Every finding on record at St Johns Place

Based on interview and record review, the facility failed to electronically submit to the Center of Medicaid and Medicare Services (CMS) complete and accurate direct care staffing information for Fiscal Year Quarter Three 2025 (April 1 through June 30) and failed to enter nursing hours in the Payroll Based Journal (PBJ) 9/16/25 through 9/30/25. The census was 56. Review of the facility's Reporting Direct-Care Staffing Information (Payroll-Based Journal policy, dated October 2017, showed:-Policy statement: Staffing and census information will be reported electronically to CMS through the PBJ system in compliance with 6106 of the Affordable Care Act;-Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees;-Providers who are employed by the facility (including physicians) are included in direct-care staffing information; providers who bill Medicare directly are not included;-For auditing purposes, reported staffing information is based on payroll records, or other verifiable information;-Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both;-Manual entries are made only by designated personnel with training on the PBJ user interface;-Staffing data includes the number of hours worked each day by each staff member;-Census data is reported each fiscal quarter and includes resident census on the last day of each month of the quarter;-A manual log is available to record information should the facility experience temporary internet outage and cannot record staffing data directly to the PBJ system. This log may also serve as a tool to record data that will be manually uploaded quarterly. Review of the facility's PBJ Staffing Data Report dated Fiscal Year Quarter Three 2025 (April 1-June 30), showed:-Failed to submit data for the quarter, result triggered, definition: Trigger=no data submitted for quarter;-One star staffing rating, result triggered, definition: Trigger=star staffing rating equals 1;-Excessively low weekend staffing, result this metric is suppressed for this facility and quarter,-No Registered Nurse (RN) hours, this metric is suppressed for this facility and quarter;-Failed to have Licensed Nursing Coverage 24 hours/day, result this metric is suppressed for this facility and quarter;-Possible reasons for suppressed metrics: Invalid data, facility is too new to rate, and special focus facility. Review of the facility's validation report, dated 10/17/25, showed:-Submission date/time was 10/17/25 at 2:48 P.M.;-Submission file status: Received. Please check each file status below;-# of files processed: 1;-# of files accepted: 1;-# of files rejected: 0;-# of files submitted without facility authority: 0;-Total # of messages: 0. During an interview on 12/5/25 at 11:18 A.M., a CMS representative said the validation report does not confirm the data submitted was complete or accurate. It only confirms that some data was submitted with no fatal errors. The CMS representative suggested the facility run staffing reports that are available in [NAME] (system that provides quality measure information) using the job codes for the quarters dated April 1 through June 30, 2025, and July 1 through September 30, 2025. During an interview on 12/8/25, the Administrative Assistant said he has been submitting his PBJ information, and he has not received any errors. He provided the report for July 1 through September 30, 2025. He was unable to access the [NAME] job code report for April 1 through June 30, 2025. During an interview on 12/16/25 at 2:06 P.M., the CMS representative said the provider did not enter the Licensed Practical Nurse (LPN) hours after 9/16/25 and no Registered Nurse (RN) hours were provided from 9/16/25 through 9/30/25 in the PBJ.

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for two of two residents sampled (Residents #49 and #68). The census was 56.1.Review of the facility's admission and Discharge report, dated 12/3/25, showed between 8/1/25 and 12/1/25, there were 11 residents who transferred or discharged from the facility. 2. Review of Resident #49's progress note, dated 11/5/25 at 3:46 P.M., showed the nurse was alerted to the resident's room. Upon assessment, the resident could barely speak. When asked was it hard to breathe, the resident nodded his/her head. Doctor notified of transfer to the hospital. Review of the resident's undated census sheet, located in the electronic medical record, showed the resident discharged to the hospital on [DATE]. Review of the resident's medical record, showed no information regarding notification to the Ombudsman of the resident's transfer to the hospital. 3. Review of Resident #68's progress notes, dated 9/23/25 at 5:09 P.M., showed staff alerted the nurse that the patient's family took the resident out of the building to move out. Director of Nursing (DON) notified. Social Worker notified. Review of the medical record showed, no information regarding the Ombudsman was notified of the discharge. 4. During an interview on 12/1/25 at 11:02 A.M., a representative from the LTC Ombudsman said he/she looked for August, September, October and November of 2025 and they have not received any discharge/transfer notifications during those months. 5. During an interview on 12/9/25 at 1:25 P.M., Social Services (SS) said the Ombudsman should be notified of the discharges and transfers monthly. She did not have any documentation showing the Ombudsman were notified during the months from August to November. SS said sometimes she handed the discharge and transfer notifications to the Ombudsman while they were in the building, or she may send it to them, or she may notify them by phone. 6. During an interview on 12/9/25 at 4:35 P.M. the Administrative Assistant said the ombudsman should be notified of discharges and transfers. At one point, the facility was notifying them by e-mail.

Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect Resident needs. This failure affected three residents (Residents #45, #6 and #44), whose care plans did not accurately address recent falls with interventions and the use of side rails. The sample size was 22. The census was 56.Review of the facility's Care Plan policy, revised December 2016, showed:-A comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The comprehensive, person-centered care plan will: Include measurable and objective time frames; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Identify the professional services that are responsible for each element of care; Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/11/25, showed:-Cognitively intact;-Moderate difficulty hearing, speaker has to increase volume and speak distinctly;-Diagnoses included: heart failure, diabetes and hip fracture;-Independent for chair/bed-to-chair transfer;-Supervision or touching assistance (helper provided verbal cues and or touching/steading and/or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) for sit to stand (mechanical lift);-Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs but provides less than half the effort) for toilet transfers and tub/shower transfer. During an interview on 12/3/25 at 3:00 P.M. the resident said he/she fell in July. He/She was being weighed and when he/she grabbed the bar on the scale to pull up, the bar came forward, and he/she fell and broke his/her hip. Review of the care plan in use at the time of survey, showed no documentation the resident fell or if he/she was a fall risk. No documentation of the resident's transfer status. During an interview on 12/9/25 at 2:05 P.M., the MDS nurse said she would be responsible for completing the care plans. Care plans were updated quarterly, with a significant change and as needed. The Director of Nursing (DON) and floor nurses could also update care plans. If a resident fell, that should be on the care plan along with interventions. The resident's transfer status should be on the care plan. The care plan should be complete, accurate and a reflection of the resident's care needs. 2. Review of Resident #6's electronic physician's order sheet (ePOS), showed an order dated 6/5/25, resident may have side rails for mobility and self-care. Review of the resident's quarterly MDS, dated [DATE], showed:-Mild cognitive impairment;-Impaired upper and lower extremities on both sides;-Required substantial/maximal assistance for transfers;-Diagnoses included fractures, dementia and seizures. Review of the resident's Bed Rail Assessment, dated 10/20/25, showed the use of bilateral side rails. Review of the resident's care plan, revised 11/18/25, in use during the time of the investigation, showed no information regarding the use of side rails. Observations on 12/3/25 at 10:41 A.M., 12/4/25 at 8:16 A.M. and 12/5/25 at 12:08 P.M., showed the resident lay in bed. Quarter length side rails were raised on both sides. 3. Review of Resident #44's Bed Rail Assessment, dated 10/20/25, showed:-Bilateral side rail placement;-Side rails/assist bar are indicated and serve as an enabler to promote independence. Review of the resident's care plan, revised 11/2/25, in use during the time of the investigation, showed no information regarding the use of side rails. Review of the resident's comprehensive MDS, dated [DATE], showed:-Cognitive impairment;-Dependent on staff for all transfers;-Diagnoses included cancer and dementia. Review of the resident's ePOS, showed an order, dated 10/20/25, may have side rails up for mobility and self-care. Observations on 12/3/25 at 10:41 A.M., 12/4/25 at 8:29 A.M., and 12/8/25 at 12:46 P.M., showed the resident lay in bed on his/her back. Full length side rails were raised on both sides. During an interview on 12/8/25 at 2:14 P.M., Certified Nursing Assistant (CNA) D said the residents used side rails for positioning and transfers. During an interview on 12/9/25 at 2:02 P.M., the MDS Nurse said care plans were updated quarterly and as needed and should reflect each resident's individual needs. The use of side rails should be included on care plans. 4. During an interview on 12/9/25 at 4:35 P.M., The DON said the care plan should include falls with interventions, transfer status and side rails. The care plans should be accurate and individualized for each resident's care needs.

Based on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents on the weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to residents who required one on one activities (Residents #2 and #44). This deficient practice had the potential to affect all residents in the facility. The sample size was 22. The census was 56.Review of the facility's Activity Evaluation policy, revised June 2018, showed:-Policy Statement: In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities;-Policy Interpretation and Implementation: The resident's activity evaluation is conducted by Activity Department Personnel, in conjunction with other staff who evaluate related factors such as functional level, cognition and medical conditions that may affect activities participation. 1. Review of the facility's November 2025 Activity Calendar, showed:-On 11/1/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. social time, 11:00 A.M. church service, 5:00 P.M. movie time and 7:00 P.M. Blues game;-On 11/2/25 at 9:00 A.M. social time, 10:00 A.M. exercise, 2:00 P.M. bingo and 6:00 P.M. movie time;-On 11/8/25 at 7:00 A.M. tea and crumpets, 10:00 A.M. reminisce, 6:00P.M. movie time and 7:00 P.M. Blues game;-On 11/9/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. social time, 2:00 P.M. bingo;-On 11/15/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. exercise, 7:00 P.M. Blues game;-On 11/16/25 at 9:00 A.M. exercise, 10:00 A.M. social time, 3:00 P.M. church service, 2:00 P.M. bingo;-On 11/22/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. social time, 2:30 P.M. Blues game, 3:00 P.M. worship service;-On 11/23/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. reminisce, 2:00 P.M. bingo, 7:00 P.M. movie time;-On 11/29/25 at 7:00 A.M. tea and crumpets, 9:00 A.M. card games, 2:00 P.M. board games, 3:00 P.M. worship service and 7:00 P.M. Blues game. During an interview on 12/4/25 at 9:17 A.M., four residents, who the facility identified as alert and oriented, attended the group meeting. All four residents said activities are offered during the week during the afternoons. On weekends, there were no activities. There were church services on occasion and someone came in one Saturday once per month for bingo. They were bored on the weekends and wanted more activities. During an interview on 12/5/25 at 7:37 A.M., Certified Nursing Assistant (CNA) D said he/she worked at the facility for over a year, and activities were not offered during the weekends. Someone may come to the facility on Sundays for church services and one resident's family member comes in about once a month on a Saturday for bingo. He/She had overheard residents express concerns regarding the lack of activities on the weekends and was not aware of any residents receiving one on one activities. During an interview on 12/8/25 at 1:33 P.M., the Activity's Director said he/she was the only staff person who worked in the activities department, and he/she worked Monday through Friday, from 8:00 A.M. to 4:00 P.M. There was no activity staff on the weekends. Church services were offered three Sundays per month. Weekend activities were self-directed. There were no structured activities offered during the weekends. One on one activities were provided for bed-bound residents. He/She had not had the time to do one on one activities and did not have a list of residents receiving one on one activities. He/She did not have any documentation of one on one activities provided. 2. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/16/25, showed:-Cognitively intact;-No behaviors;-Diagnoses included heart failure and diabetes. Review of the resident's Activities assessment, dated 10/24/25, showed:-Resident attends activities of choice;-Resident does not attend any activities unless it's in the dining room. He/She attends bingo and attends the social events. He/She has come outside a few times. Resident likes to read and do word searches. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 12/1/25, COVID isolation with droplet precautions in private room with all care and services to be provided in room due to positive COVID test. During an observation and interview on 12/3/25 at 12:27 P.M., the resident lay in bed in an isolated unit. One other resident was on the unit. The resident's television was not working. He/She said he/she was placed on the unit a few days ago. He/She stared at the walls all day and all night because his/her television was not working and staff was afraid to enter the isolated area. The resident participated in activities when he/she was in his/her regular room. Staff was aware the television was not working and had not offered any one on one activities since he/she had been on isolation. During an observation and interview on 12/4/25 at 11:14 A.M., the resident lay in bed in an isolated unit. He/She said he/she was staring at the walls again today. The television was not working. During an interview on 12/5/25 at 7:37 A.M., CNA D said the resident had been on the isolated unit since the past Sunday. His/Her television was not working and staff was aware. There were no activities on the isolated unit. He/She was not sure why activities were not provided. 3. Review of Resident #44's Activity's assessment, dated 10/21/25, showed:-Resident attends activities of choice;-Resident does not attend activities. I have tried to get her to come to activities, but he/she refuses. I will keep trying. Review of the resident's care plan, updated 11/2/25, in use during the time of the investigation, showed:-Focus: I make my own activity choices;-Goal: To participate in the things I enjoy most if I choose to. I may need assistance from staff/family;-Interventions: Inform me of the daily activity and I will choose to attend. Assist me if needed to activity of choice if I prefer to participate. Encourage participation/socialization with others. Review of the resident's comprehensive MDS, dated [DATE], showed:-Cognitive impairment;-No behaviors;-Diagnoses included cancer and dementia. During an observation and interview on 12/3/25 at approximately 11:45 A.M., the resident lay in bed with no television or radio on in his/her room. The resident said he/she could not get the television to work and was not sure how long it was not working. At 11:53 A.M., Nursing Assistant (NA) I entered the resident's room. He/She said the resident's television was not working. He/She believed the resident had been in the room for three to four days without a working television. Observation on 12/3/25 at 5:39 P.M., showed the resident lay in bed in his/her bedroom. No lights, television or radio were on in the resident's room. When asked if the resident wanted to watch television, he/she said yes. Observation and interview on 12/5/25 at 12:13 P.M., showed the resident's family member in the resident's room holding the television remote controller. He/She said he/she was trying to fix the television and it had not been working. Staff was aware of the television not working. The resident could benefit from having a working television. 4. During an interview on 12/8/25 at 1:33 P.M., the Activity's Director said Residents #2 and #44 did not have working televisions and she was just made aware of it. Activities were also not provided for residents on isolation, as he/she was unable to go on the isolated unit due to health concerns. He/She was the only one in the activity department so the residents on the unit had not had any activities. 5. During an interview on 12/9/25 at 4:36 P.M., the Director of Nursing (DON) and the Administrative Assistant said activities were provided during the week for all residents. On the weekends, there were self-directed activities. Televisions were not a requirement. Although there was no documentation of residents receiving one on one activities, they have received it. They would expect activities to be provided to all residents, including residents on the isolation unit.

Based on interview and record review, the facility failed to ensure Nursing Assistants (NAs) who were employed by the facility were certified within four months of hire, for four out of four sampled NAs. The census was 56. Review of the facility's Nurse Aide Qualifications and Training Requirements policy, dated August 2022, showed:-Policy statement: Nurse aides must undergo a state-approved training program;-Definition: Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. This term may also include an individual who provides these services through an agency or under a contract with the facility, but is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay;-The facility will not employ any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or otherwise, unless: -That individual is competent to provide designated nursing care and nursing related services; and; -That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; -That individual has been deemed competent as provided in S483.1S0(a) and (b) of the requirements of participation. Review of the facility's current list of employees, hired since 3/20/24, showed:-NA L's hire date was 7/7/25;-NA M's hire date was 5/22/25;-NA N's hire date was 5/21/25;-NA O's hire date was 7/28/25. Review of the facility's daily staffing schedules dated 11/8/25 through 12/8/25, showed:-NA L was on the schedule on 11/10, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/24, 11/25, 11/27, 11/28, 11/29, 11/30, 12/2, 12/3, and 12/4;-NA M was on the schedule on 11/10, 11/11, 11/13, 11/14, 11/16, 11/18, 11/19, 11/20, 11/21, 11/23, 11/24, 11/25, 11/27, 11/29, 11/30, 12/2, 12/3, 12/4 and 12/5;-NA N was on the schedule on 11/10, 11/11, 11/12, 11/13, 11/15, 11/16, 11/17, 11/19, 11/20, 11/24, 11/26, 11/27, 12/3,12/4 and 12/5;-NA O was on the schedule on 11/8, 11/9, 11/11, 11/12, 11/14, 11/25, 11/26, 11/27, 11/28 and 12/3. During an interview on 12/5/25 at 12:15 P.M., the Director of Nursing (DON) said NAs have four months to take their Certified Nurse Aid (CNA) test. Two NAs were taken off the schedule until they complete their test. The DON did not know who the NAs were that was taken off the schedule. If an NA failed their test or if the NA did not complete their test within four months, they would be terminated. The NAs have had a hard time getting their test scheduled because there are only three places in St. Louis for them to take their test. During an interview on 12/9/25 at 1:15 P.M., CNA P (CNA staffing supervisor) said the facility had NAs who worked at the facility. NAs must complete their test within 4 months. If they pass one of their tests, they can continue to work. NA O was no longer at the facility. NA L received a separation letter last week. NA M has scheduled his/her test and NA N took his/her knowledge test yesterday and had his/her other test scheduled for Friday (12/12/25). All four NAs worked past their four months. During an interview on 12/9/25 at 4:35 P.M. The Administrative Assistant said NAs cannot work if they have not completed their CNA test within four months. The NAs are having a hard time getting their test scheduled because there are hardly any testing sites in St. Louis. Two staff have completed their test, and one NA has a test date scheduled, and one NA was terminated. The staffing supervisor was responsible for tracking the NA time.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 31 opportunities observed, 8 errors occurred resulting in a 25.80% error rate (Residents #48, #59, #9 and #56). The census was 56.Review of the facility's Adverse Consequences and Medication Errors policy, revised April 2014, showed:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services;-Examples of medication errors include: Omission, unauthorized drug, wrong dose, wrong route of administration, wrong dosage form, wrong dug, and wrong time;-Failure to follow manufacturer instructions and/or accepted professional standards. 1. Review of Advair Diskus (inhaled medication, used to treat lung disease) manufacturer instructions obtained from Advair.com, showed, Advair can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Advair to help reduce your chance of getting thrush. Review of Resident #48 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/25, showed:-Cognitively intact;-Diagnoses included diabetes. Review of the resident's order summary report, showed:-A physician order dated 4/8/25: Dapagliflozin Propanediol (used to treat diabetes) 10 milligrams (mg) by mouth in the morning for diabetes mellitus (DM);-A physician order dated 6/29/25: Advair Diskus Inhalation Aerosol Powder BreathActivated 100-50 microgram/actuation (mcg/act), 1 puff inhale orally two times a day for COPD (chronic obstructive pulmonary disease, lung disease);-A physician order dated 5/3/25: Senna (stool softener) 8.6 mg, give 1 tablet by mouth two times a day for constipation. Observation on 12/4/25 at 8:52 A.M., showed Certified Medication Technician (CMT) J prepared the resident's morning medications. He/She placed the tablets from the multi-dose packet into a medicine cup. The medications Dapagliflozin and Senna were not placed in the medication cup. The CMT provided the resident his/her Advair inhaler prior to giving the tablets. The CMT did not provide water and instructions for the resident to rinse and spit after using the inhaler. The CMT then gave the medication cup with the tablets to the resident. The resident took the tablets and drank water. Review of the resident's Medication Administration Record (MAR) at approximately 10:00 A.M., showed the CMT did not document the medication Dapagliflozin as given and documented that Senna was given. At 11:20 A.M., MAR showed Dapagliflozin was documented by CMT J as given. During an interview on 12/4/25 at 11:23 A.M., the resident said the CMT did not come back and administer any other medications. At 11:28 A.M., CMT J said the medication Dapagliflozin was not available and was not given. He/She could not find the Senna in the medication cart drawer and it was not given. He/She said whatever medications were signed off means they were given. He/She did not have the resident rinse and spit out after using the Advair inhaler. During an interview on 12/9/25 at 12:54 P.M., Registered Nurse (RN) B said residents on Advair should be provided with water to rinse and spit out after using the medication. 2. Review of Resident #59's quarterly MDS dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included heart failure, kidney failure, and hyponatremia (low sodium/salt level). Review of the resident's order summary report, showed:-A physician order dated 8/18/25: Klor-Con Oral (Potassium Chloride), 20 milliequivalent (mEq), give 1 packet by mouth one time a day related to hypo-osmolality (excess water, levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia;-A physician order dated 6/2/25: Thiamine HCl (vitamin B1) 100 mg, give 1 tablet by mouth one time a day for supplement;-A physician order dated 6/9/25: Aspirin EC Delayed Release 81 mg by mouth one time a day for deep vein thrombosis/blood clot). Observation on 12/5/25 at 8:42 A.M., showed CMT K prepared the resident's morning medications. He/She placed the tablets from the multi-dose packet into a medicine cup. The medications Potassium Chloride, Thiamine, and Aspirin were not placed in the medication cup. The CMT documented these medications as given. He/She administered the medications in the cup to the resident, then proceeded to prepare another resident's medications. He/She did not obtain the three medications from any packaging or stock bottles. During an interview on 12/8/25 at 10:24 A.M., the Director of Nursing (DON) said if over the counter (OTC) medications were not available in the resident medication packets, she expected the staff to use the stock bottles. The DON said the facility should have aspirin and thiamine in stock. During an interview on 12/8/25 at 4:07 P.M., Licensed Practical Nurse (LPN) A said all resident medications should be administered as ordered. Staff should not document medication as given if medications were not available. If not given, document in progress notes the reasons medications were not given. 3. Review of the manufacturer's instructions for administering Tresiba insulin (long-acting insulin), dated July 2025, showed how do I use Tresiba flextouch pen:-Check the insulin type;-Attach a new needle;-Prime your pen (turn the dose selector to 2 units. Press and hold the dose button until the dose counter shows 0. Make sure a drop appears;-Select the dose;-Give the injection. Review of Resident #9's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included diabetes. Review of the order summary report, dated 12/5/25, showed, a physician order for Tresiba flextouch pen-injector 200 unit/milliliter (mL). Inject 14 units subcutaneous (under the skin) in the morning for diabetes. Observation on 12/4/25 at 10:05 A.M., showed Licensed Practical Nurse (LPN) H removed the Tresiba insulin pen from the drawer, cleaned the end of the insulin pen and placed the needle on the pen, then he/she turned the dial to 14 units and administered the insulin. The nurse did not prime the insulin pen. 4. Review of the Novolog Flexpen (short-acting insulin) manufacturers instruction for use, showed:-Pull pen cap straight off;-Check the liquid in the pen;-Select a new needle;-Push the capped needle straight into the pen and twist;-Pull off the outer needle cap;-Pull off the inner needle cap;-Turn the dose selector to select 2 units;-Hold the pen with the needle point up. Tap the top of the pen gently a few times to let any air bubble rise to the top;-Hold the pen with needle pointing up. Press and hold in the dose button until the dose counter shows 0;-Turn the dose selector to select the number of units needed to inject.-Choose injection site;-Insert needle into the skin;-Press and hold down the dose button until the dose counter shows 0. Review of Resident #56's admission MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes. Review of the order summary report, dated 12/5/25, showed:-A physician order for: Novolog flexpen 100 unit/mL, inject as per sliding scale: if 251 - 300 = 8 units subcutaneously with meals for diabetes;-A physician order for: Novolog injection solution 100unit/mL, inject 10 unit subcutaneously three times a day with meals related to diabetes. Observation on 12/4/25 at 9:25 A.M., showed LPN H completed the resident's fingerstick blood sugar test with a result of 254. At 9:45 A.M. LPN H removed the NovoLog insulin pen from the drawer, cleaned the end of the insulin pen and placed the needle on the pen, then he/she turned the dial to 18 units and administered the insulin. The nurse did not prime the insulin. During an interview on 12/9/25 at 12:53 P.M., Registered Nurse (RN) B said insulin should be primed then turn the dial to the amount of insulin to be administered. 5. During an interview on 12/9/25 at 4:35 P.M., the Director of Nursing (DON) said insulin pens should be primed before turning the dial to the amount to be administered. The staff should administer resident medications as ordered. 260218726020932603584

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified one Certified Medication Technician (CMT) cart, one Nurse cart, one treatment cart and one medication room. Two out of the three carts and the medication room were checked for medication storage. Issues were found in the Nurse cart. The census was 56. Review of the facility's Medication Labeling and Storage policy, dated February 2023, showed:-The medication label includes, at a minimum: medication name (generic and/or brand); strength; and resident's name;-For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: the medication name; strength; quantity; accessory instructions; lot number; and expiration date (if applicable);-Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.1. Observation on 12/5/25 at 8:10 A.M., in the top drawer of the Nurse cart, showed one out of two insulin pens were open and undated. There was a blue cup with two green oval tablets, with no resident name or label identifying what the medication was and one bottle of Senna (stool softener) that was open with no lid on the medication. Registered Nurse (RN) B said the insulin pen did not have a name on it and he/she did not know when it was opened. He/she could not explain why there were pills in a cup with no name or label or why there was no lid on the senna. The nurse removed and items from the medication cart and discarded them.2. During an interview on 12/9/25 at 4:35 P.M., the Director of Nursing said there should not be medications in a cup with no label on it and medication bottles should have a lid on them.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for two residents (Resident #34 and #8). In addition, the facility failed to ensure staff used good infection control practices for one resident (Resident #19) when staff failed to perform hand hygiene between dirty and clean when personal care was provided and when staff placed the soiled brief and linens directly on the floor. The census was 56.Review of the facility's Implementing the use of EBP in Skilled Long Term Care Nursing Facilities policy, dated 2024, showed EBP should be used for residents with any of the following: indwelling devices (e.g., indwelling urinary catheter, feeding tube, and chronic wounds, that increase their risk of acquiring MDROs:-Recommendations for following EBP for nursing home staff based on care activities: Examples of care activities: providing care under clothes or dressings; taking the resident to the toilet or providing perineal care (peri care, cleansing of the genitals and buttocks area); and providing bed mobility, including rolling from side to side;-Infection control recommendation: Use hand hygiene, gown and gloves (high-contact activities). 1. Review of Resident #34's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/1/25, showed:-Moderately impaired cognition;-Total dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers) for toilet hygiene and chair/bed to chair transfer;-Had an indwelling urinary catheter;-Diagnoses included renal (kidney) insufficiency (partial kidney function failure), renal failure or end stage renal disease (ESRD, chronic irreversible kidney failure). Review of the care plan in use at the time of survey, showed:-Focus: the resident has an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) diagnoses;-Goal: the resident will maintain current level of function in through the review date;-Interventions: Bed mobility, totally dependent on 1-2 staff for repositioning and turning in bed and as necessary; Dressing, totally dependent on 1 staff for dressing; Transfer, totally dependent on 2 staff for transferring, mechanical lift for transfers. Review of the resident's order summary report, dated 12/9/25, showed a physician order to change indwelling urinary catheter monthly and as needed. Observation of the resident's room, showed:-On 12/3/25 at 3:13 P.M. and 12/4/25 at 11:34 A.M., no EBP signage on the door nor any personal protective equipment (PPE) available inside or outside the resident's room;-On 12/5/25 at 7:13 A.M., the resident lay in bed. His/her urinary catheter drained to gravity. No EBP signage on the door nor any personal protective equipment (PPE) available inside or outside the resident's room. Observation on 12/5/25 at 7:35 A.M., showed Nurse Aide (NA) E and NA F entered the room, performed hand hygiene and put gloves on. NA E provided peri care, while NA F held the resident over on his/her side. They placed the mechanical lift pad under the resident. NA E emptied the resident's catheter drainage bag. Then, attached the lift cloth to the lift and transferred the resident from the bed to the chair. Neither NA wore a gown while providing care. 2. Review of Resident #8's significant change MDS, dated [DATE], showed:-Severe cognitive impairment;-Diagnoses included: high blood pressure, stroke and malnutrition, and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability);-Feeding tube while a resident. Review of the resident's care plan in use at the time of survey, showed:-Focus: the resident has unplanned/unexpected weight loss related to poor food intake3/22/24 weight has stabilized. New feeding tube placement related to malnutrition. Resident refused to eat related to paranoia;-Goal: the resident will consume 50% two of three meals/day;-Interventions included tube feeding as ordered. Review of the resident's physician order summary, dated 12/4/25, showed a physician order for Jevity 1.5 (nutrition supplement) at 60 milliliters (mL)/hour continuous. On at hour of sleep (HS) and off at 6 A.M., flush with 75 mL of water every 4 hours. Observation on 12/5/25 at 5:40 A.M., showed no EBP signage on the door nor any PPE available inside or outside the resident's room. The resident lay in bed. The tube feeding infused at 60 mL/hour. The resident said he/she was waiting for the nurse to come in and disconnect the tube feeding so he/she could get up. Observation on 12/5/25 at 6:00 A.M., showed Registered Nurse (RN) C entered the resident's room, performed hand hygiene and put gloves on. The nurse stopped the tube feeding and flushed the g-tube with 30 mL of water. The nurse did not wear a gown. Observation on 12/5/25 at approximately 6:15 A.M., showed NA G, performed hand hygiene and put on gloves. NA G assisted the resident to the toilet and with dressing. NA G did not wear a gown. 3. During an interview on 12/9/25 at 12:53 P.M., RN B said today was the first day he/she started wearing PPE (gown and gloves) for residents with feeding tubes. Prior to today, staff only wore PPE for catheter care. 4. Review of the facility's Peri Care policy, dated revised February 2018, showed wet washcloth and apply soap; wash perineal area, wiping from front to back; cleanse the genitals; continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. Review of Resident #19's admission MDS, dated [DATE], showed:-Moderately impaired cognition;-Substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toilet hygiene (the ability to maintain perineal hygiene);-Partial/moderate assistance (helper does less than half the effort. Helper lifts hold or supports trunk or limbs or supports trunk or limbs but provides less than half the effort) for rolling left to right;-Always incontinent of bowel and bladder;-Diagnoses included atrial fibrillation (A-fib, irregular heart rhythm) or other dysrhythmia, high blood pressure and arthritis. Review of the resident's care plan, in use at the time of survey, showed:-Focus: the resident had bowel and bladder incontinence related to impaired mobility;-Goal: the resident will remain free from skin breakdown due to incontinence and brief use through the review date;-Interventions: clean peri-area with each incontinence episode. Observation on 12/4/25 at 5:50 A.M., showed NA G entered the resident's room and asked the resident if he/she wanted to be changed. NA G unfastened the resident's brief, went into bathroom to wet the washcloth, assisted the resident to roll towards the window, and removed the resident's brief. NA G placed the soiled brief directly on the floor, cleaned the resident's buttocks, and placed the soiled washcloth/towel on the floor. NA G placed a new brief under the resident and assisted him/her to roll back onto his/her back, cleaned the front, wiping front to back without using a new area of the washcloth after each wipe. NA G did not change his/her gloves and perform hand hygiene between dirty and clean areas. After he/she finished providing care, he/she picked up the soiled items off the floor and placed them in a plastic bag and removed them from the room. 5. During an interview on 12/8/25 at 2:07 P.M., Certified Nurse Aide (CNA) D said to provide peri care for a resident he/she would prepare a tub with some water and soap and use 3 towels. He/She would wipe the resident's peri area from front to back, using one wash cloth for each wipe. He/She was trained to use the four-corner method, fold the washcloth into 4 quarters, and use one corner for each wipe. CNA D said he/she did not think there were any residents who required EBP. 6. During an interview on 12/8/25 at 4:07 P.M., Licensed Practical Nurse (LPN) A said when staff provided peri care they should prepare 2 small trash bags, 1 for dirty and 1 for clean. Gather soap and enough towels. Wash using the 4-corner method, then rinse off with clean towels and dry off. Wash front to back. Place used or dirty towels in the bag, not on the floor and always do hand hygiene. 7. During an interview on 12/9/25 at 4:35 P.M., the Director of Nursing (DON) said residents who had catheters or feeding tubes were on EBP. The EBP signage was located on the PPE container on the resident's door. Staff should wear gown and gloves when they provide direct patient care such as dressing, personal hygiene and peri care. Residents #34 and #8 were on EBP. The facility used the four-corner method (a technique where a washcloth is folded into four sections (corners) to ensure a fresh, clean surface for each wipe, promoting hygiene and preventing cross-contamination) for peri care. Staff should place soiled items in a plastic bag.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a staff member used profanity while speaking on the phone while he/she was in a resident room (Residents #3 and #35) and when staff failed to pull the privacy curtain while providing perineal care (peri-care, cleansing of the genitals and anal area) for one resident (Resident #19). The census was 56. The sample was 22. Review of the facility's Confidentiality of information and personal property policy, revised October 2017, showed:-Policy Statement: The facility will protect and safeguard resident confidentiality and personal privacy;-Policy Interpretation and Implementation:-The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records; -The facility will strive to protect the resident's privacy regarding his or her: -Accommodations; -Medical treatment; -Personal Care. Review of the facility's Resident's Rights Policy, revised February 202, showed:-Policy Statement: Employees shall treat all residents with kindness, respect, and dignity;-Policy Interpretation and Implementation: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity. 1. Review of Resident #3's medical record, showed:-admission to the facility on 3/13/23;-Diagnoses included bipolar disorder (mood disorder that can cause intense mood swings), high blood pressure and anxiety disorder. Review of the resident's care plan in use during the survey, showed:-Focus: Current Functional Performance;-Goal: Resident's functional status will progress toward personal discharge goals during stay;-Interventions: Resident's performance: Dressing- Limited assist /one-person physical assist. Observation on 12/8/25 at 4:44 P.M., showed a staff member talking on the phone and using profanity while providing personal care to the resident as the resident lay in bed. The bedroom door was open, and the privacy curtain was not drawn. The resident's roommate, Resident #35, was in the room as the staff member provided personal care to Resident #3. The staff member could be heard outside the bedroom door cursing loudly. Upon entering the room, the Surveyor heard the staff member say That's fu-ked up. She needed that shit cuz. That's why she was doing that. The Surveyor turned around and walked out of the room. As the Surveyor waited in the hallway, the staff member could still be heard using profanity in the residents' room. The staff member walked out of the residents' room with the phone on speaker and up to his /her mouth/ear and could be heard using profanity as he/she walked down the hallway. During an interview on 12/8/25 at approximately 4:46 P.M., Resident #3 said he/she guessed the door should have been closed. During an interview on 12/9/25 at 6:00 P.M., The Administrative Assistant said the door should have been closed while the staff member provided personal care to Resident #3, and the staff member should not have been using profanity. 2. Review of Resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/15/25, showed:-Moderately impaired cognition;-Substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toilet hygiene (the ability to maintain perineal hygiene);-Partial/moderate assistance (helper does less than half the effort. Helper lifts, hold or support trunk or limbs or supports trunk or limbs but provides less than half the effort) for rolling left to right;-Always incontinent of bowel and bladder;-Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm) or other dysrhythmia, high blood pressure and arthritis. Review of the care plan in use at the time of the survey, showed:-Focus: The resident has bowel and bladder incontinence related to impaired mobility;-Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date;-Interventions: Clean peri-area with each incontinence episode. Observation on 12/4/25 at 5:50 A.M., showed Nurse Aide (NA) G entered the resident's room. The resident's roommate was awake in his/her bed. NA G asked Resident #19 if he/she wanted to be changed, then unfastened the brief and provided perineal care. The NA did not pull the privacy curtain between the residents' beds. During an interview on 12/5/25 at 12:05 P.M., the resident said he/she preferred for the privacy curtain to be pulled, and the door closed when care was provided. During an interview on 12/9/25 at 4:35 P.M., the Director of Nursing said staff should pull the privacy curtain while providing care if the resident had a roommate. 2634756

Based on observation, interview and record review, the facility failed to accurately document medications administration on the Medication Administration Record (MAR) for two residents (Residents #48 and #59) and staff failed to document when a resident fell and was sent to the hospital for one resident (Resident#45). The sample was 22. The census was 56. Review of the facility's Physician Services policy, dated April 2013, showed physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA, a federal law impacting Medicaid/SSI eligibility and funding for long-term care) regulations and facility policy. 1. Review of Resident #48's order summary report, showed:-A physician order dated 4/8/25: Dapagliflozin Propanediol (used to treat diabetes) 10 milligrams (mg) by mouth in the morning;-A physician order dated 5/3/25: Senna (stool softener) 8.6 mg by mouth two times a day for constipation. Observation on 12/4/25 at 8:52 A.M., showed Certified Medication Technician (CMT) J prepared the resident's morning medications. He/She placed the tablets from the multi-dose packet into a medicine cup. The medications Dapagliflozin and Senna were not placed in the medication cup. He/She then administered the medications to the resident. Review of the resident's medication administration record (MAR), showed CMT J documented the Dapagliflozin and Senna was given. During an interview on 12/4/25 at 11:23 A.M., the resident said CMT J did not come back and administer any other medications. At 11:28 A.M., CMT J said the medication Dapagliflozin was not available and was not given. He/She could not find the Senna in the medication cart drawer and it was not given. He/She said whatever medications were signed off means they were given. 2. Review of Resident #59's order summary report, showed:-A physician order dated 8/18/25: Klor-Con Oral (Potassium Chloride), 20 milliequivalent (mEq), give 1 packet by mouth one time a day;-A physician order dated 6/2/25: Thiamine HCl (supplement) 100 mg by mouth one time a day;-A physician order dated 6/9/25: Aspirin EC Delayed Release 81 mg by mouth one time a day. Observation on 12/5/25 at 8:42 A.M., showed CMT K prepared the resident's morning medications. He/She placed the tablets from the multi-dose packet into a medicine cup. The medications Potassium Chloride, Thiamine, and Aspirin were not placed in the medication cup. CMT K documented these medications as given in the electronic medical record and administered the medications in the cup to the resident. He/She did not obtain the three medications from any packaging or stock bottles. 3. During an interview on 12/8/25 at 4:07 P.M., Licensed Practical Nurse (LPN) A said all resident medications should be administered as ordered. If not given, staff document in progress notes the reasons medications were not given. 4. Review of the facility's Managing Falls and Fall Risk policy, dated March 2018, showed it failed to identify how staff should document when a resident falls. Review of Resident #45's care plan, in use at the time of survey, showed no documentation the resident had a history of falls or if he/she was a fall risk and no documentation of the resident's transfer status. During an interview on 12/3/25 at 3:00 P.M. the resident said he/she fell in July. He/She was being weighed, when he/she grabbed the bar on the scale to pull up, the bar came forward, and he/she fell and broke his/her hip. Review of the resident's hospital facility transfer sheet with admission date 7/22/25, showed presented to emergency department (ED) from his/her nursing home after a fall and left hip pain. Patient said that nursing staff was trying to weigh him/her, down he/she fell, and landed on his/her bottom, he/she has been complaining of left hip pain which is worse with any kind of movement. Review of the resident's progress notes dated 7/22/25, showed no documentation the resident fell and was sent to the hospital. During an interview on 12/9/25 at 12:53 P.M., Registered Nurse (RN) B said the CNA reported the resident was being weighed and he/she lost his/her balance and fell. The nurse assessed the resident. He/She would not let anyone touch him/her, he/she was complaining of pain in his/her leg/hip area, 911 was called and the resident went to the hospital. Falls are documented in fall risk management and in the progress notes. Falls should be documented. 5. During an interview on 12/9/25 at 4:35 P.M., the Director of Nursing said she would expect the medical record to be complete and accurate. Medications should be accurately documented. She audits the MARs weekly and corrects anything that needed to be corrected. Falls should be documented in risk management, which will pull a progress note over. 26020932603584

Based on interview and record review, the facility failed to follow their Resident and Family Group Policy and Grievance Policy and Procedure to maintain an effective grievance process for residents in resident council meetings and resolve them in a timely manner. The failure had the potential to affect all residents. The sample size was 4. The census was 54.Review of the facility's Resident and Family Group Policy, undated, showed the following:-Purpose: To ensure residents of facility and their family members or representatives, have the right to organize and participate in resident and family groups. This policy affirms our commitment to supporting such groups by providing space, privacy, staff support, and prompt consideration of their recommendations;-The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility;-A. The facility must be able to demonstrate their response and rationale for such response.-B. This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. Review of the facility's Grievance Policy and Procedure, undated, showed the following:-This policy is intended to provide fair and prompt consideration to all residents' complaints. The facility encourages all residents to use the grievance procedurewithout fear of retaliation within the grievance process and with the assurance that his/her concerns will be respected. It is the policy of St. [NAME] Place to maintain allgrievances for at least three years from resolution. A copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance anddocumentation; in applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty-one calendar days. -Procedure: All grievances must be in writing, containing the name and address of the person filing the grievance. The complaint must state the problem or action alleged along with the date, approximate time, place, name(s) of individuals involved in the incident that is being grieved. You cannot file anonymously. Review of the Resident Council Minutes, dated 4/24/25 at 2:30 P.M., showed the following:-Old Business: The care lights are not being answered in a timely manner;-Nursing: The nursing staff are making smart remarks to the residents when they are asked questions or for help;-Dietary: The breakfast is getting bad, and the residents are given food they cannot eat;-Laundry: The residents have missing clothes.-There was no documentation of resolution for these grievances or concerns. Review of the Resident Council Minutes, dated 5/22/25 at 2:30 P.M., showed the following:-Old Business: The call lights are not being answered in a time manner. The residents are missing clothes when laundry washes them. The breakfast has not been tasting all that good. The residents are getting food they cannot eat.-There was no documentation of resolution for these grievances or concerns.-Nursing: Nursing is not doing their job. The Certified Nurse Aides (CNA) are not answering call lights in five minutes but taking two hours and have an attitude. The night shift is terrible. The night shift is loud and the residents cannot sleep;-Dietary: The residents are receiving food they are not supposed to eat and some foods are salty;-Laundry: The residents are not getting their clothes back. Review of the Resident Council Minutes, dated 6/25/24 at 10:30 A.M., showed the following:-Old Business: The residents are not getting the correct medications. The call lights are being answered in a timely manner. The night shift staff are not nice and they are loud and the residents are being kept up at night. The resident are not getting their clothes returned to them. The residents are not being listened to and the problems are not being taken care of promptly.-There was not documentation of resolution for these grievances or concerns.-Nursing: The night shift is loud and they use profanity and are keeping the residents from sleeping;-Laundry: Some residents are still missing their clothes. During an interview on 8/13/25 at 12:09 P.M., the Activity Director (AD) said he/she oversees the resident council meeting and the meetings are held once a month. The residents have not had the meeting for the month of August. The AD said in the meetings, the residents discuss the previous minutes and discuss current concerns and grievances regarding each department. The AD said he/she will write down the concerns and grievances and give them to the Director of Nursing (DON) for her review. The AD said he/she would like a resolution before the next meeting. The AD has been with the facility since January, 2025 and has not gotten a resolution for any of the grievances or concerns. He/She did not know if the grievances or concerns had been addressed. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/23/25, showed the following:-Moderate Cognitive Impairment;-No moods or behaviors;-Independent with most activities of daily living;-Diagnoses of high blood pressure and high cholesterol. During an interview on 8/13/25 at 1:26 P.M., the resident said he/she is the resident council president. The resident said in the meetings, concerns include people missing clothes and the night staff talking and laughing loud. The resident said nothing has been done about these concerns and it makes the residents feel terrible. During an interview on 8/13/25 at 1:55 P.M., the DON said she has been coming in (the facility) in the middle of the night and has seen the concerns. The DON said some staff have been terminated and some staff were talked to by the CNA Supervisor about being loud. During an interview on 8/21/25 at 11:39 A.M., the Administrative Assistant (AA) said he/she expected the policies to be followed. The residents are able to file a grievance or concerns anonymously. The AA said resident council meeting is not for grievances. The meetings are for concerns of the residents. If the residents have a grievance, it must be filed with the Grievance Officer, which is the Social Services Designee. The AA said they do address all grievances and concerns, they just do not document all the resolutions.

Based on interview and record review, the facility failed to ensure a resident was free from significant medication errors when the facility failed to administer ordered pain medication for one resident (Resident #5). The sample size was 11. The census was 55.Review of the facility's Medication Orders policy, revised 11/14, showed:-Each resident must be under the care of a licensed physician authorized to practice in this state and must be seen at least every sixty days;-A current list of orders must be maintained in the clinical record of each resident;-When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. Review of the facility's Controlled Substance Policy, revised 4/19, showed:-Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications;-Upon Administration: The nurse administering the medication is responsible for recording name of the resident receiving the medication, name, strength and dose of the medication, time of administration, method of administration, quantity of the medication remaining, and signature of nurse administering medication. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/25, showed:-Moderately impaired cognition;-No hallucinations and delusions behavior;-Impairment on one side to lower and upper extremities;-Diagnoses included atrial fibrillation (heart rhythm disorder), high blood pressure, aphasia (communication disorder), hemiplegia or hemiparesis (weakness or paralysis on one side of the body), and depression. Review of the resident's electronic medication administration record (eMAR), for June 2025, showed:-Acetaminophen Oral tablet (used to relieve mild to moderate pain and fever), give 650 milligrams (mg) by mouth every 4 hours as needed for elevated temperature and pain;-Staff documented the medication as given one time for the month, on 6/21/25 at 12:46 A.M.;-Tylenol with Codeine #3 (used to help relieve mild to moderate pain) oral tablet 300-30 mg, give 1 tablet by mouth two times a day for pain, order date 3/25/25, discontinued date 6/8/25;-Oxycodone HCL (opioid pain reliever used to manage moderate to severe pain) oral tablet 5 mg, give one tablet by mouth three times a day related to hemiplegia and hemiparesis, start date 6/8/25; -No documentation to show Oxycodone HCl was administered until 6/25/25. The first dose was given on 6/26/25. The MAR showed blank boxes for all dates prior to 6/26/25;-On 6/28/25, the 8:00 A.M. and 12:00 P.M. doses were marked #9 by an agency staff, which according to the Chart Codes, #9 indicated Other/ See Progress Notes. No progress notes documented. Observation and interview on 7/1/25 at 12:40 P.M., showed the resident in bed, grimacing and complaining of left leg pain. He/She said he/she was in pain every day. He/She only received headache medicine, and it did not help with the severe chronic pain he/she experienced daily. During an interview on 7/1/25 at 12:47 P.M., Registered Nurse (RN) A said the resident just had his/her pain medicine. He/She would have the resident repositioned to help alleviate the pain. Observation and interview on 7/2/25 at 10:02 A.M., showed the resident sat up in a wheelchair, in the hallway, right outside of his/her room. The resident said he/she was in continuous pain and wanted to have stronger pain medications.During an interview on 7/2/25 at 10:06 A.M., RN A said the resident always complained of pain and it became worse and more excruciating when he/she needed to get up. The resident was on routine Tylenol #3 and which was replaced with Oxycodone HCl on 6/8/25 per physician's order. During an interview on 7/2/25 at 10:41 A.M., the Director of Nursing (DON) said the resident did not like to get up so he/she would complain of pain when up. The resident had an order for Tylenol #3 two times a day for a while, then it was changed to Oxycodone 5mg three times a day. She was not aware and did not know why there was no documentation in the eMAR from 6/8/25 to 6/25/25. She would do some research on what happened. She said there was a revision of the Oxycodone order on 6/26/25. The resident was seen by the pain management provider at least every three weeks, but the Primary Care Physician (PCP) prescribed the Oxycodone on 6/8/25. However, it was not active and did not show in the staff eMAR until 6/26/25. The DON said she was not certain how the order remained in queue or not activated. If the order was queued, the nurses or Certified Medication Technicians (CMTs) would not show as to be administered, until the physician un-queued the order. During an interview on 7/2/25 at 12:41 P.M., the Primary Care Physician (PCP) confirmed the Oxycodone HCl 5 mg order on 6/8/25. The psychiatrist recommended the medication to help with the resident not only for the pain but mostly for his/her behaviors. He/She placed orders in the resident's electronic medical record (EMR), then sent an electronic prescription to the pharmacy. Normally the pharmacy received the prescriptions immediately. He/She said there may have been a computer glitch, which could be a reason why the pharmacy did not receive his/her electronic prescription. The PCP added that the resident was seen by the pain physician during the time in-between 6/8/25 through 6/26/25, and the resident did not complain of pain. At 12:54 P.M., the PCP showed his/her phone with a screenshot of the Oxycodone HCl 5 mg electronic prescription that was sent to the pharmacy on 6/8/25. The image showed an escript (electronic prescription) dated 6/8/25, to dispense Oxycodone HCL 5 mg TID (three times a day), quantity 90. The PCP said the pharmacy should have received the prescription. She expected the medication orders to be followed and administered as ordered.During an interview on 7/2/25 at 12:57 P.M., the pharmacy staff said they received a prescription for the resident on 6/8/25. The prescription was for Oxycodone 5 mg, 90 pills, for a 30 day supply. The medication was delivered to the facility on 6/8/25 at 6:56 P.M., and was received and signed by Licensed Practical Nurse (LPN) A. Observation and interview on 7/2/25 at 1:49 P.M., showed the narcotics locked box in the medication cart had 18 tablets of Oxycodone 5 mg in plastic sachet, in an individualized continuous packaging. RN A said they were not in bubble cards because they were pulled from their emergency kit (e-kit). They pulled 19 tablets with 1 tablet administered to the resident at 10:00 A.M. RN A said CMT C notified him/her that morning there were no cards of the resident's Oxycodone. RN A said she did not know where the medication cards were but had to use their stock from the e-kit immediately so the resident could have his/her pain medicine. He/She pulled the medication in the e-kit with the DON.During an interview on 7/2/25 at 3:24 P.M., the DON said there had not been any issues with drug diversion for a long time. She would initiate an investigation immediately.During an interview on 7/3/25 at 8:22 A.M., the DON provided an investigation report and said the Oxycodone cards for the resident were not found. The facility had surveillance cameras but did not save recorded images and videos. She said the agency staff who worked on 6/28/25 walked out of the facility after two hours of starting the shift. They were not able to contact the agency staff.Review of the investigation report provided by the DON, showed:-Date of incident: 7/2/25;-Summary of Incident: On the morning of 7/2/25, a CMT reported to the charge nurse that he/she needed medication for the resident. The charge nurse notified the facility's RN who immediately began a preliminary investigation;-The facility initiated an initial investigation that included staff interviews, medication reconciliation, physical search, and record reviews;-Findings: As of the evening of July 2, 2025, following a full review of the eMAR and physical documentation, approximately 74 pills of narcotic medications remain unaccounted for. There is no documentation, paper trail, or physical record currently explaining their use, destruction, or removal from the facility. In addition, a full narcotic audit of all residents was completed. All other resident medications, including controlled substances, were found to be accounted for and properly documented. This indicates that the discrepancy is isolated to the specific medications reported missing on July 2, 2025;-Immediate actions and preventive measures: Resident medications will continue to be administered and supplied by facility, until a new script is filled. The facility is in the process of updating its narcotic handling protocols. A new narcotic resident inventory list will be implemented and placed at the front of the Control Count Book to assist with rapid reconciliation and tracking. Ongoing review and monitoring of narcotic handling procedures will be conducted to identify any procedural gaps and prevent recurrence;-Status: The investigation is now closed. Despite a thorough review of medication records, staff interviews, and a facility-wide narcotic audit, the source of the discrepancy involving the missing 74 pills of narcotic medication could not be definitively identified. All other resident medications, including controlled substances, have been accounted for. The incident has been documented, and the facility has implemented procedural improvements to prevent recurrence.On 7/3/25 at 11:39 A.M., attempts were made to contact CMT C with no return-call.During an interview on 7/3/25 at 11:42 A.M., LPN B said he/she received and signed the Oxycodone medication from the pharmacy for the resident on the evening of 6/8/25. LPN B placed the medication cards in the medication cart's locked box with the other narcotics. LPN B did not have to administer the medication during his/her shift. The nurses count the narcotics at the beginning or end of the shift. He/She did not recall any issues with the count.During an interview on 7/3/25 at 11:52 A.M., the DON said she expected staff to assist the residents in pain properly and provide the medications as ordered. The PRN (as needed) medication should be administered, if available. She said even if the medication cards were available, they would not be administered if there was no active order. The Oxycodone medication was started on 6/26/25 after the PCP activated the order. The DON expected physician's orders to be followed as ordered. MO00256411

Based on interview and record review, the facility failed to protect two residents from misappropriation of property when former Office Manager (OM) E had one resident write checks made out to OM E to pay for room and board instead of the facility (Resident #1). In addition, OM E mislead a family member make electronic transactions to the employee's personal account to pay for room and board (Resident #11). These monetary transactions were intended as payments for the facility's care and services. The sample was 11. The census was 55. The facility was notified on 7/1/25 of the past non-compliance. The facility terminated OM E. He/She did not return to work following suspension and has had no further engagement with the facility post-investigation. The facility updated their forms of payment accepted to checks, money orders, cash with a receipt at time of transaction for resident-related charges. In addition, the facility no longer accepted electronic peer-to-peer payments. The updated policy was included in their amended admission packet policy. Going forward, Administration will conduct monthly audits of all resident billing and payment reconciliation. The deficiency was corrected on 5/9/25.Review of the facility's undated Abuse Prevention policy, showed:-Each resident has the right to be free from mistreatment, neglect and misappropriation of property;-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful use of resident's belongings or money;-If any employee is in question, employee shall be suspended during the rest of the investigation;-If an employee is named by an alert and oriented resident, employee may be terminated. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/25, showed:-Cognitively intact;-No psychosis or delusional behaviors;-No functional impairment to upper extremities. Review of the resident's electronic health records showed:-admission date of 3/28/23;-Responsible party: Self;-Care Plan showed limited assist to mostly independent in the current functional performance;-Diagnoses included heart failure, kidney disease and diabetes. During an interview on 7/1/25 at 2:45 P.M., the resident said OM E had been assisting him/her with payments and had no issues in the past. The resident found out in May 2025 that the employee had been stealing money. He/She was approached by OM E in the beginning of May about dental and vision care services that were due. He/She told OM E no funds available in the bank at that time. OM E told the resident to go ahead and write the check, and OM E would take care of it. The resident found out an attempt was made to cash the check in a store across the street from the facility and it bounced. The resident was notified the facility started an investigation and terminated the employee.Review of the facility's photocopies of the resident's checks written to OM E and cashed, showed:-Check dated, 12/30/24, pay to the order of OM E, $197.00;-Check dated, 12/31/24, pay to the order of OM E, $197.00;-Check dated, 1/16/25, pay to the order of OM E, $394.00;-Check dated, 2/28/25, pay to the order of OM E, $188.00;-Check dated, 2/28/25, pay to the order of OM E, $394.00;-Check dated, 3/20/25, pay to the order of OM E, $900.10. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Independent with self-care and mobility. Review of the resident's electronic health records showed:-admission date of 3/1/23;-Responsible Party: Son;-Diagnoses included heart valve disorders, high blood pressure, major depressive disorder. During an interview on 7/3/25 at 10:12 A.M., the resident's Responsible Party (RP) said OM E would call on the 3rd of every month without fail. He/She worked close by the facility and finished work after banking hours. The RP would usually get cash from automated teller machine (ATM). He/She would mostly give OM E cash to pay the facility. He/She did not receive receipts. He/She had at least two cashier's check payments while the Administrator was present and provided receipts on those times. He/She notified the Administrator at one time that he/she had made cash payments to OM E. The Administrator told the RP to refrain from doing so and asked for the receipts. The RP said there were Cash App (a mobile payment service that allows users to send money peer to peer) transactions to OM E for payments to the facility and provided screen shots. The RP said he/she trusted OM E and did not think OM E was capable of taking people's money. Review of the Cash App transactions provided by the facility, showed:-7/2/24, OM E's name, note: payment sent;-8/2/24, Om E's name, note: facility name;-9/5/24, Om E's name, note: pension payments;-10/5/24, Om E's name, note: payment sent;-11/4/24, Om E's name, note: facility's name;-12/4/24, Om E's name, note: facility's name;-3/6/25, Om E's name, note: facility's name monthly care payment for resident. 3. On 7/2/25 at 9:28 A.M., attempts were made to contact OM E using two different telephone numbers on file. OM E could not be reached at either number provided. 4. During an interview on 7/1/25 at 12:06 P.M., and 7/3/25 at 2:30 P.M. the Administrator said the facility reimbursed and issued the residents credit for the total amount OM E had taken from the residents. He was not aware OM E had collected payments from self-pay residents with electronic transactions and checks made directly to OM E's account or name. The store owner across the street from the facility, which also cashes checks, contacted the Administrator on 5/7/25, notifying that a resident's check had bounced. The Administrator started an investigation and found out there were previous checks written to OM E for funds which were not given to the facility. The facility started investigating other residents who were self or private pay and discovered that Resident #11's RP also had multiple cash and electronic monetary transactions with OM E. The Administrator attempted to report the issues to the local police department, but the responding officer denied filing a report. The Administrator said he would expect employees to refrain from personal monetary transactions or receive residents' payments without providing receipts. He would check or have the responsible staff to check payments made by residents as frequently as monthly. MO00253928

Based on record review and interview, the facility failed to ensure that nurse aides (NA) completed a nurse aide certification training program within four months of hire for three of 18 NAs, who worked in the facility for more than four months (NA A, NA B, and NA C). The census was 49. Record review of all NA hire dates on 8/27/24, showed: -The facility hired NA A on 4/17/24; -The facility hired NA B on 3/12/24; -The facility hired NA C on 12/28/23; -The three NAs were not certified within the required four-month period. During an interview on 8/27/24 at 11:40 A.M., the Director of Nursing (DON) said she knew all NAs had to be enrolled in a state approved training program which resulted in their certification within four months of hire. The problem the facility was having was getting the NA's to an approved clinical testing location. All the classroom lessons and tests are provided online. The final exam could be taken online. The final clinical test had to be done at an approved testing facility. Their facility was not an approved testing facility. The NA's had to go in person to a testing site for their final clinical exams. The waiting list to take the final clinical exam could take up to a month or two to get an appointment to be tested . The closest testing facility was 15-20 miles away and some staff didn't have transportation to the testing site.

Based on interview and record review, the facility failed to electronically submit to The Center of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the quarter immediately preceding the annual survey. The census was 45. Review of the facility's Payroll Based Journal (PBJ) staffing Data Report, for fiscal year quarter 1, 2024 ([DATE] through [DATE]), showed the facility triggered for failing to submit data for the quarter. During an interview on [DATE] at 12:24 P.M., the Administrative Assistant and Director of Nursing said PBJ information had not been submitted. The Administrative Assistant said the passwords expired.

Based on observation and interview, the facility failed to provide to residents a place in the facility where personal phone calls can be conducted in private and without being heard. In addition, the facility failed to ensure residents had access to mail delivered on Saturday. These failures has the potential to affect all residents in the facility. The survey sample was 13. The facility census was 45. 1. Observation on 3/17/24 at 6:40 A.M., showed a small conference room at the beginning of the 100 residents' hall. Signage at the entrance to the conference room read Resident Phone in large green lettering. Observation of the conference room, showed no phone available to residents for private use, but contained multiple office chairs, a table, and a toilet seat cover left on the ground. Observation on 3/17/24 at 8:58 A.M., showed Resident #31 at the nurse's station using a wired connection phone to speak to his/her family member. Observation on 3/19/24 at 9:48 A.M., showed Resident #1 at the nurse's station using a wired connection phone to speak to his/her family. During the phone call, five residents were seated just a few feet behind him/her, and a housekeeping staff member operated a tile buffer to clean the floors in the area. During the call, the resident appeared frustrated with the amount of noise during the call, appearing to have difficulty hearing the person on the other end of the call. During an interview on 3/19/24 at 12:51 P.M., Resident #26 said he/she does not often make calls from the facility, but the only phone he/she is aware of that is available for resident use is the wired phone placed at the nurse's station. During an interview on 3/20/24 at 10:26 A.M., Nurse Aide (NA) C said residents are assisted in placing phone calls to outside contacts, and staff provide a phone at the nurse's station for residents to use. NA C believed there was a phone in the conference room at one time, but that room is not used for anything currently. The NA said conversations that residents may have at the nurse's station are not private, and residents should be provided a more private space to conduct personal conversations if they wish. During an interview on 3/20/24 at 10:49 A.M., the Activities Director said the phone room near the 100 hall is not used for anything, and currently is just an empty room. The Activities Director said a phone is available at the nurse's station but was unaware of any other method of private communication that the facility provided to residents. The Activities Director would not consider conversations residents have at the nurse's station to be private, and that if the room was used for resident phone calls, it would be a more private location to conduct conversations. During an interview on 3/20/24 at 12:25 P.M., the Administrative Assistant said a cordless phone had been previously kept in the phone room at the facility, but residents would use it and fail to place it back on its charger, meaning the phone would die and be unavailable for use in the future. The cordless phone was placed at the nurse's station for residents to take to a more private place for conversations if needed. At that time, the resident council was made aware of this change, but the Administrative Assistant was unsure if residents are still aware the cordless phone is available. 2. During a group interview on 3/19/24 at 9:47 A.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. All five residents said mail was not delivered on Saturdays. One resident said he/she had a package delivered on Saturday but had to wait until activities staff returned on Monday to receive the package. During an interview on 3/20/24 at 10:27 A.M., the Activities Director said she had one assistant who assisted with activities a couple of days during the week. She works Monday through Friday and was not at the facility during the weekend. Mail and packages delivered on Saturday are placed in her mailbox, and she delivers the packages when she returns on Monday. During an interview on 3/20/24 at 12:24 P.M., the Administrative Assistant and Director of Nurses (DON) said residents should receive packages on Saturdays if it was delivered on a Saturday.

Based on observation and interview, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure resident hallways were free from strong odors throughout the survey process. The census was 45. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy, revised January 2014, showed: -Purpose: The purpose of this procedure is to provide a process for the safe use and aseptic handling, washing and storage of linen; -General Guidelines; -Standard precautions; -Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linen; -All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Observation on 3/17/24 at 6:31 A.M., showed a hospital gown and two other items piled outside of room [ROOM NUMBER], directly on the floor, unbagged. The hallway emitted a strong smell of urine. Across from the soiled linen were two large white bins. One bin indicated use for trash and the other for soiled linen. Observation on 3/18/24 at 7:38 A.M. showed a small pile of dirty linens, washcloths, and a hospital gown on the floor in an opened trash bag near the doorway of room [ROOM NUMBER]. A slight malodorous scent was observed near the pile of linens. Observation on 3/18/24 at 12:24 P.M., showed a covered soiled linen cart and covered trash can on the 400 hall unit, outside of room [ROOM NUMBER]. The trash can and soiled cart emitted strong odors of urine. Observation on 3/19/24 at 8:14 A.M., showed a soiled linen cart on the 400 unit. The cart emitted a strong odor of urine. During a group interview on 3/19/24 at 9:47 A.M., five residents, whom the facility identified as alert and oriented, attended the group interview. All five residents said the facility smells like urine and bowel, but mostly early in the morning. Once day shift aides and housekeeping arrived, they cleaned the area and the smells would disappear. During an interview on 3/20/24 at 10:21 A.M., Nursing Aide (NA) C said he/she normally worked day shift and when he/she arrived to his/her shift, the smell of urine and trash was strong. Sometimes night shift staff did not remove soiled linen to the laundry room or empty trash. He/She will remove the soiled linen when he/she started his/her shift. During an interview on 3/20/24 at 10:11 A.M., Housekeeping Aide I said trash cans and the linen cart were left on the hallways during the night shift and were not emptied until the day shift aides arrived. He/She smelled urine and trash on occasions and has witnessed dirty linen on the floor. He/She had addressed this with management in the past. The soiled linen cart and trash can should be changed out every 30 minutes to prevent the smell of trash and urine. During an interview on 3/20/24 at 12:24 P.M., the Administrative Assistant and Director of Nursing said they expected the facility to be clean, comfortable, homelike and free of offensive odors. Trash cans and linen carts should be emptied after each shift. MO00232721 45083

Based on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to store food in a safe and sanitary manner to prevent potential cross-contamination, label and date food items, and failed to ensure pans, bowls and utensils were dry prior to storage. This had the potential to affect all residents who consumed food from the facility kitchen, The facility had a census of 45. Review of the Facility Food Safety High Five Policy, undated, showed; -Do not store raw foods over cooked or ready to eat foods; -Never prepare ready to eat foods on the same surface or with the same utensils used to prepare raw animal proteins; -Properly wash, rinse and sanitize all food contact utensils and equipment; -Label all food clearly, and use the first in, first out system (food that has been in storage longest, first in, should be the next food used, first out). Observation of the kitchen on 3/17/24 at 9:33 A.M., showed: -Inside the stand alone refrigerator: -A bag of wrapped lettuce sitting on top of a pan of packaged hamburger. Uncovered heads of lettuce were beneath the packaged hamburger; -A jar of chicken base, opened, undated; -A jar of garlic, opened, undated; -A package of sliced American cheese, opened, undated; -A package of shredded American cheese, opened, undated; -Two large serving trays, with pre-poured cups of mayonnaise and catchup, undated; -Containers of sweet sauce and zesty orange sauce, opened, undated; -A large bag of diced white cheese, opened, undated; -Inside the dry storage area: -A large bag of sugar inside the sugar bin. A Styrofoam cup was inside the bag of sugar and used as a scoop; -A fifty pound bag of rice, opened, undated; -Inside the stand alone freezer; -A bag of french fries, opened, undated; -Two bags diced chicken, opened, undated; -A bag of sliced bread pieces, opened, undated; -A bag of french fries, opened, and undated. Observation of the kitchen on 3/18/24 at 9:33 A.M., showed: -Inside the refrigerator, a bag of cheese cubes, opened, undated; -Inside the dry storage; -A fifty pound bag of rice, opened, undated; -A bag of pasta, opened, undated dated -Inside the freezer: -A bag of frozen fries, opened, undated; -A bag of french toast, opened, undated; -A package of chicken cubes, opened, undated; -A package of sausage links, opened, undated. Observation of the kitchen on 3/19/24 at 11:33 A.M., showed: -Inside the dry storage area, a bag of rice, opened, undated; -On the storage rack were stacked pans and bowls, with visible water droplets; -Dietary Aide B rolling utensils into cloth napkins with visible water droplets on the utensils. During an interview on 3/20/24 at 11:48 A.M., the Dietary Manager said potentially hazardous foods, such a hamburger, should be stored on the bottom rack of the refrigerator to prevent the chance of cross contamination onto the food underneath. She expected staff to date and label opened food prior to placing the food in storage. Scoops should not be stored inside containers, including Styrofoam cups, which should have been discarded. She expected pans, bowls and utensils to be fully dried before stacking or wrapping them in napkins. During an interview on 3/20/24 at 1:15 P.M., the Director of Nursing said hamburger should be stored on the bottom shelf, because the hamburger liquid could run onto the food stored below. The food underneath could potentially be contaminated by the liquid. The potential harm for storing pans, bowls and wrapped wet utensils would be a potential for mold growth.

45083 Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for one resident observed during personal care (Resident #30). Staff failed to change their gloves or sanitize their hands after removing a dirty brief and performing perineal care (cleansing of the area including the hips, genitals and anal area), prior to applying a clean brief and touching the resident. In addition, staff failed to apply hand hygiene when handling the residents' meal trays and assisting with meal set-up. Furthermore, facility failed to keep the soiled linens and gowns bagged, tied and off the floor by the residents' rooms. The sample was 13. The census was 45. Review of the facility's Standard Precautions Policy, revised September 2022, showed: -Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water; -Hand hygiene is performed with ABHR or soap and water; -Before and after contact with the resident; -Before performing an aseptic task; -Before moving from work on a soiled body site to a clean body site on the same resident; -After contact with items in the resident's room; -After removing gloves; -Hands are washed with soap and water; -When visibly soiled with dirt, blood, or body fluids; -After contact with blood, body fluids, or contaminated surfaces; -After caring for a resident with Clostridioides difficile (C. diff or Clostridioides difficile, inflammation of the colon caused by the bacteria C. diff); -In general, if rates of C. diff infection are high; -After caring for a resident with norovirus infection during an outbreak; -Before eating and after using the restroom; -Except as noted above, ABHR is preferred for hand hygiene; -Sinks, soap, water, disposable towels and ABHR are available to personnel and visitors in readily accessible and visible locations throughout the facility; -Artificial fingernails are discouraged among staff with direct resident contact; -Personnel assist the residents with hand hygiene before meals, after toileting and when indicated; -Gloves are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material; -Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms; -Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care; -Gloves with fit and durability appropriate to the task are available to personnel at all times; -Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one); -Gloves are not to be reused; -Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident; -After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy, revised January 2014, showed: -Purpose: The purpose of this procedure is to provide a process for the safe use and aseptic handling, washing and storage of linen; -General Guidelines; -Standard precautions; -Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linen; -All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. 1. Review of Resident #30's medical record, showed: -Diagnoses included cardiomyopathy (a disorder that affects the heart muscle), high blood pressure, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone); -A care plan used at time of survey, showed: -Focus: Potential for impaired skin integrity; -Goal: Skin will remain intact; -Interventions: provide skin care per facility guidelines. Observation on 3/18/24 at 10:48 A.M., showed Nurse Assistant (NA) A placed gloves on his/her hands and removed the cover off of the resident. He/She unfastened the resident's incontinence brief and rolled it under the resident while NA E assisted the resident to turn to his/her left. The resident's brief was soiled with urine. NA A cleaned the perineal area with washcloths and dried the resident. The resident was rolled side to side and NA A removed the soiled brief, and placed it with the soiled washcloths at the foot of the resident's bed. NA E assisted the resident to turn side to side and removed the incontinence pad from underneath the resident. He/She then obtained a clean brief and handed it to NA A. Neither of the NAs changed and sanitized their hands after touching the soiled brief, washcloths and pad. NA A applied the clean brief onto the resident and fastened each side. He/She then picked up the unbagged dirty brief and washcloths, exited the resident's room and placed them in the hamper and trash bin located in the hallway, two doors down across from the resident's room. During an interview on 3/20/24 at 10:21 A.M., NA C said during resident's personal care, he/she changes gloves once with pee and twice with boo-boo. He/She washed or sanitized hands before and after care. 2. Observation on 3/17/24 at 8:14 A.M., showed nursing staff retrieving breakfast trays in the main dining room from the kitchen service window and serving them to residents. During the observation, NA C passed seven resident trays to residents in the dining room, assisting with the setup of their plates, silverware, and drink cups with his/her bare hands. NA C did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. NA F passed six resident trays to residents in the dining room, assisting with the setup of their plates, silverware, and drink cups with his/her bare hands. NA F did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. NA G also passed resident trays in the dining room, occasionally wiping his/her nose with his/her bare hands, and assisting with the setup of plates, silverware, and drink cups with his/her bare hands. NA G did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. Observation on 3/20/24 at 8:37 A.M., showed NA C and NA F passing resident trays to residents in the main dining room with their bare hands, assisting with plate setup, silverware setup, and drinks. No hand hygiene was completed by either of the NAs before, during, or after passing each resident tray for the duration of the meal service. 3. Observation on 3/17/24 at 6:31 A.M., showed a hospital gown and two other items piled outside room [ROOM NUMBER], directly on the floor, unbagged. The hallway emitted a strong smell of urine. Across from the soiled linen were two large white bins. One bin indicated use for trash and the other for soiled linen. Observation on 3/18/24 at 7:38 A.M. showed a small pile of dirty linens, washcloths and a hospital gown on the floor in an opened trash bag near the doorway of room [ROOM NUMBER]. A slight malodorous scent was near the pile of linens. During an interview on 3/20/24 at 10:21 A.M., NA C said he/she normally worked day shift and when he/she arrived at his/her shift, the smell of urine and trash was strong. Sometimes, night shift staff did not remove soiled linen to the laundry room or empty trash. He/She will remove the soiled linen when he/she started his/her shift. During an interview on 3/20/24 at 10:11 A.M., Housekeeping Aide I said trash cans and the linen cart were left on the hallways during the night shift and were not emptied until the day shift aides arrived. He/She smelled urine and trash on occasions and witnessed dirty linen on the floor. He/She addressed this with management in the past. The soiled linen cart and trash can should be changed out every 30 minutes to prevent the smell of trash and urine. 4. During an interview on 3/20/24 12:24 P.M., the Director of Nursing (DON) said staff should wash or sanitize their hands before and after contact with the residents, before touching clean from dirty items or areas, and after removing gloves. She also expected staff to change gloves in the same manner, from handling dirty and prior to clean. In addition, the Administrative Assistant and DON said they expected the facility to be clean, comfortable, homelike and free of offensive odors. Trash cans and linen carts should be emptied out after each shift.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 45. Review of the facility's Surety Bond Invoice, dated March 19, 2024, showed a bond amount of $100,000.00. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $73,000.00; -For this amount, the bond amount should have been $109,500.00. During an interview on 3/20/24 at 12:02 P.M., the Facility Accountant said she was unaware of the bond amount and she had been overseeing the accounting over the last six months due to changes in staff. During an interview on 3/20/24 at 12:04 P.M., the Administrative Assistant said he was unaware the bond amount was not sufficient. He would have the bond amount increased immediately.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #4) was kept free from abuse and neglect. The resident, who was identified as a fall risk, was left by a nurse in an unoccupied room on an unoccupied hall, with the door shut. The resident was later observed to have injuries to his/her face, presumably from a fall. Additionally, the facility failed to keep Resident #4 safe from abuse when a nurse hit the resident in the head with a binder, grabbed at his/her head, and pulled the resident by the arm. The sample size was 14. The census was 46. Review of the facility's undated abuse and neglect policy, showed: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, with pain or mental anguish; -Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Each resident has right to be free from mistreatment, neglect and misappropriation of property. This includes the identification of residents whose personal histories render them at risk for abusing other residents, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis; -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness; -Abuse and neglect procedure: Should an allegation of abuse/neglect toward a resident, by an employee, be received in the future, this facility will immediately investigate the allegation and the abuse; -Should the allegation be credible, as determined by the administrator or designee; the administrator or designee will immediately suspend said employee or instruct the employee to have no contact with any resident and be placed on one to one supervision for the remainder of the investigation to ensure that no further potential abuse could occur; -Should the abuse be substantiated, the employee shall be disciplined accordingly; -Investigation Procedures: The following situations may trigger an investigation by the director of nursing (DON) of abuse: -Any bruise with no report of a fall; -Welts or grip marks; -Unexplained swelling. -Lacerations of unknown origin; -Fractures of unknown origin; -Sudden change of a resident's behavior; -Steps to the investigation process include: -A certified nurse aide (CNA) reports any new area on a resident to the charge nurse; -A charge nurse completes a full body assessment and fills out incident report notifying the physician and family following any orders received by the physician; -Any of the previously written items shall be reported to the DON immediately; -The DON completes her own full body assessment and interview with the resident and documents the findings; -The DON notifies the administrator immediately; -The DON gathers staffing information for 24 hours prior to first observation of injury or behavior; -Interviews are conducted on scheduled staff. Documentation is kept confidential; -Interview is conducted with resident's roommate if interviewable, documentation of interview shall be maintained; -If any employee is in question, employee shall be suspended during the rest of investigation; -If an employee is named by an alert and oriented resident, employee may be terminated; -When an alleged violation of neglect or abuse shows a reasonable cause to believe abuse or neglect occurred all agencies shall be notified by the DON or administrator; -If alleged violation is found correct all agencies shall be notified the same; -Employee in question shall submit a statement of occurrences to the director of nursing. 1. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/21, showed the following: -admitted to the facility on [DATE]; -Brief interview for mental status (BIMS, a screening tool used to determine cognitive impairment), score of 0 (severe cognitive impairment); -Adequate hearing and vision; -Unclear speech; -Rarely/never understood; -Rarely/never understands; -No behaviors; -Required physical assistance with transfers, bathing, toilet use and dressing; -Incontinent of bowel, had a urinary catheter; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, edited 3/9/21, showed the following: -Problem: Anxiety; -Goal: The resident will show signs of relief of his/her anxiety; -Approach: Medication as ordered, psychiatric management as needed; -Problem: At risk for wandering related to dementia and agitation; -Goal:The resident will remain safe within the facility; -Approach: Wanderguard as directed; -Problem: The resident was at risk for falls; -Goal: He/she will be free from falls; -Approach: Staff will offer the resident assistance to the toilet before and after meals; Physical therapy and occupational therapy evaluate and treat if indicated; Nonskid socks. Review of the resident's nurse notes, showed the following: -3/13/21 at 8:42 A.M., the resident was found in vacant room having fallen. Abrasions to right side of face. Was found on carpet, appear to be rug burn. Neurologically no deficits or diversions were noted from baseline. Administered two Tylenol from as needed (PRN) order. Called family to make aware; -3/13/21 at 1:02 P.M., the resident continues to have swelling above right orbital bone (bone surrounding the eyeball), appears to have collection of fluid possible subdermal (located beneath the skin) hematoma (collection of blood outside of blood vessel). The physician was called and a stat x-ray two view of the head was ordered; -3/15/2021 at 2:55 P.M., the resident exhibited with some bruises/discoloration to his/her right eye above and below the orbital socket lip and discoloration to his/her left eye. Slept most of this shift with 25% of meals/fluids consumed. No nonverbal cues noted indicative of pain or discomfort. Resident now up and walking around, easily redirected. No events noted during this shift. Will continue to monitor; -3/17/2021 at 6:13 A.M., resident on observation for incident follow up (IFU)/Fall. Resident continues to have swelling to right orbital area. Some swelling and slight discoloration for left orbital area. Resident has several abrasions to face and jaw line. Exhibits no pain or discomfort at this time. Resident currently wandering unit at this time. No acute distress noted. No other concerns noted or mentioned at this time; -3/19/2021 at 11:16 A.M., the resident's daughter here for a visit, expresses concerns regarding resident's injury post fall. Daughter called the police; -3/19/2021 at 12:49 P.M., the resident's daughter here, plans on taking the resident to the emergency room (ER). Spouse called and gave approval for the daughter to transport to the hospital. Review of the facility's investigation of the 3/13/21 incident, undated and signed by the DON, showed the following: -3/13/21, the resident was found on the floor in room [ROOM NUMBER] with facial injuries by the nurse on duty. The nurse on duty contacted the DON regarding the procedure. The resident was assessed and brought to the nurse station, to continue to assess neurological changes if they occurred. The family and the physician were notified and x-rays were obtained; -3/15/21, the administrative assistant and social services assessed the resident and reviewed the nurse's notes; -3/16/21, the resident's husband visited the resident. The DON spoke with his/her husband who stated the resident had done the exact same thing at home once; -3/19/21, the resident's daughter visited the resident and expressed concerns regarding the resident's injuries. He/she felt the resident did not fall and that his/her community parent received an anonymous phone call and was told another resident jumped the resident. The daughter left the facility and returned with the police. He/she requested camera footage of the resident's room. Explained to him/her footage of the resident's room are not obtained. Police report made by responding police officer expressed no concerns. The daughter and family member wanted to take the resident to the hospital. The resident's spouse gave permission. The resident was discharged to the daughter's care; -Investigation/conclusion: After employee and resident interview, no abuse was found. The nurse followed fall procedures; -A written statement on 3/19/21 at 2:32 P.M., signed by CNA K showed: Saturday morning (3/13/21) while making rounds, he/she saw the resident wandering as usual and headed down hall 100. The resident seemed fine at the moment, with no cuts, scrapes or anything on his/her face. CNA K went to 300 hall to assist another resident for approximately five minutes. A staff member told him/her the resident had fallen. At the nurse station, he/she saw the resident sitting next to Nurse L. The resident's face had rug [CONDITION(S)] and was kind of swollen. He/she asked Nurse L if the resident would be sent out to the hospital and the nurse replied no. He/she went back to work. There were no other residents on hall 100; -A written statement on 3/19/21 at 2:23 P.M., signed by CNA M showed: The resident was walking like he/she does. CNA M saw him/her again at the nurse station and he/she was hurt; -A written statement on 3/21/21 untimed, signed by Housekeeper (HK) G showed: He/she reported to work on 3/13/21 at 7:00 A.M., and went to the nurses' station to clean. He/she heard a lot of hollering for 15 minutes. He/she saw Nurse L exit from room [ROOM NUMBER]. He/she asked Nurse L who was hollering and he/she did not reply. Nurse L sat at the nurse station, after a while he/she said it was Resident #4. HK G went to the room and saw the resident laying on the floor. He/she called for the nurse. Nurse L came and got the resident up and took him/her to the nurse station. He/she did not see Nurse L do an assessment. The resident's face was [OBSCENITY] ed up. Nurse L gave the resident two Tylenol. Nurse L was the only nurse there. During an interview on 4/12/21 at 1:52 P.M., HK G said he/she was cleaning at the nurse station on 3/13/21 and heard loud screams and a hollering noise. He/she was trying to figure out where the noise was coming from. No one else was at the nurse station. He/she witnessed Nurse L exiting room [ROOM NUMBER]. There should not be anyone down the 100 Hall because the rooms are empty. Nurse L walked to the nurses station and sat down. He/she asked Nurse L what the commotion was about and who was screaming. Nurse L did not reply. He/she repeated the questions till Nurse L answered. He/she said Resident #4 was in the room. HK G then walked to room [ROOM NUMBER]. The door was closed. He/she opened the door and saw the resident lying on the floor. The resident was face down, fully dressed and next to the bed with his/her feet positioned by the door. HK G hollered to the nurses station at Nurse L and said he/she needed to come help the resident because the resident was on the floor. Nurse L walked to the room and said the resident fell . Nurse L then said to the resident, get up (said his/her name), get up. Nurse L then picked up the resident by putting his/her arms under the resident's arm pits and raised him/her to his/her feet and walked the resident to the nurse station. The resident appeared dizzy and HK G brought a wheelchair to the nurses station for the resident to sit down. The resident's face was swollen. HK G did not witness Nurse L do any assessment, and no one else was in the room or at the nurse station. Nurse L gave the resident two Tylenol. HK G sat at the nurses station with the resident for a few minutes, notified CNA K and then returned to his/her work. Approximately 10 minutes later when HK G returned to the nurse station, the resident was no longer there. Nurse L said the resident was tired and went to sleep in his/her room. HK G reported the incident to his/her supervisor the next day he/she worked. HK G felt uncomfortable about the situation and said he/she should have reported it to someone immediately. During an interview on 4/19/21 at 12:42 P.M., Nurse L said he/she worked for a temporary agency staffing company and had been assigned to the facility at least 30 shifts. The resident was a very aggressive wanderer with extreme anxiety. The resident's family refused to allow him/her to take medication. The resident could not sit still. Nurse L worked 16 hours on 3/13/21. He/she heard a scream and went to room [ROOM NUMBER] with a CNA or a housekeeper. Nurse L did not know the names or titles of the staff at the facility. The resident fell in room [ROOM NUMBER]. The resident was found lying on the floor with his/her head positioned at the foot of the bed, face down. Nurse L made sure the resident was alert and oriented and talked to the resident. The resident did not use full sentences, only mumbled and cursed. The resident seemed to be at his/her baseline. Nurse L sat the resident up on his/her bottom, then stood the resident up with help from a CNA. Nurse L was on the right side of the resident and the unknown CNA was on the left side. They slowly stood the resident up to a standing position. The resident's hand grips were strong, the neurological test was fine and his/her pupils were equal, round and reactive to light. The resident had scrapes and rug [CONDITION(S)] on his/her face. Nurse L struggled to remember details of the event. He/she was the only nurse in the building for 46 residents and there was not a certified medication technician (CMT) there so Nurse L was also passing medications and was very busy. Nurse L said if an assessment was completed, the details would be documented in the resident's medical record in nursing notes. He/she doesn't remember if a note was written. Nurse L did come to the conclusion that the resident had a fall. If someone was beating the resident, they would have hid in the room and he/she did not see anyone in the resident's room. He/she could not recall if the resident walked in the room or not, but if A plus B equals C, then the resident must have walked in the room. Nurse L refused to answer any other questions. During an interview on 4/19/21 at 1:38 P.M., CNA K said he/she worked 3/13/21 along with Nurse L, and Nurse's Aide (NA) M. The resident was sweet, never bothered anyone, wandered a lot and sometimes took a seat to eat. CNA K was in a room taking care of a resident when HK J entered the room and said the resident was hurt. CNA K immediately went to the nurses station and observed the resident injured at the nurse station. He/she asked Nurse L if the resident needed to go to the hospital and the nurse said no. The resident had a large knot on the side of his/her head, was bleeding near his/her mouth and nose, was bruised in the face and appeared to be in pain. CNA K did not see Nurse L do an assessment of the resident, did not witness the resident fall, see the resident in room [ROOM NUMBER] nor assist Nurse L in getting the resident up. During an interview on 4/19/21 at 1:55 P.M., NA M said he/she worked 3/13/21 and started at 7:00 A.M. First thing in the morning, NA M washed the resident's face, got him/her dressed and took him/her to the dining room. NA M did not witness the resident walking into room [ROOM NUMBER], did not witness the resident fall, did not witness Nurse L complete an assessment on the resident and did not assist the resident with Nurse L in the room. NA M later brought the resident lunch at the nurse station. The resident looked like he/she fell because his/her face was all bruised up. NA M did not know anything else about the incident and did not provide any other care for the resident that day. During an interview on 4/19/21 at 2:16 P.M., HK/NA (housekeeper/ nurse aide) O said he/she worked on 3/13/21 day shift on hall 400. He/she first saw the resident that day at approximately 10:30 A.M., at the nurse station. The resident was eating and his/her face looked very swollen. HK/NA O did not witness any abuse or falls. HK/NA O did not see the resident in room [ROOM NUMBER], did not assist the nurse with the resident and did not provide any care for the resident. During an interview on 4/12/21 at 1:34 P.M., Nurse H said he/she did not work the day of the incident. On 3/15/21, he/she was told, during shift change report, that the resident had a fall on 3/13/21. When he/she observed the resident, he/she saw the right side of his/her face was bruised along with his/her forehead and a black eye. The resident also had a gash on his/her lip. A few days later, the resident's other eye turned blue as if a bruise was coming up to the surface. Nurse H would do a full assessment of a resident, if they had fallen or were found on the floor. If there was a head or face injury he/she would also do a neurological test and send them out to the hospital, especially a resident like Resident #4, because he/she was not able to verbalize what happened. During an interview on 4/19/21 at 8:01 A.M. and 10:35 A.M., Social Worker (SW) J said the resident liked to wander around the facility. The resident suffered from dementia, was sweet, non-verbal and easy to re-direct. He/she needed help with eating and dressing. SW J did not work on 3/13/21. On the morning of 3/15/21, SW J was at the nurses station and overheard staff talking about the resident's injuries. The staff were not directly talking to him/her and were gossiping to each other. He/she immediately went to check on the resident. The resident looked bad, had a cut under one eye, a bruise on the forehead and what appeared as possible rug burn to his/her nose and cheek. SW J called the administrative assistant (AA) and asked him to come to the floor. Together they went to the resident's room. AA said the resident had a fall and it was documented in the resident's chart. No one reported this to SW J nor did anyone ever report to him/her they suspected abuse. SW J did not call to report abuse because he/she was told it was a fall, and it was documented as a fall in the chart. He/she did not know if the fall was witnessed. He/she was not included in the fall investigation. SW J scheduled families for visitation with residents. The resident's spouse came in to visit and spoke with the DON who stated the resident had a fall. On 3/19/21, the resident's daughter came to visit and was very upset with how the resident looked. The resident's family called the police and took the resident out of the building. During an interview on 4/12/21 at 2:00 P.M., the DON said she was informed the resident had a fall on 3/13/21 by Nurse L. Nurse L described the resident's injuries and said all neurological assessments were normal. He/she told Nurse L to bring the resident to the nurses station. The DON saw the resident on 3/15/21 when she returned to work. The outcome of her investigation was that the resident fell . During an interview on 5/19/21 at 10:00 A.M., the administrator said he does not know for sure if the resident was left alone in the room with the door shut or not. It would be inappropriate if a resident was in acute distress to leave the resident alone in a room with the door shut. However, they are not sure if that is what happened in this situation. 2. Review of Resident#4's nurse notes, showed the following: -10/6/20 at 5:21 P.M., the resident is up ad lib (as desired) ambulating around the nurse station and dining area. Redirected from alarm doors. No complaints of pain or distress indicated; -10/7/20 at 6:18 A.M., the resident continues skilled therapy, rested throughout the night. He/she is up at present ad lib ambulating the unit. Easily redirected, no acute distress noted; -10/9/20 at 7:34 P.M., the resident is up ad lib ambulating around the nurse station and dining area. One episode of emesis noted; -10/10/20 at 6:15 A.M., the resident is resting in bed with call light in reach. No indications of having pain or distress. Review of the facility's security video, dated 10/10/20 at 2:28 P.M., showed the resident walked by the nurses station at a regular pace, followed by NA Q, who stopped at the nurses station. There was no audio to the video. Nurse A walked into the nurses station wearing headphones and carrying a jacket and another unidentifiable object in his/her hands. Nurse P, walking at a fast speed, came behind the resident, and hit the resident on top of his/her head with a yellow office binder. Nurse P, stretching his/her arm towards the resident and grabbed the back of the resident's head. The resident ducked his/her head forward and pulled his/her body in the opposite direction from Nurse P. Nurse P then grabbed the resident's upper arm and pulled the resident towards the hall. The resident pulled his/her body away from Nurse P with his/her arm stretched out, due to Nurse P holding on to it. Nurse P did not let go of the resident's arm. Further review of the facility's security video, showed Nurse A immediately turned towards the resident and Nurse A, after witnessing Nurse P hit the resident on top of his/her head with the large yellow binder, followed close behind both Nurse P and the resident. Nurse A's back was turned to the camera. Nurse P and the resident walked towards the hall, with the resident trying to jerk his/her arm away from Nurse P's grip. Nurse A walked a few steps away from the pair while they were walking towards the hall. Nurse P stopped and stood with the resident, still holding the resident's arm. Nurse A walked over and stood very closely to the resident and Nurse P. The resident tried to pull away from Nurse P's grip. The video showed Nurse A speak to Nurse P, as Nurse P turned his/her head towards Nurse A. Nurse A then inserted him/herself physically in between Nurse P and the resident, forcing Nurse P to let go of the resident's arm. Nurse A walked away with the resident out of view of the camera. Nurse P walked back towards the nurse station, with the yellow binder still in his/her hand. Further review of the resident's nurse notes, showed: -10/10/20 at 3:50 P.M., the incident was reported to DHSS; -10/10/20 at 5:00 P.M., message left for the resident's spouse; -10/10/20 at 8:45 P.M., the resident is up ad lib ambulating around nurse station and dining room. Body and skin assessment performed. No bruises or any compromising skin integrity noted. No complaint of pain nor distress indicated. Review of Nurse P's written statement provided to the Missouri Board of Nursing, dated 10/28/20, showed the following: -A registered nurse (RN) for [AGE] years; -Worked in various aspects of nursing; -Showed love, compassion, empathy, great bedside manner, and [NAME] customer service towards the residents in his/her care; -Was a very [NAME] person and never involved in a physical altercation; -The whole incident that took place on 10/10/20 was misconstrued and taken the wrong way; -He/she did hit resident with a binder on the head, but it was not intended to hurt the resident; -He/she was joking and the nurse who intercepted the incident did not know the situation; -Nurse A immediately called the DON after the incident and reported it to her; -The DON asked Nurse P to leave the premises immediately; -Nurse P believed Nurse A was retaliating against him/her because Nurse P reported Nurse A to the administrative staff for yelling at other staff members and residents, insubordination, and not calling or showing up for work; -Nurse P did not say his/her actions towards the resident was right, recognized it was not appropriate behavior, but the resident was not hurt by Nurse P's actions of hitting the resident on top of his/her head with a binder; -Nurse P was in management since obtaining his/her nursing license and should have known not to hit residents. During an interview on 4/28/21 at 1:08 P.M., Nurse P said he/she started working at the facility in 2019 and does not remember the exact date or when he/she quit. He/she needs a lawyer because he/she did not do anything. He/she is a good nurse. He/she was accused of physical abuse, but he/she doesn't know what or when. Nurse P says he/she plays with the residents and has fun. His/her patients all love him/her. Nurse P typed up a five or six page report and sent it to the state capitol after an investigator (from the Board of Nursing) called him/her. Nurse P answered all of his/her questions. One day, Nurse A walked into the facility when he/she wasn't even scheduled to work. We were having fun. We were playing. He/she was joking and lightly tapped the resident on the head. Nurse A grabbed Nurse P's arm and said don't do that. He/she told Nurse A don't touch me, you don't know what's going on. For no reason, Nurse P was asked to leave the building. He/she never hurt anyone, if he/she was going to hurt someone, he/she could hurt them and not with a tap on the head. Nurse P got upset but left the building. No one from the facility ever told him/her why he/she was fired. Abuse is physically grabbing or hitting a resident causing harm. Nurse P has never done that. As a nurse, he/she is a mandated reporter. He/she has two hours to report abuse to the DON or the administrator. Nurse P is no longer answering any more questions because he/she is a perfect nurse and needs to work. Nurse P has never hurt anyone in his/her life. During an interview on 4/19/21 at 3:38 P.M., Nurse A said he/she was just coming into the building when he/she saw Nurse P hit the resident with a binder. Nurse P hit the resident on the head, grabbed him/her by the neck and the arm. He/she tried to separate Nurse P from the resident. He/she told Nurse P to let the resident go, Nurse P said he/she knows what (he/she) is doing, has worked psych before. Don't get in between (him/her) and the resident. Nurse A was able to separate Nurse P from the resident and took the resident down the hall as he/she called the DON. Nurse P was told to leave the building, who said to Nurse A that he/she better watch his/her back. During an interview on 4/16/21 at 1:56 P.M., HK I said the following: -The resident liked to walk a lot, wandering around the facility without seeking exit; -The resident was a beautiful and nice person; -He/she worked the day Nurse P hit the resident over the head with a large thick binder; -He/she was at the nurses station and witnessed Nurse P hit the resident over the head with a large thick binder; -A loud noise was heard when the binder hit the resident's head; -He/she believed Nurse P was upset that the resident walked by the nurse station and that was why Nurse P hit the resident over the head; -Nurse A also witnessed the incident, intervened and stopped Nurse P from hitting the resident again. During an interview on 4/28/21 at 12:38 P.M., NA Q said: -The resident wanders, walked around the facility all the time, never did harm to anyone, he/she rarely spoke, had dementia and wasn't all there; -Nurse P must have had enough because he/she hit the resident on the head with a binder; -The hit was hard and loud. The resident said, Oh,[OBSCENITY] -Nurse P was holding on to the resident's arm, manhandling him/her and would not let go; -Nurse A intervened, and said, Let (him/her) go; -Nurse A took the resident away from Nurse P; -NA Q then returned to work. During an interview on 4/19/21 at 8:01 A.M., Social worker (SW) J said the resident liked to wander around the facility. The resident suffered from dementia, was sweet, non-verbal and easy to re-direct. The resident needed help with eating and dressing. During an interview on 4/28/21 at 1:53 P.M., the DON and the administrative assistant (AA) said abuse is not tolerated at the facility. All staff are in-serviced on abuse, neglect and facility policies upon hire and on review. Nurse P was told to leave the facility immediately when they were made aware of the abuse. After reviewing the video and completing the investigation, Nurse P was called and told her/his services would no longer be needed at the facility and he/she was terminated due to his/her action on 10/10/20. Nurse P is not eligible for re-hire at the facility. The facility reported Nurse P to the Board of Nursing as well. MO 735 MO 911 MO 958

Based on interview and record review, facility staff failed to call emergency personnel (911) and provide basic life support, including cardiopulmonary resuscitation (CPR), for one full code resident, found without signs of life (Resident #1). The census was 63. The Director of Nursing (DON) was notified on [DATE] at 2:00 P.M., of the Immediate Jeopardy (IJ) Past non-Compliance which occurred on [DATE]. On [DATE], the assistant administrator and DON became aware of the violation of the facility CPR policy. The staff member was suspended pending investigation. The facility inserviced the staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. Review of the facility's CPR policy, dated [DATE], showed: -Policy Statement: --Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic lift support for victims of sudden [MEDICAL CONDITION]; -Emergency Procedure for CPR: --If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR; --Instruct a staff member to call 911; --Verify or instruct a staff member to verify the DNR (Do Not Resuscitate) or code status of the individual. If basic CPR is to be started, place the resident on a hard, flat surface; --Initiate the basic life support sequence of events, chest compressions, airway and breathing; Review of the resident's admission physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Full Code (perform CPR in the event of [MEDICAL CONDITION]). Review of the nurses's notes, documented by Nurse A, dated [DATE] at 1:33 [NAME]M., showed: -Checked on resident at 12:20 [NAME]M., temperature down to 98.8 (normal 98.6 degrees Fahrenheit); -Checked on resident at 12:45 [NAME]M., no pulse; -Called physician at 12:50 [NAME]M., and informed of resident's passing; -At 1:00 [NAME]M., called resident's aunt and informed of resident's passing. She was going to try and contact resident's mother who was on a cruise; -At 1:15 [NAME]M., called coroner and all information given. Their office will contact the physician next week. Review of night shift (11:00 P.M. to 7:00 [NAME]M.) Nurse A's statement, dated [DATE], showed: -On [DATE] at 12:20 [NAME]M., Nurse A went into the resident's room and the resident was breathing; -At 12:45 [NAME]M., Nurse A went back into the resident's room and the resident was not breathing, his/her skin was cool to touch and he/she had no pulse or heart beat; -Nurse A went to the nurse's desk and told the certified nurse aides (CNAs) the resident was not breathing and his/her skin was cool to touch; -Nurse A called the resident's physician and gave him/her all of the information; -Nurse A called the resident's aunt, since the resident's mother was on a cruise; -The resident's physician called back and asked if CPR was started. Nurse A told the physician no and that the resident was cool to touch, with no pulse or heart beat; -The resident's aunt and uncle came to the facility to get the resident's belongings; -Nurse A called the coroner and gave all of the resident's information; -Nurse A notified the DON per text of the resident's passing. During an interview on [DATE] at 3:20 P.M., Nurse A said: -Nurse A verified his/her nurse's notes from [DATE]; -Nurse A had received an inservice regarding CPR not long ago; -Nurse A knew where to check for the code status of the resident; -Nurse A could not say why he/she did not check the code status or start CPR on the resident; -Nurse A should have checked the code status and started CPR for the resident on [DATE]. Review of night shift Certified Medication Technician (CMT) B's statement, showed: -On [DATE] at 1:00 [NAME]M., CNA C told CMT B that the resident had passed away; -CMT B went to the nursing station and Nurse A was on the telephone; -CMT B thought Nurse A was on the telephone with 911, but it was the physician; -Nurse A said the resident was already dead; -The CNAs cleaned the resident and CMT B went to check the residents on his/her hall. Review of night shift CNA C's statement, dated [DATE], showed CNA C was notified by another CNA that the resident had expired. During an interview on [DATE] at 12:45 P.M., the assistant administrator and DON, said: -Nurse A worked at the facility almost [AGE] years, and signed the CPR policy on [DATE]; -On [DATE], Nurse A did not check the resident's chart to see if the resident was a full code; -Nurse A was terminated on [DATE]; -Inservices regarding CPR were immediately started with staff on [DATE], before they worked again at the facility; -The monthly CPR code drills have been done. Review of the inservices, dated [DATE], showed staff were inserviced regarding emergency procedures, location of code status book, CPR, crash cart and mock code. Review of facility mock code sheets, showed the last monthly mock code was done on [DATE], at which time Nurse A attended. Review of the Separation Report Form, dated [DATE], showed Nurse A was terminated for improper conduct and failure to follow CPR policy. During an interview on [DATE] at 2:10 P.M., the resident's physician said staff should have called 911 and performed CPR for the resident when he/she was found without signs of life on [DATE]. MO 203

Based on observation, interview and record review, the facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident with a full code order. The resident was found unresponsive by a Certified Nurse Aide (CNA) who reported it to the only nurse in the building. The nurse failed to check the medical record for the resident's code status, initiate CPR or call 911, but waited 20 to 30 minutes for the Director of Nurses to arrive for instruction. No directives were given to staff to call 911 or to call a code for other staff to respond to the resident who expired. In addition, the facility failed to ensure at least one staff member was CPR certified on the night shift and failed to ensure they had an appropriate emergency policy/procedure to direct staff on what to do in the event a resident was found without signs of life, and ensure staff were trained on and were aware of the facility's emergency procedures. (Resident #27) The facility census was 60, with 40 full code residents. Review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation, dated 2001 and revised on (YEAR), showed the following: -Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compressions and artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION] (the heart stops); -General Guidelines: 1. Sudden [MEDICAL CONDITION] is a loss of heart function due to abnormal heart rhythms. [MEDICAL CONDITION] occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A [MEDICAL CONDITION] refers to impaired blood flow to the heart which leads to damage of the heart muscle. A [MEDICAL CONDITION] can cause sudden [MEDICAL CONDITION] (SCA). Typically [MEDICAL CONDITION] are less sudden than SCA. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing presentations of SCA. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is CPR/BLS certified shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation or automated external defibrillator (AED) (provides a shock that can potentially stop an irregular heart beat and allow a normal rhythm to resume following sudden [MEDICAL CONDITION]) exists for that individual or there are obvious signs of irreversible death (e.g. rigor mortis (Stiffening of the joints and muscles of a body after death. Rigor mortis generally sets in about three to four hours after death, peaks at 12 hours, and dissipates after 48 hours). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. 8. If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives. -Preparation for Cardiopulmonary Resuscitation: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care or facility BLS training material. 3. Provide periodic Mock Codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. 4. Select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 5. The CPR Team in this facility shall include at least one nurse, and two Certified Nursing Assistants (CNAs), all of whom have received training and certification in CPR/BLS. 6. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 7. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. -Emergency Procedure - Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR. A) Instruct a staff member to activate the emergency response system (code) and call 911. B) Instruct a staff member to retrieve the automatic external defibrillator (AED). C) Verify or instruct a staff member to verify the DNR or code status of the individual. D) Initiate the BLS sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: A) Following initial assessment, begin CPR with chest compressions. B) Push hard to a depth of at least 2 inches at a rate of at least 100 compressions per minute. C) Allow full chest recoil after each compression. D) Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via Abu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. Trained rescuers should also provide ventilation's with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency personnel arrive. Review of the facility Death of a Resident Documenting policy, revised on 7/2017, showed the following: -Policy Statement: Appropriate documentation shall be made in the clinical record concerning the death of a resident; -Policy Interpretation and Implementation: 1. A resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law. Review of Resident #27's facility face sheet, showed the following: -admission date of [DATE]; -Code status: Full code (if a resident is found with no signs of life, the resident has elected for CPR to be performed); -Date of Birth: 10/5/59; -[DIAGNOSES REDACTED]. Review of the resident's care plan, updated 3/18/18, showed the following: -[DIAGNOSES REDACTED]. -Showed no documentation regarding the resident's code status. Review of the resident's Restorative Therapy Assessment, dated 5/31/18, showed the following: -Range of motion (0% - within normal limits) right upper extremity 75% and left upper extremity 50%; -No loss of range of motion documented concerning the right or left lower extremities. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/22/18, showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -No mood or behavioral problems; -Required total staff assistance for all activities of daily living; -Functional limitation in range of motion for upper and lower extremity; -Incontinent of bowel and bladder. Review of the resident's progress note, dated 8/29/18 at 5:45 A.M., showed the following: -Nurse A entered the resident's room to administer his/her morning medication; -Nurse A called the resident's name and received no response; -Nurse A checked for a pulse and was unable to find one; -Nurse A called the resident's physician who gave a [DIAGNOSES REDACTED]. -Nurse A placed a call to the resident's responsible party and left a message; -There was no documentation whether the nurse checked the resident's medical record for his/her code status, initiated CPR or called 911; -At 7:54 A.M.: Nurse A called the coroner. Review of the resident's physician's orders [REDACTED]. -Code status: Full code; -Location: expired. During the initial tour of the facility, on 9/7/18 at 8:03 A.M., Resident #27's name was observed on the door of a semi-private room. Observation showed a resident lay awake in one of the two beds in the room. This surveyor asked the resident if he/she was Resident #27. The resident said he/she was Resident #54. Resident #27 was his/her sibling, but he/she died approximately one week ago. He/she was surprised about his/her siblings death, because he/she didn't seem sick. He/she would be attending the sibling's funeral later that day, 9/7/18. During an interview on 9/9/18 at 6:55 A.M., Certified Nursing Assistant (CNA) O said he/she has worked at the facility for a month on evenings. He/she took care of Resident #27 on the evening shift of 8/28/18. He/she seemed fine, breathing was normal and had no complaints, on the evening shift. During an interview on 9/9/18 at 7:27 A.M., CNA N said he/she worked the night shift on 8/28/18 through the morning of 8/29/18. At the beginning of the shift, he/she routinely makes a round throughout the facility. When he/she checked on Resident #27, he/she looked different to him/her that night, like he/she didn't feel well. He/she normally doesn't talk unless you are caring for him/her and he/she didn't say anything at the time. CNA N didn't report it to anyone, because he/she thought the facility staff was already aware. The resident was on CNA P's assignment that night. He/she heard CNA P say the resident was dead when he/she entered the room. CNA P called Nurse A, who went in immediately. He/she doesn't know what else was done after that. No one asked him/her anything about the resident's death. He/she didn't receive any instructions from the nurse or see a CPR cart or oxygen. No ambulance was called. The resident lived in the room with his/her sibling. During a telephone interview on 9/9/18 at 12:33 P.M., CNA P said he/she has worked the night shift. He/she took care of the resident the night/morning he/she passed away. The resident required total care, so he/she checked him/her frequently. He/she started the shift at 11:00 P.M., checked him/her for wetness and found him/her dry at that time. The resident said hi when he/she spoke to him/her. The resident looked the same as always to him/her. During the 12:00 A.M. rounds, the resident was ok and not soiled. At 2:30 A.M., the resident was wet, he/she provided care and he/she was ok. He/she started his/her last rounds at 5:00 A.M. After providing care to two other residents, he/she entered Resident #27's room. The resident felt warm to touch, but didn't respond when he/she nudged him/her, nor answer when his/her name was called. That's when he/she noticed the resident wasn't breathing. He/she immediately left the room and reported to Nurse A, that the resident looked as if he/she had passed away. Nurse A immediately went into the room and checked to see if he/she was breathing. He/she (CNA P) left the room at that time to take care of another resident. Nurse A did not give him/her any instructions to do anything, so he/she went to take care of someone else. He/she didn't know the resident's code status and wasn't sure what the nurse did once he/she left the room. Shortly after finding the resident, he/she provided post mortem care (care after death). He/she said the resident's death was unexpected and hard to deal with. During a second interview conducted at the facility on 9/11/18 at 5:50 A.M., CNA P said he/she had been a CNA for [AGE] years, but only worked at the facility for four months. He/she went straight from being hired to working the midnight shift. He/she trained one night with another CNA before being assigned to work alone. No one showed him/her how to identify a resident who was a full code as opposed to a no code during training. He/she is still not aware of how to determine a code status. He/she had not received an in-service about the two code status books the Director of Nursing (DON) completed or where they were located. Had he/she known the resident was a full code, he/she would have discussed coding the resident with the nurse that morning. He/she is not CPR certified and had not been offered CPR training by the facility. He/she had been told there was no crash cart. He/she did not know if the computer system the CNAs use for documenting showed a resident's code status or not. On the morning he/she found the resident passed away, he/she touched the resident on his/her upper arm through his/her hospital type gown. The resident appeared to be sleeping and he/she still felt warm. After telling Nurse A about the resident being dead, he/she received no instructions regarding CPR from the nurse. He/she assumed the resident was a DNR and left to check on a couple more residents. He/she returned to complete post-mortem care on the resident no later than 20 to 30 minutes after first finding the resident. The resident's left upper arm was always stiff and contracted. When he/she turned the resident onto his/her side, all the other resident's limbs were loose. The resident's back side was pale in color, but there was no discoloration. The DON came to the facility around 6:30 A.M. that morning. The DON did not ask him/her any questions about the resident's passing. Since that day, he/she had not received any in-services regarding CPR, the policy for CPR, code status or the code status books. Had he/she known the resident was a Full Code he/she would have started CPR. During a telephone interview on 9/10/18 at 9:26 A.M., Nurse A said his/her shift began at 11:00 P.M. At the beginning of the shift, he/she receives report from the evening nurse which usually takes approximately 30 minutes. At approximately 11:40 P.M. he/she would make rounds on the hall to check residents. When he/she saw the resident at the beginning of shift, he/she was awake and alert. At 1:00 A.M., he/she was sleeping and breathing. Between 2:30 A.M., and 3:00 A.M., he/she checked the resident's tube feeding pump and the resident appeared to be sleeping. At approximately 5:40 A.M., the resident was deceased . His/her hands and feet were cold. The resident did not respond when he/she did a sternum rub or call him/her by name. He/she had received no previous training, instructions or inservices on what to do in case of a death. He/she did not call a code, start CPR or oxygen and did not call 911. He/she had no knowledge of a crash cart, or where the Ambu bag (a device used to provide breaths to a unconscious person) was located. This was his/her first death as a new nurse and he/she was not sure of the steps to take. He/she decided to wait for the DON to come in which was usually around 6:00 A.M. When the DON arrived she instructed him/her to call the physician and the coroner. It took some time for the physician to call back, maybe 20 to 30 minutes. After he/she received a [DIAGNOSES REDACTED]. At 6:30 A.M., the DON approached him/her at the desk and said the resident was a full code. The DON said she saw the code status while looking for another number to contact the family. She asked him/her if CPR was started and he/she said no. The DON said again, the resident was a full code, and without providing any guidance or inservicing, she walked away from the desk. This was his/her first experience with a resident that died and he/she did not know what he/she should have done. He/she was the only nurse on duty. During a second interview conducted at the facility on 9/11/18 at 6:53 A.M., Nurse A said he/she began working at the facility on 6/11/18. This was his/her first job since completing nursing school. On 6/12/18 or 6/13/18, he/she informed the DON, he/she had no CPR certification. The DON said the facility would have a CPR class soon and he/she could sign up for that class. Until that time, if anything happened to a resident, he/she was instructed to call 911. There were days between starting at the facility and attending the CPR class on 8/14/18, that he/she was the only nurse working. He/she did not know what staff, if any, he/she had worked with had current CPR certifications. On her first night working, he/she arrived on time. Nurse Q, the night nurse that was to train him/her, had not shown up at the shift change and the two evening nurses left him/her alone. Nurse Q arrived 25 to 30 minutes later. He/she followed the nurse around that night, but got the impression he/she was in the way. He/she did not feel comfortable asking Nurse Q questions. Nurse Q did not tell him/her anything about the CPR policy, a resident's code status, when to begin CPR or if the facility had a code status book or ambu bags. Originally, he/she was to train for three nights then be by him/herself. He/she did not feel comfortable being by him/herself, so he/she spoke to the DON and told her he/she did not receive appropriate training from Nurse Q. The DON said to take the next night off and come in on the following day shift. On that day, the DON asked him/her what training he/she needed and he/she said the tube feeding pumps which he/she received from one of the nurses. Another nurse, Nurse B, reviewed computer training with him/her that day, but did not review policies regarding CPR or how to identify a full code resident from a DNR resident. Again, he/she told the DON he/she wasn't comfortable with working the night shift by him/herself. The DON had an ADON from their sister facility come to work with him/her on nights. The ADON explained that policies are different in each building, so he/she was unable to be specific about what procedures he/she needed to follow. Over the course of time, he/she independently discovered how to identify a resident's code status in the computer records. The shift when Resident #27 passed away began as normal and he/she was the only nurse working. He/she received no concerns about the resident during report from the evening staff. He/she made rounds around 2:30 A.M. or 3:00 A.M. and the resident slept and appeared stable. Around 5:40 A.M., as he/she was going to the resident's room, CNA P came out of the room in a panic saying the resident was dead. The CNA was loud and repeated the resident was dead. The CNA said he/she went in to provide perineal care and found the resident dead. When Nurse A entered the room the resident appeared very pale, paler than he/she was at 2:30 A.M. or 3:00 A.M He/she did a sternum rub and called out the resident's name. The resident did not have a pulse. His/her hands and feet were very cool and his/her heels were a little purple. He/she did not notice any other discoloration or rigor mortis. He/she did not check his/her chart to determine the code status because the resident was already dead. He/she thought CPR was to be initiated only if someone is present when someone stops breathing, not if they are found dead. After that, he/she walked out of the room and was in shock. He/she did not know what to do as far as paper work and calling the physician, and the DON would be in around 6:00 A.M., so he/she decided to wait for her to ask. He/she returned to the resident's room after approximately 10 minutes. CNA P was providing post mortem care. The CNA had turned the resident onto his/her side while he/she was in the room, but he/she did not see the resident's backside, so he/she did not know what color the resident's back side was. The DON arrived using the same entrance as she always did. She was walking up the hall, the same hall where the resident's room was located, when he/she told the DON the resident had died . The DON kept walking to his/her office and did not enter the resident's room or ask him/her any questions. It was not until later that morning, when the DON came to the nurse's station and said the resident was a full code, and asked Nurse A if he/she coded him/her. He/she told the DON he/she had not and could tell at that time he/she must have done something wrong by the look on the DON's face. The DON did not tell him/her CPR should have been initiated or review any policies regarding CPR with him/her that day. It was not until this morning (9/11/18) that the DON and Administrator told him/her where the policy books, two code status books and ambu bags were located. He/she had never noticed the policy of code status books because there are a lot of books at the nurse's station. If he/she had to code someone prior to today, he/she would have had to do mouth to mouth respirations. They told him/her it was his/her responsibility to know what was in the policy books. Nurse A reviewed the CPR policy the DON said she reviewed with Nurse A the morning the resident passed away. Nurse A said he/she was not inserviced on the policy until this morning. Review of the facility staffing reports from 6/11/18 through 8/14/18, showed Nurse A worked as the only nurse on the night shift and without CPR certification, with no other staff with CPR certification on the following dates: 6/18, 6/19, 6/28, 7/3, 7/7, 7/8, 7/16, 8/4, 8/5, 8/7, 8/8, 8/10 and 8/13/18. Further review of the facility staffing reports, from 6/11/18 through 9/11/18, showed on 6/24, 8/11, and 8/20/18, night shifts, no CPR certified staff were on duty. Review of Nurse A's Employee Orientation sheet, signed and dated by Nurse A on 6/11/18, showed a check mark by the following: -Tour of the facility and staff introduction, emergency procedures; fire and disaster plan reviewed, job description signed, copy received; -The comments section was blank. Review of Nurse A's Employee Inservice Tracking form, showed the following inservices on the following dates: -4/8/18 (the nurse did not begin working at the facility until 6/11/18): Administration of as Necessary Medication; -8/7/18: Abuse and Neglect; -9/5/18: Professional Documentation, Med Errors, MD Orders, Accu-checks and Narcotic Count. Review of Nurse A's CPR card, showed a class completion date of 8/14/18 and an expiration date of 8/14/20. Review of the facility's Employee Manual, dated 6/12/03, showed the following: -(Licensed Practical Nurse) LPN-RN (Registered Nurse) Charge Nurse Essential Competencies for Practice and Outcome Statements; -Policy statement: Provide [MEDICATION NAME], resident centered, and affordable healthcare to all residents served within the facility; -Nursing policies and procedures: Emergency medications/crash cart. Maintain a properly stocked and prepared emergency cart, remove and replace any expired medications; -Emergency protocols: Function in designated roles(S) during emergency situations (Team Leader, Procedure Nurse, Circulator, Recorder). Follow protocols for resident treatment during specific emergencies (Triage, Abrasions/Lacerations, Severe Allergic Reactions, Acute Asthma, Burn Injuries, [MEDICAL CONDITION], Chest Pain/Possible MI). During an interview on 9/10/18 at 10:25 A.M. Nurse D said: -He/she is on his/her second day of on the floor orientation; -The facility did not orientate on when to start CPR, they just briefly touched on it by stating when in doubt begin CPR; -However, he/she has been a nurse for a long time and knows what to do in an emergency situation; -Staff was given a quick tour during orientation and he/she thinks the crash cart might be in the medication room, but not sure; -The facility's e-charting system has each resident's code status listed; -He/she did not know there was a Code Status book at the nurse's station; -He/she did not remember going over the CPR policy during orientation, does not know where to find the CPR policy and is not even sure if they have an actual CPR policy to review. During an interview on 9/10/18 at 10:33 A.M., Nurse B said: -He/she was hired as a Graduate Practical Nurse (GPN) and this was his/her first nursing position; -He/she received no orientation or education on when to start CPR, what to do in an emergency situation, what to do in the event of a death or where to find a resident's code status; -He/she was just thrown on the floor and learned the job from a classmate he/she had graduated with and who started at the facility approximately one and a half months before he/she did; -The DON said they did not have a crash cart, because the fire department was right next door and the police were across the street. So, if something happened, they could be in the facility by the time they started CPR; -He/she was not told how to find a resident's code status or how to navigate the e-charting system; -He/she did not know what to do in the event of finding a resident unresponsive. He/she had an incident similar to this and would not have known what to do if another nurse on duty would not have been there to show him/her what to do. The other nurse assisted him/her through it step by step; -He/she felt like the facility did not provide him/her with any training or information unless he/she specifically asked for it; -He/she felt like there were a lot of instances when some education/orientation would have helped him/her to do a better job caring for his/her residents and work with the resident and families better; -The DON very rarely answers her phone; she will sometimes text you back and sometimes not answer at all; -The DON does not connect well with the staff. If staff goes to her with a problem, she will just say oh, just don't worry about it and takes care of it herself instead of teaching staff how to resolve the issue; -In-services consist of the DON putting packets out at the nurse's station that staff is supposed to read on their own and then sign a paper stating they read it. They sometimes have computer lessons, but it is mainly reviewing the packets; -He/she has been the only nurse on the floor during the day shift for the last week and a half. The DON has not offered him/her any assistance and is never on the floor assessing the residents; -He/she is CPR certified. During an interview on 9/10/18 at 10:39 A.M., the DON said she was not aware CNA P was the first staff member to find the resident. It was her understanding, Nurse A found the resident. She had not spoken to CNA P regarding what happened that morning. That same day she reviewed the facility CPR policy with Nurse A, but she did not document that or have Nurse A sign she had reviewed the information with him/her. She also reviewed and updated all of the residents' code status to ensure they match their advance directive. They have always had a code status book at the nurse's station, but now they have two, one with all the residents listed and one with DNRs only. The new code status books are at the nurse's station. She did not in-service staff about the books, because having a code status book is not new, they are just in two books now. Review of the code status books on 9/10/18, showed out of the facility census of 60, 40 residents had a full code status. Observation on 9/11/18 at 6:40 A.M., showed CNA P logged onto the computer system at the nurse's station. He/she clicked on a random resident's name to demonstrate what he/she sees. At the top of the random resident's page was a green stop sign symbol. The CNA, at the direction of the surveyor, ran the cursor over the symbol and a small box appeared that showed: advanced directive full code. The CNA said he/she did not know that did that. He/she did not know what the symbol meant. CNA M stood next to CNA P watching at that time, and said he/she did not know that either. During an interview on 9/10/18 at 10:53 A.M. Certified Medication Technician (CMT) G said: -He/she is not CPR certified. Only the nurses are CPR certified; -He/she does not remember if he/she had received any education or in-services on when to start CPR, what to do in an emergency, where to find the code status of each resident; -He/she knows what to do in an emergency, because he/she has worked in the nursing field for a very long time; -He/she does not know if the facility has a CPR policy or where to find it; -He/she was able to show this surveyor a wheeled crash cart in the oxygen room on 400 hall that contained: --2 small oxygen tanks with no tubing; --an uncovered suction machine with the unbagged tubing already attached and no extra supplies noted; --one Ambu bag; --two staple remover kits; --a tube of wound gel; --blood glucose test strips with no glucometer; and --a pulse oximeter machine, but no other vital sign equipment. During an interview on 9/10/18 at 11:06 A.M., Nurse C said: -He/she did receive orientation on when to start CPR, what to do when you find a non-responsive resident, and where to find a resident's code status; -There was a white book at the nurse's station that held all the residents' code status; -He/she had never read the CPR policy, but it can be found in the policy book at the nurse's station. During an interview on 9/10/18 at 11:16 A.M., CNA J said: -He/she does not remember if he/she received orientation on when to start CPR or what to do in an emergency situation; -He/she attended training in (MONTH) to receive his/her CPR certification. He/she was not CPR certified prior to that; -In-services consist of packets that require reading and videos to watch on your own as you can fit it in your day. During an interview on 9/11/18 at 6:50 A.M., CNA L said: -His/her orientation did not include when to start CPR, what to do when you find a non-responsive resident or during an emergency situation; -He/she did not know if the facility had a crash cart (or any other cart with supplies for an emergency situation/CPR) or where it might be if there was one; -He/she was not working the night Resident #27 passed away; -He/she had not received any additional education or in-service since the resident passed in regards to when to start CPR, what to do in an emergency situation or upon finding an unresponsive resident, where to find a resident's code status or where the crash cart was located; -No one ever told him/her how to find a resident's code status. No one told him/her the DON placed code status books at the nurse's station. He/she still did not know how to find a code status; -He/she does not know what role he/she would play in an emergency situation, what to do to assist with CPR, or what to do if he/she were to find an unresponsive resident except to notify the nurse; -He/she is not CPR certified, the night CNAs were not offered a chance to sign up for the class in August. During an interview on 9/11/18 at 7:00 A.M. CNA M said: -He/she was working another hall the night Resident #27 passed away; -He/she was aware the resident had passed because he/she heard another CNA say he/she is dead; -He/she was not a part of the care provided to the resident and is unaware of what occurred; -He/she doesn't know why CPR was not started, he/she would have assisted with CPR if he/she would have been asked. He/she knew how to do the chest compressions and all. His/her CPR was expired, but he/she had known how to do CPR for a long time; -He/she had received no orientation or education on what to do in an emergency situation, when to start CPR, if the facility had a crash cart or where to find the resident's code status; -He/she figured out that the code status was in the e-charting; -He/she was never told or shown the code status books at the nurse's station; but it'

Based on observation, interview and record review, the facility failed to have a system in place to monitor one resident with a history of wandering from exiting the facility unnoticed by an alarming unlocked exit door. The resident was found by a community member and driven to the police station. The resident was transported by ambulance to a local hospital and admitted with a [DIAGNOSES REDACTED]. (Resident #54). The census was 58. 1. Review of Resident #54's hospital discharge note, dated 11/10/17, showed the following: -Resident found wandering around a college campus by campus police. Campus police obtained a family member's name and number from the resident's wallet and contacted the family member. The resident taken to hospital due to showing signs of confusion; -[DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Review of the resident's nurse's notes, showed the following: -On 11/20/17 at 9:48 P.M., the resident set alarms off several times, was taken to bed but got back up. The resident stated he/she was ready to head for the hills; -On 11/21/17 at 4:26 P.M., the resident made one attempt to open exit doors; -On 11/22/17 at 10:36 P.M., the resident made one attempt to open exit doors; -On 11/25/17 at 3:20 A.M., resident ambulating in hallway, tripped and fell . Abrasion noted to right cheek; -On 12/2/17 at 10:48 P.M., the resident was exit seeking majority of shift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/17, showed the following: -admission date of [DATE]; - Severe cognitive impairment; -Wandering occurred 1 to 3 days, but less than daily, during the seven day review period; -Wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as outside the facility; -Walked independently in room, corridor, and off unit; -Required supervision for locomotion on the unit; -Indwelling catheter; -Two falls with injury since admission; -Received antipsychotic medication during the last 7 days. Review of the resident's care plan, dated 2/20/18, showed the following: -Problem start date: 2/20/18; -Problem: The resident has a history of wandering out of the building without awareness for own safety; -Goal: The resident will be safe in his/her environment: -Approach: The resident will be reassessed quarterly, wander guard on at all times. Review of the resident's nurse's notes, showed the following: -On 2/21/18 at 8:11 A.M., the resident does not follow directions and becomes agitated with redirection; -On 2/25/18 at 7:06 A.M., the resident sounded 300 hall alarm, came back up hallway. The nurse turned off the alarm, and the resident was not found. Staff conducted a search inside, outside, and around the perimeter of the property. Staff unable to locate resident. Staff used car to widen search. Police department notified the facility the resident was with them. Paramedics took the resident to the hospital from the police department. DON and Administrator made aware. During a telephone interview on 3/8/18 at 12:50 P.M., Officer MM said he/she responded when the resident was brought to the police department on 2/25/18. A community member (CM) saw the resident at an intersection down the road. The resident had made it down the hill to the intersection. The CM was able to get the resident into his/her van and bring the resident to the police station. The resident was basically nude, wearing only a hospital gown and socks. An ambulance responded and took the resident to the hospital. The emergency medical technicians (EMTs) covered the resident with warming blankets. He/she guessed the resident was from the facility since it was located in the area. He/she also saw Nurse M looking around the convenience store parking lot for the resident, and the nurse confirmed they had a resident missing. He/she went over to the facility after the resident left for the hospital so he/she could speak with Nurse M about the incident. He/she did not write a report. Observation showed the area where the resident was found by CM was at a intersection of a busy four lane road approximately three tenths of a mile from the facility. Review of Underground Weather for 2/25/18 at 4:45 A.M., showed a temperature of 34 degrees Fahrenheit with a nine mile an hour wind. Review of the ambulance run report, dated 2/25/18, showed the following: -Call received at 5:09 A.M.; -Chief complaint: resident found wandering down road; -Resident found alert and oriented times 1-2, following commands appropriately, cold, shivering, calm and cooperative; -Blankets applied to resident; -Resident taken to hospital at 5:23 A.M. Review of the resident's hospital admission summary, dated 2/25/18, showed the following: -Resident demonstrated an altered mental status; -Resident left nursing home around 4:00 A.M.; -Found wandering down the road with catheter strapped to leg; -A CM took the resident to police department and ambulance called; -Resident's body temperature was 95.9 degrees F; -The resident was hypothermic and complained of generalized weakness; -Resident noted to have elevated troponins (proteins in the blood to assess heart damage); -Resident demonstrated aggressive behavior while in the hospital and tried to attack nursing staff taking care of him/her; -Resident admitted with [DIAGNOSES REDACTED]. Review of a copy of the facility's Emergency Checklist for Missing Resident form, no date, and obtained from the Administrator in Training at the facility on 3/5/18 at 11:50 A.M., showed the following: -Spaces for the date and time; -Instructions to initial steps #1-7; -Step 1, if off-duty, notify the Administrator or Director of Nursing; -Step 2, organize and institute a thorough search of the facility and surrounding grounds and buildings; -Step 3, call 911 or police department; -Step 4, organize and institute an expanding search of the neighborhood surrounding the facility; -Step 5, contact DHSS Central Registry Unit at [PHONE NUMBER]; -Step 6, notify responsible family member; -Step 7, supply resident's picture from medical records to search team members; -Spaces for signature and date. Review of the resident's medical record and electronic health record (EHR), on 3/5/18, showed no elopement assessment in the admission paperwork, in the assessments, or in any other part of the EHR. During an interview on 3/5/18 at 5:15 A.M., CMT R said he/she worked the night shift passing medications for the 200 and 300 halls. He/she was familiar with the Resident #54. The resident wore a wanderguard and set off the alarm. He/she recently eloped from the facility between 4:00 A.M. - 5:00 A.M. on 2/25/18. The last time he/she saw the resident that morning, the resident was sitting at the nurse's station with Nurse W. He/she was in the medication room when the alarm went off. Everyone checked their assigned areas. He/she came out of the medication room and checked the board at the nurse station that showed the 300 hall exit door had been opened, so he/she went to that exit door. He/she did not see the resident or go outside to look. He/she heard a staff member got in their car and drove around and that another staff member had went outside with a flashlight. He/she is not sure if there is an elopement policy and cannot recall the last time he/she had training on elopement procedures. During an interview on 3/5/18 at 5:55 A.M., CNA S said he/she worked the night shift at the facility and was familiar with Resident #54. The resident often set off the door alarms about 6 or 7 times a day. He/she worked the weekend of the elopement. The resident did not sleep much that night. Nurse W and Nurse M were working that night. When the alarm went off, Nurse M was outside smoking, Nurse W was in the bathroom or something and he/she was sitting in the foyer area, near the nurse's station. The alarm makes a noise that can be heard throughout the building. Nurse W told everyone to start looking for Resident #54. They checked all the rooms, showers, and closets. They double checked the building and then looked outside. It took them about an hour to check the building. The police called the facility around 5 A.M. He/she did not know how the resident got out. During an interview on 3/5/18 at 6:05 A.M., CNA DD said he/she worked the night shift at the facility and was familiar with Resident #54. On 2/25/18, the resident was anxious. The resident set off the door alarm and then went toward his/her room. Nurse W went and got the key from Nurse M to turn off the alarm. Nurse W told everyone the resident was missing and to look everywhere. He/she looked down halls 100, 300, and 500. Someone else checked halls 200 and 400. He/she is not sure exactly how long it took to check the whole building, about an hour. Nurse M got in his/her car and went to look around the neighborhood. He/she has not had any elopement training and does not know if there is an elopement policy. He/she had never seen one. There are two residents who are an elopement risk, but he/she cannot remember their names at the moment. Wandering was typical behavior for Resident #54. The resident would do it every night. That is why he/she was sitting at the nurse's station or sitting somewhere they could watch him/her. During an interview on 3/5/18 at 11:20 A.M., CNA HH said he/she worked the day shift at the facility and is very familiar with Resident #54. Whenever the door alarms go off, there are three residents they automatically look for: Residents #54, #1, and #52. Resident #54's gait was very unsteady. He/she once fell with staff standing right next to him/her. The resident used a wheelchair because he/she was so unsteady. He/she was not a fast walker. It would take him/her 2-3 minutes to walk 25 steps from his/her room to the exit door. He/she often wandered down the halls and to the exit doors, but did not seem to be exit seeking. During an interview on 3/5/18 at 11:50 A.M., the Administrator in Training said the keys for the delayed egress doors are kept on both of the nurse's key rings. The key rings should be kept with the nurse or readily accessible. The elopement policy is the Emergency Checklist for Missing Resident form. There is no other policy. A request for the resident's elopement assessment was made at that time. During an interview on 3/6/18 at 6:09 A.M., Nurse M said he/she worked the night shift at the facility and was familiar with Resident #54. The resident was quiet, confused with some agitation, and always looking for an exit. He/she always had a coat on and was ready to go. He/she was easily redirected. His/her gait varied from day to day. He/she had several falls with significant injuries while at the facility. On 2/25/18, around 4:30 A.M., the resident was sitting at the desk with Nurse W. The resident headed down the 300 hall with Nurse W. He/she went outside at this point so he/she did not actually see them go down the hallway. He/she had stepped out front of the building so he/she did not see what was happening inside the building. He/she could not hear the alarm outside. He/she was outside about two minutes when Nurse W came out and got the key. It did not take long to get the key. Nurse W came back up the hall and said the resident was not in his/her room. They completed a full building search. They checked and double checked. The search inside the building took no more than 35 minutes. The resident had never stepped outside before. They had no reason to think he/she had gone outside. It had been raining earlier so it was slick and cold outside. He/she had gone outside to look for the resident, and he/she was shivering. Nurse W was outside, and he/she met Nurse M there. He/she grabbed his/her car keys to go look for the resident. He/she ran into the police officer while looking in the convenience store parking lot. The police officer said they found the resident down the road. A CM found the resident and called the police. He/she went back to the facility and let the management know. Nurse W made the nurses note, and the DON called DHSS. Hypothermia was definitely a possibility that morning. Ninety-five degrees is cold for a body temperature, although the resident typically ran about 97 degrees. He/she does not know if the facility had an elopement policy. The facility should have an elopement assessment for the residents in their admission paperwork on the computer. There were three CNAs and two nurses at the facility at the time of the elopement. During an interview on 3/6/18 at 6:40 A.M., CNA K said he/she worked night shift at the facility. He/she was familiar with Resident #54 and was working the night of the incident. The resident wandered all day and all night. They would place the resident at the nurse's station to keep an eye on him/her. He/she does not know if the resident had an elopement assessment. He/she only knows the resident wore a wander guard. The resident was definitely exit seeking. On 2/25/18 at 4:30 A.M., Nurse W fed the resident and put him/her in bed. At 4:45 A.M., he/she heard the alarm. Nurse W came up the hall and asked if we saw the resident. The resident walked slowly but had a very unsteady gait. It would have taken him/her about two minutes to get from his/her room to the exit door at the end of the hallway. When the alarm sounded, everyone jumped up and started checking hallways, closets, and under beds. Everyone took a hall. They checked the facility two times. It was rainy, muddy, and cold outside that morning, but the resident had never exited the building before. CNA L and CNA S went outside to check for the resident. The facility does not have an elopement policy he/she is aware. During an interview on 3/6/18 at 7:00 A.M., CNA L said he/she worked nights at the facility, was familiar with Resident #54 and was present when the resident eloped. That night, the resident sat at the nurse's station all night. Between 4:15 and 4:30 A.M., Nurse W took the resident to bed then came back to the desk to do his/her charting. He/she sat in the foyer area near the nurse's station with CNA S and CNA K. He/she could see Nurse W behind the computer at the nurse's station, but he/she could not see down the hallways. At 4:45 A.M., he/she heard the alarm go off. When the alarm went off they all jumped. Nurse W redirected the resident to go to bed and went outside to get the key from Nurse M. Nurse W came back inside and went down the hall to lock the door. The nurse returned and asked if we had seen the resident. The resident was always everywhere, so they looked in the building before going outside. It was probably five minutes before anyone went outside. CNA S, Nurse W, and he/she went outside to look for the resident. It was very cold and wet that morning, but it was not raining. He/she heard the resident was found at a road that is far away from the facility. He/she walked every day and that would take him/her a while to walk to the road where the resident had been found because it is uphill from the facility. He/she did not think the resident could get up the hill. The resident was extremely weak and unsteady. The resident never got outside the facility before this incident. He/she never would have thought he/she would get out. Typically, when the resident heard the alarm, he/she would instantly turn around and walk away from the door. During an interview on 3/6/18 at 9:55 A.M., Nurse JJ said there have been no elopements other than Resident #54. There are currently no residents at risk to wander or elope at the facility. The elopement assessments are found in the nurses assessments in the electronic records. She looked in the electronic record but could not find an elopement assessment for Resident #54. During an interview on 3/6/18 at 10:05 A.M., Nurse GG said he/she was familiar with the residents. There have been no elopements other than Resident #54. There are currently no residents who wander or are elopement risks. During an interview on 3/6/18 at 12:00 P.M., Administrative Staff NN said the Emergency Checklist for Missing Resident form is the facility's elopement policy. There is no other policy. If a resident wears a wanderguard they should have an elopement assessment on file. He/she did not know why the resident had no elopement assessment. During a telephone interview on 3/8/18 at 7:10 A.M., Nurse W said he/she worked the night shift at the facility. She was very familiar with the resident. The resident had a history of [REDACTED]. The resident would wander. On 2/25/18, the resident was up all night. The first part of the night, the resident was hungry so he/she shared his/her dinner with the resident. He/she fed the resident and put him/her to bed. The resident got back up so he/she let the resident sit with him/her at the nurse's station. Around 4:30 A.M., the resident started to doze off, and he/she asked the resident if he/she wanted to go lay down. He/she put the resident to bed and went back to the nurse's station to prepare for the 5:00 A.M. medication pass. He/she did not leave the desk at any time. Around 4:45 A.M., the resident had set off the exit door alarm. He/she walked halfway around the nurse's station and saw the resident coming back up the hallway toward his/her room, but he/she did not see the resident go into his/her room. He/she went to get the key to turn off the alarm from Nurse M, who was outside smoking. It only took a couple of seconds to get the keys from Nurse M. He/she came back inside the building and walked down the 300 hall. He/she did not see the resident. He/she turned off the alarm. The resident was known to go into other resident rooms and get into their beds so he/she looked into other residents' room on his/her way back up the hallway. He/she checked the resident's room and bathroom and did not see the resident. The resident had never gone back to the exit door once the alarm went off. He/she had no reason to think the resident had tried to exit the door again. When he/she got back to the top of the 300 hall, he/she told the staff to spread out and look for the resident. Some staff were doing rounds and some were sitting in the foyer area near the nurse's station. They searched the building first. It took about five minutes to search inside the building. He/she got a flashlight off the medication cart and went outside to search the perimeter of the property. It was very dark outside. He/she walked up the road next to the facility, around the building, and to the front door. It took him/her about 5-10 minutes to look outside. He/she saw Nurse M at the front of the building and asked if he/she had his/her car keys. Nurse M went into the building for the car keys and then got in his/her car to go look for the resident. He/she went back into the building to call the DON. The DON said to call the family and the DON would call the Administrator. Around 5:30-6:00 A.M., Nurse M came back into the building and said the resident was with the police. He/she called the resident's family to let them know the resident was safe and going to the hospital. No one from the facility called the police because they were still actively looking for the resident. A police officer came to the facility and said a CM found the resident at an intersection down the road. The CM put the resident in his/her car and took the resident to the police department. The resident was wearing only a gown and gripper socks, nothing else. The resident had a suprapubic catheter (sterile tube used to drain urine from the bladder, inserted through the lower abdomen) with a leg bag (collects the urine and is strapped to the leg). The resident was taken to the hospital. He/she had not seen a facility elopement policy before. He/she may have seen it during orientation. There was no checklist or anything to work from during an elopement. The facility only does elopement assessments during admission. He/she had no clue if elopement assessments are done on paper or electronically. The DON is responsible for that. The only way he/she knows a resident is an elopement risk is if the resident wears a wanderguard. There are two residents who wear a wanderguards: Residents #54 and #53. When he/she left the 300 hallway to get the keys from Nurse M, the exit door was alarming, but he/she did not assign anyone to monitor the door while he/she left to get the key. He/she was not aware the exit door did not stay locked while the alarm was sounding. Had he/she known that he/she would have assigned someone to watch the door or asked someone else to grab the keys while he/she watched the door. He/she said since the elopement there have been no changes on how they handle elopement situations that he/she is aware of. They had not had any in-services, and there is not an elopement policy. There have been no changes to where the door keys are kept. The keys are still kept on the medication carts. There are two nurses key rings but only one key ring has the door alarm key on it. In order to turn off the alarm, he/she would still have to go get the key from whomever was working the medication cart at the time. If the door sounded on the 300 hall and the medication cart was on 500 hall then he/she would still have to go get the keys. Review of the facility employee handbook, last revised on 6/12/2003, showed no elopement policy/statement. During an interview on 3/7/18 at 10:35 A.M., the Administrator, DON, Administrator in Training, and Administrative Staff NN said Resident #54 had an elopement assessment. It was a paper assessment and not in the EHR. Resident #54 came from the hospital with a wanderguard and wears it. There are four residents with wanderguards. The wanderguards alarm at two doors, the side entry by the nurse's station and the smoking area. The rest of the doors are delayed egress. Resident #54's Potential Wanderer Assessment forms, received by DHSS by fax on 3/7/18, showed the following: -Form dated 11/21/17, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -Form dated 1/19/18, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -Form dated 2/3/18, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -All of the completed assessments showed the resident was a high risk to wander and the policy for wandering residents should be implemented, but it did not show what should be implemented; -Completed by the DON. During an interview on 3/8/18 at 10:30 A.M., the Medical Director said he is Resident #54's personal physician and the facility's Medical Director. The facility contacted him on 2/25/18, and told him that the resident eloped that morning. They said they got the resident back, and they were looking to find another facility which had a locked unit for the resident. He is not sure if he was aware the resident had a history of [REDACTED]. He had not seen the resident's original hospital discharge report upon admission to the facility. He does not make the decision regarding the placement of a resident at the facility. When the facility accepts a resident there is the assumption they can care for the resident appropriately. With the additional information regarding the resident's multiple attempts to elope while at the hospital prior to his/her admission to the facility, he would say the resident would have benefited from a facility with a locked unit. However, the hospital must have thought the facility was appropriate for the resident. Generally, a resident with a wanderguard would be fine at the facility as long as they are able to monitor and redirect the resident. He knew the resident wandered, but he did not know the resident was assessed as a high risk for elopement. The facility contacted him mostly about the resident's medical issues, not behavioral issues. If the resident demonstrated wandering then the resident should have been reassessed as to whether they could continue to care for him/her appropriately. In regards to the resident's hypothermia, a body temperature of 95.9 is low, but it is not that low. It would need to be corrected. During an interview on 3/9/18 at 5:50 A.M., Nurse CC said he/she had worked at the facility on the night shift. Resident #54 was confused and always tried to leave saying he/she was going to the store or his/her mother's house. He/she tried to get out so many times. The facility did not keep a list of residents identified as wanderers. The facility had no list of residents that wore a wanderguard. He/she thought Residents #1 and #51 wore wanderguards, although he/she was not sure about Resident #51. If Resident #51 does not have a wander guard he/she needed one. There is no policy for checking wanderguards or testing the battery in the wanderguard he/she was aware of. He/she did not know if the facility had additional wanderguards on hand in case one is not working or is missing. The door by the patio is a wanderguard door and the doors at the ends of the halls require a key to reset if they are opened. He/she was not sure if the doors at the end of the hallways relocked without resetting the alarm or not. There are two nurse's key rings, team 1 and team 2. There is a key to reset the hallway doors on each key ring but the key on team 1's key ring does not work so you have to get the team 2 key ring. He/she had not seen a policy regarding missing residents, wander guards, or the exit doors. He/she had not received any in-services regarding Resident #54's elopement. He/she had not been told not to leave an alarming door unattended. During an interview on 3/9/18 at 5:53 A.M., CNA DD said he/she has not received any training or verbal instructions since Resident #54 eloped. He/she does not know off the top of his/her head which residents are at risk of elopement. He/she thinks the residents with wander guards are probably at risk, but he/she does not know which residents wear wander guards. Any resident who goes by the doors is probably at risk for elopement. He/she does not check or record placement of the wanderguard. He/she does not know who does that. His/her responsibility for residents at risk is to keep an eye on them. No one has told him/her what she is supposed to do exactly. If a resident went out the door, he/she would look out the door and around the hallway while he/she tried to find a nurse. He/she would have to leave the door unattended while she found a nurse as the nurses have the key to turn off the alarm. He/she does not know if there is an elopement policy, because he/she has never seen it. He/she is not aware of any elopement checklist. The wanderguard doors are the front double doors by the nurse's station. The delayed egress doors are at the end of the hallways. He/she thinks the dining room requires a code. If an alarm sounded on the delayed egress doors, the doors will remain locked. If a resident sets off the alarm and goes outside, the doors will lock behind them. During an interview on 3/9/18 at 6:08 A.M., CNA S said he/she has not received any training or verbal instructions since Resident #54 eloped. He/she overheard the nurses discussing the matter between themselves. She knows some of residents are at risk for elopement: Residents #51, #54, and #23. Resident #54 wore a wander guard. Resident #23 wanders around the facility. Resident #51 tried to leave the facility on Wednesday, 3/7/18, around 10:00 A.M. When the resident tried to leave, he/she pushed open the hall door, but the shower aide went outside and got the resident. He/she does not know how long the resident was outside. He/she does not know any details about how the resident got out, because she was in a different part of the building at the time. He/she is not responsible for checking the placement of the wanderguards. The nurses probably do it, and they make sure the wander guards work. He/she does not know which doors are protected by a wanderguard. He/she knows hallways are delayed egress doors. If the alarm for the delayed egress doors sounded, the doors would be locked. If a resident set of the alarm and walked out the door, the door would lock behind them. The facility might have an elopement policy in the employee handbook, but he/she does not know the policy. There is no checklist that they work from during an elopement. During an interview on 3/9/18 at 6:10 A.M., Nurse V said he/she had worked at the facility since 12/2017. There is a key to the hallway door alarms on the team 2 key ring, but the team 1 key ring does not have one. There is no policy he/she was aware of regarding missing residents. The facility does not keep a list of residents that wear wanderguards. There are two residents that have a wanderguard, Resident #1, and #54 had one when he/she was here. There are two wanderguard doors, one by the patio and one in the dining room. The hall doors need a key to reset the alarms. There was only one key ring that had a key and that was team 2's. He/she had not received any in-service regarding Resident #54's elopement. He/she had not been told not to leave an alarming door unattended. During an interview on 3/9/18 at 6:24 A.M., CNA D said he/she has not received any training or verbal instructions since Resident #54 eloped. If he/she heard the door alarm then he/she would keep an eye on the resident. If he/she did not see the resident, he/she would see what alarm was sounding on the board at the nurses station, go to the door, and look around inside and outside for the resident. The residents at risk for elopement are Residents #54, #1, and #51. The residents who wear a wander guard are Residents #23, #52, #24, #1, and #51. He/she checks for the wanderguards during his/her shift but does not document it anywhere. He/she does not know if the facility has an elopement policy or if there is an elopement checklist. The front door is protected by wanderguards. The rest of the doors are delayed egress. If the alarm for the delayed egress door is sounding then the door is locked. During an interview on 3/9/18 at 7:00 A.M., the surveyor went to the nurse's station where Nurse CC, Nurse V and Nurse AA sat. The surveyor asked all three nurses if they had been spoken to by anyone regarding Resident #54's elopement or if they had been spoken to about a key being on both nurse's key rings. All three nurses said no one had spoken to them about the resident's elopement and they were not aware that both key rings had a key to the delayed egress door alarms. During an interview on 3/9/18 at 7:08 A.M., CNA BB said he/he has not received any training or verbal instructions since Resident #54 eloped. He/she probably had some elopement training during orientation. It might have been in the employee manual that he/she had to read. The manual probably had an elopement policy, but he/she had not looked for it. He/she does not know if there is a checklist or anything to work from during an elopement. If someone got out of the facility, he/she would just alert everyone and call 911. He/she does not know if there is a list of residents who are an elopement risk or wear wanderguards. He/she does not know which residents are at risk, but they are probably the residents who wear wander guards. There are two residents who wear wander guards: Residents #54 and # 53. The wanderguard doors are the front double d

Based on observation, interview and record review, the facility failed to have a system in place to monitor one resident with a history of wandering from exiting the facility unnoticed by an alarming unlocked exit door. The resident was found by a community member and driven to the police station. The resident was transported by ambulance to a local hospital and admitted with a [DIAGNOSES REDACTED]. (Resident #54). The census was 58. 1. Review of Resident #54's hospital discharge note, dated 11/10/17, showed the following: -Resident found wandering around a college campus by campus police. Campus police obtained a family member's name and number from the resident's wallet and contacted the family member. The resident taken to hospital due to showing signs of confusion; -[DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Review of the resident's nurse's notes, showed the following: -On 11/20/17 at 9:48 P.M., the resident set alarms off several times, was taken to bed but got back up. The resident stated he/she was ready to head for the hills; -On 11/21/17 at 4:26 P.M., the resident made one attempt to open exit doors; -On 11/22/17 at 10:36 P.M., the resident made one attempt to open exit doors; -On 11/25/17 at 3:20 A.M., resident ambulating in hallway, tripped and fell . Abrasion noted to right cheek; -On 12/2/17 at 10:48 P.M., the resident was exit seeking majority of shift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/17, showed the following: -admission date of [DATE]; - Severe cognitive impairment; -Wandering occurred 1 to 3 days, but less than daily, during the seven day review period; -Wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as outside the facility; -Walked independently in room, corridor, and off unit; -Required supervision for locomotion on the unit; -Indwelling catheter; -Two falls with injury since admission; -Received antipsychotic medication during the last 7 days. Review of the resident's care plan, dated 2/20/18, showed the following: -Problem start date: 2/20/18; -Problem: The resident has a history of wandering out of the building without awareness for own safety; -Goal: The resident will be safe in his/her environment: -Approach: The resident will be reassessed quarterly, wander guard on at all times. Review of the resident's nurse's notes, showed the following: -On 2/21/18 at 8:11 A.M., the resident does not follow directions and becomes agitated with redirection; -On 2/25/18 at 7:06 A.M., the resident sounded 300 hall alarm, came back up hallway. The nurse turned off the alarm, and the resident was not found. Staff conducted a search inside, outside, and around the perimeter of the property. Staff unable to locate resident. Staff used car to widen search. Police department notified the facility the resident was with them. Paramedics took the resident to the hospital from the police department. DON and Administrator made aware. During a telephone interview on 3/8/18 at 12:50 P.M., Officer MM said he/she responded when the resident was brought to the police department on 2/25/18. A community member (CM) saw the resident at an intersection down the road. The resident had made it down the hill to the intersection. The CM was able to get the resident into his/her van and bring the resident to the police station. The resident was basically nude, wearing only a hospital gown and socks. An ambulance responded and took the resident to the hospital. The emergency medical technicians (EMTs) covered the resident with warming blankets. He/she guessed the resident was from the facility since it was located in the area. He/she also saw Nurse M looking around the convenience store parking lot for the resident, and the nurse confirmed they had a resident missing. He/she went over to the facility after the resident left for the hospital so he/she could speak with Nurse M about the incident. He/she did not write a report. Observation showed the area where the resident was found by CM was at a intersection of a busy four lane road approximately three tenths of a mile from the facility. Review of Underground Weather for 2/25/18 at 4:45 A.M., showed a temperature of 34 degrees Fahrenheit with a nine mile an hour wind. Review of the ambulance run report, dated 2/25/18, showed the following: -Call received at 5:09 A.M.; -Chief complaint: resident found wandering down road; -Resident found alert and oriented times 1-2, following commands appropriately, cold, shivering, calm and cooperative; -Blankets applied to resident; -Resident taken to hospital at 5:23 A.M. Review of the resident's hospital admission summary, dated 2/25/18, showed the following: -Resident demonstrated an altered mental status; -Resident left nursing home around 4:00 A.M.; -Found wandering down the road with catheter strapped to leg; -A CM took the resident to police department and ambulance called; -Resident's body temperature was 95.9 degrees F; -The resident was hypothermic and complained of generalized weakness; -Resident noted to have elevated troponins (proteins in the blood to assess heart damage); -Resident demonstrated aggressive behavior while in the hospital and tried to attack nursing staff taking care of him/her; -Resident admitted with [DIAGNOSES REDACTED]. Review of a copy of the facility's Emergency Checklist for Missing Resident form, no date, and obtained from the Administrator in Training at the facility on 3/5/18 at 11:50 A.M., showed the following: -Spaces for the date and time; -Instructions to initial steps #1-7; -Step 1, if off-duty, notify the Administrator or Director of Nursing; -Step 2, organize and institute a thorough search of the facility and surrounding grounds and buildings; -Step 3, call 911 or police department; -Step 4, organize and institute an expanding search of the neighborhood surrounding the facility; -Step 5, contact DHSS Central Registry Unit at [PHONE NUMBER]; -Step 6, notify responsible family member; -Step 7, supply resident's picture from medical records to search team members; -Spaces for signature and date. Review of the resident's medical record and electronic health record (EHR), on 3/5/18, showed no elopement assessment in the admission paperwork, in the assessments, or in any other part of the EHR. During an interview on 3/5/18 at 5:15 A.M., CMT R said he/she worked the night shift passing medications for the 200 and 300 halls. He/she was familiar with the Resident #54. The resident wore a wanderguard and set off the alarm. He/she recently eloped from the facility between 4:00 A.M. - 5:00 A.M. on 2/25/18. The last time he/she saw the resident that morning, the resident was sitting at the nurse's station with Nurse W. He/she was in the medication room when the alarm went off. Everyone checked their assigned areas. He/she came out of the medication room and checked the board at the nurse station that showed the 300 hall exit door had been opened, so he/she went to that exit door. He/she did not see the resident or go outside to look. He/she heard a staff member got in their car and drove around and that another staff member had went outside with a flashlight. He/she is not sure if there is an elopement policy and cannot recall the last time he/she had training on elopement procedures. During an interview on 3/5/18 at 5:55 A.M., CNA S said he/she worked the night shift at the facility and was familiar with Resident #54. The resident often set off the door alarms about 6 or 7 times a day. He/she worked the weekend of the elopement. The resident did not sleep much that night. Nurse W and Nurse M were working that night. When the alarm went off, Nurse M was outside smoking, Nurse W was in the bathroom or something and he/she was sitting in the foyer area, near the nurse's station. The alarm makes a noise that can be heard throughout the building. Nurse W told everyone to start looking for Resident #54. They checked all the rooms, showers, and closets. They double checked the building and then looked outside. It took them about an hour to check the building. The police called the facility around 5 A.M. He/she did not know how the resident got out. During an interview on 3/5/18 at 6:05 A.M., CNA DD said he/she worked the night shift at the facility and was familiar with Resident #54. On 2/25/18, the resident was anxious. The resident set off the door alarm and then went toward his/her room. Nurse W went and got the key from Nurse M to turn off the alarm. Nurse W told everyone the resident was missing and to look everywhere. He/she looked down halls 100, 300, and 500. Someone else checked halls 200 and 400. He/she is not sure exactly how long it took to check the whole building, about an hour. Nurse M got in his/her car and went to look around the neighborhood. He/she has not had any elopement training and does not know if there is an elopement policy. He/she had never seen one. There are two residents who are an elopement risk, but he/she cannot remember their names at the moment. Wandering was typical behavior for Resident #54. The resident would do it every night. That is why he/she was sitting at the nurse's station or sitting somewhere they could watch him/her. During an interview on 3/5/18 at 11:20 A.M., CNA HH said he/she worked the day shift at the facility and is very familiar with Resident #54. Whenever the door alarms go off, there are three residents they automatically look for: Residents #54, #1, and #52. Resident #54's gait was very unsteady. He/she once fell with staff standing right next to him/her. The resident used a wheelchair because he/she was so unsteady. He/she was not a fast walker. It would take him/her 2-3 minutes to walk 25 steps from his/her room to the exit door. He/she often wandered down the halls and to the exit doors, but did not seem to be exit seeking. During an interview on 3/5/18 at 11:50 A.M., the Administrator in Training said the keys for the delayed egress doors are kept on both of the nurse's key rings. The key rings should be kept with the nurse or readily accessible. The elopement policy is the Emergency Checklist for Missing Resident form. There is no other policy. A request for the resident's elopement assessment was made at that time. During an interview on 3/6/18 at 6:09 A.M., Nurse M said he/she worked the night shift at the facility and was familiar with Resident #54. The resident was quiet, confused with some agitation, and always looking for an exit. He/she always had a coat on and was ready to go. He/she was easily redirected. His/her gait varied from day to day. He/she had several falls with significant injuries while at the facility. On 2/25/18, around 4:30 A.M., the resident was sitting at the desk with Nurse W. The resident headed down the 300 hall with Nurse W. He/she went outside at this point so he/she did not actually see them go down the hallway. He/she had stepped out front of the building so he/she did not see what was happening inside the building. He/she could not hear the alarm outside. He/she was outside about two minutes when Nurse W came out and got the key. It did not take long to get the key. Nurse W came back up the hall and said the resident was not in his/her room. They completed a full building search. They checked and double checked. The search inside the building took no more than 35 minutes. The resident had never stepped outside before. They had no reason to think he/she had gone outside. It had been raining earlier so it was slick and cold outside. He/she had gone outside to look for the resident, and he/she was shivering. Nurse W was outside, and he/she met Nurse M there. He/she grabbed his/her car keys to go look for the resident. He/she ran into the police officer while looking in the convenience store parking lot. The police officer said they found the resident down the road. A CM found the resident and called the police. He/she went back to the facility and let the management know. Nurse W made the nurses note, and the DON called DHSS. Hypothermia was definitely a possibility that morning. Ninety-five degrees is cold for a body temperature, although the resident typically ran about 97 degrees. He/she does not know if the facility had an elopement policy. The facility should have an elopement assessment for the residents in their admission paperwork on the computer. There were three CNAs and two nurses at the facility at the time of the elopement. During an interview on 3/6/18 at 6:40 A.M., CNA K said he/she worked night shift at the facility. He/she was familiar with Resident #54 and was working the night of the incident. The resident wandered all day and all night. They would place the resident at the nurse's station to keep an eye on him/her. He/she does not know if the resident had an elopement assessment. He/she only knows the resident wore a wander guard. The resident was definitely exit seeking. On 2/25/18 at 4:30 A.M., Nurse W fed the resident and put him/her in bed. At 4:45 A.M., he/she heard the alarm. Nurse W came up the hall and asked if we saw the resident. The resident walked slowly but had a very unsteady gait. It would have taken him/her about two minutes to get from his/her room to the exit door at the end of the hallway. When the alarm sounded, everyone jumped up and started checking hallways, closets, and under beds. Everyone took a hall. They checked the facility two times. It was rainy, muddy, and cold outside that morning, but the resident had never exited the building before. CNA L and CNA S went outside to check for the resident. The facility does not have an elopement policy he/she is aware. During an interview on 3/6/18 at 7:00 A.M., CNA L said he/she worked nights at the facility, was familiar with Resident #54 and was present when the resident eloped. That night, the resident sat at the nurse's station all night. Between 4:15 and 4:30 A.M., Nurse W took the resident to bed then came back to the desk to do his/her charting. He/she sat in the foyer area near the nurse's station with CNA S and CNA K. He/she could see Nurse W behind the computer at the nurse's station, but he/she could not see down the hallways. At 4:45 A.M., he/she heard the alarm go off. When the alarm went off they all jumped. Nurse W redirected the resident to go to bed and went outside to get the key from Nurse M. Nurse W came back inside and went down the hall to lock the door. The nurse returned and asked if we had seen the resident. The resident was always everywhere, so they looked in the building before going outside. It was probably five minutes before anyone went outside. CNA S, Nurse W, and he/she went outside to look for the resident. It was very cold and wet that morning, but it was not raining. He/she heard the resident was found at a road that is far away from the facility. He/she walked every day and that would take him/her a while to walk to the road where the resident had been found because it is uphill from the facility. He/she did not think the resident could get up the hill. The resident was extremely weak and unsteady. The resident never got outside the facility before this incident. He/she never would have thought he/she would get out. Typically, when the resident heard the alarm, he/she would instantly turn around and walk away from the door. During an interview on 3/6/18 at 9:55 A.M., Nurse JJ said there have been no elopements other than Resident #54. There are currently no residents at risk to wander or elope at the facility. The elopement assessments are found in the nurses assessments in the electronic records. She looked in the electronic record but could not find an elopement assessment for Resident #54. During an interview on 3/6/18 at 10:05 A.M., Nurse GG said he/she was familiar with the residents. There have been no elopements other than Resident #54. There are currently no residents who wander or are elopement risks. During an interview on 3/6/18 at 12:00 P.M., Administrative Staff NN said the Emergency Checklist for Missing Resident form is the facility's elopement policy. There is no other policy. If a resident wears a wanderguard they should have an elopement assessment on file. He/she did not know why the resident had no elopement assessment. During a telephone interview on 3/8/18 at 7:10 A.M., Nurse W said he/she worked the night shift at the facility. She was very familiar with the resident. The resident had a history of [REDACTED]. The resident would wander. On 2/25/18, the resident was up all night. The first part of the night, the resident was hungry so he/she shared his/her dinner with the resident. He/she fed the resident and put him/her to bed. The resident got back up so he/she let the resident sit with him/her at the nurse's station. Around 4:30 A.M., the resident started to doze off, and he/she asked the resident if he/she wanted to go lay down. He/she put the resident to bed and went back to the nurse's station to prepare for the 5:00 A.M. medication pass. He/she did not leave the desk at any time. Around 4:45 A.M., the resident had set off the exit door alarm. He/she walked halfway around the nurse's station and saw the resident coming back up the hallway toward his/her room, but he/she did not see the resident go into his/her room. He/she went to get the key to turn off the alarm from Nurse M, who was outside smoking. It only took a couple of seconds to get the keys from Nurse M. He/she came back inside the building and walked down the 300 hall. He/she did not see the resident. He/she turned off the alarm. The resident was known to go into other resident rooms and get into their beds so he/she looked into other residents' room on his/her way back up the hallway. He/she checked the resident's room and bathroom and did not see the resident. The resident had never gone back to the exit door once the alarm went off. He/she had no reason to think the resident had tried to exit the door again. When he/she got back to the top of the 300 hall, he/she told the staff to spread out and look for the resident. Some staff were doing rounds and some were sitting in the foyer area near the nurse's station. They searched the building first. It took about five minutes to search inside the building. He/she got a flashlight off the medication cart and went outside to search the perimeter of the property. It was very dark outside. He/she walked up the road next to the facility, around the building, and to the front door. It took him/her about 5-10 minutes to look outside. He/she saw Nurse M at the front of the building and asked if he/she had his/her car keys. Nurse M went into the building for the car keys and then got in his/her car to go look for the resident. He/she went back into the building to call the DON. The DON said to call the family and the DON would call the Administrator. Around 5:30-6:00 A.M., Nurse M came back into the building and said the resident was with the police. He/she called the resident's family to let them know the resident was safe and going to the hospital. No one from the facility called the police because they were still actively looking for the resident. A police officer came to the facility and said a CM found the resident at an intersection down the road. The CM put the resident in his/her car and took the resident to the police department. The resident was wearing only a gown and gripper socks, nothing else. The resident had a suprapubic catheter (sterile tube used to drain urine from the bladder, inserted through the lower abdomen) with a leg bag (collects the urine and is strapped to the leg). The resident was taken to the hospital. He/she had not seen a facility elopement policy before. He/she may have seen it during orientation. There was no checklist or anything to work from during an elopement. The facility only does elopement assessments during admission. He/she had no clue if elopement assessments are done on paper or electronically. The DON is responsible for that. The only way he/she knows a resident is an elopement risk is if the resident wears a wanderguard. There are two residents who wear a wanderguards: Residents #54 and #53. When he/she left the 300 hallway to get the keys from Nurse M, the exit door was alarming, but he/she did not assign anyone to monitor the door while he/she left to get the key. He/she was not aware the exit door did not stay locked while the alarm was sounding. Had he/she known that he/she would have assigned someone to watch the door or asked someone else to grab the keys while he/she watched the door. He/she said since the elopement there have been no changes on how they handle elopement situations that he/she is aware of. They had not had any in-services, and there is not an elopement policy. There have been no changes to where the door keys are kept. The keys are still kept on the medication carts. There are two nurses key rings but only one key ring has the door alarm key on it. In order to turn off the alarm, he/she would still have to go get the key from whomever was working the medication cart at the time. If the door sounded on the 300 hall and the medication cart was on 500 hall then he/she would still have to go get the keys. Review of the facility employee handbook, last revised on 6/12/2003, showed no elopement policy/statement. During an interview on 3/7/18 at 10:35 A.M., the Administrator, DON, Administrator in Training, and Administrative Staff NN said Resident #54 had an elopement assessment. It was a paper assessment and not in the EHR. Resident #54 came from the hospital with a wanderguard and wears it. There are four residents with wanderguards. The wanderguards alarm at two doors, the side entry by the nurse's station and the smoking area. The rest of the doors are delayed egress. Resident #54's Potential Wanderer Assessment forms, received by DHSS by fax on 3/7/18, showed the following: -Form dated 11/21/17, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -Form dated 1/19/18, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -Form dated 2/3/18, resident is mobile, history of wandering, voices desire to leave the facility or go home, confusion, [DIAGNOSES REDACTED]. -All of the completed assessments showed the resident was a high risk to wander and the policy for wandering residents should be implemented, but it did not show what should be implemented; -Completed by the DON. During an interview on 3/8/18 at 10:30 A.M., the Medical Director said he is Resident #54's personal physician and the facility's Medical Director. The facility contacted him on 2/25/18, and told him that the resident eloped that morning. They said they got the resident back, and they were looking to find another facility which had a locked unit for the resident. He is not sure if he was aware the resident had a history of [REDACTED]. He had not seen the resident's original hospital discharge report upon admission to the facility. He does not make the decision regarding the placement of a resident at the facility. When the facility accepts a resident there is the assumption they can care for the resident appropriately. With the additional information regarding the resident's multiple attempts to elope while at the hospital prior to his/her admission to the facility, he would say the resident would have benefited from a facility with a locked unit. However, the hospital must have thought the facility was appropriate for the resident. Generally, a resident with a wanderguard would be fine at the facility as long as they are able to monitor and redirect the resident. He knew the resident wandered, but he did not know the resident was assessed as a high risk for elopement. The facility contacted him mostly about the resident's medical issues, not behavioral issues. If the resident demonstrated wandering then the resident should have been reassessed as to whether they could continue to care for him/her appropriately. In regards to the resident's hypothermia, a body temperature of 95.9 is low, but it is not that low. It would need to be corrected. During an interview on 3/9/18 at 5:50 A.M., Nurse CC said he/she had worked at the facility on the night shift. Resident #54 was confused and always tried to leave saying he/she was going to the store or his/her mother's house. He/she tried to get out so many times. The facility did not keep a list of residents identified as wanderers. The facility had no list of residents that wore a wanderguard. He/she thought Residents #1 and #51 wore wanderguards, although he/she was not sure about Resident #51. If Resident #51 does not have a wander guard he/she needed one. There is no policy for checking wanderguards or testing the battery in the wanderguard he/she was aware of. He/she did not know if the facility had additional wanderguards on hand in case one is not working or is missing. The door by the patio is a wanderguard door and the doors at the ends of the halls require a key to reset if they are opened. He/she was not sure if the doors at the end of the hallways relocked without resetting the alarm or not. There are two nurse's key rings, team 1 and team 2. There is a key to reset the hallway doors on each key ring but the key on team 1's key ring does not work so you have to get the team 2 key ring. He/she had not seen a policy regarding missing residents, wander guards, or the exit doors. He/she had not received any in-services regarding Resident #54's elopement. He/she had not been told not to leave an alarming door unattended. During an interview on 3/9/18 at 5:53 A.M., CNA DD said he/she has not received any training or verbal instructions since Resident #54 eloped. He/she does not know off the top of his/her head which residents are at risk of elopement. He/she thinks the residents with wander guards are probably at risk, but he/she does not know which residents wear wander guards. Any resident who goes by the doors is probably at risk for elopement. He/she does not check or record placement of the wanderguard. He/she does not know who does that. His/her responsibility for residents at risk is to keep an eye on them. No one has told him/her what she is supposed to do exactly. If a resident went out the door, he/she would look out the door and around the hallway while he/she tried to find a nurse. He/she would have to leave the door unattended while she found a nurse as the nurses have the key to turn off the alarm. He/she does not know if there is an elopement policy, because he/she has never seen it. He/she is not aware of any elopement checklist. The wanderguard doors are the front double doors by the nurse's station. The delayed egress doors are at the end of the hallways. He/she thinks the dining room requires a code. If an alarm sounded on the delayed egress doors, the doors will remain locked. If a resident sets off the alarm and goes outside, the doors will lock behind them. During an interview on 3/9/18 at 6:08 A.M., CNA S said he/she has not received any training or verbal instructions since Resident #54 eloped. He/she overheard the nurses discussing the matter between themselves. She knows some of residents are at risk for elopement: Residents #51, #54, and #23. Resident #54 wore a wander guard. Resident #23 wanders around the facility. Resident #51 tried to leave the facility on Wednesday, 3/7/18, around 10:00 A.M. When the resident tried to leave, he/she pushed open the hall door, but the shower aide went outside and got the resident. He/she does not know how long the resident was outside. He/she does not know any details about how the resident got out, because she was in a different part of the building at the time. He/she is not responsible for checking the placement of the wanderguards. The nurses probably do it, and they make sure the wander guards work. He/she does not know which doors are protected by a wanderguard. He/she knows hallways are delayed egress doors. If the alarm for the delayed egress doors sounded, the doors would be locked. If a resident set of the alarm and walked out the door, the door would lock behind them. The facility might have an elopement policy in the employee handbook, but he/she does not know the policy. There is no checklist that they work from during an elopement. During an interview on 3/9/18 at 6:10 A.M., Nurse V said he/she had worked at the facility since 12/2017. There is a key to the hallway door alarms on the team 2 key ring, but the team 1 key ring does not have one. There is no policy he/she was aware of regarding missing residents. The facility does not keep a list of residents that wear wanderguards. There are two residents that have a wanderguard, Resident #1, and #54 had one when he/she was here. There are two wanderguard doors, one by the patio and one in the dining room. The hall doors need a key to reset the alarms. There was only one key ring that had a key and that was team 2's. He/she had not received any in-service regarding Resident #54's elopement. He/she had not been told not to leave an alarming door unattended. During an interview on 3/9/18 at 6:24 A.M., CNA D said he/she has not received any training or verbal instructions since Resident #54 eloped. If he/she heard the door alarm then he/she would keep an eye on the resident. If he/she did not see the resident, he/she would see what alarm was sounding on the board at the nurses station, go to the door, and look around inside and outside for the resident. The residents at risk for elopement are Residents #54, #1, and #51. The residents who wear a wander guard are Residents #23, #52, #24, #1, and #51. He/she checks for the wanderguards during his/her shift but does not document it anywhere. He/she does not know if the facility has an elopement policy or if there is an elopement checklist. The front door is protected by wanderguards. The rest of the doors are delayed egress. If the alarm for the delayed egress door is sounding then the door is locked. During an interview on 3/9/18 at 7:00 A.M., the surveyor went to the nurse's station where Nurse CC, Nurse V and Nurse AA sat. The surveyor asked all three nurses if they had been spoken to by anyone regarding Resident #54's elopement or if they had been spoken to about a key being on both nurse's key rings. All three nurses said no one had spoken to them about the resident's elopement and they were not aware that both key rings had a key to the delayed egress door alarms. During an interview on 3/9/18 at 7:08 A.M., CNA BB said he/he has not received any training or verbal instructions since Resident #54 eloped. He/she probably had some elopement training during orientation. It might have been in the employee manual that he/she had to read. The manual probably had an elopement policy, but he/she had not looked for it. He/she does not know if there is a checklist or anything to work from during an elopement. If someone got out of the facility, he/she would just alert everyone and call 911. He/she does not know if there is a list of residents who are an elopement risk or wear wanderguards. He/she does not know which residents are at risk, but they are probably the residents who wear wander guards. There are two residents who wear wander guards: Residents #54 and # 53. The wanderguard doors are the front doub

Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development of pressure ulcers and treat those residents with pressure ulcers. Facility staff failed to consistently ensure pressure ulcer treatments were obtained timely, completed as ordered and per acceptable nursing standards, ensure residents were turned and repositioned and thoroughly assess residents and their pressure ulcers, document assessments and measurements and update physicians to obtain treatment orders when new pressure ulcers were identified or when a pressure ulcer deteriorated. The facility identified two residents in the facility, as having pressure ulcers. Those two residents were sampled and problems were found with both, who developed unstageable facility acquired pressure ulcers. One additional resident the facility identified as being dependent on staff for all care needs was found to have a pressure ulcer previously identified by facility staff but not treated and three additional pressure ulcers. (Residents #7, #41 and #40). The census was 71. 1. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/15/17, showed the following: -Brief Interview for Mental Status (BIMS): Score of 5 (a score of 0 - 7 indicates severe cognitive impairment); -Rejection of care: Behavior not exhibited; -Total dependence of one person required for bed mobility, transfers and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -At risk for pressure ulcers; -No pressure ulcers; -Pressure reducing device for chair and bed. Review of the resident's care plan, updated on 10/21/17, showed the following: -Onset 10/21/17: Difficulty making decisions: Anticipate needs, can sometimes answer yes or no questions; -Onset 10/21/17: Incontinent of bowel and bladder: Assist with hygiene, provide good perineal care as needed; -Onset 10/21/17: At risk for skin breakdown: Will be free from skin breakdown, therapeutic mattress, turn resident every two hours and as needed to maintain comfort, weekly skin assessments, keep bed linens clean, dry and wrinkle free. Review of the resident's physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) and progress notes, through 11/21/17, showed no documentation explaining the need for a wound management company consult and no pressure ulcers noted, assessment or treatment. Review of the resident's weekly skin assessment, dated 11/22/17 and completed by facility staff, showed the resident had no new areas of skin impairment. Review of the resident's wound management company initial assessment, dated 11/24/17 and completed by Nurse Practitioner (NP) Y, showed the following: -New consult for buttock pressure ulcer; -Presents with pressure ulcers to the left buttock and left ischium (lower portion of the buttock near where the thigh and buttock converge); -No treatment orders are in place at this time; -Negative for wound related pain; -Wound #1: -Left buttock: Pressure Ulcer/Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). (MONTH) also present as an intact or open/ruptured blister). Length 0.6 centimeters (cm), Width 3.5 cm, Depth 0.1 cm. 100% pink with scant serous (typically pale yellow or transparent serum (fluid) drainage. Duoderm ([MEDICATION NAME] dressing) and change every three days and as necessary (PRN); -Wound #2: -Left ischium: Pressure ulcer/Stage II. 1.0 cm by 2.5 cm by 0.1 cm. 100% pink with scant serous drainage. Apply Duoderm, change every 3 days and PRN; -Plan: Check patient every two hours, turn and reposition, provide incontinence care if needed; -Teaching methods: Verbal, Person(s) taught: Staff member at facility, Topics Taught: Dressing Changes; -Follow up in one week. Review of the resident's TAR and nurse's progress notes, dated 11/1/17 through 11/30/17 and 12/1/17 through 12/31/17, showed the following: -An order, dated 11/24/17, for staff to cleanse the pressure ulcers on the left ischium and left buttock with normal saline (NS), apply Duoderm and change every three days; -The TARs showed staff documented the treatments were completed on 11/27/17, 11/28/17, 12/1/17 and 12/4/17. Review of the resident's weekly skin assessment, dated 12/6/17 and completed by facility staff, showed no new areas of skin impairment. Review of the resident's wound management company assessment, dated 12/6/17 and completed by NP Y, showed the following: -Negative for facial grimacing or moaning with dressing changes; -Wound #1: -Left buttock: Pressure ulcer/Stage II. Wound status: Improved. 0.5 cm by 0.5 cm by 0.1 cm. 100% pink with scant serous drainage. Duoderm dressing change every 3 days and PRN; -Wound #2: -Healed; -Specialty bed/mattress: Off-loading (pressure reducing), turn and position every 2 hours; -Follow up in 1 week. Review of the resident's TAR, dated 12/1/17 through 12/31/17, and nurse's progress notes through 12/10/17, showed the following: -Staff documented the resident's Duoderm treatment as being completed on 12/7/17; -No documentation to show the treatment had been completed as scheduled on 12/10/17; -No documentation to show the pressure ulcer was getting better or worse or any new pressure ulcers developed from 12/7/17 through 12/10/17. Review of the resident's wound management company assessment, dated 12/11/17 and completed by NP Y, showed the following: -Negative for facial grimacing or moaning with dressing changes; -Wound #1: -Left buttock: Pressure ulcer/Unstageable (unstageable - slough and/or eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin), 3.0 cm by 2.5 cm by unable to determine (UTD) depth. Necrotic (dead) tissue - moderate 50%. Granulation: pink 50%. Odor - None. Drainage amount: small. Drainage color: Yellow. Apply Santyl (enzymatic - debrides or removes the dead tissue), cover with foam dressing daily and PRN. Turn and position every two hours; -Wound #2: -Sacrum (area above the middle of the top of the buttocks and the lower back): Pressure ulcer/Unstageable, 4.0 cm by 1.0 cm by UTD depth. Necrotic Tissue: moderate 50%. Granulation: pink 50%. Odor: None. Drainage amount: small. Drainage color: Yellow. Apply Santyl, cover with foam dressing daily and PRN. Turn and position every 2 hours; -Follow up in 1 week. Review of the resident's TAR and progress notes, dated 12/1/17 through 12/31/17, showed the following: -A treatment order dated 12/11/17, to cleanse the left buttock and sacrum with NS, apply Santyl and foam dressing daily; -Staff documented the treatment as completed on 12/11, 12/12, 12/13, 12/14 and 12/15/17; -No documentation the resident's physician had been notified regarding the left buttock pressure ulcer deteriorating from a Stage II to an unstageable or the new unstageable pressure ulcer on the resident's sacrum as documented by wound management company NP Y on 12/11/17, or any description of the pressure ulcers between 12/11 and 12/15/17. Review of the resident's weekly skin assessment, dated 12/13/17 and completed by facility staff, showed no new areas of skin impairment. The assessment noted the area to the sacrum looked worse and the treatment changed. There was no description of the pressure ulcers between 12/13 and 12/14/17. Review of the resident's progress notes, showed the following: -12/15/17 at 11:01 A.M., transported to a local hospital by ambulance; -12/16/17 at 2:17 A.M., admitted to the hospital for [MEDICAL CONDITION] (high sodium level). Review of the resident's hospital Physical Examination, dated 12/16/17, showed regarding the skin assessment: Has decubitus (pressure ulcer) on coccyx (between the lower back and top of the buttocks) about 7 cm by 7 cm with some darkish eschar. Review of the resident's hospital Impression and Plan Records, dated 12/16/17, showed the following: -[DIAGNOSES REDACTED]. -Decubitus wound care per protocol. Wound nurse has been consulted. (MONTH) need debridement (the removal of necrotic tissue to promote wound healing). Review of the resident's MDS, entry tracking record, showed a readmission to the facility on [DATE]. Review of the resident's progress notes, dated 12/21/17, showed the following: -At 4:36 A.M., required one person assist to turn and reposition. Incontinent of bowel and bladder. Open area noted to coccyx. Area cleansed and dry dressing applied. Will make treatment nurse aware in morning; -At 3:15 P.M., area to sacrum measured 6.0 cm by 4.0 cm by 3.0 cm; -There was no other description of the pressure ulcers. Review of the resident's POS, dated 12/1/17 through 1/31/18, showed the following: -An order dated 12/21/17 and discontinued on 1/4/18, for staff to cleanse the area on the coccyx with Dakins (an antiseptic used prior to surgical procedures or with wound care to prevent infection), apply Santyl and [MEDICATION NAME] (antibiotic ointment), cover with dry dressing two times daily (BID); -An order dated 12/22/17 and discontinued on 1/4/18, for staff to cleanse sacralbuler (unknown) with Dakins, apply moistened gauze and Santyl, cover with dry dressing daily (QD). Review of the resident's TAR, dated 12/1/17 through 12/31/17, showed the following: -An order dated 12/21/17, to cleanse the area to the coccyx with Dakins solution, apply [MEDICATION NAME] ointment and Santyl ointment to the coccyx and cover with a dry dressing BID, morning and shift 3. The order had no discontinue date; -No documentation staff completed the morning or shift 3 treatments on 12/21, 12/23, 12/26 (the wound management company did see the resident on 12/26/17, so one of the two treatments had been done); -An order dated 12/22/17, for staff to cleanse sacralbuler with Dakins, apply moistened gauze and Santyl, cover with a dry dressing QD. The order had no discontinue date; -No initials for 12/23/17. Review of the resident's progress note, dated 12/23/17 at 10:50 A.M., showed a wound sample for culture had been obtained and sent to the lab. The documentation did not show if staff had completed the resident's treatment at the time they obtained the culture. Review of the resident's wound management company assessment, dated 12/26/17 and completed by NP Y, showed the following: -Follow-up visit for resident with an infected 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; -Positive for wound related pain, facial grimacing or moaning with dressing change; -Final wound culture and sensitivity (C/S) is pending; -Wound #2: -Sacrum: Pressure ulcer/Stage IV. Quality of tissue: Deteriorated. Wound status: Deteriorated, 7.5 cm by 10.0 cm by UTD. Necrotic tissue: Extensive 100%. Odor: Strong. Infection present: Yes. Tenderness: Present. Specialty bed/mattress. Apply Santyl, pack with Dakins, cover with foam dressing daily and PRN; -This pressure ulcer is going to need extensive surgical debridement, more than can be performed at the bed side and more than the resident can tolerate. Recommend surgical consult or refer to wound clinic if alright with resident's physician; -Check resident every 2 hours, turn and reposition, provide incontinence care as needed; -Wound C/S pending; -Will follow up after debridement. Review of the resident's progress notes, dated 12/27/17, showed the following: -At 3:58 A.M.: Dressing to sacrum changed per PRN orders. Foley catheter (a tube inserted through the urethra into the bladder to drain urine). No foul odor noted. Repositioned to right side; -At 11:50 A.M.: Call out to physician regarding wound culture; -At 12:07 P.M.: Physician returned call, new order for antibiotics for wound to buttock. Review of the resident's POS, dated 12/1/17 through 1/31/18, showed an order dated 12/27/17, for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) one tablet BID at 8:00 A.M. and 8:00 P.M. Review of the resident's progress notes, dated 12/29/17, showed the following: -At 9:06 A.M.: The decubitus sacral area has foul odor, center is gray, peri-wound area (the skin surrounding the pressure ulcer) is broken down with skin moisture. No documentation if staff notified the wound management company or the resident's physician; -At 3:09 P.M.: Screaming while treatment is being done (help me, help me, please stop). Antibiotic continues. When treatment finished, resident stopped screaming out. Review of the resident's TAR, dated 12/1/17 through 12/31/17, showed the following: -An order dated 12/21/17, to cleanse the area to the coccyx with Dakins solution, apply [MEDICATION NAME] ointment and Santyl ointment to the coccyx and cover with a dry dressing BID, morning and shift 3. The order had no discontinue date; -No documentation staff completed the morning or shift 3 treatments on 12/30 (a progress note dated 12/30/17 at 2:42 A.M., showed at least one of treatments had been done) and 12/31/17; -An order dated 12/22/17, for staff to cleanse sacralbuler with Dakins, apply moistened gauze and Santyl, cover with a dry dressing QD. The order had no discontinue date; -No staff initials documented for 12/31/17. Review of the resident's progress notes, dated 12/30 and 12/31/17, showed the following: -On 12/30/17 at 2:42 A.M.: Coccyx treatment done without difficulty. Wound bed is gray in color with odor. Remains on antibiotic therapy; -No documentation on 12/31/17, to show the treatment had been done. Review of the resident's TAR and progress notes, from 12/21/17 through 1/4/18, showed facility staff continued to document the completion of both treatments at times and there was no clarification in the progress notes as to which treatment, Santyl and [MEDICATION NAME] BID or Santyl daily, was accurate. Review of the resident's wound management company assessment, dated 1/4/18, showed the resident was being sent to the hospital. Facility to notify the wound management company office if resident readmitted and required further services. Review of the resident's progress notes, showed the following: -On 1/5/18 at 1:27 A.M., admitted with [DIAGNOSES REDACTED]. -On 1/9/18 at 7:42 P.M., arrived to facility from hospital. New hospice orders verified with physician. Review of the resident's POS, dated 12/1/17 through 1/31/18, showed an order dated 1/9/18, for staff to cleanse the wound on sacrum with wound cleanser, apply Santyl ointment and a dry dressing daily and PRN. Review of the resident's progress note, dated 1/10/18 at 7:05 A.M., showed the resident was on hospice care. Every two hour turns related to wound to coccyx for comfort measures. Dressing clean/dry/intact. Review of the resident's facility wound assessment, dated 1/10/18 at 1:58 P.M. and completed by Nurse G, showed the following: -admitted : 1/9/18; -Wound type: Pressure ulcer; -An anatomical diagram with a dot located on the coccyx/sacrum area; -Skin condition: 6.4 cm by 3.8 cm by 2.4 cm; -Exudate amount: Light; -Stage: Stage IV; -Pain type: Acute on chronic; -Pain score: Hurts little more; -Pain intensity: Moderate; -Type of treatment: Large hole; -Skin and ulcer treatments: Pressure reducing device for bed, turning and repositioning program, ulcer care. Review of the resident's TAR, dated 1/2018, showed staff documented the resident's Santyl treatment as completed on the morning shift of 1/9, 1/10 and 1/11/18. Observation on 1/12/18 at 7:15 A.M., showed the resident lay in bed on his/her right side on a low air loss mattress (LAL, a specialty mattress with air holes in the mattress top surface that continually blow out air causing the resident to float, reducing skin pressure and wicking moisture away). At 8:10 A.M., 8:55 A.M., 10:10 A.M. and 11:20 A.M., the resident remained on his/her right side. During an interview on 1/12/18 at 11:25 A.M., the Director of Nurses (DON) said a resident using a LAL mattress did not need to be turned and repositioned every two hours since the LAL mattress was doing the repositioning. Observation on 1/12/18 at 12:00 P.M., showed the resident continued to lay in bed on his/her right side. Nurse N and Certified Nurse Aide (CNA) Z entered the room to complete the resident's treatment, at the surveyor's request. As they turned the resident further onto his/her right side, a strong pungent odor permeated the air. The large dressing that covered the resident's entire coccyx/sacrum area was completely saturated with drainage. Nurse N, standing directly over the resident, turned his/her head quickly and exhaled loudly. Nurse N verified the date on the dressing as 1/9/18. He/she said the facility did not have the type of dressing that was on the resident and it must have been put on at the hospital. He/she removed the dressing revealing a large deep crater with stringy greenish, yellowish and dark slough throughout the pressure ulcer. During an interview on 1/16/18 at 8:25 A.M., Nurse G said on 1/10/18, he/she noticed the resident's pressure ulcer had not been assessed when the resident was readmitted on [DATE]. So, he/she removed the dressing, assessed and measured the pressure ulcer, but did not clean it or apply a new treatment. After assessing the pressure ulcer, he/she put the same dressing back on, because he/she did not have the treatment cart at that time. When asked where the treatment cart was, Nurse G said it was at the nurse's station. He/she also worked on 1/11/18, but was too busy to do the treatment that day, and asked the evening shift nurse to do it. During an interview on 1/16/18 at 8:55 A.M., the DON said she had no problem with Nurse G placing the dressing, dated 1/9/18, back on the resident's pressure ulcer on 1/10/18. It was ok to do if staff were just measuring the pressure ulcer. The treatment should have been completed sometime on 1/10/18 or 1/11/18. Review of the facility wound assessment for the resident's sacrum, dated 1/16/18 and completed by facility staff, showed the following: -9 cm by 9 cm by 3 cm; -Tunneling: 3 cm at 3 O'clock (a clock face is used to reference the direction of the tunneling). Review of the resident's care plan, updated on 1/16/18, showed the following: -Onset 1/16/18: Hospice care. Resident will be free from pain and maintain dignity throughout the dying process; -Onset 1/16/18: Stage IV pressure ulcer to coccyx. Treatment as ordered while still maintaining comfort. During a telephone interview on 1/18/18 at 8:30 A.M., wound management company NP Y said a LAL mattress was provided for comfort and pressure relief, however it did not mean a resident did not need to be turned and repositioned. That should still be done at least every two hours. Turning and repositioning was important in the prevention and/or healing of a pressure ulcer. She always documented a resident needed to be turned and repositioned every two hours on her assessments. She was no longer involved in the resident's care after he/she returned from the hospital on [DATE]. As a wound specialist, she would never ever recommend removing a dressing and placing it back on the pressure ulcer or wound. The nurse on 1/10/18, should have removed the old dressing, cleansed the pressure ulcer, measured it, applied the new treatment and then placed a clean dressing over it. Placing an old dressing back on a pressure ulcer would increase the risk of infection. During a telephone interview on 1/19/18 at 9:30 A.M., the resident's physician said although he approved the wound management company seeing the resident, he still expected to be updated when a pressure ulcer was not healing or deteriorated. He could not recall if staff had contacted him on 12/21/17, when the pressure ulcer changed from a Stage II to unstageable and a new unstageable pressure was identified. Treatments should be completed as ordered and documented. Turning and repositioning, even when on a LAL mattress was still important to prevent and/or heal a pressure ulcer. The nurse should have completed the resident's treatment on 1/10/18 and not have put a dressing back on that was a day old. It would increase the risk of infection. 2. Review of Resident #41's annual MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory problems; -Required total staff assistance for all activities of daily living; -Incontinent of bowel and bladder; -No pressure ulcers. Review of the resident's care plan, dated 11/11/17, showed the following: -Problem: Incontinent of bowel and bladder; -Goal: To be clean, dry and odor free; -Approach: Check every two hours and as needed. Provide good perineal care and apply protective ointment after incontinent episodes; -No documentation regarding high risk for skin breakdown (until 1/16/18). Review of the resident's POS, dated 12/1/17 through 12/31/17, showed an order dated 11/9/17, to cleanse left buttock with wound cleanser, apply Duoderm, change every five days and as needed. Order discontinued on 12/14/17. Review of the resident's TAR, dated 12/1/17 through 12/31/17, showed the following: -Cleanse left buttock with wound cleanser, apply Duoderm and change every five days and as needed until healed; -Staff documented the treatment as completed: 12/4, 12/9 and 12/14/17. Review of the resident's skilled nurse's notes, showed the following: -1/8/18 at 2:52 P.M.: Skin Condition: Any new skin issues this shift: No, no other skin concerns noted; -1/9/18 at 11:30 A.M.: Skin Condition: Any new skin issues this shift: No, no other skin issues noted; -1/10/18: No skilled nurse's note; -1/11/18: No skilled nurse's note. Review of the resident's progress notes, dated 1/11/18 at 3:18 A.M., showed the following: -Open area to right heel; -Area cleaned and dressing in place; -No further documentation regarding the right heel pressure ulcer description, size or whether staff notified the physician until the surveyor questioned staff on 1/12/18. During an interview on 1/12/18 at 6:00 A.M., when asked about residents in the facility with pressure ulcers, Nurse AA identified three residents, including Resident #41, who had a right heel pressure ulcer. Observation on 1/12/18 at 6:30 A.M., showed the resident lay on his/her back, in bed, on a pressure relief mattress. CNA U (night shift) entered the room, applied gloves and pulled back the covers revealing bilateral heel protectors on the resident's feet. CNA U removed both heel protectors, which revealed a hard, dark area to the right bunion area and a dressing to the right heel dated 1/11/18. The left foot had no dressing. After loosening the brief, CNA U said he/she needed help to turn the resident, left the room and returned with Nurse AA (night shift). CNA U opened the resident's brief and a strong smell of body odor permeated the room. CNA U turned the resident to his/her left side, pulled down the brief, revealing an uncovered pressure ulcer approximately 2 cm in size to the left buttock and a moderate amount of soft feces between the buttocks. When asked if he/she was going to provide perineal care, CNA U said no and reapplied the same brief. Nurse AA provided no instruction to the CNA about providing care and they both left the room with the resident positioned on his/her back. During an interview on 1/12/18 at 6:40 A.M., Nurse AA said he/she had worked at the facility for approximately two weeks. He/she had received inservice information to read, but no formal instruction on policies at the facility. The nurse did not say anything about the pressure ulcers to the resident's left buttock, right heel or bunion area. Observation on 1/12/18 at 8:30 A.M., showed the resident lay on his/her back, in bed, on a pressure relief mattress. His/her position was unchanged. Observation on 1/12/18 at 10:22 A.M., during a skin assessment, showed the resident lay on his/her back, in bed, on a pressure relief mattress. Nurse E removed the left heel protector which revealed a dark area to the outer ankle. The nurse said the pressure ulcer was unstageable and measured 2 cm by 1.4 cm. He/she described the right heel as dark in color, necrotic, circular, unstageable and 2.8 cm by 2.8 cm. He/she described the right bunion area as dark in color, unstageable and 1.1 cm by 0.7 cm. CNA CC entered the room to assist Nurse E with positioning the resident. The CNA said he/she was assigned to the resident and had not provided any care to the resident that morning and was unaware of any pressure ulcers. CNA CC turned the resident to the left side, removed the urine and stool saturated brief revealing an uncovered pressure ulcer to the left buttock. A strong smell of body odor, urine and stool permeated the room. Nurse E said the pressure ulcer measured 0.5 cm by 1 cm and was a Stage II. During an interview on 1/12/18 at 10:55 A.M., Nurse E said staff made him/her aware of the right heel pressure ulcer on 1/11/18, but he/she did not call to notify the physician or obtain a treatment. He/she was unaware of the unstageable pressure ulcers to the resident's right bunion area and left outer ankle. The nurse was aware of the pressure ulcer to the resident's left buttock and thought there was a treatment in place. She would have expected staff to notify him/her of any changes in the resident's skin. He/she reviewed the resident's POS and said there were no treatment orders documented for the buttocks. Review of the resident's POS, dated 1/1/18 through 1/31/18, showed orders dated 1/12/18, for the following: -Cleanse buttock with wound cleanser, apply Duoderm, change every five days and as needed until healed; -Cleanse left lower ankle with wound cleaner, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film) daily; -Cleanse right bunion with wound cleaner, apply skin prep daily; -Cleanse right heel with wound cleanser, apply skin prep daily. During an interview on 1/12/18 at 11:10 A.M., the DON said the pressure ulcer to the left buttock healed on 12/14/17 and had reopened. She was unaware of the pressure ulcers to right bunion, right heel and left ankle. CNA staff do not document any open areas in their daily charting. If they saw a wound they were to report it to the charge nurse. She would expect the nurse to assess, measure and notify the physician of any wounds or pressure ulcers for a treatment. She didn't know why Nurse E failed to call the physician regarding the pressure ulcer on the right heel. The right heel pressure ulcer did not look like a pressure ulcer and she would have the nurse call the physician for a venous Doppler (type of ultrasound used to identify blood flow problems/blockage in a vessel) of the right leg. Review of the resident's Wound Assessment, completed by the DON, showed the following: -Initial assessment completed 1/12/18; -Location: Left buttock: -Present upon admission: No; -Measurement: 0.5 cm by 1 cm; -Pressure ulcer exists: Yes; -Stage II; -Treatment start date: 1/12/18; -Location: Right bunion: -Present upon admission: No; -Measurement: 1.1 cm by 0.7 cm; -Pressure ulcer exists: Yes; -Deep tissue injury: unstageable; -Location: Right heel: -Present upon admission: No; -Measurement: 2.8 cm by 2.8 cm; -Pressure ulcer exists: Yes; -Necrotic tissue; -Stage IV; -Location:Left ankle: -Present upon admission: No; -Measurement: 2 cm by 1.4 cm; -Pressure ulcer exists: Yes; -Stage II. Review of the resident's Venous Doppler Ultrasound results, dated 1/13/18, showed the following: -Compression and flow demonstrated throughout the visualized bilateral lower extremity; -Conclusion: No evidence of [MEDICAL CONDITION] (blood clot) within either lower extremity. Observation on 1/16/18 at 6:52 A.M., showed the resident lay in bed. Restorative aide D entered the room to apply the resident's splint and said he/she took care of the resident on 1/9/18, and reported the pressure ulcers on the right bunion and right heel to Nurse E that same day. He/she doesn't recall seeing the pressure ulcer on the left outer ankle. The pressure ulcer on the buttock comes and goes and wasn't there on 1/9/18. Observation of the resident's skin at that time, showed no Duoderm treatment covered the left buttock pressure ulcer. During an interview on 1/16/18 at 7:42 A.M., the DON said the nurses were doing daily skilled nurse's notes, which included a skin assessment, for the resident and would not have to complete weekly skin assessments. Staff failed to complete a daily skilled nurse's note for 1/10 and 1/11/18 and she didn't know why. CNAs do not document skin concerns. Any pressure ulcers/wounds found during care are reported to the nurse. During an interview on 1/19/18 at 9:30 A.M., the resident's physician said he would have expected staff to notify him of any changes with the resident's skin. The pressure ulcers to the resident's skin were treatable and avoidable. Staff should have notified him of the pressure ulcer to the resident's right heel and obtained a treatment order. 3. Review of Resident #40's admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -Short/long term memory problem; -Rejection of care: Not exhibited; -Total dependence of one person required for bed mobility, transfers and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Number of Stage IV pressure ulcers present upon admission: 3; -Number of unstageable pressure ulcers present upon admission: 2; -Dimensions of unhealed 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. (MONTH) include undermining or tunneling) or IV pressure ulcer: 6.0 cm by 7.2 cm by 0.4 cm. Review of the resident's medical record on 1/12/18, showed no care plan. Review of the resident's weekly skin assessment, dated 12/14/17, showed the following: -Back of left leg: 3.0 cm by 1.4 cm; -Left ankle: 2.8 cm by 2.0 cm by UTD; -Left outer foot: Blister, 6.0 cm by 1.5 cm; -Left heel: 7.0 cm by 3.0 cm by UTD; -Right foot: 0.8 cm by 2.0 cm by UTD; -Right inner foot: 1.8 cm by 2.0 cm by UTD; -Right heel: 7.5 cm by 5.0 cm by UTD; -Lower back: Deep tissue injury (unable to determine the extent of the tissue damage); -Right hip: 4.8 cm by 5.0 cm by 1.2; -Left hip: 4.0 cm by 3.0 cm; -Left ischial: 7.0 cm by 4.3 cm by UTD; -Coccyx: 10.5 cm by 5.0 cm by 1.4 cm. Review of the resident's Braden Scale (a tool used to determine a resident's risk for developing pressure ulcers), dated 12/15/17, showed a score of 11 (10 - 12 is considered high risk). Review of the resident's POS, dated 12/1/17 through 1/31/18, and TARs dated 12/14/17 through 12/31/17 and 1/1/18 through 1/8/18, showed the following: -POS: An order dated 12/14/17 and discontinued on 12/23/17, to cleanse the bilateral hips with Dakins solution and apply Santyl BID at 8:00 A.M. and 8:00 P.M.; -TAR: Staff failed to document the treatment as complete

Based on observation, interview and record review, the facility failed to assess, monitor and complete treatments as ordered for residents with, and at risk for, pressure ulcers (Resident #4, #6, #5 and #7). They failed to provide proper incontinence care for one resident with unstageable pressure ulcers (Resident #4). The census was 69. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/13, showed: -[DIAGNOSES REDACTED]. -Clear speech and comprehension; -Brief Interview for Mental Status (BIMS, a brief screen that aids in detecting cognitive impairment) Score of 0 of 15 (severe cognitive impairment); -Symptoms of inattentiveness, disorganized thinking, wandering and behavioral symptoms not directed towards others; -Required limited assistance of one for bed mobility, locomotion on/off of the unit and eating; -Total dependence on two people for transfers; -Total dependence on one for walking, dressing, toileting, hygiene and bathing; -Incontinent of urine and bowel; -Risk for developing pressure ulcers. An open lesion present to a foot and a skin tear were present, with interventions of pressure reducing device for the bed, application of nonsurgical dressings, and application of medications to the skin. Review of the resident's nurse notes, showed: -4/25/14 at 10:06 P.M. to 10:08 P.M., the aide reported the resident had open areas to his/her right and left buttocks. The nurse observed Stage I pressure ulcers (intact skin with non-blanchable redness of a localized area usually over a bony prominence) to the resident's buttocks. The ulcers were a pale pink color and had no odor or drainage. The right buttock pressure ulcer measured 0.1 centimeters (cm) in diameter. The left buttock ulcer measured 0.2 cm. in diameter. The physician was called and new orders were received to cleanse the wounds with wound cleaner and apply Polymem Opsite (wound dressing). Change every three days and as needed until healed; -There was no other documentation regarding the pressure ulcers. Review of the resident's April 2014 physician's orders [REDACTED]. Change every three days and as needed until healed. There was also an order [REDACTED]. Review of the resident's Treatment Administration Record (TAR), showed the Polymem dressing was first applied to the resident's buttocks ulcers on 4/26/14. Review of the facility's Weekly Pressure Sore Log, dated 4/30/14, showed no pressure ulcer assessments or measurements. Review of the resident's May 2014 POS, showed on 5/3/14, the treatments for the resident's bilateral buttock wounds were changed. New orders instructed staff to cleanse the area with wound cleanser then apply Santyl (wound debridement ointment) and a dry dressing daily. Further review of the facility's Weekly Pressure Sore Log, showed: -5/7/14: The resident had facility acquired stage III pressure ulcers (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) to his/her right and left buttocks. The right buttock measured 1.0 cm by 1.3 cm by 0.3 cm. The left buttock measured 0.3 cm by 0.3 cm by 0.3 cm. Drainage was present to both ulcers. Interventions included an air mattress, Santyl treatments, vitamin therapy and supplements; -5/14/14: Facility acquired stage III pressure ulcers noted to the resident's right and left buttocks. No measurements were present. Drainage was present to both ulcers. Interventions included a therapeutic bed, Santyl treatments, vitamin therapy and supplements; Observation on 5/15/14, showed: -10:10 A.M.: The resident sat in his/her wheelchair across from the nurse's station. The wheelchair had no cushion. His/her bed did not have an air mattress; -11:19 A.M., The resident lay in bed with his/her eyes closed. There was no air mattress on the bed and no cushion the wheelchair. The resident did not wear heel protectors; -2:45 P.M.: Nurse C and Certified Nurse Aide (CNA) A entered the room while the resident slept. CNA A washed and gloved his/her hands, then removed the resident's blankets. There were green, brown and red tinged stains on the pad that lay beneath the resident. CNA A untaped the resident's soiled brief and pulled it down. CNA A rolled the resident to one side and removed the soiled pressure ulcer dressings. CNA A used wet soapy towels to cleanse the resident's genitalia from front to back and back to front, then rolled him/her to the right side. As CNA A rolled the resident from side to side, the resident complained of leg pain and repeately asked the aide to wait. The resident asked if he/she could help move him/herself in the bed. CNA A told the resident to hold onto the bed rail and he/she would turn him/her in the bed. CNA A used wet soapy towels to wipe the excess stool from the resident's buttocks. Then CNA A used another towel to wipe the buttocks from front to back and back to front several times. CNA left stool on the resident's upper left thigh and buttock. Without changing gloves or washing hands, CNA rolled a clean pad and brief underneath the resident. CNA A then took the visibly soiled, unbagged linen, exited the room and walked down the hallway with it. CNA A returned to the room to wash his/her hands; -2:55 P.M.: Nurse C washed his/her hands. He/she then cut 4 x 4 gauze squares in half and cut pieces of tape. Nurse C applied Santyl to the smaller pieces of gauze. Nurse C wet additional 4 x 4s with normal saline. He/she placed all of the supplies onto a barrier on top of the treatment cart. The resident's left buttock ulcer was approximately 1.0 cm by 1.0 cm by 0.1 cm covered with 100% slough (a mass of necrotic tissue). The resident's right buttock ulcer was approximately 2.0 cm by 2.0 cm by 1.0 cm with a pink wound bed. Nurse C started the treatment without cleaning the stool off of the resident's left thigh and buttock. Without gloving his/her hands, the nurse wiped the resident's right pressure ulcer with a normal saline saturated gauze, then applied Santyl and dry gauze over the open area. Nurse C than wiped the resident's left pressure ulcer with normal saline saturated gauze. He/she went into the bathroom and washed and gloved his/her hands. Nurse C applied Santyl and a dry dressing to the open area. Nurse C removed the gloves and washed his/her hands. During an interview on 5/15/14 at 3:05 P.M., Nurse B said he/she worked for the facility about five years. He/she used to be the facility's treatment nurse. Currently, the facility did not have a treatment nurse, so the floor nurses were responsible for completing the treatments. On occasion, Nurse B sometimes did the wound treatments for all of the residents. He/she only did the measurements for existing wounds. Nurse B did wound measurements for the residents assigned to him/her when working as a floor nurse. Nurse B said it was the floor nurses' responsibility to measure their resident's wounds every week. The nurses gave him/her the measurements and Nurse B put them into the wound report. When an open area was found, the aide should report it to the nurse. The nurse was supposed to assess and measure the wound, get orders for a proper treatment and complete the treatment. The assessment and intervention should be documented and done within the shift. Wounds were assessed weekly until healed. If wound progression declined, staff referred the resident to a wound specialist. He/she was not aware of the resident's open areas until 4/30/14. She saw a treatment was in place. She added the resident to the next wound report. She felt the other nurses were not aware of their responsibilities regarding issues with residents' skin. Nurse B said she was far behind on completing weekly skin assessments and did not have time to do them all, along with all of his/her other responsibilities. He/she needed some help. During an interview on 5/22/14 at 2:03 P.M., CNA A said staff should explain care to residents prior to beginning. CNA A said the resident was confused when he/she said to wait. CNA A just kept the residents in their comfort zones by reassuring them. He/she didn't normally rush through perineal care, but he/she was in a hurry that day. He/she did not realize the resident's skin was not completely clean. Proper perineal care technique required gathering supplies and washing the resident front to back. Skin should be thoroughly washed. The perineal soap was in a no-rinse form. The resident was able to independently turn in the bed and CNA A did not know why he/she did not allow the resident to help with turning. Sometimes the resident was confused and would not follow instructions. Staff should change gloves when going from dirty to clean. Dirty gloves should not be used to touch anything clean. He/she did not know the facility's policy on leaving the rooms with unbagged soiled linen. He/she was in a rush. During an interview on 5/22/14 at 1:52 P.M., Nurse C said the CNA should always explain what they are about to help the residents with, but sometimes they did not. When a resident requested to wait, the aide could wait and proceed when the resident was ready. Perineal care could be rushed, if the resident was agitated as long as it was done correctly. During perineal care, residents should be washed from front to back. The residents could help with bed mobility, if possible, but the resident would not have understood what it meant to help. During perineal care, skin should be thoroughly cleaned, rinsed and dried. He/she did not realize the resident's skin was not properly cleaned. Even with leg pain, Nurse C thought the aide should have continued care because the resident was confused. The resident's skin should have been thoroughly cleaned prior to doing the treatment. He/she did not realize the resident's skin was not thoroughly clean. Nurse C said staff should wear gloves when applying medications. He/she was not sure of what the facility's policy was. Nurse B wrote resident wound measurements and assessments every Tuesday. The facility did not measure wounds for residents seen by the specialized wound management nurse practitioner, as they did their own wound measurements. Review of the resident's undated care plan, faxed to the Department of Health and Senior Services (DHSS) on 5/23/14, showed: -Problem: Unstageable pressure ulcers to bilateral buttocks. Bilateral buttocks opened on 4/30/14; -Goal: Ulcers will show healing or be healed within 90 days; -Interventions: Treatments as ordered, anti-pressure mattress, able to self-reposition while in bed, medi-boots (boots used for heel pressure relief) on while in bed, and specialized wound management as indicated. During an interview on 6/4/14 at 12:21 P.M., the Director of Nurses (DON) said all residents had therapeutic mattresses. They placed cushions into the resident's wheelchairs. Residents also had occupational therapy evaluations, if needed. If staff discovered a resident with an open area to the skin, the nurse should assess it, call the physician and get a treatment for [REDACTED]. The nurse practitioner did head to toe assessments and resident wound assessments every week. The floor nurses completed weekly skin assessments, including measurements. The floor nurses gave the measurements to the MDS nurse. The MDS nurse formulated the wound report. The wound report was reviewed by the quality assurance team and medical director every week. She did not know why the resident's weekly skin assessments were not in their skin assessment binder, but she'd look for them. Weekly wound assessments and measurements should be documented as part of the resident's medical chart. If a wound got progressively worse, staff should make a specialized wound referral. Staff should explain what they were about to do, before initiating care with a resident. Depending on the resident, staff could stop care if the resident requested to wait. This was because some residents were demented and all they said was stop. If the resident was combative, the staff should stop and wait until later. When asked about the importance of cleansing resident skin after being soiled with feces, changing gloves and the proper way to perform perineal care for a male resident, the DON said it depended on the situation. Due to the residents' cognitive status, sometimes staff had to rush and do the best they could. The nurse should wear gloves when performing treatments. Visibly soiled, unbagged laundry should not be carried out of the room up the hall, but if the linen cart was outside the door, it was acceptable to take linen outside the door unbagged. Review of weekly nursing skin assessment sheets, faxed to DHSS on 6/5/14, showed the resident had: -4/25/14: Stage II (Partial thickness loss of the dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) right and left buttocks, no description or measurements; -5/2/14: Stage II right and left buttocks, no description or measurements; -5/9/14: Stage III right and left buttocks, no description or measurements. During an interview on 6/25/14 at 1:40 P.M., Nurse B said the resident's weekly nursing skin assessments were not completed on the dates that they should have been done. They were done when the DON asked him/her to complete them, before they were faxed to DHSS on 6/5/14. Review of documents faxed from the facility to DHSS on 6/30/14, showed: -A handwritten note, dated 4/30/14, that facility quality improvement meetings were done on Wednesdays. The resident's wounds were not measured before the meeting. The pressure ulcer log was for in-house communication only and was not part of the medical record. It was used by the team to discuss current wounds; -One page care plan, updated 4/30/14, showed the resident had unstageable ulcers to both buttocks and the right heel. Both buttock ulcers opened 4/30/14 and the heel on 5/18/14. All listed interventions were the same as on prior copies of the resident's care plan; -Wound healing record, dated 4/25/14, for the left buttock, measured 0.2 cm by 0.2 cm. Stage I. No drainage, odor or pain present. Surrounding tissues were normal for skin. The right buttock was measured 0.1 cm by 0.1 cm. Stage I. No drainage, odor or pain present. Surrounding tissues were normal for skin. Both records indicated the care plan was updated; -Wound healing record, dated 5/3/14, for the left buttock, measured 0.3 cm by 0.3 cm. Stage III. No drainage, odor or pain present. Surrounding tissues were normal for skin. Slough in the wound bed. The right buttock measured 1.3 cm by 1.3 cm by 0.3 cm. Stage III. No drainage, odor or pain present. Surrounding tissues were normal for skin. Slough in the wound bed. Deteriorated response to treatment. Both records indicated new treatments were obtained and the care plan was updated; -Wound healing record, dated 5/7/14, for the left buttock, measured 0.3 cm by 0.3 cm by 0.3 cm. Stage III. No drainage, odor or pain present. Surrounding tissues were normal for skin. Slough in the wound bed. Deteriorated response to treatment. The right buttock measured 1.0 cm by 1.3 cm by 0.3 cm. Stage III. Surrounding tissues were normal for skin. Slough in the wound bed. Drainage, pain and odor were not assessed. Deteriorated response to treatment; -Wound healing record, dated 5/14/14, for the left buttock, measured 1.0 cm by 1.0 cm by undetermined. Unstageable. No drainage, odor or pain present. Surrounding tissues were normal for skin. Slough in the wound bed. The right buttock measured 1.0 cm by 2 cm by undetermined. Unstageable. Surrounding tissues were normal for skin. Slough in the wound bed. No drainage, pain and odor present. Deteriorated response to treatment; -Wound healing record, dated 5/20/14, for the left buttock, measured 1.5 cm by 1.5 cm by undetermined. Staging was not provided. No drainage, odor or pain present. Surrounding tissues were normal for skin. Slough in the wound bed. Deteriorated response to treatment. The right buttock measured 1.5 cm by 2 cm by undetermined. Unstageable. Surrounding tissues were normal for skin. Slough in the wound bed. No drainage, pain and odor present. Deteriorated response to treatment. Both records indicated treatment from a specialized wound treatment team and care plan updates (On-site 5/15/14); -Nurse Notes, from 4/27/14 through 5/10/14, showed only one note that specifically addressed the resident's pressure ulcers. Note, dated 5/3/14 at 11:20 A.M., showed the resident's treatment for [REDACTED]. 2. Review of Resident #6's face sheet, showed a facility admission date of [DATE]. Review of the resident's pressure ulcer risk assessment, dated 4/10/14, showed a high risk for skin breakdown. Review of the resident's nurse's notes, showed the following: -4/10/14 at 11:00 A.M., he/she was admitted to the facility with a stage II (A partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) left buttock pressure ulcer (no measurements given). He/she was alert and oriented to self, lungs diminished, left buttock duoderm applied, bilateral lower extremities dry and flaky with a callous on his/her left heel. He/she was incontinent of bowel and bladder and required total assistance of staff for activities of daily living. -4/11/14 at 2:00 P.M., DuoDERM (a gel wound dressing which both donates moisture and absorbs drainage) was applied to his/her right buttock (no measurements given). Review of the resident's MAR, dated 4/1 through 4/30/14, showed no order for DuoDERM on 4/11/14. Review of the facility's weekly pressure sore quality improvement log, dated 4/16/14, showed the resident was admitted on [DATE], with a stage II pressure ulcer on his/her left buttock, which measured 1.0 cm long by 1.0 cm wide by 0.2 cm deep. Treatment with DuoDERM was provided. Review of the resident's admission history and physical, dated 4/16/14, showed his/her [DIAGNOSES REDACTED]. He/she had a left buttocks decubitus. Review of the resident's POS, dated 4/16/14, showed an order to cleanse the left buttock with wound cleanser and apply DuoDERM every five days and as needed. Review of the resident's MAR, dated 4/1/14, showed his/her sacrum cleansed with wound cleanser and DuoDERM applied on 4/16/14. The treatment was discontinued on 4/20/14. Review of the resident's nurse's notes, dated 4/20/14, late entry (date not indicated), showed the resident's bottom is worse, went from stage II to deep tissue, measuring 10.0 cm long by 14.0 cm wide by unable to determine depth. Treatment changed. Review of the resident's POS, dated 4/20/14, showed an order to cleanse the sacrum with wound cleanser, apply Santyl (a prescription ointment that cleans wounds to clear the way for healthy tissue), cover with moist gauze and dry dressing twice daily and as needed. Review of the resident's nurse's notes, dated 4/23/14 at 10:45 A.M., showed the resident was placed on wound management medication. Family agreed to have mobile wound company evaluate and treat. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Total dependence on staff for transfers, locomotion on and off the unit, dressing, eating, toileting and hygiene; -Always incontinent of bowel and bladder; -Wheelchair use; -High risk for pressure ulcers, current pressure ulcer, an unstageable suspected deep tissue injury with eschar (a piece of dead tissue that is cast off from the surface of the skin), pressure reducing device for chair and bed and turning/repositioning program. Review of the facility's weekly pressure sore quality improvement log dated 4/23/14, showed the resident had an unstageable pressure ulcer on his/her sacrum, which measured 10.0 cm long by 14.0 cm wide by unable to determine depth, with drainage. Treatment was changed to Santyl. Review of the resident's POS, dated 4/23/14, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. Review of the resident's MAR, dated 4/20 through 4/28/14, showed his/her sacrum cleansed with wound cleanser, Santyl and dry dressing applied on the following: -Once daily on 4/20, 4/21, 4/22, 4/24, 4/26, 4/27 and 4/28/14; -Twice daily on 4/23 and 4/25/14. Review of the mobile wound company report, dated 4/29/14, showed the following: -Sacrum, unstageable, measured 8.0 cm by 16.0 cm by unable to determine depth. Cleansed with wound cleanser, Santyl and moist to dry dressing. Dressing to be changed by nursing staff daily and as needed. Offloading with a low air loss mattress. Review of the resident's nurse's notes, dated 4/29/14 at 9:15 A.M., showed the mobile wound company saw the resident and new treatment orders were received. Review of the resident's POS, dated 4/29/14, showed an order to cleanse the sacrum with wound cleanser, apply Santyl ointment, cover with moist gauze and dry dressing once daily and as needed. Review of the resident's nurse's notes, dated 4/29/14 at 12:20 P.M., showed the resident developed hematuria (the presence of blood in the urine) after his/her indwelling catheter (a tube inserted into the bladder and left in place to drain urine) was changed. The physician was notified and new orders received to transfer the resident to the hospital. At 12:25 P.M., the power of attorney was made aware. Review of the resident's MAR, dated 4/29/14, showed his/her sacrum cleansed with wound cleanser, Santyl and dry dressing applied once daily. Review of the facility's weekly pressure sore quality improvement log, dated 4/30/14, showed the unstageable pressure ulcer on his/her sacrum, involved deep tissue, had 70% yellow eschar, and measured 8.0 cm long by 16.0 cm wide by unable to determine depth, with drainage. Treatment continued with Santyl. Review of the next nurses note, dated 5/5/14 at 9:45 P.M., showed the resident in bed, resting. There was no documentation regarding the resident's skin. Review of the resident's POS, dated 5/5/14, showed an order to cleanse sacral ulcer with wound cleanser, apply Santyl ointment, cover with moist gauze and dry dressing twice daily and as needed. Review of the resident's care plan, updated on 5/5/14, showed the following: -Problem: deep tissue injury to sacrum and bilateral buttocks, and unstageable pressure ulcer on his/her left foot and risk for further skin breakdown; -Interventions included for staff to provide treatment as ordered, notify physician for any changes or sign of infection, turn and reposition every two hours, pressure relief cushion in wheelchair, therapeutic mattress, mediboot while in bed, provide good peri-care and use protective barrier for skin after incontinence, refer to mobile wound company, maintain proper diet and observe for pain, and document weekly on deep tissue injury location, appearance, drainage and wound bed. Further review of the mobile wound company report, dated 5/6/14, showed the following: -Resident was hospitalized with hematuria and treated for [REDACTED]. He/she is on [MEDICATION NAME] (antibiotic used to treat bacterial infections) through 5/10/14. -Sacrum: unstageable, measured 11.0 cm by 13.0 cm by unable to determine depth. Cleansed with wound cleanser, Santyl and moist to dry dressing. Dressing to be changed by nursing staff daily and as needed. Offloading with a low air loss mattress; -Superficial dorsal (back) left foot abrasion noted. Review of the resident's nurse's notes, showed the following: -5/6/14 at 9:00 A.M., resident seen by mobile wound company. New order noted to cleanse left dorsal foot abrasion and apply topical antibiotic ointment and a dry dressing daily and as needed until healed; -5/7/14, continue with antibiotic for wounds. Review of the facility's weekly pressure sore quality improvement log, dated 5/7/14, showed the unstageable pressure ulcer on his/her sacrum, measured 8.3 cm long by 15.0 cm wide by unable to determine depth, with drainage. Treatment continued with Santyl. Review of the resident's nurse's notes, showed the following: -From 5/8/14 through 5/12/14, continue with antibiotic for wounds; -5/13/14 at 1:30 P.M., resident seen by mobile wound company. New order received for left dorsal foot area. Review of the mobile wound company report, dated 5/13/14, showed the following: -Sacrum: unstageable, measured 8.3 cm by 15.0 cm by unable to determine depth. Cleansed with wound cleanser, Santyl and moist to dry dressing. Dressing to be changed by nursing staff daily and as needed. Offloading with a low air loss mattress; dorsal left foot abrasion: unstageable, measured 0.4 cm by 0.4 cm by unable to determine depth. Skin prep applied to the skin and to be done by nursing staff daily and as needed until healed. Review of the resident's POS, dated 5/13/14, showed an order to apply skin prep to left dorsal foot daily until healed. Review of the resident's MAR, dated 5/14/14, showed skin prep applied to left dorsal foot. Review of the resident's nurse's notes, dated 5/14/14 with no time noted, showed dressing intact to coccyx. Review of the facility's weekly pressure sore quality improvement log, dated 5/14/14, showed the unstageable pressure ulcer on his/her sacrum, measured 8.3 cm long by 15.0 cm wide by unable to determine depth, with drainage. Treatment continued with Santyl. A left foot wound measured 0.4 cm by 0.4 cm by unable to determine depth. Treatment was skin prep. Review of the resident's MAR, dated 5/5/14 through 5/15/14, showed the resident's sacral ulcer was cleansed with wound cleanser, applied Santyl, covered with moist gauze then with dry dressing performed twice daily, except on 5/8 and 5/15/14, when it was done once daily. Observation and interview, on 5/15/14, showed the following: -At 8:38 A.M., the resident lay in bed asleep on a low air loss mattress on his/her right side, with his/her head of the bed raised 45 degrees. His/her indwelling catheter drained clear yellow urine. He/she had oxygen per nasal cannula at 3.5 liters per minute, bilateral foot protectors on and quarter side rails up on both sides at mid-bed; -At 10:20 A.M., the resident remained in bed, now positioned on his/her left side, with oxygen and bilateral foot protectors intact. He/She was awake and alert, but not verbal. Nursing staff had just completed his/her dressing change to his/her coccyx. Nurse C said the area had slough, was treated with Santyl and that the resident was seen by a mobile wound company weekly; -At 12:25 P.M., the resident remained in his/her bed on his/her left side, asleep, with oxygen, the indwelling catheter and bilateral foot protectors intact; -At 2:40 P.M., the resident lay asleep in his/her bed on his/her back, with oxygen, the indwelling catheter and bilateral foot protectors intact. Review of the resident's medical record, on 5/15/14, showed no skin incident report, no weekly skin assessment sheet and no wound/skin healing record. Review of the facility's information faxed to DHSS, dated 5/16/14, showed the following: -A treatment report provided by a mobile wound company, dated 4/29/14, for his/her sacral pressure ulcer; -A hospital facility transfer record, dated 5/5/14, which showed wound care on 4/29/14, to the resident's sacrum, which measured 11 cm by 13 cm with full thickness and small purulent drainage. A wound to the dorsal foot measured 2.5 cm by 2 cm and was a dry black eschar; -A treatment report provided by a mobile wound company on 5/13/14, for his/her sacral pressure ulcer and left foot abrasion. During an interview on 5/29/14 at 1:30 P.M., the DON said the resident's wound measurements had worsened after he/she was readmitted to the hospital from 4/29 through 5/5/14. He/she was in decline and the facility was trying to get him/her admitted to hospice, but had difficulty reaching the family. 3. Review of Resident #5's pressure ulcer risk assessment, dated 2/13, showed he/she was at a high risk for skin breakdown. Review of the resident's weekly skin assessment sheet, dated 2/3/14, showed skin intact. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Total dependence on staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toileting and hygiene; -Always incontinent of bowel and bladder; -Wheelchair use; -High risk for pressure ulcers, no current pressure ulcer, pressure reducing device for chair and bed and turning/repositioning program. Review of the resident's POS, dated 3/23/14, showed an order to cleanse the right buttock with wound cleanser, apply Santyl ointment and dry dressing daily and as needed until healed. Review of the resident's nurse's notes, showed the following: -3/23/14 at 8:00 A.M., resident has open area to right buttock, 1.3 cm long by 1.0 cm wide by 0.1 cm deep. Physician was called. New order to apply Santyl once daily until healed; -3/26/14 at 1:40 P.M., treatment done to buttock this morning (no measurements); -3/26/14 at 8:00 P.M., dressing to right buttock site dry and intact. Incontinence care per staff. Turned and repositioned every two hours and as needed to offload pressure on wound; -3/28/14 at 11:00 A.M., treatment done to buttock (no measurements). Review of the facility's weekly pressure sore quality improvement log, dated 3/26/14, showed a facility-acquired stage II pressure ulcer on his/her right buttock, measured 1.3 cm long by 1.0 cm wide by 0.1 cm depth, with drainage. Treatment was with Santyl. Review of the resident's POS, dated 3/28/14, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. Review of the resident's nurse's notes, showed the following: -4/1/14 at 2:40 P.M., treatment done to coccyx as ordered (no measurements); -4/3/14 at 10:50 A.M., treatment done to buttock as ordered this morning (no measurements); -4/5/14 at 2:40 P.M., treatment done to coccyx as ordered (no measurements); -4/6/14 at 11:00 A.M., treatment done to buttock (no measurements); -4/7/14 at 1:45 P.M., treatment done to coccyx, shows improvement (no measurements); -4/9/14 at 8:15 P.M., dressing clean, dry and intact; -4/10/14 at 11:00 A.M., treatment done to buttock (no measurements); -4/13/14 at 11:00 A.M., treatment done to buttock, shows improvement (no measurements); -4/14/14 at 2:40 P.M., treatment done to coccyx as ordered (no measurements); -4/15/14 at 10:55 A.M., treatment done to coccyx (no measurements); -4/16/14 at 11:20 P.M., coccyx healed. Review of the resident's MAR, dated 4/1 through 4/16/14, showed his/her right buttock cleansed with wound cleanser, Santyl and dry dressing applied once daily, except for 4/8/14 and 4/12/14, when no treatment was administered. Review of the facility's weekly pressure sore quality improvement log, showed the following: -On 4/2/14, facility-ac

Based on observation, interview and record review, the facility failed to thoroughly investigate, implement corrective interventions, document assessment in the residents' records and update care plans for resident accidents and falls for three sampled residents, two of which sustained significant injuries (Residents #8, #9 and #10). The census was 69. 1. Review of Resident #8's face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the facility's fall/accident log report and the resident's nurse's notes, from 1/1/14 through 6/17/14, showed the resident sustained [REDACTED]. Review of the resident's care plan problem list, dated 2/10/14, on 5/30/14, showed the following; -Trying to change pants and fell in room on 11/5/13; -On 1/15/14, fell in the hallway and hit head and received a large hematoma (a collection of blood outside the blood vessels) to head, went to the hospital. All tests were negative; -On 5/6/14, found on the floor in room; -On 5/7/14, trying to pull pants up and fell backwards. Review of the resident's undated care plan for falls, showed the following interventions: -Monitor for any changes or decline in balance or gait when ambulating; -Be sure wearing well fitted shoes with non skid soles or gripper socks each day; -Educate on safety awareness as needed, remind to use grab bars near the shower, toilet or tub for safety; -Please check frequently to be sure needs are being met, able to use call light; -Refer for physical therapy or occupational therapy evaluation for the need of any assistive devices; -Please use a gait belt for safety when ambulating; -Be sure room and pathway are free of any clutter; -Keep bed in a low, locked position; -Offer to assist to the toilet before meals and after meals; -Notify physician and family promptly of any falls; -Monitor for 72 hours after any fall with vital signs taken and neuro checks done if indicated. Review of the resident's fall risk assessment form (a tool used by staff to determine if a resident was at risk for falls), dated 4/4/14, showed the facility identified him/her as a high risk for falls. Review of the resident's nurse's notes, showed the following; -On 5/6/14 at 11:30 P.M., found on the floor in the bathroom in a sitting position facing the sink. A certified nursing assistant (CNA) alerted nurse. Nurse responded quickly and assessed the resident. Range of motion preformed, vital signs taken, transferred safely to bed. No bruises, no injury. Neuro checks initiated; -5/7/14 at 7:30 A.M., guardian notified; -5/7/14 at 8:00 A.M., primary care physician notified; -5/7/14 at 8:01 P.M., found on the floor in the hallway. Resident was observed attempting to pull up his/her pants, before staff could intervene and help, the resident fell . Staff assessed the resident, no bruising or open areas noted. The resident denied pain. Neurological checks initiated. -5/7/14 at 8:06 P.M., staff notified the resident's primary care physician and legal guardian; -5/9/14 at 11:55 A.M., resident sitting in wheelchair at nurse's station, he/she was trying to fix the pad in the wheelchair and slid out of the wheelchair. The resident hit his/her head on the nurse's station, hematoma noted to back of his/her head (no description or size of hematoma noted in the nurse's notes). -No documentation the primary care physician or guardian was notified of the resident's fall; -No further documentation of hematoma in nurse's notes. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/14, showed: -Usually understands and is understood; -Signs and symptoms of delirium included inattention and disorganized thinking; -Behavior symptoms included physical and verbal behaviors occurring one to three times per week; -Resisted care and displayed wandering behaviors one to three times per week; -[DIAGNOSES REDACTED]. -Had falls in the month prior to admission; -Had falls in the last two to six months prior to admission; -Has had two falls since admission without injury; -Brief Interview for Mental Status (BIMS, an assessment of cognitive function) score: 3 of 15; -Required supervision and set up help only with transfers, ambulation, locomotion and dressing; -Required limited assistance and assistance from one staff person for eating; -Required extensive assistance from one staff person for toilet use and personal hygiene needs; -Not steady, but able to stabilize without human assistance with moving from a seated to standing position, walking with an assistive device, moving on and off the toilet and surface to surface transfer (transfers between bed and chair or wheelchair); -No functional limitations with range of motion in upper extremities or lower extremities; -No restraints used. Review of the resident's nurse's notes, showed the following: 5/13/14 at 8:15 P.M., walking behind the wheelchair, slipped and fell to the floor. Did not hit his/her head or sustain any injury. Will place on incident follow up (IFU) and monitor accordingly; (no further documentation about resident's condition) 5/14/14 at 12:00 P.M., primary care physician assessed. No new orders. Aware that the resident has been putting self on floor; 5/14/14 at 12:30 P.M., order per primary care physician to consult psychiatric services. Order per psychiatrist to send resident to hospital for inpatient treatment; 5/14/14 at 1:15 P.M., call placed to hospital all patient information provided to hospital; 5/14/14 at 1:20 P.M., guardian notified of pending transfer to hospital; 5/14/14 at 2:00 P.M., ambulance at facility to transport resident to the hospital. Review of the resident's psychiatric evaluation, dated 5/14/14, showed he/she was admitted to the acute psychiatric unit for evaluation and treatment due to worsening of baseline psychosis. The resident was calm comfortable and in no distress. His/Her vital signs were within normal limits. His/Her medical [DIAGNOSES REDACTED]. Review of the resident's acute hospital history and physical, dated 5/16/14, showed he/she was transferred from the psychiatric hospital to an acute medical hospital due to the worsening baseline psychosis. The psychiatric hospital had ordered a CT scan for left sided weakness, which showed a big bilateral (both sides) subdural hematoma (a collection of blood between the skull and the brain) with a midline shift (the brain has shifted from it's normal position) of 7.6 millimeters (mm). The resident was transferred to an acute care hospital due to unavailable neurosurgery services at the other hospital. He/She had multiple falls at the nursing home. On 5/15/14, the resident underwent [REDACTED]. Review of the resident's readmission nursing assessment, dated 5/23/14, showed he/she returned to the facility with nine staples to the left side of the head (all supporting documentation and photographs, showed it was the right side of the head). Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED]. -Up ad lib-independent for transfers Review of the resident's nurse's notes, showed the following: 5/23/14 at 12:15 A.M., (all other documentation showed it was P.M.) readmitted to the facility. Dressing to left forehead saturated with blood. Nursing assessment completed. Primary care physician notified of re-admission, all orders verified. (no further nursing documentation for 5/23/14). Observation on 5/30/14 at 9:30 A.M., showed the resident lay in bed with the head of the bed up at a 45 degree angle and oxygen via nasal cannula at 2 liters per minute. Bilateral siderails were in the up position. There were nine intact staples to the right side of his/her head. A visitor sat at the bedside. The resident kept his/her eyes closed and would only answer yes or no to questions. Review of the resident's undated care plan, on 5/30/14, showed no new interventions related to falls since his/her re-admission on 5/23/14. Review of the facility's communication book, dated 6/4/14 through 6/13/14, showed no documentation regarding interventions put in place to prevent the resident from falling. Review of the Physical Therapy daily treatment notes, showed the following: -6/2/14, passive range of motion (PROM)/active range of motion (AROM) to bilateral lower extremities. ROM began as passive, resident would begin assisting after 3-4 repetitions. Bed mobility with moderate assistance for turns side to side. Moderate assistance for moving supine (laying flat) to sitting. Minimum assistance for moving from sitting to supine. Resident unable to resist challenges to his/her sitting balance (cannot sit up without assistance); -6/3/14, transfer from wheelchair to mat with moderate assistance. Sitting balance on edge of mat required moderate assistance to maintain balance. Resident unable to recover challenges independently. Resident kept eyes closed throughout the treatment unless asked to open them; -6/4/14, sat on edge of bed for 10-30 minutes with stand by assistance to minimal assistance. Resident able to sit with stand by assistance for 45 seconds and then loses balance and requires minimum assistance to regain balance; -6/5/14, performs bed mobility spontaneously and follows simple commands such as roll and sit up. Resident requires stand by assistance to transfer from a sitting to supine position. Resident requires stand by assistance to transfer from supine to sitting position. Resident required stand by assist to roll from side to side. Resident required moderate assistance from two to transfer from the bed to the wheelchair. Discussed safety issues with CNAs; -6/6/14, given double dose of Ativan (anti-anxiety medication) by nursing due to agitation and risk of falling out of chair or bed (no information about why resident was given a double dose of anti anxiety medication provided by facility after the assistant administrator was asked for it on 6/12/14 at 11:00 A.M.). PROM to prevent contractures. Consulted with CNA regarding positioning. Review of the resident's Skilled Occupational Therapy daily treatment notes, showed the following: -6/2/14, seen at bedside for feeding. Resident completed self feeding task with maximum assistance and maximum verbal cues. Placed cup in resident's hand, resident able to hold cup but not strong enough or alert enough to lift cup to mouth, requiring maximum assistance to lift cup. Resident's eyes were closed for the duration of the treatment session. Resident responded when asked questions and was able to follow cues to wash his/her face. Resident consumed 50% of meal with maximum encouragement; -6/3/14, completed wheelchair to edge of mat transfer with max assistance of one and minimum assistance of one. Resident completed 17 minutes of sitting balance; -6/4/14, required minimum to moderate assistance for supine to sitting position. Minimum assistance for sitting to supine position. Positioned resident in bed with head and foot of bed elevated. Nursing staff report the resident has been moving around in bed all day and has been combative at times; -6/5/14, required moderate assistance for wheelchair to mat transfers. Resident exhibiting constant motion while seated in wheelchair, staff concerned with resident falling out of wheelchair. Dumped (lowered) seat and provided cushion to wheelchair to increase comfort and prevent resident from sliding out of chair. Resident would benefit from tilt-in-space wheelchair (A wheelchair that gives the user the ability to adjust the orientation of their wheelchair by allowing for the redistribution of pressure from one area to another by tilting the seating area. This particular type of wheelchair offers a variety of positioning and adjustments that will maintain certain angles providing stability and pressure relief at the thighs, knees and ankles. Tilt-in-space wheelchairs will also help with digestion and the respiratory needs of the user. Also called a reclining wheelchair), but none is available at this time that are appropriate for the resident; -6/6/14, located a tilt-in-space wheelchair with foot buddy (a cushion attached to the bottom of a wheelchair that prevent a resident's legs from swinging backward), contoured cushion and lateral supports to prevent the resident from falling out of the wheelchair due to decreased motor control and safety awareness. Resident is lying in bed and not alert to verbal stimuli. Issued the tilt-in-space wheelchair and educated nursing staff on the wheelchair and positioning interventions. Will assess positioning at next treatment session when resident is up in wheelchair. Review of the resident's nurse's notes, for 6/8/14, showed the following: -9:15 A.M., the nurse was sitting at the nurse's station when he/she heard a thumping sound. The nurse got up to see where the sound was coming from and saw an empty reclining wheelchair by the wall. The resident was lying on the floor on his/her left side with knees bent. No bleeding noted. Hematoma to left side of head. ROM within normal limits. Assisted X 2 into reclined wheelchair. Vital signs obtained (no documentation neurochecks were initiated and no neurocheck flow sheet was provide by the facility); -9:30 A.M., staff notified the primary care physician and legal guardian; -10:00 A.M., sent to hospital. During a telephone interview on 6/9/14 at 10:00 AM, the Director of Nurses (DON) said the resident fell on Sunday (6/8/14). Therapy had been working with him/her and on Friday (6/6/14) and recommended a tilt-in-space chair. The resident was agitated on Friday (6/6/14) and the physician ordered Roxinal (narcotic pain medication), which seemed to help. The resident was up, fine and without problems in the new wheelchair on Saturday (6/7/14). On Sunday (6/8/47), the resident was out by the nurse's station after breakfast, tilted back in the tilt-in-space wheelchair. No one actually saw the fall. The DON does not think the resident tried to stand up because that would have been very hard with the wheelchair in the tilted back position. Since the resident was found on his/her left side, he/she might have rolled out of the tilt-in-space chair. The resident had a hematoma to the left side of his/her face and was sent to the hospital where the CT scan showed bilateral chronic subdural fluid collection. The DON does not know if this was new or just fluid collection after surgery from the last time, when the resident had the chronic bilateral subdural hematoma. A neurosurgeon consult will be done to see if the fluid needs to be drained. A helmet could not be used until the resident's staple site and injuries were healed from last time. The guardian has asked them to restrain the resident, but was told if he/she wanted restraints, he/she would need to move the resident somewhere else to live because the potential dangers involved with using restraints. OT will re-evaluate the tilt-in-space wheelchair and see if any additional positioning devices are needed along with the chair. She was getting ready to go out of town for an emergency but would initiate an investigation and fax it to the regional office. Review of the resident's hospital discharge summary, dated 6/10/14, showed the following: -Presented to the hospital on [DATE], for evaluation after a fall; -CT scan of the head done on 6/8/14, showed bilateral chronic subdural fluid collection; -Resident admitted to hospital for further evaluation; -discharged from the hospital back to the nursing home on 6/10/14, because his/her mental status is at his/her baseline from prior discharge. Review of the resident's POS, dated 6/11/14, showed the following: -May attend social outings with supervision; -Up ad lib-independent for transfers: -Ativan intensol (liquid) 1 mg every 12 hours. Review of the resident's nurse's notes, showed the following: -6/10/14 at 8:00 P.M., returned from the hospital at 6:30 P.M. Resident attempting to get out of bed. Routine Ativan given as ordered. Both siderails up. Head of bed elevated at 45 degree angle. Call light in reach; -6/14/14 at 5:18 A.M., found on the floor next to the bed. Staff assessed the resident for injury and put him/her back in bed with the bed in the lowest position (no information documented if the bed was already in the low position and/or if mats were on the floor); -6/14/14 at 8:30 A.M., found on the floor between the beds. Placed the resident back in bed with assistance of two staff. No apparent injury; -6/17/14 at 1:15 A.M., found on floor next to bed on left side facing the wall. Nursing assessment done. No apparent injury. During a telephone interview on 6/12/14 at 8:30 A.M., Occupational Therapist (OT) K said he/she saw the resident on 6/6/14. The facility had located a tilt-in-space wheelchair, but the resident was too sleepy to get out of bed and be assessed in the wheelchair. OT K worked with the wheelchair to make sure it had a foot buddy, lateral supports and a headrest. He/She put the chair in the resident's room, but did not assess the resident in the wheelchair. He/She provided instructions for the use of the wheelchair to a CNA and might have told a nurse, but does not remember any names. He/She told the CNA that when the resident was up in the wheelchair, the foot buddy, lateral supports and headrest must be in place. The resident should be supervised by staff at all times when up in the wheelchair. He/She did not write the information on the resident's care plan or put the information in the communication book. The facility does not use signs to relay information in resident rooms. Therapy is now assessing to see if the resident could benefit from a lap buddy (a cushion placed across the lap and secured to the wheelchair arms, used for positioning and to prevent falls). During an interview on 6/12/14 at 11:00 A.M., the assistant administrator said the DON was out of town and not available until Monday (6/16/14). He was not sure how the investigation into the resident's fall, on 6/9/14, was progressing. He thought the DON left instructions for staff to fill out paperwork, but is not sure. He will fax what information he has to the regional office. He is not sure how information regarding resident care is passed on to the nursing staff from the therapy department. He does not think it is appropriate for therapy staff to give report to a nursing assistant. Therapy is in the process of evaluating the resident for a lap buddy. Every staff member has been told the resident is not to be left unattended when he/she is up in the wheelchair. He will find out the progress of the investigation and fax what information they have to the regional office. Review of the investigation faxed to Department of Health and Senior Services (DHSS) office, on 6/17/14 at 1:22 P.M., showed the following: -A copy of the daily staffing schedule for 6/8/14; -A list of four employees' names and contact information; -Two pages containing four witness statements all filled out in the same handwriting; -First statement; signed by CNA N, dated 6/8/14, no time indicated, showed the resident was already up in the reclining wheelchair when he/she arrived at work. He/She fed the resident breakfast, brought him/her to the nurse's station, locked the wheelchair and reclined the chair back and went down the hallway. The resident was agitated during the meal; -Second statement; not signed, not dated, showed CNA M got the resident up at 5:15 A.M. (no date specified). The resident was not agitated. He/She brought the resident to the nurse's station; -Third statement; not signed, not dated, showed Nurse H said the resident sat at the nurse's station with him/her then the resident was taken to the dining room and placed against a table in his/her wheelchair and staff locked the chair; -Forth statement; not signed not dated, showed Nurse N was sitting and heard a "thump", saw the resident laying on the floor on his/her left side. Hematoma to left side of head. Ice applied and sent to hospital; -A copy of the resident's care plan, dated 6/9/14, showed the resident was high risk for falls. Interventions included; up in tilt-in-space wheelchair, 1:1 supervision while up in wheelchair, head of bed up at all times, OT to evaluate and treat for safe seating options, medicate for pain as needed, medicate for agitation as needed. -Update to care plan, dated 6/12/14, intervention added; lap buddy while up in chair, release every 30 minutes and during meals. -The investigation did not include determining factors that may have caused or contributed to the fall or an analysis of the risks. During a telephone interview on 6/18/14 at 9:34 A.M., CNA M said he/she worked the night shift from 11:00 P.M., on 6/8/14 until 7:00 A.M., on 6/9/14. She got the resident up on 6/9/14 around 5:15 A.M., and put him/her in the wheelchair that was in the room. He/she had not received any kind of report on the resident or how to care for the resident. He/she was not aware of any recommendations by therapy for the resident. He/she was never told not to leave the resident unattended once the resident was up in the reclining wheelchair. The nurse working the night shift told him/her to get the resident up in the wheelchair. The nurse did not provide any special instructions regarding the resident or safety measures to provide to the resident. When he/she left the facility at 7:00 A.M., the resident was in the reclining wheelchair at the nurse's station. During an interview on 6/18/14 at 9:45 A.M., CNA L said he/she worked on the day shift on 6/8/14 and the resident was on his/her assignment. When he/she arrived at work at 7:00 A.M., the resident was already sitting in a wheelchair at the nurse's station. The resident was anxious and fidgeting in the chair. CNA L fed the resident breakfast and then put the resident in his/her wheelchair by the nurse's station. CNA L reclined the chair and locked the wheelchair brakes, then went down the hall to care for other residents. At around 9:30 A.M., the charge nurse yelled down the hall, the resident had fallen out of the wheelchair. CNA L and Nurse N assessed the resident for injury and put the resident back into the wheelchair. The resident was then transferred to the hospital. This was the first day CNA L saw the resident in the tilt-in-space wheelchair. The resident stayed in bed on Saturday (6/7/14). CNA L did not receive a verbal report about the resident being in a new wheelchair and did not receive any instructions about the chair or to not leave the resident unattended when up in the wheelchair. CNA L did not take the resident to the bathroom, change his/her linens in the wheelchair or reposition the resident prior to the resident's fall at 9:30 A.M. CNA L did not know if the resident had been provided any anti-anxiety or pain medications. During an interview on 6/18/14 at 10:00 A.M., Nurse N said he/she no longer works at the facility. He/she was working on the day shift on 6/8/14, when the resident fell out of his/her wheelchair. When he/she arrived to work the resident was already up and sitting in the wheelchair. He/she was surprised to see the resident up that early in the morning because the resident had been staying in bed. The resident was very anxious and kept trying to get out of the wheelchair. Nurse N provided the resident's routine Ativan at 8:00 A.M., for restlessness and anxiety. He/she did not provide the resident any pain medications. The resident required constant cueing to remain seated in the wheelchair. Nurse N did not receive any written or verbal instructions regarding the resident's wheelchair or interventions put in place to prevent the resident from falling. The facility has no systems in place to receive report about residents. There is a communication book, but the nurses often fail to put important information in it. There was nothing in the communication book about the resident getting a new wheelchair with adaptive devices and no instructions the resident should not be left unattended when up in the wheelchair. Resident care plans are not updated to reflect the care they need, other than giving a verbal report to the CNAs there is no system in place to instruct them how to care for the residents at the facility. He/she was not asked to fill out a statement about the residents fall or participate in the investigation by the facility. Review of the resident's care plan for falls, dated 6/9/14, provided by the DON on 6/25/14, showed no additional interventions put in place after 6/12/14. During an interview on 6/25/14, the DON said the resident had been discharged to another facility. Nursing assistants are given report by the nurses at the beginning of each shift. There is a communications book that nursing is supposed to use to pass information about residents from one shift to another. During an interview on 7/14/14, at 11:30 A.M., the resident's primary care physician (also the facility's medical director) said the resident's care plan should have been updated after each fall with interventions to try and prevent further falls. The resident should not have been put into a wheelchair that he/she had not been assessed in by the therapy department as safe and all staff had been inserviced on the proper use of the wheelchair. He was aware of the resident's multiple falls after his/her return to the facility, but was not aware the care plan had not been updated and was not aware the therapy department had not approved the tilt-in-space wheelchair prior to staff sitting the resident in it. 2. Review of Resident #9's Fall Risk Assessment form, dated 11/27/13, showed the resident scored a 13, which indicated a high risk for falls. Review of the significant change MDS, dated [DATE], showed the following: -BIMS score, 4 (severe impairment); -Rejection of care one to three days of seven days; -Required one person physical assistance with transfers, walking in room, and toileting; -One fall with minor injury and one fall with major injury; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 1/20/14, showed the resident was at low risk for falls and included the following staff approaches: -Educate on safety awareness as needed; -Ambulate about the facility independently; -Remind to use handrail in hallways if needed and use grab bars near shower or toilet when transferring; -Make sure bed is in a low, locked position at all times. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -An order, dated 11/27/13, for aspirin (blood thinner) 81 milligrams (mg) daily; -An order, dated 4/4/14, to discharge the resident from skilled physical therapy and place on a restorative nursing program for ambulation up to five times per week. Review of the restorative therapy assessment, dated 4/4/14, showed the following: -Confusion and decreased safety awareness; -Assistance needed for path negotiation; -Stand-by assistance needed for transfers. Review of the resident's nurses' notes, showed the following: -4/5/14 at 10:00 P.M., the resident was up walking around in room. An old bruise on the right eyebrow had been scratched and a small amount of bleeding was noticed. Resident was put to bed. -4/5/14 at 11:30 P.M., Nurse D called Physician Y about the resident's eyebrow. The physician said since the resident did not fall, he/she did not need neurological checks. The physician told the nurse to watch the area. -4/5/14 at 11:40 P.M., Nurse D called Physician Z (the resident's designated primary physician). -4/5/14 at 11:50 P.M., Nurse E told Physician Z about the open area to the resident's right eye, large hematoma with bruising all around right eye. The physician ordered the resident to the hospital. -4/5/14 at 11:55 P.M., Nurse E noted the resident rested at the nurses' station and was alert. The resident's vital signs were: blood pressure 166/86 (normal range, 90/60 to 120/80), pulse 68 (normal range, 60 to 100), respirations 16 (normal range, 12 to 18), and temperature 98.8 degrees Fahrenheit (F, normal range, 97.8 to 99.1 degrees F). During an interview on 5/7/14 at 2:15 P.M., CNA F said most of the resident's falls occurred once he/she was in bed and then he/she would get up and walk on his/her own. Nurse D put the resident to bed on 4/5/14 between 8:00 and 9:00 P.M. The CNA was in another resident's room when he/she heard a scream from the resident's room. The CNA went to the resident's room to see if anyone needed assistance. The CNA did not know who screamed (staff or resident). The resident and Nurse D were by the resident's bed. The nurse said the resident scratched him/herself. The CNA thought the resident fell . The resident and his/her roommate were unable to tell what happened. The CNA saw blood on the bathroom floor and the raised toilet seat looked knocked over. The CNA said he/she usually stayed in the bathroom with the resident when he/she used the toilet. No one in management asked the CNA about the circumstances of the resident's injury. During an interview on 5/6/14 at 9:15 A.M., Nurse D said the resident and his/her roommate both get up at night, and the nurse entered the room to check on them on 4/5/14. Nurse D said he/she took the resident to the bathroom (adjacent to the bedroom) and then went into the bedroom to straighten the resident's bed. The nurse did not see any injuries on the resident when the nurse brought the resident to the bathroom. The resident stood up on his/her own from the toilet. A CNA came into the room and they saw the resident had a scratch on his/her eye. The nurse knew the resident did not fall because he/she was in the bedroom and did not hear any yells, screams, thuds or other loud noises. There was no bruising or swelling on the resident's eye. The nurse saw no blood on the door frame or sink. The nurse put a dry dressing on the area, and another nurse said later that the area looked like it needed stitches. During an interview on 5/2/14 at 10:55 A.M., Nurse E (night shift) said the resident was confused and fell often. Staff checked on the resident frequently. The nurse thought the resident could get up on his/her own if he/she fell . When the nurse arrived for night shift on 4/5/14, the resident sat by the nurses' station with steri-strips and a dry dressing. Nurse D did not know what happened and said the resident had a scratch. Nurse E called the physician and wanted the resident sent out due to the large hematoma over his/her eye. Nurse E did not know if staff had already called the physician or if they had started neurological checks. Nurse E knew he/she wanted the resident sent to the hospital. The nurse said in his/her opinion, staff should have sent the resident to the hospital sooner. The nurse said the Director of Nurses (DON) never talked to him/her about the incident. Review of the resident's hospital record, dated 4/6/14, showed night shift staff found the resident in a wheelchair with a bandage on his/her right eyebrow, and evening shift staff did not know what happened to the resident. The resident complained of right hip pain. The resident's baseline cognition was alert and oriented times one (to self). The resident was confused and could not provide any information. The resident had a right periorbital contusion (bruising around the eye) and a 2 centimeter (cm) laceration to the right eyebrow, which hospital staff closed with six sutures. Further review of the nurses' notes, showed the following: -4/6/14 (time not documented), the resident returned from the hospital with six stitches and a dry dressing covering the right eye. -On 4/6/14 at 10:00 A.M., the resident's bruising and swelling continued with the right eye almost swollen shut. Review of the facility's investigation of the resident's 4/5/14 injury, showed the resident was found ambulating in room with blood to the eye and eyebrow. The DON noted blood on the bathroom door frame and sink base. The injury was unwitnessed and the resident stated he/

Based on record review and interview, facility staff failed to obtain orders for PT/INR lab testing for one resident (Resident #8) which resulted in the resident being hospitalized with a critical condition and guarded prognosis, and for one additional resident (Residents #20) on anticoagulant therapy, failed to obtain a PT/INR lab as ordered by the physician for two residents (Residents #6 and #19) on anticoagulant therapy, failed to obtain a STAT (immediate) PT/INR lab within acceptable time frames for one resident (Resident #19) on anticoagulant therapy, and failed to obtain a lab test for one resident (Resident #14). Facility staff documented administering [MEDICATION NAME] (an anticoagulant medication-interferes with blood clotting) on one date when the order was to hold the medication for one resident (Resident #19). (PT/INR are [MEDICATION NAME] time and International normalized ratio which are laboratory tests that help to show the ability of a person's blood to clot.) 1. Review of the Drug Information Handbook for Nursing, 2007, 8th edition, showed the following information regarding [MEDICATION NAME]: - [MEDICATION NAME] is a high alert medication and has a heightened risk of causing significant patient harm when used in error. - Hemorrhage is the most significant risk, and bleeding, accidents, or falls must be reported by patients. - The elderly may be more sensitive to anticoagulant therapy. - Laboratory testing (PT/INR) must be monitored closely. - Monitor patient frequently for adverse reactions (including bleeding from any site). - A risk of bleeding complications has been associated with increased age. 2. Review of Resident #8's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/7/13, showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - Required extensive assistance of one staff member with bed mobility, transfers, toileting, personal hygiene, and bathing; - Required limited assistance with dressing; - Used a wheelchair; - Had an ostomy; - Had a [MEDICAL CONDITION]; - Had dementia; - Had anxiety disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION]; - Did not receive an anticoagulant during the last seven days. Review of the resident's corresponding plan of care, dated 11/7/13, showed staff did not plan care for the use of an anticoagulant. Review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME] 5 milligrams (mg) at bedtime daily for a [DIAGNOSES REDACTED]. Review of the resident's nurse's notes showed the resident was hosptalized on [DATE] and returned to the facility on [DATE]. Review of the resident's POS, dated 12/31/13, showed the physician ordered to continue [MEDICATION NAME] 5 mg at bedtime daily. Review showed the POS did not contain orders for PT/INR laboratory monitoring. Review of the resident's nurse's notes, dated 1/27/14, showed staff documented the resident had a small amount of blood in his/her [MEDICAL CONDITION] bag. Review showed staff did not notify the physician of the blood in the resident's [MEDICAL CONDITION] bag on that date. Review of the resident's nurse's notes, dated 1/31/14 at 6:30 P.M., showed staff documented a CNA called the nurse into the resident's room. The CNA said he/she was attempting perineal care on the resident and noted blood in the [MEDICAL CONDITION] bag. Staff documented the resident had dark red blood in the [MEDICAL CONDITION] bag mixed with feces and the resident had dark red blood "dried up" in the resident's mouth. Staff documented they notified the physician at 6:34 P.M. and obtained an order to send the resident to the emergency room . Review of the resident's hospital History and Physical (H&P), dated 2/1/14, showed: - The resident was admitted to the hospital on [DATE] with a severe [MEDICAL CONDITION] and acute blood loss [MEDICAL CONDITION] with ongoing loss. - The resident was on [MEDICATION NAME]. - The resident's INR was greater than 10. - Hematocrit (the measure of packed red cells in relation to the total blood volume) was 32.4 (normal range 36.0-48.0). - The resident continues to have maroon blood in the ostomy. - The resident received anticoagulation reversal. - Condition critical, prognosis guarded. Review of the resident's facility nurse's notes, dated 2/4/14, showed the resident returned to the facility. During an interview on 2/12/14 at 12:35 P.M., the Director of Nursing (DON) said there were no orders for PT/INR when the resident returned from the hospital on [DATE]. The DON said normally the physician orders [REDACTED]. The DON said once the PT/INR is in a therapeutic range, the physician will order monthly PT/INRs. The DON said she did not expect staff to notify the physician of a small amount of blood in the [MEDICAL CONDITION] bag as noted in the resident's nurse's notes on 1/27/14 because it was a "small amount." During an interview on 2/12/14 at 6:35 P.M., the resident's physician/facility Medical Director said staff did not notify him when the resident returned to the facility on [DATE] without any orders for PT/INR laboratory testing. The MD said he would have ordered PT/INR testing within three days to one week after the resident returned to the facility. 3. Review of Resident #6's most recent MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance to complete his/her activities of daily living; -Received an anticoagulant medication during the last seven days. Review of the resident's care plan, dated 08/06/13, showed staff planned care to address the resident's potential for injury due to being on anticoagulant therapy. The plan directed staff to: -Observe the resident's skin daily when assisting with care and report any bruising to the resident's skin to the charge nurse if noted; -Observe for any signs of bleeding; -Administer the resident's medications as ordered; -Monitor the resident's lab reports and notify his/her physician promptly of any abnormal results. Review of the resident's physician's orders [REDACTED]. Review of the footnotes for the resident's PT/INR laboratory reports showed for standard anticoagulant, a range of 2.0-3.0 INR and for aggressive anticoagulant, a range of 2.5-3.5 INR. Review of a laboratory report for a PT/INR collected on 11/05/13 showed a PT of 14.7 (high) and an INR of 1.4 (high). A physician's orders [REDACTED]. Review of the laboratory section of the resident's medical record showed no further PT/INR labwork completed until 12/03/13 (four weeks after the resident's [MEDICATION NAME] dose was increased and staff received the order to repeat the PT/INR in two weeks). During an interview on 02/13/14 at 10:09 A.M., the DON said the resident refused a laboratory draw on 11/14/13. The DON said the next labwork that was drawn for the resident was on 12/03/13. Review of the laboratory requisition for labwork that was to be drawn for the resident on 11/14/13 showed the labwork scheduled to be completed on 11/14/13 was a [MEDICATION NAME] and CMP (comprehensive metabolic panel). The requisition did not show that a PT/INR was scheduled to be completed on that date. Review of the PT/INR results for 12/03/13 showed a PT of 89.0 (high) and an INR of 7.8 (critically high). physician's orders [REDACTED]. (for blood clotting). 4. Record review of Resident #19's MDS, dated [DATE], showed staff assessed the resident as: - Brief Interview for Mental Status (BIMS) score of 2 (severely impaired cognitive impairment); - [MEDICAL CONDITION] [MEDICAL CONDITION] (TIA), or Stroke; - Not receiving anticoagulants. Review of the resident's most recent care plan showed: - No interventions or guidance to staff regarding the resident's anticoagulant therapy. Review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME] 8 mg (milligrams) daily except Wednesdays for a [DIAGNOSES REDACTED]. - Repeat PT/INR in one month (1/14/14). Review of the resident's January 2014 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's lab reports showed: - No PT/INR listed in the lab report for 1/14/14; - No PT/INR lab results on any date between 12/17/13 and 2/3/14. Review of the resident's nurse's notes showed: - On 2/2/14 at 2:00 P.M. staff documented the resident had a slight nose bleed, the resident's physician was contacted and the physician ordered a STAT PT/INR. Review of the laboratory sheet documenting the PT/INR showed the lab was drawn on 02/03/14 at 04:22 (AM) (this was 14 hours and 22 minutes after the order was received). Review of the laboratory results showed on 02/03/14 at 12:03 P.M. EST (Eastern Standard time) the results showed PT of 37.7 and INR of 3.4. Review of the laboratory's Critical Lab Values showed an INR of greater than 4.0 is considered critical. Review of the nurse's notes dated 02/03/14 showed staff documented the results were called to the physician at 4:00 P.M. (This would be approximately five hours after the time of the lab results.) New orders were received to hold the [MEDICATION NAME] for two days and then change the dosage to [MEDICATION NAME] 6 mg daily. The DON provided a "STAT Eligible List" for the laboratory used by the facility which showed the laboratory guidelines included: "STAT service requests shall be handled in five (5) hours or less from the time the request is received." PT was listed as a STAT eligible laboratory test. During an interview on 2/13/14 at 8:40 A.M., the DON said she expected staff to get a STAT lab order to the lab within 1/2 hour. She said staff would call the the STAT lab in or order it online and since 02/02/14 was a Sunday it would have gone to an answering service. She said the lab requisition was marked as STAT and she would check with the laboratory representative to see if there may have been a lab error since the order was received from the physician at 2:00 PM on 02/02/14 but not drawn until 4:22 A.M. 02/03/14. During an interview on 02/13/14 at 9:45 A.M. the DON said she did not find a PT/INR for the resident as ordered for 01/14/14 and she did not know why the lab was not drawn since a [MEDICATION NAME] level was drawn on that date. The DON said the STAT PT/INR was called to the lab and staff only call if it is a STAT or other special circumstance. She said there was not a way for facility staff to know lab staff did not come within the 5 hour time frame since there may have been a different nurse at shift change. During an interview on 02/21/14 at 9:00 A.M., the DON said the requisition for the STAT PT/INR lab was faxed to the laboratory by facility staff (not called) so no one at the lab was aware of it right away. She said staff now call STAT lab orders to the laboratory. She said staff would call critical lab results to the physician immediately, but there was no specific timeframe for labs that were not critical to be called to the physician. She said staff do not check the fax machine constantly and it may take a while to see there is a lab result. The DON checked the facility fax machine at 9:12 A.M. and said the time on the machine showed 12 P.M. During an interview on 02/21/14 at 9:40 A.M., the DON said when the staff member put in his/her initials and the administered code for Wednesday 01/01/14 for the [MEDICATION NAME] which directed staff to Hold [MEDICATION NAME] on Wednesdays (in the electronic record) it may have meant he/she did not give it, and it was not possible to determine for sure since the nurse no longer worked at the facility and the medication card would no longer be available. 5. Review of the nurse's notes for Resident #14 in the resident's closed record showed he/she was admitted to the facility on [DATE] for end of life care. Review of the POS [REDACTED]. Review of the Medication Status as of 01/14/2014 showed a list of medications for the resident and labs including an A1C (HgbA1C or hemoglobin A1C is a test to determine how well diabetes is controlled over a period of time). Review of the lab requisition form dated 01/16/14 showed the HgbA1C was not checked as a lab to be drawn on that date. Review of the resident's lab reports for 01/16/14 showed a HgbA1C was not included in the report. During an interview on 02/13/14 at 3:10 P.M. the DON said staff did not include HgbA1C on the lab requisition so it was not drawn with the other labs. 6. Record review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Brief Interview for Mental Status (BIMS) score of 8 (moderately impaired cognitive impairment); -Activities of Daily Living (ADL): supervision and one person physical assistance for transfers, walking in the room, walking in the corridor, locomotion on/off unit, and toilet use; -Functional Limitation in Range of Motion: upper and lower extremity-impairment on one side; -Cane/crutch; -[MEDICAL CONDITION] [MEDICAL CONDITION] (TIA), or stroke; -[MEDICAL CONDITION] or [MEDICAL CONDITION]; -No anticoagulants. Record review of the resident's Portable X-Ray/Patient Report, dated 01/30/14, showed: -Fall, pain, limited (ROM) range of motion; -Left hip and knee views; -Fracture identified involving the left femoral neck. Record review of the resident's hospital H & P Notes (continued) showed a [MEDICATION NAME]-INR collection and result: -01/30/14 at 4:35 P.M. -PT 13.8 (Range 12.1-14.8 seconds), INR 1.1 Record review of the resident's Hospital Discharge Summary, dated 01/30/14 admission, showed the following nursing facility instructions: -Treating right lower extremity [MEDICAL CONDITIONS]. Currently bridging [MEDICATION NAME] with [MEDICATION NAME]. -Continue [MEDICATION NAME] 80 mg every 12 hours until INR is therapeutic (2-3) on [MEDICATION NAME] for 2 days. After which may discontinue [MEDICATION NAME] and to remain on [MEDICATION NAME]. -Please obtain INR every 3 days and titrate [MEDICATION NAME] for INR of 2-3. -Weight bearing as tolerated, bilateral lower extremities. -Regular diet. -Physical therapy. Record review of the resident's nurse's notes, dated 02/06/14 at 7:17 P.M., showed the resident arrived per ambulance. Record review of the resident's POS, dated 02/01/14 to 02/28/14, showed: -Order date (02/06/14): Aspirin 81 mg chewable tablet-chew and swallow one tablet by mouth daily (left [MEDICAL CONDITION]); -Order date (02/06/14): [MEDICATION NAME] sodium ([MEDICATION NAME]) 6 mg tablet-one tablet by mouth at bedtime (left [MEDICAL CONDITION]); -Order date (02/06/14): [MEDICATION NAME] sodium ([MEDICATION NAME])-inject 1 ml (100 mg) subcutaneous twice daily for 14 days (left [MEDICAL CONDITION]); -No orders for PT/INR. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME] sodium administered on: 02/07, 02/08, 02/09, 02/10, 02/11, 02/12; -[MEDICATION NAME] sodium administered on: 02/06, 02/07, 02/08, 02/09, 02/10, 02/11. During an interview on 02/12/14 at 5:30 P.M., Registered Nurse (RN) N said the resident did not have physician's orders [REDACTED]. Record review of the resident's POS showed a telephone order (T. O.) dated 02/12/14 at 5:39 P.M.: order Stat PT/INR and a PT/INR to be drawn in five days (02/17/14) and PT/INR monthly on the first Thursday of the month. Record review of the resident's Specimen Collected Report dated 02/12/14 at 19:50 (7:50 P.M.) showed (coagulation) PT 25.7 (high-normal range 9.5-11.8 seconds) INR 2.3 (high-normal range 0.9-1.1). Footnotes: standard anticoagulant: 2.0-3.0 INR and aggressive anticoagulant: 2.5-3.5 INR.

Based on observation, interview and record review, the facility staff failed to follow their "Wound Care Policy and Procedures" and implement preventative measures to prevent the development and healing of pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) and/or have failed to consistently provide proper care and services to prevent residents at high risk from a reoccurrence of pressure ulcers by staff's failure to reposition residents in a timely manner when sitting in their wheelchairs; use of a wedge cushion to keep a resident off his/her back when in bed; and failed to develop and update care plans for the management of pressure ulcers for four residents (Residents #2, #3, #8, and #11) and for one closed record review (Resident #14) of 15 sampled residents. The facility census was 70 residents. Record review of the February 2009 - Pressure Ulcer Prevention and Treatment Quick Reference Guide developed by the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP), pages 7-8, showed the following definitions of a pressure ulcer and the stages of pressure ulcers: International NPUAP-EPUAP Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. "We have agreed upon four levels of injury. Recognizing that the terms, unclassified/unstageable and deep tissue injury are generally graded as " IV " in Europe, NPUAP has agreed to put them separately in the text in the guideline. This difference will remain an issue when comparing cross-country data. Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. . Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate " at risk " persons. Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/ Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover " and should not be removed. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." 1. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/11/11, showed staff assessed the resident as the following: -Severely impaired in cognitive skills for daily decision making; -Totally dependent on two plus staff for bed mobility and transfers from chair to bed etc.; -Did not ambulate; -Totally dependent on staff for nutrition; -Always incontinent of bowel and bladder; -Weight loss due to physician-prescribed weight loss regimen; -At risk for pressure ulcers; -One Stage II pressure ulcer (- Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.); -Date of oldest Stage II pressure ulcer, 01/03/2011; -Pressure reducing devices for bed and chair; and -Turning and repositioning program. Review of the resident's physician's orders [REDACTED].: -Pureed diet with nectar thick liquids; -[DEVICE] (a tube surgically implanted into the stomach) care each day; -FSHN (a liquid meal substitute usually given through a [DEVICE]) continuously at 60 ml/hr from 8:00 P.M. to 6:00 A.M.; -Use wedge to offload pressure; -Cleanse coccyx wound with 0.125 Dakins solution, apply Santyl ([MEDICATION NAME] agent) and [MEDICATION NAME] (antibiotic) ointment, pack with gauze, apply skin prep around the wound, then cover with transparent dressing twice daily and as needed; -Up in wheelchair for meals only for less than one hour; and -[MEDICATION NAME] liquid 500 mg per [DEVICE] three times a day for 10 days for wound infection. Review of the resident's plan of care dated 8/18/11 with a review date of 11/18/11 (no signatures), showed staff assessed the resident with a Stage III pressure ulcer (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.) Further review of the plan of care included the following interventions: -Anti-pressure device on bed; -Anti-pressure device on chair; and -Reposition every two hours. Review of the resident's plan of care dated 3/10/11, 6/10/11, 9/10/11, and 12/10/11 (no signatures) showed staff assessed the resident with difficulty making decisions, unable to provide own activities of daily living. Review of the resident's Weekly Skin Assessment, dated 8/15/11, showed staff assessed the resident's skin was intact. Review of the resident's Nutrition Progress Note, dated 8/17/11, showed the resident did not have any pressure ulcers. Review of the resident's Skin Alteration Charting Sheet showed staff documented on 8/18/11 the resident had a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) on his/her coccyx. The coccyx Stage II pressure ulcer measured 3.0 cm X 0.8 cm and was 0.2 cm in depth. Staff documented treatment included the following: -A therapeutic mattress; -Wheelchair cushion; -Occupational therapy screen for a positioning device; and -Turn and reposition every two hours. Review of the resident's Weekly Skin Assessment, dated 8/22/11 showed the resident with a Stage II pressure ulcer on his/her coccyx. Review of the resident's Skin Alteration Charting Sheet showed staff documented on 8/25/11 the resident's Stage II coccyx pressure ulcer measured 4.6 cm X 1.8 cm and was 0.2 cm in depth. Staff documented treatment included the following: -A therapeutic mattress; -Wheelchair cushion; -Occupational therapy screen for a positioning device; and -Turn and reposition every two hours. Review of the resident's Plan of Treatment, electronically signed by the Occupational Therapist (OT) on 9/1/11, and signed by the physician on 9/7/11, showed OT assessed the resident for positioning deficits that included "sacral (coccyx) sitting" that resulted in a Stage II pressure ulcer to the posterior thigh. The OT assessed the resident with the following: -[DEVICE]; -Pureed diet with nectar thickened liquids; -Stage II pressure ulcer -Dependent for repositioning; -Dependent for all activities of daily living (ADLs); -Dependent for transfers to and from bed or chair; -Dependent for mobility; -Above the knee amputations to both legs; -Currently seated in a tilt/recline geri chair; and -With deficits in strength and mobility influencing skin integrity and ability to reposition self while seated. OT documented the resident continues to remain at risk and skilled therapy is required to improve positioning for decreased risk of pressure ulcers.... The OT further documented the "Caregiver demonstrates 0% compliance with positioning strategies due to lack of training and new w/c (wheelchair) not delivered yet." The resident exhibits skin breakdown and hips sliding forward in chair while on geri chair for six hours. Review of the resident's Skin Alteration Charting Sheet showed staff documented on 9/2/11 the resident's Stage III coccyx pressure ulcer measured 6.0 cm X 2.0 cm and was 0.2 cm in depth. Staff documented treatment included the following: -A therapeutic mattress; -Wheelchair cushion; -Occupational therapy screen for a positioning device; and -Turn and reposition every two hours. Review of the resident's Skin Alteration Charting Sheet showed staff documented on 9/6/11 to "see SWM (Specialized Wound Management) progress notes." Review of the resident's Specialized Wound Care Management (SWM) Nurse Practitioner's (NP) notes, dated 9/6/11, showed the NP documented the resident's coccyx pressure ulcer opened on 8/18/11. The resident had an above the knee [MEDICAL CONDITION] to both legs and had a Stage III pressure ulcer to his/her coccyx. The wound measured 5.1 cm X 0.9 cm with a depth of 0.3 cm. The wound bed was pink with a scant amount of sero-sanguinous (consisting of serum and blood). The NP's plan of care for the coccyx pressure ulcer included the following interventions: -Offload pressure; -Reposition resident every two hours and as needed; and -Toilet every two hours for incontinence. The NP further documented pressure ulcer care pressure relief treatment positioning reviewed with the resident and the resident's nurse. Short term goals were listed as follows: -Implement pressure redistribution strategies; -Promote healing; -Prevent complications; -Heal the pressure ulcer. Review of the resident's Occupational Therapy Progress Report dated 9/1/11 - 9/7/11 and electronically signed by the OT on 9/7/11 showed the OT documented the resident was seen only for initial evaluation at this time, waiting for a new tilt-in-space wheelchair to be ordered and delivered. The resident continues to require skilled treatment for [REDACTED]. Review of the resident's Weekly Skin Assessment, dated 9/18/11, showed the resident with a Stage III pressure ulcer to his/her coccyx. Review of the resident's Specialized Wound Care Management (SWM) Nurse Practitioner's (NP) notes, dated 10/4/11, showed the NP assessed the resident with a Stage III pressure ulcer on his/her coccyx. The wound measured 1.0 cm X 0.4 cm and was 0.2 in depth. The wound bed was pink with scant sero-sanguinous (serum and blood) drainage. The resident had a low air loss mattress. The NP planned care that included the following: -Offload pressure; -Reposition every two hours and as needed; and -Toilet every two hours for incontinence. The NP further documented pressure ulcer care pressure relief treatment positioning reviewed with resident and resident's nurse. Review of the Specialized Wound Care Management (SWM) Nurse Practitioner's (NP) notes, dated 11/15/11, showed the NP included in the plan of care for a Stage III pressure ulcer on the resident's coccyx as follows: -A new wheelchair cushion has been ordered; -Recommend not to use the resident's chair until the cushion is available; -Use of wedge for offloading; -Turn and reposition every two hours; and -Toilet every two hours for urinary and fecal incontinence. The NP further documented pressure ulcer care and pressure relief treatment positioning reviewed with resident and resident's nurse. Review of the Specialized Wound Care Management (SWM)Nurse Practitioner's (NP) notes, dated 11/29/11, showed the NP documented the resident's coccyx pressure ulcer was being treated with Santyl. The pressure ulcer's healing was complicated by immobility and incontinence. A new wheelchair cushion was ordered, but had not yet arrived. The resident had a pressure relieving mattress and wedge for positioning. The NP documented the pressure ulcer assessment as follows: -Coccyx pressure ulcer measured 2.0 cm X 1.1 cm with a depth of 0.2 cm; -Wound bed was pink with a thin yellow necrosis (dead tissue); and -Drainage was scant, sero-sanguinous (consisting of serum and blood). Further review showed the NP's care plan, dated 11/29/11, included the following interventions: -Limit time in wheelchair until new cushion is available; -Turn and reposition every two hours; and -Toilet every two hours for urinary and fecal incontinence. Plan of care reviewed with resident and resident's nurse. Review of the Specialized Wound Care Management (SWM)Nurse Practitioner's (NP) notes, dated 12/16/11, showed the NP documented "A new wheelchair cushion has been ordered but according to the DON (Director of Nursing), the family has refused to purchase it." The NP further documented the resident with a Stage III pressure ulcer that measured 5.0 cm X 3.0 cm with a depth of 03. cm. The wound bed was a pink tissue granulation with thin yellow necrosis multiple scattered ares and a scant amount of yellow drainage. Review of the Specialized Wound Care Management (SWM)Nurse Practitioner's (NP) notes, dated 1/10/2012 showed the NP documented information that included the following information: -Resident is [AGE] years old; -Coccyx pressure ulcer is currently being treated with Santyl but continues to decline; and -Healing is complicated by immobility and incontinence. Further review showed the NP documented an assessment that showed the following: -Coccyx pressure ulcer measured 2.5 cm x 2/3 cm with a depth that was unable to be determined due to the wound bed was not visible; -Wound bed was covered with yellow and grey necrosis (dead tissue); and -Pressure ulcer had a moderate, yellow and tan colored drainage with no odor. The NP further noted he/she performed selective debridement and removed necrotic and devitalized tissue, to promote healing. "WOUND STATUS: Declined, wound culture collected." The NP documented under CARE PLAN: Wound care pressure relief treatment positioning reviewed with resident and resident's nurse. During an interview on 1/16/12 at 4:20 P.M., Licensed Practical Nurse (LPN) I said the resident had a Stage II or III pressure ulcer on his/her coccyx. LPN I said he/she was unsure when he/she last saw the pressure ulcer, but he/she did see it occasionally. He/She said the treatment nurse RN A usually did the treatment five days a week, but the resident was incontinent of bowel and the dressing was frequently changed because of soiling. LPN I said the pressure ulcer did not look good the last time he/she saw it. Observation on 1/17/12 at 6:37 A.M. showed the resident lay in bed on his/her back with the head of the bed up at a 30 degree angle. The resident did not have a wedge cushion under his/her back to offload the pressure from his/her coccyx. At 6:55 A.M. the resident continued to lay on his/her back without a wedge in place to offload the pressure from his/her coccyx. At 9:10 A.M. the resident continued to lay in the same position without a wedge in place to offload the pressure from his/her coccyx. Staff rolled the resident to his/her right side. The NP arrived and assessed the resident's coccyx pressure ulcer. The NP measured the wound as 4 cm X 3 cm. She said the depth of the pressure ulcer could not be determined because too much of the wound bed was covered with necrotic material, but it was 2+ cm deep. The pressure ulcer was open directly over the resident's coccyx. RN A, treatment nurse completed the dressing change. He/She placed a 2 inch X 2 inch gauze, with ointments on the gauze, loosely inside the wound and covered it with a 4 X 4 gauze and transparent dressing. During an interview on 1/17/12 at 9:25 A.M. Certified Nurses Aides (CNA) J and CNA K said they usually get the resident up for breakfast, but left him/her in bed this morning for the NP to see his/her pressure ulcer. The CNAs said they usually leave the resident up for about 20 minutes and then lay her back down, because he/she needs to be off of his/her buttocks. The CNAs said the resident gets up for each meal. Observation on 1/17/12 at 11:20 A.M. the resident sat up in a geri chair in the dining room in front of the TV. A Hoyer lift sling (the sling used with a mechanical lift to transfer non-weight bearing persons) was under the resident and the chair did not contain a pressure relieving cushion. At 12:10 P.M. the resident continued to sit up in the geri chair without a cushion. At 12:41 P.M. the resident still in the geri chair, sat at the dining room table. At 12:55 P.M. the resident received her meal tray. At 1:25 P.M. the resident remained in the geri chair without a pressure relieving device, at the dining room table. CNA J assisted him/her with his/her pureed meal. At 2:10 P.M. CNA J and LPN C assisted the resident into bed with the use of the Hoyer lift. The resident sat up in the geri chair without a pressure relieving device for at least two hours and 50 minutes before staff repositioned and assisted the resident back to bed. Observation on 1/18/12 at 8:35 A.M. showed the resident sat up in his/her geri chair in the dining room. Staff assisted the resident with his/her pureed meal. At 10:05 A.M. the resident continued to sit in his/her geri chair in the dining room in front of the TV. At 10:47 the resident continued to sit in his/her geri chair in the dining room in front of the TV. At 11:15 A.M. the resident remained in the dining room in his/her geri chair. At 12:10 P.M. the resident continued to sit in his/her geri chair at the dining room table and at 12:40 P.M. the resident remained in that position. Observation on 1/19/12 at 1:00 P.M. showed the resident sat in his/her geri chair in the dining room with a pureed diet. At 2:05 P.M. the resident continued to sit up in the geri chair in the dining room in front of the TV. At 2:15 P.M. staff wheeled the resident to the nurses station in his/her geri chair. At 2:17 P.M. LPN C wheeled the resident to his/her room. At 2:20 P.M. LPN C prepared medications at the medication cart in the hall outside the resident's room and then administered the medications to the resident via the [DEVICE]. The resident remained in his/her geri chair. At 3:15 P.M. the resident lay on his/her back in bed with the head of the bead up at 30 degrees. The resident did not have a wedge in place to offload the pressure on his/her coccyx. During an interview on 1/19/12 at 9:30 A.M. the consultant registered and licensed dietician (RD/LD) said he/she reviewed the nutritional needs for the residents who received tube feeding and/or had wounds such as pressure ulcers on a monthly basis when she visited the facility. The RD/LD said she there was an oversight in December 2011 and she did not come to the facility. She said the most recent weight she had for any of the residents was from October 2011, because when she visited the facility in November 2011 the weights for November had not been completed. She said it was very difficult to provide a good assessment for a resident who receives a tube feeding without current weights and labs. During an interview on 1/19/12 at 3:55 P.M. RN A, treatment nurse, said staff placed an air mattress on the resident's bed on 1/18/12. He/She said the air mattress was on another resident's bed, but that resident went to the hospital and was not expected to return. The RN said at one time the resident had a cushion in his/her chair, but it caused him/her to slide forward so it was taken out of the chair and had not been used for some time. RN A said the resident likes to sit up and watch TV so sometimes he/she sits up until after lunch. He/She said the resident had a wedge cushion to offload the pressure on the resident's coccyx. The RN said he/she expects staff to lay the resident down within one hour of getting him/her up as the physician orders [REDACTED]. Observation on 1/19/12 at 4:00 P.M. with RN A showed the resident lay on his/her back in the bed with the head of the bed up at 30 degrees. The resident did not have a wedge in place to relieve the pressure on his/her coccyx. A wedge cushion lay in the floor at the head of the bed. 2. Record review of Resident #8's quarterly Minimum Data Set (MDS) with assessment reference date 11/07/11 showed that the resident: - Reentered the facility on 06/28/2010; - Had severe cognitive impairment; - Did not walk; - Used wheelchair for mobility; - Was totally dependent on staff to transfer, toilet, dress and bathe; - Was at risk for pressure ulcer development; - Frequently incontinent of bowel and bladder; - Did not have an indwelling Foley catheter (tube that drains urine from the bladder); - Was currently without pressure ulcers; - Had two arterial ulcers (sores caused by lack of blood flow to the skin); - Used pressure reducing device on chair and bed; - Was on a turning/repositioning program; - Received ulcer care. Record review of Resident #8's Pressure Ulcer Risk assessment dated [DATE] showed he/she was at high risk for pressure ulcer development. Record review of Resident #8's Specialized Wound Management documentation dated 10/25/11 showed the resident was being treated for [REDACTED]. Record review of Resident #8's Specialized Wound Management documentation dated 11/01/11 showed the resident being treated for [REDACTED]. "The right thigh ulcer healed last week." The resident currently has a Foley for wound healing. Record review of Resident #8's Specialized Wound Management documentation dated 01/10/2012 showed the resident had a Stage III left heel pressure ulcer. Record review of Resident #8's unsigned care plan last dated 11/07/11 showed: - At risk for skin breakdown; - No mention of any type of ulcer (arterial or pressure); - Turn and reposition at least every two hours; - Urinary catheter not documented on the care plan. Observation of Resident #8 on 01/17/12 at 6:35 A.M. showed he/she sat in his/her wheelchair. Observation of Resident #8 on 01/17/12 at 8:00 A.M. showed he/she sat in his/her wheelchair in the dining room eating breakfast. Observation of Resident #8 on 01/17/12 at 8:50 A.M. showed the resident sat in his/her wheelchair at the nursing station. Observation of of Resident #8's wound treatment on 01/17/12 at 9:20 A.M. by NP Specialized Wound Management showed a Stage III ulcer measuring 1.5 cm x 1.2 cm x 0.2 cm on left heel. During an interview at the same time the NP said it was a pressure ulcer, not an arterial ulcer. He/she further said that almost all ulcers to the heels are caused by pressure. The NP was not aware of any current ulcers on the right and left thighs though he/she said he/she knew the resident did have pressure ulcers in these locations in the past. He/she said they tend to heal and then reopen. The resident remained up in the wheelchair throughout the treatment. Observation of Resident #8 on 01/17/12 at 11:30 A.M. sitting asleep in his/her wheelchair in the activity room. Observation on 01/17/12 at 12:45 P.M. showed Resident #8 sat in his/her wheelchair in the dining room eating his/her noon meal. The resident had sat up in the wheelchair without repositioning for six hours and 10 minutes. Observation of Resident #8 on 01/17/12 at 2:15 P.M. showed resident lying in bed. RN A was observed changing the dressing to the left medial thigh. During an interview at that time, RN A said it looked like the ulcers were now healed but they would continue to apply a dressing to prevent further breakdown. The left and medial thighs showed scarring from past ulcers. RN A said the resident had sat up in the wheelchair all morning and that he/she usually lays down in the afternoon. During an interview with Resident #8's physician on 01/18/12 at 12:40 P.M., he said that he/she classified the resident's heel ulcer as ischemic (arterial) rather than pressure even though the NP was documenting it as pressure. 3. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, dated 11/01/11, showed staff assessed the resident as: - Short and long term memory problems; - Severely impaired cognitive skills for daily decision making; - Total dependence for toileting, bed and wheelchair mobility, transfer, dressing and personal hygiene and eating; -Incontinent of bowel with a urinary catheter; and -Pressure ulcer. Observation on 01/17/12, at 09:00 A.M. of pressure ulcer care by the Specialized Wound Care Management Nurse Practitioner (NP) and RN A showed a .3 cm x 1.2 cm wound to the sacrum, a .7 cm x .3 x .1 cm wound to the left buttock and a 1.8 cm x 2.3 cm x .2 cm wound to the right lateral ankle. Review of the resident's plan of care for pressure ulcers, dated 11/01/11, showed an intervention to turn and position every two hours. Review of the resident's plan of care, dated 11/01/11, for activities of daily living (ADL), showed the resident was fully dependent and required a Hoyer lift (mechanical lift used for non-weight bearing transfers) and two persons assist to transfer. Observation of Resident #2 on 01/16/12, at 3:30 P.M.-5:30 P.M. showed the resident in the wheel chair at the bedside, 6:00 P.M. showed the resident in the dining room for dinner. Observation of Resident #2 on 01/19/12, at 09:00 A.M. showed the resident in the dining room being fed breakfast; 11:30 A.M. in front of the television in dining room, and 1:00-5:00 P.M. showed the resident in front of the television in dining room. Observations of Resident #2 during the week of 01/16/12-01/20/12 showed the facility failed to reposition the resident every two hours. 4. Review of Resident #11's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument dated 11/14/11, showed staff assessed the resident as: - Short and long term memory problems; - Moderately impaired cognitive skills for daily decision making; - Impaired vision; - Total dependence for toileting, bed and wheelchair mobility, transfer, dressing and personal hygiene and eating; - Incontinent of bowel and bladder; - [MEDICAL CONDITION]; - Fall in past 30 days; and -At risk for pressure ulcers. Review of the resident's Pressure Ulcer Assessment forms showed a history of pressure ulcers as follows: -06/13/11, a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to the left hip; -08/09/11, a Stage II pressure ulcer, location not given; and -12/20/11 showed a Stage II pressure ulcer to the left and right inner buttocks. All three forms indicate the resident is to be turned every two hours and as needed. Observation of Resident #11 on 01/17/12, at 06:35 A.M. showed the resident in the wheel chair for A.M. care; 07:10 A.M. transported to the dining room and, 09:00 A.M. in the dining room being fed breakfast. Observation of Resident #11 on 01/19/12, 09:00 A.M. showed the resident in the wheel chair in the dining room being fed breakfast; 10:15 A.M. participating in group activities; 11:30 A.M. in the dining room for lunch at 12:30 P.M.; 2:30- 5:00 P.M. in the dining room. Observation of Resident #11 during the week of 01/16/12-01/20/12 showed the facility failed to reposition the resident every two hours. During an interview on 01/18/12 at 3:00 P.M., the DON said CNAs can get report from the nurses on new patients and have access to the Plan of Care (POC) and medical record at the nurse's station. He/she said if residents' care deviates from normal care information, it will be in the CNA guide book at the nurse's station. Review of the CNA Guide Book showed information on hand washing, pressure ulcer prevention and a list of residents at risk for pressure ulcers dated 11/01/10. Review of the CNA Guide Book's "How to Prevent Pressure Ulcers " showed resident position should be changed every two hours when in bed and every one hour when in a chair. Review of the facility training "Pressure Ulcer Prevention Points" directed bed-bound residents be repositioned every 2 hours and chair-bound residents every hour. 5. Record review of Resident #14's closed medical record of the resident's "Resident Admission Information" sheet showed the resident was admitted to the facility on [DATE] (incorrect date listed which should be 7/16/11 per the resident's "Admission Nursing Assessment" form, admission Nurse's Notes (NN), and other documentation listed). Record review of the resident's "Admission Nursing Assessment" form dated 7/16/11 completed and signed by Licensed Practical Nurse (LPN) B showed the following assessment in part for the resident: - Weight: 183.6 pounds; - Height: 5 feet, 4 inches; - Skin Condition Description: Skin W/D (warm/dry) intact; -- Current Status: - General Skin Condition: Dry and Warm; -- Functional Status: - Transfers-able to transfer: Two Person Assist and Total Assist; - Ambulation-able to ambulate: Wheelchair Only; - Weight bearing-able to bear: Full Weight; - Supportive Devices Used, e.g. abductor pillow, pressure relieving mattress, etc.: Blank; - Communication: Aphasic (Partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain caused by injury or disease); Language(s) spoken: English; - Personal Hygiene/Grooming: Dependent for shower, bed bath, oral hygiene, shave, grooming, dressing, and shampoo; - ADL (Activities of Daily Living) Status: Dependent for bed mobility, UE (Upper Extremity) dressing, LE (Lower Extremity) dressing, and feeding; - Eating/Nutrition: Needs Assist - Type/consistency of diet: Regular NAS (No Added Salt), NSS; - Bowel and Bladder Evaluation: Marked "No" for not continent for bowel and bladder habits; - Psychosocial Aspects: Alert; Cooperative; Friendly; Answers Questions: Readily; Mood: Elated; Oriented: Yes; Resident participated in assessment: No; Family participated in assessment: No Record review of the resident's admission Nurse's Note (NN) dated 7/16/11 at 3:40 A (Note: This should have been P.M.) showed in part the resident arr