Every finding on record at Summit, The

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 6 sampled residents (Resident #4, #5, #6, #7, #14 and #15) out of 15 sampled residents when live bedbugs were observed in their rooms. The facility census was 55 residents. Review of the facility's Bedbug Policy dated 2024 showed:-Staff should report immediately any signs of bedbug infestation to the department head, direct supervisor and/or the administrator.-When bedbugs were discovered in a resident room, if possible, the resident should be showered or bathed, clothes changed and transferred to another room; resident belongings, equipment and furnishings including beds should not leave the room until thorough inspection found them bed bug free; bedclothes should be carefully removed, tightly sealed in bags, directly put into a washer or dryer and dried on the hot setting to kill all the stages of the bed bugs.-If bedbugs were confirmed in personal belongings, the resident should be informed their belongings may be infested.-Potential bed bug access points to adjacent rooms should be sealed by filling gaps that occur where plumbing penetrated common walls and around electrical, cable and phone outlets.-Waiting rooms, visitor lounges, common areas, laundry rooms and equipment such as wheelchairs and food carts should be regularly inspected for bed bugs.-Environmental services should be contacted to clean the room thoroughly. Inspection of resident should be continued periodically, monitoring for side effects.-The pest control company should be contacted if needed.-The Environmental Protection Agency (EPA) recommended the following treatments for removing bed bugs: heat should be used to kill bed bugs by placing items with the infestation in a clothes dryer on high heat or in a sealed, black plastic bag in a hot closed car; items with the infestation should be placed in a sealed bag and put in the freezer at 0 degrees for four days.-A steam cleaner should be used to treat bedding, furniture, carpets and cracks and crevices. Temperature should be set at a minimum of 130 degrees and a diffuser used to prevent the scattering of the bed bugs.-Regular inspections of headboards, bedding, carpet edges, mattresses and box springs should be conducted.-Bedding should be washed and dried on high heat.-Clothing and luggage should be inspected when returning from travel.-A pest management company should be contacted before an outbreak occurred, to assist in prevention and identification, for infestation and treatment. 1. Review of Resident #5's admission Record face sheet showed he/she was admitted to the facility on [DATE]. During an interview on 12/5/25 at 11:30 A.M., Resident #5 said:-He/She did not have any active bites.-He/She swatted some live bugs off him/herself a few days ago.-His/Her room had previously been treated before very nicely.-He/She thought the facility was doing everything they could. 2. Review of Resident #6's admission Record face sheet showed he/she was admitted to the facility on [DATE]. During an interview on 12/8/25 at 11:45 A.M., Resident #6 said:-He/She had previously had bedbugs in his/her room, but they were gone.-He/She did not have any bites. 3. Review of Resident #7's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Observation of Resident #7's room on 12/5/25 at 11:50 A.M. showed the room to be very cluttered with two 40-gallon bags full of trash and many clothing items stacked on the bed. A live bedbug was seen on the room floor, and dead bed bugs were seen in the bathroom clustered around the trashcan. During an interview on 12/5/26 at 11:50 A.M., Resident #7 said:-He/She was allergic to the room spray and did not want his/her room sprayed.-His/Her roommate had his/her mattress replaced three times due to the bedbugs.-He/She had been going through his/her things and throwing things away.-He/She had a bite on his/her right upper arm and left lower leg. During an interview on 12/5/25 at 2:30 P.M., the Social Worker said:-Resident #7's had been informed about the bedbugs and that his/her room needed to be treated. -It was hard to get the resident to understand; he/she was not listening.-They had served the resident a dirty room notice and explained why they had needed to do it. -They were letting the resident sort through his/her things so the room could be treated.-They tried to stay on top of the residents who were hoarders to keep their rooms clean. 4. Review of Resident #4's admission Record face sheet showed he/she was admitted to the facility on [DATE]. During an interview on 12/5/25 at 11:55 A.M., Resident #4 said:-He/She had bedbugs in his/her room.-He/She did not think he/she had any bites.-The room had been treated with spray twice a week. 5. Review of Resident #15's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Observation of Resident #15 on 12/8/25 at 11:05 A.M. showed he/she had bites on his/her back, legs and ankles. During an interview on 12/8/25 at 11:05 A.M., Resident #15 said:-He/She saw two or three live bedbugs in his/her room every day.-He/She had new bites on his/her waist.-He/She had been in the facility a couple weeks.-His/Her room had been sprayed, but had not been heat treated.-He/She told housekeeping about the bedbugs when he/she found them.-He/She changed his/her own bedding every day and bagged it up. 6. Review of Resident #14's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Observation of Resident #14 on 12/8/25 at 11:10 A.M. showed he/she had bites visible on his/her neck and back. During an interview on 12/8/25 at 11:10 A.M., Resident #14 said:-He/She saw live bedbugs in his/her room around 3:00 A.M. that day.-He/She told the nursing staff.-He/She had bites on his/her neck and back.-When he/she was taken to the shower, he/she had two bedbugs in his/her bra. During an interview on 12/8/25 at 11:30 A.M., Licensed Practical Nurse (LPN) A said staff found bedbugs in Resident #14's bra, curtains, bed and floor. 7. During an interview on 12/5/25 at 11:05 A.M., the Maintenance Director said:-Exterminators had been at the facility for roaches and mice, but not for bed bugs.-The previous maintenance supervisor did not stay on top of pest control.-He/She had been exterminating in the facility using spray.-Baseboards would be sprayed. Bed rails and frames should be washed.-The facility had a heat-treating machine, and the process had started to heat treat the rooms to ensure the non-survival of bed bug eggs. -There were 60 rooms in the facility.-He/she would look for any kind of infestation in the folds and creases of material, clothes, fabric furniture linens.-A plain flashlight worked to spots the bugs. They appeared as speckles in potential nesting places. Larva and young bed bugs were transparent.-If residents found bed bugs, they should notify the nursing staff, and the nursing staff would notify him/her.-Curtains and bedding would be placed in water soluble bags and go to the laundry. -He/She had previously used smaller heat-treating machines at other facilities made by the same company.-He/She had done two online tutorials on usage of the heat machine.-He/she only was treating the rooms with identified bed bugs. During an interview on 12/5/25 at 11:35 A.M., Certified Nursing Assistant (CNA) A said:-The staff tried to manage the rooms that had bedbugs by minimizing the clutter.-A lot of residents didn't like to come out of their rooms so the rooms could be heat treated.-Those rooms were still sprayed.-He/She had not seen any bites on residents on shower days.-If a resident said there were bedbugs in his/her room, they try to treat it as soon as possible. During an interview on 12/5/25 at 1:15 P.M., the Corporate Maintenance Director said:-He/She had been to the facility four or five times and got rid of the bed bugs.-The facility admitted some people in the last month that brought more in.-The facility Maintenance Director was new, and he/she planned on meeting with him/her on 12/8/25 to review the treatment program.-He/She was aware of the heat treatment machine.-He/She thought if the second floor was being treated, the first floor should be treated as well.-This process would take several weeks to get completed.-Maintenance had to be on board, know what they were doing and why they were doing it.-Wet treatments, meaning spray, should be done in the common areas; outlet covers had to be taken off.-They also had to follow up, take pictures and keep paperwork on treatments.-The rooms were monitored while being heat treated; clothing was left hanging, and the machine would be moved around.-It was a six-to-seven-hour process to heat treat.-They would probably need to heat treat all the rooms, although empty rooms had not been a problem. During an interview on 12/5/25 at 1:25 P.M., the Director of Nursing (DON) said:-He/She had not seen any residents with bed bug bites.-There were some rooms that had bed bugs.-The rooms were on a spray schedule.-There was a whole protocol for the heat machine.-It had a digital readout that showed how hot the room was. During an interview on 12/5/25 at 2:05 P.M., the Corporate Director of Operations said:-The facility does an internal bedbug extermination that does a better job than extermination companies.-The extermination companies did a terrible job with small heat machines.-Whenever they had an outbreak, they used their commercial grade heat machine.-When there was notification of an outbreak, they would take a heat machine to the facility to use in the rooms.-The machines could get as hot as 140 degrees.-When a room was reported, it was locked down.-There had not previously been a problem getting the residents out of the rooms.-When bedbugs were found in a room, nothing would go in and out of the rooms.-Every 30 minutes someone would go in the room during the heat process and tear up the rooms so everything could be heated.-All linens were bagged; clothing was put in the dryer, then washed, then dried again.-The resident would be given a gown to wear and sent to the shower and all their clothes were cleaned.-The linen company would let them know if they found bedbugs in the linens.-When they were notified of bedbugs, they would act almost immediately, identify the people involved, and they would treat the room or rooms. They did not take it lightly or wait around.-Most of the residents in the facility would go in and out in the community, so there was no way to track what they brought in. Staff could bring in bedbugs as well. During an interview on 12/8/25 at 11:00 A.M., CNA B said:-The resident rooms were checked for bedbugs when the residents said they had them. Checks were not routinely scheduled.-If a resident said he/she had bedbugs in his/her room, he/she would let the housekeeping manager know.-He/She had gotten bedbugs on his/her person at the facility.-He/She killed them when he/she saw them.-He/She took his/her clothing to the Environmental Services Supervisor and had it treated. During an interview on 12/8/25 at 12:40 P.M., Exterminator A said:-His/Her company had not treated for bedbugs at the facility for over a year. They had treated for other pests, but not bedbugs.-The facility did treatments in-house using sprays two times a week.-Most chemicals could not be used very often because you had to wait at least two weeks to a month between treatments.-He/She had seen the facility heat machine and it was an effective means of treatment.-Every room should be inspected.-If the bedbugs were not seen, the heat machine would not necessarily be needed, but it could be used.-If there was an issue in a room, the rooms above, below, on either side and across from that room should be treated for the facility heat machine to be effective. -The common areas should be inspected, because the facility could not prevent the residents from leaving their rooms.-Eggs were white spots and harder to see, but not invisible. They were like grains of salt.-Bugs and the eggs could be vacuumed up.-The advantage of heat was that it kills the eggs and bugs. During an interview on 12/8/25 at 1:30 P.M., the Administrator said:-Bedbugs were in the facility before he/she became Administrator three years ago.-Resident rooms were sprayed twice a week and mattresses that had bed bugs were replaced.-They had begun heat treating the rooms.-The Maintenance Director was new, so that was why the heat treatments had not started sooner.-The facility had residents who didn't want the spray in their rooms, and didn't want to shower. They could not make them do things.-Resident #7's room was the worst.-He/She let the residents know if they didn't allow their rooms to be treated, they were a hazard to other residents.-If a resident found bedbugs, he/she should let the staff know, who would let the appropriate staff know so the room could be treated.-The previous Maintenance Director had been treatment the rooms.-Spray was used to treat common areas.-The corporate office made the decision to use the heat treatment machines instead of a professional exterminator.-The corporation owns two machines for their four buildings. One was at this facility and stayed there.-The facility gets a lot of people admitted who were homeless or from the city mission and they could bring the bedbugs in. 2683107

Based on observation and interview, the facility failed to ensure there was negative air flow (a ventilation system that continually attempts to move air out of the room) in required areas such as the soiled utility/biohazard rooms, shower rooms and the restrooms of resident rooms. This practice affected all residents, because none of the resident room restrooms had negative air flow. The facility census was 56 residents.1. Observation on 7/29/25 with Maintenance Person A showed the following:-At 10:04 A.M., there was the absence of negative air flow in the biohazard room located behind the first floor nurse's station.-At 10:10 A.M., there was the absence of negative air flow in the restroom of resident room [ROOM NUMBER]. -At 10:37 A.M., there was the absence of negative air flow in the restroom of resident room [ROOM NUMBER].-At 1:32 P.M., there was the absence of negative air flow in the second floor biohazard room. 2. During an interview on 7/29/25 at 10:05 A.M., Maintenance Person A said he/she did not know how long there had not been any negative air flow.During an interview on 7/29/25 at 10:06 A.M., the Corporate Maintenance Person said the motor which operated the negative airflow in the first floor biohazard room, and rooms throughout the facility, was broken.

Based on interview and record review the facility failed to ensure Quality Assurance and Performance Improvement (QAPI-a structured approach to improving quality in healthcare settings) and QAPI activities (development of performance improvement action plans, monitoring, analysis and feedback) were documented to show how the facility was measuring the success of quality improvement actions and performance. This failure potentially affected 56 residents. The facility census was 56.1. Review of the facility Certification and Survey Provider Enhanced Reports (CASPER-reports generated from information submitted by the facility to assess their performance and identify areas for improvement. The report provides insights into various aspects of care, such as staffing levels, quality measures, and compliance with regulations) dated 7/21/25, showed repeat deficiencies were cited in prior survey processes (since July 2022) in the areas of resident rights, resident care, rehabilitation services, Staffing, Infection Control, Dietary Services, and Life Safety Code. Review of the facility's Payroll Based Journal Report showed:-The facility had low weekend staffing in two quarters: July 2024 to September 2024 and October 2024 to December 2024.-The facility had one star rating in one quarter: July 2024 to September 2024. Review of the undated Facility Assessment showed:-The facility would audit and review the demography, Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) data information and current nursing assessments to obtain the data, current and average 12-month data.-The Quality Assurance and Performance Improvement (QAPI) team and the operational director are responsible to annually obtain, review and revise the information on the facility profile.-The QAPI team updated the information if needed or significant changes in the facility profile.-Revise and document the information accordingly.-Extract data from the MDS to obtain information for resident diseases and conditions, physical and mental disabilities, ethnic and cultural population, religion and religious practices.-Extract data on resident census and condition and the roster sample matrix.-Extract the CASPER report to review all quality measure reports to assess and correct information. Review of facility documentation provided showed the facility did not submit documentation of a completed QAPI plan since the last survey (June 2023) or within the last year (June 2024 to June 2025) as requested during the entrance conference for review. During an interview on 8/4/25 at 10:41 A.M., the Administrator said:-The Quality Assurance (QA) Committee included the Administrator, Corporate Manager, Medical Director, Social Services Director, Dietary Manager, Director of Nursing, Maintenance Director, and sometimes the Activity Director attends.-The QA Committee met at least quarterly and their last meeting was May 2025.-They determined areas of concern by reviewing prior citations, weekly reports they used that showed falls, wounds, weight loss, medications-antibiotic and antipsychotic medication use, infections, behavior incidents, and resident counsel reports to determine what areas they may need to develop an improvement plan for.-Once they determined what areas they were going to focus on-depending on what the concern area was - they would develop the plan of action and then they in-serviced the staff on the plan and how it was to be carried out.-He/She and whomever they determined would be responsible for monitoring the plan would meet weekly or as often as needed to determine the success of the plan and reviewed it as needed.-They have not been documenting any QAPI plan of action, performance improvement plan (PIP), monitoring of action plans and QA areas they have completed a QAPI for.-They reported the results of any QAPI, PIP/action plans in the QA Committee meeting verbally and did not have documentation of prior or current action plans, monitoring of their QAPI , or any action plans/PIP or QAPI that was resolved.-He/She did not know this information had to be documented.

Based on observation and interview, the facility failed to repair a drainpipe that was coming off the Victory Refrigerator and dripping water on to the floor next to a bolt which was causing it to rust instead of draining directly into the nearby drain. The facility census was 56 residents.1. Observation on 7/31/25 from 9:04 A.M. to 1:33 P.M. showed:-The drainpipe leading from the Victory Refrigerator was not draining into the adjacent drain.-It was draining on the floor next to a bolt which was causing it to rust and then the rust and water would run on to the floor into the drain. During an interview on 7/31/25 at 1:33 P.M. Dietary Manager said:-The drainpipe had not reached the drain for about a month. -He/She did not know what happened to it.-He/She thought it was on the schedule to be fixed but wasn't sure.

Based on observation and interview, the facility failed to ensure the fan in the laundry area was free from a heavy buildup of dust. This practice potentially affected an unknown number of residents because the fan was directed towards the clean clothing on a hanger. The facility census was 56 residents.1. Observation on 7/28/25 at 1:41 P.M., showed one fan with heavy buildup of dust on the blades and the grate (the plastic/metal covering over the exposed parts of machinery) which was directed towards the clean clothes on a hanger behind Laundry Aide (LA) A.During an interview on 7/28/25 at 1:42 P.M., LA A said he/she did not know the last time the fan was cleaned.During an interview on 7/28/25 at 1:49 P.M., the Housekeeping/Laundry Supervisor said he/she brought the fan out of a closet somewhere and did not know the last time the fan was cleaned.

Based on interview and record review, the facility failed to provide the required annual 12 hours of in-service training and competencies skill check off for Certified Nursing Assistants (CNAs). This had the potential to affect all of the residents residing in the facility. The facility census was 56 residents. Review of the facility's Certified Nursing Assistant (CNA) Continuing Education Policy dated 5/25/23 showed:-All CNA's must complete a minimum of 12 hours of continuing education annually, in accordance with State and Federal regulations. -The Director of Nursing (DON) will create an annual training schedule and ensure relevant topics are covered. -CNAs must submit proof of completed training (e.g., certificates of completion) to the facility human resource department. -Supervisor will review training records quarterly to ensure compliance and document compliance. -Supervisor will track compliance and maintain records in personnel files. 1. Review of the undated Facility Assessment showed:-Administration did not have any information regarding how the facility would complete staff training. During an interview on 7/31/25 at 12:00 P.M., CNA C said:-The facility had recently offered in-services related to hand hygiene and perineal (peri the cleaning and maintenance of the perineum, the area between the anus and genitals) care. -Normally there were monthly in-services on pay days. -He/she was not aware if in-services were documented anywhere. Review of the facility CNA and nursing staff in-services and skills check offs showed:-The documents were requested on 8/1/25 and 8/4/25.-The Director of Nursing (DON) and the Administrator were not able to provide the current employee in-services and skills check offs.-There was no documentation provided to show current employees had the required amount of in-service training hours and competencies. During an interview on 8/1/25 at 8:40 A.M., Certified Medication Technician (CMT) A said:-He/she had recent in-services related to hand hygiene.-Normally there were monthly in-services on pay days.During an interview on 8/4/25 at 11:10 A.M. the DON said: -The facility provided in-services monthly but he/she was not able to provide written documentation of those trainings.-The facility had not completed nursing staff and CNA skills check off/staff competencies and did not have any documentation of any past skills check offs. -He/She was responsible for completing competency skills check offs for all nursing staff including CNAs. -He/She did not have any documentation to show the current employees had the required 12 hours annual training. During an interview on 8/4/25 at 2:10 P.M. the Administrator said:-He/she would expect the facility to have documentation to show in-services and skills check offs/competencies for the CNA's required 12-hour training were completed.

Based on observation and interview, the facility failed to maintain the fan vent cover in the dining room that had heavy dust buildup; maintain the floor behind and under equipment where debris had built up; maintain the drains throughout the kitchen especially by the Victory refrigerator that had grime build up; maintain the cleanliness of the floor in the dry goods storage room; maintain the cleanliness of the ceiling above the wall mounted fan had food splashes present; maintain the fans inside the refrigerator that had debris on them that were blowing directly on drinks and the bottom shelf; maintain the cleanliness of the stove from dust and grime built up on the front, sides, the shelf, and behind on the hoses; maintain the cleanliness of the racks, floors, and walls in refrigerator #3 that had a white substance growing on it; failed to utilize sanitizer strips, and sanitizer not being used to wipe down surfaces, cloth being used to wipe down surfaces not being stored properly; there were no test strips available for the dishwasher; surfaces not maintained or cleaned, the plastic papers on the bottom shelf of the preparation table by the refrigerator had food residue spilled on it and had clean dishes sitting on the contaminated paper; items in the refrigerator were not labeled and dated; and staff members working in the kitchen failed to wash their hands. This practice potentially affected all 56 residents who ate the food from the kitchen. The facility census was 56 residents.1. Observation on 7/28/25 9:25 A.M. during the initial walk-through meal preparation showed:-There were opened and cut up food items with no dates in the refrigerator.-There was a plastic baggie with red sauce in it with no label to identify the food item and no date to show when the food item was placed in the refrigerator.-The refrigerator bottom shelf had debris on it.-The refrigerator fans were blowing debris on to uncovered drinks. -Freezer #1 had food that was not in a container and not covered. -The ceiling above the wall mounted fan had food splashes present.-The dish machine did not have any test strips available. Observation on 7/31/25 from 9:04 A.M. to 12:00 P.M. during the lunch meal preparation showed:-The fan vent cover in the dining room had heavy dust buildup. -The floors by the handwashing sink, stove, and refrigerator had debris and grime build up. -The stove had a red plastic funnel behind it along with dust build up on the hose. -There was grime built up on the side, front, top, and the shelf. -There were white tablets on the floor under the wire rack by the chest deep freezer.-The floor in the dry storage area had black sticky residue present. -Refrigerator #3 had liquid on the floor and white substance growing on the racks and walls. -The drains especially by the refrigerator had grime build up. -The wall mounted fan and the portable fan by the stove had a buildup of dust on them. -The peanut butter container that sat out in room temperature had jelly residue on it. -The bottom shelf of the preparation table had clean dishes sitting on a dirty cover. -The [NAME] used a towel to wipe off the preparation tables but did not store the towel in the sanitizer bucket when it was not in use. -Staff did not use sanitizer test strips to test the sanitizer solution.-The Dietary Aid asked the Dietary Manager (DM) for test strips the DM took out a rolled strip with no date or label on them as to what they were for and if they were still valid. -The kitchen staff did not wash their hands before putting on gloves to start working. -The [NAME] did not wash his/her had before putting on gloves before putting chicken strips in the pan to be baked. -The Dietary Aid did not wash his/her hands after he/she handled the trash, before handling juice.-The Cook/Aid came into the kitchen with gloves on, touched multiple items in the kitchen, left and returned to the kitchen with a box then proceeded to place small bowls of pudding on a tray while wearing the same gloves. During an interview on 7/31/25 at 12:00 P.M. the [NAME] said:-Test strips were available.-Only one bucket was used to wipe down the steam table. -He/She did not test the sanitizer solution to ensure it was appropriate.During interview on 7/31/25 at 1:33 P.M. the DM said:-Deep cleaning in the kitchen happened once a week on Thursday. -The refrigerators were cleaned on Thursday. -Staff should wash their hands every time they come into the kitchen, every time they have touched something different, and before putting on gloves.-Staff should check the sanitizer solution every two hours.-Staff should check the temperatures of the dish machine after every meal and it should be drained and restarted. -The dish washer was a low temperature machine.-Test strips for the dish machine were discarded when cleaning and more needed to be ordered. -The white tablets on the floor were a new type of pest control the company put down. The staff would sweep them up when they cleaned.

Based on interview and record review, the facility failed to ensure an on-going process for monitoring facility-wide Infection Prevention Control Program (IPCP) was established; failed to ensure surveillance logs were maintained with written documentation for 17 months out of 18 months (January 2024 to May 2025) of surveillance to include but not limited to: documentation of monitor, track, and identify trends of infections in the facility and outcome of findings; and failed to ensure infection control prevention practice of proper hand hygiene preformed during personal care for one sampled resident (Resident #2) out 24 residents. The facility census was 56 residents.Review of the facility General Infection Control Program dated 2023 showed:-A system for surveillance is designed to establish and maintain data base with describes endemic rates of nosocomial infections or facility-acquired infections. -A systematic observation on the occurrence and distribution of facility-acquired infections among the resident for the propose of prevention and control. Surveillance implies that the data has been complied to examined and reviewed in order to determine problems that may exist within the environment. -Infection Control Preventionist (ICP), a person designated to serve as coordinator of the facility's infection prevention and control program. -Surveillance including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting (as required by state and federal law and regulation). Review of the facility's Hand Washing policy dated 2020 showed:-All care staff must apply proper hand washing before, after and between care deliveries. -Perform hand washing after remove gloves. Review of the facility's Gloving policy and Procedure dated 2024 showed:-Changes gloves from a soiled body site to a clean one on the same resident. -Before exiting a resident room. Review of the facility's undated Facility Assessment showed: -General nursing related infections preventions: Identification, containment of infection and prevention of infections, 1. Review of the facility Infection Control Surveillance log on 8/4/25 at 10:38 A.M., showed: -The Director of Nursing (DON) did not have written infection surveillance tracking from January 2024 to May 2025.-The DON recently completed the June 2025 infection surveillance tracking and trending of residents with infections and had started entering data for July 2025.-The DON did not have written monthly infection control reports that were presented to the Quality Assurance (QA) Committee for review and follow-up on any resident infections with trending patterns. During an interview on 8/4/25 at 10:41 A.M. the Administrator said:-The QA Committee included Administration, Corporate, the Medical Director, Social Services, Dietary, the DON, the Maintenance Director, sometimes the Activities Director attended the meetings.-The Infection Control Surveillance was being completed by the DON currently, who was not ICP certified. -The facility was going to have a prior ICP come back to be the facility ICP again.-Licensed Practical Nurse (LPN) B was in training for ICP. He/She had started June 2025 and did not have his/her certification of completion because he/she took the classes but did not pass the final ICP exam. -The DON had not been tracking and trending infections until June 2025.-The DON was responsible for completing the facility's infection control surveillance to include tracking and trending of infections. -He/she was not aware the DON had not been completing the documentation for tracking and trending of infections nor antibiotic stewardship. During an interview on 8/4/25 at 11:10 A.M., the DON said: -He/she was responsible for completing the facility's infection control surveillance to include tracking and trending of infections. -Licensed Nursing staff were responsible for completing Appropriate Antibiotic Use Audit tool which would be placed in an antibiotic/infection binder/log book found at the nursing station. -He/She was responsible for completing the documentation for each month's infection surveillance. -He/she had not been documenting ongoing monthly infection surveillance tracking and trending since the last ICP left in June 2024. -During the QA meeting he/she would discuss residents with current infections and also discussed any infections during care plan meetings.-He/she did not document infection prevention interventions and did not document any education provided due to any infection trends found. -The facility administration and the DON did not document outcome from infection control review by the QA team. 2. Review of Resident #2 admission Face sheet showed the resident admitted with the following diagnoses:-Cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth).-Dementia (is the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's day to day activities).Review of the resident's Activities of Daily Living (ADL's) Care Plan dated 3/21/24 showed:-The resident was dependent on 1-2 staff for bathing and personal care. -The resident could be resistant to laying down and incontinence care during the day shift. Review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 7/15/25 showed the resident: -Was cognitively intact able to make his/her needs known. -Required assistance with personal care and was incontinent of bowel and bladder. Review of the resident's Physician Order Sheet (POS) dated July 2025 showed:-Calmoseptine (skin protective barrier cream) cream apply topically to buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) twice daily as needed for wound healing. Observation on 7/29/25 at 2:46 P.M. of the resident's incontinence care showed:-The resident was in bed.-There was a lingering smell of urine.-The resident required total staff assistance with bed mobility/turning and personal care. -Certified Nursing Assistant (CNA) C entered the resident room and washed his/her hands prior to putting on gloves, while CNA A entered the room.--CNA A did not sanitize or wash his/her hands prior to placing gloves on hands. -The resident's brief was wet, which had leak through to the bed sheet and his/her hospital gown was wet. -CNA C provided perineal care, (peri care the cleaning of the genital and anal areas) for the resident. -CNA C used one wipe at a time to clean the front area and changed gloves from the front to back care process. -CNA C removed the gloves and placed clean gloves on hands without sanitize hands to finish resident incontinence care. -CNA C with gloved hands placed small amount of cream on top of his/her right-hand glove, then with his/her left gloved hand, placed the cream onto the resident's open reddened areas on his/her lower buttocks. -CNA C then placed new clean brief on the resident with same soiled gloves. -CNA A put new sheets and bed chucks on the resident's bed and changed the resident's gown. -CNA C did not wash or sanitize his/her hands between each glove changes or from the dirty to clean process. -CNA C removed gloves and washed hands prior to leaving the resident room. -CNA A did not wash or sanitize his/her hands before putting on gloves. During an interview on 7/31/25 at 12:00 P.M., CNA C said:-He/she should have washed or sanitized his/her hands between each glove change and from a dirty to clean process. -He/she recently had peri care training to include hand hygiene. During an interview 8/1/25 12:06 P.M., CNA B said:-He/she would sanitize or wash his/her hands when going from clean to dirty process and between each glove change. During an interview on 8/4/25 at 9:59 A.M., Licensed Practical Nurse (LPN) A said:-He/she would expect staff to perform hand hygiene by either sanitizing or washing their hands with soap and water prior to resident care, when going from a dirty to clean process and between each glove change. During an interview on 8/4/25 at 11:10 A.M., DON said: -He/She would expect staff to perform hand hygiene before and after any resident care, when going from a dirty and clean processes, and between each glove change. -He/She had provided recent in--services on hand hygiene and peri care to all staff.

Based on observation, interview, and record review, the facility failed to employ a certified Infection Control Preventionist at least part time to coordinate the surveillance of the facility's Infection Control and Prevention Program. The facility census was 56 residents. Review of the facility General Infection Control Program Policy dated 2023 showed:-Infection Control Preventionist (ICP), a person designated to serve as coordinator of the facility's infection prevention and control program. -Surveillance including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting (as required by state and federal law and regulation. 1. Review of the requested copy of the facility ICP's certification on 8/4/25 at 10:30 A.M. showed:-The facility did not have a current employee with a certificate of completion as an ICP.-The Director of Nursing (DON) and Licensed Practical Nurse (LPN) B, who was in training for the ICP position, did not have an active ICP certification. During an interview on 8/4/25 at 10:41 A.M. in the Quality Assurance (QA) interview the Administrator said:-The QA Committee included Administration, Corporate, Medical Director, Social Services, Dietary, DON, Maintenance Director, and sometimes the Activities Director attended the meetings.-The Infection Control Surveillance was being completed by the DON currently, who was not ICP certified. -The facility was going to have a prior IC Preventionist come back to be the facility IC Preventionist again.-LPN B was in training for the IC Preventionist, he/she had just started last month (June 2025) and he/she did not have his/her certification of completion because he/she took the classes but did not pass the final ICP exam. -The DON had not been tracking and trending infections until last month (June 2025).-The DON was responsible for completing the facility's infection control surveillance to include tracking and trending of infections. -He/she was not aware that the DON had not been completing the documentation for tracking and trending of infections nor antibiotic stewardship. During an interview 8/4/25 at 11:10 A.M., the DON said: -The facility did not employee a certified Infection Control Preventionist at that time.-The last ICP employee had left the facility in June 2024. -The DON had not completed the ICP program and was not ICP certified. -The facility hired a nurse in June 2025, who was working on getting the ICP certification.

Based on observation, interview and record review, the facility failed to ensure perineal (peri) care was provided as needed for one sampled resident (Resident #3) out of 24 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Policy for Daily Activities of Daily Living (ADL) dated 2024 showed bed mobility care is performed daily every 2 hours for limited mobility residents and every 4-6 hours depending on tissue tolerance and whenever needed. 1. Review of Resident #3 admission Record showed he/she was admitted on [DATE], with the following diagnoses:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).-Essential Hypertension (HTN chronic condition of high blood pressure).-Hyperlipidemia (high level of lipids in the blood). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/12/25 showed the resident:-Was cognitively impaired.-Always incontinent. -Dependent on staff. Review of the resident's Care Plan dated 3/12/25, showed:-The resident had comfort measures related to terminal illness.-The resident was on hospice (end of life care).-The resident had an Activities of Daily Living (ADL) self-care performance deficit related to weakness from Dementia. -The resident was totally dependent on staff. -The resident required the use of a Hoyer lift for transfer.-The resident had cognitive impaired function/Dementia or impaired thought process related to severe Dementia. -The resident had a communication problem related to mental status Dementia with confusion. Review of the resident's nursing care sheet dated July 2025 showed:-Peri care was done for the day.-It did not list out the time of day that the care was provided. Review of the resident's Hospice notes dated 7/15/25, showed:-The resident had bowel incontinence.-The resident had inability to change position.-The resident had urine incontinence. -Incontinence was being managed by briefs and proper skin care. During an interview on 7/29/2025 at 2:00 P.M. Certified Nursing Assistant (CNA) B said staff would check the resident every two hours.Observation on 7/30/25 from 10:26 A.M. to 12:20 P.M. showed:-Staff did not perform any peri care checks on the resident.-Staff did not reposition the resident. -The resident was served lunch at 12:20 P.M.Observation on 7/30/25 at 1:22 P.M. showed the resident was seen in the same position.Observation on 8/1/25 from 9:14 A.M. to 12:34 P.M., showed:-Staff did not perform any peri care checks on the resident.-Staff did not reposition the resident. -Resident was served lunch at 12:34 P.M. During an interview on 8/1/25 at 11:23 A.M., Licensed Practical Nurse (LPN) A said staff would check the resident every two hours. During an interview on 8/1/25 at 2:40 P.M., CNA A said:-He/She checked the resident every two hours or whenever he/she would get assistance. -He/She checked the resident in the morning and had LPN A assist him/her. -He/She did not know what time he/she checked the resident on 8/1/25.-The nursing cares sheet did not break the day up into hours, so he/she wasn't sure what time he/she checked the resident. During an interview on 8/1/25 at 3:07 P.M., LPN A said:-He/She thought he/she checked the resident on 8/1/25 at 10:00 A.M. and at 12:00 P.M.-He/She would check him/her discretely and sometimes take him/her to the bath house to check. During an interview on 8/4/25 at 12:30 P.M., the Director of Nursing (DON) said:-A resident that was unable to perform his/her own ADLs should be checked by a staff member every two hours.

Based on observation, interview and record review the facility failed to ensure physician's orders for self-administration and care for a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) were obtained and documented on the Physician's Order Sheet (POS) for one sampled resident (Resident #13) out of 24 sampled residents. The facility census was 56 residents.Review of the facility's undated Ostomy-Colostomy policy and procedure showed the purpose was to prevent infection and ensure proper drainage, enhancing hygiene and dignity. It showed:-The resident will be informed of care for the (colostomy).-A resident who is able to perform self-care will be provided information and education on (colostomy) care. -There was no procedure or documentation showing how physician's orders should be written for self-care of the colostomy. 1. Review of Resident #13's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including heart disease, pain, depression, alcohol abuse, and colostomy. Review of the resident's Physician's Telephone Orders showed there was a telephone order dated 10/11/23, to:-Check the stoma (a surgically created opening on the abdomen that connects the large intestine to the outside of the body) and (skin around the) stoma area for skin issues, redness moisture or mucous daily (ordered 10/11/23).-There was no physician's telephone order for self-care and administration of the resident's colostomy. Review of the resident's Care Plan updated 8/14/24, showed the resident had altered bowel elimination related to colostomy placement. Interventions showed staff would:-Monitor the resident's colostomy site daily and document monitoring on the resident's Treatment Administration Record (TAR).-Make sure the colostomy bag was sealed properly and monitor for odors, gas, obstruction and loose stool.-Monitor for signs and symptoms of infection, bleeding or injury at the site and notify the physician.-Assess the resident for self-care of the colostomy quarterly and as needed with a change in condition.-Provide the colostomy bag as needed and provide assistance as needed. Review of the resident's Assessment for Self-Care of Colostomy dated 5/17/25, showed the resident:-Understood the reason for the colostomy.-Was fully capable of using proper infection control (handwashing, using gloves) during the procedure.-Was fully capable of completing the procedure for emptying and changing the pouch and cleaning the skin.-Completed return demonstration for self-care successfully. Review of the resident's POS dated May 2025 and June 2025, showed physician's orders to:-Check the stoma and (skin around the) stoma area for skin issues, redness moisture or mucous daily (ordered 10/11/23).-There was no physician's order for self-care and administration of the resident's colostomy. Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated, 7/10/25, showed the resident:-Was alert and oriented with no cognitive incapacity.-Had no behavioral symptoms.-Was independent or needed set up assistance only with bathing, dressing hygiene, eating and toileting.-Had lower extremity impairment and used a wheelchair for mobility.-Used a colostomy. Review of the resident's POS dated July 2025, showed physician's orders to:-Check the stoma (a surgically created opening on the abdomen that connects the large intestine to the outside of the body) and (skin around the) stoma area for skin issues, redness moisture or mucous daily (ordered 10/11/23).-There was no physician's order for self-care and administration of the resident's colostomy. Observation and interview on 7/29/25 at 10:01 A.M., showed the resident was in his/her room and had just come from the bathroom. Noted there was a clean colostomy bag that was sitting on top of the dresser under his/her television. The resident was alert and oriented and said:-He/She had a colostomy for at least two years and he/she changed and cared for it himself/herself without staff assistance.-The nursing staff just cut the hole in the bag to make sure it fit on the opening of his/her stoma if needed.-He/She did not want to show the colostomy site or have observation of his/her colostomy cares.-He/She did not have any problem or difficulty caring for it himself/herself. During an interview on 7/30/25 at 2:37 P.M., Licensed Practical Nurse (LPN) C said:-The resident could and did change and empty his/her own colostomy bag and performed colostomy care.-The nursing staff checked it (the colostomy and stoma site) daily to make sure it looked okay and was not red or bleeding.-The nursing staff documented their monitoring on the resident's TAR.-There should be physician's orders for the resident's colostomy bag and self-care of the colostomy and stoma. During an interview on 8/4/25 at 9:10 A.M., LPN A said:-The resident was able to care for and change his/her colostomy independently.-Staff completed quarterly assessments where the resident had to provide demonstration of how to change and care for his/her colostomy in order to continue to be able to do this independently.-The nursing staff only provided minimal assistance as needed and they completed skin checks to ensure the area was not infected or had any issues.-There should be a physician's order for self-care and it should be in the resident's care plan.-Lately nursing staff have had to assist more because the resident had declined in his/her overall health and needed more help. During an interview on 8/4/25 at 12:36 P.M. the Director of Nursing (DON) said:-The resident had been performing self-care of his/her colostomy independently for a long time.-The resident had been re-assessed to continue to provide self-care of his/her colostomy and was able to successfully do so.-There should be a physician's order for self-administration and care of his/her colostomy care but it must have fallen off of the POS.-Self administration and care of the resident's colostomy should be on the resident's care plan.

Based on observation, interview and record review the facility failed to thoroughly assess the resident's chewing and swallowing ability, failed to re-assess the resident's dietary need and preferences to address the resident's weight and eating status and failed to care plan recent weight loss and nutritional interventions for one sampled resident (Resident #13) with gradual weight loss out of 24 sampled residents. The facility census was 56 residents.Review of the facility's Unplanned Weight Management policy and procedure dated 2006, showed the purpose was to ensure each resident received appropriate nutritional care and ensure significant weight loss or gain be addressed and clinically managed. It showed:-The Director of Nursing (DON)/Assistant Director of Nursing (ADON) will be responsible for establishing a monthly/weekly weight schedule.-The appointed nursing staff responsible for weighing will compare the current weight and the previous weight and shall re-weigh if there is a 5-pound variance.-The weight record shall be communicated with the Quality Assurance Committee or the weight committee.-Residents with a weight loss or gain of more than 5 percent in a 30 day period; 7.5 percent in a 90 day period and 10 percent in a 180 day period will be assessed by a licensed nurse for causative factors, referred to the Registered Dietician for further evaluation, notified to the physician for medical interventions and referred to the weight committee for reviewing and revising the care plan.-Charge Nurses will be responsible for documentation, progress, implementation of treatments. -Documentation of exceptions shall reflect the change in status, condition, implementation of the care plan and physician's orders.-Residents who are observed declining in feeding ability or refuse to eat; consumes less percent of intake (compared to normal intake) will be evaluated by the weight committee.-The care plan shall reflect the interventions recommended by the Registered Dietician.-The Quality Assurance Committee/weight committee shall meet at least monthly or more frequent if needed to monitor for progress and successful implementation in order to develop or revise the care plan.-All weight gain or loss within the parameter of concerns above will be documented on the weight gain/loss assessment. 1. Review of Resident #13's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including heart disease, pain, depression, alcohol abuse, and colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). Review of the resident's annual Registered Dietician assessment dated [DATE], showed:-The resident had no significant changes during the year.-The resident ate a regular diet and ate independently with a few broken teeth.-His/Her weight was stable with health shakes three times daily.-The resident's weight fluctuated between 138 and147 pounds. Current weight was 140 pounds.-The resident consistently refused nutritional supplements.-The resident had an order for Remeron (an appetite stimulant) which favors (his/her) appetite.-There was an undated addendum to discontinue the nutritional supplement due to resident refusal. Review of the resident's Care Plan showed the most recent update was 8/14/24. The care plan showed the resident was at risk for infection and gastrointestinal disturbance due to improper food storage, keeping perishable items past the expiration date, storing food and dishes from the dietary department in his/her room. It showed the resident refused dietary supplements as recommended by the Registered Dietician (protein snacks and liquid nutritional supplements). The care plan showed the resident was at risk of overall health decline due to alcohol abuse and intoxication. Interventions showed staff would:-Check the resident's refrigerator weekly.-Check the resident's room daily for food from prior meals and throw them away.-Educate the resident not to keep food from the previous meals and explained that improper storage of meals could cause the resident to become sick.-Dietary staff would encourage the resident to take supplements and offer flavors of choice.-Staff will complete monthly weights. Review of the resident's Registered Dietician Note dated 1/25/25, showed:-The resident had weight loss over the past year.-The resident continued to abuse alcohol and refused the nutritional supplement.-The physician recently increased Remeron to 15 milligrams (mg).-There were no additional notes regarding the resident's nutritional status or interventions that may assist with the resident's weight loss (re-evaluating preferences, evaluating the resident's swallowing/chewing status). -There was no documentation showing the resident was educated on his/her current health status and consequences of continued weight loss. Review of the resident's Weight Record showed the resident was receiving weekly weights. The resident's monthly weights showed-On 2/26/25 he/she weighed 128.5 pounds.-On 3/19/25 he/she weighed 130 pounds.-On 4/30/25 he/she weighed 129 pounds. Review of the resident's quarterly Dietary Notes dated 5/21/25, showed:-The resident continued on a regular diet with no changes.-Dietary staff continued to provide the resident paperware related to the resident holding dishes in his/her room.-Dietary staff would continue to monitor for any changes.-The quarterly note did not show the resident's weight status over the last quarter, any weight loss concerns, eating habits and preferences, behaviors, whether he/she was on a nutritional supplement or had any nutritional interventions during the quarter. -There were no additional dietary notes documented in the resident's medical record. Review of the resident's Physician's Notes dated 5/26/25, showed the physician completed a physical exam and reviewed the resident's medicines, labs and review of medical symptoms. The physician documented the resident had been doing well with no recent mental status changes and no medical concerns. There were no medication changes. The physician did not address the resident's nutritional status, weight loss/changes or nutritional interventions. Review of the resident's Weight Record showed on 5/28/25 he/she weighed 125.5 pounds (a weight loss of 3.5 pounds since the prior month). Review of the resident's Physician's Order Sheet (POS) dated June 2025 showed physician's orders for:-A regular diet with a protein snack between meals twice daily.-Remeron 15 mg at bedtime for depression and appetite (ordered 12/6/24). Review of the resident's Nursing Notes dated 6/18/25, showed:-Nursing staff documented the resident had weight loss of five pounds in two weeks. -Nursing staff notified the resident's physician. -The resident stated that he/she did not have an appetite. -There was no documentation showing nursing staff made a referral to the Registered Dietician for follow up. Review of the resident's Physician's Notes dated 6/24/25, showed:-The physician completed a physical exam and reviewed the resident's medicines, labs and review of medical symptoms. -The physician documented the resident's presenting problem was anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss). -Facility staff reported the resident had not been eating regularly over the last few weeks and the resident had lost five pounds in one week due to the food served in the facility. -The physician documented he/she discussed this with the resident and nursing staff at length and ordered labs. -Recommendations included weekly weights, push fluids and the resident would likely need supplements. -He/She documented the resident was at high risk for decline with ongoing weight loss. Review of the resident's Nursing Notes dated 6/24/25, showed:-The Nurse Practitioner visited the resident regarding weight loss and gave orders for lab work.-A follow up appointment with the gastrointestinal clinic was set for 6/30/25 and the resident was informed of the appointment scheduled for 6/30/25. -There was no documentation showing the resident went to the appointment or that staff obtained the result of the consultation (there were no further notes until 7/8/25). Review of the resident's Weight Record showed:-On 6/25/25 he/she weighed 120 pounds (a loss of 5 pounds since the prior month). -The weight record showed the resident continued to lose weight. Review of the resident's Medical Record showed:-There was no documentation showing the facility staff evaluated the resident for a chewing or swallowing problem. -Re-evaluated his/her diet for appropriateness and texture (mechanical soft (ground meat) or puree (like pudding)), food preferences (based on the resident's likes/dislikes or type of food items he/she would eat), re-established nutritional supplements that the resident may accept, or re-evaluated current nutritional interventions for continued appropriateness to try to encourage the resident to eat. -There was no documentation showing the Registered Dietician re-evaluated the resident's nutritional status, diet order or nutritional interventions to try to address the resident's continued weight loss. Review of the resident's Physician's Notes dated 7/8/25, showed:-The physician completed a physical exam and reviewed the resident's medicines, labs and review of medical symptoms. -The physician documented the resident was seen due to abnormal lab results. -The resident's labs showed several results were low (potassium, sodium, calcium, albumin). -The resident was noted to have difficulty eating and was still not eating well. -The physician started calcium supplements and added Prosource (provide the nutrients necessary for the dietary management of protein-energy malnutrition and protein deficiency) 30 milliliters (ml) twice daily. -Encourage hydration and nutrition. -The resident was at high risk if he/she continued to not be able to optimize nutrition. Review of the resident's POS dated July 2025 showed a physician's order for Prosource 30 ml daily for protein (ordered 7/8/25). Review of the resident's Nursing Notes showed:-7/8/25 showed the resident needed assistance with daily cares to include bathing and dressing. -7/21/25 showed nursing staff documented the physician ordered the resident to be sent to the hospital for a non-emergency evaluation (reason undocumented). The resident returned to the facility with a physician's order for Amoxicillin (an antibiotic) daily every 12 hours for 7 days. -7/22/25 the nurse documented the resident had an abscess (a swollen area within body tissue, containing an accumulation of pus) to his/her left side of his/her neck that was cool to the touch. The resident had no complaints of neck pain. Review of the resident's Physician's Notes dated 7/22/25, showed:-The physician completed a physical exam and reviewed the resident's medicines, labs and review of medical symptoms. -The physician documented the resident was seen due to a follow up to a hospital visit. -The physician documented the resident was sent to the hospital due to a mass to the left side of his/her neck. -The area was golf ball sized and was slightly painful to the touch. -The resident was diagnosed with left sided parotid gland (salivary gland that is located just beneath and in front of each ear and produce saliva) infection and was prescribed an antibiotic for seven days. -The physician documented the resident may need hospitalization if the area was not improved and ordered staff to continue to monitor the resident's weights and to encourage hydration and nutrition. Review of the resident's Care Plan showed there were no changes in the resident's nutritional care plan that showed there were concerns with the resident's weight or nutrition, changes in nutritional interventions since the resident had continued weight loss, that the facility re-evaluated the resident's diet, diet texture or food preferences to try to manage the resident's weight loss. Review of the resident's Weigh Record showed:-On 7/30/25 he/she weighed 117 pounds (a loss of 3 pounds since the prior month). -The Weight Record showed a loss of 8.56 percent in 6 months; a loss of 6.4 percent in 3 months and a loss of 2.50 percent in 30 days. -The resident had gradual weight loss that was not yet significant weight loss. Review of the resident's POS dated July 2025 showed physician's orders for:-A Regular diet with a protein snack between meals twice daily.-Remeron 15 mg at bedtime for depression and appetite (ordered 12/6/24).-Prosource 30 ml twice daily for protein (ordered 7/8/25). Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated, 7/10/25, showed the resident:-Was alert and oriented with no cognitive incapacity.-Had no behavioral symptoms.-Was independent or needed set up assistance only with bathing, dressing hygiene, eating and toileting.-Had lower extremity impairment and used a wheelchair for mobility. -Had no chewing or swallowing difficulty, had no significant weight loss and did not receive a mechanically altered diet. Review of the resident's Medication Administration Record (MAR) dated July 2025, showed physician's orders for Remeron 15 mg at bedtime for depression and appetite (12/4/24) and Prosource 30 ml twice daily for protein (7/8/25). The MAR showed:-The resident was administered Remeron 15 mg daily as ordered.-Prosource was not administered according to physician's orders. --Prosource was not administered at the morning dose on 7/8/25, 7/18/25, 7/19/25, 7/20/25, and from 7/21/25 to 7/31/25. ---Documentation showed the resident refused most morning doses. (on 7/20/25 and 7/27/25 there was no documentation).--The resident was administered the Prosource evening dose every day except on 7/8/25, 7/18/25, 7/19/25, 7/26/25, 7/27/25 and 7/28/25. Review of the resident's daily Meal Consumption Record dated July 2025, showed daily areas to document the percent of food the resident ate at each meal and how much fluid the resident drank at each meal. The documentation showed:-The resident's meal percentages were not consistently documented for every meal (many of the meals were left blank)-For dates that were not left blank, showed the resident ate zero percent of meals.-During the week of 7/26/25 to 7/31/25 showed the resident only ate breakfast on 7/29/25 (he/she ate 100 percent); only ate lunch on 7/28/25 (he/she ate 10 percent) and only ate dinner on 7/26/25 and 7/28/25 (he/she ate 100 percent on these dates). Observation and interview on 7/28/25 at 10:37 A.M., showed the resident was sitting in his/her wheelchair in the hallway. The resident had a small round mass on the left side of his/her neck. He/she was alert and oriented and said:-He/She was doing well here, he/she tried to do all of his/her own care and ate independently.-The food could be better but he/she understood the staff had to cook to meet everyone's needs so he/she always put extra condiments on his/her food.-He/She preferred to eat in his/her room. Observation and interview on 7/29/25 at 10:01 A.M., showed the resident was in his/her wheelchair in his/her room. He/she was dressed for the weather and had a small round mass on the left side of his/her neck. There were two plates that were covered with a napkin that were sitting on top of his/her dresser under his/her television. There were several packaged snacks surrounding the plates such as donuts, snack cakes, chips and granola type snacks. On the first plate was partially eaten chicken leg with uneaten fries (less than 15 percent eaten). On the second plate was two pieces of chicken with mashed potatoes and green beans that looked untouched (zero percent eaten). The plates were both cold. On the dresser next to the resident's bed were more donuts and bags of chips, cup of noodles (unopened) and unopened cans of Vienna sausage and soup. The resident was alert and oriented and said:-He/She was not eating well and didn't have an appetite.-He/She had snacks and food items in his room he could eat when he/she wanted to.-He/She did not always like what was served at meals in the facility but those foods he/she would eat he/she took to his/her room.-He/She was not concerned with his/her weight.-He/She had some pain and received pain medications every 6 hours as needed.-He/She spoke with the physician about his/her pain last week and the physician said he/she would look at trying a different medication to better manage it. During an interview on 7/30/25 at 2:30 P.M., Certified Nursing Assistant (CNA) B said:-The resident was able to feed himself/herself independently and did eat in the dining room, but he/she had been taking his/her food to his/her room and then he/she still would not eat it.-He/She had seen the resident just eat bites of food before taking it to his/her room.-He/She was aware that the resident had weight loss and had recently gone to the hospital but he/she came right back to the facility.-When they go in to check on the resident, and see that he/she had not eaten, they tried to remove the plate and the resident would become angry and not allow them to take it, so the plate would remain in his/her room until he/she left the room and they could go in and remove it.-He/She had also seen where there may be two plates in the resident's room that the resident had not eaten, and the resident could not eat it because the food had either been there overnight or it was cold.-Usually if the resident was in pain or had difficulty eating (chewing/swallowing), he/she would let the nurse know or ask for pain medication.-To his/her knowledge the resident did not have any difficulty chewing or swallowing.-The nursing staff was supposed to document the resident's meal intake on the meal intake records for each meal daily.-They had not been documenting the resident's intake like they should but he/she knew that the resident had not been eating many meals in the facility.-The resident did not receive a nutritional supplement at meals-he/she refused them in the past. During an interview on 7/30/25 at 2:37 P.M., Licensed Practical Nurse (LPN) C said:-The resident had always been non-compliant with a variety of cares to include medications, smoking, following care instructions and he/she had recently been refusing to eat.-The resident had a mass that developed on his/her neck that they sent him/her to the hospital for and the hospital staff wanted to admit the resident but the resident refused.-The resident had an infection and the hospital prescribed an antibiotic that the resident had been refusing to take.-The resident had been refusing to eat over the past couple months and had been losing weight.-The resident had been prescribed liquid nutritional supplements but the resident refused to drink it so it was discontinued.-The resident currently had orders for Prosource but he/she had been refusing it also.-The resident would go to the dining room and get his/her meal, take it to his/her room and then would not eat it.-The resident did not have any difficulty with chewing or swallowing.-They had not gotten a swallow study completed on the resident to rule out swallowing difficulty.-The resident went out in the community and had come back smelling of alcohol then he/she did not want to eat or have an appetite.-Drinking alcohol seemed to be more important to the resident and he/she just chooses not to eat.-They had care planned weight loss interventions for the resident.-The Registered Dietician had come to see the resident and reviewed his/her nutritional status and weight loss but was not sure how recent this was.-To his/her knowledge they had not spoken to the resident about Hospice/palliative care (if the resident continues to decline food). During an interview on 8/1/25 at 9:13 A.M., the Dietary Manager said:-The resident had a history of coming to the dining room to get meals, but he/she would then take his/her plate to his/her room.-The resident did not eat the meal and when dietary staff went in his/her room to get the plate, they saw the resident had not eaten or had eaten very little and they threw away full plates of food.-The resident went out in the community and drank alcohol so he/she was not wanting to eat when he/she came back to the facility.-He/She did not know if or whether the resident was eating in the community.-The resident continued to be on a regular diet and did not have a chewing or swallowing problem.-They tried to give the resident foods he/she liked and food preferences. He/she would eat anything with gravy so they made extra gravy and put that on his/her food to try to entice him/her to eat.-The resident was prescribed a nutritional supplement, but he/she refused to drink it so they discontinued it.-The resident's weight fluctuated and they have done what they could to try to get him/her to eat since he/she ate independently.-The Registered Dietician had assessed the resident and tried to implement interventions to address the resident's nutritional status. During an interview on 8/1/25 at 11:10 A.M., Certified Medication Technician (CMT) A said:-The resident had weight loss and had been refusing medications lately because he/she was having trouble swallowing.-They sent him/her to the emergency room about a week or two ago and the hospital wanted to keep him/her, but the resident refused to stay and came back to the facility.-He/She looked at the resident's MAR dated July 2025 and said he/she started refusing medications around 7/18/25, and had only taken them on a few occasions since then.-The resident did have physician's orders for Remeron for appetite stimulant and Prosource due to his/her weight loss. During an interview on 8/4/25 at 9:10 A.M., LPN A said:-The resident had not been eating meals and had been having difficulty swallowing.-The resident was sent to the hospital and they wanted to keep him/her due to the mass that developed on his/her neck, but the resident refused to be admitted .-Since the resident had returned to the facility he/she had not been eating and had been taking his/her plate from the dining room to his/her room and then it sat there until staff eventually threw it away.-The resident would eat soups and biscuits with gravy but he/she did not receive these items routinely and he/she did not know why.-They should provide soft foods to the resident and food items they know he/she would eat, since they were easier to swallow.-The resident's diet was still regular and had not been adjusted to accommodate his/her ability to swallow.-The resident also used to receive liquid nutritional supplements but they were discontinued due to him/her refusing.-He/She did not know if it was the flavor of the supplement that he/she did not like or if they had tried a variety of flavors to see if he/she would drink any of the flavors.-It really did not matter if the resident liked to drink alcohol, they should provide foods that he/she could and would eat and encourage him/her to eat as much as possible until they could resolve his/her swallowing issue.-When he/she worked with the resident he/she tried to get him/her something that he/she would eat, not just what was being served, because the resident had told them that he/she did not like all of the food items/meals being served there.-The resident would eat any foods with gravy so they should give him/her gravy with all of his/her foods served and serve foods that he/she could eat or that are soft and easier to swallow.-The Registered Dietician had been in the facility, but there had been no new recommendations for the resident.-The resident was going to the hospital today for follow up because he/she was declining. -Nursing staff now have to assist him/her more with dressing and bathing and personal cares due to weakness.-He/She had spoken to the resident about the mass on his/her neck, the possibility that his/her health condition may be more serious and that he/she probably should have remained in the hospital so they could have completed further testing. During an interview on 8/4/25 at 12:36 P.M. the Director of Nursing (DON) said:-The Registered Dietician completed an annual nutritional assessment and then quarterly notes on the residents unless there was a nutritional concern.-The Registered Dietician came to the facility monthly, but he/she also had access to the resident's electronic medical record and could see the resident weights and changes at any time.-The Dietary Manager and nursing staff also informed the Registered Dietician of changes in resident nutritional status/weight loss so if the Registered Dietician needed to visit someone more frequently he/she could.-When they know a resident was having weight loss they would notify the Registered Dietician and the physician so nutritional interventions could be implemented.-They reviewed weights weekly and reviewed interventions to determine if they were adequate or needed to be changed and then they implemented new interventions or maintained the current interventions if they were working.-When the resident initially stopped eating and they noticed he/she was losing weight, they started the resident on liquid nutritional supplement but the resident wouldn't drink it, so they discontinued it.-The resident was also prescribed an appetite stimulant that he/she received daily and started weekly weights.-They obtained labs on the resident, and they notified the physician when the resident's labs were abnormal.-The physician addressed the abnormal labs and they sent the resident to the hospital for further evaluation, but he/she refused to be admitted .-They initiated Prostat most recently to try to support the resident's nutritional status.-They tried to give the resident foods that he/she liked, but he/she did not know if the resident's preferences were re-evaluated and documented.-The resident was not having difficulty swallowing until the mass was noted on 7/21/25 when he/she was sent to the hospital.-They had not ever gotten a swallow study for the resident to rule out swallowing difficulty.-Nursing staff was supposed to document the resident's meal intake on the daily meal intake sheets for each meal and it should be accurate.-All of the interventions regarding the resident's nutritional status and weight loss should have been in his/her care plan.-They asked the resident this weekend if he/she wanted to try a mechanical soft diet and he/she declined.-The resident liked gravy and would eat gravy on most foods but they did not put gravy on all of his/her food to try to get him/her to eat more.-They have gotten a physician's order to crush his/her medications to make them easier to take and he/she may not continue to refuse them.-They have not discussed Hospice/palliative care with the resident.-The resident went to the hospital regarding the mass on his/her neck today for further evaluation.

Based on observation, interview and record review the facility failed to ensure physician's orders were followed for monitoring and documenting one sampled resident's (Resident #1) dialysis access site (a surgically created pathway that allows blood to be removed from and returned to the body during hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) out of 24 sampled residents. The facility census was 56 residents.Review of the facility's undated Dialysis policy and procedure showed staff was to:-Palpate (to feel) the vascular access to feel for a thrill (vibration) that indicates arterial and venous blood flow and patency.-Auscultate (to listen) the vascular access with a stethoscope (a medical instrument for listening to the action of someone's heart, breathing or internal system) to detect a bruit (swishing sound) that indicates patency.-Check the patient's circulation by palpating the pulses further from the vascular access site and assessing for numbness, tingling, altered sensation, coldness, in the affected area.-Document assessment findings, any interventions, and patient responses, patient teaching and the patient's level of understanding. 1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including End Stage Renal Disease (ESRD a condition where the kidneys are damaged and cannot filter blood effectively), left leg fracture, depression, anxiety disorder, high cholesterol, low iron, and dependence on dialysis. Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/24/25, showed the resident:-Was alert and oriented with no cognitive incapacity.-Was independent or needed supervision with bathing, dressing hygiene, eating and toileting.-Had lower extremity impairment and used a wheelchair for mobility. -Received dialysis treatments. Review of the resident's Dialysis Notes and Communication dated March 2025 to July 2025, showed:-The communication was being completed with each visit. -Dialysis notes showed the resident's access site was checked at each dialysis treatment. Review of the resident's Physician's Order Sheet (POS) dated July 2025, showed physician's orders to:-Check the resident's left upper extremity access shunt (a surgically created connection between an artery and a vein, typically in the arm, to provide a reliable access point for dialysis) site for thrill and bruit every shift (ordered 10/4/23).-Assess the shunt area for blisters, check pulses distal to access for circulation, tingling, numbness, infection, warmth, tenderness and open sores daily (ordered 10/4/23).-Resident had dialysis Monday, Wednesday and Friday (location documented). Review of the resident's Treatment Administration Record (TAR) dated July 2025, showed physician's orders to check the resident's shunt for bruit and thrill every shift, assess the shunt area for blisters, check pulse distal to vascular access for circulation, tingling, numbness, signs of infection, redness warmth, tenderness, and open sores daily. Documentation on the TAR showed:-Assessment of the shunt area was completed daily except on 7/11/25, 7/20/25 and 7/30/25 (areas were left blank with no rationale as to why it was not completed).-Assess the shunt for thrill and bruit every shift was not completed at all on 7/11/25, and 7/29/25; was only completed twice daily on 7/3/25, 7/8/25, 7/9/25, 7/14/25, 7/20/25 and 7/28/25 (6 of 30 days) and was only completed as ordered on 7/5/25,7/6/25, 7/12/25, 7/13/25, 7/15/25, 7/16/25, 7/19/25, 7/26/25 and 7/27/25 (9 of 30 days). -For those dates and times the nurse did not assess the resident's shunt and check for thrill and bruit, there was no documented rationale showing why it was not completed as ordered. Observation and interview on 7/29/25 at 2:21 P.M., showed the resident was in his/her room, laying on his/her bed. The resident showed on his/her left upper arm was the shunt site and it was intact with no redness, swelling or open areas indicating any concern. The resident said:-He/She performed all of his/her own care and did not need much assistance from staff for bathing, dressing, toileting, eating or ambulating.-He/She went to dialysis three times weekly, on Monday, Wednesday and Friday, and he/she had no concerns with dialysis treatments or his/her dialysis shunt at this time.-The nursing staff did not check his/her dialysis shunt before he/she left to go to dialysis because he/she left before 5:00 A.M. to go to dialysis, but the nurse did assess and check his/her shunt after he/she returned from dialysis. During an interview on 7/30/25 at 1:48 A.M., Licensed Practical Nurse (LPN) C said:-They kept the resident's dialysis communication book at the nursing station.-The nurse documented the resident's vital signs and weight on the communication sheets and the dialysis center sent their communication back on dialysis days.-When the resident returned from dialysis, the nurse was supposed to check the thrill and bruit of the resident's access site and document it on the resident's TAR.-Upon looking at the TAR dated July 2025, he/she said they were to assess the shunt and check the thrill and bruit on every shift daily and document it on the TAR, and they were supposed to also assess the site for any redness, bleeding or bruising and document that information on the TAR also. -The TAR did not show that the nurses had been documenting their assessment and monitoring according to the physician's orders. During an interview on 8/4/25 at 12:36 P.M. the Director of Nursing (DON) said:-The physician's order should be complete and show where and how often the nursing staff was to monitor and care for the resident's dialysis access site.-He/She expected the nurses to follow physician's orders to check thrill and bruit daily on every shift and document their access of the resident's dialysis access site on the resident's TAR.-The resident used to have his/her access site checked three times daily when he/she first had the shunt placed, but now they probably only need to check it once daily and only check the thrill and bruit once daily.-They needed to follow the physician's orders as written until the order was changed.

Based on observation, interview, and record review, the facility failed to ensure medication refrigerator temperatures were checked daily and documented on the facility temperature log sheet to maintain safe storage of temperature controlled refrigerated medication; and failed to ensure to medication refrigerators were cleaned as scheduled and free of spills. This deficient practice had the potential to affect all residents with medication stored in the medication refrigerators. The facility census was 56 residents.Review of the facility's Storage of Medications policy dated 2024 showed:-Medications are to be stored in a safe, secure, and orderly manner.-Drugs are to be stored at proper temperatures. -Temperature logs are to be completed daily by the 11:00 P.M. -7:00 A.M. night shift. 1. Observation on 7/31/25 at 9:59 A.M of the facility second floor medication room showed:-The current refrigerator temperature was 34 degrees.-The refrigerator side door and inside had a sticky purplish substance noted. -The temperature log for July 2025 had 10 missing temperatures out 30 opportunities.-The refrigerator had unopened diabetic insulin and house stock emergency kit of insulin. During an interview on 7/31/25 at 9:59 A.M., Certified Medication Technician (CMT) A said: -The night nursing staff were responsible for checking and documenting medication refrigerator temperatures nightly.-Night nursing staff was scheduled to clean the medication refrigerators as needed. During an interview on 8/4/25 at 9:59 A.M., Licensed Practical Nurse (LPN) A said: -Night shift nursing staff were responsible for cleaning the medication refrigerator as scheduled and check refrigerator temperatures nightly and document findings on the posted temperature log.During an interview on 8/4/25 at 12:35 P.M., the Director of Nursing (DON) said:-Night nursing staff were responsible for checking refrigerator temperatures and cleaning the medication refrigerator as needed.-Night nursing staff were responsible for documenting the medication refrigerator temperature nightly on the posted temperature log.-He/She was responsible for oversite to ensure the safe medication storage in the refrigerator and cleanness of the medication refrigerator.

Based on observation, interview and record review, the facility failed to ensure physician orders were followed regarding a medical device being placed by proper personnel and administered as ordered for one sampled resident (Resident #1) that was not supposed to be self-administered out of 24 sampled residents. The facility census was 56 residents.Review of the facility's Medication Administration policy and procedure dated 2024, showed there was no policy or procedure for administering treatments or medical equipment or devices. Review of the facility's Self Administration policy and procedure dated 2018, showed there was no policy or procedure for self-administering medical equipment or devices.1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including end stage renal disease (ESRD a condition where the kidneys are damaged and cannot filter blood effectively), left leg fracture, depression, anxiety disorder, high cholesterol, low iron, and dependence on dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/24/25, showed the resident:-Was alert and oriented with no cognitive incapacity.-Was independent or needed supervision with bathing, dressing hygiene, eating and toileting.-Had lower extremity impairment and used a wheelchair for mobility. Review of the resident's Care Plan updated 3/28/25, showed the resident had modified independence for meeting physical, social, emotional and intellectual needs. It showed the resident was a fall risk related to weakness at times. The care plan:-Did not show the resident's current ambulatory status, and did not show that the resident had any health concerns with his/her legs.-Did not show that the resident needed or used a bone stimulator, did not show what it was used for, how it was to be administered, who was to administer it and how staff was monitoring its use. -It did not show the resident was able to self-administer the stimulator. Review of the resident's Physician's Order Sheet (POS) dated July 2025, showed physician's orders for:-A bone stimulator to the resident's left lower extremity for 20 minutes daily (ordered 3/14/25).-Check the resident's lower left extremity for integrity every shift (ordered 12/19/24).-The physician's orders did not show orders that the resident was to self-administer the bone stimulator. Review of the resident's Treatment Administration Record (TAR) dated July 2025, showed physician's orders to check the resident's left lower extremity every shift for integrity and to (apply) the bone stimulator to the left lower extremity for 20 minutes daily. The TAR showed:-Nursing staff initialed that they administered the bone stimulator as ordered daily except on 7/10/25, 7/11/25, 7/20/25 and 7/29/25, where there was no documentation or rationale for why it was not documented. Review of the resident's Medical Record did not show any documentation showing the facility assessed the resident for his/her ability to apply and administer bone stimulator device. Observation and interview on 7/29/25 at 2:21 P.M., showed the resident was in his/her room sitting up on his/her bed. There was a black, round device strapped on his/her lower leg that was connected to a machine that showed a timer. The machine was on and running. When the timer was completed, the resident removed the device from his/her leg and began placing it back in the container that was sitting beside him/her on the bed. The resident said:-The device was a bone stimulator that he/she wore for 20 minutes daily.-The bone stimulator helped his/her leg bone to heal because after he/she fractured his/her leg, it was not healing properly.-He/She used the bone stimulator independently and staff did not assess or monitor him/her while he/she used it.-He/She received the bone stimulator at the orthopedic clinic and had been using it since February/March 2025.-When he/she finished using the bone stimulator, he/she put it away (in the case) and let the nurse know he/she was finished.-He/she learned how to use the bone stimulator at the orthopedic clinic. During an interview on 8/1/25 at 1:59 P.M., Certified Nursing Assistant (CNA) B said:-He/She had seen the resident use the bone stimulator on his/her leg and saw him/her use it yesterday, but he/she did not know what it was for or what it did for the resident.-He/She had not ever administered it on the resident and had never been told to administer it on the resident.-When he/she asked the nurse, the nurse said the resident used the bone stimulator to heal his/her leg bone. During an interview on 8/1/25 at 2:28 P.M., Licensed Practical Nurse (LPN) A said:-The resident used the bone stimulator for bone healing-it was like an ultra sound for his/her leg.-The resident used the device because his bone was not healing due to his/her smoking.-The orthopedic clinic just checked the healing of the resident's bone again recently and it was still not completely healed so they would continue to have them use the bone stimulator.-The device cost $5000.00 and the orthopedic clinic brought it to the facility and trained him/her on its use.-He/She usually put it on the resident at around 1:30 P.M. daily and he/she administered it for 20 minutes for each area (there were two areas on the resident's leg that were to receive treatment).-When the treatment was completed, he/she removed it, then took the machine to charge it and store it in the medication room.-The bone stimulator remained in the medication room until the next use.-The resident was not authorized to use it himself/herself and should not have it in his/her room without the nurse present.-He/She was not working on 7/29/25, but the nurse in charge should not have put it on and left the resident or given it to the resident to use on his/her own. That never should have happened.-The resident sometimes did not like to have the bone stimulation treatment done and would complain and cuss at him/her but he/she knew it was to help the bone to heal.-LPN A then took the bone stimulator machine from the medication room and followed the resident upstairs and said he/she would be administering it to the resident. During an interview on 8/4/25 at 12:36 P.M. the Director of Nursing (DON) said:-The resident used the bone stimulator because his/her leg bone was not healing properly, and this was supposed to stimulate bone growth.-The resident was not authorized to operate the bone stimulator independently.-The nurse was supposed to place the bone stimulator on the resident's leg and set the timer.-The resident had two areas of his/her leg that were to receive treatment for 20 minutes each.-The nurse was to remove the stimulator once treatment was completed.-Nursing staff was aware the resident had removed the stimulator before.-The nurses had at times placed the bone stimulator on the resident and then left the room.-Once the treatment was completed, the resident usually informed the nurse so the nurse could remove the stimulator or change the position of the stimulator.-The resident should not remove the bone stimulator himself/herself for any reason.

Based on observation, interview and record review, the facility failed to ensure an individualized activity plan was goal directed and incorporated the interest and ability of one sampled resident (Resident #20) out of 24 sampled residents. The facility census was 56 residents. Review of the facility Activity policy dated 2022, showed:-The purpose to ensure residents receive meaningful activities. To ensure assessments for activities preferences are completed on admission. To ensure progress documentation of activity assessment. -Provide a plan of activities appropriate to the needs of the residents. -Assess resident needs and develop resident activities goals for the written care plan. -Encourage resident participation in activities and document outcomes. -Review goals and progress notes. -Properly document Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) reports and progress notes. Develop a plan of care addressing activity preferences and services. -Obtain necessary equipment and supplies and provide for their accessibility through organized storage.-Quarterly documentation on activity progress note and whenever needed, changes in conditions or preferences. -The Activity director is to ensure communication with all departments via morning meetings and Quality Assurance (QA) meetings regarding activity assessments or changes in level of activities. -The Activity director conducts resident council meeting and reports to the QA team for interventions and follow-up. 1. Review of Resident #20's admission sheet showed the resident was admitted to the facility on [DATE], with the following diagnoses:-Unspecified Dementia (dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Anxiety disorder (a common mental health condition characterized by excessive and persistent worry, fear, and nervousness).-Muscle weakness.-Rheumatoid Arthritis (an inflammatory disease that may lead to serious joint damage and disability).-Urinary incontinence.-Other malaise (is a non-specific symptom that general feeling of discomfort, illness, or lack of well-being). Review of the resident's quarterly MDS dated [DATE], showed the resident: -Needed modified independence-some difficulty in new situations only.-Needed setup or clean-up assistance with eating and dental care. -Needed partial/moderate assistance with transferring, dressing, and toileting. -Needed substantial/maximal assistance with bathing. -Was dependent on a wheelchair. -Note: His/Her activity preferences were not identified on this assessment.Review of the resident's Care Plan dated 7/15/25, showed:-On 5/30/24 the resident had limited to no activity involvement. Currently, one to one activities to help with engagement.-On 8/21/24 the resident had limited involvement in group activities and continued one to one.-The goal showed the resident would participate in activities of choice times per week by review date. --The goal did not indicate how many times per week the resident would participate in activities. -Interventions showed one to one activities and the resident preferred socializing, nail care, and enjoyed the television (tv) channels 4, 41, 9, and 5.-Staff was to explain to the resident the importance of social interaction, and leisure activity time. -Encourage the resident's participation by notifying in advance of activities, announce activities on intercom, and personally invite. Review of the resident's Special Programming One to One Log showed:-One to one activities only occurred one time per week.-7/7/25-nail care; 7/14/25-nail care; 7/21/25-nail care; 7/28/25-nail care.-There was no other documentation showing the resident was offered any other one on one activities.-There was no other documentation of the resident participating in scheduled activities. Observation on 7/29/25 from 11:30 A.M. to 12:20 P.M. showed: -The resident was sitting in a wheelchair in the tv community area and kept repeating to staff that they needed to close the cupboard doors until the staff closed the doors.-The resident then would say it was time to eat and to go get another resident. -Staff would tell him/her that the resident was sleeping. Resident would keep saying they needed to go get the other resident. Observation on 7/30/25 showed:-At 2:13 P.M. the resident was in bed with his/her eyes closed and the bed was low to the floor with fall mats next to it. -At 3:03 P.M. the resident was awake and said he/she was tired and was going to get up at 4:00 P.M. for dinner. -The activity calendar showed on Tuesdays at 2:00 P.M. was residents' choice. -There were no scheduled activities after 2:00 P.M. Monday to Friday. Observation on 8/1/25 at 9:17 A.M., showed:-The resident was sitting in the community tv area eating his/her breakfast. -He/She ate all his/her breakfast. -There were no activities going on.-There was nothing available for the resident's to do before scheduled activities began.During an interview on 8/1/25 at 9:17 A.M. the resident said:-He/She was feeling better today.-He/She was getting a bath later. Review of the posted activity calendar dated August 2025 showed:-Scheduled activities did not start until 10:00 A.M. Monday to Friday. During an interview on 8/1/25 at 10:06 A.M., Certified Medication Technician (CMT) A said:-He/She believed the resident used to be a Registered Nurse and liked to direct the staff.-He/She had seen the resident be constant and repetitive verbally.During an interview on 8/1/25 at 10:30 A.M., Certified Nursing Assistant (CNA) C said:-The resident would be demanding and authoritative. -The resident used to be a nurse.-He/She could redirect the resident by using the residents nursing background. -He/She would also use positive enforcement and previous examples of the resident doing similar things to get them to do it today. -In the beginning they tried to redirect the resident with activities like puzzles, but it didn't work. -Redirecting the resident to church or reasoning with him/her like a nurse and having the resident refer to his/her nursing training worked. During an interview on 8/1/25 at 11:23 A.M., Licensed Practical Nurse (LPN) A said:-He/she would redirect the resident by going over and talking with him/her.-The resident liked to go to church on Mondays, going to parties, and bingo. During an interview on 8/4/25 at 11:15 A.M., the Activity Director said:-He/She would do the resident's nails.-He/She would trim his/her hair occasionally when the resident wanted it. -The resident would go to the community activities.-The resident liked to have his/her mail read to them. -The resident used to be a CNA. -The resident was able to participate in nursing home week.-He/She had one on one activities with the resident every Monday when doing his/her nails. -He/She said they had heard of measuring goals for the residents but had not started with this resident.-He/She did not know why the resident needed one on ones was just told it was because the resident didn't do a lot of other activities. During an interview on 8/4/25 at 12:36 P.M., the Director of Nursing (DON) said:-If a resident was not involved in group activities and if their level of participation or function was lower then what they could comprehend then the resident should be on one on ones. -There should be documentation as to why the person should have one on ones. -There should be documentation as to how many times a week they were getting one on ones. -There should be documentation what the resident's goals were and how those goals were to be measured. -The resident liked to be involved in one on ones with snacks.-The resident also liked to be involved with what's going on.-The resident was not big on tv, music or puzzle books.-Personal care was very important to the resident. -The staff would redirect him/her with what was in front of them, for example if there was food staff would have the resident take a bite. -If there was nothing to use then they would redirect the resident to go wash his/her hands or with some other grooming tasks. -The resident enjoyed personal care.-The resident was a retired nurse.

Based on observation, interview, and record review, the facility failed to ensure resident smoking materials were stored safely for one sampled resident (Resident #40); failed to ensure a safe smoking environment after a resident fell asleep while holding a lit cigarette; failed to re-assess the resident for safe smoking; and failed to develop care plan interventions to prevent the incident from recurring for one sampled resident (Resident #42), out of 24 sampled residents. The facility census was 56 residents. Review of the facility's Smoking Policy dated 2022 showed:-The resident's Safe Smoking ability was to be completed yearly or on quarterly assessments.-Assess resident's safe smoking behavior. Determine needs for safety such as a smoking apron, 1:1 supervision and address in the care plan. -Smoking policy given to the resident at the time of admission and signed by the resident or responsible party to acknowledge understanding of the policy. -Staff will round every hour to monitor resident who are identified with risk behavior from history of smoking in non-designated areas. -If do not follow smoking policy, could result in smoking material removed from the resident's possession. 1. Review of Resident #40 admission Face sheet showed the resident:-Had a diagnosis of Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others).-Used tobacco. Review of the resident's admission Smoking Policy and Procedure agreement signed on 8/7/23 showed:-He/She had agreed to the facility smoking policy.-He/She would be responsible for compliance and noncompliance with this policy. Review of the resident's Annual Smoking Safety screen dated 7/4/24 showed:-He/She was safe to smoke without supervision. Review of the resident's Smoking Care Plan dated 4/9/25 showed:-He/She smoked.-Would follow the facility smoking rules and would be safe from any smoking hazards. Observation on 7/28/25 at 10:30 A.M., of the resident's room showed:-The resident had a Styrofoam cup of full of used cigarette butts. -He/She was not in the room at the time of observation. -The resident had a roommate. -No storage container for smoking material. Observation on 7/29/25 at 11:40 A.M. showed the resident:-Had collected old cigarette butts.-Was opening the butts to remove the filter and empty the tobacco out onto newspaper. During an interview on 7/29/25 at 11:40 A.M. the resident said he/she:-Was saving the cigarette butt paper to use to roll the tobacco in.-It was cheaper to collect used cigarette butts and then empty the tobacco out to make his/her own cigarettes. -Did not have new cigarette rolling papers.-Had been using the old cigarette butt paper to roll tobacco into, to be able smoke.-Was made aware of the potential risk when he/she used someone else's cigarette butts by facility nursing staff.-Did not have a safe container to store the used cigarette butts in. During an interview on 8/1/25 3:04 P.M., Certified Medication Technician (CMT) A and Certified Nursing Assistant (CNA) C said:-They were aware some residents collected used cigarettes butts, due to not having money to buy cigarettes. -The residents would obtain the tobacco out of the old butts to make own cigarettes. -They were not aware the resident was removing the filter and used the old cigarette butt paper to roll the tobacco in. -The facility did not provide cigarette rolling paper and some residents were able to get facility bought cigarettes. -He/she was not aware if the facility provides storage container for smoking materials. During an interview on 8/4/25 at 9:59 A.M., Licensed Practical Nurse (LPN) A said: -Some of the residents who smoked were able to store smoking materials in their room.-Social services was responsible for completing the resident's smoking assessment. -He/She was not aware of the facility providing the resident with safe smoking materials storage container. -Most residents kept smoking material in their bedside table drawer. -The facility had open smoking times. During an interview 8/4/25 at 12:35 P.M., Director of Nursing (DON) said:-Most of the residents were able to keep smoking material in their rooms. -The residents who wished to smoke were assessed for safe smoking by social services upon admission and annually. -The resident was not provided a secure box to place store smoking materials in.-If a resident violated the signed smoking agreement, he/she would require supervised smoking and possible safe smoking apron to wear. -Smoking time for the indoor smoking area were posted on smoking room door. -Housekeeping was responsible for monitoring resident's smoking at least every hour. -He/She was not aware Resident #40 was collecting other peoples used cigarette butts.-He/She was not aware the resident was rolling own cigarettes with used cigarette filter papers. 2. Review of Resident #42's Face Sheet showed the resident was admitted to the facility with diagnoses that included heart disease, high blood pressure, depression, anxiety, diabetes and back pain. Review of the resident's Care Plan dated 5/9/23, showed the resident was non-compliant with the facility smoking policy and procedure. Interventions showed the facility staff would:-Educate the resident on the facility smoking policy and consequences for violations.-Evaluate the resident quarterly and as necessary for smoking assessment.-The resident knew that continued non-compliance with smoking and fire safety could result in discharge from the facility.-Ensure the resident had signed the smoking agreement. Review of the facility's undated Smoking Log showed:-The resident was one of the resident's that smoked in the facility-The resident's Smoking assessment dated [DATE] showed the resident was fully capable of understanding the smoking policy and procedure, hold a cigarette properly and dispose of ashes/use the ashtray, able to use a lighter safely and properly and safely discard the cigarette, butts and ashes.-The assessment did not show whether the resident fell asleep when smoking, was easily distracted, or if he/she smoked in prohibited areas. -The assessment did not show if the resident was able to complete return demonstration.-The assessment did not show if the resident was deemed to be fully capable of smoking without assistance or monitoring, or if he/she required any assistive devices. Review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/5/25, showed the resident:-Was alert and oriented with no cognitive incapacity.-Was independent or needed supervision with bathing, dressing hygiene, eating and toileting.-Had no behaviors or mood disorders.-Ambulated with a walker. Review of the resident's Smoking Safety assessment dated [DATE], showed:-The resident had no cognitive, vision or dexterity impairments.-The resident smoked between 5 and 10 cigarettes daily throughout the day and night.-The resident was able to light his/her own cigarette and did not require any assistance or adaptive equipment to smoke.-The resident was deemed to be able to smoke safely and independently without supervision. Review of the resident's Nursing Notes dated 7/6/25 showed:-Facility staff found the resident in the designated smoking room with his/her head down, asleep while holding a lit cigarette in his/her hand, with his/her hand resting on his/her clothes.-Staff immediately woke the resident and informed him/her that he/she could not sleep in the designated smoke room with a lit cigarette.-The writer also noticed a hole in the resident's clothing close to where he/she was holding a cigarette.-The resident raised his/her head opened his/her eyes and exited the smoke room after putting out his/her cigarette.-There were no additional notes regarding this incident in the nursing notes and there were no notes showing the resident received any additional monitoring after the incident occurred. Review of the resident's Care Plan showed there was no update to the resident's care plan that showed the resident had an incident of falling asleep while holding a lit cigarette and interventions to try to prevent this from recurring and to promote safety while the resident smokes. Review of the resident's Medical record showed:-There was no smoking re-assessment completed after the incident on 7/6/25.-There was no documentation showing nursing staff completed follow up monitoring of the resident after the incident.-There were any new interventions implemented to keep the resident safe while smoking. Observation and interview on 7/29/25 at 11:50 A.M., showed the resident was in the lobby area dressed for the weather and was clean and well-dressed without odor. There did not seem to be any holes in his/her clothing from smoking. The resident was ambulating with his/her walker and went to smoke in the designated indoor smoking room. There was no staff supervision at the nursing station or in the designated indoor smoking area. The resident was able to light his/her own cigarette and smoke without any issues. When he/she was done, the resident put his/her cigarette in the self-closing smoking container and ambulated out of the smoking room. The resident said:-He/She had been living in the facility for three years and usually smoked in the indoor smoke room, but also smoked outside.-He/She was not having any issues with smoking and was aware of the smoking policy and procedure. During an interview on 8/1/25 at 2:19 P.M., the Administrator said:-The resident was found asleep in the designated smoking area with a lit cigarette in his/her hand, but he/she had not burned a hole in his/her clothing at that time and there was no injury to the resident.-The resident smoked in the designated smoking areas indoors and outside and some of the resident's clothes have holes in them.-They did not document an incident report because the resident did not sustain any injury. During an interview on 8/1/25 at 2:48 P.M., CNA B said:-The resident usually smoked independently and was safe to smoke without supervision.-He/She was unaware of an incident where the resident was found sleeping in the smoke room with a lit cigarette in his/her hand.-If nursing staff found the resident that way, they would take the cigarette out of the resident's hand and wake the resident up.-They would then let the charge nurse know what happened and they would not allow the resident to go back to smoke independently until after the nurse had assessed him/her.-They probably would implement a smoking smock for the resident to use while smoking and if the resident refused, they would no longer be able to smoke without supervision.-The nurse would need to document it in the resident's medical record. During an interview on 8/4/25 at 12:09 P.M., LPN A said:-If the resident was independently smoking and the staff caught the resident asleep with a lit cigarette in his/her hand, they would take the cigarette, wake the resident and assess the resident for any injury if needed.-They should re-assess the resident for smoking safety and they would supervise the resident's smoking until the resident no longer was at risk.-They may also provide a smoking apron for the resident to further protect the resident.-Interventions should have been documented in the nursing notes and care plan because the resident had a change in his/her ability to smoke independently and safely. During an interview on 8/4/25 at 12:36 P.M. the DON said:-Residents ability to maintain their own smoking materials was dependent on the residents ability to smoke independently.-Residents sign a smoking acknowledgement form which had the rules for smoking on it and they explained the rules for smoking.-If the resident was violating a smoking policy, the resident was already aware they could have their cigarettes removed if they were deemed to be unsafe to smoke.-The Social Worker completed smoking assessments annually and as needed.-Smoking times were posted on the door for indoor smoking and they had no designated smoking times for outdoor smoking.-Staff smoke outdoors on the designated smoking patio also and were sometimes outside at the same time as the residents, but they did not have staff assigned to supervise smoking when the residents go smoke.-The expectation regarding the resident's incident was for staff to arouse him/her then remove the cigarette; educate him/her on falling asleep with her cigarette; then inform the nurse and social worker and let the staff know what happened.-The Social Worker should re-assess the resident for safe smoking.-They should have provided the resident with an apron to wear during smoking, and they should also monitor his/her smoking for at least two weeks.-The resident's care plan should have also been updated.-He/She was informed when the incident occurred the nursing staff immediately implemented the smoking apron and the resident was accepting to that.-He/She had not seen the resident smoking.

Based on interview and record review, the facility failed to ensure a closed record was complete by showing a recapitulation of stay for one sampled closed record resident (Resident #62) out of 24 sampled residents. The facility census was 56 residents. 1. Review of Resident #62's admission sheet showed the resident was admitted to the facility on [DATE], with diagnoses of Congenital Dyserythropoietic Anemia (rare blood disorder resulting from a decrease number of red blood cells), Post Traumatic Stress Disorder (PTSD), Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety), Essential Hypertension (High Blood Pressure), Alcohol Dependence, absence of right leg above knee, Anemia (a decrease in hemoglobin in the blood to levels below the normal range), absence of left leg below knee, homelessness, Type 2Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), low back pain, other chronic pain, sleep disorder, and dependence on wheelchair. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/9/25, showed the resident:-Was cognitively intact.-Had medically complex conditions. Review of resident's nursing notes dated 6/2/25 showed the resident was discharged by facility van to his/her siblings house. Review of resident's discharge instructions dated 6/2/25 showed a list of medications. Review of the resident's medical record showed on 6/2/25 there was no recapitulation of stay.During an interview on 8/4/25 at 11:03 A.M., Social Services Designee said:-He/She did not know what a recapitulation was. -He/She did not have a list of items that the resident brought with them to the facility. During an interview on 8/4/25 at 12:36 P.M., the Director of Nursing (DON) said:-There should have been a recapitulation. -The charge nurse was responsible for the recapitulation.

Based on interview and record review, the facility failed to ensure wound care treatments and skin assessments were completed and documented for one sampled resident (Resident #3) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Non-Pressure Ulcer Assessment and Treatment dated from 2006 showed: -The purpose of the policy was to maintain skin integrity and prevent any type of wound development. -All non-pressure ulcers would be assessed and documented weekly using the provided form. -All residents would be assessed every thirty days for skin integrity. -All non-pressure wounds would be treated according to physician order. -Skin screenings were done according to bath schedule. -Assessment weekly/monthly or more frequent would occur as instructed by the Registered Nurse (RN) or Director of Nursing (DON). -A focused assessment should be completed of the wound area. -Communicate among shifts of progress and healing. -Provide treatment per physician order not limited to pain or infection. 1. Review of Resident #3's admission Record showed he/she admitted to the facility with the following diagnoses: -Cerebral Palsy (a group of conditions that affect movement and posture caused by damage that occurs to the developing brain, most often before birth). -Peripheral Vascular Disease (PVD- inadequate blood flow to the extremities). Review of the resident's undated care plan showed: -He/She had limited physical mobility related to his/her diagnosis of cerebral palsy. -He/She had PVD with the following interventions: --The resident was to wear bunny boots (a protective boot for foot wounds designed to offload pressure). --Monitor the extremities for signs and symptoms of injury, infection or ulcers. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by staff for care planning) dated 2/24/25 showed: -The resident was cognitively intact. -The resident had a Stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) or great, a scar over a bony prominence, or non-removable dressing/device. -The resident did not have any pressure ulcers with the seven day look back period. -The resident did not have any current venous ulcers (a wound on the leg or ankle caused by abnormal or damaged veins). Review of the resident's Physician Order Sheet (POS) dated March 2025 showed: -An order for skin gel protective (an invisible skin protectant gel that moisturizes and protects while the skin is recovering), apply topically to his/her right great toe two times a day. -An order for staff to clean the resident's right foot with water and soap, apply vitamin A and D ointment (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) and zinc ointment (ointment containing zinc oxide, used for various skin conditions) to areas on his/her right great toe and third toe daily dated 3/10/25. -An order for staff to clean bilateral lower extremities with water and soap, apply Vitamin A and D ointment, two times a day. -An order for staff to apply Calmoseptine to the resident's open areas on his/her right leg daily. Review of the resident's Treatment Administration Record (TAR) dated March 2025 showed: -The resident missed or lacked documentation of seven treatments of the skin gel protective during the 7:00 A.M. to 3:00 P.M. shift through the month of March 2025. -The resident missed or lacked documentation of his/her right great toe and third toe treatments eight times from 3/10/25 through 3/31/25. -The resident missed or lacked documentation of his/her bilateral lower extremities treatment seven times during the 7:00 A.M. to 3:00 P.M. shift through the month of March 2025. -The resident missed or lacked documentation of his/her bilateral lower extremities treatment ten times during the 3:00 P.M. to 11:00 P.M. shift through the month of March 2025. -The resident missed or lacked documentation of his/her right leg treatment 15 times through the month of March 2025. Review of the resident's POS dated April 2025 showed an order for skin gel protective (an invisible skin protectant gel that moisturizes and protects while the skin is recovering), apply topically to his/her right great toe two times a day. Review of the resident's TAR dated April 2025 showed the resident missed or lacked documentation of 12 right great toe treatments during the 3:00 P.M. shift to 11:00 P.M. shift from 4/1/25-4/20/25. Review of the resident's weekly skin assessment on 4/21/25 for the month of April 2025 showed the resident's last skin assessment was 4/10/25. During an interview on 4/21/25 at 12:37 P.M. Licensed Practical Nurse (LPN) A said: -The resident's open wounds had healed, so the facility's contracted wound care team had stopped seeing the resident. -It was identified the resident's previous heel wound had opened back up. -The resident was to start seeing the contracted wound care team at the facility later in the week due to his/her heel wound opening back up. During an interview on 4/21/25 at 2:47 P.M. Certified Nursing Assistant (CNA) A said: -Resident skin was checked by CNAs during resident showers. -If CNAs were to find any new skin issues, they were responsible for telling the nurse on duty immediately. -The resident had chronic wounds to his/her feet. -The resident had a history of heel wounds, so the resident wore heel protectant boots. -The resident's heel wound had re-opened. During an interview on 4/21/25 at 3:20 P.M. LPN A said: -Residents skin assessments were in a separate binder from the resident's regular medical chart. -Skin assessments were completed weekly by the facility nurses. -There was a skin assessment schedule in the skin assessment binder. -The nurses were expected to document the skin assessments upon completion of the assessment. -The nurses were expected to perform treatments as ordered by the physician. -The Director of Nursing (DON) was responsible for ensuring the completion of treatments. -He/She was unsure why the other shifts were not getting wound treatments done. -He/She thought that treatments were getting done and not getting documented. -The nurses were expected to document the completion of each treatment. During an interview on 4/22/25 at 8:46 A.M. the DON said: -Skins assessments were completed weekly. -There was a schedule that was in the skin assessment binder that staff were expected to follow in order to get the assessments completed. -He/She was responsible for ensuring completion of the skin assessments. -Treatments should be done as ordered. -The nursing staff tell him/her that the treatments are getting completed, the nursing staff are just not documenting the completion of the treatments. -He/She expected staff to document on the TAR when treatments were completed. -The nursing staff should have been documenting all of the resident ' s wound treatments. -Resident #3 should have had an additional skin assessment completed between 4/10/25-4/21/25. During an interview on 4/24/25 at 1:04 P.M. LPN B said: -He/She worked the 3:00 P.M. to 11:00 P.M. shift. -Treatments were supposed to be documented on resident TARs upon completion of the treatment. -He/She had too much work to do on his/her shift and he/she did not have time to document treatments. -The residents did get their treatments on the days he/she worked at the facility. -The DON was responsible for ensuring treatments were documented on resident TARs. -The resident should have had an additional skin assessment completed between 4/10/25-4/21/25. -He/She only treated the resident's wounds when the resident had open wounds. -The resident had refused some treatments in the past. -If a resident refused any treatment, it should be documented on the TAR. -The resident only had redness on his/her feet and buttocks. MO00252072

Based on interview and record review, the facility failed to ensure that wound care treatments were completed and documented including weekly wound tracking and measuring was completed for one sampled resident (Resident #2) who had pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin); and failed to ensure weekly skin assessments were completed and documented for one sampled resident (Resident #1) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Pressure Ulcer Treatment Policy and Procedure dated from 2006 showed: -Staff were to assess pressure ulcers by using the wound assessment form weekly and for any change in condition. -The staff were to use appropriate topical therapy per physician order or recommendation from wound care specialists. -The staff were to monitor skin surfaces daily and document on the appropriate form. Review of the facility's policy titled Ulcer Documentation dated from 2006 showed: -After assessing a wound, proper documentation was necessary for medical, legal, and reimbursement reasons. -The documentation was to include: --The resident's name and date of assessment or treatment. --Vital signs if applicable. --If the dressings were intact or not. --Locations of wound. --Size of wound. --Any tracking or undermining of the wound. --Any wound drainage or odor. --What the wound tissue looked like. --The stage of the pressure ulcer. --Past treatment and current treatment. --Any follow-up needed. 1. Review of Resident #2's admission record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Diabetes Mellitus (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Essential Hypertension (high blood pressure). Review of the resident's Physician Order Sheet (POS) dated March 2025 showed an order for the resident to be admitted to hospice (end of life care) on 3/23/25. Review of the resident's skilled nursing visit note from hospice dated 3/23/25 showed: -The resident had a left medial buttock/gluteal fold Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but, bone, tendon, or muscle is not exposed. Slough may be present but dies not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer which measured two and a half centimeters (cm) in length, two cm in width, and one cm in depth. -The resident had a right arm/elbow Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister)which measured four cm in length and one cm in width. -The resident had a right arm/elbow unstageable (slough and/or eschar, known but not stageable due to coverage of wound bed by slough and/or eschar)pressure ulcer which measured two cm in length and two cm in width. -The resident had a right proximal arm/forearm Stage II pressure ulcer which measured four cm in length and one cm in width. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/25/25 showed: -The resident was severely cognitively impaired. -The resident had one or more unhealed pressure ulcers at Stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) or higher. -The resident had four Stage II. -The resident had one Stage III -The resident had one unstageable pressure ulcer. -The resident was receiving hospice care. Review of the resident's hospice visit note dated 4/2/25 showed: -The resident's right upper arm wound appeared to be a Stage III pressure ulcer. -The resident had two left ischial wounds which were improving. -The resident had a coccyx wound which was improving. -The resident had right forearm wounds that were improving. -No wound measurements were documented in this note. Review of the resident's care plan dated 4/8/25 showed: -The resident had a pressure ulcer to the left ischium (a paired bone forming the lower and back part of the hip bone) with the following interventions: --Staff were to administer treatments as ordered and to monitor effectiveness. --Staff were to assess/record/monitor wound healing weekly. --Staff were to measure the length, width, and depth where possible. --Report improvements and declines to the Medical Director. Review of the resident's POS dated April 2025 showed: -An order for Calmoseptine (primarily used as a moisture barrier to protect and heal skin irritations) to be used on his/her right arm open areas, daily, every shift with an order stop date of 4/11/25. -An order for betadine (rapidly kills bacteria commonly responsible for wound and skin infections) to be used on the left hip, daily, every shift. Review of the resident's Treatment Administration Record (TAR) dated April 2025 showed: -The resident missed or lacked documentation for one treatment of Calmoseptine from 4/1/25-4/11/25 on the 7:00 A.M. to 3:00 P.M. shift. -The resident missed or lacked documentation for nine treatments of the Calmoseptine from 4/1/25-4/11/25 on the 3:00 P.M. to 11:00 P.M. shift. -The resident missed or lacked documentation of seven treatments of the Calmoseptine from 4/1/25-4/11/25 on the 11:00 P.M. to 7:00 A.M. shift. -The resident missed or lacked documentation of two treatments of the betadine from 4/1/25-4/21/25 on the 7:00 A.M. to 3:00 P.M. shift. -The resident missed or lacked documentation of 17 treatments of the betadine from 4/1/25-4/20/25 on the 3:00 P.M. to 11:00 P.M. shift. -The resident missed or lacked documentation of nine treatments of the betadine from 4/1/25-4/20/25 on the 11:00 P.M. to 7:00 A.M. shift. -On 4/9/25 the resident's four arm wounds were measured. NOTE: The measurements on 4/9/25 were the only measurements found in the resident's medical record documented by the facility. 2. Review of Resident #1's admission Record showed the resident admitted to the facility on [DATE] with the following diagnoses: -Diabetes Mellitus (DMII- a complex disorder or carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Acquired Absence of Other Right Toes. -Acquired Deformities of Toes, Unspecified Foot. -Fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia). - Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet). Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was at risk for developing pressure ulcers. -The resident had a Stage I or greater, a scar over bony prominence, or non-removable dressing/device. -The resident had one Stage III pressure ulcer that was present upon admission to the facility. Review of the resident's undated care plan showed the resident did not have a care plan focus for skin impairment. Review of the resident's wound report assessment completed by the facility's contracted wound company on 4/4/25 showed the resident had an open pressure wound on his/her coccyx. Review of the resident's weekly skin assessment form on 4/21/25 for the month of April 2025 showed the resident had not had a full body skin assessment sine 4/9/25. 3. During an interview on 4/21/25 at 12:37 P.M. Licensed Practical Nurse (LPN) A said Resident #2 was unable to see the facility's contracted wound care team due to the resident receiving hospice services. During an interview on 4/21/25 at 2:00 P.M. LPN A said the back of resident TARs was the place nurses were to document wound measurements. During an interview on 4/21/25 at 2:47 P.M. Certified Nursing Assistant (CNA) A said: -Resident #2 had his/her wounds upon admission to the facility. -Resident #2 had a tendency to pick at the treatments that were done to the wounds on his/her arm. -Resident's skin was checked by CNAs during resident showers. -If CNAs were to find any new skin issues, they were responsible for telling the nurse on duty immediately. -Any resident with wounds should have a wound care focus on their care plan. During an interview on 4/21/25 at 3:20 P.M. LPN A said: -Resident skin assessments were in a separate binder from the resident's regular medical chart. -Skin assessments were completed weekly by the facility nurses. -There was a skin assessment schedule in the skin assessment binder. -The nurses were expected to document the skin assessments upon completion of the assessment. -Wound measurements were completed weekly. -The hospice company was responsible for measuring the Resident #2's wounds weekly. -Resident #2's wounds were improving, and some were almost healed. -The nurses were expected to perform treatments as ordered by the physician. -The Director of Nursing (DON) was responsible for ensuring the completion of treatments. -He/She was unsure why the other shifts were not getting wound treatments done. -He/She thought that treatments were getting done and not getting documented. -The nurses were expected to document the completion of each treatment. During an interview on 4/22/25 at 8:46 A.M. the DON said: -Skins assessments were completed weekly. -There was a schedule that was in the skin assessment binder that staff were expected to follow in order to get the assessments completed. -He/She was responsible for ensuring completion of the skin assessments. -He/She expected weekly wound measurements to be completed for all identified wounds in the building. -The contracted wound care team was responsible for measuring the wounds. -The nurses were expected to document the weekly measurements on the resident's TARs. -Resident #2's TAR should have more than just the one weekly measurement on his/her TAR. -Daily documentation of the wounds should be completed with wound type and response to treatment. -He/She was aware that the daily wound documentation was not getting completed. -Resident #2 did not have any pressure ulcers. -Resident #2's wound on his/her bottom was almost healed. -He/She was unsure of what type of wounds Resident #2 had. -Treatments should be done as ordered. -Resident #2 was unable to see the contracted wound team due to being on hospice, so the hospice company managed the Resident #2's wounds. -The facility should also be measuring Resident #2's wounds, not just hospice. -The nursing staff tell him/her that the treatments are getting completed, the nursing staff are just not documenting the completion of the treatments. -He/She expected staff to document on the TAR when treatments were completed. -The nursing staff should have been documenting all of the resident's wound treatments. -Resident #1 did not have a skin/wound care plan because he/she had not created one yet. -Resident #1 should have had an additional skin assessment completed between 4/9/25-4/21/25. During an interview on 4/24/25 at 1:04 P.M. LPN B said: -He/She worked the 3:00 P.M. to 11:00 P.M. shift. -Treatments were supposed to be documented on resident TARs upon completion of the treatment. -He/She had too much work to do on his/her shift and he/she did not have time to document treatments. -The residents did get their treatments on the days he/she worked at the facility. -Resident #2's wounds were healing. -He/She was unsure if Resident #2's hospice nurse completed weekly wound measurements. -Weekly measurements were completed for all wounds in the facility. -The contracted wound care team usually came to the facility during the 7:00 A.M. to 3:00 P.M. shift, so he/she did not normally have to measure wounds. -All wound measurements could be found in the wound book. -The DON was responsible for ensuring the weekly measurements were completed. -The DON was responsible for ensuring treatments were documented on resident TARs. -Resident #1 should have had an additional skin assessment completed between 4/9/25-4/21/25. -Resident #1 should have a wound/skin focus on his/her care plan. MO00252072

Based on interview and record review, the facility failed to ensure adequate Cardiopulmonary Resuscitation (CPR - a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) efforts were provided, and monitored for effectiveness by trained staff when Licensed Practical Nurse (LPN) A initiated CPR on one sampled resident (Resident #1), who desired to have a full-code status (all life saving measures taken), out of six sampled residents. LPN A then discontinued CPR after obtaining a faint pulse without obtaining vital signs to ensure the resident was stable, to collect transfer hospital paperwork, leaving Certified Nursing Assistant (CNA) A, who was not CPR certified, to assess and monitor the resident until Emergency Medical Services (EMS) arrived. LPN A was the only CPR certified staff in the building at the time. Upon EMS arrival, Resident #1 was found to have no pulse and was not breathing, resulting in EMS initiating CPR upon arrival. The resident subsequently died at the facility. The facility census was 44 residents. The administrator was notified on [DATE] of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility's undated Policy for Medical Emergency Response showed: -CPR Policy: --Begin external cardiac massage and assisted ventilation when a resident with full code status is found unconscious without pulse and/or respirations. CPR will continue according to the American Red Cross Program. --The physician and guardian/family will be notified immediately by staff designated by the charge nurse. --The Administrator and Director of Nursing (DON) will review staffing to ensure a CPR-certified nurse is on duty for each shift. -During the emergency situation, such as a resident is found unresponsive with no response in neurological check; severe injury; or excessive bleeding: --Initiate the nursing assessment along with the assigned duty to call 911 or Emergency Medical Services (EMS). --Initiate CPR if applicable for CPR policy and procedures. -The charge nurse at that shift is in charge of the emergency procedure, including ensuring the reports are given properly to other agencies and the documentation reflects the actual procedures. -During the emergency situation, the charge nurse immediately assigns the duties to staff to include: --Who calls 911? --Who brings the emergency supplies to the scene? --Who initiates CPR? Who assists? --Who calls the family and the attending physician? --Who writes notes? Where are the notes written? --Who takes vital signs? --What information will be given to EMS, and who will prepare that information? --Who will administer medications? --Who does the documentation related to the resident's response and nursing procedures? --Who contacts the administrator and/or the DON? -An Information about CPR attachment gave additional information including: --A person should stop CPR when help arrives to take over, or the victim starts to move. --Agonal respirations happen when the heart stops beating in cardiac arrest, but the breathing center in the brain is still alive for a couple of minutes and causes the victim to take a few abnormal breaths and will disappear in a couple of minutes. Abnormal breathing should not stop a person from doing CPR. --If the victim regains breathing and a pulse, they should be placed in the recovery position, which means placing the person on his/her side. This allows for the person not to choke on saliva and helps keep the airway open. The downside arm may be raised to support the head. 1. Record review of Resident #1's Admission Record showed he/she: -admitted to the facility on [DATE]. -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] --End stage kidney disease. --Stroke (occurs when a blood vessel to the brain is either blocked or bursts). --Spastic [CONDITION(S)] (increased muscle tone or contractures occurring in half of the body) affecting right dominant side. --[CONDITION(S)] (paralysis) and [CONDITION(S)] (slight paralysis/weakness) affecting the right side of the body following a stroke. --Type 2 Diabetes Mellitus (a chronic disease characterized by high levels of sugar in the blood and insulin resistance) with diabetic chronic kidney disease. -- [CONDITION(S)]. --High blood pressure. Record review of the resident's medical record showed: -An Acknowledgement of Rights on Life Choice Information form choosing Full Code status and signed and dated by the resident and a witness on [DATE]. Record review of the resident's care plan, dated [DATE], showed the resident: -Had a code status of Full Code. -The care plan did not identify goals or interventions for the full code status. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning), dated [DATE], showed the resident: -Had severe cognitive impairment. -Had clear speech and was able to make his/her needs known. -Was able to understand others. -Required extensive assistance to total dependence for all Activities of Daily Living (ADLs). -Received [CONDITION(S)] treatment. Record review of the resident's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Had a code status of Full Code. Record review of the facility's Time Clock Daily Report for [DATE] - [DATE] showed: -Certified Nursing Assistant (CNA) A worked from 9:43 P.M. to 6:47 A.M. -CNA B worked from 10:46 P.M. to 11:46 P.M. -Housekeeper A worked from 11:49 P.M. to 5:10 A.M. -Licensed Practical Nurse (LPN) A worked from 10:48 P.M. and did not clock out. Record review of the resident's Nurse's Notes written by Licensed Practical Nurse (LPN) A, dated [DATE] for the 11:00 P.M. to 7:00 A.M., shift showed: -At 1:00 A.M., CNA A went in to check on the resident during rounds. -CNA A went to get LPN A due to the resident's face being slanted and swollen. -LPN A took the resident's pulse and it was very faint. -LPN A was unable to get any vital signs from the resident. -LPN A called 911 for emergency medical services (EMS) at 1:15 A.M. -LPN A started CPR on the resident. -LPN A stopped CPR and called the resident's physician's nurse practitioner at 1:25 A.M. and left a message. -LPN A called the resident's physician's on-call phone number at an undocumented time. -LPN A called the resident's spouse at 1:45 A.M. and received approval from him/her to discontinue CPR since it had been performed for 30 minutes. -LPN A received a call back at an undocumented time from an on-call physician. LPN A notified the physician that a police officer wanted to know who would sign the death certificate for the resident, and also notified him/her that the resident had expired, and that paramedics had called the time of death at 1:50 A.M. -LPN A called the funeral home at 2:15 A.M. and the resident's body was picked up by the funeral home at 2:50 A.M. -LPN A documented that the EMS paramedics stated the cause of death was cardiac arrest, and that the medical examiner's report was faxed and a release was signed by the funeral home. -LPN A contacted the DON and notified him/her of the situation. -No vital signs were recorded. Record review of the EMS report completed by EMS A, dated [DATE], showed: -The call to 911 was placed at 1:11 A.M. by a bystander. -The Emergency Medical Dispatcher (EMD) Complaint was Cardiac Arrest/Death and the priority was Emergent. -EMS responders arrived at the facility at 1:22 A.M. and were at the resident at 1:24 A.M. -The disposition of the resident upon EMS arrival was patient dead on scene - resuscitation attempted (without transport). -The resident was lying on his/her back. -CPR was initiated by [NAME] Crew A at 1:20 A.M. -The resident was unresponsive and had a Glasgow coma scale (GCS - a scale used to assess neurological responses to determine the level of a person's consciousness) of three (completely unresponsive; no signs of life). -The resident's initial electrocardiogram (ECG - a machine that detects the electrical activity of the heart by electrodes attached to the skin) rhythm was documented as asystole (no heartbeat). -The resident had no pulse. -The resident was apneic (not breathing). -Advanced Cardiovascular Life Support measures were initiated by EMS staff, including administering oxygen, administering doses of [MEDICATION(S)], raising the resident's blood sugar, and continuous CPR. The resident could not be resuscitated. During an interview on [DATE] at 9:36 A.M., LPN A said: -He/She was the only nurse in the building on the night shift beginning [DATE] at 11:00 P.M. to [DATE] at 7:00 A.M. He/She was responsible for resident oversight on both the first and second floor. -On [DATE] at 1:00 A.M., CNA A did rounds to check on residents. CNA A came and got LPN A and said that the resident did not look good. -He/She went to the resident's room and checked the resident's pulse and noticed that the resident's face looked different. The resident had had a previous stroke which had disfigured his/her face somewhat, but it looked more drooped. -He/She did a sternal rub on the resident's chest and he/she did not wake up. LPN A felt the resident's neck artery and felt a faint pulse. -He/She told CNA A to stay in the room and LPN A ran and called 911. -He/She returned to the resident's room and did another sternal rub and felt a faint pulse. -He/She started CPR on the resident. LPN A performed CPR for about five minutes or so, but then stopped to try to gather paperwork for the paramedics/EMS before they got there. -When LPN A was performing CPR, he/she did chest compressions only (no breaths). -EMS arrived within 15 to 20 minutes of the call to 911. -He/She did not think that CNA A performed CPR while LPN A was out of the room, and did not know if CNA A was CPR-certified, or if CNAs should perform CPR on residents who have Full Code status. -He/She was filling out the transfer form when EMS arrived. He/She took them into the resident's room. -When they hooked the resident up to the rhythm machine, LPN A believed he/she saw a slight pulse. -EMS staff immediately started CPR on the resident and continued for about 30 minutes. -EMS staff asked LPN A to call the resident's spouse to see if he/she wanted them to stop CPR. The resident's spouse said yes. -He/She said CPR training taught that CPR should be done until paramedics arrived, but considering that he/she was the only nurse in the building, it was impossible. -CNA A was the only CNA in the building at that time. LPN A had him/her stay in the resident's room when LPN A was preparing paperwork, because someone needed to stay with the resident at all times. -The resident was not on hospice and had a code status of Full Code. -LPN A did not say when he/she should start CPR -Technically he/she should have done CPR until EMS arrived, but he/she knew he/she had to get paperwork ready for a quick transfer out of the facility due to the resident's condition and with Covid-19, there was so much more paperwork that had to be filled out. -LPN A did not feel that he/she could wait to do the paperwork because the resident had a faint pulse and he/she was trying to get everything ready so they could get him/her help at the hospital. -The resident had a faint pulse and he/she documented the faint pulse. During an interview on [DATE] at 12:01 A.M., CNA A said: -He/She worked both the first and second floor during his/her shift. He/She was the only CNA in the building for the night shift beginning on [DATE] at 11:00 P.M. to [DATE] at 7:00 A.M. -He/She did rounds at 11:00 P.M. on [DATE]. He/She did not physically touch the resident or see him/her move, but did not notice anything out of the ordinary with the resident while he/she was sleeping. Rounds were done every two hours. -During rounds at 1:00 A.M., CNA A checked on the resident who resided on the second floor. CNA A described the resident as his/her lip was drooping kinda to the side a little bit, so his/her face looked different. CNA A did not notice any facial discoloring or anything else different about the resident's body. -The resident did not respond when CNA A said his/her name several times. -He/She pushed the call light to notify the nurse that he/she needed assistance, but then decided to run and get the nurse. -LPN A entered the room with CNA A and LPN A checked the resident. -He/She saw the resident's chest moving at that time to indicate the resident had taken breaths. -He/She then left the room for a couple of minutes to get some towels; when he/she came back, he/she observed LPN A doing CPR on the resident (chest compressions, no breaths were observed) on the resident bed. -He/She could not recall exactly, but believed CPR was started within 10 - 15 minutes of first finding the resident unresponsive. -He/She did not know how long CPR was done, as he/she was not in the room when it was started. -He/She stayed with the resident while LPN A went to call 911 for emergency medical services. -He/she checked the resident's pulse and it remained faint when LPN A left to get paperwork. -While he/she was in the room with the resident alone (during the time LPN A was calling 911), he/she checked the resident's pulse at least twice before the ambulance arrived, and it was faint, but it was there. -At no time did LPN A delegate tasks or ask CNA A for help with calling 911 or with gathering paperwork for the resident. -He/She was not sure how long it took for EMS staff to arrive, but it did not seem very long. LPN A entered the room with EMS staff. -EMS staff asked to move the empty bed out of the room to have more space, and CNA A and LPN A assisted with that. -The resident was moved from his/her bed to the floor. When EMS hooked up the little monitor, he/she believed that the monitor showed that the resident had a pulse. -EMS staff took over and began CPR. -He/She was not currently CPR-certified, but had been in the past. -Nurses or other CPR-certified staff are responsible for performing CPR when needed. -He/She did not perform CPR on the resident. -Staff knew residents' code status by checking inside their chart. He/She does not believe there is any indication of code status (such as a colored sticker) on the outside of the chart, and there is no indication in the residents' rooms, inside or out. -He/She knew the resident had a code status of Full Code, and had known that for a while. He/She did not remember how he/she got that information. -He/She had worked at the facility for almost 90 days. During an interview on [DATE] at 3:09 P.M., Housekeeper A said: -He/She worked as a floor tech at the facility. He/She was responsible for sweeping and mopping rooms. -He/She did not provide any kind of care to residents. -He/She was working during the overnight shift on [DATE] - [DATE], sitting behind the desk on the first floor. -If he/she heard any type of problem or emergency from a resident, he/she would get a nurse to help as quickly as possible. He/She would not respond to a resident directly. -He/She was not CPR certified. -He/She was aware that a resident passed away during the overnight shift on [DATE] - [DATE], but he/she did not see or hear anything. -He/She was notified of the resident emergency and was told that he/she would need to let EMS workers into the building. He/She believed it was one of the charge nurses who called him/her from the second floor to let him know. -He/She let the EMS workers into the building, and he/she thought this was sometime after 1:00 A.M. -He/She did not really know the resident, so he/she did not recall seeing him/her earlier while still alive on [DATE]. Record review of email communication form the Administrator, dated [DATE] at 3:36 P.M. showed: -LPN A was on the second floor at the time of incident and LPN A was assigned to both floors. -CNA A was assigned to the first floor and was to alternate between the floors. -Housekeeper A was assigned to the front desk on the first floor. During an interview on [DATE] at 10:49 A.M., the resident's spouse said: -He/She was called by one of the head nurses at the facility on [DATE] sometime after 1:00 A.M. and was told that the resident was not responsive when they went to check on him/her. EMS had worked on him/ her for half an hour. -The nurse on the phone asked for his/her decision to continue CPR. He/She told the nurse to have EMS stop CPR and to let the resident go. -He/She did not have durable power of attorney (DPOA) for the resident's medical decisions, he/she was the resident's spouse and a representative for him/her. -He/She had no DPOA. -He/She did not recall discussions with the facility about code status, but if the facility would have asked him/her about the resident's code status, he/she would have told them to do CPR in an emergency. -He/She expected staff at the facility to do CPR until EMS workers arrived and the resident would have wanted this as well. During an interview on [DATE] at 12:08 P.M., the DON said: -It was expected that when CPR is needed, staff would start CPR, notify another person to call 911, and continue CPR until EMS arrived. -Staff were not to stop performing CPR to complete paperwork. The paperwork could be done later. -If there is one CPR-certified staff on duty and one non-CPR-certified staff, the following is expected: --CPR-certified staff should directly assist the resident and do CPR. --Non-CPR-certified staff should help with whatever else is needed, such as calling 911 or gathering paperwork. During an interview on [DATE] at 3:25 P.M., LPN B said: -He/She was CPR-certified. -If he/she found a resident unresponsive, he/she would: --Check vital signs. --Send someone to check the resident's code status in the chart if he/she did not know it. --Start CPR. --Have that delegated staff also call 911. If no other staff were around, he/she would call 911 on his/her cell phone that he/she kept in his/her pocket at all times, and then resume CPR. --Continue CPR until EMS arrived. During an interview on [DATE] at 3:38 P.M., CNA B said: -He/She was CPR-certified. -If he/she found a resident unresponsive, he/she would: --Check for pulse and if the resident is breathing. --If the resident is not responsive, he/she would call for help, or would push the help button to call another nursing staff for help. --If needed to move a resident from a chair or a bed, which could require some assistance, so he/she would definitely call for assistance from any staff. --Have another staff check for the resident's code status in the chart if he/she did not know it. --Use the crash cart if needed. It is somewhere, but he/she is not sure where, but believed it was on the second floor. He/She thought it contained a back board. --Delegate another staff to call 911. He/She would not leave the resident, but the priority would be to get a nurse in there to assist as soon as possible. --Perform CPR until EMS arrived or until a nurse took over. It was not permitted to just stop doing CPR. During an interview on [DATE] at 3:45 P.M., Certified Medication Technician (CMT) A said: -He/She was CPR-certified. -If he/she found a resident unresponsive, he/she would: --Holler for help from other staff. --Check for breathing. --Ask other staff to check the resident's chart for code status if he/she did not know it. ---For residents with a Do Not Resuscitate (DNR) order, there was a red round sticker next to the resident's name on the wall outside their room, in the medication book, and in the medical record. --Start CPR if a resident had a code status of Full Code. --Continue CPR until: ---The resident was revived (evidenced by the resident obviously breathing, or speaking and telling CMT A to get away); or ---EMS arrived and took over or another staff took over doing CPR. During an interview on [DATE] at 10:58 A.M., EMS Deputy Medical Chief said: -Immediately initiating CPR on the resident would indicate that the resident was not breathing and was pulseless. -EMS responders would not initiate CPR on a person who showed obvious signs of life. During an interview on [DATE] at 10:58 A.M., EMS Deputy Medical Chief said: -There was no written report from [NAME] Crew A as that crew deferred to the EMS report written dated [DATE]. -[NAME] Crew A was the first to arrive to the facility on [DATE] at a little before 1:20 A.M. in response to the 911 call regarding the resident. -Emergency Medical Technician (EMT) [NAME] Crew A told EMS Deputy Medical Chief that on arrival facility staff were not observed to perform CPR. -The resident was found lying on his/her back in bed. -The resident was pulseless and he/she was not breathing. -The resident was moved to the floor, EMT [NAME] Crew A immediately started CPR and continued until EMS arrived and took over. During an interview on [DATE] at 10:35 A.M., the resident's physician said: -If a resident has a code status of Full Code, it is expected for staff to perform CPR on the resident if he/she is found unresponsive. -CPR should be performed until EMS or another CPR-certified person takes over, or until there is resuscitation (evidenced by obvious signs of life). -It is expected that staff would continue CPR and delegate other tasks such as paperwork to someone else, or have another CPR-certified staff take over CPR so that other tasks could be handled if needed. -Staff should perform CPR until EMS or another CPR-certified person takes over and continues CPR. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation to a D level at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO 880

Based on observation, interview and record review, the facility failed to provide supervision to prevent elopement for one resident (Resident #1), when staff failed to complete an elopement risk assessment upon admission per the facility policy, failed to accurately assess the resident on his/her Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, assessment, and failed to follow the resident care plan for monitoring to prevent the resident from eloping. On 3/10/20 the resident eloped from the facility. Staff failed to facilitate a safe return for the resident when he/she eloped and failed to follow their elopement and missing resident policies including resident assessment, thorough incident documentation and physician notification. The facility census was 50. The administrator was notified on 3/16/20 at 5:10 P.M. of an Immediate Jeopardy (IJ) which began on 3/10/20. The IJ was removed on 3/16/20, as confirmed by surveyor onsite verification. Review of the facility Elopement Risk Assessment Policy and Procedure, dated 2019, showed: - Elopement is defined as an unassisted, unsupervised, or unscheduled departure from the facility by a resident requiring the implementation of the resident response protocol. - Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. - Residents at all levels will be assessed for the potential of elopement. - Residents deemed to be at risk for elopement would be monitored. The care plan will outline methods of monitoring. - Staff will be oriented and in-serviced to this policy and the Missing Resident Protocol regarding assessing and identifying the residents who are at risk of elopement to prevent and report such occurrences. - Elopement shall be reported to the Police Department (PD), the regulatory agency, the physician and family. - Each resident is assessed for elopement risk using the Elopement Risk Assessment tool upon admission, quarterly, annually and with change in condition. - Upon risk identified at the minimal to severe level, the resident will be placed on a monitoring schedule. - Documentation of each incident including elopement attempts and successful elopement. - The Physician should be notified of the incident. - The Director of Nursing (DON) and the Administrator to use missing resident protocol. Review of facility Elopement Risk Assessment, dated 2019, showed: - Completed upon admission, then quarterly, annually if risk is identified. Score 0 for no indicator, 1 for minimal, 2 for moderate and 3 for severe indicator. Upon risk assessment, follow the policy and procedure for interventions used (check as appropriate). Total scores will indicate risk factors, 0-2: no risk, 3-8 minimal risk, 9-15 moderate risk and 16-36 severe risk. - Evaluation Factors include cognitive skills, history of elopement and independent ambulation. - Interventions for resident specific and environmental that could be check marked and dated included monitoring frequency, photo on elopement risk list, proper door coding system, locking system, missing resident protocol, staff communication and risk awareness. Review of the facility Missing Resident policy, dated 2018, showed: - To ensure that all necessary steps are taken in the event that a resident wanders away from the facility. - To identify residents who walk about unrestricted and are a threat to leave the facility unattended due to their confusion. - Should a resident be determined missing, the charge professional should be notified and direct the search for the resident. - If the resident is not found within 15 minutes, notify the PD, Administrator and the DON. - Upon return of the resident to the facility, the resident will be assessed for injuries and a thorough incident report will be filled out by the charge nurse detailing an accounting of the incident in its entirety and given to the Administrator and also documented in the resident's medical record. Contact the physician and report findings and conditions of the resident. Follow orders. - The person in charge shall be responsible for documenting the incident in the resident's nurse's notes. All documentation must be concise and reflect the actual facts as they relate to the incident including times, persons contacted, condition of the resident upon return to the facility, physician notification, physician's orders, treatment indicated and other pertinent information. 1. Review of Resident #1's face sheet showed he/she was admitted on [DATE]. Review of the resident's Social Services (SS) assessment, dated 11/21/19, showed: - The resident cannot recall any numbers. - The resident only knows family. - The resident is not oriented to time. - The resident did not pass assessment to receive the facility door code. Review of the resident's SS Cognitive Status Assessment, dated 11/21/19, showed: - The resident cannot tell the current year, season, month, day or date. - The resident cannot tell what state, country, town or facility he/she is in. - The resident scored a zero out of 30 points indicating that he/she was Definitely Impaired. - The resident cannot participate due to his/her [CONDITION(S)] (TBI). Review of the resident's care plan, dated 11/21/19, showed: - Thought processes impaired regarding loss of memory due to TBI. - Problem, resident has diagnoses of seizures. - Problem, unsteady gait and loss of balance. Staff to monitor residents condition and provide assistance with Activities of Daily Living (ADL)'s. Staff to monitor the resident's location at least every two hours. Document his/her location as instructed on the flow sheet. - Advise family to visit the resident in the facility. - Resident used a walker. Review of resident's Care Plan Evaluation, undated, showed: - 11/21/19, No To Door Code. Review of the resident's facility records showed staff did not complete an elopement assessment on admission as directed by the policy. Review of the resident's facility Admission Nursing Assessment, dated 11/24/19, showed: - Had clear communication. - He/She was oriented to time, place and person. - He/She was alert. - He/She had quick comprehension. Review of the resident's admission MDS, dated [DATE], showed conflicts with other facility assessments included: - Clear speech. - Makes self-understood. - Cognitively intact. - Did not include TBI where indicated. - Wandering not exhibited. Review of the resident's Care Plan Evaluation, undated, showed: - 2/21/20, No To Door Code. Review of an undated SS Semi-Annual Summary for the resident showed: - The resident's speech impaired due to TBI. - The resident speech is rambled when making his/her needs known. Review of the resident's Physician Order Sheet (POS), dated 3/1/2020, showed diagnoses of seizures and TBI. Review of the resident's quarterly review MDS, dated [DATE], showed: - Clear speech; - Makes self-understood; - Cognitively intact; - Did not include TBI where indicated. - Wandering not exhibited. Record review showed staff did not complete 2 hour checks as directed by the resident's care plan during March 2020. Review of Resident #2's quarterly review (QR) MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact. Review of the resident's care plan dated, continued 12/17/19, showed: - Social Inappropriate Behavior, Drinks alcohol constantly and is intoxicated. Separate from peers if behavior occurs. Staff to monitor closely by observation. Review of resident's Social Services (SS) Progress Notes of Overall Status, dated 12/18/19, showed: - Alert and oriented times two. - Alcohol abuse. Review of the residents QR MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact. Review of facility security camera video provided by the Director of Operations (DOP) showed on 3/10/2020 at 1:12 P.M., Resident #1 and Resident #2 walked from the first floor corridor and entered the facility front lobby. Resident #1 used his/her walker to mobilize. The wall clock behind the lobby desk showed 1:12 P.M. The wall clock behind the chairs positioned opposite of the front desk showed 1:12 P.M Review showed no staff were in the lobby area or at the lobby desk. Resident #2 entered a door code unlocking the front entry way door, opened the door to the outside and went outside followed by Resident #1. Review of Licensed Practical Nurse (LPN) A nurse's notes, dated 3/10/20, showed: -A bar owner called the facility stating Resident #1 was at the bar and appeared lost. The bar owner asked for staff to provide transportation for the resident. The facility does not have transportation. The bar owner stated he/she would send the resident back in a cab. PD brought the resident back to the facility. The resident had not been drinking. - Review showed no documentation of assessment for injuries or documentation details of the incident as directed by the facility policy. -Review showed no documentation that the physician or DON was notified as directed by the facility policy. Review of the facility Summary of Investigation regarding the incident on 3/10/20 dated 3/15/20, showed: - Resident #1 and Resident #2 were seen hanging out together on 3/10/20. - Resident #1 said Resident #2 went with him/her when he/she left the facility. - Resident #1 said that he/she left the facility with that man with long hair. He/She walked a long time to the store. During an interview on 3/11/20 at 3:00 P.M. Certified Med Tech (CMT) A said: - On 3/10/20, he/she worked from 6:00 A.M. to 6:00 P.M. - On 3/10/20 at about 5:00 P.M., the resident was at supper. - The resident would usually go and smoke after he/she ate; however he/she was not sure what the resident did after supper on 3/10/20. During an interview on 3/12/20 at 3:31 P.M., the Administrator said staff reported observing Resident #1 with Resident #2 prior to Resident #1's 3/10/20, elopement. During an interview on 3/13/2020 at 4:54 P.M., License Practical Nurse (LPN) A said on 3/10/20 he/she last saw the resident a little after 5:00 P.M., at supper. During an interview on 3/16/20 at 2:24 P.M., Certified Nurse Aide/Housekeeping staff (CNA/HSK) said: - He/She worked 3/10/20 from 3:00 P.M. to 11:00 P.M - He/She saw Resident #1 at 5:00 P.M. during supper. - The facility does not have any elopement risk residents. - He/She has never been instructed to monitor any particular residents for elopement risk. - All residents should know the door code. - There are no resident's that he/she has been informed of that staff have to monitor within certain time frames. During an interview on 3/19/20 at 1:00 P.M., CNA A said he/she observed Resident #2 hanging out with Resident #1 a lot. Resident #1 was normally a loner. Resident #2 goes out of the facility often. He/She saw them together on 3/10/20 during the day shift. He/She was concerned that Resident #2 might be getting money from Resident #1. On 3/10/20, he/she reported his/her concern to a charge nurse. During an interview on 3/19/20 at 4:30 P.M., CNA B said on 3/10/20 he/she saw Resident #1 at 5:00 P.M. during supper time. During an interview on 3/18/20 at 3:55 P.M., Individual A said: - On 3/10/20, he/she found the resident walking outside on a sidewalk by a road with a lot of traffic, especially for someone with a walker. The resident showed an identification card (ID) for a city 13 miles away and said he/she was lost and looking for a bus to take him/her home. He/She took the resident into a bar and called the PD. The resident sat down and drank a lot of water and said he/she was tired. The resident had an alert bracelet with a phone number for Family Member (FM) A and a card with the facility phone number in his/her pocket. - He/She notified FM A who said the resident was supposed to be at the facility. - He/She called the facility. Facility staff told him/her that no one was working who could come and pick the resident up. The staff showed no concern. They did not offer a taxi, an Uber (car transport service) or anything. - PD arrived and said they were taking the resident to the facility. During an interview on 3/13/20 at 1:26 P.M., FM A said: - On 3/10/20 at 7:00 P.M., he/she received a call from Individual A, who was a stranger. Individual A told him/her that the resident was at a bar. FM A notified the facility. - It was unsafe for the resident to be out of the facility on his/her own. The resident is not verbally able to say what he/she is thinking or feeling. The resident is not able to comprehend what is being said. The resident has seizures. During an interview on 3/18/20 at 3:06 P.M., a PD officer said: - On 3/10/20 at 7:02 P.M., the PD received a call from Individual A who reported the resident was alone at a bar. He/She and his/her partner responded and found the resident did not know who to contact, where he/she was or where he/she was supposed to go. The resident had a hard time understanding the questions they were asking him/her. The resident had a small grocery bag with soda in it, a wallet and a card with a phone number. The resident said he/she walked all day long and his/her feet hurt. The resident did not want to go to the hospital. - There was heavy traffic on the streets in front of the bar. - No one from the facility notified them of a missing resident. - No one from the facility contacted them. - No one from the facility requested they provide transportation for the resident. - No one arranged for them to transport the resident from the bar to the facility. - He/She and his/her partner decided to transport the resident to the facility. They left the bar at 7:25 P.M. and arrived at the facility at 7:33 P.M. They went to the front entry of the facility and had to knock to get someone to answer the door. A staff responded, the staff person did not act like it was a concern that the resident had been missing. During an interview on 3/11/20 at 2:50 P.M. and on 3/19/20 at 3:21 P.M., Registered Nurse (RN) A, who was a charge nurse at the time, said: - He/She had worked 3/10/20 from 2:00 P.M. to 8:00 P.M. - He/She did not know the resident was missing and was not told the resident was gone during report. - He/She had received a phone call about 7:15 P.M. from an unknown caller who said he/she had thought he/she had a facility resident at his/her bar. - The caller identified the resident as Resident #1. - The caller said the resident had been there a minute and appeared to be lost. - The caller had found numbers in the resident pocket which led them to contact the facility. - The caller said it did not seem like the resident was all there. - He/She told the caller the facility was unable to go and pick up the resident and the caller said if the PD were unable to bring the resident back the caller would call a taxi. - It was dark outside. - He/She did not know who the caller was, he/she did not know what bar and he/she did not know how long the resident was gone from the facility. - Later, FM A called him/her stating he/she received a call from an individual who said the resident was at the bar. - He/She did not notify the physician. - They were not waiting to greet the resident when he/she returned to the facility, because no one called them to tell them they would be there. - He/She did not know how the resident got back to the facility or who let him/her in. - He/She did not know when the resident returned to the facility. - He/She did not complete an assessment on the resident, because he/she was getting ready to go off duty at the time. - He/She did not document the incident or write a statement. - He/She did not notify the DON the resident was missing. During interviews on 3/11/20 at 3:25 P.M., on 3/13/20 at 4:54 P.M., and on 3/19/20 at 3:21 P.M., LPN A, who was a charge nurse at the time, said: - On 3/10/20, RN A told him/her that he/she had gotten a call that the resident was at a bar. - The bar had wanted to know if the facility could get the resident and when they told them no, the bar was to get the resident a cab. - FM A called and wanted a phone call when the resident was back. - He/She did not contact the PD. - After they were notified the resident eloped, they did not check facility exit doors or conduct a head count of residents. - They were not waiting for Resident #1 when he/she returned to the facility, because no one called to let the facility know they were bringing the resident back. -They did not notify the DON the resident was missing. During an interview on 3/16/20 at 4:19 P.M., Housekeeper (HSK) A said: - He/She was not aware Resident #1 was not supposed to leave the facility. He/She was never informed to monitor the resident. He/She has observed the resident use the door code and go outside to smoke a cigarette. - On 3/10/20 around 7:00 P.M., no one knew the resident was missing. He/She was moping the floor. He/She just happened to see two PD officers at the front door. They said when they found the resident wondering in front of a bar not knowing how to get back to the facility. He/She opened the front door, the resident came in and went to his/her room. He/She did not observe nursing staff check on him/her. He/She informed LPN A of the PD bringing the resident back to the facility. - The resident gets confused a lot throughout the day. The resident says he/she wants to go up in the elevator when he/she means he/she wants to go down. Staff have to interpret what the resident means when he/she is speaking. - Some residents try to take advantage of others. Resident #2 goes in and out of Resident #1's room all the time. Resident #2 tries to get money from other residents. He/She has reported this to nursing staff in the past and it was stopped. - He/She has never been informed of which residents can go outside on their own and who cannot. During an interview on 3/11/20 at 2:50 P.M., RN A said on 3/10/20: -The resident was unable to answer questions and RN A did not know when the resident left the facility. -He/She had seen the resident on the elevator going back upstairs just before 7:40 P.M., when he/she left to go off duty. During an interview on 3/11/20 at 3:25 P.M., LPN A said on 3/10/20: - Staff did not have insurance to transport the resident back to the facility from the bar in their cars. -The PD just dropped the resident off at the facility. The bar had said a taxi would bring the resident back. He/She did not know why the PD brought the resident back. -He/She did not know who had let the resident back in the facility. -About 7:50 P.M., HSK A told him/her that the resident was back and he/she met the resident in the elevator. - The resident was unable to tell him/her where he had been or what happened, only that he/she did not like Resident #2. He/She did not know why the resident did not like Resident #2. -He/She smelled no liquor on the resident, he/she assessed the resident and found no cuts, bruises, or injuries. -He/She had not recorded his/her assessment of the resident in his/her nursing notes or anywhere else. -He/She did not notify the physician that the resident eloped and what his/her condition was upon his/her return to the facility like he/she should have. - At 7:51 P.M., he/she texted the Administrator that the resident was back safe and sound. -The resident was supposed to take a shower; but went to bed, he/she did not want to wake the resident and did not check on him/her after 8:30 P.M. and his/her shift ended just after 11:00 P.M. - The facility did not have a list of residents to show which residents could not go out on their own. During an interview on 3/11/20 at 2:20 P.M., the Administrator said: - On 3/10/20 at about 7:15 P.M., the charge nurse called him/her and said a resident was brought back to the facility by the PD. He/She was not notified prior to this call that the resident was not at the facility. - He/She was still investigating and he/she was under the understanding that Resident #2 had taken Resident #1 to a bar. - Resident #1 had failed the door code assessment and was not given the door code to get in and out of the building independently. -Someone had to have taken Resident #1 out of the facility. Observation on 3/12/20 at 12:35 P.M., showed Resident #1 used a wheeled walker to mobilize with a steady gate. During an interview on 3/12/20 at 12:41 P.M., Resident #1 said: - He/She had a head injury and had to be hospitalized for a long time. - The other day he/she walked around town. - He/She did not remember going outside. - He/She went with another man. - He/She did not know Resident #2. During an interview on 3/12/20 at 12:53 P.M., Resident #2 said: - On 3/10/20, he/she went to a store on his/her own. - He/She did not know Resident #1. - He/She did not see Resident #1 leave the facility. He/She did not know anything about Resident #1 leaving the facility. During interviews on 3/11/20 at 2:30 P.M., 3:15 P.M., and 3:50 P.M., on 3/12/20 at 12:26 P.M. and 1:53 P.M., and on 3/16/20 at 2:00 P.M., regarding the 3/10/20 incident, the DON/MDS Coordinator said: - The streets in the facility area were very busy and were a safety risk for Resident #1. He/She thought with Resident #1 having to use a walker to ambulate, that it would take him/her 20 minutes to walk to the bar where he/she was found. The sidewalks were hard to maneuver for anyone with a walker. It is believed the resident left after the 5:00 P.M. supper. At that time of day, car traffic was normally heavy. Resident #1 would not know how to go to the location he/she was found without Resident #2. Resident #1 required a responsible person to be with him/her when outside the facility. He/She should not be out of the facility alone. He/She could have fallen, had a [CONDITION(S)], been robbed, or hurt. - He/She thought the incident could have occurred due to the residents getting paid on 3/10/20. Resident #2 would have known that Resident #1 had money. The two residents were not close friends. Resident #1 would not be able to perceive that Resident #2 was taking advantage of him/her. Resident #2 may have wanted Resident #1's money. Resident #2 should have never let Resident #1 out of the facility. - When Resident #1 was returned to the facility, LPN A should have documented a complete assessment of the resident but did not. LPN A did not practice documenting in the nurse's notes as he/she was trained. There was no way to know if the resident fell . A fall was a potential for the resident due to his/her diagnoses, his/her gait and the terrain he/she would have walked on. The resident would likely not be able to remember if he/she fell . Nursing staff should have implemented fifteen minute neuro checks of the resident's head and pupils and should have documented the checks. - Nursing staff should have immediately notified the physician of the incident and obtained orders on how often to monitor the resident. He/She did not know if the physician was ever notified of the incident. There was no documentation of a physician notification. It was his/her responsibility to check for physician notification and he/she had not checked. He/She expected staff to notify him/her of the resident elopement and they did not. - On 3/11/20 at 1:00 P.M., he/she spoke to Resident #2 about what occurred on 3/10/20. Resident #2 was intoxicated during the interview. Resident #2 said on 3/10/20, he/she had went out to buy cigarettes. Resident #2 would often go out and buy liquor and sit outside on the porch smoking and drinking. Resident #2 denied the incident and then later said he/she was at a bar. Resident #2 regularly goes to bars. During an interview on 3/16/20 at 1:05 P.M., the Nurse Practitioner (NP) for Resident#1's physician said: - He/She was first notified of Resident #1's elopement by the administrator on 3/11/20 at 8:00 P.M. - Staff should have notified the physician at the time of the incident. Upon return to the facility staff should have completed a head to toe assessment including checking to see if the resident fell , was in pain and/or frightened. Staff should have documented the assessment. Staff should have provided ongoing monitoring. The monitoring should have been either one to one to up to 15 minute checks to assure he/she was still in the facility. The assessment from the facility nurse was needed in order to determine if additional monitoring was required. - The resident is alert and oriented times two. The resident is not able to recall names of people. - The resident should be supervised when outside of the facility. - The resident does not know the name of the facility. - It was not safe for the resident to be out of the facility alone. - The resident would not know safety when it comes to being near cars. - The resident would not know that he/she would have to stop for street lights when crossing a road. - The time of day with higher traffic put the resident at a higher risk. - The resident used a walker and was at risk of tripping on the uneven walkway near the facility. - The resident's TBI, risk of seizures and speech difficulty could affect his/her safety. - The resident has difficulty understanding others. - Staff should have picked the resident up from the bar for him/her to see a familiar face to help him/her cope due to the confusion of being lost. - The resident would benefit from a wander guard. - Staff should have been following the care planned monitoring for the resident. - The resident admitted to the facility from home which made him/her a higher potential for elopement risk. - All residents should be assessed for elopement risk at the time they are first admitted to the facility. During an interview on 3/18/20 at 2:36 P.M., Family member (FM B) said: - Just after the elopement, Resident #1 pointed to Resident #2 and said I do not like him/her. - Staff told him/her that Resident #2 goes into Resident #1's room. - Staff should have notified police when they learned Resident #1 was at a bar, but did not. The person that found the resident called the police. - It was not safe for the resident to be out of the facility on his/her own. During an interview on 3/16/20 at 7:18 P.M., the Administrator said since the elopement, no interventions were initiated to assure contact between Resident #1 and Resident #2 was monitored. The intervention of 15 minute checks were initiated on 3/12/2020 for elopement. During an interview on 3/12/20 at 2:47 P.M., the Receptionist said he/she worked at the front entry way receptionist desk Monday through Friday 8:00 A.M. to 4:30 P.M Prior to Resident #1 eloping, there was no list to show which residents could not have the door code. Staff covering the entry way reception desk should have had a list in order to know who could go outside on their own. Observation on 3/12/20 from 5:00 P.M. to 6:30 P.M., showed the traffic next to the facility was a total of six lanes of heavy traffic. The location where Resident #1 was found by Individual A was 0.5 miles away from the facility. The narrow two lane roads in front of the location were heavy with car traffic and people walking around. During an interview on 3/13/20 at 1:00 P.M., LPN A said: - Prior to Resident #1's facility elopement, he/she was not aware of the care plan directing staff to log monitoring of the resident every two hours. There was no form to use in order to log monitoring of the resident. - The resident has a bad memory. It was unsafe for the resident to be out of the facility on his/her own. He/She would not be able to remember how to get back to the facility. The resident does not know the area surrounding the facility. The street next to the facility is a busy. It is not safe to drive on the street let alone walk near or across it. - He/she did not know how he/she was to respond when a resident eloped. - He/she should have known to call the physician but, did not. - At the time he/she was notified that the resident had returned to the facility, he/she had to continue administering resident medications and did not immediately check on him/her. - After the elopement the administrator and DON instructed him/her to keep an eye on the resident, but there was no specific timeline on how often to monitor him/her of form to use to document the monitoring. During an interview on 3/16/20 at 1:54 P.M., the Social Services Coordinator (SSC) said when Resident #1 eloped his/her safety was at risk. It would have been very confusing for him/her. The sidewalks in the area were uneven and would have been unstable for the resident who has bad feet. The resident said his/her feet were hurting. Due to the residents unclear speech people who came in contact with him/her would have had a hard time understanding him/her. They only did social services specific assessments and door code key assessments. During an interview on 3/16/20 at 3:15 P.M., the Plant Operation Supervisor (POS) said there are no residents that he/she has been informed of to monitor for wandering. He/She has never been provided any information of document to show residents who are at risk of elopement. During an interview on 3/30/20 at 2:41 P.M., the receptionist said: - When he/she came to work on 3/9/20, the day after daylight savings time day, someone had changed the time on the wall clock on the wall behind him/her and on the wall clock in front of him/her to the correct time. - The wall clock on the wall behind his/her desk currently showed 2:42 P.M. - The wall clock on the wall behind the chairs positioned in front of him/her currently showed 2:41 P.M. During interviews on 3/11/20 at 3:05 P.M. and on 3/16/20 at 1:54 P.M., the SSC said: - On 11/21/19, Resident #1 was determined unable to leave independently with the door code access. -The door code assessment checked if the resident knew the time, place or where he/she was at and if the resident knew people. -All staff should know the resident had a history of TBI and did not pass the door code assessment. This information was passed on to staff by word of mouth. -If the resident wanted to go outside a staff person was to go with him. He/She should not be out of the facility on his/her own. The resident is in an unfamiliar surroundings. - SSC was responsible to assess the ability of a resident to have the door code on admission. During an interview on 3/12/20 at 11:48 A.M., the Social Services Director (SSD) said: - SSC completed the facility assessment tool with care plan for resident door code access. - Residents whose facility assessment tool for the door code showed they were not eligible to have the door code would signal a potential elopement risk and the need to complete an elopement assessment for the resident. - The DON/MDS was responsible to complete the elopement assessment. - The SSC and SSD made the DON/MDS aware of residents who do not score high enough on the door code assessment causing the need for an elopement assessment. - There was no formal communication between the SSC/SSD and the DON/MDS to show the door code assessment results. They did not give a copy of the door code assessment to the DON/MDS. - He/She or the SSC would have had the responsibility to inform the DON/MDS of Resident #1's assessment showing he/she was not eligible for the door code. He/She did not recall informing the DON/MDS of Resident #1's door code assessment. They did not document or track communication between SSC/SSD and the DON/MDS regarding the door code. - They needed to improve their system through documentation to communicate door code status results. - They did not have a key code [NAME] [TRUNCATED]

Based on interview and record review, the facility staff failed to timely assess and document in the resident's medical record his/her change in condition, and to timely notify the physician of radiology results that showed a spiral fracture for one cognitively impaired resident (Resident #2) of seven sampled residents. The staff on the evening and night shifts, did not have access to the fax machine necessary to send radiology results to the physician. The resident had increased pain overnight prior to being sent to the hospital for evaluation and treatment. The facility census was 58 residents. Record review of the facility policy observing change of condition during rounds, dated 2006, showed, in part: -Purpose: to ensure all changes from the residents are recognized immediately for effective and prompt interventions. -Policy: During round, the staff is asked to observe any complaints of pain, unknown injury (bruise; skin tears; abnormal gait; etc), change in skin condition. All findings are reported immediately to the charge nurse and Director of Nursing (DON). -Procedures: Any abnormal changes are reported to the physician upon nursing assessment. Any abnormal findings shall be documented in the medical records. Nursing interventions including monitoring, assessment, plan to reduce, minimize, mitigate the risks or alleviate conditions shall be documented in the medical record. 1. Record review of Resident #2's annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated 3/18/15 showed he/she: -Was admitted originally on 2/8/10; -Has moderately impaired cognition for daily decision making; -Required extensive assistance of one person for transfer, bed mobility, and toileting; -Had no impairment with range of motion; -Had active [DIAGNOSES REDACTED]. Record review of the resident's care plan for actual pain, last updated 9/9/13, showed he/she: -Experienced neck pain daily and his/her pain scale was an 8 (on a scale of 0-10.). -Takes [MEDICATION NAME] ([MEDICATION NAME]) 5 milligrams (mg) every six hours as needed for pain. Record review of the resident's Physician Order Sheet (POS), dated 5/1/15-5/31/15, showed, a physician order for [REDACTED]. Record review of the resident's POS dated 5/26/15, showed a hand written verbal order to elevate the resident's right leg after it has been wrapped with a ace bandage. Record review of the resident's nurse's notes showed no nurses notes for 5/26/15, or the early morning of 5/27/15. Record review of the resident's nurse's notes dated 5/27/15, at 10:00 A.M., showed: -This nurse was called to the resident room, observed the resident lying in bed and complaining of pain in his/her right leg, observed his/her right ankle swollen with bruised discoloration, and a knot with swelling on the lower right part of his/her leg. The physician was notified and ordered an X-ray of the resident's right ankle and lower leg. Record review of the resident's physician's telephone order sheet dated 5/27/15, showed an order for [REDACTED]. Record review of the resident's physician's telephone order sheet dated 5/27/15, showed an order to double wrap the resident's right leg with ace wraps from knee to foot and immobilize the right leg as much as possible. Keep on bed rest, increase [MEDICATION NAME] to 40 mg every four hours as needed for increased pain. Record review of the resident's hospice (end of life) bi-monthly comprehensive assessment dated [DATE], showed in part: -On hospice services with end-stage dementia, comorbidities of [MEDICAL CONDITION], and depression. -The facility charge nurse approached the nurse on arrival at nursing facility to have this nurse go down to the room to assess the resident's right lower leg which has a swollen knot and bruising noted and ankle bruising noted with possible fracture to right lower leg suspected. The charge nurse stated the resident has increased severe pain to lower extremity with movement and has been kept in the bed this morning and was not gotten up for breakfast this morning. -The physician was contacted by the charge nurse and new orders received for mobile X-ray to come to the nursing facility to X-ray lower right leg. Mobile X-ray contacted to arrive today. -The resident was fed lunch in bed and ate fairly. The resident unable to make needs known but can answer direct questions with yes/no answers. The patient is very thin and frail, and emaciated with thin skin. -resident has [MEDICATION NAME] 20 mg one tablet every four hours scheduled for pain. -The nursing facility to notify hospice with results of X-ray to right leg. Educated nursing staff to call hospice 24/7 with any changes, needs or concerns. Record review of the resident's radiology report of the resident's right tibia (also called shin, inner and larger of the two bones of the lower leg, showed it was faxed to the facility on [DATE], at 3:47 P.M., and showed: -Conclusion: acute spiral fracture (occurs by a turning or twisting motion) of the mid to distal (situated away from the center of the body or from the point of attachment) tibia. Record review of the resident's controlled drug record dated 5/27/15, showed he/she received [MEDICATION NAME] 20 mg one tablet every four hours as needed for pain, as follows: -At 8:00 A.M., one tablet; -At 12:00 P.M., one tablet; -At 6:00 P.M., two tablets and -At 11:00 P.M., two tablets. Record review of the resident's controlled drug record dated 5/28/15, showed the resident received [MEDICATION NAME] 20 mg two tablets every four hours as needed for pain, as follows: -At 4:00 A.M., two tablets; -At 8:00 A.M., two tablets; -At 12:00 P.M., two tablets. (Note: hospital records showed the resident was at the hospital being examined by a physician at 11:15 A.M. and not present in the facility.) Record review of the resident's nurse's notes showed no documentation that the resident's physician and hospice provider were notified of the resident's spiral fracture on 5/27/15 after 3:47 P.M. until the following morning. Record review of the resident's nurse's notes dated 5/28/15, at 11:00 A.M., showed a new order from the physician to send the resident to the hospital emergency room (ER) for evaluation and treatment. Emergency medical services here to transport, he/she was taken supine on cart times two staff. Hospice and his/her durable power of attorney (DPOA) notified regarding the x-ray, going to the hospital ER for evaluation. Record review of the resident's patient transfer form dated 5/28/15, showed the resident was sent to the emergency room due to right lower leg pain. Record review of the resident's hospital discharge summary dated 5/29/15, at 2:15 P.M., showed: -The resident with severe dementia, debilitated in wheelchair. [DIAGNOSES REDACTED]. Presented to the hospital after complaining of lower right leg pain. The nursing home did an X-ray and they reported it showed a right tibia spiral fracture. The resident was unable to provide any information as to what happened due to his/her dementia. The nursing home staff were unsure as to what happened that caused the fracture. Upon presentation the resident did not complain of any pain and several X-rays were ordered. X-ray of his/her tibia/fibula showed an acute minimally displaced tibia spiral fracture. He/she had a splint placed by orthopedic service. He/she was started on [MEDICATION NAME] 2 mg and [MEDICATION NAME] 10 mg for pain and a note in records from the nursing home showed he/she was on [MEDICATION NAME] 40 mg. Orthopedic re-evaluated him/her after splint placement and recommended that he/she was stable and no surgical intervention was needed and to follow-up in two weeks in the clinic. The patient continued to not complain of pain and was discharged back to hospice care in stable condition. The resident responded well to small or moderate doses of narcotics while inpatient. During an interview on 6/1/15, at 11:00 A.M., Certified Nurse's Assistant (CNA) A said: -He/she came into work on Wednesday morning and the restorative aide (RA) said the night aide said the resident did not want to get up and then after breakfast he/she lifted the resident's cover and he/she observed the resident's foot was swollen, he/she lifted the pant leg and observed the leg had a knot and was discolored. He/she went to get the charge nurse, Licensed Practical Nurse (LPN) A, who called for an X-ray. The resident was left in bed and fed in bed. The resident was in pain because when he/she tried to put his/her sock on he/she said ouch. During an interview on 6/1/15, at 12:30 P.M., Resident #4 who is the resident's roommate said: -On Tuesday 5/26/15, when CNA B was putting Resident #2 to bed, and he/she cried out in pain. He/she heard CNA B say are you ok? Oh your ankle is swollen. I'll go get LPN B. LPN B came in and referenced calling hospice. -On Wednesday about midnight the night CNA's came in and the resident was in pain. CNA C asked the resident what was wrong and he/she said, my leg, my leg. CNA C tried to make the resident comfortable and said, I'm going to tell LPN C your in pain. -About 30-40 minutes later, he/she heard CNA D tell LPN C that the resident was hurting and LPN C brought in some pain medication. -Then later in the early morning, CNA C came in to get the resident dressed and CNA C asked which body part was hurting. The resident said he/she could not explain it. CNA C told the resident I'm going to tell LPN C you are in pain. -Around breakfast or just after breakfast, CNA A came in asked the resident how he/she was doing and the resident said he/she was hurting. CNA A said ok, your ankle, look here. Then LPN A came in checked the resident and got an X-ray of the resident's leg. That night, Wednesday night the resident had a bad night and was in a lot of pain. LPN A brought the resident pain medications and tried to make him/her comfortable. Thursday morning 5/28/15, they sent him/her to the hospital. -The curtain was closed but he/she heard all of these statements/incidents. During an interview on 6/1/15, at 4:00 P.M., LPN B said: -He/she was confused about the exact days. He/she became aware the resident's feet were swollen, not sure of the day. But he/she has [MEDICAL CONDITION] at times. -Thinks it was Tuesday (5/26/15) or Wednesday (5/27/15), he/she found out about the residents leg, they suspected it was broken, thinks it was the same day as the day of the X-ray. -Hospice nurse was in, the hospice nurse called the physician who gave an order to wrap the leg with ace wrap, and increased the resident's pain medication from [MEDICATION NAME] 20 mg every four hours as needed for pain to 1-2 tablets, or 20 to 40 mg. The physician said he/she would be in the next morning to see the resident. -The resident was in a lot of pain, he/she was concerned about overmedicating him/her with the 40 mg [MEDICATION NAME]. He/she helped turn the resident three times that evening, they kept the leg immobilized. The resident was resting and asleep when he/she left that night. -If there were results from the X-ray he/she would have called the physician. If the X-ray results are not called to them they do not have access to the fax machine after the office staff/administrative staff leave. They don't usually leave until 4:30 P.M. He/she would have thought someone would have been in the office at 3:47 P.M. 5/27/15. -He/she believes the physician would have sent the resident to the hospital had he/she been notified of the fracture on Wednesday evening. During an interview on 6/2/15 at 4:25 A.M., LPN C said: -He/she became aware of a problem with his/her leg last Wednesday morning when CNA C was trying to get him/her up in the morning, he/she was in pain. He/she asked if he/she thought the [MEDICATION NAME] would help and he/she said he/she thought so. -He/she was in bed, he/she helped turn the resident. He/she did not favor the leg or anything when he/she and CNA C turned him/her. The resident said his/her leg hurt. He/she thought it was arthritis pain, which is routine for him/her. He/she passed it on to the next shift. -They used the draw sheet to move him/her up in bed and then moved him/her from his right side onto his/her back so he/she could give him/her the pain pill. It was about 5:00 A.M. -He/she thought his/her pain medication was scheduled at Midnight and 4:00 A.M. he/she was late with it. -He/she did not work Wednesday night, LPN A worked. -The resident has aches and pains, sometimes shoulder pain, sometimes back pain, neck pain, different body parts. -He/she is not able to access the lab or X-ray results from the fax machine overnight because the fax is locked in one of the offices. The first floor nurses desk has fax but it goes to pharmacy. He/she has told X-ray to call with results and they do. He/she has also called to check and they have given the results. During an interview on 6/2/15 at 5:00 A.M., CNA C said: -On Tuesday morning he/she got the resident up and dressed and he/she was just fine. -On Tuesday night into Wednesday morning, about midnight the resident was crying like he/she has not seen before, he/she told LPN C and he/she gave the resident pain medication. The resident kept saying my leg, my leg.LPN C thought his/her arthritis was bothering him/her. CNA D was with him/her in the resident's room. -A couple of hours later, the resident was still crying, as he/she attempted to dress him/her he/she got to the pants and he/she would not let him/her touch his/her right leg. He/she did not look at the right leg. He/she told LPN C. LPN C went to the room at that time. He/she was not there when LPN C went into the room. -He/she passed word onto RA A he/she in pain but he/she did not know what was wrong. The resident said he/she wanted to just lay there and rest. During an interview on 6/2/15 at 5:30 A.M., LPN C said: -Yes, he/she remembers now it was about midnight when CNA C first let him/her know about the resident's pain, had said his/her leg hurt. He/she checked on him/her and he/she was asleep. He/she does not remember two hours later the resident crying or complaining his/her leg hurt. -He/she does not remember being told he/she was crying saying my leg hurts. -He/she would have done a full assessment had the resident been crying and said my leg hurts. He/she would have checked for open areas, done range of motion. During an interview on 6/2/15 at 6:30 A.M., CNA D said: -He/she helps upstairs when CNA C asked for help. -Last Tuesday/Wednesday, the resident put the light on and he/she helped CNA C answer it. -The resident was sitting on the side of the bed. Asked him/her why sitting up. CNA C told him/her it's midnight, lay back down. CNA C lifted the resident's legs onto the bed. He/she does not remember the resident crying. He/she thought he/she saw the resident's leg was discolored and swollen. The resident said he/she was hurting. CNA C told the resident he/she would tell LPN C to bring you medication. -He/she thought it was the right leg that was discolored. -He/she does not know anything else about the resident's pain. During an interview on 6/2/15 at 6:55 A.M., RA A said: -He/she came in on Wednesday and CNA C said he/she was in bed because his/her leg hurts and does not want to get up. During an interview on 6/2/15, at 7:00 A.M., LPN A said: -He/she worked days on Tuesday and the resident was fine. He/she came out in his/her wheelchair and was propelling self down the hall. He/she was moving in wheelchair and gave no indication of any pain. -He/she worked on Wednesday day shift and left about 2:00 P.M. and then came back at 11:00 P.M. to work the night shift. -He/she was called into the resident's room that morning 5/27/15 by CNA C who told him/her the resident's right ankle was swollen and he/she was in pain. He/she went to look, observed discoloration in the ankle and that it was slightly swollen on the inside part, he/she pulled up the leg that hurt and observed a knot on the inside of the calf. The leg was not wrapped or anything at that time. -He/she came out notified the physician obtained an order for [REDACTED]. -Later that morning, the hospice nurse came out and he/she notified him/her about the resident's leg. -After 2:00 P.M., the hospice nurse wrapped the resident's leg, he/she knows because he/she returned at 11:00 P.M. and the leg was wrapped and that was in report. The X-ray results weren't back yet. The hospice nurse received an order from the physician to wrap the leg and increased the resident pain medications. -X-ray company called him/her at about 12:30 A.M. wanted to confirm they had the results of the X-ray, he/she said no but asked for them to verbally give the results of the X-ray and that person said they could not give it over the phone. -He/she did not have access to the fax machine, it is locked in the offices overnight from about 4:30 P.M. to 7:00 A.M. -At around 7:00 A.M., on 5/28/15, he/she went to the office to get the results himself/herself. The physician was in the building at about 8:00 A.M. was informed of the resident's spiral fracture and gave the order to send the resident to the hospital. He/she prepared the resident to be sent out, and he/she was out of here by 9:00 to 9:30 A.M. He/she called the hospice nurse who notified the residents DPOA. -Overnight, Wednesday to Thursday morning the resident was in pain all night. He/she was in with the resident holding his/her hand most of the night, rubbing his/her head, gave him/her the increased pain medication at 12 midnight and 4:00 A.M. The resident was more comfortable after 4:00 A.M. dose of [MEDICATION NAME]. He/she felt bad for the resident, he/she had hoped the 40 mg [MEDICATION NAME] would have helped him/her; it took it a couple of hours for it to kick the pain. As long as he/she did not move his/her leg he/she was okay. During an interview on 6/2/15, at 8:30 A.M., the DON said: -The fax machine is not accessible after the office staff/administrative staff leave at about 4:30 P.M. and return at 7:00 A.M., and not available all weekend. -The lab results are faxed to the first floor nursing station, but that might be broken. -He/she is not sure as to why the fax is not available. It has been that way since he/she has been here for 8 years. -It's unusual for the X-ray company not to share the results over the phone verbally. They have given results over the phone before. During an interview on 6/2/15, at 8:46 A.M., Mobilex service technician said: -The X-ray results were read by the radiologist and report completed on 5/27/15 at 3:46 P.M., and the results were faxed to the facility on [DATE] at 3:47 P.M. The results were refaxed on 5/28/15 at 5:28 A.M. -Usually the service technician can read the results verbatim to a nurse. He/she would not know why they did not happen. During an interview on 6/2/15 at 9:00 A.M., the Administrator said: -Years ago he/she had two incidents one of staff making copies of resident medical records and one of staff copying another employees pay stub and that is why the copy machine and fax machine are locked up after the office/administrative staff leave. -His/her memory is that the X-ray technician called back with the tentative results before LPN A left that afternoon, stating it was a fracture. He/she thought that was when the hospice nurse called the physician who gave order to wrap and increased the residents pain medications. -He/she had LPN A come to talk to us. During an interview on 6/2/15, at 9:10 A.M. LPN A said: -That was right, the X-ray tech called before he/she left and said it was a fracture. -He/she had called the physician, but he/she was busy, when he/she called back he/she spoke to the hospice nurse. The physician gave order to wrap, increased his/her pain medications and said he/she would be in in the morning. -He/she thought the hospice nurse was aware of the fracture. During an interview on 6/2/15 at 11:05 A.M., Hospice Nurse Case Manager said: -He/she arrived at the facility at about 11:45 A.M. and left the facility at 5:00 P.M. because he/she saw four patients at the facility. -When he/she got there LPN C took him/her to see the resident. LPN C said he/she suspected the leg was fractured. LPN C had already called the physician, obtained order for X-ray. He/she observed X-ray technician in building to get the X-ray. -He/she spoke with the physician, who gave an order to wrap the residents leg and to increase the resident's pain medication to [MEDICATION NAME] 40 mg every four hours as needed. The physician said he/she would be in the next morning to see him/her. A different nurse was there at the time he/she got the above order, it was LPN B. He/she placed an ace wrap and profo boot in order to immobilize the leg. -He/she was not informed the resident had a spiral fracture until Thursday morning. He/she then called the resident's DPOA. -He/she believes the fracture likely occurred during a transfer as he/she was an assist of one with a gait belt. -The resident does have chronic pain in his/her neck. He/she has an order for [REDACTED].>During an interview on 6/3/15, at 2:04 P.M., Physician A said: -He/she was first notified of the X-ray results on Thursday morning 5/28/15 when he/she was at the facility. -He/she was called the day before and informed the resident was having severe pain. He/she ordered the leg X-ray, to immobilize the leg and increased his/her pain medication. -He/she thought they would cast the leg, they only placed a splint on it. -Had he/she known the previous afternoon the leg was broken, he/she would have sent the resident to the hospital at that time. Complaint #'s MO 056 and MO 079.

Based on observation, interview and record review, the facility staff failed to assess and to track the condition of non-pressure wounds according wound policy for two sampled residents (Resident #14 and #15); to implement their policy concerning the tracking of non-pressure wounds and to develop a care plan to address the non-pressure wound of one resident (Resident #14); to follow the care plan for the non-pressure wound of one resident (Resident #15); and to document the completion of physician's orders [REDACTED].#14 and #15) of 15 sampled residents. The facility census was 59 residents. Record review of the facility's policy titled Non-Pressure Ulcer Treatment dated 2006, showed staff was directed to do the following: -All non-pressure ulcers will be assessed and documented weekly using the provided form. -All residents will be assessed every 30 days for skin integrity. -Documentation should be completed on the form provided. -Complete skin screenings according to the bath schedule. -Assess weekly/monthly or more frequent as instructed by the Director of Nursing (DON) or Registered Nurse (RN). -Communicate among shifts of progress, and healing. Record review of the facility's policy titled Wound Assessment and Care dated and implemented as April 2007, showed staff was directed to: -Assessment is the starting point of ulcer treatment. -Note the size, depth, necrotic (dead) and granular (soft pink or red fleshy, healing tissue) tissue. -Reassess at least weekly or sooner if deterioration of the ulcer is noted. Record review of the facility's Wound Assessment Non-Pressure Ulcer form dated 2005, showed staff was directed to: -Complete a description and type of the wound, the cause of the wound, any treatment, any complications and the notifications of the physician and family. -Document the location, size, depth, draining and infection of the wound daily/weekly till the wound was healed. Record review of the facility's Weekly Wound Assessment form dated 2005, showed staff was directed to complete and check off the appropriate areas: -Document the date, location, size, depth, drainage, and infection. -Document on a daily/weekly basis until the wound is healed. -Check off the goal of treatment. -Check off the nursing intervention. -Document after two weeks of treatment the healing progress, size, granulation, slow healing and the need to reevaluate for new treatment and any notes. Record review of the facility's Skin Audit form dated 2005, showed staff was directed to: -Investigate if the policy had been followed. -Determine if the clinical interventions had been implemented and the preventive measurements are in place to prevent reoccurrences. -Use the audit sheet as an internal improvement tool. 1. Record review of Resident #14's Admission Face Sheet form showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's physician progress notes [REDACTED]. -Used a wheelchair for mobility. -Had an open wound on his/her right lateral (side) heel. Staff were directed to start [MEDICATION NAME] 1% cream (a topical antimicrobial cream used to prevent and treat wound bacterial infection) and dress with gauze. This to be apply to the wound daily. Record review of the resident's physician's orders [REDACTED]. -A physician's orders [REDACTED]. Record review of the resident's Treatment Administration Record (TAR) dated August 2014, showed: -A physician's orders [REDACTED].M. to 11:00 P.M. shift. -Staff had not initialed that the treatment was completed on 8/28/14, 8/29/14 and 8/30/14. -No documentation on the back of the TAR to show the resident refused the treatment. Record review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff for care planning) dated 9/11/14, showed he/she: -Was independent with decisions in daily decision making. -Needed the extensive assistance of one staff person for transfers. -Needed the extensive assistance of one staff person for mobility in the facility in a wheelchair. -Did not have any type of wound, including a [MEDICAL CONDITION] or open lesion on the foot. Record review of the resident's TAR dated September 2014, showed: -A physician's orders [REDACTED].M. to 11:00 P.M. shift. -Staff had not initialed 9/5/14, 9/12/14, and 9/15/14 through 9/30/14 to show that the treatment had been done or refused. -Staff documented on the Nursing System Review form the treatment was done on 9/19/14 and 9/20/14. -No documentation on the back of the TAR to show the resident had refused any treatments. Record review of the resident's Nursing System Review form showed: -On 9/1/14, staff documented he/she had two areas on his/her right heel which were black/purple, without drainage; and no documentation of the area's measurements. -On 9/2/14, staff documented he/she had an area on his/her right outer heel that was black without odor or drainage. Staff documented he/she had a 0.5 centimeter (cm) x 0.5 cm bruised area on the bottom of his/her heel. -On 9/6/14 and 9/7/14, staff did not document if the resident had a wound on his/her right heel. -From 9/11/14 through 9/17/14, staff did not consistently document if the resident had a wound to his/her right heel. Staff documented on two days that the wound was on the left heel and on one day the wound was on the right heel. Staff did not document if the resident had a wound on the other days, and did not document any assessment or measurements of his/her wound. -On 9/19/14, staff documented the treatment to his/her right heel and the color was black without drainage; and no documentation of the area's measurements were found. -On 9/20/14, staff documented the treatment to his/her right heel and the color was black without drainage; and no documentation of the area's measurements were found. -On 9/21/14, staff documented he/she had a right heel wound, and no documentation of an assessment of the wound. -From 9/22/14 through 9/30/14, no documentation was found regarding his/her wound to the right heel. Record review of the resident's POS dated October 2014, showed: -A physician's orders [REDACTED]. Record review of the resident's TAR dated October 2014, showed: -A physician's orders [REDACTED]. -A line was drawn across the dates from 10/1/14 and Dc' d (for discontinued) was noted. -Documentation did not show a date when the order was discontinued. Record review of the resident's POS dated November 2014, showed: -A physician's orders [REDACTED]. Record review of the resident's TAR dated November 2014 showed: -A physician's orders [REDACTED]. -Staff had not initialed any day in November to show if the treatment had been done or refused. -No documentation on the back of the TAR to show that the resident had refused the treatments. Record review of the resident's physician progress notes [REDACTED].>-On 11/25/14, no documentation of any wounds on the resident, and staff were directed to continue the present regimen. Record review of the resident's POS dated December 2014, showed: -A physician's orders [REDACTED]. Record review of the resident's TAR dated December 2014, showed: -A physician's orders [REDACTED]. -Staff had not initialed any day in December to show if the treatment had been done or refused. -No documentation on the back of the MAR indicated [REDACTED]. Record review of the resident's care plan evaluated on 12/1/14, showed: -In the care plan for the potential of impaired skin integrity, no documentation he/she had any wounds or open areas; and -No documentation he/she had any wounds or open areas in any of his/her other care plans. Record review of the resident's Monthly Summary forms dated 8/23/14, 9/10/14, 10/18/14, 11/15/14, and 12/28/14 showed no documentation of any open areas to his/her right heel. Record review of the resident's nurse's notes dated 10/18/14 through 12/29/14, showed: -No documentation of a wound on his/her right heel. Record review of the facility's list of wounds provided by the DON and dated 12/30/14, showed the resident not listed as having any current wounds. Record review of the outside wound team's forms which were filed in a notebook showed: -The resident had last been seen by the outside wound team on 5/13/14 for a wound to the left heel. -No documentation was found to show the resident had been seen by the wound team for a wound on his/her right heel. During an interview on 12/30/14 at 3:24 P.M., Licensed Practical Nurse (LPN) B said: -The resident still had the wound on his/her right heel. -The wound was almost healed and the resident was still receiving treatment. -The treatment was done daily. -The outside wound team saw the wound weekly. -Treatments were charted in the treatment book. During an interview on 12/30/14 at 3:35 P.M., the DON said he/she had been told the resident's wound had cleared, and he/she was admitted to the hospital on [DATE] with a medical issue unrelated to any wound. 2. Record review of Resident #15's face sheet showed he/she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was independent with decisions in daily decision making. -Was independent in activities of daily living, not requiring assistance from staff. -Did not have any type of wound, including a [MEDICAL CONDITION] or open lesion on the foot. Record review of the resident's hospital Magnetic Resonance Imaging (MRI, a radiology test to form images of the body) of his/her left foot dated 10/18/14, showed: -He/she had a history of [REDACTED]. -The study showed acute osteo[DIAGNOSES REDACTED] (an infection of the bone) of the second toe with non viable (dead) tissue related to the infection. Record review of the resident's Admission Nursing assessment dated [DATE], showed he/she had no skin issues or wounds listed except for puncture areas on both of his/her arms in the inside elbow areas, which were noted as possible intravenous sites. Record review of the resident's Physician's Progress Notes showed: -On 10/28/14, he/she had a wound on his/her left foot, the second toe was amputated, and he/she was wearing a boot. Record review of the resident's POS dated December 2014, showed: -A physician's orders [REDACTED]. -A physician's orders [REDACTED]. Record review of the resident's TAR dated November 2014, showed: -An undated physician's orders [REDACTED]. -Staff had not initialed on 11/17/14, 11/19/14, 11/21/14, 11/25/14, 11/27/14 and 11/29/14 to show if the treatment had been done or refused. -Staff had initialed on 11/15/14 and 11/22/14 that the treatment was done, and no other initials were documented between 11/15/14 and 11/30/14. -No documentation was found on the back of the TAR to show if the resident had refused the treatment. Record review of the resident's Podiatrist note dated 11/14/14, showed his/her second toe was amputated (in October) and his/her left foot was wrapped from the amputation site. Record review of the resident's Monthly Summary dated 11/20/14, showed staff documented the resident's skin turgor was good except for his/her foot. Record review of the resident's Physician's Progress Notes showed: -On 11/25/14, the documentation did not address any wounds on the resident. Record review of the resident's Nursing System Review forms from 10/26/14 through 11/22/14, showed his/her wound assessment dated [DATE] documented he/she had a dry scab. Record review of the resident's Nurse's Notes from 10/20/14 through 12/23/14, showed staff did not document any assessments or treatments to his/her foot wound after 11/22/14. Record review of the resident's care plan on 12/1/14, showed: -A care plan for his/her toe amputation with staff being directed to assess the skin condition every shift and to provide treatment as ordered. Record review of the resident's TAR dated December 2014, showed: -A physician's orders [REDACTED].M. to 3:00 A.M. -Staff had not initialed on 12/6/14 and 12/7/14, on 12/9/14 and 12/10/14, on 12/12/14 and 12/13/14, and 12/14/14 to show if the treatment had been done or refused. -A line was drawn across the dates from 12/20/14 and Dc' d (for discontinued) was noted, with no date showing when the order was discontinued. Record review of the resident's Monthly Summary dated 12/28/14, showed no documentation of a wound on his/her left foot. Record review of a list of wounds dated 12/30/14 and provided by the DON, showed the resident's name was included on the list. During an observation and interview on 12/30/14 at 11:42 A.M., the resident was walking down the hallway, and when asked about the wound, he/she said staff was not changing the dressing anymore. During an interview on 12/30/14 at 11:50 A.M., LPN A said: -The treatment had stopped to the resident's foot about three weeks ago. -The facility did not require nurses to do weekly skin checks. -The certified nursing assistants (CNA) did the resident showers, and if they saw anything they would tell the nurses. -He/she had no wound training outside of his/her nursing training. -He/she usually split the wound treatments with the evening nurse. -He/she documented if the wound was red, open, had any drainage, the color of the drainage, any odor, the size. -He/she did not stage the wounds. -He/she usually only measured the wound's length and width, and they brought in the wound care team if the wound had any depth to it. -He/she documented the wounds in the nurse's notes or on the admission assessment. -He/she didn't know of any other nurses measuring the wounds besides the wound care team, the DON or himself/herself. -He/she had not seen or used any of the facility's wound forms listed in the policy Skin Management Program. -Any physician's orders [REDACTED]. -The physician's orders [REDACTED]. During an interview on 12/30/14 at 3:24 P.M., LPN B said: -Physician orders [REDACTED]. -Discontinued orders are marked off on the POS, Medication Administration Record [REDACTED] -He/she had not filled out the Wound Assessment forms. -He/she had not seen the facility forms in the facility's policy Skin Management Program. During an interview on 12/30/14 at 3:35 P.M., the DON said: -The nurses keep track of the wounds and he/she knows who has a wound in the facility. -He/she becomes aware of any residents with wounds during the morning stand-up meetings and when he/she becomes aware of any new wounds, he/she assesses the wound. -He/she documents any wounds he/she sees in the nurse's notes. -The nurses document on the TARs and in the nurse's notes. -The nurses are to address any resident wounds first and then let the DON know. -He/she expects the nurses to assess the wound and document the wound's appearance, size, measurements, odor (or lack of), any drainage, or eschar. -He/she expects the nurses to assess the wound when first found, during treatment changes and if there is any change in the nature of the wound. -He/she expects the nurses to notify him/her and the resident's physician when finding any new wounds or with any change of the wound. -The forms listed in the facility policy Skin Management Program were used by the facility but not when the resident was being seen by the wound care team. -He/she said the Weekly Wound Assessment Form was used by the nurse on the first floor. -Both Resident #14 and #15 resided on the second floor. -He/she expected any discontinued physician's orders [REDACTED]. -He/she expected the nursing staff to make a line through the physician's orders [REDACTED]. During an interview on 1/13/15 at 1:05 P.M., the resident's facility physician said: -He/she expected the facility staff to follow the facility's policy and procedures in place to assess, monitor, treat and evaluate resident's wounds. -When the staff have an issue, they notify him/her and he/she goes to the facility at least once a month, or more if necessary. -He/she was under the impression Resident #14's surgical site had healed. -He/she did not know about the facility's documentation of the resident's wounds. Complaint MO 926

Based on observation, interview, and record review, the facility staff failed to notify the resident's physician and the Director of Nursing (DON) in a timely manner of the changes in the resident's anxiety level, crying, restlessness, bruising, swelling, and complaints of severe pain; to assess and monitor a resident with severe contractures of his/her lower extremities who exhibited increased severe pain and anxiety; to notify the resident's physician and the DON that the resident had a hinged knee (allows for limited movement of the joint) long leg brace that was applied to the resident's left leg for a distal fractured femur at the knee and femur joint, and to assess and monitor the leg brace; for one sampled resident (Resident #1) out of three sampled residents. The facility census was 53 residents. Record review of the facility's policy titled Physician Notification Policy dated 2013, showed it's purpose was to improve care delivery to the residents by enhancing the system of communication to the attending physician for follow-up or further treatments of the resident's condition; and included the following instructions for the staff: -Nursing staff must conduct an assessment and notify the resident's attending physician when any changes in conditions or clinical status occurred in the resident, fall, injury, and any incidents, bruises, changes in physical conditions or needs of therapy treatment, and other concerns. -The facility adopts the physician notification protocol published by the American Medical Director Association for the policy and procedure on what clinical conditions are recommendations from the professionals; -A summary chart is available at the nurse's station to help the nursing staff in the notification protocol; -The facility staff consults with the resident and notifies the attending physician within 24 hours for the following conditions; --An accident involving the resident which results in injury, an accident regardless if any injury occurred, a deterioration in the health, clinical complications of health conditions, the need to alter treatment, and a decision to transfer the resident from the facility. -Assess the resident's condition and document findings in the resident's medical records; -Notify the attending physician to clarify the orders and transcribe it correctly to the locations of medical records (MAR), Physician order [REDACTED]. -For re-admitting residents, do not resume the previous orders without contacting and consulting the physician and write all orders on the POS despite of new or existing orders; -Describe the relevant information from the nursing assessment; -Follow-up after leaving a fax or a voice message; -Communicate with nursing staff regarding condition and follow-up; -Document in medical records, orders, and care plan; -Notify the administrator/ DON. Record review of Lippincott's Manual of Nursing Practice, eighth edition titled Clinical Manifestations of a Fracture, showed the physical findings of a fracture included: -Pain at the site of injury; -Swelling; -Tenderness; -Ecchymosis (bruising); and -Loss of movement. Record review of the facility's policy titled Safe Transfer dated 2013, showed it's purpose was to ensure safe techniques when transferring residents from bed to chair and from chair to bed, and included the following: -Assess the resident's weight bearing ability; -Always use a gait belt to assist with transfer techniques; -Maintain body mechanics when assisting residents; -Use a Hoyer lift (mechanical hydraulic lift) after nursing assessment or therapy assessment that determines the resident is non weight bearing; -The procedure to determine a safe transfer of the resident included: --Determine if the staff person has been trained and is physically able to help a resident complete the transfer safely; --Use a gait belt for safety and position the gait belt so that the assisting person can have a safe hold without pulling on the resident's clothes or arms; --If unsure about completing the transfer safely, seek further assistance rather than risk injury to the resident or to yourself; Record review of the facility's policy titled Therapy Services dated 2012, showed the purpose of the policy was to ensure the residents receive professional rehabilitation services including: Physical Therapy (PT) and Occupational Therapy (OT); -Therapy services are only processed per physician orders [REDACTED]. -The resident's care plan would address additional services if applicable or needed to accommodate the resident's condition (ex: a leg brace) per the therapist's instructions. -The orders for therapies are documented on the POS; -The progress notes for these services are documented by the professional therapists and communicated with nursing staff; -A referral to therapy services can be made by the licensed nurse to the physician in the following resident conditions: --Candidate for rehab services, --Declining in condition, --Declining or change in mobility level; weakness or activities of daily living (ADLs); --A fall that related to mobility or muscle weakness upon nursing assessment/investigation; --A condition that requires therapy services; -The procedure for ordering therapy services included the following: --A nursing assessment upon condition; --No therapy services are without a physician orders; --Obtain the order from the physician and document clearly on the resident's medical record; --Notify the contractor therapy company to inform the services the physician's orders [REDACTED]. -The policy did not show that therapy services should be contacted regarding the application and safety measures of the resident's new hinged long leg brace; -The policy did not show that nursing staff should receive inservice /education regarding instructions on the use and care of the resident's new hinged long leg brace (an apparatus that is not routinely used at the facility). Record review of the American Geriatric Society recommendations for Pain Management Nursing titled Persons with Advanced Dementia: Guiding Principles for the Assessment of Pain, included the following: -Musculoskeletal and neurological disorders are the most common causes of pain and should be given priority in the assessment process. A recent fall or other acute pain-related problem could be the cause of the resident's pain. -Some behaviors are common and typically considered pain related (e.g., facial grimacing, moaning, groaning, rubbing a body part), but others are less obvious (e.g., agitation, restlessness, irritability, confusion, combativeness, particularly with care activities or treatments, or changes in appetite or usual activities) and require follow-up evaluation. -Typical pain behaviors are often not present, and more subtle indicators may represent pain. Use the American Geriatric Society's indicators of pain (AGS, 2002) or a nonverbal pain assessment tool that is appropriate, valid, and reliable for use with this population. -Observe for behaviors recognized as indicators of pain in this population. Facial expressions, verbalizations/vocalizations, body movements, changes in activity patterns or routines, and mental status changes have been identified as categories of potential pain indicators in older persons with dementia (AGS, 2002). A list of indicators included in these categories and an algorithm for evaluating pain in persons unable to self-report are -Behavioral observation should occur during activity whenever possible, because pain may be minimal or absent at rest. 1. Record review of Resident #1's Admission Face Sheet showed he/she was on 5/7/99 and readmitted on [DATE], with the following Diagnoses: [REDACTED]. --Alzheimer's (a disease marked by the loss of cognitive ability); --[MEDICAL CONDITION] Joint Disease (DJD; [MEDICAL CONDITION]; the progressive and permanent long-term deterioration of the cartilage surrounding the joints); --[MEDICAL CONDITION] (the term referring to a form of chronic joint inflammation caused by deterioration of joint cartilage. --Osteopenia (refers to bone density that is lower than normal peak density but not low enough to be classified as [MEDICAL CONDITION]); --[MEDICAL CONDITION] (the thinning of bone tissue and loss of bone density); --Old femur fracture (the long leg bone) --Old pelvic fracture (ramus); --Deformity of the foot and ankle (unstated right or left). Record review of the resident's Care Plan for Falls dated September 2010, showed a problem of the resident needing total assist of one to two staff persons with transfers, as he/she was unable to do anything for himself/herself. The interventions included: -The resident was at risk for falls due to improper positioning, dementia, and the inability to transfer himself/herself; -The care plan did not show if the resident should be transferred with a gait belt or a mechanical lift; -The care plan did not show the resident had contractures of his/her left arm and left leg; -The care plan did not show the resident had a deformity of his/her (unstated left of right) foot and ankle; -The care plan did not show the resident's weight bearing status; -The care plan did not show a current quarterly or updated care plan. Record review of the resident's Care Plan for ADLs dated September 2010, showed a problem of the resident being unable to do anything for himself/herself except feeding himself/herself, and the intervention included: -The resident required total assistance with all his/her ADLs; -The care plan did not show the resident had contractures of his/her left arm and left leg; -The care plan did not show a current quarterly or updated care plan. Record review of the resident's Care Plan for Urinary Incontinence dated September 2010, showed the following: -The resident could almost always use the toilet, but at night he/she was incontinent of his/her bladder and would use pads and briefs for protection; -The resident was incontinent of his/her bowel and bladder control at intervals and required maximum assistance of one to two staff persons for pericare; -The resident was able to use the toilet with staff assist routinely; -The care plan did not show that the resident was contractured of his/her left leg; and -The care plan did not show a current quarterly or updated care plan. Record review of the resident's medical record for September 2014, showed the following: -The resident did not receive additional as needed (PRN) pain medication for June, July, and August 2014; -The September MAR showed an increase of nine doses of [MEDICATION NAME] (antianxiety medication) given from 9/17/14 to 9/29/14 at the initial onset of the resident's left leg pain, for a total of 13 doses for September; -The resident received four doses of Tylenol and one dose of [MEDICATION NAME] (narcotic pain medication used to treat severe pain) for complaints of severe left leg pain from 9/16/14 through 9/25/14. Record review of the resident's POS dated 9/1/14 through 9/30/14, showed the following physician's orders [REDACTED]. -Administer [MEDICATION NAME]/apap ([MEDICATION NAME]/Tylenol-a narcotic pain medication) 5 milligrams/325 milligrams (mg), one tablet twice in a 24 hours period (received at 8:00 A.M. and 6:00 P.M.) -Administer Tylenol 325 mg, one tablet every four hours PRN for pain; -Administer [MEDICATION NAME] one mg every four to six hours PRN for anxiety. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/8/14, showed the staff assessed he/she: -Had severely impaired cognition; -Was oriented to person and place; -Had required maximum assistance of one to two staff persons for bed mobility, transfers, dressing, pericare, and personal hygiene; -Had impairment of both upper and lower extremities; -Had chronic pain; -Had received routine pain medication in the past five days since assessment; -Had not received a PRN pain medication in the past five days since assessment; -Had received non-medication interventions in the past five days since assessment. Record review of the resident's Nurse's Notes dated 9/16/14 at 1:05 P.M., showed the following: -The licensed nurse had documented that the PRN medication was beginning to be effective; -The wheelchair foot support braces were reattached to his/her wheelchair; -The nurse's notes did not show the resident's left knee area was slightly swollen as reported by the licensed nurse (during an interview on 10/23/14); -The resident's nurse's notes did not show that the licensed nurse had assessed the location of the change in the resident's left leg pain and rated the pain level of the resident's left leg pain; -The licensed staff did not document that the resident's physician and the DON were notified of the change in the resident's left leg pain and his/her left knee area was swollen; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's leg was injured since 9/16 when the resident's left leg was left unsupported and after that the resident started complaining of pain. Record review of the resident's Nurse's Notes dated 9/17/14 at 3:00 P.M., showed he/she: -Had complained of pain specifically in his/her left leg; -Had received PRN Tylenol for pain and the licensed nurse had not documented the effectiveness of the PRN medication; -Had requested to be laid down in his/her bed after breakfast and refused to be up in his/her wheelchair for lunch; -The licensed staff did not document that the resident's physician was notified of the resident's increase in his/her left leg pain and his/her left knee swelling; -The licensed staff did not document that the DON was notified of the resident's increase of his/her left leg pain; -The resident's nurse's notes did not show that the licensed nurse had assessed the location of the change in the resident's left leg pain, had rated the pain level of the resident's left leg pain, and the effectiveness of the pain medication that had been administered; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's injury to the resident's left leg had possibly happened and when the resident's injury had occurred; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's leg was injured since 9/16 when the resident's left leg was left unsupported and after that the resident started complaining of pain. Record review of the resident's Nurse's Notes dated 9/17/14 at 11:20 P.M., showed he/she: -Was in his/her bed yelling to get up and was placed in his/her wheelchair at the nurse's station; -Was complaining of pain specifically in his/her left leg; -His/her left leg continued to be slightly swollen (during an interview on 10/24, the licensed nurse said the resident had swelling above his/her knee and the swelling had increased up into the femoral (femur-upper leg bone) area; the location of the swelling was not documented in the nurse's notes); -Received a PRN pain medication (was not documented on the resident's MAR for Tylenol ) at 11:10 P.M. and the licensed nurse had not documented the location of the pain of the resident's left leg, the rating of the resident's pain level, and the effectiveness of the PRN medication; -Had become agitated, continued to state that his/her left leg was hurting, what hospital was he/she going to and what time was it? -Was given [MEDICATION NAME] at 11:10 P.M. for agitation and instructed to relax and allow the pain medication to work; -The licensed staff did not document the effectiveness of the resident's Tylenol or [MEDICATION NAME] that had been given to the resident in the nurse's notes or on the resident's MAR. -The licensed staff did not document that the resident's physician was notified of the resident's increase in his/her left leg pain and the increasing swelling above his/her left knee; -The licensed staff did not document that the DON was notified of the resident's increase of his/her left leg pain and left leg swelling; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's injury to the resident's left leg had possibly happened and when the resident's injury had occurred as evidenced by an increase in his/her left leg pain and the knee swelling to the femoral area; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's leg was injured since 9/16 when the resident's left leg was left dangling and after that the resident started complaining of pain. Record review of the resident's MAR dated 9/17/14, showed: -At 3:50 P.M., the licensed staff did not document that the resident had received Tylenol for complaints of left leg pain, the level of pain the resident was having and the effectiveness of the pain medication; -At 11:10 P.M., the licensed staff did not document that the resident had received Tylenol for complaints of left leg pain, the level of pain the resident was having and the effectiveness of the pain medication; -At 11:20 P.M., the resident received [MEDICATION NAME] for anxiousness and yelling with no follow-up of effectiveness of the medication. Record review of the resident's Nurse's Notes dated 9/19/14 through 9/24/14, showed the following: -The licensed staff did not document the status of the resident during the three shifts for this time period; -The licensed staff did not document in the nurse's notes that the resident had received PRN medication for anxiety and pain, the location of the resident's pain, the rating of the pain level, and the status of the resident's outcome for receiving the PRN medications for this time period; -The licensed staff did not document that the resident's physician was notified of the resident's increase in his/her left leg pain and his/her left leg swelling; -The licensed staff did not document that the DON was notified of the resident's increase in his/her left leg pain and his/her left leg swelling; -The licensed staff did not document the new bruising on the back of the resident's knee that was found and reported to the licensed staff by the Certified Nursing Assistant (CNA) on 9/24/14. Record review of the resident's Nurse's Notes dated 9/25/14 at 10:15 A.M., showed the resident's physician was at the facility and orders were received to discontinue one of the resident's medications; -The licensed staff did not document that the resident's physician was notified of the resident's increase in his/her left leg pain, swelling, and bruising on the back of the resident's knee; -The licensed staff did not document that the DON was notified of the resident's increase in his/her left leg pain, swelling, and new onset of bruising on the back of the resident's knee. Record review of the resident's Nurse's Notes dated 9/25/14 at 3:50 P.M., showed he/she: -Was up in his/her wheelchair at the nurse's station complaining of his/her left leg hurting, painful to touch and upon movement and had increased swelling of his/her left leg; -The CNA informed the charge nurse that he/she had reported a purpled colored bruise on the resident's left leg in the back of the resident's knee to the charge nurse on the day before (9/24/14) and that it had increased in size; -The resident refused to allow the charge nurse to assess back of his/her left leg and his/her left knee; -At 3:50 P.M., the resident received Tylenol for complaints of left leg pain that was not documented on the resident's MAR; -The resident's pain level was not assessed and the location of the pain of the resident's left leg; -The effectiveness of the medication was not assessed. -The charge nurse attempted to notify the resident's physician by calling the physician's cell phone and left a message; -At 4:50 P.M., the charge nurse called the resident's physician's home phone and left a message; -At 8:00 P.M., the charge nurse had not received a call back from the resident's physician and documented he/she would call the resident's physician in the morning; -The resident had received his/her routine [MEDICATION NAME] at 6:00 P.M. and had not complained of pain at 8:00 P.M.; -The licensed staff had not documented the assessment, intensity, duration and follow-up of the resident's [MEDICATION NAME] and Tylenol pain medication that was given on the resident's MAR or nurse's notes. Record review of the resident's Nurse's Notes dated 9/26/14 at 1:15 P.M., showed the following for the resident: -The resident's physician was notified of the resident's left leg swelling and the charge nurse received orders to apply a cold compress PRN to the resident's left leg bruise PRN and monitor for 24 hours; -The charge nurse did not document that the resident's physician was notified of the resident's increase in his/her left leg pain and painful to touch or movement, and signs and symptoms of an injury; -The licensed staff did not document that the DON was notified of an increase in the resident's left leg pain, the resident's leg swelling, and the resident's leg bruising; -The licensed staff did not document that the resident's physician and the DON was notified of how the resident's injury to the resident's left leg had happened and when the resident's injury had occurred as evidenced by an increase in his/her left leg pain and the knee swelling; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's leg was injured since 9/16 when the resident's left leg was left dangling and after that the resident started complaining of pain. Record review of the resident's Nurses's Notes dated 9/29/14, showed: -At 3:50 P.M., the resident received [MEDICATION NAME] for complaints of severe left leg pain, crying and anxiety; Record review of the resident's Nurse's Notes dated 9/29/14 at 3:40 P.M., showed he/she: -Was assisted by staff up into his/her wheelchair for supper; -Was crying and complaining of severe pain in his/her left leg; -Had purple bruising from his/her left knee to his/her left hip; -The charge nurse called the resident's physician's office and spoke with the physician's office nurse and was told by the nurse that he/she would have the physician call the facility; -At 8:30 P.M., the physician was notified of the resident's condition and the resident was transferred to the emergency room (ER); -The licensed staff did not document that the DON was notified of the resident's increase pain that was now, according to the resident was severe left leg pain, the resident's left leg had increased swelling, and the resident's left leg bruising; -The licensed staff did not document that the resident's physician was notified of the resident's potential injury of unknown origin and the resident had a potential fall episode as evidenced by the resident's increase pain in his/her left leg, increased swelling from the knee up to the femoral area, increased bruising on the back of his/her leg; -The licensed staff did not document that the resident's physician and the DON were notified of how the resident's leg was injured since 9/16 when the resident's left leg was left unsupported and after that the resident started complaining of pain. Record review of the resident's facility transfer sheet to the hospital emergency room (ER) dated 9/29/14, showed he/she: -Required help to transfer from bed to a chair; -Had a fall days ago (the resident's facility medical record did not show documentation of a fall during the time period of 9/25/14 through 9/29/14); -Had a purple bruising on the back of the resident's left lower extremity from his/her left knee up to his/her left hip; -He/she had complained of severe pain. Record review of the resident's ER admission report dated 9/29/14, showed the reason for the exam was the resident had left hip and left leg pain and the resident had fallen three days prior as reported by the facility nursing staff to the ER staff nurse. Record review of the resident's Nurse's Notes dated 9/30/14 at 2:45 A.M., showed he/she: -Was returned from the ER with a [DIAGNOSES REDACTED]. Record review of the hospital's ER discharge instructions dated 9/30/14, showed the following: -The resident had a contusion (bruise); -The resident was to have ice applied to the contusion: -The resident was to avoid using the injured body part; -The resident should follow-up with his/her physician in two days. Record review of the resident's Nurse's Notes dated 10/1/14, showed the following: -The licensed staff had documented for the day shift and the night shift, regarding the resident's activities of being up in his/her wheelchair for meals and not having pain issues, but no documentation for the resident's status on the evening shift; -The licensed staff did not document if the resident's continued to have left leg swelling or bruising; -The licensed staff did not document if the staff had applied a cold compress to the resident's bruised area per the discharge instructions; -The resident continued to receive [MEDICATION NAME] at 8:00 A.M. and 6:00 P.M.; -The licensed staff did not document if the resident's left leg pain was relieved by the scheduled [MEDICATION NAME] after each administration of the pain medication. Record review of the resident's controlled substance MAR dated 10/2/14 at 3:45 P.M., showed: -The resident received [MEDICATION NAME] for crying and anxiety; -The record showed the medication was effective at 5:45 P.M. as indicated by the licensed nurse documentation on the resident's controlled substance record; -The licensed staff did not document in the resident's nurse's notes regarding the resident's reason for crying and anxiety. Record review of the resident's MAR dated 10/7/14 at 11:30 P.M., showed: -The resident received [MEDICATION NAME] for crying and anxiety; -The record showed the medication effectiveness was pending (no time was documented); -The licensed staff did not document in the resident's nurse's notes regarding the resident's reason for his/her crying and anxiety. Record review of the resident's controlled substance MAR dated 10/8/14 at 9:30 A.M., showed the resident: -Had received [MEDICATION NAME] for crying and yelling wanting out of the chair; -The resident's nurse's notes did not show documentation of the resident's assessment for crying and wanting to be out of his/her wheelchair; -The medication was effective at 11:30 A.M.; -The licensed staff did not document in the resident's nurse's notes regarding the resident's activity at that time. Record review of the resident's controlled substance MAR dated 10/10/14 at 5:00 P.M., showed the resident: -Had received [MEDICATION NAME] for restlessness, anxiety, and can't be still; -The resident's nurse's notes did not show documentation of the resident's assessment for restlessness and anxiety; -The medication was effective at 9:00 P.M.; -The licensed staff did not document in the resident's nurse's notes regarding the resident's activity at that time. Record review of the resident's Nurse's Notes dated 10/11/14 at 3:00 P.M., showed the following: -The charge nurse documented that the resident was up in his/her wheelchair, sitting in the hall by the dining room; -The resident had complained of pain in his/her left leg and was given a PRN medication that was not documented on the resident's MAR and was not documented in the resident's nurse's notes; -The licensed staff did not document the resident's pain rating and the follow-up showed partial relief with no further follow-up documented; -The licensed staff did not document that the resident's physician was notified of the resident's continued pain, anxiety, crying, and restlessness. Record review of the resident's Nurse's Notes dated 10/12/14 at 8:00 P.M., showed the following: -The resident had complaints of left leg pain and was given his/her scheduled [MEDICATION NAME] at 6:00 P.M.; -The licensed staff did not document the resident pain rating; -The medication was partially effective; -The licensed staff did not document in the resident's nurse's notes regarding the resident's status at that time; -The licensed staff did not notify the resident's physician that the resident's pain was not being controlled. Record review of the resident's Nurse's Notes dated 10/16/14, showed the following: -At 12:00 noon, the resident complained of left knee pain; -The resident's physician was notified and the resident was transferred to the emergency room for evaluation. Record review of the resident's hospital medical record dated 10/21/14, showed the following: -The resident had a distal femur fracture and was admitted to the hospital for pain management and evaluation for orthopedic surgery; -The orthopedic surgeon had recommended conservative therapy for the femur fracture with a hinged brace and non-weight bearing for the lower left extreamity (LLE); -The resident was to have PT and OT for evaluation and treatment; -The nursing home staff reported to the hospital emergency room that the resident rolled out of his/her bed that was low to the ground on 10/13/14; -The resident's nurse's note for 10/13/14 did not show that the staff had documented that the resident had fallen out of bed on 10/13/14. -The licensed staff did not document that the resident's physician was notified of the resident's falling out of his/her bed on 10/13/14. Record review of the resident's hospital discharge instructions dated 10/21/14, included the following: -The activity level for the resident was non-weight bearing on the LLE; -The resident had a long leg brace to the LLE; -Monitor the resident's skin for breakdown; -Follow-up with the orthopedic clinic in two to three weeks; -Continue the resident's previous medications; -The resident may have [MEDICATION NAME] pain medication, one tablet to two tablets every four hours as needed for pain. Record review of the resident's Nurse's Notes dated 10/21/14, showed the following: -At 2:45 P.M., the resident was returned to the facility from a hospital admission from 10/16/14 through 10/21/14 with a [DIAGNOSES REDACTED]. -The resident had a brace to his/her left leg; -The resident had bruising all over his/her body; -The resident had dark purple/blue bruising of his/her left upper arm; -The resident's physician was notified of the admission orders [REDACTED] -The licensed staff did not document that the resident's physician had been notified of the resident's bruising, fracture, and the type of brace; -At 10:00 P.M., the licensed staff had documented the resident had been up in his/her wheelchair for supper, had a long leg brace on his/her left leg, and he/she had received [MEDICATION NAME], one tablet at 7:50 P.M., and also had received his/her scheduled [MEDICATION NAME] at 6:00 P.M.; -The licensed staff did not document the assessment of the resident's breakthrough pain at 7:50 P.M.; -The resident's non-bearing weight bearing status was not documented in the nurse's notes; and -The resident's knee hinged long leg brace was not documented in the nurse's notes. Record review of the resident's POS dated 10/21/14, showed the following: -The resident's non-weight bearing status was not documented on the resident's POS; -The resident's leg brace was not identified as a knee hinged long leg and documented on the resident's POS; -an order for [REDACTED]. -The resident's physician was not notified of the need for therapy as per their policy for when to request thera