the food. He/she was not sure who cleaned them;-If they have kitchen issues, they let the DM know and she tells maintenance. During an interview on 08/22/25, at 9:16 A.M., DA N said he/she didn't know who cleaned the fans in the fridge and freezer, but they shouldn't have black stuff on them.During an interview on 08/22/25, at 9:25 A.M., the DM said maintenance cleans the fans in the walk-in fridge and freezer. He/she didn't know how long it had been since they were cleaned. They should not have black fuzzy stuff on them.During an interview on 08/22/25, at 9:57 A.M., the Administrator said fans in the walk-in fridge and freezer are cleaned by maintenance. They should not have black fuzzy lint on them.5. Observations on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-Two vents to the right of the steam table on the ceiling had a fuzzy lint;-A vent over the food prep area on the wall had fuzzy lint on it;-A vent to the right as you enter the kitchen, on the ceiling, near clean dishes, had fuzzy lint.(The lint could fall on food items or food service items.)During an interview on 08/22/25, at 8:50 A.M., DA L said he/she believed maintenance cleaned the vents, he/she didn't know how often or when they were clean last time. Fuzzy lint could fall into the food.During an interview on 08/22/25, at 9:05 AM., DA M said he/she is not sure who cleans vents on walls and ceiling, but fuzzy lint could get into the food.During an interview on 08/22/25, at 9:16 A.M., DA N said he/she didn't know who cleaned the vents, but they shouldn't have lint. During an interview on 08/22/25, at 9:25 A.M., the DM said vents in the kitchen are cleaned by maintenance. He/she didn't know how often they're cleaned. He/she did not realize they have fuzzy lint on them.During an interview on 08/22/25 at 3:11 P.M., the Maintenance Director said he/she was responsible for cleaning the vents in the kitchen. He/she cleaned those as needed, but isn't sure how long it had been since they were cleaned. They should not have fuzzy lint on them. During an interview on 08/22/25, at 9:57 A.M., the Administrator said the following:-All vents in the kitchen are cleaned by maintenance. He/she looks at them weeklyThe vents get dirty quickly due to the grease, but they should not have fuzzy lint;-The DM is monitoring the cleaning of the kitchen.

Based on observation, interview, and record review, the facility failed to ensure the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate when staff failed to assess for, care plan regarding, and obtain a physician's order for self-administration and bedside storage one medications for three residents (Resident #37, #148, and #31). The facility census was 149. Review of the facility policy titled Bedside Medication Storage, dated December 2017, showed the following information:-Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber, and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team;-A written order for the bedside storage of medication is present in the resident's medical record;-Bedside storage of medications is indicated on the resident Medication Administration Record (MAR) and in the care plan for the appropriate medications;-For residents who self-administer medications, for bedside storage to occur the manner of storage must prevent access by other residents, lockable drawers or cabinets were required only if unlocked storage was deemed inappropriate, and facility management should have acopy of the key in addition to the resident;-The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy, or in the original container if a nonprescription medication;-The resident is instructed in the proper use of bedside medications, including what the medication is for, how it is to be used, how often it may be used, proper cleaning of inhalers where applicable, proper storage of the medication;-All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.Review of the facility policy titled Medication Administration - General Guidelines, dated December 2017, showed the following:-Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.1. Review of Resident # 37's face sheet (brief look at resident information) showed the following information:-re-admission date of 08/04/25;-Diagnoses included ocular hypertension (a condition where the pressure inside the eye is consistently higher than normal).Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 08/20/25, showed the following information:-Vision impairment;-Required partial to moderate assistance from staff for mobility;-Diagnoses include cataracts (clouding of the normally clear lens of the eye), glaucoma(a group of eye conditions that can cause blindness), and/or macular degeneration (an eye disease that causes vision loss).Review of the resident's care plan, dated 08/25/25, showed the following information:-The resident had cataracts and glaucoma;-Arrange consultation with eye care practitioner as required;-Review medications for side effects that affect vision;-Tell the resident where you are placing their items and be consistent.(Staff did not care plan related to the resident ability to maintain at bedside and self-administer medications.) Review of the resident's August 2025 Physician Order Sheet (POS) showed no order to maintain the drops at bedside and self-administer the drops.Review of the resident's record show no documented self-administrator assessment for the resident. Observation and Interview on 08/22/25, at 8:54 A.M., showed Certified Medication Technician (CMT) H said the resident kept his/her eye drops in his/her room. Upon entering the resident's room, two bottles of eye drops were observed on the resident's bedside table. The bottles had prescription labels identifying one bottle as prednisolone acetate 1 % (a topical corticosteroid ophthalmic suspension used for treating inflammatory eye conditions) and Systane (an over-the-counter lubricant eye drop used to relieve dryness, burning, and irritation in the eyes).2. Review of Resident #148's face sheet showed the following:-admission date of 11/24/21;-Diagnoses included chronic pain syndrome (persistent pain interferes with daily life), suicidal ideations, and anxiety disorder.Review of the resident's care plan, last updated 03/27/25, showed the following:-Resident had depression and anxiety with a history of suicidal ideations;-Staff should monitor, document, report as needed any risk for harm to self: suicidal plan, past attempt at suicide, and risky actions including stockpiling pills;-Staff should administer medications as ordered and monitor and document for side effects and effectiveness.(Staff did not care plan regarding the resident self-administering medications or having medications at bed side.) Review of the resident POS, current as of 08/25/25, showed the following:-An order, dated 01/11/22, to monitor side effects of all medications;-An order, dated 11/24/23, for acetaminophen tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for pain.(Staff did not document an order related to the resident self-administering medications or storing medications at bedside.) Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.Review of the resident's record show no documented self-administrator assessment for the resident. Review of the resident's August 2025 Medication Administration Record (MAR) showed the following:-An order, dated 11/24/23, for acetaminophen 325 mg, give 2 tablets by mouth every 6 hours as needed for pain;-On 08/03/25, at 9:41 P.M., staff documented resident had a pain level of 6 out of 10 and acetaminophen 325 mg two tablets were administered and documented as effective response;-On 08/04/25, at 10:08 P.M., staff documented resident had a pain level of 5 out of 10 and acetaminophen 325 mg two tablets were administered and documented as effective response.During observation and interview on 08/17/25, at 5:00 P.M., the resident said staff told him/her that there was not a pain pill available for his/her chronic back pain and instead gave him/her Tylenol. Observation of resident room showed a medication cup with four white round tablets on the bedside table. The resident said the tablets were Tylenol and that Tylenol was not effective for his/her pain, so he/she did not take them.Review of the resident's August 2025 Medication Administration Record (MAR) showed the following:-On 08/17/25, at 10:06 P.M., staff documented resident had a pain level of 6 out of 10 and acetaminophen 325 mg two tablets were administered and documented as effective response.During observation and interview on 08/18/25, at 2:25 P.M., the resident said that he/she had physical therapy today and that his/her left shoulder pain had increased. Staff provided with him/her two Tylenol, but it did not help, so he/she did not take it. The resident picked up a medication cup from his/her bedside table that had four round white tablets. The resident said he/she did not know what to do with the medications because he/she was not going to take the Tylenol.3. Review of Resident #31's face sheet showed the following:-admission date of 02/16/23;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), metabolic encephalopathy (brain's function is impaired due to a chemical imbalance or issue in the body), and cognitive communication deficit.Review of the resident's care plan, updated 08/12/25, showed the following:-Resident had altered respiratory status and difficulty breathing related to COPD and asthma;-Staff should administer medications as ordered and monitor for effectiveness and side effects;-Resident had alteration in neurological status related to metabolic encephalopathy;-Staff should cue and re-orient as needed;-Staff should administer medications as ordered and monitor for effectiveness and side effects;-Resident had impaired cognitive function and/or dementia or impaired thought processes confusion diagnosis of encephalopathy;-Staff should administer medications as ordered and monitor for effectiveness and side effects.Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.Review of the resident's POS, current as of 08/25/25, showed the following:-An order, dated 06/15/23, to monitor side effects of all medications;-An order, dated 06/15/23, for albuterol sulfate inhalation solution (used to a help with breathing) 108 micrograms (mcg)/actuation (act), give 2 puffs orally every 4 hours as needed for shortness of breath.(Staff did not document orders regarding medications being left at bedside or self-administration of medications.)Review of the resident's record show no documented self-administrator assessment for the resident. Observation on 08/17/25, at 5:20 P.M., showed the resident was resting in bed with eyes closed. There was an albuterol inhaler on the top of the bedside dresser.Observation on 08/20/25, at 12:00 P.M., showed the resident was not in his/her room and an albuterol inhaler was on the top of the bedside dresser.4. During an interview on 08/22/25, at 11:08 A.M., Certified Nursing Assistant (CNA) J said the following:-He/she did not believe residents were able to keep medications at bedside;-He she would report medications at beside to the charge nurse.During an interview on 08/22/25, at 10:00 A.M., Certified Medication Tech (CMT) D said staff are to stay with residents until any medication has been taken. Staff should not leave medications at bedside for the resident to take later unless the resident had an order to keep at bedside. When he/she has seen medications at bedside in the past, he/she would take the medication and notify the charge nurse. During an interview on 08/22/25, at 12:30 P.M., CMT A said medications should not be left at bedside for residents unless there was a physician order for bedside medications. He/she would remove the medication and notify the charge nurse if found in a resident's room. During an interview on 08/25/25, at 10:20 A.M., CMT G said medications should not be left at resident's bedside. Staff should stay and ensure the resident takes the medication and if necessary, take the medication and return later if the resident did not want to take it at that time.During an interview on 08/22/25, at 12:35 P.M., the Wound Nurse said the following:-Medications can be kept at bedside, but the resident must be screened for safety of administration prior. The type of medication also mattered;-A physician's order was also required to keep medications at bedside.During an interview on 08/22/25, at 2:02 P.M., Licensed Practical Nurse (LPN) A/Unit Manager said the following:-Residents can keep medications at bedside if they have a physician's order to do so;-Medications being on the resident's bedside has not been brought to her attention.During an interview on 08/22/25, at 12:40 P.M., Registered Nurse (RN) C said staff should not leave any type of medication, including over the counter, at resident's bedside to be taken later. There were too many safety concerns for that resident and other residents if medications were left in resident rooms. During an interview on 08/22/25, at 2:22 P.M., the Director of Nursing (DON) said the following: -Only certain medications can be kept at bedside;-A physician's order is needed;-Staff must fill out a self-administration assessment on the resident to ensure safe administration;-The residents must keep the medications in a lock box in their room.During an interview on 08/25/25, at 12:29 P.M., the Administrator said the following:-In order for a resident to keep medications at bedside, there must be a physician's order;-Staff should care plan medications at the bedside;-There would have to be a process to keep that medication locked up from other resident's if the resident was safe to keep their own medications. Complaint numbers 1534273, 1534275, 2585250

Based on record review and interview, the facility failed to promote and facilitate each resident's right of self-determination when staff failed to provide timely bathing, in the form the resident preferred, for four residents (Resident #20, Resident #37 and Resident #113) out of a sample of nine resident. The facility census was 149. Review of the facility's policy titled, ADL (activities of daily living) Care Bathing, dated 07/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity; -The charge nurse will be made aware of residents who refuse bathing. 1. Review of Resident #20’s face sheet showed the following information: -admission date of 06/06/24; -Diagnoses included nontraumatic intracerebral hemorrhage (type of stroke when bleeding occurs on the brain), encephalopathy (condition that affects the brain’s function leading to various issues), hemiplegia (paralysis of one or both sides of the body), and depression (persistent feelings of sadness). Review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 08/06/25, showed the following: -Moderately impaired cognition; -Dependent upon staff for showers. During interviews on 08/17/25, at 4:56 P.M., on 08/20/25, at 9:35 A.M., and on 08/21/25, at 3:20 P.M., the resident said the following: -He/she was not receiving showers. He/she didn’t know how long it had been since he/she received a shower. He/she had received some bed baths, but he/she would prefer a shower; -He/she feels yucky when he/she does not get regular showers; -He/she had not refused a bed bath, there have been times when the resident didn’t understand the staff giving a bed bath when he/she would like a shower; -He/she would rather the staff give him/her a shower instead of receiving a bed bath from a family member. Review of the resident’s July 2025 Shower Sheets showed the following: -On 07/24/25, the resident received a bed bath; -On 07/29/25, the resident’s family provided a bed bath; -On 07/31/25, staff noted the resident refused a bed bath. Review of the resident’s August 2025 Shower Sheets showed the following: -On 08/05/25, the resident’s family member provided a bed bath (seven days after the last document bed bath); -On 08/08/25, staff noted dryness over much of the resident’s body, Staff noted the resident’s head was washed, but did not indicate there was a shower; -On 08/11/25, the resident’s family member provided a bed bath; -On 08/14/25, staff noted resident bathed. Staff did not specify if it was a shower or bed bath; -On 08/18/25, the resident’s family member provided a bed bath. During an interview on 08/22/25, at 11:10 A.M., Certified Nurse’s Aide (CNA) I said he/she didn’t know if the resident was getting showers. He/she had not been at the facility when the resident had been given a shower. He/she had not given the resident a shower. During an interview on 08/22/25, at 12:22 P.M., Licensed Practical Nurse (LPN B) the resident or his/her parents have complained about showers. He/she believed the resident had received a bed bath, as the shower hurts his/her back. He/she didn’t know if the resident was offered a shower. During an interview on 08/22/25, at 2:22 P.M., Director of Nursing (DON) said the resident used to receive a bed bath. He/she didn’t know if that had changed. He/she would assume staff are offering him/her a shower. 2. Review of Resident #37’s face sheet showed the following information: -admission date of 08/04/25; -Diagnoses included fracture to lower left leg. Review of the resident’s entry MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Substantial with showers. Review of the resident’s care plan, dated 08/18/25, showed the following: -Resident had ADL self-care performance deficit related to activity intolerance, impaired balance, limited mobility and pain; -Staff to offer bathing/showering two times per week and as necessary; -Staff to offer sponge bath when a full bath or shower cannot be tolerated. During interviews 08/18/25, at 9:40 A.M., and on 08/21/25, at 8:12 A.M., the resident said the following: -He/she admitted on [DATE], and he/she has received one sponge bath on 08/08/25 and 08/20/25; -He/she can’t have a full shower but would like a couple of sponge baths per week. Review of the resident’s August 2025 Shower Sheets showed the following: -On 08/08/25, staff signed off on the shower review sheet, but did not specify what type of shower was provided; -On 08/15/25, (seven days after the previous shower/bed bath), staff noted the resident refused a shower. The unit manager signed off as the charge nurse. (Staff did not document if a bed bath was offered.); -On 08/17/25, staff noted the resident refused a shower. The unit manager signed off as the charge nurse. (Staff did not document if a bed bath was offered.); -On 08/20/25, staff noted resident had a shower, but didn’t specify the type. During an interview on 08/22/25, at 12:22 P.M., LPN B said he/she believed the resident was receiving showers, as far as he/she knew. The resident hadn’t complained to him/her about not receiving showers; During an interview on 08/22/25, at 2:22 P.M., the DON said the resident received bed baths due to his/her leg cast. 3. Review of Resident #113’s face sheet showed the following information: -admission date of 02/19/21; -Diagnoses included altered mental status. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Substantial assistance with showers. During interviews on 08/18/25, at 1:18 P.M., and on 08/21/25, at 10:44 A.M., the resident said the following: -The resident has a calendar where he/she kept track of showers; -He/she showed the surveyor his/her calendar and he/she had one day in July where he/she was provided a shower, and it was 07/10/25; -He/she had no days marked in August. He/she said he/she had not received a shower in August; -He/she feels dirty. He/she would like two showers per week, it doesn’t matter the day; -He/she had not refused any showers, but there have been a couple of times he/she wanted to participate in activities, and he/she came back to his/her room immediately after the activity to wait for a shower and never got one; -He/she has asked for showers several times and they don’t have time. Review of the resident’s July 2025 and August 2025 Shower Sheets showed the following: -On 07/18/25, staff noted the received a shower; -On 07/23/25, staff noted the resident received a shower (a five day gap); -On 07/29/25, staff noted the resident received a shower (a six day gap); -On 08/09/25, staff noted the resident received a shower (an 11 day gap); -On 08/12/25, staff noted the resident received a shower; -On 08/17/25, staff noted the the resident received a shower (a five day gap). During an interview on 08/22/25, at 11:10 A.M., CNA I said he/she imagined the resident had been given a shower, but he/she had not seen the resident take one and he/she had not given the resident a shower. During an interview on 08/22/25, at 12:22 P.M., LPN B said the resident was receiving showers. During an interview on 08/22/25, at 2:22 P.M., DON said the resident was receiving showers as he/she requests them. 4. Review of Resident # 39’s face sheet showed the following: -admission date of 11/21/23; -Diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction affecting left non-dominant side, and cognitive communication deficit (condition where a person experiences difficulties with various aspects of communication due to underlying cognitive impairments). Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for bathing. Review of the resident’s care plan, updated 07/28/25, showed the following: -Resident had an ADL self-care performance deficit due to activity intolerance, hemiplegia, and impaired balance; -The resident required two staff assistance for bathing. Review of the facility’s “Skin Monitoring: Comprehensive CNA Shower Review” forms, showed the following: -On 06/18/25, staff documented no new skin issued; -On 06/25/25, staff documented no new skin issued (a seven-day gap); -On 07/03/25, staff documented arterial wound on coccyx region (small triangular bone at the base of the spinal column) (eight-day gap); -On 07/10/25; staff documented resident received a bed bath and hair was washed (seven day gap); -On 07/17/25, staff documented resident refused; -On 08/06/25, staff documented resident received a bed bath and hair was washed (20 days after last offered shower); -On 08/13/25, staff documented resident received a bed bath and hair was washed (a 7 day gap). Review of the resident’s medical record showed staff documented in nursing progress notes on 08/19/25, at 2:23 P.M., that neurosurgery office called and stated that resident needed a shower and the pads in his/her neck brace needed changed and the ones in there now need washed. During an interview on 08/20/25, at 11:00 A.M., the resident said he/she would prefer two baths per week. He/she felt dirty without a bath at least that he/she had a shower list laminated in the shower room. Most residents received two showers per week. twice per week. During an interview on 08/22/25, at 1:00 P.M., CNA E the resident preferred two bed baths per week. He/she was not aware of him/her going longer than once per week. During an interview on 08/25/25, at 11:20 A.M., DON said the resident had no scheduled shower dates attached to his/her room number. 5. During an interview on 08/22/25, at 11:10 A.M., CNA I said the following: -The residents should be offered a shower at least two times per week. He/she believed the residents are receiving showers, but may refuse; -When a resident received a shower, it’s documented in the EHR (electronic health record) and on a shower sheet. If the resident refuses staff get a signature on the sheet; -Residents should have an option to have a shower or bed bath. During an interview on 08/22/25, at 11:24 A.M., CNA K said the following: -He/she was not sure if they [NAME] a shower aide for 500 and 600 halls. He/she did not know of a shower schedule; -Sometimes the shower aide from 300 and 400 halls will do the 500 and 600 halls; -He/she was not sure how often a resident should be offered a shower. He/she washes the residents up when they need it. He/she has offered a shower when he/she she has time; -The residents should be given an option of a bed bath or shower; -The shower aide completes a shower sheet on each resident, and he/she didn’t know if showers are documented in the EHR; -If a resident refused a shower, he/she isn’t sure but thinks maybe they let the nurse know. During an interview on 08/22/25, at 1:00 P.M., CNA E said that he/she had a shower list laminated in the shower room. Most residents received two showers per week. During an interview on 08/22/25, at 11:35 A.M., Certified Medication Technician (CMT) A said the following: -The shower aide for 500 and 600 hall was out and now the CNAs working the floor were giving showers; -He/she was not sure how often showers were offered. They should offer a shower first and then a bed bath; -CNAs document the showers on shower sheets and he/she didn’t know if they’re documented in the HER; -If the resident refused the shower, staff wrote refused on the shower sheet. He/she didn’t know of the nurse was told about the refusal. During an interview on 08/22/25, at 12:22 P.M., LPN B said the following: -The aides are expected to provide showers to the residents. They should offer showers at least weekly and maybe two times per week; -Residents should be offered a shower or a bed bath. If they’re attending activities, they should offer at another time; -The showers are documented on a shower sheet, and he/she believed they’re also put into the computer; -If a resident refuses, they should put refused on the sheet. He/she doesn’t know that they tell the nurse; -He/she had one resident complain and they gave him/her a shower. During an interview on 08/22/25, at 2:02 P.M., the Unit Manager/LPN said the following: -All CNAs can give residents showers. The CNAs should be offering daily to anyone that wants a shower; -The residents should be able to choose whether it’s a shower of bed bath; -There is a task in the EHR where the staff select when a shower is provided. They should also be completing shower sheets. If the resident refuses, they should note that and offer another day. They should also let the nurse know when the resident refuses; -If the resident is going to an activity, staff should offer a shower later. During an interview on 08/22/25, at 2:22 P.M., DON said the following: -They do not have a specific shower aide. Any aide can give showers; -The residents should be offered showers at last two times per week. Every room comes with two days for showers. This is provided upon admission; -He/she has a schedule, which is flexible, with certain rooms scheduled on certain days; -Some residents are given a bed bath if therapy makes that suggestion, or the resident prefers a bed bath. He/she would assume aides are offering a shower. During an interview on 08/25/25, at 12:30 P.M., the Administrator said the following: -He/she wanted every resident to be happy about getting a shower; -If a resident refused, they would work hard to get them to take one; -Residents should be asked daily if they want a shower; -If residents want two per week, they should be getting them and they should have a choice; -Any nursing staff can give showers. They don’t have a specific shower aide for 400 and 500 halls since the regular aide is out. Complaint #2572207

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the floors, walls, doors, and/or bathrooms for 9 residents (Resident #13, #36, #94, #123, #125, #39, #73, #51, and #141), when staff failed to address odors in the rooms of 5 residents (Resident #13, #123, #125, #141, and #135), when staff failed to a provide a clean over the bed table to one resident (Resident #72), when staff failed to maintain the facility at comfortable temperature in a family dining room and two residents' rooms (Resident #148 and #103), and when staff failed to maintain furniture in good condition in the special care unit. The facility census was 149. 1. Review of Resident #13's face sheet showed an admission date of 06/27/25. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/10/25, showed the resident had severely impaired cognitive skills. Observations on 08/19/25, at 9:46 A.M., and on 08/20/25, at 10:27 A.M., of the resident’s room showed the following: -The room had a strong urine odor;-The wall under the window had paint peeled off;-The bathroom floor had brown substances in the corner. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor acknowledged the resident's bathroom floor had some black substance in the corner and the resident's wall under the window had paint peeled off. He/she did not know how long the resident's wall had areas of peeling paint. 2. Review of Resident #36's face sheet showed an admission date of 04/15/24. Review of the resident's quarterly MDS assessment, dated 07/13/25, showed the resident had severely impaired cognitive skills. Observation on 08/18/25, at 2:34 P.M., of the resident’s room showed the resident's bathroom floor contained a brown substance on the caulking around the toilet stool. The bathroom floor felt sticky to the bottom of shoes. During an observation on 08/19/25, at 9:46 A.M., a housekeeper had his/her cart and went into the resident's room to clean. Observation on 08/19/25, at 9:51 A.M., of the resident’s room, after the housekeeper cleaned the room, showed the following: -The resident's floor under his/her bed contained several ants, two to three pair of shoes, chunks of a black unknown material the size of a half dollar and brown splatters;-The floor under the chair located next to the resident's bed had brown splatters;-The resident's bathroom floor felt sticky to the bottom of shoes. Observation on 08/19/25, at 10:48 A.M., of the resident’s room showed the following: -The resident sat on his/her bed;-The resident's bathroom floor contained a brown substance on the caulking around the toilet stool;-The bathroom floor felt sticky to the bottom of shoes;-The floor under the resident's bed had a few ants, several pair of shoes, chunks of a black unknown material the size of a half dollar, and brown splatters;-The floor under the chair located next to the resident's bed had brown splatters. Observation on 08/20/25, at 10:27 A.M, of the resident’s room showed the following: -The bathroom floor contained a brown substance on the caulking around the toilet stool;-The bathroom floor felt sticky to the bottom of shoes;-The floor under the resident's bed had a few ants, several pair of shoes, approximately three chunks of a black unknown material the size of a half dollar, and brown splatters;-The floor under the chair located next to the resident's bed had brown splatters. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said the following:-Staff keep cans of bug spray on supply. The pest control company comes twice per month and treats for ants;-The resident's bathroom floor around the toilet needed cleaned;-The resident's floor under his/her bed and chair should be swept and mopped;-If the mop water is too cold, the mop solution can become sticky. Staff should re-mop the floors if they are sticky. 3. Review of Resident's 94's face sheet showed an admission date of 04/20/24. Review of the resident's quarterly MDS assessment, dated 07/13/25, showed the resident had moderately impaired cognitive skills. Observations on 08/19/25, at approximately 9:50 A.M., of the resident’s room showed the following: -The resident's bathroom floor contained a brown substance around the base of the toilet stool;-The resident's wall in the bathroom had a black substance on the wall with paint peeled off. Observations on 08/20/25, a 10:27 A.M., showed the following: -The resident's bathroom floor contained a brown substance around the base of the toilet stool; -The resident's wall in the bathroom had a black substance on the wall with paint peeled off. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said he/she did not know what the black substance was on the wall. During an observation and interview on 08/22/25, at 3:15 P.M., the Maintenance Supervisor said the resident's wall in the bathroom needed cleaned and painted. 4. Review of Resident #123's face sheet showed an admission date of 08/30/19. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #125’s face sheet showed an admission date of 04/07/21. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview and observation on 08/18/25, at 1:00 P.M., Resident #123 and #125’s room, showed the following:-The room had an unpleasant odor, that can be smelled in the hall before opening the door;-There was a beside commode with no lid with bag full of urine tied into the commode;-There was debris and crumbs on the floor;-The corner of the wall had several areas of to damage dry wall;-The toilet seat was loose and moved when pressure placed on the seat;-When the light switch was turned on the above bed light did not illuminate;-The resident said it had been almost two months since maintenance staff said he/she would fix the above light bulb above his/her bed and the door handle had been broken for several months. Review of the Maintenance Log at the 100/200 nurses’ station showed staff wrote the following on the log:-On 07/21/25, Residents #123 and #125 room, staff noted neither overhead light worked when the switch was turned on. Staff did not mark or note that had been completed;-On 08/16/25, staff noted “bathroom needs help.” Staff marked as done on 8/21/25. During an interview on 08/21/25, at 1:24 P.M., Housekeeper (HK) DD said he/she noticed the room had an odor. The odor could be smelled in the hallway. He/she sprayed the room with an air freshener which the residents did not like. 5. Review of Resident #39’s face sheet showed an admission date of 11/21/23. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #73’s face sheet showed an admission date of 10/10/18. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.-Use of wheelchair; Observation on 08/19/25, at 4:00 P.M., of Resident #39’s and #72’s room showed the following:-Bathroom air and heat vent on the wall showed gaping holes above and below the air vent approximately 4 inches tall and the width of the vent approximately 12 inches and approximately 2 inches tall by the width of the vent with no drywall in place;-The inside of the wall was visible and air coming out surrounding the vent could be felt;-Air and heat vent in the resident room on the floor had rust colored damage throughout the vent and the floor vent right side was pulled away from the wall by approximately 2 inches;-The towel rod and toilet paper holder were not attached to the wall. 6. Review of Resident #72’s face sheet showed an admission date of 06/13/25. Review of the resident’s MDS, dated [DATE], showed the resident had severely impaired cognition. Observations, on 08/25/25, showed the following:-At 10:05 A.M., the resident was not present in his/her room. The resident’s bed was made, and an adjustable height rolling table was positioned over the bed. The surface of the table was soiled, as was the plate-sized square blue non-slip pad stuck to the table. A full, uncovered mug of ice water was on the table;-At 10:48 A.M., the resident was not present in his/her room. The resident’s bed was made, and an adjustable height rolling table was positioned over the bed. The surface of the table remained soiled, including the blue non-slip pad stuck to the table. A full, uncovered mug of ice water was on the table. During an interview on 08/25/25, at 11:53 A.M., the Director of Nursing (DON) said staff should clean residents’ bedside tables as needed, especially after a meal. The resident would not be expected to clean his/her own table. During an interview on 08/25/25, at 1:06 P.M., the Administrator said a resident’s bedside table should not be left soiled. Staff should ensure the table was cleaned after a meal. 7. Review of Resident #51’s face sheet showed a readmission date of 11/15/24. Review of the resident’s quarterly MDS, dated [DATE], showed the resident had moderately impaired cognition. Observation on 08/17/25, at 4:30 P.M, showed a softball-sized jagged hole in the lower part of the hollow core closet door. Observation on 08/22/25, at 3:00 P.M., showed the same softball-sized jagged hole in the lower part of the hollow core closet door. Observation and interview on 08/25/25, at 10:14 A.M., showed the same softball-sized jagged hole in the lower part of the hollow core closet door. The resident said the large hole was on his/her roommate's side of the closet and said, It doesn't look very good. He/she thought it had been that way for a while. Review on 08/25/25, at 11:28 A.M., of the Maintenance Book, showed no documentation regarding the damaged closet door. 8 .Review of Resident #141's face sheet showed an admission date of 04/26/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Observation and interview on 08/17/25, at 5:01 P.M., showed the following:-The room had an unpleasant odor, that could be smelled in the hall;-An empty soda box was under the resident’s bed, clothes were on the floor, and the tables had various items on them, including empty bottles;-The floor appeared dirty with brown places and pieces of food on the floor;-The floor had clothes, stuffed animals, and soda on it;-The trashcan was mostly full;-The urinal was half full of urine. Observation and interview on 08/21/25, at 11:00 A.M., showed the following:-The room has an unpleasant odor, that could be smelled in the hall;-An empty soda box under the resident’s bed, clothes on the floor, the tables had various items on the, including empty bottles;-The floor appeared dirty with brown places and pieces of food on the floor;-The urinal was fourth of the way full of urine;-The floor had clothes, stuffed animals and soda on it;-The resident’s dogfood bowl had spilled and there was dogfood in the floor. During an interview on 08/22/25, at 11:10 A.M., CNA I said he/she felt like the dog was causing most of the odors in the room. When he/she comes in, the urinal is usually full, so that probably adds to the odors. During an interview on 08/22/25, at 12:22 P.M., Licensed Practical Nurse (LPN B) said he/she had noticed odors in and around the room. He/she had also received complaints from staff about the odors. He/she believed it was a combination of things. During an interview on 08/22/25, at 2:02 P.M., LPN A/Unit Manager said he/she had received complaints about the resident’s room. He/she had addressed the complaints with housekeeping who should be cleaning the room and making sure the trash is emptied. Nursing should make sure the urinal in empty. During an interview on 08/22/25, at 2:22 P.M., the Director of Nursing (DON) said the resident does not want housekeeping in his/her room. He/she knew there were odors in and around the resident’s room. During an interview on 08/25/25, at 12:30 P.M., the Administrator said because of the resident’s size, weight, and food choices, his/her odors can be different. The room has been a challenge as the resident doesn’t want housekeeping in his/her room when he/she is asleep. The staff have taken the dog out because the dog will sometimes pee in the room as the resident doesn’t always take the dog out timely. During an interview on 08/25/25, the Housekeeping Supervisor said the resident did not like for his/her room to be cleaned often. Some days the resident will allow him/her to clean, but most days he/she will say no. When the resident refuses he/she will do what he/she can, and try to get a deep clean in the room one time per week. He/she notices odors coming from the resident room. 9. Review of Resident #135's face sheet showed an admission date of 02/26/25. Review of the resident's quarterly MDS assessment, dated 07/30/25, showed the resident had cognitively intact skills. Observation on 08/17/25, at 5:30 P.M., showed the resident lay in his/her bed. The resident's room smelled of urine. The hallway just outside the resident's room smelled of urine. During an observation and interview on 08/18/25, at 11:00 A.M., the resident lay in his/her bed. The resident said he/she received his/her shower and had no complaints of his/her care. The resident's room smelled of urine. The hallway just outside the resident's room smelled of urine. Observations on 08/19/25, at 11:33 A.M., and 2:00 P.M., showed the resident lay in his/her bed. The resident's room smelled of a strong urine odor. The hallway just outside the resident's room smelled of urine. During an interview on 08/21/25, at 10:45 A.M., LPN A/Unit Manager said the resident had odors in his/her room and the hall at times. During an interview on 08/21/25, at 12:23 P.M., the Director of Nursing (DON) said the following: -The resident's former roommate moved out because the resident smelled;-Staff should monitor for odors on rounds;-Offensive odors is not homelike. 10. During an interview on 08/21/25, at 9:21 A.M., CNA I said housekeepers mop and sweep daily. Staff check the halls for odors and change a resident if needed. During an interview on 08/20/25, at 6:48 P.M., CNA K said staff should report to the housekeepers if there is something on a resident’s floors. During an interview on 08/21/25, at 1:24 P.M., HK DD said the following:-Housekeeping clean the residents' rooms every day;-Housekeeping should take out the trash, refill the bathrooms with washcloths, and sweep and mop the floors;-Housekeeping should sweep and mop under the residents' beds;-Staff should report to maintenance of any damage to walls. During an interview on 08/21/25, at 1:56 P.M., Registered Nurse (RN) EE said the following: -Staff should check under residents' beds daily for debris and items;-He/she had complaints of odors and sticky floors in the residents' rooms. He/she did not know what housekeeping mopped with but there were several rooms with had sticky floors. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said the following:-A housekeeper was on every hall every day;-Housekeeping staff sweep, mop, and disinfectant the sink and toilet every day;-Housekeeping staff should clean under residents’ beds.-He/she walked the halls when he/she arrives on shift and made a list of resident rooms with a stronger odor. He/she informs the charge nurse if it is a task outside of his/her department such as incontinent care. During an observation and interview on 08/22/25, at 3:15 P.M., the Maintenance Supervisor said the following: -He/she audited every room to determine what repairs are needed;-Staff should report any damage to him/her and write in the maintenance logbook. During an interview on 08/25/25, at 12:29 P.M., the Administrator said the following:-Housekeeping should make sure rooms with odors are clean;-Any person in the building including staff and visitors can inform staff of odors;-The facility did not have a policy for repairs. Staff, family members, vendors or anyone can inform facility staff of a repair that needs addressed. The maintenance logbook is available 24 hours seven days a week for any staff member. Maintenance staff reviews the logbook and implements;-Staff should report any repairs needed and write it in the maintenance log;-The water should be hot for staff to mop the floors. Housekeeping should check the floors and re-mop if the floor are sticky. 11. Multiple observations on 08/18/25, at 10:18 A.M., through 08/20/25, at 10:27 A.M., during survey showed a recliner in the dementia unit's sunroom that contained a dried brown substance on both arm rests, seat, and down the footrest. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said the recliner in the sunroom needed wiped down. During an interview on 08/21/025, at 1:24 P.M., HK DD said the recliner in the sunroom was dirty. During an observation and interview on 08/22/25, at 3:15 P.M., the Maintenance Supervisor said the recliner in the sunroom was ”disgusting.” During an interview on 08/25/25, at 12:29 P.M., the Administrator said the recliner in the sunroom should be clean. 12. Review of Resident #148’s face sheet showed the following:-admission date of 10/13/21;-Diagnosis included anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview and observation on 08/17/25, at 4:30 P.M., of the resident’s room, showed the temperature in the room measured 84.6 degrees Fahrenheit (F). The resident said that it was very warm and without his/her small fan it would be too hot. Observation on 08/17/25, at 5:10 P.M., showed the thermostat in the 200-hallway set at 71 degrees F with the temperature reading 82 degrees F. 13. Observation and interview on 08/17/25, at 5:00 P.M., of Resident #103’s room showed the following: -The resident flushed/red in color and said the following he/she was hot;-The resident said the 300-hall air conditioner unit had been broken for about a month and his/her room gets too warm for comfort;-The facility provided mini-air conditioner units for his/her room, but it does not help much. Observation on 08/17/25, at 5:15 P.M., showed the thermostat outside the resident’s room was set to 71 degrees F, but the temperature read 84 degrees F. Observation on 08/17/25, at 6:17 P.M., showed the resident’s room temperature measured 84.2 degrees F. 14. Observation on 08/19/25, at 3:07 P.M., showed the private family dining room’s temperature measured 84.4 degrees F. 15. Review of the Maintenance Director’s weekly temperature logs showed the following:-On 08/08/25, the highest temperature collected for 300 hall was 78 degrees F;-On 08/15/25, the highest temperature obtained for 300 hall was 77 degrees F. 16. During an interview on 08/22/25, at 2:22 P.M., the DON said the following:-She believed by regulation, building temperatures should be kept below 80 degrees F;-The facility bought ten mini-air conditioners and fans for the residents for half of 300 hall to keep them comfortable;-The air conditioner has been restored. During an interview on 08/25/25, at 12:30 P.M., Administrator said there had been an issue on the 100 hall with the air conditioner but that air conditioner unit had been replaced. The 300 hall had more than one air conditioner and one of the units had been weaker and it had affected a few of the rooms. There was bid out for the air conditioner to be replaced. There was not an air conditioner on the 200-hall broken. No one had shared with her that 200 hall had been hot. She obtained mini-air conditioners for each resident that was in the affected area. She was not aware that any residents were too hot. The air conditioner has been restored. Complaint #1534275, #1534276, #2572207, #2590129, and #2591593

Based on interview and record review, the facility failed to ensure each resident, or resident's representative, received written notice of transfer and/or discharge when the facility failed to have a process in place to routinely provide transfers letters including three sampled residents (Resident #39, #65, and #103) transferred to the hospital. The facility census was 149.Review of the facility policy titled Discharge / Transfer – Involuntary, dated October 2021, showed the following information:- Transfer and discharge included movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not;- If transferred to another health care facility upon order of the physician, a transfer form is completed, and a copy is sent with the resident. 1. Review of Resident #39's face sheet showed an admission date of 11/21/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/03/25, showed the resident was cognitively intact. Review of the resident's medical record showed staff documented the following:-On 07/20/25, at 7:33 P.M., a nurse was called to resident's room for a fall out of bed. The resident was observed laying on his/her left shoulder with both legs wrapped in the sheets up on the side of bed. Blood was observed on the floor from a wound to left temple distal hair line. Staff lowered legs to floor and injury to lower extremity noted. No injuries noted to upper extremities at this time. Resident removed from floor to bed via sheet lift. Wound to head is slightly raised. Staff cleaned area. Resident stated he/she had a slight headache and neck pain, but no different than his/her normal chronic headaches. The resident stated his/her head hurts on the left side slightly from hitting on the neighbor's bed; -On 07/20/25, at 7:35 P.M., staff called emergency medical services (EMS) for transport. Staff called emergency contact and informed of resident being sent to hospital. Review of the facility provided, Bed Hold Acknowledgement, showed the resident and a facility representative signed the form on 07/21/25 for resident hospitalization starting on 07/20/25. Review of the resident's medical record showed staff did not have a copy or documentation of a hospital transfer letter provided. 2. Review of Resident #65's face sheet showed an admission date of 10/10/23. Review of the resident's quarterly MDS, dated [DATE], showed the resident was severally cognitively impaired. Review of the resident's July 2025 Progress Notes showed the following:-On 07/27/25, resident had a change in condition with altered mental status. Blood tests and chest x-ray were ordered by the physician. Resident's family requested the resident be sent to the emergency room;-On 07/27/25, the physician was notified, and the resident was sent to the emergency room for evaluation and treatment. Review of the resident's medical record showed a Bed Hold Acknowledgement, dated 07/27/25, which was signed by the facility staff, had the resident's name written on it, and staff noted the resident's family was being notified by telephone. Review of the resident's medical record showed staff did not have a copy or documentation of a hospital transfer letter provided. 3. Review of Resident #103 face sheet showed an admission date of 09/29/23. Review of the resident's comprehensive MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's medical record showed an SBAR Communication Form, dated 08/10/25, and showed the following information:-The resident was experiencing altered level of consciousness;-The resident was experiencing increased weakness;-The resident was unresponsive;-The resident's oxygen saturation was 60 %, with a normal range of 95 %-100 %;-Staff notified the primary physician at 8:15 P.M., who gave orders to send the resident to the hospital;-Staff notified the resident's next of kin. Review of the resident's medical record showed a Bed Hold Acknowledgement, dated 08/10/25, which was signed by the facility staff, with the resident's name written, and with verbal written beside it. Review of the resident's medical record did not show a hospital transfer letter. Review of the resident's medical record showed staff did not have a copy or documentation of a hospital transfer letter provided. 4. During an interview on 08/22/25, at 12:40 P.M., Registered Nurse (RN) C said he/she was not aware of sending a hospital transfer letter to the resident or resident's family. During an interview on 08/22/25, at 1:10 P.M., the Social Services Director (SSD) said when residents were sent to the hospital, he/she would notify the ombudsman at the beginning of every month. He/she was not aware of a transfer letter sent to residents or resident representatives related to the transfer. During an interview on 08/25/25, at 11:20 A.M., the Director of Nursing (DON) said she was not aware of a transfer letter mailed to resident representative. During an interview on 08/25/25, at 12:30 P.M., the Administrator said she was not aware of any information sent related to hospital transfer letter.

Based on observation, interview, and record review, the facility failed to provide activity programs to meet the needs of all residents when staff failed to provide activities as scheduled on the Special Care Unit (SCU); when staff failed to document routinely offering or completing meaningful activities to with three residents (Resident #13, #17, and #123); and when staff failed to provide preferred independent activities for one resident (Resident #123). The facility census was 149.Review of the facility policy titled Activities, dated 09/14/23, showed the following:-It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive evaluation, care plan, and preferences. Facility sponsored group, individual, and dependent activities will be designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the facility;-Activities may be conducted in several ways including one-on-one programs; person appropriate; activities relevant to the specific needs, interests, culture, background and program of activities; and include a combination of large and small groups, 1:1, and self-directed as the resident desires to attend. 1. Observations during the survey showed staff provided an activities calendar for the SCU on a large board outside of the dining room. Review of the August 2025 Activity Calendar showed a music activity scheduled for 08/18/25 at 3:00 P.M. Observation on 08/18/25, at 3:05 P.M. and 3:13 P.M., showed no activities were observed on the unit at that time. Review of the August 2025 Activity Calendar showed an activity scheduled for 08/21/25, at 2:00 P.M., for a craft activity. Observation on 08/21/25, at 2:02 P.M., showed no activities offered at that time. 2. Review of Resident #13's face sheet showed the following:-admission date of 06/27/25;-Diagnoses included hypertension, and bilateral primary osteoarthritis of knee. Review of the resident's initial review of activities, dated 07/08/25, showed the following:-The resident refused to answer his/her activities/interests/hobbies;-Current activity participation unknown. Review of the resident's admission Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 07/10/25, showed the following:-Severely impaired cognitive skills-No rejection of care;-Not important at all for activities. Review of the resident's current care plan, undated, showed the following:-The resident required assistance for meeting emotional, intellectual, physical, and social needs;-One-on-one bedside/in-room visits and activities if unable to attend out of room events;-Invite to scheduled activities. Review of the resident's August 2025 Participation Record showed on 08/08/25 through 08/13/25, 08/15/25, 08/18/25, and 08/20/25, staff did not document attendance at or offering of a group, independent, or one-on-one activity. 3. Review of Resident #17's face sheet showed the following:-admission date of 10/25/23;-Diagnoses included cognitive communication deficit, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's admission MDS assessment, dated 11/06/23, showed the following:-The resident has severely impaired cognitive skills;-No behaviors;-The resident prefers listening to music and participating in favorite activities. Review of the resident's care plan, revised 08/14/25, showed the following:-The resident required assistance for meeting emotional, intellectual, physical and social needs related to cognitive deficits;-Assist/escort the resident to activity functions;-Invite the resident to scheduled activities;-Preferred activities are music programs, coffee socials, arts and crafts and cardio drumming. Review of the resident's quarterly activities participation review, dated 08/19/25, showed the following:-Staff to provide clear verbal reminders and assist the resident to the location of activities;The resident generally enjoys singing during sing along and musical groups;-The resident enjoys groups with snacks, ice cream, coffee and social time. Review of the resident's activity participation record showed on 08/01/25 through 08/10/25, 08/15/25 through 08/17/25, and 08/19/25 staff did not document attendance at or offering of a group, independent, or one-on-one activity. 4. Review Resident #123’s face sheet showed the following:-admission date of 08/30/19;-Diagnoses included muscle weakness, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), and congestive heart failure (CHF – condition in which the heart can't pump enough blood to the body's other organs). Review of the resident’s care plan, updated 07/25/26, showed the following:-Resident enjoyed activities such as creative being on his/her computer, having friends over, listening to music and watching movies;-Staff should ensure that the activities the resident attended were compatible with physical and mental capabilities;-Staff should establish and record resident’s level of activity involvement and interests;-Staff should thank resident for attendance at activity function. Review of the Activities Quarterly Participation Review, dated 04/30/25, showed the following:-Resident preferred independent activities;-Resident’s favorite activities included playing on the computer and talking on the phone. Review of the facility provided Activity Participation Form, dated August 2025, showed staff did not document any information. During an interview on 08/18/25, at 10:15 A.M., the resident said he/she did not see activity staff for one-to-one visits. He/she said that it would be nice if he/she could get library books at times and even get a library card so he/she could check out books online. He/she said that it would be nice if the staff would tell him/her what was available to residents. During an interview on 08/25/25, at 9:10 A.M., Activities Certified Nurse Aide (CNA) F said that he/she visited with residents in their room and asked if need anything and if doing okay. The conversation only lasted about five minutes. There was a log that activities staff document activities attendance including one-to-one visits. He/she opened a 3-ring binder and turned to the resident’s sheet. There was no documentation of visits for the month of August. He/she said he/she forgot to document the dates he/she talked to the resident. 5. During an interview on 08/21/25, at 1:56 P.M., Registered Nurse (RN) EE said the following: -Staff try to do activities on the SCU, but it is difficult because the residents have attention spans like children;-Activity staff have coffee and conversation, movies, and balloon toss;-He/she did not see any one-on-one activities on the unit;-He/she thinks there should be more activities on the SCU; During an interview on 08/22/25, at 8:21 A.M., the Activity Director said the following:-He/she worked at the facility for three weeks;-Activity staff asked the resident's interests upon admission;-Activity staff asked the residents of group and one on one interests;-Activity staff should document activity attendance in the logbook for each hall;-Activity staff should document activity progress notes for residents;-Activity staff did not document on activities other than the activity assessment;-He/she needed to educate the activity staff to document one-on-one activities;-He/she expected activity staff to document one-on-one activities;-The activity program was for quality of life for residents and having something for them to participate in. During an interview on 08/22/25, at 8:40 A.M., Certified Nurse Aide (CNA) FF said staff did not instruct him/her to provide any one-on-one activities with the residents on the dementia unit. During an interview on 08/22/25, at 8:42 A.M., Certified Medication Technician (CMT) G said he/she did not observe any one-on-one activities with the residents on the dementia unit. The residents ambulate up and down the halls. During an interview on 08/22/25, at 9:00 A.M., Activity Staff GG said the following:-Activity staff complete an activity assessment with the residents;-Activity staff ask what the resident likes to do in their spare time;-Activity staff ask the resident of hobbies, if they like to read;-Activity staff document on the activity assessment and give it to the director who enters the information in the computer;-The care plan coordinator develops the care plan;-Activity staff talk with the residents and family members who reside on the dementia unit to determine interests;-It is more difficult for one-on-one activity on the dementia unit due to the residents change every five minutes and some did not converse. During an interview on 08/25/25, at 10:40 A.M., the Director of Nursing (DON) said she expected one-on-one activities on the dementia unit and for staff to document activities provided to residents. During an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected staff to provide one-on-one and group activities on the SCU. Activities should be provided to all residents, even residents not attending in the activity room. Complaint 1534276

Based on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to document administration or refusal of medications on the Medication Administration Record (MAR) for two residents (Resident #169 and #200) and when staff failed to follow-up with a provider when one resident (Resident #141) went to an outside appointment and received an order for a medication. The facility census was 149. Review of the facility policy titled “ Medication Administration – General Guidelines,” dated December 2017, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; 1. Review of Resident #169's face sheet showed the following:-admission date of 06/10/25;-Diagnoses included acute kidney failure, cognitive communication deficit, Type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood) with hyperglycemia (high blood sugar levels) and pressure ulcer. Review of the resident's Nursing admission Evaluation and Baseline Care Plan dated 06/10/25, at 3:43 P.M., showed Licensed Practical Nurse (LPN) A/Unit Manager documented the following:-The resident admitted from the hospital;-Current medication list provided to the resident and representative;-Physician orders: see current MAR and TAR orders. Review of the resident's June 2025 POS showed an order, dated 06/10/25, with a start date of 06/11/25, for apixaban (Eliquis-anticoagulant-blood thinner) tablet 5 milligrams (mg), give one tablet by mouth two times a day for anticoagulant. Review of the resident’s June 2025 Medication Administrator Record (MAR) showed the following:-On 06/14/25, at 8:00 A.M. and 4:00 P.M., staff did not document administration of the Eliquis on the MAR;-On 06/15/25, at 08:00 A.M. and 04:00 P.M., staff did not document administration of the Eliquis on the MAR;-On 06/16/25, at 08:00 A.M. and 04:00 P.M. staff did not document administration of the Eliquis on the MAR. Review of the resident's June 2025 POS showed an order, dated 06/10/25, for mirtazapine (treats depression) tablet 15 mg, for staff to give by mouth at bedtime for depression. Review of the facility's June 2025 MAR showed the following:-On 06/14/25, at 8:00 P.M., staff did not document administration of the mirtazapine tablet on the MAR;-On 06/15/25, at 8:00 P.M., staff did not document administration of the mirtazapine tablet on the MAR;-On 06/16/25, at 8:00 P.M., staff did not document administration of the mirtazapine tablet on the MAR. Review of the resident's June 2025 POS showed an order, dated 06/10/25, for oxycodone (treats moderate to severe pain) HCL oral tablet 5 mg, give one tablet by mouth every four hours as need for moderate to severe pain for five days. Review of the facility's Medication Machine Report and June 2025 MAR showed the following:-On 06/14/25, at 10:58 P.M. the machine dispensed oxycodone 5 mg tablet two times;-On 06/14/25, staff did not document administration of the oxycodone on the MAR;-On 06/15/25 at 7:21 P.M., the machine dispensed oxycodone 5 mg tablet two times;-On 06/15/25, staff did not document administration of the oxycodone on the MAR. Review of the resident's June 2025 POS showed an order, dated 06/10/25, start date of 06/11/25, for pantoprazole sodium (treats gastroesophageal reflux disease) tablet delayed release 40 mg, give 40 mg by mouth two times a day for gastrointestinal (GI). Review of the facility's June 2025 MAR showed the following:-On 06/14/25 at 8:00 A.M. and 4:00 P.M., staff did not document administration of the pantoprazole sodium tablet;On 06/15/25, at 8:00 A.M. and 4:00 P.M., staff did not document administration of the pantoprazole sodium tablet;-On 06/16/25, at 8:00 A.M. and 4:00 P.M., staff did not document administration of the pantoprazole sodium tablet. Review of the resident's June 2025 POS showed an order, dated 06/10/25, start date of 06/11/25, for potassium chloride (treats low levels of potassium in your body) ER tablet extended release 10 milliequivalent (meq), give one tablet by mouth one time a day for supplement. Review of the resident’s June 2025 MAR showed the following:-On 06/14/25, at 8:00 A.M., staff did not document administration of the potassium chloride ER tablet on the MAR;-On 06/15/25, at 8:00 A.M., staff did not document administration of the potassium chloride ER tablet on the MAR;-On 06/16/25, at 08:00 A.M., staff did not document administration of the potassium chloride ER tablet on the MAR. Review of the resident's June 2025 POS showed an order, dated 06/10/25, for tizanidine (treats muscle spasms) HCL tablet two mg, one tablet by mouth every eight hours for muscle relaxant. Review of the resident’s June 2025 MAR showed the following:-On 06/14/25, at 6:00 A.M., 2:00 P.M., and 10:00 P.M., staff did not document administration of the tizanidine on the MAR;-On 06/15/25, at 6:00 A.M., 2:00 P.M., and 10:00 P.M., staff did not document administration of the tizanidine tablet on the MAR;-On 06/16/25, at 6:00 A.M., 2:00 P.M., and 10:00 P.M., staff did not document administration of the tizanidine tablet on the MAR. During interviews on 08/22/25, at 10:02 A.M and 3:00 P.M., and on 08/25/25, at 10:11 A.M., Licensed Practical Nurse (LPN) A/Unit Manager said the following: -Staff should document if the resident refused medications;-He/she was not sure what happened with the resident' medications not documented on the MAR. -Resident was noncompliant with care;-Staff should had notified the physician if the resident refused cares;-The resident refused his/her medications;-Staff should document if a resident refuses medications. During interviews on 08/22/25, at 3:50 P.M., and on 08/25/25, at 11:20 A.M., the MDS Coordinator said the following:-Staff did not administer the resident's morning medications on 06/14/25 due to the resident was not in the building;-On 06/15/25, the resident was in the facility and staff administered the medications;-Staff sent the resident out for an evaluation on 06/16/25;-Staff should document on the MAR of medications to show the medication was given. During an interview on 08/24/25, at 7:20 P.M., Registered Nurse (RN) X said the following:-Staff should document if the resident refused his/her medications;-He/she did not remember the issue with staff not documenting the resident's medications on the MAR for 06/14/25 through 06/16/25. During an interview on 08/25/25, at 10:40 A.M., the Director of Nursing (DON) said she did not know what happened with the resident's medication dropping of the MAR. 2. Review of Resident #141's face sheet showed the following:-admission date of 04/26/24;-Diagnosis of type 2 diabetes (body does not use insulin effectively and morbid obesity (excessive weight). Review of the resident's quarterly Minimum Data Set, dated [DATE], showed the following:-Resident was cognitively intact;-No noted skin issues. Review of the resident's care plan, updated 01/17/25, showed the following:- Staff will complete skin observations weekly and as needed. Report changes in skin integrity to the nurse;-Administer medications as ordered;-Resident has diabetes. Check all body for breaks in skin and treat promptly. Review of the resident's July 2025 POS showed the following:-An order, dated 09/04/24, for Elocon cream (topical corticosteroid used to treat inflammation), every 24 hours as needed for rash, eczema (chronic skin condition characterized by itchy, inflamed red skin);-An appointment, on 07/30/25, with the dermatologist. Review of the resident’s progress note, dated 08/04/25, showed the following:-Review of the resident’s systems, noting on dermatological, skin rash due to psoriasis;-Physical exam psoriasis, an order as needed for Elocon cream, daily, recent appointment with dermatology; note not available. No new orders. During an interview and observation on 08/17/25, at 5:01 P.M., the resident said he/she saw the dermatologist on 07/30/25. He/she said they sent in a prescription for a diagnosis of psoriasis (inflamed patches of skin with silvery scales). The facility had not applied the cream, and he/she did not believe they had the cream. He/she had told a nurse, and he/she didn’t know if they followed up with the clinic. The spots are uncomfortable and itch. The resident had multiple large, and small red raised spots on his/her arms. The Resident also has multiple spots on his/her legs of a darker color. He/she reported asking several staff to look into the prescription. Review of the resident’s August 2025 POS showed an order, dated 08/22/25, for Triamcinolone Acetonide externa cream 0.1% (used to treat various inflammatory skin conditions including psoriasis). During an interview on 08/22/25, at 11:35 A.M., Certified Medication Technician (CMT) A said the following;-He/she does nothing with the orders. The nurses put new orders into the resident’s electronic record;-He/she did not apply cream to residents, that was the nurses’ job;-He/she has seen spots on the resident. During an interview on 08/22/25, at 12:22 P.M., LPN B said the following:-If a resident brings a prescription back from an outside provider, he/she gets it clarified with the facility doctor. Once it’s cleared, he/she would put the order into the electronic record, and it shows on the MAR;-He/she didn’t recall the resident bringing a prescription back from the dermatologist;-The resident did bring it to his/her attention that he/she had been prescribed a medication, and the resident was going to call the dermatologist to follow up. The resident did call and told him/her that a prescription had been sent into the pharmacy;-He/she called the dermatology clinic a couple of times, but didn’t get through. He/she didn’t recall when that was, and he/she didn’t document that in the resident’s progress notes;-If it was sent to the pharmacy, it should have been delivered to the facility. He/she did not follow up with the pharmacy;-He/she did text the resident transport driver and the driver said he/she didn’t know if the resident had a prescription;-He/she said the calls to the dermatologist clinic and the pharmacy should have been documented. During an interview on 08/22/25, at 2:02 P.M., LPN A/Unit manager said the following:-Nurses are responsible for putting in new orders;-If the resident comes back from an outside appointment, the nurse should be following up with the provider, especially if the resident did not bring back paperwork;-He/she was not aware of the resident going to the dermatologist, or getting a prescription for a cream;-He/she would expect the nurse to follow up with the provider to see which prescription was ordered and the pharmacy until they have obtained the prescription. During an interview on 08/22/25, at 2:22 P.M., DON said the following:-If a resident does not bring back paperwork from an outside appointment, the nurse should be following up with the provider to see what was done for the resident;-If the resident was ordered a medication, the nurse should call the outside clinic to see what was ordered, and the pharmacy if needed to ensure the medication is there and follow up until it’s delivered to the facility. During an interview on 08/25/25, at 10:37 A.M., the resident’s physician said the following:-He/she would expect staff to let him/her know if there is an outside order from another provider;-If the resident did not provide paperwork after an appointment, he/she would expect the nurse to follow up with the provider for direction, and to see if there were new orders. During an interview on 08/25/25, at 12:30 P.M., the Administrator said staff should follow up with the provider if a resident does not bring paperwork back from the appointment. Staff should see if a medication was prescribed and follow up to get the medication. 3. Review of Resident 200’s face sheet showed the following information:-admission date of 08/06/25;-Diagnosis included acute post-hemorrhagic anemia (type of anemia (condition characterized by a low level of red blood cells or hemoglobin in the blood) that develops rapidly after a significant and acute loss of blood, such as from an injury, surgery, or internal bleeding, leading to a reduced ability to deliver oxygen to tissues), type 2 diabetes mellitus with hyperglycemia (chronic condition where the body doesn't use insulin effectively (insulin resistance) and/or doesn't produce enough of it, leading to consistently high blood sugar (hyperglycemia) levels), malignant neoplasm (cancer) of the colon (large intestines), and paroxysmal atrial fibrillation (type of irregular heartbeat that occurs in short, intermittent episodes). Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/06/25, for apixaban oral tablet 5 mg (blood thinner medication), give 1 tablet by mouth two times a day for atrial fibrillation. Review of the resident’s August 2025 MAR showed the following:-On 08/06/25, at 8:00 P.M., staff documented apixaban 5 mg as received; -On 08/07/25, at 8:00 A.M. and 8:00 P.M., staff documented apixaban 5 mg as administered;-On 08/08/25, at 8:00 A.M., staff did not document if medication was given or not given;-On 08/08/25, at 8:00 P.M., staff documented apixaban 5 mg as administered;-On 08/09/25 through 08/11/25, staff did not document if medication was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/06/25, for glipizide oral tablet 10 mg (used to manage blood sugar levels), give 1 tablet by mouth two times a day for diabetes mellitus. Review of the August 2025 MAR showed the following:-On 08/06/25, at 5:00 P.M., staff did not document if glipizide was given or not given;-On 08/07/25, at 8:00 A.M. and 5:00 P.M., staff documented the glipizide 20 mg as administered;-On 08/08/25 through 08/11/25, staff did not document if the glipizide was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/06/25, for pantoprazole sodium oral tablet delayed release 40 mg (used to treat and manage conditions caused by excessive stomach acid), give 1 tablet by mouth two times a day for gastroesophageal reflux disease (GERD – type of acid reflux). Review of the resident’s August 2025 MAR showed the following:-On 08/06/25, at 5:00 P.M., staff did not document if the pantoprazole was given or not given;-On 08/07/25, at 5:00 A.M. and 5:00 P.M., staff documented the pantoprazole as administered;-On 08/08/25, at 5:00 A.M., staff documented the resident as out of the facility;-On 08/08/25, at 5:00 P.M., staff did not document if the pantoprazole was given or not given;-On 08/09/25, at 5:00 A.M., staff documented the pantoprazole as administered;-On 08/09/25, at 5:00 P.M., through 08/11/25, staff did not document if the pantoprazole was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/06/25, for gabapentin oral capsule 100 mg (used to treat seizures and nerve pain), give 1 capsule by mouth three times a day for nerve pain. Review of the resident’s August 2025 MAR showed the following:-On 08/06/25, at 6:00 P.M., staff did not document if the gabapentin was given or not given;-On 08/07/25, at 7:00 A.M., 12:00 P.M. and 6:00 P.M., staff documented the gabapentin 100 mg was administered;-On 08/08/25 through 08/11/25, staff did not document if the gabapentin was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/07/25, for aspirin 81 mg, give one tablet by mouth one time daily for coronary artery disease. Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented aspirin 81mg as administered;-On 08/08/25 through 08/11/25, staff did not document if the aspirin was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/07/25, for bupropion extended-release tablet 150 mg (used to treat depression), give 1 tablet by mouth one time a day for depression. Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented bupropion 150 mg as administered;-On 08/08/25 through 08/11/25, staff did not document if the bupropion was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/07/25, for duloxetine capsule delayed release 30 mg (used to treat depression, anxiety, and some chronic pain), give 1 capsule by mouth one time a day for depression. Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented the resident received the duloxetine;-On 08/08/25 through 08/11/25, staff did not document if the duloxetine was given or not given. Review of the resident’s POS, current as of 08/11/25, showed an order, dated 08/07/25, for ferrous sulfate oral tablet 325 mg (form of mineral iron used to treat and prevent anemia), give 1 tablet by mouth one time a day for anemia. Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented the resident received the ferrous sulfate;-On 08/08/25 through 08/11/25, staff did not document if the ferrous sulfate was given or not given. Review of the resident’s POS, current as of 08/11/25, an order, dated 08/07/25, for metoprolol extended-release tablet 25 mg (used to treat high blood pressure, chest pain, and heart failure), give one-half tablet by mouth one time a day for hypertension (high blood pressure). Hold if systolic blood pressure (first/top number of blood pressure) measured 100 millimeters of Mercury (mm/Hg) or less and notify physician if held for three consecutive doses. Review of the resident’s August 2025 MAR showed the following:-On 08/07/25, at 8:00 A.M., staff documented the resident received he metoprolol with a blood pressure reading of 143/64 mm/Hg;-On 08/08/25 through 08/11/25, staff did not document if the metoprolol was given or not given. 4. During an interview on 08/25/25, at 9:15 A.M., Certified Medication Tech (CMT) AA said staff should document on the MAR any administered medications. During an interview on 08/22/25, at 10:00 A.M., CMT D said staff should be documenting medications as administered or not administered with the reason. There should not be blank areas on the MAR. During an interview on 08/22/25, at 12:30 P.M., CMT A said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR. During an interview on 08/22/25, at 12:40 P.M., RN C said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR. During an interview on 08/25/25, at 11:20 A.M., Director of Nursing (DON) said staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR. If was not documented it was not done. During an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected staff to administer resident's medications as ordered and document on the MAR. Staff should be documenting medication as administered or not administered with the reason. There should not be blank areas on the MAR. Complaints number #1534273, #1534275, #2572207, and #2585250

Based on observation, record review, and interview, the facility failed to ensure residents were free of medication errors greater than 5% when the staff failed to administer the correct medication dose for two residents (Resident #109 and #97), when staff administered the wrong medication for one resident (Resident #38), and when staff failed to prime insulin pens prior to administration for two residents (Resident #23 and #132). This resulted in 5 medication errors out of 25 observations opportunities resulting in an error rate of 20%. The facility census was 149.1. Review of the facility policy titled “Medication Administration – General Guidelines,” dated December 2017, showed the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-The five rights of medication administration were the right resident, right drug, right dose, right route, and right time. These are applied for each medication being administered. A triple check of these rights is recommended;-Prior to administration of any medication, the medication and dosage schedule on the resident's Medication Administration Record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.-If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit;-Medications are administered in accordance with written orders of the prescriber. 2. Review of Resident #109’s face sheet showed the following:-admission date of 01/07/25;-Diagnoses included adult failure to thrive (condition characterized by a significant decline in weight, muscle mass, and overall health and function in adults). Review of the resident’s quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 08/01/25, showed the resident had severe cognitive impairment. Review of the resident’s Physician Order Sheet (POS), current as of 08/25/25, showed an order, dated 01/07/25, for folic acid (man-made B vitamin, also known as folate or vitamin B9, that is essential for cell growth, red blood cell formation, and proper brain health) 1 milligram (mg), give 1 tablet by mouth one time daily for supplement. During observation on 08/21/25, at 9:20 A.M., Certified Medication Techn (CMT) D prepared and administered folic acid 800 micrograms (mcg) one tablet to the resident. During an interview on 08/22/25, at 9:15 A.M., CMT A if a resident’s order was written for folic acid 1 mg the staff should not administer 800 mcg. He/she said that staff should get clarification from the physician and ask central supply staff to order the 1 mg if not available in the facility. During an interview on 08/22/25, at 10:00 A.M., CMT D said the order for folic acid 1 mg should have been given as 1 mg. It should not have been given as 800 mcg. Currently the 1 mg dose was not available. He/she had placed an order for the 1 mg dose. He/she said the nurse had contacted the doctor about the 800 mcg dose being available, but did not know the response. He/she said the folic acid dose should have been held until received clarification if could give the 800 mcg that was available. 3. Review of Resident #38’s face sheet showed the following information:-admission date of 07/28/23;-Diagnoses include diabetes, vitamin d deficiency, high blood pressure, and muscle weakness. Review of the resident’s comprehensive MDS, dated [DATE], showed intact cognition. Review of the resident’s care plan, dated 08/04/25 showed the following:-Give medications as ordered;-Monitor and record medication side effects and notify physician as needed. Review of the resident’s August 2025 POS showed an order, dated 07/28/25, for ferrous sulfate (also known as iron with a higher concentration of elemental iron per dose compared to ferrous gluconate; used to treat iron deficiencies) 325 mg, give one tablet daily. Observation on 08/20/25, at 11:53 A.M., showed Registered Nurse (RN) O obtained one tablet of ferrous gluconate (also known as iron, used to treat iron deficiencies.) 27 mg from its bottle in the top of 300 hall’s medication cart. The RN then then administered it to the resident. During an interview on 08/22/25, at 10:30 P.M., RN C said staff should not give ferrous gluconate 27 mg if order is ferrous sulfate 325 mg. 4. Review of Resident #97’s face sheet showed the following information:-admission date of 10/02/24;-Diagnoses included kidney failure, weakness, and iron deficiency. Review of the resident’s quarterly MDS assessment, dated 08/01/25, showed the resident had moderate cognitive impairment. Review of the resident’s care plan, dated 10/18/24, showed staff to administer medications as ordered. Staff to monitor for and document side effects and effectiveness. Review of the resident’s August 2025 POS showed an order, dated 03/08/25, for folic acid 400 mcg one time a day. Observation on 08/20/25, at 10:46 A.M., showed RN O obtained one tablet of folic acid 800 mcg from its bottle in the top of 300 hall’s medication cart. The RN then administered the tablet to the resident. 5. During an interview on 08/22/25, at 9:15 A.M., CMT A said staff should follow physician orders for medication administration and should follow the five rights of medication administration, including the right dose. During an interview on 08/22/25, at 10:00 A.M., CMT D said staff should give medications and doses as ordered by the physician. During an interview on 08/22/25, at 10:50 A.M., Director of Nursing (DON) said staff should provide medications as ordered. Staff should provide folic acid in the dose ordered. If there was an order for 1 mg staff should not provide 800 mcg and if there was an order for 400 mcg staff should not give as 800 mcg. Staff should not administer ferrous gluconate if the order was for ferrous sulfate. Staff should notify central supply and the correct items can be ordered if they are out of any over-the-counter supplements. During an interview on 08/22/25, at 11:10 A.M., the Administrator said staff should follow physician orders for administering medications. Staff should not administer the incorrect dose or the incorrect medications. If the order was for Folic acid 1 mg or Folic acid 400 mcg, staff should provide as ordered. Staff should not give ferrous gluconate if the order was for ferrous sulfate. 6. Review of the facility policy titled “Injectable Medication Administration,” dated August 2018, showed prime pen needle per manufacturer guidelines. Review of Lilly manufacturer instructions titled “Humalog (insulin lispro – rapid actin insulin) KwikPen – Instructions for Use,” dated March 2020, showed the following:- KwikPen™ is a disposable prefilled pen containing 300 units of insulin;-Multiple doses are in one pen;-Prime the pen before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If you do not prime before each injection, you may get too much or too little insulin. 7. Review of Resident #23’s face sheet showed the following:-admission date of 08/09/24;-Diagnoses included Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) with diabetic polyneuropathy (complication of diabetes that damages the nerves, causing various symptoms and health problems) and hyperglycemia (high blood sugar levels). Review of the resident’s quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Used of insulin seven days of the prior seven days. Review of the resident’s care plan, updated 07/21/25, showed the following:-Resident had diabetes mellitus;-He/she was prescribed hyperglycemic medication;-Staff administer diabetes medication as ordered by doctor;-Staff should monitor/document for side effects and effectiveness. Review of the resident’s POS, current as of 08/25/25, showed the following:--An order, dated 01/25/25, for Humalog injection solution 100 unit/milliliter (ml), inject 12 unit subcutaneously (applied under the skin) with meals for diabetes mellitus in addition to sliding scale;-An order, dated 01/28/25, for Humalog injection solution 100 unit/ml, inject as per sliding scale (diabetes management method that involves administering a dose of fast-acting insulin based on a person's current blood glucose reading) as follows:-If blood sugar measures 0 to 119 mg/deciliter (dL), then administer no inulin;-If blood sugar measures 120 mg/dL to 160 mg/dL, then administer 3 units of insulin;-If blood sugar measures 161 mg/dL to 200 mg/dL, then administer 5 units of insulin;-If blood sugar measures 201 mg/dL to 240 mg/dL, then administer 8 units of insulin;-If blood sugar measures 241 mg/dL to 280 mg/dL, then administer 12 units of insulin;-If blood sugar measures 281 mg/dL to 320 mg/dL, then administer 16 units of insulin;-If blood sugar measures 321 mg/dL or more, then administer 20 units of insulin and notify physician if blood sugar is 400 mg/dL or greater. Observation and interview on 08/21/25, at 9:30 A.M., showed the following:-RN C prepared medications for the resident at the nurse’s cart near the resident room;-The resident’s blood glucose reading was 225 mg/dL;-He/she prepared the Humalog KwikPen by removing the top cap, wiped with the rubber stopper with an alcohol wipe, applied the needle, turned the dial to 21 and the returned to 20 units. The nurse did not prime the pen;-The nurse said that he/she did not prime the Humalog pen due to it not being a new pen and the medication would already be at the top of the syringe. He/she said only brand-new pens were primed and if they were not primed the resident may not receive the correct dose;-The nurse entered the resident’s room and wiped the resident’s abdomen with an alcohol wipe and administered Humalog. 8. Review of Resident #132’s face sheet showed the following information:-admission date of 08/30/24;-Diagnoses include diabetes. Review of the resident’s quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident’s care plan, dated 09/17/24, showed staff to administer medications as order and monitor for side effects and effectiveness. Review of the resident’s August 2025 POS showed the following orders:-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject 7 units subcutaneously with meals, in addition to the sliding scale;-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject as per sliding scale that follows:-If blood sugar is 0 mg/dL to 119 mg/dL, then do not administer insulin;-If blood sugar is 120 mg/dL to 160 mg/dL, then administer two units of insulin;-If blood sugar is 161 mg/dL to 200 mg/dL, then administer four units of insulin;-If blood sugar is 201 mg/dL to 240 mg/dL, then administer six units of insulin;-If blood sugar is 241 mg/dL to 280 mg/dL, then administer eight units of insulin;-If blood sugar is 281 mg/dL to 320 mg/dL, then administer 11 units of insulin;-If blood sugar is 321 mg/dL or greater, then administer 15 units of insulin and notify the physician if blood sugar is over 400 mg/dL. Observation on 08/20/25, at 12:24 P.M., showed RN O obtain the resident’s blood sugar at 148 mg/dL. RN O performed hand hygiene, donned gloves, obtained Humalog and drew up nine units of insulin and administered the insulin to the resident. RN O did not prime the needle prior to administering the insulin. 9. During an interview on 08/20/25, at 12:50 P.M., RN O said the following:-Staff do not prime insulin pens;-The insulin pens have plungers in them, so there is no need to prime the pen;-If there are bubbles seen in the pen, staff should just watch how they position the pen while administering the insulin;-Even if the resident does get a little bit of air injected, it won't hurt them. During an interview on 08/22/25, at 10:30 P.M., RN C said he/she was not aware that insulin pens required primed with each use. He/she thought it was just with new pens. During an interview on 08/22/25, at 10:50 A.M., the DON said all insulin pens are required to be primed each time before insulin is administered. Insulin pens should be primed before each use, every pen, every time. This is manufacturer guidelines. The dose would not be correctly administered if not primed. During an interview on 08/22/25, at 11:10 A.M., the Administrator said all insulin pens require priming each time. During an interview on 08/22/25, at 11:20 A.M., Corporate Nurse Consultant said that staff should always prime insulin pens with each use. Complaint #1534275, #2585250

Based on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors when staff failed to document administration of insulin to two residents (Resident #5 and #65) and when staff failed to prime insulin pens prior to administration for two residents (Resident #23 and #132). The facility census was 149. Review of the facility policy titled “Medication Administration – General Guidelines,” dated December 2017, showed the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-The five rights of medication administration were the right resident, right drug, right dose, right route, and right time. These are applied for each medication being administered. A triple check of these rights is recommended;- The medication administration record (MAR) is always employed during medication administration.-Medications are administered in accordance with written orders of the prescriber. Review of the facility policy titled “Injectable Medication Administration,” dated August 2018, showed the following:-Check order on the medication administration record to see that an injection is currently ordered and due;-Prime pen needle per manufacturer guidelines;-Check five rights again after dose is prepared and before medication is put away and injection administered. 1.Review of Resident #5's face sheet (resident's information at a quick glance) showed the following:-admission date of 04/20/24;Diagnoses included Type 2 diabetes (body can’t use insulin properly resulting in high blood sugar levels). Review of the resident's care plan, updated 07/22/25, showed the resident had diabetes mellitus. Staff to administer diabetes medication as ordered by the doctor. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 08/20/25, showed the following:-Cognitively intact;-Diagnosis of diabetes. Review of the resident's July 2025 Physician Order Sheet (POS) showed the following:-An order, dated 06/09/25, for admelog soslstar (insulin lispro – rapid acting insulin), subcutaneous (under the skin) solution pen-injector 100 unit/milliliter (ml), inject subcutaneously before meals related to type two diabetes with hyperglycemia as per sliding scale that follows:-If blood sugar level measured 124 milligrams/deciliter (mg/dL) to 150 mg/dL, administer two units of insulin;-If blood sugar level measured 151 mg/dL to 200 mg/dL, administer four units of insulin;-If blood sugar level measured 210 mg/dL to 250 mg/dL, administer six units of insulin;-If blood sugar level measured 251 mg/dL to 300 mg/dL, administer eight units of insulin;-If blood sugar level measured 301 mg/dL to 350 mg/dL, administer 10 units of insulin;-If blood sugar level measured 351 mg/dL to 400 mg/dL, administer 12 units of insulin;-An order, dated 06/13/25, to monitor resident’s blood sugar. Review of the resident’s July 2025 MAR showed the following:-On 07/09/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/09/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/09/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/10/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/10/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/10/25, at 4:;30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/11/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/11/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/11/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/24/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/24/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/24/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/25/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/25/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/25/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/26/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/26/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/28/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/28/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 07/29/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/29/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/29/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered-On 07/31/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 07/31/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered. Review of the resident's August 2025 POS showed the following:-An order, dated 06/09/25, for admelog soslstar, subcutaneous solution pen-injector 100 unit/milliliter (ml), inject subcutaneously before meals related to type two diabetes with hyperglycemia as per sliding scale that follows:-If blood sugar level measured 124 mg/dL to 150 mg/dL, administer two units of insulin;-If blood sugar level measured 151 mg/dL to 200 mg/dL, administer four units of insulin;-If blood sugar level measured 210 mg/dL to 250 mg/dL, administer six units of insulin;-If blood sugar level measured 251 mg/dL to 300 mg/dL, administer eight units of insulin;-If blood sugar level measured 301 mg/dL to 350 mg/dL, administer 10 units of insulin;-If blood sugar level measured 351 mg/dL to 400 mg/dL, administer 12 units of insulin;-An order, dated 06/13/25, to monitor resident’s blood sugar. Review of the resident August 2025 MAR showed the following:-On 08/01/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 08/01/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 08/01/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 08/02/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 08/02/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 08/02/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered;-On 08/03/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 08/03/25, at 11:30 A.M., the blood sugar was not checked, and no insulin administered;-On 08/03/25, at 4:30 P.M., the blood sugar was not checked, and no insulin administered. 2.Review of Resident #65's face sheet showed the following:-admission date of 10/10/23;-Diagnosis included Type 2 diabetes (body can’t use insulin properly resulting in high blood sugar levels. Review of the resident's care plan, last updated 05/13/25, showed resident had diabetes mellitus. Staff to administer diabetes medication as ordered by the doctor. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severally cognitively impaired;-Diagnosis of diabetes. Review of resident's July 2025 POS showed an order, dated 10/31/25, for insulin glargine (long-acting insulin) subcutaneous solution 100 unit/ml, inject 25 units subcutaneously two times a day for diabetes. Review of the resident July 2025 MAR showed the following:-On 07/09/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/10/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/11/25, at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/16/25 at 7:00 P.M., the blood sugar was not checked, and no insulin administered;-On 07/24/25 at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/24/25 at 7:00 P.M., the blood sugar was not checked, and no insulin administered;-On 07/25/25 at 7:00 A.M., the blood sugar was not checked, and no insulin administered;-On 07/26/25 at 7:00 A.M., the blood sugar was not checked, and no insulin administered. 3. During an interview on 08/22/25, at 11:35 A.M., Certified Medication Technician (CMT) A said the following;-He/she knew which medications to administer by looking at the MAR;-The MAR tells staff when to administer or check the blood sugar of a resident;-He/she didn’t do the blood sugar checks or administer insulin, the nurse did it;-If a medication is not administered, it would be a medication error. During an interview on 08/22/25, at 12:22 P.M., Licensed Practical Nurse (LPN B) said the following:-Staff know which medications to administer by looking at the MAR, which is driven by the physicians’ orders;-When the medication is due, or the blood sugar check, it pops up on the MAR and the staff know to complete that medication or check;-He/she didn’t believe it was an administration issue if the MAR was blank because he/she believed all the blood sugar checks were being completed and the insulin was being administered. During an interview on 08/22/25, at 2:02 P.M., LPN A/Unit Manager said the following:-The MARs have the orders for each resident;-He/she would expect staff to administer the medication as ordered;-If the MAR is blank, he/she would have to assume the medication and task was not completed and it would be a medication error;-He/she expected staff to follow the five medication rights. During an interview on 08/25/25. at 9:25 A.M., the Medical Director said the following: -Staff should document a resident's blood sugar and administration of insulin;-He was very particular on insulin orders;-Staff should check blood sugars three to four times a day;-If it is not documented, it was not done;-He considers insulin not administered as a significant medication error. During an interview on 08/22/25, at 2:22 P.M., the Director of Nursing (DON) said the following:-The staff know who is responsible for which medication as they each have a MAR;-The MAR tells staff what medications or task need to be completed at what time;-The electronic medication record (EMR) pops up the task or medication at that time and the staff should mark off if it’s being administered or why if it’s not;-Some staff go through and check blood sugars, writing them down and come back and put them into the computer and administer insulin as needed when they get to the resident;-If the MAR is blank, it could mean the medication or blood sugar check was missed and that would be a medication error. During an interview on 08/25/25, at 12:30 P.M., the Administrator said when residents have an order for insulin, he/she would expect staff to administer the medication as ordered. If checking the blood sugar is required before, they should be checking the blood sugar. Staff should be double checking the MAR to ensure all tasks and medications have been administered. 4. Review of Lilly manufacturer instructions titled “Humalog (insulin lispro – rapid actin insulin) KwikPen – Instructions for Use,” dated March 2020, showed the following:- KwikPen™ is a disposable prefilled pen containing 300 units of insulin;-Multiple doses are in one pen;-Prime the pen before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If you do not prime before each injection, you may get too much or too little insulin. 5. Review of Resident #23’s face sheet showed the following:-admission date of 08/09/24;-Diagnoses included Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) with diabetic polyneuropathy (complication of diabetes that damages the nerves, causing various symptoms and health problems) and hyperglycemia (high blood sugar levels). Review of the resident’s quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Used of insulin seven days of the prior seven days. Review of the resident’s care plan, updated 07/21/25, showed the following:-Resident had diabetes mellitus;-He/she was prescribed hyperglycemic medication;-Staff administer diabetes medication as ordered by doctor;-Staff should monitor/document for side effects and effectiveness. Review of the resident’s POS, current as of 08/25/25, showed the following:--An order, dated 01/25/25, for Humalog injection solution 100 unit/milliliter (ml), inject 12 unit subcutaneously (applied under the skin) with meals for diabetes mellitus in addition to sliding scale;-An order, dated 01/28/25, for Humalog injection solution 100 unit/ml, inject as per sliding scale (diabetes management method that involves administering a dose of fast-acting insulin based on a person's current blood glucose reading) as follows:-If blood sugar measures 0 to 119 mg/deciliter (dL), then administer no inulin;-If blood sugar measures 120 mg/dL to 160 mg/dL, then administer 3 units of insulin;-If blood sugar measures 161 mg/dL to 200 mg/dL, then administer 5 units of insulin;-If blood sugar measures 201 mg/dL to 240 mg/dL, then administer 8 units of insulin;-If blood sugar measures 241 mg/dL to 280 mg/dL, then administer 12 units of insulin;-If blood sugar measures 281 mg/dL to 320 mg/dL, then administer 16 units of insulin;-If blood sugar measures 321 mg/dL or more, then administer 20 units of insulin and notify physician if blood sugar is 400 mg/dL or greater. Observation and interview on 08/21/25, at 9:30 A.M., showed the following:-RN C prepared medications for the resident at the nurse’s cart near the resident room;-The resident’s blood glucose reading was 225 mg/dL;-He/she prepared the Humalog KwikPen by removing the top cap, wiped with the rubber stopper with an alcohol wipe, applied the needle, turned the dial to 21 and the returned to 20 units. The nurse did not prime the pen;-The nurse said that he/she did not prime the Humalog pen due to it not being a new pen and the medication would already be at the top of the syringe. He/she said only brand-new pens were primed and if they were not primed the resident may not receive the correct dose;-The nurse entered the resident’s room and wiped the resident’s abdomen with an alcohol wipe and administered Humalog. 6. Review of Resident #132’s face sheet showed the following information:-admission date of 08/30/24;-Diagnoses include diabetes. Review of the resident’s quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident’s care plan, dated 09/17/24, showed staff to administer medications as order and monitor for side effects and effectiveness. Review of the resident’s August 2025 POS showed the following orders:-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject 7 units subcutaneously with meals, in addition to the sliding scale;-An order, dated 08/29/25, for insulin lispro 100 u/ml, inject as per sliding scale that follows:-If blood sugar is 0 mg/dL to 119 mg/dL, then do not administer insulin;-If blood sugar is 120 mg/dL to 160 mg/dL, then administer two units of insulin;-If blood sugar is 161 mg/dL to 200 mg/dL, then administer four units of insulin;-If blood sugar is 201 mg/dL to 240 mg/dL, then administer six units of insulin;-If blood sugar is 241 mg/dL to 280 mg/dL, then administer eight units of insulin;-If blood sugar is 281 mg/dL to 320 mg/dL, then administer 11 units of insulin;-If blood sugar is 321 mg/dL or greater, then administer 15 units of insulin and notify the physician if blood sugar is over 400 mg/dL. Observation on 08/20/25, at 12:24 P.M., showed RN O obtain the resident’s blood sugar at 148 mg/dL. RN O performed hand hygiene, donned gloves, obtained Humalog and drew up nine units of insulin and administered the insulin to the resident. RN O did not prime the needle prior to administering the insulin. . During an interview on 08/20/25, at 12:50 P.M., RN O said the following:-Staff do not prime insulin pens;-The insulin pens have plungers in them, so there is no need to prime the pen;-If there are bubbles seen in the pen, staff should just watch how they position the pen while administering the insulin;-Even if the resident does get a little bit of air injected, it won't hurt them. During an interview on 08/22/25, at 10:30 P.M., RN C said he/she was not aware that insulin pens required primed with each use. He/she thought it was just with new pens. During an interview on 08/22/25, at 10:50 A.M., the DON said all insulin pens are required to be primed each time before insulin is administered. Insulin pens should be primed before each use, every pen, every time. This is manufacturer guidelines. The dose would not be correctly administered if not primed. During an interview on 08/22/25, at 11:10 A.M., the Administrator said all insulin pens require priming each time. During an interview on 08/22/25, at 11:20 A.M., Corporate Nurse Consultant said that staff should always prime insulin pens with each use. Complaint #1534275, #2585250

Based on observation, interview, and record review, the facility failed to maintain equipment in the kitchen in a safe operating condition when three stove knobs were missing. The facility census was 149.Review showed the facility did not provide a policy regarding upkeep of kitchen appliances.1. Observations on 08/17/25, beginning at 3:46 P.M., and on 08/19/25, at 12:36 P.M., showed the cook stove located in the kitchen had three of the seven burner control knobs missing. During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said there are knobs missing. He/she didn't know how long they had been missing. He/she was still able to turn the stove burners on and off. The Dietary Manager was aware of the knobs missing.During an interview on 08/22/25, at 9:05 AM., DA M said stove knobs were missing, but they were still able to use them as far as he/she knew. If they have kitchen issues, they let the DM know and she tells maintenance. During an interview on 08/22/25, at 9:25 A.M., the DM said he/she was aware there were stove knobs missing. The staff were still able to turn the stove on. He/she needed to order new ones. During an interview on 08/22/25, at 9:57 A.M., the Administrator said the stove should have all knobs present.

Based on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents and staff when the floors and walls in the kitchen were not kept clean and free of debris. The facility census was 149.Review of the facility's policy titled Nutritional Services Sanitation, dated 03/31/21, showed nutritional services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with federal, state and local governing food sanitation and safety.1. Observations beginning on 08/17/25, at 3:46 P.M., showed the following:-The floors throughout the kitchen had black and white substances in several areas, especially under the sink areas and dishwasher;-There were pieces of food in and around the sink and dishwasher area;-The baseboards in most areas were black with dirt. Observation on 08/17/25, at 3:46 P.M., and on 08/19/25, at 11:29 A.M., showed the following:-The backsplash above the sink to the left when entering the kitchen had a mold looking substance along the section that met the sink, approximately 12 ft. The backsplash had a brown substance on it;-The wall underneath of the sink has large brown splatters in different sections;-The wall under the dishwasher had a black substance present;-The wall behind the stove had grease drops present.During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said the floor was swept and mopped each shift, day and evening. The evening cook was supposed to sweep and mop everywhere. The floors should be clean. The walls are cleaned sometimes. Staff have a deep cleaning day two to three times weekly and that is when the walls are done. During an interview on 08/22/25, at 9:05 AM., DA M said the floors are swept and mopped by whichever staff is working. The walls are more of a deep clean job, and those are done on occasion, he/she doesn't know how often. During an interview on 08/22/25, at 9:16 A.M., DA N said the floors were done by housekeeping. He/she was not sure how often. They should be clean. The walls are done weekly by someone. He/she was not aware of dirty walls or mold.During an interview on 08/22/25, at 9:25 A.M., the Dietary Manager (DM) M said the following:-Floors should be swept and mopped during the day and at night. They also have a deep cleaning where maintenance does a power wash. Housekeeping also buffers the floors three times per week;-He/she wouldn't expect there to not be black stuff and food on the floors. They should be clean for the most part;-The walls are cleaned by maintenance. There shouldn't be dirt or mold on the walls.During an interview on 08/22/25, at 9:57 A.M., the Administrator said the floors should be clean. The DM is monitoring the cleaning of the kitchen. He/she wasn't aware of mold long the sink where the backsplash meets.

Based on observation and interview, the facility failed to implement and maintain an effective pest control system when multiple flies were located four resident rooms affected five residents (Resident #62, #123, #125, #141 and #147). The facility census was 149.Review showed the facility did not provide a Pest Control Policy. 1. Review of Resident #62's face sheet (admission data) showed an admission date of 02/28/25. Review of the resident's significant change in status Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 07/08/25, showed the resident's cognitive skills intact. Observation and interviews on 08/17/25, at 5:35 P.M., showed the resident in bed. The resident's pillow had a black substance on it. A fly landed on the resident's pillow and the resident waved his/her hand at the fly. The resident said the fly was annoying. Observation on 08/20/25, at 10:07 A.M., showed the resident in bed. A fly flew around the resident and landed on the resident's pillow. Observation on 08/21/25, at 9:35 AM., showed the resident in bed. A fly flew around the resident's room. 2. Review of Resident #123's face sheet showed an admission date of 08/30/19. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #125’s face sheet showed an admission date of 04/07/21. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview and observation on 08/18/25, at 1:00 P.M., of Resident #123 and #125’s room showed the following:-The room had an unpleasant odor, that could be smelled in the hall before opening the door;-There were about eight to ten live flies flying in the room;-Two or three gnats were seen flying in the room;-There was a beside commode with no lid with urine in the commode;-There was debris and crumbs on the floor;-A pest control light that was not plugged in to the outlet;-Resident #123 said it had not been plugged in for some time or working to his/her knowledge. 3. Review of Resident #141's face sheet showed an admission date of 04/26/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Observation and interview on 08/17/25, at 5:01 P.M., showed the following:-The room has an unpleasant odor, that could be smelled in the hall;-An empty soda box under the resident’s bed, clothes on the floor, and the tables had various items on them, including empty bottles;-The floor appeared dirty with brown places and pieces of food on the floor;-The floor had clothes, stuffed animals, and soda present;-The trash can was mostly full;-The urinal was half full of urine;-There was a fly trap on the resident’s triangle bar, hanging above his/her bed. The sticky fly trap that hung down about 16 inches was completely full of flies;-About four or five live flies flying around the room and eight or nine dead flies laying in the window seal;-The resident said housekeeping cleaned his/her room every other day. He/she doesn’t like for housekeeping to move his/her belongings. Observation and interview on 08/21/25, at 11:00 A.M., showed the following:-The room has an unpleasant odor, that can could be smelled in the hall;-An empty soda box was under the resident’s bed, clothes were on the floor, and the tables had various items on them, including empty bottles;-The floor appeared dirty with brown places and pieces of food on the floor;-The urinal was fourth of the way full of urine;-The floor had clothes, stuffed animals and soda;-The resident’s dog food bowl had spilled and there was dogfood in the floor;-About four or five live flies flying around the room and eight or nine dead flies laying in the window seal. During an interview on 08/22/25, at 11:10 A.M., Certified Nurse’s Aide (CNA) I, he/she had noticed some flies in the resident’s room. During an interview on 08/22/25, at 12:22 P.M., Licensed Practical Nurse (LPN) B said he/she had seen flies in and around the resident’s room. He/she didn’t know how often they spray for flies. 4. Review of Resident #147’s face sheet showed an admission date of 08/07/24. Review of the resident’s annual comprehensive MDS, dated [DATE], showed the resident had severely impaired cognition. Observation on 08/22/2025, at 1:15 P.M., showed the resident eating lunch in bed. The plate contained cut-up pieces of chicken fried steak, mashed potatoes with gravy, and a sandwich. Beside the plate was an empty ice cream cup. A fly landed on the sandwich twice and continued to fly around the bed and lunch tray. The resident waved his/her hand around to shoo it away several times and said, That's just wrong; go away! 5. During an interview on 08/21/25, at 9:21 A.M., CNA I said he/she had seen flies on the 500 hall. Staff use fly swatters to kill the flies. During an interview on 08/21/25, at 1:09 P.M., the Housekeeping Supervisor said housekeepers do their best to get rid of flies. Staff should have a fly swatter to kill the flies as needed. During interviews on 08/22/25, at 12:50 P.M., and on 08/25/25, at 11:09 A.M., the Maintenance Director said he/she checked the logbooks at the nursing stations every day for staff requests. If only one fly was seen he/she would wait for the monthly pest control service. If more issues were identified he/she would quarantine the room if needed and would notify pest control to schedule services sooner. He/she has not received complaints about flies. He/she has a company that comes at least one time per month, or more often as needed. During an interview on 08/25/25, at 12:29 P.M., the Administrator said staff address flies with the use of fly baits in drains, contacting the pest control company, making sure the doors get shut faster, and making sure screens in resident rooms are intact. She was not aware of an issue with flies. There is an exterminator that comes in as needed to treat whatever is causing an issue. Complaint #1534276, #2572207

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a name tag for one resident's (Resident #62) door resulting in staff being unsure of the resident's name when addressing the resident and providing cares. The facility census was 149. Review of the facility's policy titled Resident Rights, dated 04/26/23, showed the facility shall treat residents with kindness, respect and dignity and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission. 1. Review of Resident #62's face sheet (admission data) showed the following:-admission date of 02/28/25;-Diagnoses included malignant neoplasm of upper lobe, right bronchus or lung (lung cancer) and dermatophytosis (infections caused by a group of fungi). Review of the resident's significant change in status Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 07/08/25, showed the resident's cognitive skills intact. Observation on 08/17/25, at 5:35 P.M., showed the resident lay in the first bed of the room with another empty bed by the window. The resident did not have his/her name tag on the door. The resident's roommate's name was on the door. Observation on 08/20/25, at 2:05 P.M., the resident lay in the first bed of the room with another empty bed by the window. The resident did not have his/her name tag on the door. The resident's roommate's name was on the door. Observation on 08/20/25, at 10:06 A.M., showed the resident lay in the first bed. The surveyor asked a staff member where the resident's roommate was. The staff member knocked on the door and stated the name of the resident's roommate to Resident #62. The resident said no, his/her roommate was in the hospital. Observation on 08/21/25, at 09:35 A.M., the resident lay in the first bed of the room with another empty bed by the window. The resident did not have a name tag on his/her door. The resident's roommate's name was on the door. During an interview on 08/22/25, at 1:22 P.M., the resident lay in his/her bed. The resident said he/she moved around the facility a lot. He/she noticed his/her name was not on his/her door. During an interview on 08/21/25, at 9:21 A.M., Certified Nurse Aide (CNA) I said he/she did not know who was responsible for the name tags for the resident rooms. Staff think the resident is his/her roommate due to no name tag for Resident #62. During an interview on 08/22/25, at 10:09 A.M., Certified Medication Technician (CMT) A said it was important to have the correct name tags on resident doors when passing medications to make sure staff have the right resident. During an interview on 08/21/25, at 10:32 A.M., Licensed Practical Nurse (LPN) B said name tags were important to have on resident doors if a resident was confused and not able to tell staff their name. During an interview on 08/25/25, at 8:10 A.M., LPN W said medical record staff are responsible for the name tags on resident doors. Residents are moved around, and it is helpful to have it on the door. During an interview on 08/21/25, at 12:23 P.M., the Director of Nursing (DON) said name tags should be on resident doors in order for staff not to administer the incorrect medications and for staff to know who they care for. During an interview on 08/25/25, at 8:15 A.M., the Medical Record Staff said he/she was responsible for the name tags on the door. He/she checked the census and made name tags for the resident doors. The name tag should go with the resident if they change rooms. He/she checked the name tags one time a week usually on Fridays. During an interview on 08/25/25, at 12:29 P.M., the Administrator said she expected the correct name tag on a resident's door upon admission and if they are moved. Complaint #1534259

Based on observation, interview, and record review, the facility failed to ensure there was a process in place that clearly and consistently noted each resident's code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) when two residents (Resident #12 and Resident #18) were not listed on the Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped) list who had DNR orders/directive in place. The facility census was 149. Review of the facility's policy titled Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)), dated [DATE], showed the following:-It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on healthcare, to refuse/accept treatment, to make informed decision, and/or appoint a health care agent to make decisions on behalf of the resident when the resident lacks the capacity to do so;-Resident with capacity: To enter a DNR order for an adult resident who has decision-making capacity enter the DNR order in medical record;-Residents who lack capacity: To enter a DNR order for an adult resident without capacity who has appointed a health care agent by written power of attorney for healthcare determine that the resident lacks capacity as required by the power of attorney health care law and document decision in medical record. 1. Review of Resident #12's face sheet (admission data) showed the following:-admission date of [DATE];-Diagnoses included unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and essential hypertension (HTN-high blood pressure). Review of the resident's Out of The Hospital Do-Not Resuscitate (OHDNR) Order Form showed the following:-The resident signed the form on [DATE];-The physician signed the form on [DATE]. Review of the resident's current Physician's Order Sheet (POS) showed an order, dated [DATE], for the resident's code status of DNR. Review of the resident's care plan, revised [DATE], showed a code status of DNR. During record review and interview, the review of a form in a purple folder labeled Code Status located on the crash cart showed an undated form with resident names listed and no identifying code status on the form. Licensed Practical Nurse (LPN)/Unit Manager A said the list was for residents with a code status of DNR. Review of the form in showed the resident's name was not on the list. During an interview on [DATE], at 10:45 A.M., LPN/Unit Manager A said the resident had a code status of DNR and he/she should be on the list. 2. Review of Resident #18's face sheet showed the following information:-admission date of [DATE];-No CPR;-Diagnoses include diabetes, chronic obstructive pulmonary disease (COPD - a group of lung disease that blow airflow and make it difficult to breathe), fluid overload, and syncope and collapse (fainting or sudden temporary loss of consciousness). Review of the resident's comprehensive MDS, dated [DATE], showed the resident was on hospice services. Review of the resident's OHDNR showed the following:-The resident signed the OHDNR order on [DATE];-The residents physician signed the order on [DATE]. Review of the resident's care plan, dated [DATE], showed the following:-DNR code status;-Inform physician and staff of DNR status;-Provide comfort measures as ordered;-Review routinely for any change in code status and update as indicated;-Withhold CPR per the residents wishes. Review of the resident's [DATE] Physician Order Sheet (POS) showed an order, dated [DATE], for DNR. Review of the form in the purple folder labeled Code Status showed the resident's name was not on the list for a code status of DNR. During an interview on [DATE], at 10:45 A.M., LPN/Unit Manager A said the resident had a code status of DNR and he/she should be on the list. 3. During an observation and interview on [DATE], at 11:33 A.M., LPN A/Unit Manager said the following:-A purple folder labeled Code Status located on the crash cart at the nurses' station;-The form did not have a date. The form had 100-600 halls listed with resident names who resided on each hall;-The form did not designate a code status;-LPN/Unit Manager A said the form was the list of residents who had a code status of DNR;-She had an updated list in his/her office. During an interview on [DATE], at 12:10 P.M., LPN H said the following:-Staff find a resident's code status on the computer and in a purple folder with a list of residents who are DNR;-Medical records staff update the code status of residents;-Residents code status of DNR should be on the code status list in the purple folder located on the crash cart;-The SSD reviewed a resident's code status with the resident and/or the representative;-The physician signs the DNR form. During an interview on [DATE], at 6:48 P.M. Certified Nurse Aide (CNA) K said the following:-He/she notified the charge nurse if he/she found a resident unresponsive;-He/she asks the nurse of a resident's code status. During an interview on [DATE], at 10:09 A.M., Certified Medication Technician (CMT) A said the following:-Staff find a resident's code status on the medication administration record in the computer;-He/she did not know about the code status list in the purple folder. During an interview on [DATE], at 10:32 A.M., LPN B said the following:-Staff find a resident's code status on the computer;-He/she did not use the purple folder on the crash cart. He/she was not sure of a resident's code status on the form. During an interview on [DATE], at 10:45 A.M., LPN/Unit Manager A said the following:-Staff verify a resident's code status if found unresponsive;-The forms in the purple folder on the crash cart for all the halls designate a code status of DNR for those listed residents;-Staff finds a resident's code status on the computer;-The SSD provides an updated code status list every Thursday for the weekly risk meeting;-The SSD updates the code status list if a resident changes their code status or if the resident returns from the hospital with a changed code status;-Staff were informed of the DNR code status form in the purple folder on the crash cart;-Staff are completing an updated version of the form with DNR and a date at the top of the form;-The form should have a date for staff to know if it is a current DNR list. During an interview on [DATE], at 3:26 P.M., the SSD said the following:-He/she asks the resident on admission of their code status;-He/she changed the code status as requested;-The interdisciplinary team reviewed residents' code status quarterly;-Staff find a resident's code status on the face sheet, on the computer, or in the purple folder. During an interview on [DATE], at 12:23 P.M., the Director of Nursing (DON) said the following:-Staff find a resident's code status on the computer;-SSD completes a list of DNR code status and places it in the purple binder;-Staff will add a date and DNR on the form;-A resident should be on the form that is in the code status book if they are a code status of DNR. -He/she informed staff verbally of the code status is DNR on the form in the folder on the crash cart;-The residents were not on the form for a code status of DNR in the purple folder. During an interview on [DATE], at 12:29 P.M., the Administrator said she expected a resident's code status to be clear and consistent throughout the medical record.

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate wound tracking of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), failed to obtain treatment orders for an identified pressure ulcer in a timely manner, and failed to document wound treatments per physician orders for one resident (Resident #169) who was admitted from the hospital. The facility's census was 149.Review of the facility policy titled Wound Management, dated 11/15/22, showed the following:-To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders;-Wound treatment will be provided in accordance with physician's order: cleansing method, type of dressing, and frequency of dressing change;-Charge nurse will notify physician in the absence of treatment orders;-Treatments will be documented on the Treatment Administration Record (TAR). 1. Review of Resident #169's face sheet (admission data) showed the following:-admission date of 06/10/25;-Diagnoses included pressure ulcer of other site stage 3 (full-thickness loss of skin). Review of the resident's Nursing admission Evaluation and Baseline Care Plan dated 06/10/25, at 3:43 P.M., showed Licensed Practical Nurse (LPN) A/Unit Manager documented the resident admitted from the hospital. Skin had treatment ordered or required.Review of the resident's Physician Order Sheet (POS), dated 06/10/25, showed no order for wound care. Review of the resident's June 2025 TAR showed no orders for wound care added at admission. Review of the resident's Skin Observation Tool dated 06/11/25, at 2:05 P.M., showed LPN A/unit manager documented the following:-Present on admission: Edema (swelling) to bilateral lower extremities with bruising and scabs to bilateral upper extremities;-Open area to left abdominal fold;-Bruising to left shoulder;-Open area to left buttock.(Staff did not document measurements, description of, or treatment orders for the opean area on the resident's buttock.) Review of the resident's admission note dated 06/11/25, at 2:25 P.M., showed LPN A/Unit Manager documented the resident admitted from the hospital. The resident's skin was warm and dry. The resident had scabs and bruising to the resident's bilateral upper extremities. The resident had an open area to his/her right abdominal fold and an open area to his/her left buttock. Review of the resident's POS, dated 06/11/25, showed the following:-An order, dated 06/10/25, for staff to complete Skin Observation Tool form on day shift on Tuesday one time a day, every Tuesday for skin observation.-An order, dated 06/11/25, for wound company consult.(The POS did not show an order for wound care of the resident's open area to buttock.) Review of the resident's wound physician's visit , dated 06/12/25, showed the following:-At the request of the referring provider, a thorough wound care assessment and evaluation was performed;-The resident had wounds on his/her left and right buttock (previously only left buttock documented);-The resident was non ambulatory with bowel incontinence and stage 3 pressure wounds of the bilateral buttocks;-Stage 3 pressure wound of the left buttock measured 8 centimeters (cm) long by 6 cm wide by 0.4 cm in depth, light serosanguinous (a fluid that contains both clear, watery and blood), 50% granulation (red bumpy tissue) tissue, and noted to be present on admission per staff;-Stage 3 pressure wound of the right buttock measured 12 cm long by 7 cm wide by 0.4 cm in depth, light serosanguinous, 50% granulation tissue and noted to be present on admission per staff;-Hydrocolloid paste (wound cream) apply once daily and as needed if saturated, soiled, or dislodged, for 30 days; -General recommendation cleanse wounds with wound cleanser at time of dressing changes. Review of the resident's June 2025 TAR showed staff did not add the wound care, ordered on 06/12/25, for the resident's stage 3 pressure ulcers. Review of the resident' weekly wound observation dated 06/13/25, at 3:15 P.M., showed the wound nurse documented the following:-Stage 3 pressure wound of the resident's left buttock;-The Stage 3 pressure wound was present on admission;-Overall impression: first observation, no reference;-Drainage: small amount serosanguinous;-No odor present;-The resident's left buttock wound measured 8 cm long by 6 cm wide and 0.4 cm in depth;-No inflammation/induration present;-Current treatment plan: Triad (hydrocolloid paste) once daily and as needed. Review of the resident' weekly wound observation dated 06/13/25, at 3:17 P.M., showed the wound nurse documented the following:-Stage 3 pressure wound of the resident's right buttock;-The stage 3 pressure wound was present on admission;-Overall impression: first observation, no reference;-Drainage: small amount serosanguinous;-No odor present;-The right buttock measured 12 cm long by 7 cm wide and 0.4 cm in depth;-No inflammation/induration present;-Current treatment plan: Triad once daily and as needed. Review of the resident's hospice nurse practitioner's visit notes, dated 06/13/25, showed the following:-Reports of wound to the resident's sacrum (bottom of spine);-Sacral wound reported, unable to assess the resident this visit. The resident reports the wound doctor evaluated him/her on 06/12/25. Review of the resident's POS, dated 06/13/25 showed the following:-An order, dated 06/13/25, for site 1 stage 3 pressure wound of the left buttock. Staff to cleanse area with wound cleanser, pat dry, and apply triad paste daily and as needed for wound care;-An order, dated 06/13/25, for site 2 stage 3 pressure ulcer of the right buttock. Staff to cleanse area with wound cleanser and apply triad cream daily and as needed for wound care. Review of the resident's June 2025 TAR showed on 06/13/25, 06/14/25, 06/15/25, and 06/16/25, staff did not document completion of the treatment to the resident's wounds on his/her buttocks.During an interview on 08/20/25, at 6:48 P.M., Certified Nurse Aide (CNA) K said if he/she observed a new skin area on a resident, he/she would report it to the charge nurse. During interviews on 08/21/25, at 10:32 A.M., and on 08/22/25, at 9:47 A.M., LPN B said the following: -The admission director was responsible for new admissions;-Nurses complete a skin assessment for any abnormalities, breakdown, and wound, for new admissions;-Nurses enter wound orders. The wound nurse is responsible, but if a resident was admitted after hours, the charge nurse would notify the physician to obtain a temporary wound care order. -He/she did not do wound care on the resident. During interviews on 08/21/25, at 10:45 A.M., on 08/22/25, at 10:02 A.M., and on 08/25/25, at 10:11 A.M., LPN A/Unit Manager said the following: -The admissions coordinator completes new admissions and conducts a skin assessment;-Staff should assess if a resident's skin;-Staff notify the wound nurse if a resident has wounds;-The admission Director or the admitting nurse enters all orders upon admission; -On 06/10/25, the resident was admitted to the facility. He/she should had called the physician to obtain a wound order;-The wound physician comes to the facility on Thursdays; -There should be an order for wound care if a resident has a stage 3 pressure wound;-Staff should provide wound treatments unless the resident was noncompliant;-Staff should document if the resident refused wound treatments;-Staff complete skin assessments upon admission;-Staff enter admission wound orders or follow the wound doctor orders.During an interview on 08/21/25, at 1:29 P.M., Registered Nurse (RN) X said the following:-He/she had not completed any skin assessments;-He/she did not observe the resident's wounds;-The wound nurse or charge nurse completed daily wound care if a resident had an order for wound care.During an interview on 08/22/25, at 10:44 A.M., the Wound Nurse said the following:-The admission Director completes the first skin assessment upon admission and enters any hospital orders;-Staff notify him/her if a resident has a wound;-He/she notifies the wound doctor for a wound order. Staff enter wound orders if received from the hospital;-The wound doctor stages any wounds;-On 06/12/25, the wound doctor saw the resident. The resident had a stage 3 wound on his/her left and right buttock;-Staff should have had a cream or notified the physician for a wound order;-Staff should not wait for the wound doctor to come to the facility and called for a wound order.During an interview on 08/21/25, at 3:07 P.M., the Admissions Director said the following:-He/she entered the orders and completes the assessments upon admission;-On 06/10/25, staff entered the resident's wound orders;-Staff should had started the resident's wound treatment the day of admission or following day.During an interview on 08/22/25, at 11:41 A.M., MDS Coordinator A said he/she said expected staff to document wound treatments. During an interview on 08/22/25, at 11:08 A.M., the resident's nurse practitioner said the following:-The admission Director received the discharge orders from the hospital for new admissions and the Medical Director adds orders if needed;-If a resident did not have orders from the hospital, staff should notify the physician of what type of wound treatment order is needed;-She did know for sure why wound orders were not entered until 06/13/25 for the resident;-If the resident was admitted from the hospital, she assumes the staff would use those orders;-Staff should document and notify the provider if the resident refused wound care treatments;-She expected staff to document wound treatment as ordered.During an interview on 08/25/25, at 9:25 A.M., the Medical Director said the following:-A resident should come with discharge orders if admitted from a hospital;-He expected staff to notify him if a resident has a significant wound and no wound treatment orders;-He considered a Stage 3 pressure ulcer as significant;-He expected staff to do whatever is appropriate and get the wound doctor involved;-He expected staff to notify him if no orders from the hospital for wound orders; -He expected staff to document on the TAR the admitting wound order and inform him of an admission;-If the resident did not have a wound order from the hospital, staff should notify him for an order before the wound doctor sees the resident.During an interview on 08/21/25, at 12:23 P.M., the Director of Nursing (DON) said the following:-The resident admitted to the facility on [DATE];-The admission director entered the physician orders for new admissions;-Staff should start wound treatments the following day after an admission;-If the resident was admitted on [DATE], staff should had called the physician to confirm wound orders and started the wound treatments the next day. During an interview on 08/25/25, at 12:29 P.M., the Administrator said the following:-Staff should document wound measurements and a description of a wound upon admission;-She expected staff to notify the physician after the admission was completed;-Staff have up to 24 hours to complete a full assessment;-If the wound doctor is on the way to the facility, staff have him look at a resident's wound but until then, the staff should notify the wound doctor of wound orders;-The wound nurse should observe a resident with a wound after or upon an admission;-She expected staff to document wound treatments on the TAR;-She expected staff to notify the physician if a resident refuses care, wound treatments medications and to document in the progress notes. Complaints 1534271, 2572207, 2590129, 2595498 and 2595716

Based on observation, interview, and record review, the facility failed to have a process in place to routinely and thoroughly track and assess pressure sores and failed to administer Augmentin (a broad spectrum antiinfective) as ordered for one resident (Resident #1). The resident was admitted to hospital and diagnosed with acute osteomyelitis (infection of the bone), involving the right ankle and foot, and required an above the knee amputation. The facility failed to follow acceptable infection control practices when providing wound care, failed to follow physician orders for wound care, and failed to routinely track/assess wounds for one resident (Resident #2). The facility census was 141. The Administrator was notified on 2/10/23, at 7:45 P.M., of an Immediate Jeopardy which began on 12/26/22. The Immediate Jeopardy was removed on 2/10/23, as confirmed by surveyor onsite verification. 1. Record review of the facility policy titled, Skin Evaluation, last reviewed on 12/28/22, showed the following: -The facility may conduct head-to-toe skin evaluation performed and documented on a weekly basis. The weekly skin evaluation will be documented electronically or on the Skin Observation Tool; -Licensed Nurses, Wound Care Nurse, Administration, and Director of Nursing (DON) are responsible; -Residents will have head-to-toe skin evaluation performed and documented on a routine basis. The evaluation will be documented electronically or on the Skin Observation Tool; -Any skin abnormality identified through this evaluation may be documented in the interdisciplinary notes. Physician, resident representative, wound nurse, and DON will be notified of any abnormalities; -Treatment will be initiated per the physician's order; -The unit manager/wound nurse will review and sign the skin observation tool if documented manually. The signature indicates follow-up, documentation, and care plan interventions have been implemented; -Manual Skin Observation Evaluations are to be kept with the treatment record and filed in the medication/treatment section of the medical record. Record review of the facility policy titled, Wound Management, last reviewed on 11/15/22, showed the following: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound documentation included location of the wound, pressure injury and stage, size (shape, depth, tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) and/or undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface), volume and exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) characteristics, pain evaluation, presence of infection, condition of wound bed and wound edges, condition of peri-wound; -The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Record review of the facility policy titled, Physician Orders, last reviewed on 9/28/22, showed: -The facility is to ensure orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Licensed nurses, nursing administration, and DON are responsible; -Physician orders shall be provided by licensed practitioners authorized to prescribe orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record; -Physician order sheet (POS) will be maintained with current physician orders as new orders are received; -Physician orders will be transcribed to the appropriate administration record, medication administration record/electronic medication administration record (MAR/eMAR) or treatment administration record/electronic treatment administration record (TAR/eTAR); -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the emergency drug supply (E-Kit) or Automatic Dispensing Unit shall be utilized for the first dose until a supply arrives from pharmacy, if available. Record review of Resident #1's admission record showed the following: -admitted to the facility from the hospital on 11/28/22; -Diagnoses included metabolic encephalopathy (brain dysfunction caused by other health condition), alcohol abuse, dementia, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), and muscle weakness. Record review of the resident's pressure injury risk assessment, completed on 11/28/22, showed the resident at high risk for the development of pressure ulcers. Record review of the resident's nursing admission screening/history, dated 11/28/22, showed the following: -Open area to the right outer ankle that measured 0.8 centimeters (cm) long by 1.0 cm wide with redness surrounding area. -Staff did not document wound stages, descriptions of wound bed, or the presence of any drainage or odor. Record review of the resident's November 2022 medication review report showed the following physician order: -An order, dated 11/28/22, for a body audit every seven days for skin observation; -Staff documented a check mark and initials indicating the audit was completed on 11/29/22. Record review of the resident's progress note dated 11/29/22, at 4:03 P.M., showed Licensed Practical Nurse (LPN) D (the wound nurse) documented the following: -Resident lying on the bed and skin assessment completed; -Left foot red old wounds; -Right lateral side toward pinky toe old wound; -Right outer ankle open area 1 cm x 0.8 cm x 0.1 cm, left hip scratches; -No other wounds at this time. -The wound nurse did not document wound stages, descriptions of wound bed or peri-wound appearance, or the presence of any drainage or odor. Record review of the facility skin log, dated 11/30/22, showed the resident had the following: -Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right outer ankle wound that measured 1.0 cm long by 0.8 cm wide by 0.1 cm deep; -Treatment order of calcium alginate (an absorbent wound dressing material)/dry dressing. -The nurse did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's December 2022 medication review report showed the following physician orders: -An order, dated 11/30/22, for wound care to right outer ankle. Clean with wound cleanser, pat dry, collagen/calcium alginate (a wound dressing used to support healing), border bandage (a bandage with an adhesive edge), keep in soft boot as needed; -An order, dated 11/30/22, for wound care to right outer ankle. Clean with wound cleanser, pat dry, collagen/calcium alginate, border bandage, keep in soft boot one time a day. Record review of the resident's progress note dated 12/3/22, at 8:35 P.M., showed the DON documented the following: -Resident was admitted to the facility on [DATE]. He/she has a wound to his/her right outer ankle that measures 1.0 cm long by 0.8 cm wide by 0.1 cm deep. Treatment is for calcium alginate. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 12/5/22, showed the following: -admitted to the facility on [DATE] from the hospital; -Total dependence on two or more staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; -Diagnoses of metabolic encephalopathy, dementia, alcohol abuse, and muscle wasting; -Risk of pressure ulcer development; -No unhealed pressure ulcers; -Other open lesion on the foot; -Application of dressings to the feet. Record review of the resident's skin observation tool, dated 12/5/22, showed the following: -Open areas to the right outer ankle, right lateral foot, and right pinky toe. -Staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the December 2022 Treatment Administration Record (TAR) showed a check mark and nurse initials, indicating completion of a body audit, on 12/6/22. There was no accompanying documentation. Record review of a handwritten note provided by the wound nurse, dated 12/7/22, showed the following wound measurements for the resident: -Right outer ankle 2.0 cm long by 1.2 cm wide by 0.1 cm deep; -Lateral foot 2.2 cm long by 2.0 cm wide by 0.5 cm deep; -Pinky toe 0.5 cm long by 0.2 cm wide; -The nurse did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the facility skin log, dated 12/8/22, showed the following: -The resident had a Stage 2 pressure ulcer of his/her right outer ankle, measured 1.0 cm long by 0.8 cm wide by 0.1 cm deep; -Treatment of calcium alginate/dry dressing; -Staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's skin observation tool, dated 12/12/22, showed the following: -Open areas to the right outer ankle and right lateral foot. -The staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's December 2022 TAR showed a check mark and nurse initials, indicating completion of a body audit, on 12/13/22. There was no accompanying documentation. Record review of the resident's progress note dated 12/14/22, at 10:50 A.M., showed the facility's Advanced Practice Registered Nurse (APRN) I documented following: -Resident seen for continued open wound to right lateral ankle; -Resident followed by the wound nurse with treatment orders in place, current wound approximately 0.5 cm long by 0.5 cm wide; -Wound care for right outer ankle - clean with wound cleanser, pat dry, apply collagen/calcium alginate, cover with border bandage, and keep foot in soft boot. -The APRN did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of a correction of the 12/14/22 wound assessment, dated 2/10/23, showed the following: -Right outer ankle 1.0 cm long by 0.8 cm wide by 0.1 cm deep with 90% necrotic (dead) tissue; -Right pinky toe 0.5 cm long by 0.2 cm wide with 95% necrotic tissue; -Both wounds with no change in measurement noted; -Left lateral foot with intact scab noted. Record review of the facility skin log, dated 12/15/22, showed the following: -The resident had a Stage 2 pressure ulcer to the right outer ankle wound, measured 2.0 cm long by 21.2 cm wide by 0.1 cm deep; -Treatment of calcium alginate/dry dressing. -The staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's progress note dated 12/16/22, at 1:59 P.M., showed the wound nurse documented the following: -Resident's wound is red and warm to touch, localized infection around area of right lateral foot. Physician notified. Starting Keflex (an antibiotic) 500 milligrams four times per day for seven days. Record review of the resident's December 2022 Registered Nurse (RN) / Licensed Practical Nurse Medication Administration Record (MAR) showed the following: -On 12/16/22, staff did not begin administration of the resident's Keflex; -On 12/17/22, staff administered Keflex four times, as ordered; -On 12/18/22, staff administered Keflex three of four ordered doses, but did not initial administration the fourth dose of Keflex. Record review of the resident's progress note dated 12/18/22, at 8:36 P.M., showed the DON documented the following: -Wound to the right outer ankle, measuring 2.0 cm wide by 21.2 cm long by 0.1 cm deep, deteriorated; -New order for Keflex 500 mg, four times per day for seven days for wound infection. Record review of the resident's progress note dated 12/19/22, at 5:17 P.M., showed a nurse documented the following: -Resident on alert charting for diagnosis of cellulitis (an infection of the tissue). Resident has a new order for Keflex. Wounds cared for by the wound nurse. No signs of symptoms of adverse reaction. Will continue to monitor. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/19/22, staff administered Keflex four times, as ordered; -On 12/20/22, staff administered Keflex two times and then the resident left the facility that day for the hospital. Record review of the December 2022 TAR showed a check mark and nurse initials, indicating completion of a body audit on 12/20/22. There was no accompanying documentation. Record review of the resident's progress note dated 12/20/22, at 10:07 A.M., showed staff transferred the resident to the emergency room due to displacement of his/her gastric feeding tube. Record review of the hospital discharge information, dated 12/26/22, showed the following: -Discharge plan instructions - Complete antibiotics. Continue wound care per wound specialty direction. Follow up with wound center in one to two weeks, outpatient; -An order for Augmentin 875/125 mg one tablet, by mouth, every 12 hours for 10 days. Record review of the resident's December 2022 medication review report, showed the following: -An order, dated 12/26/22, for a body audit every day shift for skin observation order dated 12/26/22; -Staff initialed completion of a body audit every day from 12/26/22-12/31/22. Record review of the resident's December 2022 RN/LPN MAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day for a urinary tract infection (UTI) for 10 days; -On 12/26/22, staff did not document administration of the antibiotic, area left blank; -On 12/27/22, Certified Medication Technician (CMT) L documented a '4' indicating other/see nurse notes for both ordered doses. Record review of the resident's nurses' notes, dated 12/27/22, showed staff did not address if the Augmentin was administered. Record review of the resident's progress note dated 12/27/22, at 2:20 P.M., showed a nurse documented the following: -Skin/Wound Note - Resident on charting for wound to right outer foot. Wound nurse to see. Record review of the resident's nurse admission screening/history dated 12/27/22 ,at 4:31 P.M., showed the following: -A pressure ulcer (no stage listed) to the left, lower extremity, measured 6 cm long by 4 cm wide by 0.1 cm deep; -Right lateral foot pressure ulcer, stage 3 (full thickness tissue loss. subcutaneous fat may be visible but bone tendon or muscle are not exposed. Slough (non-viable yellow, tan, gray, green or brown tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling), measured 7.5 cm long by 2 cm wide by 0.3 cm deep; -Treatment ordered or required. Record review of the resident's December 2022 TAR showed the following: -No treatment to the resident's left lower extremity; -No orders for treatment to the resident's right outer ankle or lateral foot on 12/27/22 or 12/28/22. Record review of the resident's progress note dated 12/28/22, at 4:16 P.M., showed the wound nurse documented the following: -Resident seen by wound physician today and he/she assessed the resident's right ankle/lateral foot, open areas, infected. Treatment changed to Dakin's (a topical antiseptic) wet to dry dressing daily until the wound physician sees the resident again in one week. Staff to monitor for redness to the foot. Record review of an untitled form, dated 12/28/22, with Pressure written on side of form showed the following: -Resident's right outer ankle, Stage 3, measured 2.8 cm by 2 cm by 0.3 cm, worse'; -Resident's right lateral foot, Stage 3, measured 12 cm by 3.3 cm by 0.3 cm, worse. -Staff did not document a description of the appearance of the wound bed or peri-wound, or the presence of any drainage or odor. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/28/22, CMT L documented a '4' indicating other/see nurse notes for the evening dose of Augmentin. Record review of the resident's nurses' notes, dated 12/28/22, showed staff did not address if the Augmentin was administered. Record review of the resident's re-admission history and physical, completed on 12/29/22, by Family Nurse Practitioner (FNP) H showed the following: -The resident was admitted to the hospital on 12/20/22 with a dislodged gastric (PEG) tube and low blood pressure; -The resident had excoriation from suspected scratching of the upper torso with signs of cellulitis to the left lower flank (side); -Right, lateral, lower leg and foot also had ulcerations with purulent (contains pus), odorous drainage; -He/she was started on vancomycin (antiinfective) and rocephin (antibiotic) for wounds; -Right foot MRI showed no osteomyelitis (infection of the bone); -His/her antibiotics were transitioned to oral; -Assessment and plan: Right foot wound cellulitis, continue Augmentin and continue wound care and off-loading; -Diagnosis of cellulitis of right foot. Record review of the resident's December 2022 medication review report showed the following order: -An order, dated 12/29/22, for right ankle/lateral foot. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day related to local infection of the skin and subcutaneous tissue. Record review of the resident's December 2022 TAR showed the following treatment order: -An order, dated 12/29/22, for right ankle/lateral foot treatment. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day, related to local infection of the skin and subcutaneous tissue. Record review of the resident's December 2022 RN/LPN MAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day; -On 12/29/22, CMT L documented a '4' indicating other/see nurse notes for both doses; -On 12/30/22, CMT L documented a '4' indicating other/see nurse notes for the evening dose. Record review of nurse notes (progress notes), dated 12/29/22 and 12/30/22, showed staff did not document regarding why staff did not administer the Augmentin as ordered. Record review of the resident's progress note dated 12/30/22, at 5:52 P.M., showed a nurse documented the resident is on alert charting for a new order for Augmentin. No adverse reaction have been noted. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/31/22, CMT L documented a '4' indicating other/see nurse notes for both doses. Record review of the resident's progress note dated 12/31/22, at 3:59 P.M., showed a nurse documented the following: -The resident continues on alert charting for a new order for Augmentin . No signs or symptoms of adverse effects thus far; -Staff did not document a rationale for why staff did not administer the Augmentin as ordered. Record review of the resident's January 2023 TAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day for a urinary tract infection (UTI) for 10 days; -On 1/1/23, staff did not document administration of the ordered morning dose of Augmentin 875/125 mg. Record review of the resident's January 2023 medication review report showed the following: -An order, dated 12/26/22, for body audit every day shift for skin observation. Record review of the wound physician's progress note dated 2/15/23, as a late entry for 12/28/22, showed the physician documented the resident was seen on 12/28/22 and his/her wound assessed with the wound care nurse present. Due to the concern of an acute (severe and sudden in onset) infection, staff considered starting the resident on an oral antibiotic regimen of Levaquin (antiinfective) and doxycycline (antiinfective), but were advised that the resident had already been started on Augmentin. With that understanding, we acceded to the previous order. The impression overall was that this situation was grave and that amputation of the extremity was a very possible outcome. Record review of the resident's January 2023 medication review report showed the following: -An order, dated 12/29/22, for right ankle/lateral foot. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day related to local infection of the skin and subcutaneous tissue. Record review of the resident's January 2023 TAR showed the following: -Staff initialed completion of a body audit every day on 1/1/23 and 1/2/23. Staff did not document any further information regarding the resident's wounds. -On 1/3/23, staff did not document administration of the morning dose of Augmentin 875/125 mg. Record review of the resident's progress note dated 1/3/23, at 12:02 P.M., showed a nurse documented the following: -Order to send the resident to the emergency room due to resident's gastric tube displaced. Record review of the resident's re-admission history and physical, completed on 1/23/23, by the resident's primary physician/medical director, showed the following: -The resident was readmitted to the hospital on 1/3/23, diagnosis of acute osteomyelitis (infection of the bone), involving the right ankle and foot. The resident underwent right above the knee amputation (AKA) without complications. Post-operative course was uneventful. He/she was discharged back to the facility on [DATE]. Record review of the resident's progress note, dated 1/23/23, showed APRN I documented the resident with a right above the knee amputation (AKA) of the right leg. During an interview on 2/9/23, at 9:50 A.M., Certified Nurse Aide (CNA) B said staff should inform the charge nurse if they noticed a pressure ulcer. During interviews on 2/9/23, at 10:53 A.M., and on 2/10/23, at 3:13 P.M. Registered Nurse (RN) E said the following: -If the shower aide discovered a resident had a new wound, then he/she filled out a shower sheet form and gave to the charge nurse; -RN E assessed a resident if staff reported a new wound to him/her. He/she informed the wound nurse of any new resident wound; -Staff should report a pressure ulcer to the wound nurse and unit manager and document the wound in the resident's progress notes; -He/she would measure the pressure ulcer and document what he/she observed and notify the physician for orders to treat the pressure ulcer; -Nurses should notify the physician, if the pressure ulcer or wound looks worse; -He/she did not remember the resident's wounds. During interviews on 2/9/23, at 11:52 A.M., and 2/10/23, at 11:57 A.M., RN C said the following: -Nurses should enter an antibiotic order into the computer system and check the facility's medication system to pull the first couple of doses. If the medication was not available, the nurse should send order to the pharmacy to be filled; -Nursing staff monitored residents' skin when providing incontinent care and repositioning every two hours; -Nurses should notify the physician and the wound nurse with signs of wound infection; -Nurses notify the physician by text or phone call; -The wound nurse usually entered an order in the electronic medical record, if the physician ordered an antibiotic; -The wound nurse informed the nurses of new orders for a resident. During an interview on 2/9/23, at 12:55 P.M., LPN D (wound nurse), said the following: -His/her responsibilities include weekly wound assessments, weekly skin assessments, and all skin treatments for the entire facility; -Residents with significant pressure ulcers were referred to the wound physician, by the wound nurse. The wound physician visited the facility weekly, on Wednesdays, and assessed and measured wounds for those residents on his/her caseload; -If residents were not in the facility during the wound physician's visit, the wound nurse did not measure those residents' pressure ulcers for the week; -In the past, the facility did not provide any training to the wound nurse on pressure ulcer staging or assessment; -The wound nurse did not begin staging pressure ulcers until sometime in January 2023; -On the wound nurse's days off from the facility, some of the other nurses were not completing resident skin treatments/pressure ulcer treatments as ordered; -The wound nurse said the resident's right outer foot wound contained some black tissue in the wound bed, since his/her admission, but on 12/15/22 or 12/16/22, the resident's wounds had deteriorated significantly with black and yellow tissue present to the wound bed and the wounds were much larger in size. The surrounding intact skin became red and warm to touch. The wound nurse contacted the resident's physician and obtained antibiotic order; -The wound physician saw the resident one time only, on 12/28/22; -On 12/28/22, the resident's right foot was swollen, red, and painful to touch. The right foot pressure ulcers were necrotic and draining serosanguineous (containing blood and serum) drainage of varying amounts, with no odor. During an interview on 2/10/23, at 9:45 A.M., LPN J said the following: -He/she completed skin treatments, if the treatment was ordered to be completed at night or as needed if the dressing became soiled; -If a staff member documented a '4' code on the TAR or MAR that meant the nurse did not complete the treatment or administer the medication; -The LPN said he/she had experience staging pressure ulcers, but the facility administration staff did not provide the nurse with wound care training; -The wound nurse completed the weekly skin assessments; -If the nurse observed a new pressure ulcer, he/she would notify the physician for treatment, but the physician usually referred to the wound nurse to assess and recommend a treatment; -The wound nurse then obtained the physician order and placed the order into the electronic health record; -A body audit was the same thing as a bath aide shower sheet, which was completed by the CNA/shower aide and reviewed by the nurse; -A check mark on the body audit section of the TAR, meant no new observed skin issues; -Skin treatments were the responsibility of the wound nurse or charge nurses. -He/she did not know why the CMT would sign a '4' for the resident's medications on the RN/LPN MAR indicating medication not administered; -Licensed nurses should administer any resident medications listed on the RN/LPN MAR, and CMTs administer medications listed on the regular MAR; -The nurses, not the CMTs, should have administered medications to the resident via gastric tube. During an interview on 2/10/23 at 10:28 A.M., LPN K said the following: -The facility admitted the resident from the hospital on 11/28/22, but LPN K did not complete the admission assessment until 11/29/22; -He/she documented the resident had a an area to his/her right outer ankle, measured 0.8 cm by 1.0 cm with redness surrounding the area; -He/she did not stage pressure ulcers; -If he/she observed a pressure ulcer, he/she informed the wound nurse; -If the resident was admitted without a treatment for an existing pressure ulcer, he/she would notify the nurse of the need to obtain a treatment order; -On the resident's re-admission assessment, dated 12/27/22, he/she documented the resident had a stage 3 pressure ulcer to the right lateral foot that measured 7.5 cm long by 2.0 cm wide by 0.3 cm deep and left lower extremity pressure ulcer measured 6.0 cm long by 4.0 cm wide by 0.1 cm deep; -He/she may have been mistaken when he/she documented left lower extremity, instead of right, but was unsure. During an interview on 2/10/23, at 11:10 A.M., CMT L said the following: -On the December 2022 RN/LPN MAR for the resident, the CMT documented a '4' meaning other. This meant he/she did not administer the medication, therefore it would be the responsibility of the charge nurse to administer the resident's medication because a nurse needed to administer the resident's medication via gastric tube; -The tube feeding medication should go on the RN/LPN MAR for the nurse to administer; -For some reason, the resident's Augmentin popped up on the computer for the CMT to administer, but he/she did not give the medications; -The CMT documented a code '4' and said the nurse should then know to give the resident medications; -The medication comes in plastic strips. The CMT would take the plastic strips of medications and hand the plastic strips of medication for any medications that the nurse was responsible for administering the following day and give to the nurse; -The nurse would place these medication strips into the top drawer of their nurse medication cart. The CMT did not document which nurse that he/she handed the medication to. During an interview on 2/10/23, at 11:32 A.M., and 2/15/23, at 10:19 A.M., LPN G/Unit Manager said the following: -Nurses enter an antibiotic order into the EMAR and can pull a medication from the facility medication system; -Staff can print and fax a medication order to the pharmacy, to ensure a medication will be delivered, but the electronic order goes directly to the pharmacy, once staff places the order into the electronic medical record; -He/she prints a new order listing, from the previous day, to review ordered medications. He/she then looks at the resident's MAR which was automatically populated, if the order was entered; -The nurse who took the order or recommendation from the physician, should enter the order into the system; -Staff should contact the resident's primary physician with any new treatment or medication order; -Staff can contact the physician by fax, phone call, or in-person; -Staff should document the physician order in the resident's progress note; -Staff should obtain medications for residents who have tube feeding from the facility medication system and staff should enter the order on the nurse MAR; -The order should show the route by tube or peg tube and a nurse would then be responsible for administration of any gastric tube medication. During a phone interview on 2/10/23, at 12:36 P.M., Family Nurse Practitioner (FNP) H said the following: -The facility should assess and measure resident pressure ulcers on admission and weekly thereafter; -The wound nurse should complete weekly wound documentation to include: measurements, wound bed and peri-wound appearance, any redness to surrounding skin, any odor, any necrotic tissue or slough; -If a resident's wound deteriorated, the wound nurse or assessing nurse should notify the primary physician, the wound physician, or the FNP within the same day as the nurse observed the change; -The wound physician communicates recommendations to the wound nurse; -The wound nurse should notify the primary care physician of all wound physician recommendations for change in pressure ulcer treatment or recommendations for antibiotics; -If the facility staff lacked to properly assess a resident's pressure ulcer, failed to treat a resident's pressure ulcer as ordered, or failed to administer antibiotics to a resident as ordered, these failures could contribute to the decline of the resident's pressure ulcer. During an interview on 2/10/23, at 1:39 P.M., the Corporate Nurse and DON said the following: -Prior t

Please see event ID NSH412, exit date 7/22/21, for details. Complaint MO00187969 28865 43193 25513

Please see event ID NSH412, exit date 7/22/21, for details. Complaint MO00187969 42985

Based on observation, interview, and record review, the facility failed to ensure all residents were free from manual restraint for the convenience of staff when two staff members (Certified Nurse Aide (CNA) X and Registered Nurse (RN) V) physically restrained one resident (Resident #1) against the resident's wishes and without physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home or must be paged and informed of such incident; -Staff shall provide a safe environment for the resident. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Record review of the facility's Employment Policies and Procedures, located in the facility's most current employee handbook, page 48, included the following information: -The facility strictly prohibits the abuse of dependent adults. All residents in the facility are considered to be dependent adults. It is the responsibility of all employees to safeguard residents from abuse and to report any knowledge or suspicion of abuse to the facility's Administrator or to the state's Department of Health and Senior Services (DHSS) immediately; -The following is a non-inclusive list of abusive conduct: the willful, negligent act or omission by an individual that results in physical or mental injury to a dependent adult; unreasonable confinement, restraint or corporal punishment of a dependent adult. Record review of the facility's physical Restraint Management Guidelines, revised 9/2017, showed the following definition of a physical restraint per the Centers for Medicare & Medicaid Services (CMS): -A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's progress notes, dated 6/7/21 through 7/22/21, showed no documentation of combative behavior. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed registered nurse (RN) V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During an interview on 7/13/21, at 12:45 P.M., certified nursing assistant (CNA) U said the following: -Although he/she did not work when the resident apparently fell (7/11/21), facility staff told him/her that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] -The CNA asked the resident how he/she got the bruises on his/her arms and the resident said staff hurt him/her and caused the bruises; -The resident did not identify the staff that hurt him/her. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and [MEDICATION(S)] (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V reported the fall to DON, physician, and son of the resident; -RN V completed a skin assessment which showed the resident's arms were pink, but not enough to imply there would be bruising; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident; -RN V denied any prior known combative behavior from the resident; -RN V would make sure a combative resident was in safe area, talk to de-escalate, put in a safe position, and monitor until they are calm; -RN V would try to hold the hand(s) of a combative resident, and walk away if not working. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet; -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. Sometimes, he/she hugged the agitated resident; -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. At the time, CNA X thought the night shift staff caused the bruising because, when he/she left the facility after his/her shift about ended at 6:30 P.M., the resident did not have bruising on his/her arms; -CNA X immediately reported the resident's bruises to RN V. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand were exposed revealing dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and on 7/15/21, at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her, and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. Record review of the resident's Skin Assessments showed the following: -On 7/14/21, left forearm bruising, left upper arm bruising, right forearm bruising, right upper arm bruising; -On 7/16/21, left hand (back) bruising 5 cm length (L) x 6 cm width (W), right forearm (outer) bruising 10 cm (L) x 6 cm (W), left forearm (distal post) bruising 11.5 cm (L) x 7 cm (W). During an interview on 7/14/21, at 3:05 P.M., Restorative Care Aide (RNA) S said the following: -The resident had no known history of combative behavior; -The resident told RNA S he/she did not want to talk about how he/she got the bruises; -He/she would not cross the arms of a combative resident; -He/she would document and report any combative resident behavior. During an interview on 7/15/21, at 9:20 A.M., licensed practical nurse (LPN) E said the following: -He/she observed bruises to both of the resident's forearms and left hand; -He/she asked the resident about his/her bruises and was told the girl, but could not provide any additional information. -He/she would step away from a combative resident, leave alone to calm down and attempt later; -He/she would never cross a resident's arms to calm them down; -He/she would step in, remove staff, and report if he/she witnessed a staff cross a resident's arms; -He/she would ask a resident about any observed bruises and, if unknown how the bruises were obtained, start an investigation. During an interview on 7/21/21, at 1:20 P.M., RN EE said the following: -The resident's bruises were dark purple in color on left forearm and hand; -The resident does not have a history of combative behavior. During an interview on 7/15/21, at 10:20 A.M., CMT Z said the following: -The resident has never been observed being combative. -He/she would ask for help if resident became combative; -He/she would try to calm a combative resident, then leave and return later to attempt; -He/she would never touch or cross the arms of a combative resident. During an interview on 7/15/21, at 11:30 A.M., Social Services Director (SSD) J said the following: -The resident had been upset lately; -He/she heard of alleged abuse towards the resident; -He/she saw the resident's bruises, but did not ask him/her about them; -He/she had been vaguely told details of the resident being held down; -He/she did not speak with the resident about being held down; -He/she thought another Social Worker had spoken with the resident concerning bruises and allegations; -He/she would see a resident if he/she was made aware of behavioral changes. During an interview on 7/15/21 at 12:40 P.M., SSD L said the following: -The resident has never been observed with combative behavior to SSD L's knowledge. -He/she would step out of reach and would not physically touch a combative resident; -He/she would document any combative behavior and report it to a nurse. During an interview on 7/15/21, at 12:00 P.M., LPN AA said the following: -The resident had been confused and combative two weeks prior and staff redirected the resident, then walked away to allow the resident to calm down. -He/she would walk away from a combative resident; -He/she would not cross the arms of a combative resident; -He/she would report if he/she witnessed a staff crossing the arms of a resident. During an interview on 7/16/21, at 8:50 A.M., LPN D said the following: -The resident was never observed as combative; -He/she did not observe any bruises to the resident prior to 7/12/21; -He/she observed bruises to the resident's forearms and left hand. -He/she would step away from a combative resident, if talking or distraction did not calm down; -He/she would notify physician of combative behavior and document; -He/she would consider this a physical restraint, would stop the staff and report it. During an interview on 7/16/21, at 12:47 P.M., CNA BB said the following: -He/she had never seen or heard of the resident being combative. -He/she would never touch a combative resident, but rather give them space, and notify the nurse; -He/she considered holding arms across the stomach or chest of a combative resident as a restraint and if witnessed he/she would stop the staff then report it; -He/she would not touch a resident who was upset and on the toilet; -He/she would not leave the resident, but would stand around the corner or crouch down to the resident's level to let them calm down. During an interview on 7/21/21, at 2:42 P.M., CMT FF said the following: -He/she did not recall the resident having combative behavior. -He/she would step back from a combative resident, attempt to approach later, and report the behavior to a nurse; -He/she would never hold or cross arms of combative resident. This is considered a restraint; -He/she has never witnessed a staff cross the arms of a combative resident and would stop it if witnessed. During interviews on 7/16/21, at 3:22 P.M., and 7/22/1, at 12:57 P.M., the DON said the following: -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She attempted to interview the resident who said it happened at nighttime and was a staff person, but did not know the name and was unable to describe; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -DON asked RN V why he/she thought it could have caused bruises, RN V said the bruises where resident was told to hold his/her arms; -The resident had some redness to arms, but no signs of bruising; -DON requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -The resident took blood thinners, which would have caused the bruising; -Facility staff are trained to back off and step away from an abusive resident, but not to leave them to make sure they are safe; -Facility staff should care for combative residents by taking a step back and allow the resident to calm down, reproach at a later time, ensure the resident is safe, and document any behavior of resident; -Holds that prevent a resident from getting hurt (like a fall) are not considered a restraint; -He/She would require documentation any time a resident is combative; -He/She would require documentation any time a resident is held during combative behavior; -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -He/She said if a resident is fighting against the hold it would be considered a restraint; -Restraints are not appropriate. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -The resident fell on [DATE] at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child was upset and reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell ; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up. -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -Facility staff should back away from a combative resident, but stay with resident if unsafe; -Residents who take blood thinners can bruise easily. During an interview on 7/16/21, at 4:55 P.M., the Advance Practice Register Nurse said the following: -Staff holding a resident's arms across a resident's body would not be appropriate and doing so could cause bruising on the resident, especially if the staff held the resident this way for two to three minutes; -If staff have a resident who is combative, he/she would need to step back, allow the resident to calm down and approach the resident in a different manor. During an interview on 7/26/21, at 12:39 P.M. the Medical Director said the following: -If staff held a resident's arms across their body, he/she would consider that a physical restraint. This would be appropriate if a resident's safety was at risk. If staff held a resident like this, they could definitely cause bruising; -He/she did not recall any reports of the resident being combative; -He/she did not know what kind of restraints the facility allowed. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 969

Based on observation, interview, and record review, the facility failed to ensure all residents were free from manual restraint for the convenience of staff when two staff members (Certified Nurse Aide (CNA) X and Registered Nurse (RN) V) physically restrained one resident (Resident #1) against the resident's wishes and without physician's orders. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home or must be paged and informed of such incident; -Staff shall provide a safe environment for the resident. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Record review of the facility's Employment Policies and Procedures, located in the facility's most current employee handbook, page 48, included the following information: -The facility strictly prohibits the abuse of dependent adults. All residents in the facility are considered to be dependent adults. It is the responsibility of all employees to safeguard residents from abuse and to report any knowledge or suspicion of abuse to the facility's Administrator or to the state's Department of Health and Senior Services (DHSS) immediately; -The following is a non-inclusive list of abusive conduct: the willful, negligent act or omission by an individual that results in physical or mental injury to a dependent adult; unreasonable confinement, restraint or corporal punishment of a dependent adult. Record review of the facility's physical Restraint Management Guidelines, revised 9/2017, showed the following definition of a physical restraint per the Centers for Medicare & Medicaid Services (CMS): -A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admit date of 6/7/21; -Diagnoses included pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin), anxiety, mild cognitive impairment (decline in the mental ability affecting memory, language, thinking, or judgment), chronic obstructive pulmonary disease (COPD - chronic lung disease that makes it hard to breathe), hypertension (high blood pressure), heart failure, urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra); -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's progress notes, dated 6/7/21 through 7/22/21, showed no documentation of combative behavior. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed registered nurse (RN) V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During an interview on 7/13/21, at 12:45 P.M., certified nursing assistant (CNA) U said the following: -Although he/she did not work when the resident apparently fell (7/11/21), facility staff told him/her that the resident sustained bruising on his/her arms as a result of a fall, or from the transfer after the fall; -The CNA asked the resident how he/she got the bruises on his/her arms and the resident said staff hurt him/her and caused the bruises; -The resident did not identify the staff that hurt him/her. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and Plavix (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V reported the fall to DON, physician, and son of the resident; -RN V completed a skin assessment which showed the resident's arms were pink, but not enough to imply there would be bruising; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident; -RN V denied any prior known combative behavior from the resident; -RN V would make sure a combative resident was in safe area, talk to de-escalate, put in a safe position, and monitor until they are calm; -RN V would try to hold the hand(s) of a combative resident, and walk away if not working. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet; -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. Sometimes, he/she hugged the agitated resident; -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. At the time, CNA X thought the night shift staff caused the bruising because, when he/she left the facility after his/her shift about ended at 6:30 P.M., the resident did not have bruising on his/her arms; -CNA X immediately reported the resident's bruises to RN V. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand were exposed revealing dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and on 7/15/21, at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her, and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. Record review of the resident's Skin Assessments showed the following: -On 7/14/21, left forearm bruising, left upper arm bruising, right forearm bruising, right upper arm bruising; -On 7/16/21, left hand (back) bruising 5 cm length (L) x 6 cm width (W), right forearm (outer) bruising 10 cm (L) x 6 cm (W), left forearm (distal post) bruising 11.5 cm (L) x 7 cm (W). During an interview on 7/14/21, at 3:05 P.M., Restorative Care Aide (RNA) S said the following: -The resident had no known history of combative behavior; -The resident told RNA S he/she did not want to talk about how he/she got the bruises; -He/she would not cross the arms of a combative resident; -He/she would document and report any combative resident behavior. During an interview on 7/15/21, at 9:20 A.M., licensed practical nurse (LPN) E said the following: -He/she observed bruises to both of the resident's forearms and left hand; -He/she asked the resident about his/her bruises and was told the girl, but could not provide any additional information. -He/she would step away from a combative resident, leave alone to calm down and attempt later; -He/she would never cross a resident's arms to calm them down; -He/she would step in, remove staff, and report if he/she witnessed a staff cross a resident's arms; -He/she would ask a resident about any observed bruises and, if unknown how the bruises were obtained, start an investigation. During an interview on 7/21/21, at 1:20 P.M., RN EE said the following: -The resident's bruises were dark purple in color on left forearm and hand; -The resident does not have a history of combative behavior. During an interview on 7/15/21, at 10:20 A.M., CMT Z said the following: -The resident has never been observed being combative. -He/she would ask for help if resident became combative; -He/she would try to calm a combative resident, then leave and return later to attempt; -He/she would never touch or cross the arms of a combative resident. During an interview on 7/15/21, at 11:30 A.M., Social Services Director (SSD) J said the following: -The resident had been upset lately; -He/she heard of alleged abuse towards the resident; -He/she saw the resident's bruises, but did not ask him/her about them; -He/she had been vaguely told details of the resident being held down; -He/she did not speak with the resident about being held down; -He/she thought another Social Worker had spoken with the resident concerning bruises and allegations; -He/she would see a resident if he/she was made aware of behavioral changes. During an interview on 7/15/21 at 12:40 P.M., SSD L said the following: -The resident has never been observed with combative behavior to SSD L's knowledge. -He/she would step out of reach and would not physically touch a combative resident; -He/she would document any combative behavior and report it to a nurse. During an interview on 7/15/21, at 12:00 P.M., LPN AA said the following: -The resident had been confused and combative two weeks prior and staff redirected the resident, then walked away to allow the resident to calm down. -He/she would walk away from a combative resident; -He/she would not cross the arms of a combative resident; -He/she would report if he/she witnessed a staff crossing the arms of a resident. During an interview on 7/16/21, at 8:50 A.M., LPN D said the following: -The resident was never observed as combative; -He/she did not observe any bruises to the resident prior to 7/12/21; -He/she observed bruises to the resident's forearms and left hand. -He/she would step away from a combative resident, if talking or distraction did not calm down; -He/she would notify physician of combative behavior and document; -He/she would consider this a physical restraint, would stop the staff and report it. During an interview on 7/16/21, at 12:47 P.M., CNA BB said the following: -He/she had never seen or heard of the resident being combative. -He/she would never touch a combative resident, but rather give them space, and notify the nurse; -He/she considered holding arms across the stomach or chest of a combative resident as a restraint and if witnessed he/she would stop the staff then report it; -He/she would not touch a resident who was upset and on the toilet; -He/she would not leave the resident, but would stand around the corner or crouch down to the resident's level to let them calm down. During an interview on 7/21/21, at 2:42 P.M., CMT FF said the following: -He/she did not recall the resident having combative behavior. -He/she would step back from a combative resident, attempt to approach later, and report the behavior to a nurse; -He/she would never hold or cross arms of combative resident. This is considered a restraint; -He/she has never witnessed a staff cross the arms of a combative resident and would stop it if witnessed. During interviews on 7/16/21, at 3:22 P.M., and 7/22/1, at 12:57 P.M., the DON said the following: -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She attempted to interview the resident who said it happened at nighttime and was a staff person, but did not know the name and was unable to describe; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -DON asked RN V why he/she thought it could have caused bruises, RN V said the bruises were where the resident was told to hold his/her arms; -The resident had some redness to arms, but no signs of bruising; -DON requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -The resident took blood thinners, which would have caused the bruising; -Facility staff are trained to back off and step away from an abusive resident, but not to leave them to make sure they are safe; -Facility staff should care for combative residents by taking a step back and allow the resident to calm down, reproach at a later time, ensure the resident is safe, and document any behavior of resident; -Holds that prevent a resident from getting hurt (like a fall) are not considered a restraint; -He/She would require documentation any time a resident is combative; -He/She would require documentation any time a resident is held during combative behavior; -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -He/She said if a resident is fighting against the hold it would be considered a restraint; -Restraints are not appropriate. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -The resident fell on 7/11/21 at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child was upset and reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up. -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -Facility staff should back away from a combative resident, but stay with resident if unsafe; -Residents who take blood thinners can bruise easily. During an interview on 7/16/21, at 4:55 P.M., the Advance Practice Register Nurse said the following: -Staff holding a resident's arms across a resident's body would not be appropriate and doing so could cause bruising on the resident, especially if the staff held the resident this way for two to three minutes; -If staff have a resident who is combative, he/she would need to step back, allow the resident to calm down and approach the resident in a different manor. During an interview on 7/26/21, at 12:39 P.M. the Medical Director said the following: -If staff held a resident's arms across their body, he/she would consider that a physical restraint. This would be appropriate if a resident's safety was at risk. If staff held a resident like this, they could definitely cause bruising; -He/she did not recall any reports of the resident being combative; -He/she did not know what kind of restraints the facility allowed. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00187969

Based on observation, interview, and record review, the facility failed to start an immediate investigation and take steps to protect all residents when an allegation of a manual restraint, type of abuse, involving two staff (Registered Nurse (RN) V and Certified Nurse Aide (CNA) X) and one resident (Resident #1) was reported. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will put into place steps to prevent further potential abuse, including but not limited to, staffing changes, increased supervision, protection from retaliation, and follow-up counseling for the resident(s); -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Any employee suspected of allegation of abuse, or neglect, misappropriation or exploitation must result in his/her immediate suspension to protect the resident; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for a mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed RN V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and [MEDICATION(S)] (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet. -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but then the CNA said he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. -CNA X immediately reported the resident's bruises to RN V. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand revealed dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. During an interview on 7/14/21, at 1:28 P.M., the DON said RN V had been suspended pending investigation and he/she would notify CNA X that he/she would also be suspended pending investigation (three days after the incident and two days after statements were requested by the DON and provided by RN V and CNA X.) During interviews on 7/16/21, at 3:22 P.M., and 07/22/21, 12:57 P.M., the DON said the following: -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -He/She asked RN V why he/she thought it could have caused bruises, RN V said the bruises where resident was told to hold his/her arms; -He/She requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -He/She thought he/she had read RN V and CNA X's statements prior to leaving for an out of town meeting; -He/She did not think of abuse when he/she received the statements, but helping the resident; -He/She would have suspended CNA X and RN V if he/she thought the staff were holding the resident down; -He/She denied knowing on 7/14/21 there was an issue with the two staff who said they crossed the resident's arms, as the two staff reported they had only crossed the resident's arms. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -The resident fell on [DATE] at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC had not been made aware of RN V or CNA X's verbal or written statements prior to 7/14/21; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell ; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up; -RNC said if he/she had seen the statements, both staff would have been suspended pending investigation for restricting the resident's movement. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint: MO 969

Based on observation, interview, and record review, the facility failed to start an immediate investigation and take steps to protect all residents when an allegation of a manual restraint, type of abuse, involving two staff (Registered Nurse (RN) V and Certified Nurse Aide (CNA) X) and one resident (Resident #1) was reported. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will put into place steps to prevent further potential abuse, including but not limited to, staffing changes, increased supervision, protection from retaliation, and follow-up counseling for the resident(s); -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Any employee suspected of allegation of abuse, or neglect, misappropriation or exploitation must result in his/her immediate suspension to protect the resident; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admit date of 6/7/21; -Diagnoses included pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin), anxiety, mild cognitive impairment (decline in the mental ability affecting memory, language, thinking, or judgment), chronic obstructive pulmonary disease (COPD - chronic lung disease that makes it hard to breathe), hypertension (high blood pressure), heart failure, urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra), -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for a mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed RN V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and Plavix (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet. -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but then the CNA said he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. -CNA X immediately reported the resident's bruises to RN V. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand revealed dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. During an interview on 7/14/21, at 1:28 P.M., the DON said RN V had been suspended pending investigation and he/she would notify CNA X that he/she would also be suspended pending investigation (three days after the incident and two days after statements were requested by the DON and provided by RN V and CNA X.) During interviews on 7/16/21, at 3:22 P.M., and 07/22/21, 12:57 P.M., the DON said the following: -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -He/She asked RN V why he/she thought it could have caused bruises, RN V said the bruises where resident was told to hold his/her arms; -He/She requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -He/She thought he/she had read RN V and CNA X's statements prior to leaving for an out of town meeting; -He/She did not think of abuse when he/she received the statements, but helping the resident; -He/She would have suspended CNA X and RN V if he/she thought the staff were holding the resident down; -He/She denied knowing on 7/14/21 there was an issue with the two staff who said they crossed the resident's arms, as the two staff reported they had only crossed the resident's arms. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -The resident fell on 7/11/21 at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC had not been made aware of RN V or CNA X's verbal or written statements prior to 7/14/21; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up; -RNC said if he/she had seen the statements, both staff would have been suspended pending investigation for restricting the resident's movement. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint: MO00187969

Based on record review and interview, the facility staff failed ensure all residents were free of significant medication errors when staff did not administer one resident's (Resident #1) medication as ordered, including a medication to treat seizures, and failed to notify the physician the medication was not administered. The resident was hospitalized after having a [CONDITION(S)]. A sample of seven residents was selected for review in facility with a census of 112. Record review of the facility's policy titled Policies and Procedures-Pharmacy Services for Nursing Facilities, revised August 2014, showed the following information: -The prescriber is contacted by nursing for direction when delivery of a medication will be delayed or the medication is not or will not be available; -Each medication order is to be documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An emergency order is placed with the provider pharmacy, and the medication is given as soon as reasonably possible. 1. Record review of Resident #1's face sheet (brief resident profile) showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's baseline care plan, dated 3/25/2021, showed the following information: -Required set up help only for activities of daily living (ADLs-tasks of everyday life such as eating, dressing, getting in and out of bed, taking a shower or bath and using the toilet); -The resident was alert and cognitively intact; -The resident's medication list was not reconciled with the resident/representative; -Diet order showed NPO (nothing by mouth); -Received tube feedings; (Staff did not address the resident's [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (a blood thinner), one tablet twice daily, via tube; -[MEDICATION(S)] Concentrate (a steroid) one milligram/mililiter (mg/ml), four ml via tube twice daily for pneumonia; -[MEDICATION(S)] (a steroid) tablet, one tablet daily; -[MEDICATION(S)] solution (a [CONDITION(S)] preventing medication) 100 mg/ml, five ml via tube twice daily for [CONDITION(S)] disorder. Record review of the resident's March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., as ordered: -[MEDICATION(S)]; -[MEDICATION(S)]. Record review of the resident's MAR, dated 3/25/2021, showed a note to see the nurses' notes for explanation for reason why staff did not administer [MEDICATION(S)]. Record review of the resident's nurses' notes, dated 3/25/2021, showed staff did not document the reason staff did not administer the medication. Record review of the resident's March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., as ordered: -[MEDICATION(S)]; -[MEDICATION(S)]; -[MEDICATION(S)]; -[MEDICATION(S)] solution. Record review of the resident's MAR, for date 3/26/2021, showed staff did not document the reason staff did not administer the 7:00 A.M. medications. During an interview on 3/27/2021, at 1:00 P.M., Licensed Practical Nurse (LPN) A said if a resident does not have medications available, staff should call the pharmacy to get the medications ordered, or utilize the emergency kit. If the medications are not available through either option, staff should call the physician for an alternative medication. He/she did not call the physician to make the physician aware that Resident #1 did not have [MEDICATION(S)] solution available for his/her 7:00 P.M., dose on 3/25/2021 or the 7:00 A.M., dose on 3/26/2021. During an interview on 3/27/2021, at 8:00 A.M., Hospital Social Service Staff B said Resident #1 admitted to the hospital on 3/26/2021 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/29/2021, at 12:20 P.M., Resident #1's physician said he/she would have expected the facility staff to have called to get medication for the resident. [CONDITION(S)] medications are not something a resident with seizures should go without. Lacking medication very likely contributed to his/her [CONDITION(S)]. During interviews on 3/27/2021, at 11:00 A.M. and 12:20 P.M., Registered Nurse (RN) C said medications should always be administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff should utilize the emergency kit. Staff should call the physician to get a substitution if possible. Residents should never go without their medication because it is not available. During an interview on 3/27/2021, at 11:10 A.M., RN D said medications should be administered as ordered by the physician. If a resident does not have a medication available, it should obtained from the emergency kit. If the emergency kit does not contain the medication, the staff should notify the pharmacy to get the medication sent over urgently. If the pharmacy cannot deliver the medication quickly, the physician should be notified to get another medication ordered. The resident should not go without medications because one is not available. During an interview on 3/27/2021, at 12:25 P.M., Certified Medication Technician (CMT) E said staff should always give medications per the physicians' orders. If the medication is not available, staff should first check the emergency kit. If it is not available in the emergency kit, let the nurse know. The nurse should let the pharmacy know and a STAT (emergency, immediate) delivery can be made. If the stat delivery is not an option, the nurse should call the physician for a substitution. The resident should not be without a medication. During an interview on 3/27/2021, at 1:15 P.M., the Director of Nursing and administrator said they expect medications to be given per the physicians' orders. If a medication is not available, staff should contact the pharmacy. If the resident will not have the medication available for a dose, the staff should contact the physician to get an alternative or so they know the resident is missing a dose. The resident should not go without medications because the facility is without medications. MO 295

Based on interview and record review, the facility failed to consistently assess, monitor, and obtain treatment for one resident's (Resident #1) wounds in a timely manner. The facility failed to notify the physician upon identification of new wounds. The facility failed to notify the physician when the wounds deteriorated. The resident admitted to the hospital with [REDACTED]. Five residents with skin concerns were selected for review in a facility with a census of 130. 1. Record review of the Mayo Clinic website (http:www.mayoclinic.org) showed gangrene refers to death of body tissue due to a lack of blood flow or a bacterial infection. Gangrene most commonly affects the extremities, including your toes, fingers and limbs, but it can also occur in your muscles or internal organs. The chances of developing gangrene are higher if you have an underlying condition that can damage your blood vessels and affect blood flow, such as diabetes or [MEDICAL CONDITION]. Gas gangrene typically affects deep muscle tissue and the surface of your skin may initially appear normal and as the condition progresses, your skin may become pale and then evolve to a gray or purplish-red color. Gas gangrene can be life-threatening. Treatments for gangrene include surgery to remove dead tissue, antibiotics and other approaches. The prognosis for recovery is better if gangrene is identified early and treated quickly. Record review of the facility's policy and procedure for wounds showed a one page sheet labeled Skin Practice Guide Process Flowsheet. The flowsheet did not address the following: -Completion of accurate and complete assessment after identification of a wound; -Notification to the physician and responsible party; -Implementing timely treatments and interventions; -Ongoing assessments or as needed assessments when a wound declines. Record review of Resident #1's nurses' progress notes, dated 9/24/15 (day of admission), showed the following information: -Skin intact, with an area on the abdomen with two scabs and redness. The nurse documented to see the admission assessment for the measurements; -Pulses weak in all extremities, and [MEDICAL CONDITION] in lower extremities; -Required assistance with all daily needs. Record review of the facility's Skin Worksheet, dated 9/24/15 (day of admission), used by aides to identify abnormal skin areas showed the following information: -Hard scab on the resident's right little toe; -Staff did not identify any skin concerns on the resident's left foot. Record review of the resident's physician orders [REDACTED]. Record review of the resident's care plan, dated 9/24/15, showed the following information: -At risk for alteration in skin integrity related to decreased mobility; -Staff to observe skin condition with the daily cares and report any abnormalities. Record review of the September 2015 treatment administration record (TAR) showed the following information: -Staff documented completion of the body audit by signing their initials; -Staff did not document a description of any wounds; -Staff documented completion of the body audit daily from date of admission (9/24/15) through the month of September. Record review of the physician's Nursing Home History and Physical, dated 9/29/15, showed the following information: -The physician documented he could not complete a complete skin assessment because of the resident's size. He documented the resident had a full skin assessment on admission and staff told him the resident's skin was clear, with no open areas; -The physician documented a plan to get a wound consult set up for an abdominal wound debridement. Record review of the resident's physician orders [REDACTED]. Record review of the facility's skin progress note, dated 9/30/15, showed the following information: -Staff documented an assessment of the abdominal wound; -Staff did not document any skin concerns to the resident's feet. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 10/1/15, showed the following information: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Cognitively intact and able to make his/her needs known; -Required extensive assist of two staff with bed mobility; -Total dependence on two or more staff for transfers, dressing, eating, toilet use, personal hygiene and bathing; -Mechanical lift for transfers; -Staff did not identify or document any venous or arterial ulcers, [MEDICAL CONDITION] of foot, open [MEDICAL CONDITION] of foot, rashes, cuts, skin tears or moisture associated skin damage. Record review of the October 2015 TAR, showed staff did not complete the body audit six days out of 27 days (audits not completed on 10/12/15, 10/14/15, 10/17/15, 10/20/15, 10/21/15, and 10/26/15). Record review of a facility Skin Alteration Record completed by the nurses, dated 10/5/15, showed the resident had a bruise on his/her lateral bottom of his/her left foot measuring 3.2 cm by 2.8 cm, purple/black in color, with no drainage. Staff noted the surrounding skin normal in appearance. Record review of the October 2015 physician order [REDACTED]. Record review of the care plan, updated on 10/5/15, showed the following information: -Resident with friction blister to his/her left foot and lateral bottom under the small toe, bruise to left lateral foot, skin tear to left lateral pinkie toe, and skin tear to right outer foot beside pinkie toe related to impaired mobility; -Administer treatment per physician orders [REDACTED]. -Encourage and assist resident as needed to turn and reposition, use assistive devices as needed; -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician as needed; -Use pillows and/or positioning devices as needed. Record review of the physician's Nursing Home Visit, dated 10/6/15, showed the following information: -Examination unchanged since last week although staff told the physician the resident was starting to develop some breakdown on his/her backside and heels. The physician documented the ongoing plan for a wound consultation (9/29/15 physician progress notes [REDACTED]. -The physician did not document an assessment of the resident's skin breakdown. Record review of the facility's investigation completed by Registered Nurse (RN) A, dated 10/6/15, regarding an injury of unknown origin to the resident's feet, showed the following information:-Staff reported skin issues on the resident's right foot on 10/5/15, and on assessment found the resident with skin issues on both his/her feet and buttocks; -The resident reported he/she did not know how the skin issues happened; -Resident is six feet, four inches tall and staff transfers him/her using a mechanical lift; -Family said when observing transfers in other previous facilities, the resident's feet tended to hit the post of the lifts during transfers; -The wound to the right small toe and left small toe look consistent with this type of injury; -The blister and bruise to the left foot look like his/her foot had been against the bottom foot board of the bed; -Staff assessed the wounds and applied soft boots for protection. Staff instructed to be mindful of the resident's feet when lifting the resident in the mechanical lift; -Staff notified the family and physician. Record review of the care plan, updated on 10/5/15, showed a handwritten, undated note showing, after investigation, the feet wounds had been caused by injury, not friction. Record review of the resident's October 2015 POS did not show any treatment orders for the wounds to the resident's feet. Record review of the facility's skin progress note, dated 10/8/15, showed a weekly wound team assessment. The wound team did not document an assessment of the wounds on the resident's feet. Record review of the facility's skin progress note, completed by the nurses and dated 10/11/15, showed the bottom of the resident's left foot had a blister, measuring approximately 3.2 cm by 2.8 cm, skin hard, no drainage and surrounding tissue normal in appearance. Staff did not document the presence or absence of any odor to the wound. Record review of the facility Skin Alteration Record completed by the nurses, dated 10/11/15, showed staff documented the same measurements and descriptions for the resident's left lateral and bottom of his/her left foot as on the previous assessment (10/5/15). Record review of the facility Skin Worksheet, dated 10/16/15, filled out by an aide when the resident had a bath/shower, showed staff identified the resident had a dressing on his/her abdomen, dressing and redness on his/her bottom, and breakdown on both feet. Record review of a facility provided hand written note (not a part of the resident's medical record), dated 10/21/15 and unsigned by staff, showed staff did not document any measurement or assessment of the left foot wounds. Staff documented application of skin prep to the foot, placed dry 4 by 4 gauze between the 4th and 5th toes to keep dry. Record review of the October 2015 POS did not show any physician order [REDACTED]. Record review of the facility's Skin Worksheet, dated 10/27/15 (date of discharge) and filled out by an aide when the resident had a bath/shower, showed the resident with abnormal skin condition on his/her bottom and right foot. Staff did not identify the area on the resident's left foot being abnormal. Record review of a facility provided hand written note (not a part of the resident's medical record), dated 10/27/15 and unsigned by staff, showed the resident's left foot eschar measured 15 cm by 4.8 cm. The end of the resident's 5th toe was black. The resident had an open area, measuring 4.2 cm by 1.9 cm where eschar had come off. The open area had red beefy tissue with no odor noted. The resident had an area on his/her right outer foot measuring 2.3 cm by 1.0 cm with pink tissue. The eschar pad had fallen off the area. (First assessment completed of the left foot wounds since 10/11/15, over two weeks prior) Record review of the resident's physician orders, dated 10/27/15, showed the following information: -Order for staff to use skin prep to the eschar pad on the bottom of his/her left foot daily on the day shift. (Review of the POS [REDACTED] -Order for staff to send the resident to the emergency room for evaluation and treatment. Record review of the nurse's note for a change of condition, dated 10/27/15 at 5:51 P.M., showed the resident complained of general malaise (discomfort, often a sign of infection), had four green emesis and the nurse documented his/her temperature at 99.5 orally (elevated). Staff notified the physician and received an order to send the resident to the hospital for evaluation and treatment. Staff notified the resident's family. Record review of the hospital records, dated 10/27/15, showed the following information: -Resident had black necrotic tissue on the small toe and lateral aspect of the left foot with odor consistent with gangrenous tissue; -Resident reported being sick with nausea and vomiting since 9:30 A.M. today, likely secondary [MEDICAL CONDITION]. Resident reported his/her left foot started to have changes about 1 1/2 weeks ago; -Resident admitted for further evaluation and possible surgical excision of the necrotic tissue left foot and for treatment of the nausea and vomiting; -Clinical impression included:[MEDICAL CONDITION], left foot infection, gas gangrene of the left foot, and non-intractable vomiting with nausea; -Resident had a stage fifth ray amputation (removal, usually by surgery, of a limb, part, or organ) of his/her left foot. Resident will possibly need a repeat debridement to the foot; -Resident will not return to this facility on discharge. During an interview on 11/12/15, at 10:20 A.M., Licensed Practical Nurse (LPN) C said the resident wore boots on both feet. (Review of the physician orders [REDACTED]. During an interview on 11/12/15, at 2:30 P.M., Registered Nurse (RN) A said staff asked him/her on 10/6/15, to assess the resident's wounds on his/her feet. The right foot had a skin tear on the outer pinkie that was pink/red. The resident's left foot on the top outside pinkie toe had a bruise and a blister area that was not open. The resident had a small blister at the base of the toes and the area had a purple/blue color. They did not have treatment orders for the resident's feet and he/she did not notify the physician for orders. The floor nurses call the physician for orders. RN A said the day the resident went to the hospital (10/27/15) the right toe had healed up and the left foot was black and the resident's little toe was black. The resident had some moisture between the toes and 1 to 2+ [MEDICAL CONDITION] of the lower left leg. The resident wore boots on both feet all the time. During an interview on 11/12/15, at 5:00 P.M., CNA H said two staff used a bariatric mechanical lift to transfer the resident. He/she said the resident constantly slid down in bed and his/her feet hit the bottom foot board of the bed. Staff kept moving the resident back up in the bed. The resident wore boots on both feet. During an interview on 11/16/15, at 10:45 A.M., the Director of Nursing (DON) said the wound team was made up of herself and two assistant directors, RN A and LPN B. The hall nurses do the weekly skin audits. The hall nurses document in the TAR and the nurses' notes. The DON said they send a resident to the wound clinic if the wound does not respond to treatment or if it declines. Usually when it is at a Stage III or Stage IV level, or when they cannot see the wound bed, they send the resident to the wound clinic. Physicians are updated every two weeks on the wounds or if a wound does not show progress or healing. If the staff asks a physician to look at a wound, they will. During an interview on 11/16/15, at 2:15 P.M., Certified Nurse Aide (CNA) F said it took two staff to transfer the resident with the mechanical lift. Staff put blue boots on his/her feet. CNA F said he/she knew the resident had wounds on his/her abdomen, bottom and feet. During an interview on 11/16/15, at 2:45 P.M., LPN E said the day shift staff completed the treatments and wound assessments on the resident. Staff provided care to the resident in pairs due to his/her high acuity level. The resident wore boots and socks on his/her feet. He/she did not see the resident's wounds. The day shift nurses completed the wound assessments and the treatments. During an interview on 11/16/15, at 4:05 P.M., CNA G said the resident required total care. The resident wore boots on both feet. During an interview on 11/17/15, at 3:57 P.M., the resident's physician said the resident had an injury to his/her left foot and he/she had poor circulation in his/her feet. He/she saw the resident's feet on 10/6/15, and noted the bruise on the resident's left foot. The physician said the resident's abdominal wound improved with treatment. The physician said he/she did not see the resident after 10/6/15. The physician said the wound clinic did not evaluate and treat all the resident's wounds on 10/19/15, as he/she ordered. During an interview on 11/19/15, at 3:45 P.M., the physician assistant, at the wound clinic, said they received a referral from the facility for evaluation of the resident's left buttock wound with eschar of unknown duration. After they receive a referral, the resident is usually seen within a week. The wound clinic saw Resident #1 on 10/19/15. The physician assistant said they did not evaluate the resident's abdominal wound or his/her feet as the facility only requested evaluation of the resident's left buttock wound. Complaint # MO 055

Based on interview and record review, the facility failed to complete accurate, comprehensive, and consistent assessments for one resident (Resident #1)'s left buttock pressure ulcer. The facility failed to notify the physician and obtain treatment orders in a timely manner when staff first identified the pressure ulcer. The facility failed to follow the physician's orders [REDACTED]. The facility identified the left buttock pressure ulcer deteriorated to an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (dead tissue- tan, brown, or black) in the wound bed) pressure ulcer. Five residents with skin concerns were selected for review in a facility census of 130. 1. Pressure ulcer staging according to the U.S. Dept. of Health and Human Services Clinical Practice Guidelines Number 15 showed: -Stage I pressure sore (a persistent area of skin redness without a break in the skin, that is nonblanchable); -Stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater); -Stage III pressure sore (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone); -Stage IV pressure sore (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures). Record review of the U.S. Dept. of Health and Human Services Clinical Practice Guidelines, Number 15, treatment of [REDACTED]. -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and [MEDICATION NAME] (healing by the growth of epithelium over a denuded surface). -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer. -Reassess pressure ulcers at least weekly. -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION], loss of granulation tissue, and a purulent discharge. -A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. 2. Record review of the facility's policy and procedure for wounds including pressure ulcers showed a one page sheet labeled Skin Practice Guide Process Flowsheet . The flowsheet did not address the following: -Completion of assessment after identification of a wound; -Notification to the physician and responsible party; -Implementing treatments and interventions; -Ongoing assessments or as needed assessments when a wound declines. Record review of Resident #1's nurses' progress note, dated 9/24/15 (day of admission), showed the following information: -Skin intact, with an area on the abdomen with two scabs and redness. The nurse documented to see the admission assessment for the measurements; -Resident requires assistance with all daily needs. Record review of the resident's physician orders [REDACTED]. Record review of the resident's care plan, dated 9/24/15, showed the following information: -At risk for alteration in skin integrity related to decreased mobility; -Staff to observe skin condition with daily cares and report any abnormalities. Record review of the September 2015 treatment administration record (TAR) showed the following information: -Staff documented completion of the body audit by signing their initials; -Staff did not document a description of any wounds; -Staff documented completion of the body audit daily from date of admission (9/24/15) through the month of September. Record review of the physician's Nursing Home History and Physical, dated 9/29/15, showed the following information: -The physician documented he/she could not complete a complete skin assessment because of the resident's size. He/she said the resident had a full skin assessment on admission and staff said the resident's skin was clear with no open areas; -The physician documented a plan to get a wound consult set up for an abdominal wound debridement. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/1/15, showed the following information: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Cognitively intact and able to make his/her needs known; -Required extensive assist of two staff with bed mobility; -Total dependence on two or more staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing; -Mechanical lift for transfers; -At risk for pressure ulcers; -No unhealed Stage I or higher pressure ulcer; -Staff did not identify and document any moisture associated skin damage; -Identified use of pressure reducing bed and chair; -Staff did not document a turning/repositioning program for the resident; -Staff did not document any nutrition or hydration intervention to manage skin problems. Record review of a facility Skin Alteration Record completed by Registered Nurse (RN) A, dated 10/5/15, showed the resident had a superficial open area on his/her left buttock measuring 1.3 centimeter (cm) by 1.5 cm with dark pink/red tissue, with no drainage. Staff identified the resident did not have any pain at the site. Staff did not document the stage of the pressure ulcer or presence or absence of odor. Staff noted surrounding skin as purple in color. Staff did not document notification of the physician for treatment orders. Record review of the care plan, updated on 10/5/15, showed the following information: -Resident with a wound to the left buttocks related to impaired mobility and friction; -Staff documented goals including: pressure ulcer to show no signs of infection, heal without complication and resident not to develop any new areas of skin breakdown; -Staff to administer [MEDICATION NAME] as ordered by the physician prior to treatment/therapy; -Administer treatment as physician ordered; -Encourage and assist resident as needed to turn and reposition, use assistive devices as needed; -Promat mattress (pressure reducing) on bed; -Report evidence of infection, such as purulent drainage, swelling, localized heat, increased pain etc. Notify the physician as needed; -Use pillows and/or positioning devices as needed. Record review of the physician's Nursing Home Visit, dated 10/6/15, showed the following information: -Examination unchanged since last week although staff told the physician the resident was starting to develop some breakdown on his/her backside and heels; -The physician documented the ongoing plan for a wound consultation (9/29/15 progress note) for management. The physician was advised the wound consultation had not been arranged yet; -The physician did not document an assessment of the resident's skin breakdown or a treatment plan for the pressure ulcer on the left buttocks. Record review of the facility's skin progress note, completed by the nurses and dated 10/6/15, showed staff spoke with the family member about the resident's skin issues. The family member said they knew the resident had a bruise to his/her bottom before admission, but did not know it had opened up. Record review of the facility's skin progress note, completed by the nurses and dated 10/8/15, showed a weekly wound team assessment. The resident had a wound on his/her left lower buttocks, measuring 2.1 cm by 1.8 cm (larger size from previous assessment on 10/5/15) with a dark wound bed. Staff noted the surrounding skin looked red and angry. Record review of the resident's physician order, dated 10/8/15, (three days after staff identified the pressure ulcer) showed wound care to the left buttocks pressure ulcer; clean with normal saline and pat dry. Apply wound gel to wound, apply skin prep (skin protectant) around the area and apply [MEDICATION NAME] (dressing) daily and as needed if soiled every day shift for wound care. Record review of the treatment administration record (TAR) showed between 10/8/15 and 10/19/15, the resident received the treatment on eight of the 11 days. Record review of the facility pressure ulcer healing chart for monitoring trends in PUSH (a quick tool to monitor the change in a pressure ulcer over time) scores showed staff documented the initial PUSH assessment of the left buttock pressure ulcer on 10/8/15. The assessment showed a score of 8. The score can range from 0, indicating a closed (healed) pressure ulcer with increasing numbers indicating a decline in the pressure ulcer. Maximum score is 17. Record review of the facility's skin progress note, completed by nurses, dated 10/11/15, showed the pressure ulcer on the left lower buttocks measuring approximately 2.1 cm by 1.8 cm with a very dark pink wound bed. Staff documented the surrounding skin as red with no drainage. Staff did not document the absence or presence of odor. Staff did not document the stage of the pressure ulcer or if the resident had pain with the pressure ulcer. Record review of the facility Skin Alteration Record completed by the nurses and dated 10/11/15, showed staff documented the same measurements and descriptions for the resident's left buttock pressure ulcer as on the previous assessment (10/5/15). Record review of the facility Skin Worksheet, dated 10/16/15 and filled out by an aide when the resident had a bath/shower, showed staff identified the resident had redness on his/her bottom. Record review of the resident's physician orders, dated 10/19/15, showed a treatment order to the pressure ulcer on the buttocks changed to: Wash open area with antibacterial soap and water with each dressing change. Apply [MEDICATION NAME] paste (ulcer treatment) to approximately a nickel's thickness inside the wound bed only (not to the surrounding skin). Cover with Hydrocell foam (protective foam) and dry gauze. Secure with tape every 22 hours as needed related to wound care every two days on the day shift. Record review of a facility provided hand written note (not a part of the resident's medical record), dated 10/21/15 and unsigned by staff, showed the resident's left buttock pressure ulcer, measured 4.3 cm by 4.3 cm (increased in size from 10/11/15 assessment) with dry eschar. The resident's surrounding skin was pink/healthy. Staff did not document the stage of the pressure ulcer or if it was unstageable due to eschar. Staff did not document the amount of the wound bed covered with eschar. Staff did not document if the resident had pain with the pressure ulcer. Record review of the facility pressure ulcer healing chart monitoring PUSH scores, dated 10/21/15 (13 days after the initial PUSH assessment completed on 10/8/15) showed a PUSH score of 12 (indicating a decline in the pressure ulcer). Record review of the October 2015 TAR showed the following information: -Between 10/19/15 and 10/27/15 (day discharged to the hospital) staff documented the resident received one treatment to the pressure ulcer on the left buttock. -Staff did not complete the ordered daily body audit six days (10/12/15, 10/14/15, 10/17/15, 10/20/15, 10/21/15, and 10/26/15) out of 27 days. Record review of the facility Skin Worksheet, dated 10/27/15 (date of discharge) and filled out by an aide when the resident had a bath/shower, showed the resident with abnormal skin condition on his/her bottom and right foot. Record review of a facility provided hand written note (not a part of the resident's medical record), dated 10/27/15 and unsigned by staff, showed the resident's left buttock pressure ulcer, measured 5.2 cm by 4.9 cm (larger in size from the previous assessment on 10/21/15) with 100% eschar. Staff did not document the pressure ulcer as unstageable due to the 100% eschar. Staff did not document if the pressure ulcer had odor or drainage. Staff did not document notification of the physician regarding the change in the pressure ulcer. Record review of the facility pressure ulcer healing chart monitoring PUSH scores, dated 10/27/15 (day of discharge) showed the wound deteriorated from a PUSH score of 8 initially to a PUSH score of 14 on 10/27/15 (indicating a further decline of the pressure ulcer). Record review of the change of condition nurse's note, dated 10/27/15 at 5:51 P.M., showed the resident complained of general malaise (discomfort, often a sign of infection), had four green emesis and his/her temperature at 99.5 orally (elevated). Staff notified the physician and received an order to send the resident to the hospital for evaluation and treatment. Staff notified the resident's family. Record review of the hospital records, dated 10/27/15, showed the following information: -Resident had an an unstageable pressure ulcer on his/her left buttock. The wound was irregular, black eschar, pink and moist, measuring 4 cm by 5.5 cm, with moderate drainage and strong odor. Skin surrounding the pressure ulcer had redness/pink and was dry, wound edges were open; -Clinical impression included:[MEDICAL CONDITION], left foot infection, gas gangrene of left foot, unstageable pressure ulcer on left buttock, and non-intractable vomiting with nausea. During an interview on 11/12/15, at 10:20 A.M., Licensed Practical Nurse (LPN) C said the resident went to the wound clinic for evaluation on 10/19/15. During an interview on 11/12/15, at 2:30 P.M., Registered Nurse (RN) A said staff asked him/her on 10/6/15, to assess the resident's wounds on his/her bottom and feet. RN A said the resident had a bruised area on his/her bottom that was about 4 cm and round. (This conflicts with his/her assessment documented on 10/5/15, which showed the pressure ulcer as a superficial open area, measuring 1.3 cm x 1.5 cm). RN A said the floor nurses call the physician for orders. On the day of discharge to the hospital (10/27/15) the wound on his/her bottom was open with sloughing and redness at the edges of the wound. The old dressing had an odor but no necrotic tissue noted. During an interview on 11/12/15, at 5:00 P.M., Certified Nurse Aide (CNA) H said the resident constantly slid down in bed and his/her feet hit the bottom foot board of the bed. Staff kept moving the resident back up in the bed. The resident had an open sore on his/her bottom. During an interview on 11/16/15, at 10:45 A.M., the Director of Nursing (DON) said the wound team was made up of herself and two assistant directors, RN A and LPN B. They complete the weekly pressure ulcer assessments. The wound team documents in the nurses' notes and the PUSH tool sheet. The DON said they send a resident to the wound clinic if the wound does not respond to treatment or declines. Usually when it is at a Stage III or Stage IV level, or when they cannot see the wound bed, they send the resident to the wound clinic. Physicians are updated every two weeks on the wounds or if a wound does not show progress or healing. If staff asks a physician to look at a wound, they will. During an interview on 11/16/15, at 2:15 P.M., CNA F said he/she knew the resident had wounds on his/her abdomen, bottom and feet. During an interview on 11/16/15 at 2:45 P.M., LPN E said the day shift staff did the treatments and wound assessments on the resident. Staff provided cares to the resident in pairs due to his/her high acuity level. LPN E did not see the resident's wounds. The day shift nurses did the wound assessments and the treatments. During an interview on 11/16/15 at 4:05 P.M., CNA G said the resident was total care. He/She said it took two staff to provide many of his/her cares. During an interview on 11/17/15 at 3:57 P.M., the resident's physician said on his visit on 10/6/15, he did not see the wound on the resident's left buttock; he said the facility wound team assessed it. The physician said he did not see the resident after 10/6/15. During an interview on 11/19/15, at 3:45 P.M., the physician assistant at the wound clinic said they received a referral from the facility for evaluation of the resident's left buttock pressure ulcer with eschar of unknown duration. After they receive a referral, the resident is usually seen within a week. The wound clinic saw the resident on 10/19/15. The physician at the wound clinic debrided the 3.5 cm by 3 cm area and determined the pressure ulcer was a Stage III pressure ulcer. Complaint # MO 055

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent a suspected deep tissue injury for Resident #10 to development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (dead tissue- tan, brown, or black) in the wound bed) on the left heel. Unidentified person applied an unauthorized dressing to the resident's left heel and when staff removed the dressing found an unstageable pressure ulcer. Staff failed to identify a wound until it was unstageable and failed to contact the physician and obtain an order for [REDACTED]. one resident (Resident #13). The facility census was 131. According to the National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org, deep tissue injury (DTI) is a term to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominence's (Ankrom, 2005). Although it looks like a deep bruise, deep tissue injury is sometimes mistaken for a category I pressure ulcer. This can happen if only the color and fact that the skin is intact are noted. NPAUP's proposed definition, 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 (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) to Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer even with optimal treatment. (NPAUP, 2002). Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. 1. Record review of Resident's #10's face sheet (admission data) showed the facility admitted the resident on 03/29/15, with [DIAGNOSES REDACTED]. Record review of the Hospice admission forms showed Hospice admitted the resident to Hospice services on 04/22/15, with [DIAGNOSES REDACTED]. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's treatment administration record (TAR) dated from 05/01/15-05/24/15 showed, six licensed nurses initialed the resident TAR showing daily completion of the body audits. The nurses made no documentation to indicate staff identified the resident with suspected deep tissue injuries or an open unstageable ulcer. Record review of Resident #10's Significant Change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 05/05/15, showed the following information: -Cognitively moderately impaired; -Extensive assistance by two staff for bed mobility, transfers, dressing, toileting and personal hygiene; -Total dependent for locomotion on and off unit; -Supervision for eating; -Indwelling urinary catheter; -Always incontinent of bowel; -At risk for pressure ulcer; -Pressure relieving devices in bed and chair; -No current pressure ulcers. During an interview on 06/04/15, at 3:10 P.M., the Hospice Nurse said on 05/05/15, he/she found a suspected deep tissue injury and documented he/she reported to Licensed Practical Nurse (LPN) J. On 05/25/15, he/she found the Coban and cotton dressing stuck to the pressure ulcer to the point the pressure ulcer had to be debrided. After the debridement, the pressure ulcer could not be Staged due to the amount of eschar. Sometime around 05/25/15, the suspected deep tissue injury opened up and started oozing. The Hospice nurse said he/she visited the resident on Mondays and Thursdays. He/she denied applying the Coban and cotton dressing and said he/she did not know who or why someone did this. He/she said he/she spoke with the nurses when he/she visited a resident. He/she would report concerns about the resident's catheter, red areas and all areas of concerns. He/she did not call the physician about the pressure ulcer, but said someone did and received the new physician's orders [REDACTED].>During an interview on 06/05/15, at 09:20 A.M., LPN J, denied receiving report from the Hospice nurse about the resident's left heel suspected deep tissue injury. Record review of the Hospice Registered Nurse (RN) notes dated 05/07/15, showed the following: -Site Location: Left heel; -Type: Pressure Ulcer; -Pressure Ulcer Stage: Suspected deep tissue injury; -Healing: Heel boots on; -Wound not measured; -Incision/Wound Tissue Observed: [MEDICATION NAME], purplish blue; -Surrounding Tissue Bruising -Wound Margins: Tunneling absent; -No drainage: -No dressing change. Record review of Hospice Chart/Clinical Notes dated 05/07/15, showed the resident in bed resting with eyes closed. The resident denied pain. The resident had four-plus swelling (is the abnormal accumulation of fluid inside the interstitium and is clinically explained as being how much swelling) to both lower legs, three- to four-plus [MEDICAL CONDITION] to right upper arm and hand and one plus in left upper arm and hand. New order for [MEDICATION NAME] 10 milligrams (mg) every four hours as needed for pain. Hospice RN documented reporting this information to RN N (facility's staff) in regard to resident's new order and overall status. Record review of the facility's nursing progress notes dated from 05/01/15 to 05/07/15, showed staff wrote no documentation to indicate staff identified the resident's left heel with a suspected deep tissue injury; Record review of the resident's care plan showed staff did not develop a care plan with goals and interventions for the suspected deep tissue injury. Record review of the Hospice Routine visit by Hospice RN dated 05/11/15, showed the following information: -Site Location: Left heel; -Type: Pressure Ulcer; -Pressure Ulcer Stage: Suspected deep tissue injury; -Heel protectors on; -Wound not measured; -Incision/Wound Tissue Observed: Purple blue; -Surrounding Tissue intact; -No drainage: -No dressing change. Record review of Hospice Chart/Clinical Notes dated 05/11/15, showed the resident resting in his/her bed quietly. The resident remained with a fast heart beat; otherwise his/her vital signs remained within normal limits. Hospice RN reported to RN N in regards to resident's overall status. Record review of the facility's nursing progress notes dated 05/08/15, to 05/11/15, showed no documentation to indicate staff identified the resident's left heel with a suspected deep tissue injury; Record review of the Hospice RN notes dated 05/12/15, showed the RN did not assess left heel. Record review of the Hospice Routine visit by Hospice RN dated 05/18/15, showed the Hospice nurse assessed the resident's left heel with a new unstageable pressure ulcer. The surrounding tissue showed bruising and the pressure ulcer tissue was purple/bluish in color. The RN documented the pressure ulcer did not have a dressing or drainage. The RN applied heel boots to the resident's heels. Record review of the facility's nursing progress notes dated from 05/12/15 to 05/18/15, showed staff did not identify the new unstageable pressure ulcer, did not contact the physician and did not obtain a treatment order. Record review of the resident's care plan showed staff did not develop a care plan with goals and interventions for the new unstageable pressure ulcer. Record review of the Hospice Routine visit by Hospice RN dated 05/21/15, showed the left heel had an unstageable pressure ulcer. The surrounding tissue was intact and the pressure ulcer was pink in color. The RN documented the pressure ulcer did not have a dressing or drainage. The RN applied heel boots to the resident's heels. Record review of the facility's nursing progress notes dated from 05/19/15, to 05/21/15, showed staff did not identify the unstageable pressure ulcer, did not contact the physician and did not obtain a treatment order. Record review of the Hospice Routine visit by Hospice RN dated 05/21/15, showed the left heel had an unstageable pressure ulcer. The RN did not document measurement of the pressure ulcer or the wound margin. The surrounding tissue intact and the pressure ulcer was purple/bluish. The RN documented the pressure ulcer did not have a dressing or drainage. The RN applied heel boots to the resident's heels. Record review of the change in condition progress note dated 05/25/15, at 2:48 P.M., showed RN N documented a Coban (self adhering elastic support wrap) dressing removed from the resident's left heel that showed an unstageable pressure ulcer. The RN notified the wound team and placed a protective dressing to the pressure ulcer. RN N failed to notify the physician. During an interview on 06/04/15, beginning at 12:20 P.M., RN N said the Hospice nurse asked him/her on 05/25/15, for assistance in the resident's room. Someone had placed a cotton type dressing and covered with a Coban conforming dressing to the resident's left heel. RN N said staff did not have a physician's orders [REDACTED]. RN N did not notify the physician. During an interview on 06/05/15, at 3:30 P.M., the Director of Nursing (DON) said the physician became aware of the pressure ulcer on 05/27/15, when staff received a new treatment order. There is a communication issue between Hospice and the facility's staff. The DON would have expected facility staff to notify the physician when the unstageable pressure ulcer was first identified. Staff documentation, communication and intervention between Hospice and the facility needed much improvement. Record review of the plan of care initiated 05/27/15, showed the resident has an open area on left heel related to impaired mobility, swelling, two days after staff identified and nine days after Hospice RN identified the unstageable pressure ulcer. Record review of a physician's orders [REDACTED].M., showed the physician ordered (two days after facility staff and nine days after Hospice nurse identified the unstageable pressure ulcer) staff to apply Santyl ointment (an ointment that works by breaking down dead skin) 250 unit/gram. Apply to right heel topically every day shift for wound care. (Should be the left heel). Cleanse area with normal saline pat dry. Apply Santyl to eschar and cover with [MEDICATION NAME] (self adherent absorbent foam dressing) daily. Record review of the resident's TAR showed staff first initialed the treatment completed on 05/28/15, 24 hours after receiving the physician order [REDACTED]. Record review of the nursing progress notes dated 05/27/15, showed staff documented the resident's with an open area and escher to left heel. New order for treatment to left heel. Record review of the Hospice Routine Visit by Hospice RN dated 05/28/15, showed the Hospice nurse documented the right heel, (should be left heel left heel) had an unstageable pressure ulcer. The RN did not measure the pressure ulcer or evaluate the surrounding tissues or margins. The pressure ulcer was purple/bluish in color. RN documented the pressure ulcer not healing and showed moderate amount of serosanguineous drainage. A dressing did not cover the pressure ulcer. Record review of the General Progress note dated 05/29/15, at 5:18 P.M., four days after staff identified and 11 days after Hospice nurse first identified an unstageable pressure ulcer showed staff notified the family and physician regarding the open area to left heel. Record review of the Hospice Routine Visit by Hospice RN dated 06/01/15, showed the Hospice nurse documented the right heel, (should be left heel left heel) had an unstageable pressure ulcer. The RN did not measure the pressure ulcer or evaluate the pressure ulcer margins. The pressure ulcer was purple/bluish in color. The surrounding tissue intact and the pressure ulcer tissue was pink. The RN documented the pressure ulcer not healing. Santyl was used for a treatment to the pressure ulcer. The RN documented heel boots applied. Observation on 06/03/15, beginning at 11:45 A.M., showed LPN P and DCD O entered the resident's room to assess and change the dressing to the resident's left heel. Observation of the pressure ulcer to the left heel showed, the pressure ulcer measured approximately 5 cm x 5 cm, with black eschar covering approximately 75-85 percent of the wound bed. The surrounding tissue pink in color. No tunneling observed. Resident denied pain during the wound change. LPN P cleansed the pressure ulcer with normal saline, patted dry, applied skin prep to the pressure ulcer. The pressure ulcer covered with [MEDICATION NAME] and secured with kerlix. Record review of the nursing skin note dated 06/02/15, showed late entry: wound team assessment: Right heel (wrong heel) should be left heel measured 4.5 centimeters (cm) x 4.0 cm with black eschar covers 85 percent, scant amount of drainage, resident denies pain or discomfort. Resident is on Hospice and has expected decline in status. Heels are floated. [DIAGNOSES REDACTED]. Resident does have swelling to all extremities. Turned and repositioned frequently. Physician notified with new orders. Record review showed the facility initiated a Pressure Ulcer Healing Chart (PUSH) (is a quick reliable tool to monitor the change in pressure ulcer over time) on 06/02/15, eight days after the facility identified and 15 days after Hospice RN identified the resident with an unstageable pressure ulcer. During an interview on 06/04/15, 12:30 P.M., DCD O said the wound team consisted of four staff members. DCD O did not know where the dressing (Coban) came from, who applied the dressing or why someone applied the dressing. Staff received a new treatment order two days after identifying the unstageable pressure ulcer on 05/27/15. Four days after identifying the unstageable pressure ulcer staff documented notifying the physician and the resident's family on 05/29/15. During an interview on 06/04/15, at 1:06 P.M., LPN J said he/she worked on the medication and treatment cart several times over the past month. LPN J said he/she heard the Hospice CNA telling the facility's charge nurse about the area to the resident's left heel. LPN J could not recall the charge nurse name or the date, but said it took place approximately two to three weeks ago. LPN J did not know about the Coban dressing, or who applied the dressing. LPN J said staff needed a physician's orders [REDACTED]. There is a communication issue between the facility and Hospice. Hospice should have documented in the chart. Record review of the Nurse Practitioner's (NP) progress note dated 06/04/15 at 3:33 P.M., showed the NP at the facility and assessed the resident left heel. The resident is lying in bed, awake with friends at bedside. The resident denied any complaints, shortness of breath, or nausea/vomiting or diarrhea. He/she wearing oxygen per nasal cannula. The resident has an ulcer to his/her right heel (should be left heel) which nursing reported is improving. He/she has a poor prognosis and very frail, which is to be expected. He/she has swelling, black eschar to right heel (should be left heel) approximately the size of a half dollar, surrounding tissue is pink, no redness or signs of infection. During an interview on 06/05/15, at 09:15 A.M., LPN P said the last time he/she worked with this resident was 05/08/15, before he/she left for vacation. The resident did not have a pressure ulcer before that date. LPN P said he/she left for vacation and when he/she returned two weeks later a pressure ulcer developed on the resident's left heel. During an interview on 06/05/15, at 09:25 A.M., CNA Q said the resident is scheduled for bed baths on the evening shift, Mondays and Thursdays. Hospice scheduled bed baths for the resident on day shift, Mondays and Thursdays. CNA Q said he/she never gave the resident a shower, always bed baths, and the resident would often refuse because he/she received a bed bath just a few hours before. CNA Q said he/she did not know when the pressure ulcer started and did not see a dressing applied to the resident left heel. During an interview on 06/10/15, at 1:45 P.M., the resident's physician said the resident's wound to his/her left heel was a pressure ulcer with eschar. The pressure ulcer is dry and unstageable. The resident stays in bed all the time with chronic heart failure and swelling to the lower extremities. The physician did not know if the Coban dressing had any thing to do with the wound, but said the pressure ulcer was caused by pressure. The physician said staff needed his approval before applying a new treatment. The facility should have done better. Staff should have skin preventive in place when Hospice first identified a skin issue. Staff should have alerted him when they first found this issue. Hospice nurse found the suspected deep tissue injury and failed to tell anyone. The nurse assistants and the nurses should have found the skin issue if it was there. If there was any change in a resident's condition, to include a pressure ulcer, he expected staff to notifify him within 24 hours. 2. Record review of Resident #13's initial MDS, dated [DATE], showed the following information: -admitted on [DATE]; -[DIAGNOSES REDACTED]. -Required extensive staff assistance for transfers, mobility using a wheelchair, turning and repositioning, personal hygiene and bathing, and dressing; -Prefers a daily sink bath to showers; -At risk for pressure ulcers; -One pressure ulcer, Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater), present on admission; -Skin infection present due to picking at skin to arms, legs and chest. Observation on 6/3/15 at 9:25 A.M. showed the resident on his/her bed while LPN L and CNA K performed personal hygiene for the resident. Staff turned the resident to his/her right side so that LPN L could assess the resident's coccyx and buttock areas. LPN L and the surveyor agreed that there were two open areas; one to the right buttock and one to the coccyx. The right buttock wound was approximately 3.5 cm long by 1.5 cm wide, with drainage noted as bright red blood. LPN L cleaned the wound using gauze and normal saline solution, applied Mediseptic ointment, and applied skin prep ointment to the outer edge. The coccyx wound appeared as a wide, oval-shaped split, approximately 2.5 cm long. LPN L cleaned the coccyx wound with gauze and normal saline solution and then applied [MEDICATION NAME] cream. Observation on 6/4/15 at 2:42 P.M., showed the resident on his/her right side on the bed. DCD A undid the tape on the resident's brief and lowered the left side to allow assessment of the resident's coccyx and buttocks. DCD A said there were two open areas: one to the coccyx and one to the right buttock. The left buttock skin was dark pink, but intact. DCD A said the resident had changed rooms earlier that day, but staff from the resident's previous hall did not send any skin sheets with the medical chart. Record review of documentation for all residents who had skin impairment, showed staff did not document a Skin Impairment Sheet (non-pressure ulcer) for the resident. Record review of the facility notebook containing PUSH tool sheets (pressure ulcer status of healing, which utilizes a point system to graph the wound healing) for all residents having pressure ulcers, showed staff did not document a PUSH tool sheet for the resident. Record review of the nurses' notes since the admission date of [DATE], showed the following information: -4/15/15 admit note: Skin had multiple areas noted to both arms and legs; area on coccyx (tailbone area); -4/16/15: Coccyx treatment completed per orders. Staff did not document a description of the skin; -4/17/15: Coccyx treatment completed per orders. Staff did not document a description of the skin; -4/18/15: Coccyx red with open area. Staff did not document measurements of the wound; -4/19/15: Coccyx treatment completed per orders, area continues to be red and open. Staff did not document measurements of the wound; -4/20/15 late entry by staff completing the initial minimum data set (MDS - federally mandated assessment tool completed by staff): The resident was at risk for skin breakdown and had an open area, Stage II, on sacrum (tailbone area), and a sheared area on left buttock; -4/20/15: Dressing changed to sacral wound per treatment orders; skin had multiple sheared areas around sacrum; surrounding skin reddened. Staff did not document details or measurements of the mentioned areas; -4/22/15: Coccyx treatment completed per orders. Staff did not document a description of the skin; -4/23/15: Coccyx treatment completed per orders. Staff did not document a description of the skin; -4/24/15: Treatment to sacrum continued. Staff did not document a description of the skin; -4/24/15: Staff documented that coccyx treatment was completed per orders and measurements performed. Staff did not document a description or measurements of the wound; -4/25/15: Treatment using skin prep cream (used to strengthen skin) to shearing on left buttock continued. Staff did not document information regarding the coccyx; -4/25/15: Treatment given to left buttock; dressing change to sacral area; wound healing as expected; -4/26/15: Wound care given to buttock and sacral area; wound (not specified) healing as expected; wound bed (unspecified) red, but no drainage noted; -4/27/15: Coccyx treatment completed, moderate amount of odorless drainage. Staff did not document measurements of the coccyx wound or information regarding the left buttock; -4/28/15: Coccyx treatment completed, moderate amount of odorless drainage. Staff did not document measurements of the coccyx wound or information regarding the left buttock; -4/29/15: Coccyx treatment completed, moderate amount of odorless drainage. Staff did not document measurements of the coccyx wound or information regarding the left buttock; -4/30/15: Dressing change to sacrum, wound bed pink with no signs of infection, healing as expected. Staff did not document information regarding the left buttock; -5/1/15: Dressing to sacrum and buttock applied, no signs of infection. Staff did not document a detailed description of either location; -5/3/15: Dressing changed to buttock and sacral wounds per treatment orders; skin with multiple discolored areas around sacrum, surrounding skin intact, dark red; -5/4/15: Coccyx treatment completed, wound bed dark red with a moderate amount of drainage noted to site. Staff did not document information regarding the left buttock; -5/5/15: Wound care given to sacrum. Staff did not document a description of the wound; -5/5/15 late entry (for unspecified date): Skin assessment per wound team (first noted assessment by the wound team, twenty days after the resident was admitted ). Right buttock wound measures 4 centimeters (cm) by 3.8 cm and is superficial in depth; skin surrounding the wound is old scar tissue, dark purple in color; scant amount of serous (clear, watery) drainage; skin surrounding alteration is of normal color; -5/6/15: Treatment to left buttock skin shear. Staff did not document a description of the wound. Staff did not document information regarding to the right buttock wound or the coccyx wound; -5/6/15: Dressing applied to sacrum wound; healing as expected; -5/7/15: Coccyx was dark red/purple. Staff did not document a description of the right or left buttock; -5/8/15: Area on right buttock showed no change; current treatments continued; -5/9/15: Dressings changed to buttock (unspecified side) and sacral wound per treatment orders; skin with multiple discolored areas around sacrum; surrounding skin intact, dark red; -5/10/15: Dressing changed to buttock/sacral wound per treatment orders; surrounding skin intact, dark red; -5/11/15: Treatment applied to sacrum and buttocks. Staff did not document a description of the skin wounds; -5/15/15 at 12:10 P.M.: Staff nurse documented the wound team evaluated wound to coccyx this morning. Staff did not document information pertaining to a wound team evaluation; -5/15/15 at 13:06 P.M.: One member of the wound team, DCD M, and the charge nurse (un-named) did a skin assessment. Right buttock wound measured 4 cm by 3.8 cm and was superficial in depth. The skin around the wound is old scar tissue, dark purple in color; scant amount of serous drainage. Open area to coccyx measured 1.0 cm by 0.3 cm and was superficial. Wound bed was red tissue with scant amount of serous drainage; skin-surrounding alteration is of normal color. This entry was 10 days after the previous wound team note; -5/16/15: Wound care given to bottom area. Staff did not document a description of the skin; -5/19/15: Coccyx continued to have multiple areas that had bruising and bled on occasion. Staff did not document a detailed description of the multiple areas; -5/20/15: Coccyx continued to have multiple areas that had bruising and bled on occasion. Staff did not document a detailed description of the multiple areas; -5/21/15: Weekly skin assessment completed by the wound team. Wound to coccyx measured 2.0 cm by 0.4 cm by 0.2 cm in depth. Wound edges macerated (abnormally softened); wound bed clean, pink tissue; scant amount of clear/white drainage; surrounding skin of normal color. Left buttock wound had three areas: lower area measured 0.8 cm by 0.5 cm, middle area measured 1.6 cm by 0.5 cm, and the top area measured 1 cm by 3 cm - all were superficial in depth. Surrounding skin was red. The wound had scant amounts of serous drainage from all sites. Right buttock wound measured 2.4 cm by 0.8 cm, irregular in shape. Periwound (skin surrounding or near wound) was pale pink. Skin surrounding alteration site was red scar tissue; -5/23/15: Unable to stick adhesive dressing to sacral wound because of moisture to raw, dark red skin; -5/24/15: Again, unable to stick adhesive dressing to sacral wound because of moisture to skin; improved redness from previous day; -5/25/15: Coccyx continued to have multiple open areas. Staff did not document a description of the skin; -5/26/15: Buttocks had excoriated (raw, scratched) areas with ongoing treatments. Staff did not document detailed descriptions of the skin wounds; -5/26/15: Wound care given to bottom area. Staff did not document descriptions of the wounds; -5/27/15: Weekly skin assessment per wound team. Open area to coccyx measured 1.0 cm by 0.2 cm by 0.1 cm in depth. Wound bed was dark pink; no drainage; skin-surrounding alteration was of normal color. Right buttock wound measured 3.0 cm by 1.0 cm and was superficial in depth; shape was irregular; wound bed was pale pink. Staff did not document information regarding the left buttock; -5/27/15: Wound care given to bottom area. Staff did not document descriptions of the wounds; -5/28/15: Coccyx had a small, reddened area; dressing applied; -5/29/15: Coccyx had a small, reddened area; new order for Mediseptic (ointment); -6/1/15: Wound care given to bottom area. Staff did not document descriptions of the skin wounds; -6/3/15: The sheared area to right buttock had scab covering off, with minor drainage noted. Wound elongated with jagged edges, wound bed red. Wound cleansed with wipes. Staff documented they would seek more comprehensive order for wound treatment. Staff did not document information regarding physician notification or receiving new orders; -6/3/15: late entry for 6/2/15: Weekly skin assessment per wound team. Coccyx wound was healed. Right buttock open area measured 3.2 cm by 1 cm by less than 0.1 cm in depth; moderate amount of bright red blood observed; wound bed had red tissue; surrounding skin was of normal color. Staff documented they updated the physician on the wound progress. Record review of the physician's orders [REDACTED]. 4/15/15: Cleanse open area on sacrum with normal saline and apply foam dressing to reduce pressure to area, once daily (order discontinued 5/29/15); 4/15/15: Apply skin prep to sheared area left gluteal fold every shift; 5/5/15: Cleanse right buttock open area with normal saline, pat dry and apply Mediseptic after each incontinent episode; apply skin prep to outer perimeter; 5/29/15: Apply [MEDICATION NAME] cream to coccyx topically every shift for redness/open areas. Record review of the facility's listing of residents with pressure ulcers, presented to the surveyors at the beginning of the survey, showed Resident #13 had one Stage II wound to the right buttock. During an interview on 6/4/15 at 9:40 A.M., LPN V said treatments to wounds are done by the hall nurses. For non-pressure ulcer skin issues, the hall nurses should document weekly measurements and other information in the nurses' notes and on a Skin Impairment sheet. The wound team, comprised of the Director of Nursing (DON) and the three Directors of Care Delivery (DCDs), assesses all pressure ulcers weekly and documents measurements and descriptions in the nurses' notes. The wound team also tracks the healing of pressure ulcers on a PUSH tool. When a hall nurse becomes aware of a new skin wound or other issue, they should contact the physician for orders, and document in the nurses' notes and on the 24-hour report for the following shifts. During an interview on 6/4/15 at 11:20 A.M., LPN L said the hall nurses do the assessments for all skin issues that are not pressure ulcers, and do the treatments for all wounds. The hall nurse should document wound measurements and detailed information pertaining to the skin issues in the nurses' notes and on the skin sheets. The nurse should report any negative changes to skin to the physician and to the oncoming shift nurse verbally and on the shift report. The wound team assesses all pressure ulcers and documents wound descriptions and measurements in the nurses' notes. During an interview on 6/4/15 at 11:40 A.M., DCD M said the floor nurses should document anything changed or new regarding skin issues or wounds in the nurses' notes and on the 24-hour report for oncoming shift staff. DCD M was unaware that Resident #13's coccyx wound had re-opened after the wound team completed their assessment on 6/2/15. During an interview on 6/4/15 at approximately 3:15 P.M., DCD M said he/she used the wound team docum

Based on interview and record review, the facility failed to correctly transcribe admission physician orders; follow facility policy for verification of admission orders [REDACTED] provide adequate assessment, monitoring, and documentation following medication errors for one resident (Resident #29) who received a significant overdose of insulin and incorrect dosage of [MEDICATION NAME] for three days. The facility failed to correctly transcribe (Resident #31)physician order's for [MEDICATION NAME] and Potassium and failed to administer [MEDICATION NAME] and Potassium at the physician-ordered frequency for a period of 24 to 48 hours resulting in a critically high potassium level. The facility failed to notify the resident's family or guardian of the medication error in a timely manner and failed to follow facility policy regarding follow-up assessment, monitoring, notifications, and documentation after a medication error. This deficient practice directly affected these residents and was likely to have an affect on all other residents admitted from the hospital and/or who had a change in medication orders in a facility with a census of 132. 1. Record review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, required to be completed by facility staff, dated 5/2/11, showed the following information: -Short and long term memory problems; -Severely impaired decision-making skills; -Required extensive assistance for bed mobility; -Total dependence on staff for dressing, eating, toilet use, and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the hospital discharge summary for hospital admission 7/18/11 and hospital discharge date of [DATE] showed discharge [DIAGNOSES REDACTED]. The GFR is the number used to figure out a person's stage of kidney disease), and [MEDICAL CONDITION], Record review of the hospital discharge summary for hospital admission 7/22/11 and hospital discharge date of [DATE] showed discharge [DIAGNOSES REDACTED]. Record review of the nurses' notes, dated 7/26/11, at 10:00 P.M., showed licensed practical nurse (LPN) H documented the resident arrived at the facility with family. The nurse faxed the pharmacy and called the pharmacy regarding the medication list. The nurse notified the physician of the resident's readmission. Record review of the facility to facility transfer orders, dated 7/26/11, showed the following information: -[DIAGNOSES REDACTED]. -Accuchecks (blood glucose level checks) before meals and bedtime; -Discharge/transfer medication list from hospital included the following medications: [REDACTED] -[MEDICATION NAME] 100 units/milliliter, 3 milliliter (ml) pen for a dosage of 18 units subcutaneous (SQ) injection every morning; -Humalog 100 units/milliliter, 3 ml pen with dosage of low dose correction (amount of insulin dependent on blood glucose level checks) subcutaneous with meals and at bedtime; -[MEDICATION NAME] 50 mg tablet for dose of 25 mg/half tablet at bedtime. Record review of the admission 7/26/11 physician order [REDACTED]. -[MEDICATION NAME] 100 units (SQ) every morning at 7:00 A.M. (instead of the physician-ordered 18 units) -Humalog insulin per sliding scale based on before meals and bedtime accucheck levels. -Sliding scale based on blood glucose levels as follows: 0-199-no units of insulin; 200-249-2 units; 250-299-3 units; 300-349-4 units; 350 or above-5 units. -If blood glucose greater than 400, call physician; -Notify physician if blood glucose less than 40 or greater than 400. Record review of a blank "New Admission Chart Check" form, showed the form included admission tasks to be completed including transcription of medications with completion of POS and medication administration record (MAR). The medications and orders are confirmed with the attending physician. The admitting nurse faxes the medication orders to the pharmacy. The nurse also calls the pharmacy and medications requested "STAT" (as soon as possible). A second nurse reviews and validates the transcriptions. The bottom of the form had lines for the admitting nurse and the validating nurse to sign and date. During interview on 8/15/11, at 3:59 P.M., LPN H said the resident entered the facility on 7/26/11 at 8:45 P.M. The second nurse, who is supposed to verify the transcription of the orders, is whoever can check it. That night, he/she was trying to get orders done and passed it on to the night shift. LPN H thought the admission was complete except for the verification of the orders. LPN H questioned the [MEDICATION NAME] order because he/she did not think it sounded right. He/she questioned it verbally and asked the night shift nurse to do the second check. LPN H faxed the medication list to the pharmacy and called them. The second nurse check should be noted on the physician orders. LPN H did not think anyone did the second check by the time he/she left work. No staff had signed as completing the second check. Night shift does a 24 hour chart check that includes all new orders and new admissions. The 24 hour check should be documented on the POS, he/she thought. The nurse said he/she got in a hurry and did not read the whole order carefully. Record review of the August 2011 POS, showed a pre-printed order dated 7/20/11 of [MEDICATION NAME] 18 units SQ daily in the morning. Record review of the nurses' notes, dated 7/27/11, at 4:00 A.M., showed LPN I documented the resident slept quietly through the shift. During interview on 8/15/11, at 2:17 P.M., LPN I said the nurses go back over the chart for the past 24 hours and make sure no orders were missed. If a resident has any new orders, the night shift makes sure the orders have been transcribed correctly to the MAR as appropriate. When a resident is admitted to the facility, two nurses verify and make sure the POS is checked and is correct. LPN I said he/she had seen in the past 4-5 nurses complete the checks before and still find errors. The 24 hour check is to make sure orders are correct and the MAR is correct. The night shift charts a day ahead. On the night shift (7/26/11 into 7/27/11), LPN H (evening shift 7/26/11) gave report and said the resident was back in the facility. LPN H said nothing had changed on the orders for the night shift. LPN H did not mention insulin at all. Record review of the July 2011 MAR, dated 7/26/11 admission, showed the following information: -On 7/27/11, at 6:00 A.M., the resident's blood glucose level was 152. -On 7/27/11, at 7:00 A.M., LPN J administered [MEDICATION NAME] 100 units to the resident (instead of the physician-ordered 18 units). Per the sliding scale, the resident did not receive any additional Humalog insulin. -On 7/27/11, at 11:00 A.M., the resident's blood glucose level was 283. Staff documented administering 3 units of Humalog insulin based on the sliding scale. Record review of the nurses' notes, dated 7/27/11, at 2:00 P.M., showed LPN J documented the resident rested in bed and showed no signs and symptoms of discomfort. During interview on 8/15/11, at 3:40 P.M., LPN J said he/she had taken care of the resident before. He/she had not worked that hall for awhile, it had been approximately 2 to 4 weeks. He/she thought the insulin dose was kind of unusual, but he/she did not stop to check the MAR against the orders. The resident had been back and forth to the hospital and he/she thought maybe, the dose had been increased due to the hospital stays. LPN J did not mention the unusual dose to any other staff. LPN J thought the order had already been checked by two nurses per protocol and gone over in the Eagle room (daily meeting where management team reviews medical records) . The resident's blood glucose levels were normal that day shift (7/27/11). The resident did not have any signs or symptoms of any problems. LPN J said he/she became aware of the medication error on 7/28/11 at approximately 11:30 A.M. to 12:00 P.M. One of the other nurses paged him/her and then found LPN J in the hall and asked how much insulin he/she gave on 7/27/11 morning. LPN J told the other nurse 100 units as documented on the MAR. The other nurse asked LPN J if he/she had thought to check the physician order [REDACTED]. LPN J found out the dose was supposed to be 18 units instead of 100. LPN J became upset and started to yell, but then hung up the phone and left the floor. LPN J broke down and began crying. LPN J said he/she went to his/her car and began to hyperventilate. LPN J called his/her physician and told them he/she needed to talk to someone in the physician's office. The physician said he/she wanted to see LPN J as soon as possible. LPN J told the physician he/she would need to find coverage and the physician said to find coverage at work and get there as soon as possible. LPN J came back into the facility from his/her car. The assistant director of nursing services (ADNS ) approached LPN J in the hall and thanked the nurse for being honest. LPN J said he/she became upset and told the ADNS he/she needed to leave. The ADNS said to speak to the scheduling coordinator and discussed the need to finish the medication pass and the treatments, and then LPN J could leave early. LPN J said he/she wanted to finish those tasks and do what was best for the residents. LPN J said he/she calmed down enough to do those tasks. LPN J said he/she did not complete the incident report before he/she left the facility. LPN J said he/she failed to write the error on the 24 hour report or the report sheet. LPN J said he/she did not tell the ADNS that he/she did not complete the incident report. LPN J did not notify the family or the physician of the medication error. Record review of the July 2011 MAR, for admission date of [DATE], showed on 7/27/11, at 4:00 P.M., the resident's blood glucose level was 79. Staff did not administer any Humalog insulin based on the sliding scale. Record review of the July 2011 MAR, for admission date of [DATE], showed the following information: -On 7/27/11, at 8:00 P.M., the resident's blood glucose level was 175. Staff did not administer any Humalog per the sliding scale. Record review of the nurses' notes, dated 7/27/11, at 11:30 P.M., showed LPN H documented no signs and symptoms of pain or discomfort and would continue to monitor. During interview on 8/15/11, at 3:59 P.M., LPN H said he/she worked the evening shift on 7/27/11 and he/she did not report to anyone about any medication error. The resident did not have any low blood glucose levels that day. The family and the physician had not been notified about any error. No one knew about the error. The facility had an Eagle room meeting every morning and they go through all the orders. At the time of his/her disciplinary warning, LPN H questioned management regarding how the error was not caught in the Eagle room meeting. The nurse said the resident seemed normal on 7/27/11. Staff checked the resident's blood glucose levels before meals and at bedtime and they were within normal limits that day. Staff did not complete any extra assessments or monitoring of the resident. The staff makes sure the family knows everything that is going on with the resident, especially when new staff is working. The family usually calls 2-3 times per day. During interview on 8/15/11, at 2:17 P.M., LPN I said he/she worked the night shift (7/27/11 into 7/28/11 morning). The nurse said he/she knew about the medication error within 1-2 days, not sure exactly what point. Someone had said the resident received 100 units of [MEDICATION NAME]. The resident seemed normal during the night shift of 7/27/11. The nurse peeked in at the resident usually about three times a shift. The resident seemed normal. The nurse does not check blood glucose levels unless the resident had signs and symptoms. LPN H told him/her the physician had already been notified of the error. LPN I did not notify the physician of the medication error because he/she already had been notified. [MEDICATION NAME] was to be held for 24 hours. In report, the nurse said the family had been notified of the medication error. Record review of the July 2011 MAR, for admission date of [DATE], showed the following information: -On 7/28/11, at 6:00 A.M., the resident's accucheck was 80. -On 7/28/11, at 7:00 A.M., registered nurse (RN) K circled his/her initials as holding the [MEDICATION NAME] 100 units insulin. The RN documented on the narrative on the back of the MAR, [MEDICATION NAME] not given, dosage wrong. -On 7/28/11, at 7:00 A.M., staff did not administer any sliding scale Humalog insulin per the sliding scale. -On 7/28/11, at 11:00 A.M., the resident's accucheck was 167. Staff did not administer any sliding scale Humalog insulin per the sliding scale. During interview on 8/15/11, at 1:03 P.M., RN K said he/she worked the day shift on 7/28/11. The resident always had the [MEDICATION NAME] order. The nurse signed his/her name preparing to give the [MEDICATION NAME] and noticed the MAR showed 100 units of [MEDICATION NAME] as the order. The nurse said he/she did not give the insulin that morning because he/she thought the order was not correct and questioned the dosage. They discussed it in the Eagle meeting. The Eagle meeting usually lasted until about 11:30 A.M. When the resident left for the hospital previously, the dosage had been a lot different. RN K spoke to LPN L about the dosage not being the proper dose in report. LPN L was coming on evening shift (7/28/11). RN K saw the 100 units had been given the day before (7/27/11) when he/she started to give the dose on 7/28/11. The nurse said he/she talked to the family on the phone that morning about the resident's morning blood glucose levels, but not about the medication error. RN K said he/she did not make any changes to the MAR or POS to fix the error. Record review of the nurses' notes, dated 7/28/11, at 3:15 P.M., showed the nurse documented the resident rested in bed. The resident ate well this afternoon, blood glucose within normal limits and vital signs within normal limits. The nurse documented will continue to monitor. During interview on 8/15/11, at 3:12 P.M., LPN L said he/she found out about the medication error of 100 units of insulin that had been administered on 7/27/11. LPN L said he/she came to them and told them the [MEDICATION NAME] 100 unit physician order [REDACTED]. It had been circled on 7/28/11 as held. The nurse went to the ADNS and he/she said RN K should have fixed it on the MAR. The nurse checked the admission orders [REDACTED]. The nurse said he/she found out yesterday (8/14/11) that he/she should have also discontinued the [MEDICATION NAME] 100 units order. The nurse thought he/she wrote a telephone order for the 18 units of [MEDICATION NAME]. The nurse was not sure where he/she wrote it, just that it had been added to the POS and changed on the MAR. The nurse said he/she was told the family and physician had been notified. The nurse said he/she found out the next day (7/29/11) that family had not been notified because he/she got the "brunt of it". On 7/29/11 at 11:30 A.M. to 11:45 A.M., the resident's blood glucose was 35. The nurse told the aides to give the resident pudding because the resident was not symptomatic. The nurse notified the physician at that time and the physician said to feed the resident lunch and if he/she ate, then fine. The resident did not eat lunch and the blood glucose came up to 38. The nurse administered the [MEDICATION NAME] injection at approximately 1:00 P.M. to 1:30 P.M. When the nurse rechecked the blood glucose after the injection, the blood glucose level came up to 111. Staff should document the blood glucose levels on the MAR. The nurse should document the overall situation in the resident's medical record. When the nurse mentioned to the family that the blood glucose may have dropped due to the 100 units of [MEDICATION NAME] that was given on Wednesday (7/27/11), he/she found out the family did not know. The nurse said when he/she called the physician about the low blood glucose level, the physician said to continue the [MEDICATION NAME] 18 unit order. The nurse said he/she thought the physician knew about the medication error already. The nurse said maybe the blood glucose dropped due to the 100 units of [MEDICATION NAME] dose given on Wednesday. The physician did not comment whether he/she knew about the medication error or not. The physician said 100 units should not affect the resident's blood glucose two days after the fact. The nurse said he/she talked to the on-call physician on 7/29/11 and obtained an order to check the resident's blood glucose every four hours for 24 hours. The nurse said he/she checked the resident's blood glucose on 7/29/11 at 8:00 P.M. and it was within normal limits. The nurse told the next shift to watch the resident because the resident was a very brittle diabetic and to check the blood glucose level every four hours. The nurse said on the morning of 7/29/11, the resident's blood glucose level was normal. The nurse said he/she would not hold insulin unless the physician ordered to hold it. When he/she administered the [MEDICATION NAME] 18 units on 7/29/11, the resident was not symptomatic. But, the resident is usually not symptomatic even if his/her blood glucose level is low. Record review of the July 2011 MAR, for the admission of 7/26/11, showed the following information: -On 7/28/11, at 4:00 P.M., the resident's accucheck was 77. Staff did not administer any sliding scale Humalog insulin per the sliding scale. -On 7/28/11, at 8:00 P.M., the resident's accucheck was 88. Staff did not administer any sliding scale Humalog insulin per the sliding scale. Staff did not administer any sliding scale Humalog insulin per the sliding scale. Record review of a (undated) POS, showed the following information: -With an order date starting 7/29/11, staff to monitor blood glucose every four hours for 24 hours; -An (undated) order for [MEDICATION NAME] injection for blood glucose of less than 60. Record review of the nurses' notes, dated 7/29/11, at 4:00 A.M., showed RN M documented the resident rested in bed and seemed to be comfortable. The nurse documented no other changes at this time and would continue to monitor the resident. Record review of the July 2011 MAR, for admission date of [DATE], showed the following information: -On 7/29/11, at 6:00 A.M., the resident's blood glucose level was 93. -On 7/29/11, at 7:00 A.M., LPN L administered the physician-ordered dosage of [MEDICATION NAME] 18 units. The nurse did not administer any sliding scale Humalog insulin per the sliding scale. -On 7/29/11, at 11:00 A.M., LPN L documented the resident's blood glucose was 38 and then wrote a slash and documented a blood glucose of 111 under the 38. Record review of the nurses' notes, dated 7/29/11, at 1:30 P.M., showed LPN L documented the resident's blood glucose was 38 and he/she notified the physician. Since the resident could respond, the physician was okay with feeding the resident and then rechecking the blood glucose. After meals complete, staff to recheck blood glucose. At 2:30 P.M., LPN L rechecked the resident's blood glucose and it was 38 still. The aide reported the resident only ate 25% or less. The nurse administered a [MEDICATION NAME] injection to the resident. At 3:00 P.M., the resident's blood glucose was 111 and resident was responsive. Record review of the July 2011 MAR, for admission date of [DATE], showed on 7/29/11, at 4:00 P.M., LPN L documented the resident's blood glucose was 160. Record review of the nurses' notes, dated 7/29/11, at 6:45 P.M., showed the director of nursing services (DNS) spoke with the resident's family member after multiple attempts to talk to another family member. Record review of the July 2011 MAR, for admission date of [DATE], showed the following information: -On 7/29/11, at 8:00 P.M., the resident's blood glucose was 223. -On 7/29/11, at 8:00 P.M., LPN L held the resident's physician-ordered Humalog two units per sliding scale per family request. Record review of the nurses' notes, dated 7/29/11, at 10:20 P.M., showed LPN L spoke with a family member of the resident. The family member was very upset about the incident and believes it was completely "unavoidable" and stated would be in on Monday to speak with the DNS and administrator. Record review of the nurses' notes, showed on 7/30/11, at 4:00 A.M., LPN N documented the resident rested quietly in bed. At midnight, the resident's blood glucose was 34 and [MEDICATION NAME] administered. The resident's blood glucose had risen to 90. Record review of the situation background assessment request (SBAR- form, a computerized assessment form) dated 7/30/11 at 1:00 A.M., showed the resident's blood glucose level was 34 and then 38 on recheck. The resident was responsive. The nurse administered a [MEDICATION NAME] injection and rechecked the blood glucose 20 minutes later. The resident's blood glucose was 78. The nurse documented he/she would hold the [MEDICATION NAME] per family request. The nurse notified the physician on 7/30/11 at 2:00 A.M. The nurse received a new order to monitor the resident's blood glucose every four hours for 24 hours. The nurse documented the family had been notified of the earlier blood glucose drop and would notify the family in the morning. Record review of the fax, dated 7/30/11 by LPN N to the physician showed the nurse notified the physician regarding the blood glucose of 34 at midnight and the administration of [MEDICATION NAME] that resulted in the blood glucose rising to 78 after 20 minutes. The nurse notified the physician the resident currently received blood glucose level checks every four hours for 24 hours. The nurse notified the physician regarding the request of the family to hold the [MEDICATION NAME] for a few days. The physician responded back that it would be okay to hold the [MEDICATION NAME] until Tuesday (8/2/11). Record review of the July 2011 MAR, for admission date of [DATE], showed the following information: -On 7/30/11, at 6:00 A.M., LPN N documented the resident's blood glucose was 70. -On 7/30/11, at 7:00 A.M., LPN N held the 18 units of [MEDICATION NAME]. During interview on 8/15/11, at 2:43 P.M., LPN N said he/she worked night shift and worked the 7/29/11 into 7/30/11 night shift. LPN L told him/her in report that there had there had been a transcription error and to hold the [MEDICATION NAME]. The physician was aware. Staff was to check the resident's blood glucose every four hours. During the night, the resident's blood glucose dropped. The nurse monitored the resident closely and the resident acted fine. At midnight, the resident's blood glucose level was 34. The resident was awake, not clammy or flushed. The nurse administered [MEDICATION NAME] and checked the resident's blood glucose about 15 minutes later and it was 90. The nurse faxed the physician (dated 7/30/11) and talked to the family member. The family was already aware of the situation regarding the medication error and asked further questions about the medication error. Record review of the nurses' notes, dated 7/30/11, at 10:45 A.M.,showed the nurse documented the resident rested quietly at that time. The resident's blood glucose that morning at 8:00 A.M. was 27. Staff administered a [MEDICATION NAME] injection which was effective and the blood glucose level came up to 119. The nurse documented no problems noted at this time. The nurse did not document any additional assessment of the resident. The nurse did not document notification of the family or the physician regarding the low blood glucose. During interview on 8/15/11, at 1:18 P.M., LPN O, who worked 7/30/11 day shift, said the resident's blood glucose level was low that morning when he/she got report. The aide said the resident looked flushed. The nurse looked at the resident and the resident was clammy, but his/her eyes were open. The resident's blood glucose level was 27-29. The resident was not eating or drinking that day and would not open his/her mouth. The nurse had the staff try to give the resident a couple of snacks, but the resident would not take the snacks. LPN O gave the resident [MEDICATION NAME]. He/she said it should be documented on the MAR and documentation of any follow-up should be in the nurses' notes. The resident's blood glucose came back up after the [MEDICATION NAME]. The resident was fine the rest of the shift. The resident ate well at lunch, almost 100%. The nurse said he/she did not notify the physician about the blood glucose level. The nurse said he/she was supposed to, but did not. The nurse said he/she thought the physician was supposed to be notified for blood glucose levels less than 60 or greater than 400. The nurse said he/she thought he/she sent a fax to the physician about it, but could not find it. When working to get the blood glucose stable, the resident's family member called. The resident's family member just came to the facility to check on the resident and then the nurse talked to the family member about the resident's blood glucose and condition. Record review of the July 2011 MAR, for the admission date of [DATE], showed the following information: -On 7/30/11, at 11:00 A.M., the resident's blood glucose was 222. Staff administered 2 units of sliding scale Humalog insulin per physician's orders [REDACTED]. -On 7/30/11, at 4:00 P.M., the resident's blood glucose was 207. -On 7/30/11, at 8:00 P.M., the resident's blood glucose was 58. Record review of the nurses' notes, showed the following information: -On 7/30/11, (3-11 shift), LPN A documented the resident was in bed. The resident's blood glucose at 3:30 P.M. was 207. The resident's blood glucose at 8:00 P.M. was 58. The nurse gave the resident a chocolate shake and juice. The resident's blood glucose was 49. The nurse tried to get the resident to drink more juice. The resident's blood glucose was 50. The nurse notified the physician and administered a [MEDICATION NAME] injection. The resident's blood glucose was 59. The resident's family member called at the beginning and end of the shift. The nurse told the family member about the blood glucose levels of 207 and 59. The family member said he/she wanted the [MEDICATION NAME] held and no insulin given if the blood glucose level was under 200. Record review of the July 2011 MAR, for admission date of [DATE], showed on 7/30/11, at 11:00 P.M., LPN A administered [MEDICATION NAME] for decreased blood glucose after pudding and juice. At 11:45 P.M., the resident's blood glucose was 59 after the [MEDICATION NAME]. Record review of the nurses' notes, showed the following information: -On 7/31/11, at 3:40 A.M., LPN I documented the resident's blood glucose level was 50. Protocol followed and [MEDICATION NAME] given. The nurse also gave the resident snacks. The nurse spoke with the resident's family. The resident's blood glucose level went up to 116. The nurse documented the staff was watching the resident closely per the request of the resident's family. -On 7/31/11, at 5:50 A.M., LPN I documented at 1:00 A.M., the resident's blood glucose was 98. Staff gave food and snacks to the resident. The resident's blood glucose level rose to 110. At 4:30 A.M., staff rechecked the resident's blood glucose and the level was 28. The nurse administered [MEDICATION NAME] at that time. The nurse assessed the resident as clammy. The nurse notified the family member and the family member requested a transfer to the hospital. The nurse notified the physician earlier when the blood glucose level was 50 and the physician had given an order to transfer to the hospital if the family wished. The nurse called the ambulance and gave report to the hospital. The resident left the facility at 5:40 A.M. During interview on 8/15/11, at 2:17 P.M., LPN I (worked night shift of 7/31/11 into 8/1/11) said the evening shift nurse (LPN H) said he/she had issues with the resident's blood glucose levels. LPN H told him/her the resident's blood glucose level dropped around 9:30 P.M. to 10:00 P.M. They had trouble getting it to come back up. LPN H had tried snacks, such as ice cream and supplement drink. From the time it dropped until it came back up was approximately 1 ? hours. LPN H said the [MEDICATION NAME] should have been out of the resident's system. The resident was an extremely brittle diabetic anyway. LPN I called the physician toward the beginning of the night shift. He/she talked to the on-call physician. He/she said if the blood glucose goes down, he/she could send the resident to the hospital if the family wanted. The nurse called the family and told him/her what the physician said. The family said to keep an eye on the resident and if the blood glucose dropped to send the resident to the hospital. The staff gave the resident snacks during the night. At 1:00 A.M., the resident's blood glucose level was 98. The resident's blood glucose drops fast. It rose to 110. Staff monitored the resident through the night. At 4:30 A.M., the aides went to the room to do a bed bath and said something was wrong with the resident. The resident's blood glucose was 28. The nurse administered [MEDICATION NAME] as ordered by the physician, started the paperwork to send the resident out, and called the family. When the ambulance arrived, the resident's blood glucose was 50. They started an intravenous (IV) line and gave [MEDICATION NAME] IV. The nurse said staff should document notification of the family and physician in the nurses notes. Record review of the hospital discharge summary for admission date of [DATE] and discharge date of [DATE], included discharge Diagnoses: [REDACTED]. The physician documented the reason for hospitalization as the resident inadvertently received 100 units of [MEDICATION NAME] on Thursday morning. The resident also received 18 units of regular insulin on Friday morning. Following the administration of the insulin the resident had episodes of marked [DIAGNOSES REDACTED]. The morning of admission, the resident's blood glucose was in the 20's. En route to the hospital, the resident received glucose. Record review of the resident's current care plan, admitted [DATE], showed the following information: -Activity of daily living (ADL) self care deficit as evidenced by need for assistance related to [MEDICAL CONDITION] and general decline; -Endocrine system need for monitoring related to diabetes; -Monitor and report symptoms of [DIAGNOSES REDACTED]: weakness, pallor, diaphoresis, vision changes, and change in consciousness; -Monitor glucometer readings and lab values as ordered; -Administer medication as per physician orders [REDACTED]. -Hospice care due to disease process. Record review of the Incident Report, showed the incident occurred on 7/27/11, at 7:00 A.M. The error was described as a transcription error resulting in the administration of the wrong dose of insulin. Staff notified the physician on 7/29/11 at 1:30 P.M. Following the incident, staff continued monitoring blood glucose as ordered. When the resident had a change of condition, blood glucose monitoring changed to every four hours and order obtained for [MEDICATION NAME] for blood glucose less than 60 as needed. The resident admitted to the hospital on [DATE] at 5:40 A.M.