Every finding on record at Sunterra Springs Dardenne Prairie

Based on interview and record review, the facility failed to provide documentation of ongoing assessments of a surgical wound as directed in facility policy for one resident (Resident #1), in a review of eight sampled residents, when the resident's wound deteriorated. The facility failed to notify the surgeon when the wound had an increase in bleeding for four days which caused a delay in the resident being sent to the emergency department following a miscommunication and a missed appointment with the surgeon. The facility census was 32.Review of the facility's policy, Wound Treatment Management, last revised 04/2025, showed the following:-It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Treatment decisions will be based on etiology of the wound, characteristics of the wound and location of the wound;-The facility will follow specific physician orders for providing wound care and are able to provide standard of care provisions for all residents;-Consideration for needed modification included lack of progression towards healing, changes in the characteristics of the wound, changes in the resident's goals and preferences;-The effectiveness of treatments will be monitored through ongoing assessment of the wound. Review of the facility's policy, Notification of Changes, last revised 04/2025, showed the following:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification;-The facility must inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there is a change requiring such notification;-Circumstance requiring notification includes significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status including clinical complications, circumstances that require a need to alter treatment. 1. Review of Resident #1's undated face sheet showed the following:-admission date 04/18/26;-Diagnoses included pathological fracture left femur (broken bone in an area weakened by a pre-existing medical condition), encounter for orthopedic aftercare, acute posthemorrhagic anemia (critical condition caused by a sudden rapid loss of a large volume of blood). Review of the resident's care plan, last revised 04/19/26, showed the following:-At risk for complications secondary to anti-coagulant use;-Will have no unaddressed bleeding or adverse drug event;-At risk for alteration to skin integrity secondary to left hip surgical incision;-Will have no unaddressed alteration to skin integrity;-Weekly skin check per facility schedule, notify the physician of alterations for prompt/proper intervention;-The resident has an actual skin impairment/wound, left hip incision;-Will have no unaddressed complications to skin/wound or prescribed treatments;-At risk for infection secondary to recent hospitalization, left hip incision, diabetes and multiple myeloma (a blood cancer);-Will have no untreated signs or symptoms of infection. Review of the resident's April 2026 physician order sheet showed the following:-Apixaban (blood thinner) 5 milligrams (mg) twice daily;-Clean surgical site to left hip with normal saline, apply 4x4 gauze pad and abdominal (ABD, a highly absorbent multi-layered medical dressing) pad to site, creating a pressure dressing, cover with tape daily, ordered 04/23/26. Review of the resident's progress note/weekly skin check, dated 04/26/26 at 3:01 P.M., showed the following:-Surgical wound. Wound was present on admission. Incision approximated: Yes;-Dehiscence (the separation of the stitched edges of a wound) partial or complete separation of the outer layers of the joined incision: No;-Healing Ridge: induration beneath the skin under the suture line: No;-Length 7 centimeters (cm), width 0.3 cm, depth 0.0 cm;-No undermining (tissue damage under the skin creating hidden pockets) or tunneling (wound forms passageways underneath the surface of the skin). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool to be completed by the facility, dated 05/01/26, showed the following:-Cognition was intact;-Lower extremity impairment on one side;-Surgical wound;-Frequently incontinent of bowel and bladder;-He/She required set-up assistance with personal hygiene;-He/She required substantial/maximal assistance with showers, roll left to right-right to left, and sit to standing position;-He/She was dependent on staff with toilet hygiene, transfers and sit to lying and lying to sitting position. Review of the resident's May 2026 physician order sheet showed the following:-Apixaban 5 mg twice daily was discontinued on 05/04/26;-Apixaban 2.5 mg twice daily was ordered on 05/04/26;-Surgical incision to left hip, change cover dressing with clean dry bordered gauze, ordered 05/01/26. Review of the resident's progress note, dated 05/04/26 at 7:40 P.M., showed a new order from the Nurse Practitioner (NP) to decrease apixaban 5 mg to 2.5 mg twice a day (BID) for five days then increase apixaban to 5 mg BID related to increased bleeding at the surgical incision. Review of the resident's progress note/weekly skin check, dated 05/04/26 at 8:13 P.M., showed a surgical wound. The wound was present on admission. No undermining or tunneling. (Staff did not document measurements or any other assessment of the wound.) Review of the resident's progress note, dated 05/06/26 at 2:02 P.M., showed the ADON assisted the nurse with the dressing change to the left hip incision. Upper proximal incision at distal end with moderate to heavy amount of sanguineous (fresh bright red blood that leaks from an open wound) drainage present. The resident denied increased pain or discomfort. No redness was observed to the site. The nurse doubled over an ABD pad applied for added pressure and secured with medical tape. Staples intact. Nurse to update surgeon regarding the drainage. Review of the resident's progress note, dated 05/06/26 at 2:55 P.M., showed staff notified the surgeon's office of the drainage. Review of the resident's progress note, dated 05/06/26 at 6:47 P.M., showed staff contacted the surgeon's office regarding the bleeding from the surgical incision. The surgeon's nurse wanted the resident to come into the office as early as possible on 05/07/25. The resident already had an afternoon appointment scheduled with the surgeon. The nurse wanted to be contacted to confirm if the resident could make it into the office to be seen by 9:15 A.M. Pressure dressing using ABD pad to be applied at bedtime with date and time so drainage amount could be observed at the appointment. During an interview on 05/19/26 at 12:05 P.M., Licensed Practical Nurse (LPN) A said the following:-The resident's wound gradually started to drain more, and when it saturated through the abdominal pad, he/she called the surgeon;-He/She called the surgeon to get the appointment changed earlier in the day on 05/07/26 due to the change in condition and increased drainage;-He/She spoke with the nurse at the surgeon's office and was told to bring the resident in at 9:15 A.M.;-He/She was unable to confirm with transportation if they would be able to accommodate that time and told the nurse not to cancel the afternoon appointment in case the resident was unable to come in at 9:15 A.M.;-Transport services were unable to take the resident to the morning appointment, so they took him/her to the afternoon appointment. When the resident got there, they were told the appointment was canceled and the surgeon was already gone for the day and rescheduled the appointment. During an interview on 05/20/26 at 8:50 A.M., LPN G said the following:-The resident left the faciity on the afternoon of 05/07/26 for an appointment with the surgeon, and returned to the facility without seeing the surgeon;-Upon return to the facility, staff completed a dressing change. The wound had bloody drainage, and the dressing was doubled for more absorbency;-He/She did not contact the physician to notify them of the resident not being seen by the surgeon or on the status of the wound;-He/She should have contacted the Director of Nursing (DON) and physician about the increase in the resident's wound drainage and bleeding;-He/She thought the physician was already aware of the status of the resident's wound and the resident had another appointment scheduled for the 5/11/26 with the surgeon. Review of the resident's medical record showed no documentation staff completed any assessments of the wound from 05/06/26 until 05/11/26 at 7:58 A.M. Review of the resident's progress note, dated 05/11/26 at 7:58 A.M., showed the resident's incision on the left leg was found dehisced. Staples had detached and red/brownish flesh was bulging out of the resident's incision. Staff attempted to contact the surgeon who did not answer, then notified the on-call physician. The on-call physician ordered to send the resident to the hospital. Review of the resident's hospital records, dated 05/11/26 at 5:40 P.M., showed the following:-The resident presented to the Emergency Department (ED) with bleeding from left hip surgical incision site;-The resident stated he/she had drainage since surgery, with increased pain and discomfort in the surgical site. During an interview on 05/19/26 at 1:40 P.M., the resident's family member said the following:-He/She was upset the facility did not react sooner to the wound bleeding and draining;-The facility should have taken the resident to the appointment on 05/07/26 or to the emergency department sooner. During interviews on 05/19/26 at 3:30 P.M. and 05/20/26 at 3:40 P.M., Registered Nurse (RN) I from the surgeon's office said the following:-The resident told him/her they were having a heck of a time with his/her incision and staff would not let him/her out of bed due to the wound bleeding;-The resident came to the surgeon's office on 05/07/26 at 2:30 P.M. for an appointment, however, the surgeon was out of the office so he/she did not see the resident. The office did not get a call back from the facility that morning to let them know if they were coming at 9:15 A.M. or if they were coming at 2:30 P.M.;-The resident said he/she could not get staff to listen to him/her about his/her wound;-The facility finally called 911 and sent the resident to the emergency room on [DATE];-The resident was admitted to the hospital on [DATE];-He/She tried to call the Assistant Director of Nursing two times on 05/11/26 to confirm the dosage of the resident's blood thinner and still had not received a call back;-He/She felt the facility let the wound deteriorate for too long and should have involved the surgeon, not just the facility physician. During an interview on 05/19/26 at 2:40 P.M., Certified Nurse Assistant (CNA) B said the following:-The resident's wound was always draining. As it got worse, he/she told the charge nurse, but was unable to remember exactly when that was;-Each time the resident went to the bathroom or therapy, the wound bled more and he/she told the charge nurse. During an interview on 05/19/26 at 3:05 P.M., RN H from the surgeon's office said the following:-He/She reviewed the resident's chart at their office and determined the first call from the facility was on 04/22/26 stating the resident's incision had an increase in serosanguinous drainage, staples were intact, no redness or fevers;-The nurse was instructed to use pressure dressing and to call back in the next few days if bleeding had not resolved;-He/She did not receive another call until 05/06/26 at 3:11 P.M. when LPN A called and said the surgical incision had a lot of drainage and staff had to change the dressing twice in 12 hours;-He/She returned a call to LPN A who said at the end of the previous week, the drainage increased, the blood thinner was decreased on 05/04/26, and there was no odor or purulent drainage to the wound;-The surgeon asked the facility to bring the resident to the office the following morning at 9:15 A.M. instead of in the afternoon;-LPN A could not confirm if they would have transportation available that morning;-He/She told LPN A to call him/her on his/her personal cell phone in the morning to confirm if they would be at the morning appointment or if they needed to keep the afternoon appointment;-He/She did not receive any further communication from the facility until the resident's family member called the office on 05/11/26 to see if the surgeon was going to continue the resident's care in the hospital. During an interview on 05/19/26 at 5:00 P.M., the Assistant Director of Nurses (ADON) said the following:-The resident's surgical wound had a lot of drainage and edema upon admission;-He/She helped LPN A with the dressing change on 05/06/26. All the staples were intact with drainage from the distal end, no odor, no redness and pain was controlled. There was more drainage than he/she would expect so he/she told LPN A to call the surgeon. During an interview on 05/20/26 at 10:15 A.M., the Administrator said the following:-She expected staff to follow physicians' orders;-She expected staff to contact the physician and seek treatment for a resident as soon as there was a change in wound drainage, even if the resident had an upcoming appointment. During an interview on 05/19/26 at 1:05 P.M., the resident's physician said the following:-If the facility staff would have contacted him after the surgeon did not see the resident on 05/07/26, he would have contacted the surgeon for further orders or instructions;-In the best-case scenario, the resident would have been sent to the emergency department a couple of days earlier. Complaint 3014866

Based on observation, interview and record review, the facility failed to follow current infection control standards for five residents (Resident #4, #40, #41, #56 and #57), in a review of 15 sampled residents, when staff failed to perform proper hand hygiene, change gloves, properly handle contaminated linens and follow enhanced barrier precautions (EBP) by wearing personal protective equipment (PPE) to prevent infection while providing personal care. The facility census was 32. Review of the facility policy, Hand Hygiene, revised 04/2025, showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility;-Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Alcohol-based hand rub with 60% to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom;-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of the facility policy, Personal Protective Equipment, revised April 2025, showed the following:-This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff;-Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators);-All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely;-PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status;-Multiple factors determine the appropriate selection of PPE for a particular task: -The type of exposure anticipated (e.g., splash/spray versus touch); -The volume of fluid or tissue to which there is a potential exposure; -The likelihood of exposure; -The probable route of exposure (e.g., direct contact versus inhalation); -The need for transmission-based precautions;-Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intactskin, or potentially contaminated surfaces or equipment is anticipated;-Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene;-Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn; -Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material;-Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. Review of the facility policy, Enhanced Barrier Precautions, revised April 2025, showed the following:-Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms;- Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities;-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions;All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions;-Initiation of Enhanced Barrier Precautions:-An order for enhanced barrier precautions will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.)-Implementation of Enhanced Barrier Precautions:-High-contact resident care activities include: -Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care (any skin opening requiring a dressing), and device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters);-Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility policy, Handling Soiled Linen, last revised 04/25 showed the following:-It is the policy of this facility to handle, store process, and transport linen in a safe and sanitary method to prevent the spread of infection;-This policy pertains to soiled linen;-Linens can become contaminated with pathogens from contact with intact skin, body substances, or from environmental containments;-Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen;-All used linens should be handled using standard precautions (gloves) and treated as potentially contaminated;-Linens should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces and persons;-Used or soiled linens shall be collected at the bedside and placed in a linen bag or designated linen receptacle;-When the task is complete, the bag shall be closed securely and placed in the soiled utility room;-Soiled linens shall not be kept in the resident's room or bathroom. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/28/25, showed the following:-He/She was dependent on staff for toilet hygiene;-He/She had an indwelling urinary catheter (tube inserted into the bladder to drain urine);-He/She was always incontinent of bowel. Review of the resident's Care Plan, last revised on 11/07/25, showed the following:-He/She had a urinary catheter;-The resident required enhanced barrier precautions;-He/She had osteomyelitis (an infection in the bone) to the sacrum (triangular bone in the lower back);-Encourage and assist with proper perineal care;-He/She had a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) to the coccyx/sacrum;-He/She required assistance with toileting;-Staff were instructed to provide incontinence care after each incontinent episode. Review of the resident's physician's orders, dated January 2026, showed the following:-Diagnoses included osteomyelitis of vertebra, neuromuscular dysfunction of bladder (injury or disease interrupts the electrical signals between your nervous system and bladder function);-Indwelling urinary catheter;-The resident had a wound. Ensure enhanced barrier precautions are maintained every shift;-Cleanse wound with wound cleanser or normal saline, lightly pack with collagen particles (used to promote wound healing) and calcium alginate with silver (a natural, highly absorbent material from brown seaweed, used primarily in advanced wound dressings to create a moist healing environment and absorb exudate, forming a gel that promotes healing and reduces infection risk, while also functioning as a food stabilizer and in tissue engineering), cover with foam dressing every day and as needed for wound saturation or dressing comes off. Observation on 01/13/26 at 11:00 A.M. showed a sign posted outside of the resident's room showing the resident was on enhanced barrier precautions and directed staff to use gowns and gloves when directly assisting the resident with care needs. Gowns and gloves were present in a storage container in the hallway outside the resident's room. During an interview on 01/13/26 at 11:00 A.M., the resident said staff did not wear gowns when they provided his/her care. Observation on 01/13/26 at 11:15 A.M. showed the following:-Certified Nurse Assistant (CNA) A and CNA B were in the resident's room to provide incontinence care. Both staff wore gloves and gowns; -The resident had a urinary catheter and was incontinent of bowel; -With gloved hands, CNA A cleaned the resident's perineal area, including around the resident's urinary catheter, with a soapy washcloth; -Without removing his/her gloves and/or performing hand hygiene, CNA A removed a pillow from between the resident's legs, removed the catheter drainage bag from the resident's bed frame and placed it on top of the resident's legs, obtained clean wet wash clothes, and assisted the resident to roll onto his/her right side; -With gloved hands, CNA B cleaned feces from the resident's rectal area with a disposable wipe.-Wearing the same soiled gloves, he/she grabbed another wipe from the package with the same hand he/she used to clean the resident's rectal area, cleaned more feces from the resident's rectal area, removed the resident's soiled incontinence brief, positioned a clean brief under the resident, and moved the package of wipes to the bedside table; -CNA A removed the gloves he/she wore when cleaning the resident's perineal area, and without performing hand hygiene, opened the door and exited the resident's room;-While wearing the same gloves he/she wore when providing incontinence care, CNA B sat in the chair in the resident's room and rested his/her gloved hands on the arm rests as he/she waited for CNA A to return to the room; -CNA A returned to the room, did not perform hand hygiene, and put on gloves and a gown;-The Assistant Director of Nursing (ADON) entered the resident's room, put on gloves and a gown;-As the ADON changed the resident's dressing, CNA B held the resident's legs. CNA B wore the same gloves he/she wore to provide incontinence care to the resident; -The ADON exited the room, and CNA A and CNA B put an incontinence brief on the resident and positioned the resident in the bed. Observation on 01/13/26 at 2:30 P.M. showed the following:-CNA A and CNA B entered the resident's room. -CNA A and CNA B put on gloves, but neither staff put on a gown;-CNA A and CNA B pulled the resident up in bed and repositioned him/her in the bed. During an interview on 01/13/26 at 2:30 P.M., CNA B said the following:-He/She did not always put on a gown when providing care to residents who had EBP instructions and PPE outside of the door;-He/She followed what the other staff did. If other staff did not wear PPE, he/she did not wear PPE;-He/She could read the sign on the door and knew he/she was supposed to wear PPE, but he/she just did not wear it;-He/She was not supposed to touch any clean items with contaminated gloves/hands;-He/She should perform hand hygiene after he/she removed his/her gloves. He/She did not realize he/she did not complete hand hygiene. 2. Review of Resident #40's admission MDS, dated [DATE], showed the following:-He/She was dependent on staff with toilet hygiene;-He/She had an indwelling catheter;-He/She had an ostomy (opening in the abdomen, rerouting waste such as urine or stool from the digestive or urinary tract to exit the body into a collection pouch). Review of the resident's care plan, last revised on 11/09/25, showed the following:-He/She had osteomyelitis of the sacrum;-He/She had a stage IV sacral wound;-He/She had a colostomy (an opening (stoma) in the abdomen, redirecting part of the colon to the outside of the body, allowing stool and gas to exit into an external pouch instead of the anus);-He/She had a urinary catheter;-Staff were to assist with proper peri-care, catheter care and ostomy care;-Staff were to follow enhanced barrier precautions when providing care. Review of the resident's physician's orders, dated January 2026, showed the following:-Diagnoses included osteomyelitis and colostomy;-Enhanced barrier precautions;-Urinary catheter with catheter cares every shift and as needed. Observation on 01/14/26 at 8:30 A.M. showed a sign located outside the resident's room which identified the resident was on EBP and directed staff to use gloves and gowns when providing care. There was a cart, stocked with gowns and gloves, outside the resident's room. Observation on 01/14/26 at 8:30 A.M. showed the following:-CNA D entered resident's rooms and put on gloves. CNA D did not put on a gown;-CNA D removed the resident's gown;-The resident had a urinary catheter and a colostomy that was full of feces;-The resident had a wound vac system connected to a wound dressing on the resident's sacral area;-CNA D used wipes to clean the resident's perineal area, assisted the resident to his/her side, and cleaned between the resident's buttocks;-CNA D removed his/her gloves and without performing hand hygiene, put on new gloves. CNA D put a second glove over the glove on his/her right hand, applied barrier cream to his/her right hand, wiped the barrier cream on the resident's groin and perineal areas, and removed the outer glove on the right hand;-CNA D obtained a clean incontinence brief and placed it under the resident, assisted the resident onto the side of bed, put a gait belt around the resident, placed a walker in front of the resident, assisted the resident to dress, adjusted the resident's wound vac tubing, and pulled the urinary catheter tubing through the resident's pants;-CNA D removed his/her gloves and without performing hand hygiene, exited the room; -CNA D returned to the room, did not perform hand hygiene, did not put on a gown, and put on gloves. He/She lifted the resident's shirt, opened the colostomy bag, and removed feces from the bag by squeezing the feces from the bag and rinsing the bag with water. He/She then used disposable wipe to clean feces from the colostomy bag; -He/She reattached the colostomy bag, removed his/her gloves, picked up the bags containing soiled trash, did not perform hand hygiene, and put on new gloves;-He/She pushed the resident in the wheelchair to the bathroom, assisted the resident to stand, pulled down the resident's pants, assisted the resident back into wheelchair, drained cloudy yellow urine from the catheter drainage bag, detached the catheter drainage bag and applied a leg drainage bag system, removed his/her gloves, and without performing hand hygiene, exited the room;-CNA D returned to the room, and without performing hand hygiene and putting on a gown, put on gloves and attached the leg bag to the resident's leg. During an interview on 01/14/26 at 9:30 A.M., CNA D said the following:-He/She was supposed to wash his/her hands every time he/she changed his/her gloves and when he/she was in contact with any bodily fluids;-He/She was not supposed to touch any clean items with contaminated gloves/hands;-He/She was agency staff and did not know he/she needed to wear a gown when providing care to the resident;-He/She knew what the EBP sign meant but thought he/she only had to wear a gown if he/she wanted. 3. Review Resident #56's admission MDS, dated [DATE], showed the following:-He/She had a urinary catheter;-He/She had one or more unhealed pressure ulcers/injuries;-He/She had three unstageable pressure ulcers/injuries (wound bed covered by slough and eschar);-He/She had a urinary tract infection (UTI) within the last 30 days. Review of the resident's Care Plan, revised on 01/07/26, showed the following:-Actual skin impairment to left heel, right heel, left ankle, buttocks, and left hip;-At risk for infection secondary to suprapubic catheter, recent hospitalization, weakness, and debility;-Enhanced barrier precautions; Review of the resident's physician orders, dated 01/13/26, showed the following:-Right hip surgical incision: Cleanse with wound cleanser, pat dry; and apply cover dressing every shift for wound care;-Catheter: Ensure enhanced barrier precautions (EBP) are in place every shift;-Left lateral heel: Cleanse with wound cleanser or normal saline; pat dry; apply betadine moist gauze, cover with ABD, wrap with Kerlix every day shift;-Left plantar foot: Cleanse with wound cleanser or normal saline; pat dry; apply betadine moist gauze, cover with ABD, wrap with Kerlix every day shift;-Right heel: Cleanse with wound cleanser or normal saline; pat dry; apply betadine moist gauze, cover with ABD, wrap with Kerlix every day shift;-Wound: EBP related to wound every shift for precautions. Observation on 01/13/26 at 12:30 P.M. showed the following:-Registered Nurse (RN) N entered the resident's room wearing a gown and gloves, cleaned the wound on the resident's left lateral heel/ankle with wound cleanser, patted dry, covered with betadine gauze, covered with ABD, and wrapped the wound with Kerlix. He/She doffed his/her gloves, and without performing hand hygiene, donned a new pair of gloves;-RN N removed the soiled bandages from the resident's left plantar foot, cleaned the wound with wound cleanser, patted dry, applied betadine moist gauze, covered with ABD, and wrapped with Kerlix;-RN N doffed his/her gloves, washed his/her hands, and donned new gloves;-RN N removed the soiled bandages from the resident's right heel and placed the soiled bandages into the trash;-While wearing the same gloves, RN N cleaned the wound with wound cleanser, patted dry, applied betadine moist gauze, covered with ABD, and wrapped with Kerlix; -Wearing the same gloves he/she wore to provide wound care to the resident's right heel, RN N removed the soiled dressing from the resident's right hip, cleaned the wound with wound cleanser, patted dry, cut the new bandages with scissors to fit the area, and covered the wound with the new bandage;-While wearing the same gloves he/she wore to clean the wound on the resident's right hip, RN N held the bed controller and lowered the resident's bed;-RN N doffed his/her gloves and gown;-Without performing hand hygiene or wearing a gown or gloves, RN N moved the resident's catheter bag from the bed and attached it to the left side of the resident's bed, put the call light in the resident's hand, moved the trash can near the resident's door, and then washed his/her hands. RN N placed a pillow under the resident's left leg and placed podus boots (orthotic device designed to immobilize, support, and protect the foot and ankle) on the resident's feet. During an interview on 1/13/26 at 1:30 P.M., RN N said the following:-He/She normally changed his/her gloves and washed his/her hands between dirty and clean tasks;-He/She should wear a gown and gloves when he/she provided any cares or when he/she touched the resident. 4. Review of Resident #57's physician order sheet, dated January 2026, showed the resident had t a peripherally inserted central catheter (PICC) line (a long thin flexible tube inserted into a small arm vein and threaded to a large vein near the heart, used for long-term intravenous (IV) (in the vein) fluids and medications); ensure enhanced barrier precautions are maintained every shift. Review of the resident's Care Plan, dated 01/05/26, showed the following:-He/She was incontinent secondary to decreased mobility;-Staff were to assist with toileting and incontinence care after each incontinence episode;-He/She had alterations in ADL function secondary to decreased mobility;-Staff were to assist in completing ADL tasks each day;-He/She was at risk for infection secondary to recent hospitalization and surgery;-Staff were to use universal precautions (the care plan did not address the physician order for EBP precautions). Observation of the resident's room on 01/13/26 at 9:33 A.M. showed the resident had a sign outside of the room showing he/she required enhanced barrier precautions and directed staff to use gowns and gloves when coming into direct contact with the resident. There was a storage container outside the room with gowns and gloves. Observation on 01/13/26 at 9:35 A.M. showed the following:-CNA A and CNA B were in the resident's room, giving the resident a bed bath from a basin of soapy bath water;-The resident had a bandage on the right upper arm covering a PICC line insertion site with two lumens (small tubes to administer fluids, medication, nutrition or blood products) on the outside of the bandage;-CNA A and CNA B wore gloves, but no gowns;-CNA B removed the resident's gown and covered the resident with a dry towel;-CNA B rolled the resident to his/her left side; CNA B removed a urine soaked incontinent brief from the resident and then rolled the resident to his/her back and covered him/her back up with the towel; - CNA B touched the resident's skin and towel with the same gloved hands he/she had touched the urine soaked brief with;-CNA B wet a washcloth and washed the resident's face and wet another washcloth with soap and water and washed the resident's right axilla, right arm and right hand; -CNA A washed the resident's left axilla, left arm and left hand; -CNA B wet a clean washcloth and washed the resident's chest, chest, abdomen and front perineal area, then turned the resident to his/her left side, touching the resident's right hip and shoulder and washed the resident's back and buttocks and rolled the resident to his/her back; -CNA A removed gloves, and without performing hand hygiene left the resident's room;-CNA B touched the bed remote and used it to elevate the foot of the bed for the resident;-CNA B dumped the basin of soapy bath water out in the bathroom and filled the basin up with clean warm water;-CNA B got a clean washcloth and rinsed soap off the resident's arms, chest and front perineal area and then washed the resident's hair;-He/She placed wet (urine soiled) linens in a laundry bag and dumped the soapy water from the basin and added clean water in the basin;-CNA B used a clean washcloth to rinse soap out of the resident's hair, still wearing the gloves he/she had used from the beginning of the bed bath when he/she had removed a urine soiled brief and washed the resident's peri area; -CNA B had touched the resident and personal use items with the soiled gloves;-CNA B removed his/her gloves and dried the resident's hair with a towel;-Without performing hand hygiene, CNA B donned new gloves, turned the resident to his/her left side and dried the resident's buttocks with a towel;-CNA B placed a new incontinence brief under the resident, rolled the resident to his/her back and pulled the brief between the resident's legs, rolled the resident to his/her right side and pulled the incontinence brief the rest of the way under the resident, assisted putting pants on the resident and a mechanical lift sling (a comfortable, supportive fabric sling used with a mechanical resident lift) under the resident;-Licensed Practical Nurse (LPN) E entered the room, donned gloves, and assisted CNA B to transfer the resident to his/her wheelchair; LPN E did not wear a gown. 5. Review of Resident #41's admission MDS, dated [DATE], showed the following:-He/She had moderate cognitive impairment;-He/She was dependent on staff for toilet hygiene and lower body dressing;-He/She required substantial/maximal assistance of staff for bathing and upper body dressing;-He/She was frequently incontinent of bowel and bladder. Review of the resident's care plan, last revised 12/02/25, showed the following:-He/She was incontinent secondary to inability to feel the need to void;-Staff were to apply moisture barrier to skin;-He/She had alterations in activities of daily living (ADL) function secondary to recent hip surgery with decreased mobility;-He/She required assistance completing ADL tasks each day;-He/She was at risk for alteration to skin integrity secondary to decreased mobility;-Staff were to provide skin and incontinence care assistance as needed;-He/She was at risk for infection secondary to recent hospitalization and incontinence;-Staff were to use universal precautions. Observation on 01/13/26 at 10:50 A.M. showed the following:-CNA A entered the resident's room to provide incontinence care;-With gloves on, CNA A rolled the resident to his/her left side, held the resident over with his/her gloved left hand, and with his/her gloved right hand, removed incontinence wipes from a package and cleaned feces from the resident's buttocks; with the right gloved hand, he/she removed another incontinence wipe from the package and finished cleaning the buttocks;-CNA A removed soiled linens from the bed and placed them on the floor, without putting them in a bag;-Wearing the same soiled gloves, CNA A put a clean incontinence brief under the resident, touched the resident with his/her gloved right hand and pulled on the resident's left thigh to roll him/her over to pull the incontinence brief through to the other side, assisted the resident to his/her back and fastened the incontinence brief;-CNA A removed his/her soiled gloves, and without performing hand hygiene, including washing hands with soap and water or using hand sanitizer, donned new gloves;-CNA A put the resident's sweat pants and socks on, rolled him/her to the left side, pulled his/her pants up, rolled the resident to his/her right side and finished pulling up the resident's pants;-CNA A picked the dirty linens up off the floor and carried them to the bathroom and put them on the floor in the bathroom; -CNA A removed gloves, and without performing hand hygiene, donned new gloves and put the resident's shoes on, lowered the bed and assisted the resident to sit on the edge of the bed, applied a gait belt on the resident, removed his/her gloves and left the room, leaving the resident sitting on the side of the bed, to go get a walker;-CNA A returned to the room with a walker, donned new gloves and assisted the resident to stand with the walker and transferred him/her to a wheelchair;-CNA A removed the resident's shirt, which had food particles on the front and was urine soaked in the back and put a clean shirt on the resident and removed his/her gloves without performing hand hygiene;-CNA A gave the resident a wet washcloth to wash his face, combed the resident's hair, put foot pedals on the chair and took the resident to therapy;-Staff did not clean the floor in the resident's room where staff placed dirty linens; the linens remained on the floor in the bathroom. During an interview on 01/13/26 at 2:50 P.M. CNA A said the following;-He/She should have changed gloves when going from dirty to clean;-He/She should have performed hand hygiene by washing hands with soap and water or using hand sanitizer when changing gloves;-He/She should not have put dirty linens on the floor; he/she should have placed the linens in a linen bag but there was no linen bag available;-He/She had not yet picked the linens up off the bathroom floor. 6. During an interview on 01/14/26 at 11:00 A.M., the Director of Nursing (DON) said the following:-No laundry should be placed on the floor for any reason;-She expected staff to wash hands when entering a resident room, between glove changes, and before exiting a room;-Staff should not touch any clean items with contaminated gloves and/or hands;-Staff should wear gowns and gloves every time they entered a room where a resident was on EBP; -Staff were to change their PPE if they exited and had to re-enter a resident's room; -Residents with wounds and catheters were on EBP. During an interview on 01/15/26 at 11:45 A.M., the administrator said the following:-Staff should be following facility policies;-Staff should change gloves and perform hand washing when going from dirty to clean or entering or leaving a resident's room;-EBP should be worn for the specified resident's when performing direct resident care;-Linens should never be on the floor, even if in laundry bags.

Based on interview and record review, the facility failed follow discharge process per facility policy. Staff failed to provide a copy of bed hold policy and written notice of transfer to the resident and/or the resident's representative when four residents (Residents #42, #34, #9 and #47), in a review of 15 sampled residents, were transferred/discharged from the facility. The facility census was 32. Review of the facility's policy for transfer/discharge notices, last revised April 2025, showed the following:-The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and way they can understand. The notice will include all the following at the time it is provided: -The specific reason and basis for transfer or discharge; -The effective date of transfer or discharge; -The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged ;-Emergency Transfers to Acute Care;-Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. Review of the facility's policy, Bed Hold Prior to Discharge, last revised April 2025, showed the following:-The facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold and reserve bed payment policy well in advance of being transferred to the hospital;-The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences;-The written information given to the resident and/or resident representative will include the following: -The duration of the state bed-hold, if any, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy in the state plan, if any; -The facility policies regarding bed-hold periods to include permitting residents to return to the next available bed; -Conditions upon which the resident would return to the facility. 1. Review of Resident #42's face sheet showed the resident was his/her own responsible party. Review of the Prospective Payment System (PPS), dated 12/22/25, which uses the MDS assessment to determine Medicare payments, showed the resident was cognitively intact. Review of the resident's progress notes, dated 12/28/25 at 9:19 A.M., showed staff documented the resident was sent to the hospital for increased cough and dyspnea (shortness of breath). There was no documentation to show that anyone was notified of the transfer or staff provided bed hold information. Review of the resident's medical record showed no evidence staff provided the resident with a written notice of transfer or bed hold when the resident was transferred to the hospital on [DATE]. Review of the resident's progress notes dated 01/05/26 at 5:47 P.M., the resident returned from the hospital. During an interview on 01/15/26 at 9:25 A.M., the resident said the following:-The facility did not explain or give a written copy of the transfer/discharge and bed hold process on 12/28/25 when he/she was sent to the hospital;-The facility staff told him/her he/she needed to go to the hospital due to his/her cough and dyspnea and transferred him/her. 2. Review of Resident #34's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 01/03/26 at 1:43 P.M., showed the resident was sent to hospital for low blood sugar and lethargy. Review of the resident's progress note, dated 01/06/26 at 3:52 P.M., showed the resident returned from the hospital. Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident was transferred to the hospital on [DATE]. 3. Review of Resident #9's face sheet showed the resident was his/her own responsible party. Review of the resident's progress notes, dated 01/05/26 at 10:30 P.M., showed staff documented the resident was sent to the hospital for unsafe behaviors. There was no documentation to show anyone was notified of the transfer or staff provided bed hold information. Review of the resident's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completed on 01/07/26, showed the resident had severe cognitive impairment. Review of the resident's medical record showed no evidence staff provided the resident or the resident's representative with a written notice of transfer or bed hold when the resident transferred to the hospital on [DATE]. 4. Review of Resident #47's face sheet showed the resident was his/her own responsible party. Review of the resident's progress notes, dated 11/27/25 at 12:52 P.M., showed staff documented the resident was transferred to the hospital for aggressive behaviors/agitation. There was no documentation to show that anyone was notified of the transfer or staff provided bed hold information. Review of the resident's medical record showed no evidence staff provided the resident with a written notice of transfer/discharge or bed hold when the resident transferred to the hospital on [DATE]. 5. During an interview on 01/14/26 at 3:10 P.M., Registered Nurse (RN) Q said the following:-He/She was agency staff; -He/She had not been orientated to the discharge process;-The Director of Nursing (DON) or Assistant Director of Nursing (ADON) would do the paperwork if needed. During an interview on 01/14/26 at 2:35 P.M., the facility's regional nurse said the following: -Nursing staff were responsible for completing bed hold and transfer/discharge notices when a resident transferred to the hospital;-Nursing staff should provide the bed hold and transfer/discharge notices to the resident and/or resident representative upon transfer and should document and upload the notices in the resident's electronic medical record; -Upon investigation, she was unable to locate a transfer/discharge notice for Resident #34 or #47;-She noticed staff did not complete this consistently and notices were being missed. During an interview on 01/15/26 at 11:45 A.M., the administrator said she would expect the transfer/discharge and bed hold paperwork to be done per the policy.

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #34), in a review of 14 residents and two additional residents (Resident # 100 and # 101) were free from significant medication errors. Staff failed to prime (remove the air) insulin (injectable medication to treat diabetes (inability to control the amount of sugar in the blood)) pens prior to administration of the physician ordered dose, as the facility policy and manufacturer's instructions directed, resulting in administration of less than the ordered dose of insulin. The facility census was 32. Review of the facility policy, Insulin Pen, revised 04/25, showed the following:-It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;-Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Review of the Lispro Kwik Pen (prefilled pen of fast acting insulin where a dose is dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration) package insert showed the following in part:-Prime: If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle;-Turn the dose knob and select the number of units you need to inject and administer the medication. Review of the Lantus Solostar Pen (prefilled pen of long-acting insulin where a dose is dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration) package insert showed the following in part:-Prime: If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle;-Turn the dose knob and select the number of units you need to inject and administer the medication. Review of the Aspart Flex Pen (prefilled pen of fast acting insulin where a dose is dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration) package insert showed the following in part:-Prime: If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle;-Turn the dose knob and select the number of units you need to inject and administer the medication. 1. Review of Resident #100's January 2026 Physician Order Sheet (POS) showed the following:-Diagnosis of type II diabetes;-Lispro Kwik Pen insulin 100 units/milliliter (ml) subcutaneous (tissue just below the skin), inject three units daily with meals;-Lispro Kwik Pen insulin 100 units/ml subcutaneous with meals, inject as per sliding scale (an amount to be determined based on an Accu check (finger stick procedure to determine the amount of sugar in the blood)): if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 4 401 or greater give 12 units, notify the physician. Review of the resident's January 2026 Medication Administration Record (MAR) showed the following:-Lispro 100 units/ml insulin three units daily with meals, scheduled for 8:00 A.M.;-Lispro 100/ml insulin per sliding scale, scheduled for 8:00 A.M. Observation and interview on 01/13/26 at 9:25 A.M., showed the following:-The Assistant Director of Nursing (ADON) said she was helping the nurse by completing the Accu checks and insulin administrations for him/her;-The nurse was running late on doing the Accu checks and insulins; -She had checked all the Accu checks on the hall starting at 8:45 A.M.;-Resident #100's Accu check reading was 276 milligrams per deciliter (mg/dL) (measurement of the amount of glucose or sugar in the blood) this morning and she had determined the resident would need six units of Lispro sliding scale insulin;-The ADON obtained the resident's Lispro Kwik Pen from the top medication cart drawer, removed the pen cap, cleansed the tip of the insulin pen with an alcohol pad and attached a new sterile needle. The ADON did not prime the pen;-The ADON dialed up six units of Lispro insulin for the sliding scale and three units for the scheduled dose for a total of nine units and administered the medication in the resident's abdomen. 2. Review of Resident #34's January 2026 POS showed the following:-Diagnosis of type II diabetes with hypoglycemia (low blood sugar);-Lantus Solostar insulin pen, 100 units/ml, inject 14 units subcutaneous daily;-Lispro Kwik Pen insulin 100 units/ml subcutaneous with meals, inject as per sliding scale: if 70-130= 0 units, 131-180 = 2 units, 181-240 = 4 units, 241-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, greater than 400 notify the physician. Review of the resident's January 2026 MAR showed the following:-Lantus 100 units/ml insulin, 14 units daily, scheduled for 7:00 A.M.;-Lispro 100 units/ml insulin per sliding scale, scheduled for 8:00 A.M. Observation and interview on 01/13/26 at 9:28 A.M., showed the following:-The ADON said Resident #34's Accu check reading was 243 this morning and the resident should get six units of Lispro sliding scale insulin;-The ADON obtained the resident's Lispro Kwik Pen from the top medication cart drawer, removed the pen cap, cleansed the tip of the insulin pen with an alcohol pad and attached a new sterile needle. The ADON did not prime the pen;-The ADON dialed up six units of Lispro insulin and administered the medication in the resident's abdomen; -The ADON obtained the resident's Lantus Solostar pen from the top medication cart drawer, removed the pen cap, cleansed the tip of the insulin pen with an alcohol pad and attached a new sterile needle. The ADON did not prime the pen;-The ADON dialed up 14 units of Lantus insulin and administered the medication in the resident's abdomen. During an interview on 01/13/26 at 3:05 P.M., the ADON said insulin pens were to be primed with two units when the pen was first opened and used, not with each injection. 4. Review of the Resident #101's January 2026 POS showed the following:-Diagnosis of type II diabetes with hyperglycemia and diabetic polyneuropathy (nerve damage from diabetes);-Aspart (also known as Novolog) insulin pen, 100 units/ml subcutaneous with meals, inject as per sliding scale: if 0- 150 = 1 unit; 151 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units. Max 30 units per day;-Lantus Solostar insulin pen, 100 units/ml, inject 47 unit subcutaneously one time a day. Review of the resident's January 2026 MAR showed the following:-Lantus insulin 100 units/ml, 47 units daily, scheduled for 7:00 A.M.;-Aspart insulin 100 units/ml, per sliding scale, scheduled for 7:30 A.M. Observation on 01/15/26 at 8:55 A.M. showed the following:-Licensed Practical Nurse (LPN) E obtained the resident's Accu check with results of 111 mg/dL and determined Aspart insulin sliding scale dose was to be one unit;-LPN E obtained the resident's Aspart insulin pen from the medication cart, cleaned the tip of the insulin pen with an alcohol pad and attached a new sterile needle;-LPN E did not prime the insulin pen;-LPN E dialed up one unit of Aspart insulin and administered the medication in the resident's left arm;-LPN E obtained the resident's Lantus pen from the medication cart, cleaned the tip of the insulin pen with an alcohol pad and attached a new sterile needle;-LPN E did not prime the insulin pen;-LPN E dialed up 47 units of Lantus insulin and administered the medication in the resident's left arm. During an interview on 01/15/26 at 9:05 A.M. LPN E said insulin pens were primed at the end of each injection, so it was ready for the next injection; During an interview on 01/15/26 at 11:45 A.M., the Director of Nursing (DON) said she would expect the insulin pens to be primed with two units prior to every injection.

Based on observation, interview and record review, the facility failed to follow current infection control standards for four residents (Resident #1, #3, #7 and #10), in a review of ten sampled residents when staff failed to perform proper hand hygiene and change gloves to prevent infection during personal care for Resident #1, #3, #7 and #10, and failed to properly handle soiled linens during personal care for Resident #10. The facility census was 29.Review of the facility policy for Hand Hygiene with a revision date of 4/2025 showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to tother personnel, residents and visitors. This applies to all staff working in all locations within the facility;-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hands hygiene is done when hands are visibly dirty, visibly soiled with blood or other body fluids, between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including gloves, before and after handling clean or soiled dressings, linens, before performing resident care procedures, before and after providing care to residents in isolation, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, when, during resident care, moving from a contaminated body site to a clean body site, when in doubt;-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. Review of the facility policy for Handling Soiled Linen with a revision date of 4/2025 showed the following:-It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. This policy pertains to soiled linen;-All used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated;-Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces and persons;-Used or soiled linen shall be collected at the bedside (or point of use, such as dining room) and placed in a [NAME] bag or designated linen receptacle;-Wash hands after contact with soiled linen. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of spinal stenosis (the narrowing of the spinal canal that puts pressure on the nerves and spinal cord like pain, numbness), urinary tract infection, diabetes, and end stage renal disease with dialysis (the final stage of kidney failure where the kidneys permanently stop working, requiring dialysis). Review of the resident's Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 8/29/25 showed the following:-Alert and oriented and able to make decisions;-Able to make self-understood and able to understand others;-Dependent upon staff for personal hygiene;-Indwelling catheter. Review of the resident's care plan for indwelling catheter dated 8/29/25 directed staff to complete catheter care each shift. Observation and interview on 10/31/25 at 9:55 A.M. showed the following:-Resident #1 lay in bed with an indwelling catheter, the tubing of the catheter was whitish colored with thick sediment in the tubing;-The resident said he/she went to dialysis three times a week, his/her last appointment was yesterday. The physician at the dialysis clinic said the catheter needed to be changed;-He/She had been incontinent of feces and needed to be changed. The resident turned on the call light. Observation on 10/31/25 at 10:33 A.M. showed the following:-Certified Nurse Aide (CNA) D answered the resident's call light; the resident told CNA D he/she needed to be changed;-CNA D put on a gown and took a pair of gloves out of a box. Without washing his/her hands CNA D applied the gloves, went into the resident's bathroom, put several washcloths in warm water and placed the wet washcloths on the sheet on the resident's bed;-CNA D then rolled the resident over and removed the resident's brief. With a wet washcloth he/she removed dried feces from the anal area then placed the soiled washcloth on the sheet. Without performing hand hygiene and changing gloves, CNA D opened the top drawer of the nightstand cabinet and retrieved a tube of protective, placed some of the ointment on his/her soiled gloves, and applied the ointment to the residents' buttocks. Without changing gloves and performing hand hygiene, CNA D then took a clean brief from the resident's nightstand, put the clean brief on the resident and without changing the sheet, covered the resident with blankets; -CNA D went into the resident's bathroom, placed the soiled washcloth and the soiled brief in a trash bag, removed his/her gown and gloves, and without washing his/her hands exited the resident's room. 2. Review of Resident #3's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of compression fracture of the vertebrae (a break in a bone in the spine), and diabetes. Review of the resident's comprehensive MDS dated [DATE] showed the following:-Alert and oriented and able to make decisions;-Able to make self understood and understand others;-Dependent upon staff for toileting and toilet hygiene;-Incontinent of bladder and bowel. Observation and interview on 10/31/25 at 10:45 A.M. showed the following:-The resident sat in a wheelchair beside the bed and said he/she had been incontinent and needed some help; he/she had been waiting for over an hour for help;-At 10:50 A.M. CNA D and CNA E entered the resident's room and without washing their hands applied gloves;-CNA D transferred the resident from the wheelchair to the bed and removed the resident's pants and brief that were soiled brown with urine stains and had a slight odor; -CNA E placed a package of wipes on the bed;-With the same gloved hands, CNA E took a wipe from the package and removed feces from the resident's anal area and placed the wipe on the resident's bed sheet, then got another wipe from the package and began to wipe of a thick layer of protective ointment from the resident's buttocks, using the same wipe several times to remove the protective ointment;-CNA E, without changing his/her gloves and performing hand hygiene, opened the nightstand drawer and retrieved a tube of cream, put the cream on his/her soiled gloves and applied it to the resident's buttocks;-With out changing gloves and washing hands, CNA E took a clean brief and placed it on the resident, then pulled the sheet up over the resident;-CNA E then took the soiled wipes and placed them in a trash can in the bathroom, removed his/her gloves and without washing hands exited the room. During an interview on 11/5/25 at 4:30 P.M. CNA E said the following:-He/She did not change gloves or wash his/her hands after providing incontinent care to Resident #3;-He/she should have removed his/her gloves and washed hands after providing care;-Soiled linen should not be thrown on the floor. 3. Review of Resident #7's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of kidney failure, and atrial fibrillation (irregular heartbeat). Review of the resident's admission nurses note dated 10/31/25, showed the resident was alert and oriented, able to make decisions and able to understand others and able to make self understood. Review of the resident's care plan for incontinence dated 11/3/25 showed the following:-The resident is at risk for incontinence due to decreased mobility;-Provide assistance for toileting, provide incontinence care after each incontinent episode. Observation on 11/5/25 at 11:15 A.M. showed the following:-The resident sat on the toilet in the resident's bathroom;-Without washing his/her hands or performing hand hygiene, CNA D put on a pair of gloves then transferred the resident from the toilet to a standing position at the rail in the bathroom. There was urine and feces in the toilet. CNA D took a wipe from a package and wiped the resident's anal area, the wipe had fecal matter on the wipe. CNA D folded the wipe over then wiped the resident's anal area several more times with the soiled wipe; -CNA D threw the soiled wipe in the trash can, and with the same soiled gloves, removed a clean brief from a package of briefs and placed the brief on the resident; --Wearing the same soiled gloves CNA D then pulled the resident's pants up and assisted the resident to sit down in the wheelchair, then pushed the resident in the wheelchair to the side of the bed, picked up the resident's call light, grabbed the resident's clothing, attached the call light to the resident's clothing, moved the resident's water pitcher, cell phone and television remote on the over the bed table all with soiled gloves; -CAN D then pick up the plastic trash can liner out of the trash can, removed his/her gloves and put them in the plastic bag and tied the bag;-Without washing his/her hands or performing hand hygiene CNA D walked out of the resident's room, tossed the bag with the soiled wipes and gloves onto the floor in the hall, and walked to the nurses station and began looking at paperwork. 4. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of urinary retention (the inability to completely empty the bladder), and dementia. Review of the resident's admission nurses note dated 11/4/25 showed the following:-Alert and oriented, difficulty making decisions;- Had an indwelling catheter;- Incontinent of bowel. Review of the resident's care plan for indwelling catheter dated 11/4/25 showed the following:-The resident has an indwelling catheter due to urinary retention;-Catheter care every shift and as needed. Observation on 11/5/25 at 4:00 P.M. showed the following:-CNA D was in the resident's and said the resident need to have catheter care and had been incontinent of feces;-CNA D wore a pair of gloves;-CNA D wet a washcloth in the resident's bathroom sink then returned to the resident's bedside;-CAN D rolled the resident over to his/her side and with the wet washcloth removed fecal matter from the resident buttocks, then threw the soiled washcloth on the floor. Feces remained on the resident's buttocks;-Wearing the same soiled gloves, CNA D opened the drawers of the resident's nightstand to look for more washcloths or wipes and could not find any;-Without removing his/her soiled gloves and washing his/her hands or performing hand hygiene, CNA D left the and returned with a package of wipes. He/She did not wash his/her hands or change gloves before removing a clean wipe and cleaning the remaining feces from the resident's buttocks;-With the same soiled gloves, he/she touched the resident's exposed skin on the resident's back and rolled the resident over to his/her back;-With the same soiled gloves, CNA D removed another wipe from the package and wiped around the resident's meatus (the external opening of the urethra, through which urine exits the body), and with the same soiled wipe, wiped the catheter tubing inside of the meatus. Using the same soiled wipe CAN D then wiped down the catheter tubing, placed the wipe in a plastic bag and put the plastic bag on the floor;-Without changing gloves or washing hands he/she then picked up the plastic bag and the soiled washcloth, moved the over the bed table, using the remote to the bed, lowered the bed, touched the doorknob to open the door and left the room. During an interview on 11/5/25 at 11:30 A.M. CNA D said the following:-Gloves should be changed every few residents unless there was fecal matter on the gloves;-Hands are washed when gloves are changed. During an interview on 11/5/25 at 5:30 P.M. the Director of Nursing said the following:-Staff should wash their hands or perform hand hygiene before providing care and after providing care, and between clean and dirty tasks;-Soiled linen should not be thrown on the floor, staff should bag the soiled linen and take it to the laundry. 2655993

Based on observation, interview and record review, the facility failed to secure indwelling catheter drainage tubing and bags for two residents (Resident 4, and #5), in a review of ten residents with indwelling catheters. These failures increased the residents' risk for urinary tract infections. The facility census was 29. Review of the facility policy for Catheter Care with a revision date of 4/2025 showed the following:-It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;-Catheter care will be performed every shift and as needed by nursing personnel;-Privacy bags will be available and catheter drainage bags will be covered at all times while in use;-Catheter drainage bags will be positioned below bladder level, clear from floor, and will not be level with the resident while the resident is in bed;-Ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Review of Resident #4's face sheet showed the following:-admitted to the facility on [DATE] with diagnoses of osteomyelitis (infection of the bone);- Multiple sclerosis (an autoimmune disease of the nervous system). Review of the admission assessment dated [DATE] showed the resident was alert and oriented, able to make needs known. Able to make self-understood and able to understand others. Review of the resident's care plan for Indwelling Catheter dated 10/28/25 showed the following:-The resident required an indwelling catheter at this time secondary to neurogenic bladder (a condition where nerve damage prevents the brain and bladder from communicating properly, leading to a loss of bladder control);-Interventions: catheter care every shift and as needed, ensure drainage bag has a dignity cover, keep the drain bag below the level of the bladder. Review of the resident's Physician Orders (POS) dated October 2025 showed the following:-Urinary catheter (a tube inserted in the bladder to drain urine) anchor change every Sunday;-Urinary catheter care every shift. Observation and interview on 11/5/25 at 10:20 A.M. showed the following:-The resident had an indwelling catheter with yellow urine, there was no drainage bag cover over the drainage bag;-The resident said he/she was supposed to have catheter care every shift, but this was not done. It had been several days since his/her catheter has been cleaned. Observation on 11/5/25 at 3:00 P.M. with the Assisted Director of Nursing (ADON) and Registered Nurse (RN) A showed the following:-The resident lay in bed;- The ADON provided wound care;-The resident's urinary catheter did not have an anchor on the resident's leg to secure the catheter tubing;-The urinary catheter drained yellow urine and the urinary drainage bag that was positioned on the side of the bed that was closest to the door opening to the hallway was not covered with a dignity bag. 2. Review of Resident #5's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of urinary tract infection, urinary retention and chronic kidney disease. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/27/25, showed the following:-Alert and oriented and able to make needs known;-Able to understand others and able to make self understood;-Requires assistance with Activates of Daily Living (ADL's);- Indwelling urinary catheter. Review of the resident's care plan for Indwelling Catheter dated 8/26/25 showed the following:-The resident required an indwelling catheter due to wounds and urinary retention;-Catheter care every shift and as needed, change catheter as needed, monitor for signs and symptoms of a UTI. Review of the resident's POS dated November 2025 showed the following:-Urinary catheter care every shift and as needed;-Urinary catheter anchor, change every Sunday. Observation on 11/5/25 at 10:28 A.M. showed Resident #5 sat in a wheelchair with an indwelling urinary catheter. The catheter tubing hung down and touched the floor; there was sediment in the tubing. The catheter bag did not have a dignity cover, the drainage bag was visible from the door. Observation on 11/5/25 at 2:35 P.M. with the ADON and RN A showed the following:-The resident sat in a wheelchair with an indwelling urinary catheter. The catheter tubing hung down and touched the floor; there was sediment in the tubing;-The ADON offered the resident catheter care, the resident said he/she had not had catheter care in several days;-The ADON and RN helped the resident come to a standing position and the ADON performed catheter care. There was no anchor securing the tubing to the resident's leg and the tubing pulled as the resident stood. The resident said he/she felt the catheter tube pulling down;-RN A said that the catheter tubing should not be on the floor, and he/she was going to call the physician about the sediment in the tubing. During an interview on 11/5/25 at 9:30 A.M. the Director of Nursing said the following:-Catheter care should be done every shift;-The indwelling catheter tubing should be anchored to the resident's leg to prevent the tubing from pulling and should be changed weekly and dated when changed;-Indwelling catheter tubing should not be on the floor and the catheter bag should be covered;-She would expect staff to provide catheter care every shift, place a catheter tubing anchor in place and date when applied. Catheter tubing should not be on the floor. 2655993

Based on observation, interview and record review, the facility failed to ensure staff followed physician orders for two residents (Resident #4 and #5) of ten sampled residents. Staff failed to follow physician orders for dressing changes to intravenous (IV) sites and wounds and failed to follow physician orders to secure an indwelling catheter. The facility census was 29.The facility provided no policy for following physician orders upon request.Review of the facility policy Wound Treatment Management with a revision date of 4/2025 showed the following:-To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-The facility will follow specific physician orders for providing wound care.Review of the facility policy Skin Assessment with a revision date of 4/2025 showed the following:-It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management;-A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and at least weekly thereafter. 1. Review of Resident #4's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses including osteomyelitis (infection of the bone) of vertebra, sacral and sacrococcygeal region (lower back and tailbone region of the spine), multiple sclerosis (an autoimmune disease that damages nerves). Review of the resident's care plan for infection dated 10/28/25 showed the resident had osteomyelitis of the sacrum. Staff should provide antibiotics and wound care as prescribed.Review of the resident's care plan for altercation to skin integrity dated 10/28/25 directed staff to weekly skin checks per facility schedule. Review of the resident's care plan for Stage 4 Pressure Ulcer (PU a full-thickness tissue loss where skin, fat, and muscle have been destroyed, exposing underlying bone, tendon, or muscle) dated 10/28/25 directed staff to complete treatments to the resident's pressure ulcer as prescribed.Review of the resident's Physician Orders (POS) dated October 2025 showed the following:-Complete weekly skin checks on Wednesday with an order date of 10/30/25;-PICC (Peripherally Inserted Central Catheter - (a long, thin tube inserted into a vein in the arm and threaded to a large vein near the heart. It is used for long-term intravenous (IV) treatments). Dressing change weekly and as needed with an order dated of 10/28/25;-Urinary catheter (a tube inserted in the bladder to drain urine) anchor and change every Sunday;-Urinary catheter care every shift;-Cleanse under both breasts with soap and water BID (two times a day) and apply antifungal powder;-Admit wound care standing orders: coccyx (tailbone), cleanse with wound cleanser, pat dry, apply cover dressing and notify wound care provider for further directions with a start date of 10/28/25. Review of the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated October 2025 on 11/5/25 showed the following:-Coccyx wound: sterile saline, skin prep, pack with Opticell AG (a type of silver antibacterial gelling fiber wound dressing), apply four by four dressing every 72 hours with a start date of 10/28/25;-There was no documentation staff completed this dressing change on 10/28/25;- Admit wound care standing orders: coccyx, cleanse with wound cleanser, pat dry, apply cover dressing and notify wound care provider for further directions BID (day and night) with a start date of 10/28/25; the day shift on 10/29/25 was blank with no documentation staff completed the ordered dressing change and blank on the night shift on 10/28/25, 10/29/25 and 10/30/25;-Cleanse under breasts with soap and water BID and apply antifungal powder documented was blank on 10/30/25 at 7:00 P.M. with no documentation staff completed the treatment; -Urinary catheter care was not included on the MAR/TAR for staff to document completion;-Urinary catheter anchor change every Sunday was not on the MAR/TAR for staff to document completion. Review of the resident's MAR/TAR dated November 2025 on 11/5/25 showed the following:-PICC line dressing change documented as completed on 11/3/25;-Cleanse under breast with soap and water BID and antifungal powder BID;- There was nothing documented on 11/1/25 at 7:00 A.M. or 7:00 P.M. showing staff completed the ordered treatment and no documentation on 11/2/25 at 7:00 P.M. that staff completed the treatment; -No documentation staff completed urinary catheter care;- Urinary catheter anchor change every Sunday was not part of the MAR/TAR for staff to document completion. Observation and interview on 11/5/25 at 10:20 A.M. showed the following:-Resident #4 lay in the bed with a dressing to the left upper arm where the PICC line was inserted. The dressing on the PICC line was dated 10/22/25;-An indwelling catheter bag hung on the side of the bed with yellow urine;-Resident #4 said that staff has not changed or cleaned the PICC line site since he/she admitted to the facility and staff had not performed any catheter care. His/her treatment to the wound on his/her coccyx has not been done in several days. Observation on 11/5/25 at 3:00 P.M. with the Assistant Director of Nursing (ADON and Registered Nurse (RN) A showed the following:-The ADON and RN A rolled the resident onto his/her side to change the dressing to the wound on the coccyx. The dressing on the resident's coccyx was dated 11/3/25 and when removed was soiled with fecal matter;-There was no anchor on the resident's leg to hold the indwelling catheter in place;-The dressing to the PICC line on the upper left arm was dated 10/22/25. During an interview on 11/5/25 RN A said the following:-Nurses complete the daily dressing changes. The resident's dressing should have been changed twice daily until the contracted wound nurse assessed the resident on 11/4/25 and gave new orders;-Certified Nurse Aides (CNAs) should have ensured that an anchor was in place for the catheter;-The dressing to the PICC line should have been changed. 2. Review of Resident #5's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of urinary tract infection, urinary retention and chronic kidney disease. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 8/27/25 showed the following:-Alert and oriented and able to make needs known;-Able to understand others and able to make self understood;-Requires assistance with Activates of Daily Living (ADL's);- Indwelling urinary catheter. Review of the resident's care plan for indwelling catheter dated 8/26/25 showed the following:The resident requires an indwelling catheter due to wounds and urinary retention;-Catheter care every shift and as needed, change catheter as needed, monitor for signs and symptoms of a UTI. Review of the resident's care plan for at risk for skin alterations dated 8/14/25 directed staff to complete weekly skin checks. Review of the resident's POS dated November 2025 showed the following:-Complete weekly skin assessment on Fridays;-Urinary catheter care every shift and as needed;-Urinary catheter anchor, change every Sunday. Observation on 11/5/25 at 10:28 A.M. showed Resident #5 sat in a wheelchair with an indwelling urinary catheter. The catheter tubing hung down and touched the floor; there was sediment in the tubing. Observation on 11/5/25 at 2:35 P.M. with the ADON and RN A showed the following:-The resident sat in a wheelchair with an indwelling urinary catheter. The catheter tubing hung down and touched the floor; there was sediment in the tubing;-The ADON offered the resident catheter care, the resident said he/she had not had catheter care in several days;-The ADON and RN helped the resident come to a standing position and the ADON performed catheter care. There was no anchor securing the tubing to the resident's leg and the tubing pulled as the resident stood. The resident said he/she felt the catheter tube pulling down;-RN A said that the catheter tubing should not be on the floor, and he/she was going to call the physician about the sediment in the tubing. During an interview on 11/5/25 at 4:30 P.M. the Director of Nursing said the following:-She would expect staff to follow physician orders;-Resident #4's dressing should have been changed as ordered by the physician and Resident #5's indwelling catheter should have an anchor. 265881

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of seven sampled residents. While assisting the resident to transfer from the toilet to his/her new motorized chair, staff ran the motorized chair over the resident's left foot. The resident sustained a fractured toe. The facility census was 66. Review of the facility policy for Accidents and Supervision dated 07/2024 showed the following:-The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devises to prevent accidents. This includes identifying hazards(s) and risk(s); evaluating and analyzing hazards(s) and risk(s); implementing interventions to reduce hazards(s) and risk(s); monitoring for effectiveness and modifying interventions when necessary;-The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents;-All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident;-Use specific interventions to try to reduce a resident's risks from hazards in the environment. This process includes in part: providing training as needed;-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1.Review of Resident #1's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses of end stage renal disease (ESRD, a disease in which the kidneys do not function), with dialysis, type 1 diabetes, atrial fibrillation (irregular heartbeat) and Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement). Review of the resident's care plan for Activities of Daily Living (ADL) dated 6/23/25 showed the following:-The resident has alterations in ADL function secondary to ESRD, decreased mobility and decreased strength.-Assist in completing ADL tasks each day. Review of the resident's Care Plan showed no direction related to use of the resident's new motorized chair. Review of the resident's nurses note dated 6/25/25 at 10:23 A.M. signed by Assistant Director of Nursing (ADON)/Registered Nurse (RN) showed the certified nurse aide (CNA) reported the resident's right foot was accidently rolled over by resident's power chair. Nurse Practitioner (NP) notified and assessed resident. No signs of injury currently. Resident denies pain, no changes in range of motion (ROM) to Right foot or ankle. X-rays order and set up for 4:00 P.M. when resident returned from dialysis. During an interview on 7/15/25 at 3:55 P.M. Certified Nurse Aide (CNA) B said the following:-He/She and CNA C were transferring the resident from the electric wheelchair to the toilet on 6/25/25 in the morning;-CNA C moved the electric wheelchair out of the way, as he/she dressed the resident's lower body, then CNA C began to move the electric wheelchair closer to the resident when the resident said ouch and said the electric chair was on his/her foot. He/She and CNA C looked down and saw the electric chair was on top of the resident's toes; CNA C backed the chair off the resident's foot;-He/She reported this to the nurse and there was a nurse practitioner in the facility at the time;-The resident complained of pain in the foot, but could still move the foot;-They took the resident to the front lobby as he/she had to go to dialysis. During an interview on 7/28/25 at 2:40 P.M. CNA C said the following:-He/She did not receive any training on how to use this electric wheelchair;-CNA B helped him/her transfer the resident into the electric wheelchair, took the resident into the bathroom and transferred him/her out of the electric wheelchair onto the toilet;-He/She did not remember running over the resident's foot;-He/She reported what the resident said to the ADON and the Nurse Practitioner (NP). During an interview on 7/17/25 at 8:50 A.M. Resident #1 said the following:-The staff seemed like they were in a hurry when they came to get her up and take her to the bathroom;-When the CNA's stood him/her up off the toilet, one CNA moved the electric wheelchair over towards him/her and it rolled onto his/her left foot;-The aides left the electric wheelchair on top of his/her foot; he/she told them the chair was on his/her foot;-The aids moved the wheelchair, so it wasn't sitting on his/her foot, then helped him/her into the chair and took him/her to the front lobby to go to dialysis;-No one looked at his/her foot before he/she went to dialysis;-When he/she got to dialysis, he/she could not stand to transfer, his/her foot hurt bad;-Dialysis staff were unable to transfer the resident to the dialysis chair due to his/her painful right foot, so they sent him/her to the hospital;-Once he/she was at the hospital, they x-rayed the left foot and the toes and top on his/her foot was broken so they put a walking boot on the foot. Review of the resident's progress note dated 6/25/25 signed by NP A showed the following:-In the process of getting to the toilet from the motorized wheelchair, the resident's foot was hit by the wheel of the chair;-The resident denies pain, he/she is moving the foot. Order X-Ray to the right foot due to injury. Okay to wait until after dialysis per resident's request. (The right foot was not the injured foot) Review of the local hospital X-ray report dated 6/25/25 showed x-ray of the left foot; possible fracture along the medical base of the second metatarsal (toe) concerning for mildly displaced age indeterminate fracture. Review of the resident's Orthopedic Physician progress noted dated 6/29/25 showed the following:-The resident sustained an injury recently, as scooter ran over his/her left foot. He/She has had mild to moderate amount of pain in the foot since the injury, and noticed bruising in the foot after the injury;-He/She has some bruising noted to the dorsum (the upper surface of the foot) in the left foot;-Interpretation of the residents' x-ray of the left foot: a new nondisplaced fracture at the base of the third metatarsal (toe);-This is the result of the scooter (motorize chair) rolling over his/her foot. During an interview on 7/15/25 at 4:00 P.M. the ADON said the following:-He/She was helping LPN A on 6/25/25 when CNA B and CNA C reported the electric wheelchair had been on the resident's foot;-He/She did not look at the resident's foot, NP A was in the facility, so he/she informed the NP so they could assess the resident;-The resident said that his/her foot hurt but he/she could move the foot;-The CNA incorrectly reported it was the resident's right foot. During an interview on 7/17/25 at 11:15 A.M. LPN A said the following:-He/She was aware of the accident involving Resident #1 and the electric chair, but he/she did not assess the resident, the ADON/RN took care of the assessment and notified the NP;-CNA C said the resident's foot was run over by the wheelchair, but he/she does not know which foot;-The resident went from his/her room after the incident to the front lobby for transport to dialysis. During an interview on 7/17/25 at 4:00 P.M. the Director of Nursing said the following:-Review of the resident's hospital records showed the resident sustained a fracture of the left foot;-She would expect the nurses to assess a resident after an accident, visualize the resident and document in the electronic medical record the assessment;-Staff should be shown how to operate the resident's electric wheelchair. During an interview on 7/17/25 at 4:00 P.M. the Administrator said the following:-He would expect nurses to assess a resident after an incident/accident occurred;-He would expect the staff to be trained on how to control an electric wheelchair. During an interview on 7/18/25 at 9:15 A.M. NP A said the following:-She was at the facility when the resident's right foot injured by the electric wheelchair;-The ADON/RN informed her of the incident;-The resident was in therapy when she was told of the incident;-She assessed the resident's right foot in therapy and did not see any sign of injury;-She wrote an order for an X-ray of the right foot to be done after the resident returned from dialysis;-The resident did not want to miss dialysis so he/she said that he/she could wait until he/she returned from dialysis in the afternoon. 1785365178536417853631785362

Based on interview and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of three sampled residents, when staff did not administer medications or complete assessments as ordered. Further review showed the medications not administered were available through the facility Pyxis (emergency medication supply available for the facility to pull medication from and use for resident administration) system and as stock medications. The census was 36. Review of the facility policy, Medication Administration, last revised 7/2024, showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice; Policy Explanation and Compliance Guidelines: 9. Review Medication Administration Record (MAR) to identify medication to be administered; 10. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time; 16. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 1. Review of the Pyxis medication list, showed the following medications available for staff to pull from the system as needed: -Gabapentin (medication for neuropathy pain, a type of pain from nerve damage, usually in the hands and feet) 100 milligram (mg) capsules; -Pepcid (medication for acid reflux) 20 mg tablet; -Rosuvastatin (medication for high cholesterol) 10 mg tablets. 2. Review of Resident #1's facility medical record showed the resident was admitted to the facility on [DATE] at 6:30 P.M. Review of the resident's Physician Order Sheet (POS), dated 5/2025, showed the following: -Diagnoses included: hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), anxiety disorder, acid reflux and Diabetes Mellitus II (uncontrolled blood sugar): -Gabapentin 100 mg capsule, one capsule three times daily (5/27/25); -Pepcid 40 mg, one tablet at bedtime (5/27/25); -Rosuvastatin 10 mg, one tablet by mouth at bedtime (5/27/25); -Extra Strength (ES) Tylenol 500 mg, two tablets by mouth two times daily for pain (5/27/25); -Complete and document pain assessment using numeric pain scale every shift (5/27/25). Review of the resident's Medication Administration Record (MAR), dated 5/2025, showed the following: -On 05/27/25 at 7:00 P.M., the administration boxes for the resident's ordered gabapentin, Pepcid and rosuvastatin were initaled by Licensed Practical Nurse (LPN) A along with the code number nine (other: see progress notes); -On 05/27/25 at 7:00 P.M., the ES Tylenol box was marked with an X, indicating not due and that the medication was not administered. Review of the resident's Treatment Administration Record (TAR), dated 05/2025, showed the following: -Complete and document pain assessment using the numeric pain scale every shift, day and night; -On 05/27/25 for the night shift, the box was marked with the numeral two (on a scale of 1 - 10 with 10 being the worst pain), indicating the resident had identified pain and initialed by LPN A. Review of the resident's progress notes, dated 05/27/25 at 9:09 P.M., showed LPN A documented meds not available. No documentation to show staff utilized the facility Pyxis to obtain gabapentin, Pepcid or rosuvastatin. ES Tylenol was available in the medication cart as stock medication. Review of the resident's MAR, dated May 2025, showed on 05/28/25 at 7:00 A.M., staff marked the ES Tylenol box with an X, indicating not due and the medication was not administered. Review of the resident's TAR, dated 05/2025, showed the following: -Complete and document pain assessment using the numeric pain scale every shift, day and night; -On 05/28/25 for the day shift, the box was left blank for pain number, indicating staff had not obtained or documented the resident's pain score. Review of the resident's MAR, dated 05/28/25 for 7:00 A.M. showed the administration box for the resident's ordered gabapentin was initaled by LPN A along with the number nine (other: see progress notes). Review of the resident's progress notes, dated 05/28/25, showed no documentation why the resident's 7:00 A.M. gabapentin had not been administered as ordered. No documentation to show staff utilized the Pyxis to obtain gabapentin. Review of the resident's MAR, dated May 2025, showed on 05/28/25 at 11:00 A.M., the administration box for the resident's ordered gabapentin was initialed by LPN D along with the number nine (other: see progress notes). Review of the resident's progress notes, dated 05/28/25 at 3:21 P.M. showed staff documented, medications coming from pharmacy. There was no documentation to show staff utilized the Pixis to obtain gabapentin for administration. During an interview on 06/11/25 at 3:05 P.M., LPN C said the following: -The pharmacy delivered medications daily, mid morning to noon and again in the evenings; -Medications should be administered when they are due on the same day; -If an admission comes in after 4:00 P.M. - 5:00 P.M., the medications may not get delivered the day of admission. During an interview on 06/12/25 at 11:48 A.M., LPN A said the following: -If medications were not available for a resident, he/she would check the Pyxis for the needed medications so they would not be missed; -He/She was an agency nurse and did not have access to the Pyxis; -When medications were not available, as a trained nurse, the best practice would be to verify the order and pull the needed medications from the Pyxis; -He/She did not administer medications as they were not available on the medication cart and he/she did not have access to the Pyxis; -He/She did not administer ES Tylenol. During an interview on 06/11/25 at 4:39 P.M., the Director Of Nursing said the following: -She would expect medications to be given as ordered; -If medications were not available, nursing should check the Pyxis to see if medications were available through the Pyxis; -The facility pharmacy delivered two times daily; -The facility had the ability to have medications delivered to them around the clock and within four hours. More than one pharmacy may be used; -If a resident was admitted after 4:00 P.M. - 5:00 P.M., they could call for a stat delivery, which meant medications would be delivered within four hours/24 hours a day; -She would expect nursing to utilize stock medications, if the resident's medications were unavailable, until the resident's medications were available; -ES Tylenol was available as a stock medication. MO255076

Based on interview and record review, the facility failed to notify one resident's (Resident #1) physician, in a review of three sampled residents, that ordered medications were not available for administration. The census was 36. Review of the facility policy, Notification of Changes, last revised 4/2025 showed the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; Circumstances requiring notification include those that potentially may require physician intervention including circumstances that require a need to alter treatment. 1. Review of Resident #1's facility medical record showed the resident admitted to the facility on [DATE] at 6:30 P.M. Review of the resident's Physician Order Sheet (POS), dated 5/2025, showed the following: -Diagnoses included hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), anxiety disorder, acid reflux and diabetes mellitus type II (uncontrolled blood sugar); -Gabapentin (medication to treat nerve pain, often caused by diabetes) 100 milligrams (mg) capsule, one capsule three times daily (5/27/25); -Pepcid (medication to help reduce stomach acid and treat conditions like heartburn, acid indigestion and ulcers) 40 mg, one tablet at bedtime (5/27/25); -Rosuvastatin (medication to treat high cholesterol) 10 mg, one tablet by mouth at bedtime (5/27/25); -Extra Strength (ES) Tylenol (pain medication) 500 mg, two tablets by mouth two times daily for pain (5/27/25). Review of the resident's Medication Administration Record (MAR), dated May 2025, showed the following: -On 05/27/25 at 7:00 P.M., the administration boxes for the resident's ordered gabapentin, Pepcid and rosuvastatin were initaled by Licensed Practical Nurse (LPN) A, along with the code number nine (other: see progress notes); -The ES Tylenol box was marked with an X, indicating not due and the medication was not administered. Review of the resident's progress notes, dated 05/27/25 at 9:09 P.M., showed LPN A documented medications not available. The note did not show LPN A notified the physician. Review of the resident's MAR, dated May 2025, showed the following: -On 05/28/25 at 7:00 A.M., the administration box for the resident's ordered gabapentin was initaled by LPN A along with the number nine (other: see progress notes); -The ES Tylenol box was not initialed and marked with an X, indicating not due and the medication was not administered. Review of the resident's progress notes, dated 05/28/25, showed no documentation the resident's physician was notified staff did not administer the resident's 7:00 A.M. medications as ordered. Review of the resident's MAR, dated 5/2025, showed On 05/28/25 at 11:00 A.M., the administration box for the resident's ordered gabapentin was initialed by LPN D along with the number the number nine (other: see progress notes). Review of the resident's progress notes, dated 05/28/25 at 3:21 P.M. showed staff documented, medications coming from pharmacy. No documentation to show staff notified the resident's physician the resident's medications were not available for administration. During an interview on 06/12/25 at 11:48 A.M., LPN A said the following: -The physician should be notified if medications were not administered; -He/She had not notified the physician. During an interview on 06/11/25 at 3:05 P.M. LPN C said if staff was unable to locate medications or administer medications, the physician/on-call physician should be notified to change the order; -He/She would chart meds to be delivered by pharmacy, notify the physician, and document his/her actions in the progress notes. The resident missed three ordered doses of gabapentin, one ordered dose of Pepcid, one ordered dose of rosuvastatin and two ordered doses of ES Tylenol. The resident missed seven total doses of medications. During an interview on 06/13/25 at 12:29 P.M., the Director of Nursing (DON) said the following: -She would expect medications to be given as ordered; -If medications were not administered, the physician should be notified. It would be the responsibility of the nursing staff, including agency staff, to notify the physician; -Notifications should be documented in the progress notes; -She was not aware of the missed medications; -Some of the medications were available in the Pyxis and some were available from stock supply. MO255076

Based on interview and record review, the facility failed to complete weekly skin assessments per facility policy for two residents, (Resident #1 and #2), of five sampled residents. Resident #1 admitted to the facility with no pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Staff failed to identify any issue with the resident's skin before the resident presented with a Stage III pressure ulcer on the resident's buttocks on 1/19/25 (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Resident #2 was at risk for pressure ulcers and admitted to the facility without pressure ulcers. The resident was dependent on staff for cares, was not consistent in keeping pressure off his\her heels, and would slide down in bed so his/her feet touched the footboard. The facility had not addressed the resident's heels in his/her care plan and did not complete weekly skin assessments. According to staff, therapy discovered the wounds on the resident's feet on 2/28/25. The wounds included an unstageable pressure ulcer (wound is unstageable due to a covering of slough or eschar (dead tissue) to the right heel, an unstageable pressure ulcer on the left Achilles (ankle) area, and a suspected deep tissue injury (a localized area of discolored intact skin or a blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear often appearing as a purple or maroon discoloration) on the right great toe. The facility census was 33. Review of the facility policy for Skin Assessment with a revision date of 1/2024 showed the following: -It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management; -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury; -Documentation of skin assessment includes date and time of the assessment, your name and position title, document observations (e.g. skin condition, how the resident tolerated the procedure, etc); document type of wound; document wound (measurements, color, type of tissue in wound bed, drainage, odor, pain); document if resident refused assessment and why; document other information related as indicated or appropriate. Review of the facility's Pressure Injury Prevention and Management policy with a revision date of 7/2024 showed the following: -This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries; -Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions; or revise the interventions as appropriate; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate; -Assessment of Pressure Injury Risk: licensed nurses conduct a pressure injury risk assessment, using the (fill in blank for designated tool) on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly; the tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; -Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be document in the medical record; -Nursing assistants will inspect skin during a bath and will report any concerns to the resident's nurse immediately after the task; -Interventions for Prevention and to Promote Healing; after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions; -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); minimize exposure to moisture and keep skin clean, especially of fecal contamination; provide appropriate, pressure-redistributing, support surfaces; provide non-irritating surfaces; and maintain or improve nutrition and hydration status, where feasible; -Interventions will be documented in the care plan and communicated to all relevant staff. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of parainfluenza virus with pneumonia, Parkinson's disease (a movement disorder of the nervous system that worsens over time), diabetes, heart disease, and generalized weakness. Review of the admission skilled nurses note dated 12/6/24 showed the resident's skin was clean and dry with no alterations in skin integrity. Review of the resident's comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/12/24, showed the following: -Able to make self understood and able to understand others; -Alert and oriented with some difficulty making decisions; -Dependent upon staff for activities of daily living (ADLs), transfers and walking; -Occasional incontinent of bowel and bladder; -At risk for pressure ulcers. Review of the resident's Care Plan for skin integrity dated 12/8/24 showed the following: The resident was at risk for alteration to skin integrity secondary to mobility deficits; -Goal: the resident will have no unaddressed alteration of skin integrity; -Approaches: provide skin and incontinence care assistance as needed; standard facility pressure reduction mattress; weekly skin checks per facility schedule; notify the physician for prompt/proper interventions. Review of the resident's weekly skilled charting nurses notes showed the following: -On 1/9/25 the area for assessment of the skin was blank with no documentation; -On 1/16/25 the area for assessment of the skin was blank with no documentation; Review of the resident's Weekly Wound Rounds dated 1/19/25 signed by Registered Nurse (RN) D showed the resident had an open area to the left buttock, that measured 2 cm by 1.5 cm by 0.2 depth, Stage III, found upon assessment. During an interview on 3/24/25 at 2:45 P.M. RN D said the following: -He/She was working as the RN supervisor when a staff member asked him/her look at Resident #2's bottom on 1/19/25; -He/She assessed the area, the area was open and deep. He/She documented the findings on the weekly wound rounds and notified management. During an interview on 3/24/25 at 1:04 P.M. RN B said the following: -He/She was the wound nurse and measured the wounds when found and then weekly; -Staff found the resident with a Stage III pressure ulcer on his/her left buttock on 1/19/25; -He/She had not assessed the resident's skin prior to 1/19/25; -The resident was seen by the contracted wound care company on 1/22/25. During an interview on 3/19/25 at 2:00 P.M. the Director of Nurses (DON) said the following: -Resident #1 did not have any identified issues with his/her skin until 1/19/25; -The resident had a toilet riser and may have developed the ulcer due to sitting on the toilet for a long period of time; -Staff did not find the area until it was open and at a Stage III level. During an interview on 3/24/25 at 2:00 P.M. the Nurse Practitioner for the contracted wound care company said the following: -The resident had been referred to him/her on 1/22/25 for a wound on his/her left buttock; -He/She assessed the wound to be quarter size, open with slough and was a Stage III pressure ulcer; -This was the first time he/she had seen the resident's skin. Review of the resident's weekly skilled charting nurses notes showed the following: -On 1/23/25 the area for assessment of the skin was blank with no documentation; -On 1/30/25 the area for assessment of the skin was blank with no documentation; -On 1/31/25 the area for assessment of the skin was blank with no documentation. (The resident had a pressure ulcer on his/her buttock that was identified on 1/19/25) 2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of low back pain, weakness, pneumonia, and diabetes. Review of the resident's admission skin assessment dated [DATE], showed no skin issues, buttocks red but not open. Review of the resident's Care Plan for Alteration in Skin Integrity Risk dated 1/24/25, showed the following: -Resident was at risk for skin alteration due to incontinence of bladder; -Encourage and assist with frequent repositioning to alleviate areas of pressure; provide skin and incontinence care assistance as needed. -The care plan did not address any interventions to address pressure relief specific to the resident's heels, including refusals to use devices for pressure relief or or sliding down in the bed. Review of the resident's Care Plan for Actual Skin Impairment/Wound dated 1/28/25 showed the following: -The resident had a skin tear to the right upper extremity; -Enhanced barrier precautions (a type of isolation to prevent the spread of multi resistant organisms); in house wound care provider to assess and treat; registered dietician to evaluate as needed; treatments as prescribed; resident was being followed by outside wound care provider; -The care plan did not address any interventions to address pressure relief or wounds on the resident's heels. Review of the resident's comprehensive MDS dated [DATE], showed the following: -Able to make self understood and able to understand others; -Alert and oriented able to make some decisions; -Dependent upon staff for Activities of Daily Living (ADLs), dependent upon staff to come from a sitting to a standing position and standing to sitting position, dependent upon staff for toileting transfers; -Incontinent of bowel and bladder; -At risk for the development of pressure ulcers, no pressure ulcers present. Review of the resident's Treatment Administration Record dated 2/1/25 through 2/28/25 showed no treatment orders or interventions to the resident's heels including pressure relieving boots or application of skin prep. Review of the resident's skilled nursing notes dated 1/26/25, 2/6/25, 2/14/25, 2/15/25, 2/19/25, 2/25/25 and 2/26/25 showed the section in the notes for skin assessment was left blank, with no documentation of an assessment. Review of the resident's daily skilled nursing notes dated 2/28/25 showed the following: -Right heel Issue type: Pressure ulcer/injury. Length 2.5 centimeters(cm): Width 2.5 (cm): Depth 0.003 (cm): , skin issue had not been evaluated. Location: Left Achilles (heel bone) scabbed over area. Length 2.5 (cm): Width 1.25 (cm): Depth 0 (cm). Skin note: soft boots to bilateral feet, heels floated. Review of the resident's Wound Rounds dated 2/28/25 showed the following: -Wound acquired in house. Right heel, pressure ulcer 3.3 cm by 3.0 cm. Depth unable to determine, unstageable (a full-thickness skin and tissue loss where the base of the ulcer was obscured by slough (dead fibrous tissue usually yellow in color), and eschar (dead tissue forming a crust on the surface making it impossible to determine the true depth or stage of the ulcer); -Left Achilles, pressure, 0.7 cm by 1.5 cm, unable to determine depth, unstageable; -Right great toe, pressure, 0.7 by 0.7 by 1.3, suspected deep tissue injury (a localized area of discolored intact skin or a blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear often appearing as a purple or maroon discoloration). Review of the resident's care plans dated 2/28/25 showed no care plan to address the resident's pressure ulcers to the resident's heel, Achilles area, or right great toe. Review of the resident's nurses notes dated 3/2/25, showed the resident started having acute on chronic left knee pain. The resident had called Family Member (FM) A several times throughout the night after 4:00 A.M. regarding the pain; family demanded 911 be called for evaluation. Resident sent out (to the hospital) per request. During an interview on 3/21/25 at 11:18 A.M., the resident's FM A said the following: -The resident would complain about pain in his/her feet and legs; -The night before the resident was sent to the hospital, the resident called him/her crying with the pain in his/her feet and legs; -On 3/1/25 when he/she went to the facility, he/she took pictures of the sore/open area on the resident's right foot. Review of photographs supplied by FM A ( photographs taken on 3/1/25), on 3/21/25, showed a wound to the resident's right heel the size of a quarter that had yellow slough with dried, flaky skin around the wound. During an interview on 3/19/25 at 3:55 P.M. Certified Nurse Aide (CNA) A said the following: -The resident spent a lot of time in bed and was incontinent of bladder; -The resident had complained about heel pain since admission and the resident's heels felt a little soft and were red; -The nurses put skin prep (a medication that reduces friction, protecting sensitive skin) on the resident's heels; -The resident had protective boots, but refused to wear them; -The heels did open up to a sore; -He/She thought nurses were aware of the skin on the heels opening; -On 3/1/25, the resident was in a lot of pain and the family requested that the resident be sent to the hospital. During an interview on 3/24/25 at 1:04 P.M. Registered Nurse (RN) B said the following: -He/She did weekly wound rounds with the contracted wound care nurse practitioner and measured wounds; -Nurses will notify him/her of any new wounds and he/she will measure the wounds and document in the electronic medical record in the weekly wound assessment; -The resident was not admitted with any skin issues on his/her feet, the resident did have a large skin tear on an arm that was being treated and followed by the contracted wound care nurse practitioner; -On 2/28/25, he/she was notified by therapy of the wounds on the bottom of the resident's right heel, the Achilles area of the left heel, and the right great toe; -The Achilles area of the left heel was open with slough with the wound bed was yellow, the bottom right heel was open and the wound bed covered with yellow slough and the right great toe was dark purple in color; -The resident spent a lot of time in bed with the head of the bed elevated and he/she would slide to the end of the bed with his/her feet pressed on the foot board. The resident had foot protectors, but he/she would not leave them on; -The resident went to the hospital before the outside contracted wound care provider could see the wounds. During an interview on 3/24/25 at 2:50 P.M. RN C said the following: -He/She was not aware of any wounds on the resident's feet; -He/She worked the day shift on 3/1/25 and sent the resident to the hospital due to extreme pain in his/her knee; -He/She did not look at the resident's feet before he/she sent the resident to the hospital; -The nurses would do skin checks and document the skin checks in the skilled nurses notes; -He/She did not remember any staff member telling him/her about any sores on the resident's feet. During an interview on 3/19/25 at 2:00 P.M. and 3:00 P.M. the Director of Nurses (DON) said the following: -Resident #2 was very sick upon admission; -Resident #2 had a low air loss mattress on his/her bed and had heel protectors on both heels that he/she would refuse to wear; -CNAs are to inspect the resident's skin with cares and bathing at least two times a week and inform the nurses of any concerns; -If the CNAs notice a problem with a resident's skin, they are to notify the nurses verbally of the concern and the nurses are to check the resident's skin; -Nurses should document on a wound assessment if there was a wound and notify the physician and responsible party; -The nurses are to assess the resident's skin weekly and document the results on their weekly skilled nursing note; -Resident #1 and Resident #2's weekly skilled nurses notes does not always address the resident's skin; -She would expect nurses to complete the weekly skin checks per the facility policy and thoroughly assess the resident's skin. During an interview on 3/19/25 at 3:00 P.M., the Administrator said he would expect the nursing staff to follow their policy for skin and pressure ulcers. During an interview on 3/24/25 at 9:00 A.M. facility Medical Director/Physician A said the following: -He would expect the facility nurses to follow their policy to assess the resident's skin at least weekly and document the results and if there are any skin issues or concerns to notify the physician and the contracted wound care company for orders and treatments; -The facility staff should have identified these pressure ulcers before they were a Stage III and the unstageable on the resident's heel; -Generally, the skin would have shown some type of changes, such as being discolored, reddened or a blister, before the wounds opened. MO249791 and MO250792

Based on interview and record review, the facility failed to notify the physician and/or responsible parties when two residents (Residents #1 and Resident #2), in a review of six sampled residents, had a change in condition. The facility census was 34. Review of the facility policy for Notification of Changes dated 7/2024 showed the following: -The purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -Circumstances requiring notification include significant change in the residents physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and transfer or discharge of a resident from the facility; -The facility must still contact the residents physician and notify the resident's representative, if known; -When a resident is mentally competent, such a designated family should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident; -Contact information of the resident's legal representative or family member must be recorded and periodically updated. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE] with diagnoses of diabetes with a foot ulcer, infection in the foot ulcer, vascular disease (a general term for conditions that affect the body's blood vessels, veins, and lymphatic vessels), stage four kidney disease (indicates a severe level of kidney damage where your kidneys are not functioning properly to filter waste from the blood) and atrial fibrillation (A-fib - a common type of irregular heartbeat that affects the upper chambers of the heart (atria); -No emergency or family contacts listed. Review of the resident's Social Services admission note dated 10/11/24 at 1:58 P.M., and signed by Social Services Director (SSD) showed primary contact was Family Member A. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/16/24 showed the following: -Resident able to make self understood and able to understand others; -Alert and oriented and able to make some decisions. Review of the resident's nurses notes dated 11/7/24 at 7:19 A.M., signed by Licensed Practical Nurse (LPN) B showed the resident had delusions and was confused about who the nurse was. The resident slipped out of the wheelchair and had episodes of agitation. The resident was sent to a local hospital for evaluation. Review of the resident's nurses notes dated 11/8/24 at 6:15 A.M. showed the resident admitted to the hospital. Review of the resident's medical record dated 11/7/24 and 11/8/24 showed no documentation staff notified any of the resident's contacts the resident was sent to the hospital or admitted to the hospital. During an interview on 12/5/24 at 9:55 A.M. the Social Services Director (SSD) said the following: -The facility utilized a Central Intake that inputs resident information into the electronic medical record; -The Central Intake will input what was received from the hospital and information gathered from the resident and the resident's responsible party; -She did not know why there was no responsible party listed on the face sheet for Resident #1; -She knew the resident's responsible party was Family Member A per the hospital records. During an interview on 12/5/24 at 10:08 A.M. Family Member A said the following: -The facility did not notify him/her the resident was being sent to the hospital or was admitted to the hospital; -The resident called him/her from the emergency room to let him/her know the resident was at the hospital; -He/she never got a call from the facility, even when he/she came to collect the resident belongings, no one talked with him/her about the resident or what led up to the resident going to the hospital. During an interview on 12/5/24 at 11:40 A.M. Licensed Practical Nurse (LPN) B said the following: -He/She sent Resident #1 to the hospital on 11/7/24; -The resident was very delusional; -The resident did not have anyone listed on his/her face sheet to contact; -He/She checks the face sheet to determine who to contact when a resident has a change of condition or needs to be sent to the hospital. 2. Review of Resident #2's of the Admission MDS dated [DATE] showed the following: -Resident able to make self understood and able to understand others; -Alert and oriented and able to make some decisions. Review of the resident's face sheet showed Family Member B as the resident's emergency contact, responsible party. Review of the resident's nurses note dated 11/9/24 showed the resident complained of shortness of breath (SOB) and had already received all prescribed treatments for SOB. The resident was using auxiliary muscles to breathe; 911 called and resident sent to the hospital. Review of the resident's nurses notes dated 11/9/24 showed no documentation staff contacted Family Member B regarding the resident's change of condition or that staff contacted 911 and sent the resident out to the hospital. During an interview on 12/5/24 at 10:41 A.M. Family Member B said the following: -The facility did not notify him/her the resident was sent out to the hospital; -The hospital called him/her when the resident was admitted to the hospital. During an interview on 12/5/24 at 11:00 A.M. the Director of Nursing said the following: -Staff make her aware when they notify a family member via an internal communication; -She did not find notifications made to Family Member A or B of residents' change of condition or of being sent out to the hospital; -She did not find any contacts listed on the face sheet for Resident #1; -Nurses would look at the face sheet to find a resident's contacts; -The information listed on the face sheet was completed by Central Intake which was not located in the facility; -She would expect contacts to be listed on the face sheet; -Resident #1's contact/responsible party information was on the hospital paperwork and available for the Central Intake to put on the face sheet. Resident #2's contacts were available for the nurses; -If a nurse was not able to make contact with the responsible party listed on the face sheet at the time of the condition change or sending the resident out to the hospital, she would expect this information to be passed on to the next nurse and the following nurse attempt contact. If that nurse was not successful, then the nurse should send a message to her; -She would expect nurses to document in the progress notes whether a contact was made with the responsible party or not. During an interview on 12/5/24 at 11:05 A.M. the Administrator said the following: -Resident responsible party/contact information should be available to staff on the face sheets; -He would expect staff to notify the responsible party or contact of any change of condition or hospitalization and if unable to make contact, staff should notify the DON or himself. MO244910

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of four sampled residents, who was dependent upon staff for transfers and at risk for falls. The facility failed to ensure staff followed facility policy for using a sit to stand lift. Certified Nurse Aide (CNA) A transferred Resident #1 using the sit to stand lift without assistance of an additional staff to transfer the resident. The resident sustained significant pain and bruising from the improper transfer. The facility census was 36. The administrator was notified on 9/30/24 at 3:00 P.M , of the Past Non-Compliance which occurred on 9/24/24. On 9/24/24, the administrator became aware of the injury to Resident #1 which resulted in a staff member failing to follow the facility policy on a sit to stand transfer when the staff member did not use two staff to transfer the resident. The facility began an investigation and determined that the staff did not follow the facility policy for a sit to stand transfer. The facility began in-servicing all staff on safety, the facility policy to use two staff members for all mechanical lift transfers, and competencies for staff on the use of the sit to stand lift. The G grid deficiency was removed and corrected on 9/25/24. Review of the facility policy for Safe Resident Handling Transfers revised on 7/2024 showed the following: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them; -The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs; -Two staff members must be utilized when transferring residents with a mechanical lift; -Mechanical lifts may include equipment such as fully body lifts and sit to stands lifts. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of coronary heart disease (a condition that occurs when the heart's blood vessels narrow due to plaque buildup), atrial fibrillation (irregular heart beat), diabetes and peripheral vascular disease (PVD is a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked. This can lead to reduced blood flow and tissue damage. PVD can affect any blood vessel outside of the heart, including arteries, veins, and lymphatic vessels. The legs and feet are most often affected). Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/22/24 showed the following: -Able to make self understood and able to understand others; -Brief Interview for Mental Status (BIMS-a cognitive screening tool used to identify cognitive impairment in patients in long-term care facilities and skilled nursing facilities:) of 10 (Indicates moderate impairment); -Impairments of both lower extremities, required total staff assistance with transfers, toilet hygiene and partial to maximum assistance with Activities of Daily Living (ADL's); -Frequent pain at a level of 10 (0 being no pain, 10 being excruciating pain). Review of the resident's Physical Therapy Treatment Notes dated 9/24/24 showed the following: -Transfers with sit to stand with use of lift with staff and resident raining with maximum assist of one, with another staff member to operate the machine and complete safe transfer to the wheelchair; -Resident and caregiver training: the resident and the staff member training in safe transfer technique with use of the sit to stand lift from the bed to the wheelchair and proper positioning in the wheelchair. Review of the resident's nurses notes dated 9/24/24 at 6:30 P.M., signed by the Director of Nursing (DON) showed the following: -Resident is alert and oriented. The resident reported earlier in the shift the day shift CNA came into the room to assist the resident to bed. The CNA used the sit to stand lift to transfer the resident from the chair to the bed. The resident said he/she started to scream as his/her arms were too high and he/she felt a pop in the right shoulder when he/she was raised to a standing position. The CNA continued to raise him/her then used force to put him/her into bed. The resident said he/she was screaming in pain. His/Her right shoulder was painful with a pain level of a 10 (on a scale of 1-10 with 10 being the worst pain possible). Review of the resident's nurses notes dated 9/25/24 at 12:39 P.M. signed by the DON showed the following: -X-rays to the right shoulder negative but does show a potential rotator cuff tear. The resident complains of chronic pain with movement to the right shoulder. Nurse Practitioner here to see the resident and orders to send to orthopaedic outpatient clinic. There was no fracture or rotator injuries. Possible right pectoral muscle (a group of muscles in the upper chest that connect the upper limbs to the chest wall) stain and new orders for Voltaren gel ( topical pain relieve medication). The resident continues receiving physical and occupational therapy with their recommendation to continue to use the sit to stand lift or the full mechanical lift. Review of the resident's nurses notes dated 9/29/24 at 10:07 A.M. showed staff informed the resident's the resident had a bruise to the right breast. Area was assessed and noted large purple bruising with yellowish shadowing to the right lateral (outer aspect) of the breast. This area was previously noted on 9/26/24 and DON aware. Orders received for bilateral rib X-rays. During an interview on 9/30/24 at 9:38 A.M. Resident #1 said the following: -A few days ago a staff member came into the room and told him/her that he/she was going to put him/her to bed; -The staff member brought in the sit to stand lift, he/she questioned the staff member on getting another staff member to help, and this staff member said the he/she knew how to work the sit to stand and everything was going to be okay; -The staff member put the sit to stand belt around his/her waist and began to lift him/her up. As he/she was being lifted up, the belt felt like it was cutting into his/her body, he/she began to scream out as it hurt under his/her right arm; -The staff member continued to lift him/her up and then pushed him/her into the bed and lowered him/her down onto the bed; -The staff member put his/her legs onto the bed and without positioning him/her and left the room; -Another staff member came in and positioned him/her in bed; -His/Her right side under the arm pit still hurt and caused him/her pain. Observation of the resident on 9/30/24 at 11:13 A.M. showed the following: -A large dark purple with yellow edges located on the lateral aspect of the resident's right breast; -The resident said it was tender when touched. During an interview on 9/30/24 at 2:00 P.M. the DON said the following: -She was notified on 9/24/24 that CNA A had transferred Resident #1 by him/herself using a sit to stand lift; -It is the facility policy that two staff members are required when using any mechanical lift to transfer a resident; -Therapy had assessed the resident on 9/24/24 and determined that the sit to stand lift was appropriate. Therapy then will educate the staff on how to use the sit to stand with the resident. This was done on 9/24/24 with CNA A; -The employee was an agency aide and signed that he/she was aware of the facility policy that two staff members were to be used when using the sit to stand lift; -CNA A will not be working at the facility again; -She would expect staff to follow the facility policy for using two staff members with any mechanical lift transfer. During an interview on 10/1/24 at 3:50 P.M. CNA A said the following: -He/She worked the day shift on 9/24/24. He/She had never cared for Resident #1 before; -He/She was a agency employee and did not get any report from the off going staff member, so he/she was unsure how the resident transferred; -Therapy evaluated the resident on 9/24/24 and educated the resident and staff on how to use the sit to stand for transfers with the resident; -Toward the end of the shift, the resident asked to go to bed so he/she brought the sit to stand machine to the resident, placed the belt around the resident and began to transfer the resident from the wheelchair to the bed. The resident yelled out in pain as he/she put the resident in the bed; -He/She knew that there should have been two people to use the sit to stand machine, but he/she could not find any help and the resident begged to lay down; -He/She knew how to operate the machine. The belt did not slid up under the resident's arm pits; -He/She finished care on the resident and left the room. During an interview on 10/4/24 at 8:45 A.M. the Director of Therapy said the following: -Physical Therapy had assessed the resident on 9/24/24 for the safest method of transfer which was the sit to stand lift; -Once therapy evaluates for the safest mode of transfer, they will train the staff, including agency staff, on that method. This was done with the assigned caregivers on 9/24/24; -Staff should use two staff members when using any mechanical lift including the sit to stand lift. MO242605

Based on observation, staff interview, and facility policy review, the facility failed to ensure clean pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 38 of 38 residents in the facility who received dietary services at the time of the survey. The census was 38. Findings include: Review of the facility policy ''Dishwashing Machine Use,'' dated March 2010, revealed, ''Policy Statement: Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: . i. Use overhead spray to remove loose food particles. J. After running items through the entire cycle, allow to air-dry.'' Review of the facility policy ''Manual Ware Washing - 3 Compartment Sink,'' dated June 2023, revealed, ''Policy: To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 3 compartment sink in accordance with current standards for food safety . Sanitizing procedures for the three -compartment sink are as follows: . Step III Allow pots/utensils to air dry; Store pots upside down or covered.'' Review of the facility policy ''Sanitization,'' dated October 2008, revealed, ''Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical.'' Observation and interview on 11/27/23 at 10:15 AM, with the Dietary Manager (DM) of the area located next to the dishwasher were the pots and pans were being stored, the DM confirmed three pans 6 inches by 12 inches by 3 inches deep, five pans 6 inches by 12 inches by 6 inches deep, five pans 9 inches by 12 inches by 6 inches deep, and six pans 12 inches by 24 inches by 4 inches deep were still wet when they were unstacked. The pans were found to have been stacked wet and not allowed to air dry. The DM stated, ''The pans are wet, and they should be dry, they need to air dry [before stacking].''

Based on observations, interviews, record review, and review of facility policies, the facility failed to ensure that staff and visitors were wearing the appropriate personal protective equipment (PPE) for one resident of two residents (Resident (R) 90) on isolation precautions. The facility failed to ensure the water management program was consistently maintained. The census was 38. Findings include: 1. Review of the facility policy titled ''Personal Protective Equipment'' with revision date of [DATE] read in part, ''. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely . PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status .'' Observation on [DATE] at 11:30AM revealed R90 in a room with signage that read airborne precautions. The signage gave directions for staff to clean hands upon entering and exiting the room, wear a fit tested N95 face mask or higher-level respirator before entering the room, remove mask after exiting the room, door to room must remain closed. An isolation cart outside R90's door contained face shield, blue masks, N95 masks, and gowns. There were no gloves in the cart. Observation on [DATE] at 11:21 AM revealed Certified Nursing Assistant (CNA) 8 responding to R90's call light. CNA8 donned a N95 face mask with face shield and entered R90's room. The staff member did not perform hand hygiene, nor did the staff member don gown and gloves. During an interview on [DATE] at 11:35AM, CNA8 revealed R90 was a new admission positive for COVID, and R90 was on airborne precautions. CNA8 was unable to explain why the isolation cart contained the other PPE if the signage directed the staff to wear only N95 face mask with face shield. During an interview on [DATE] at 11:45 AM, Licensed Practical Nurse (LPN) 5 revealed staff should wear gowns, gloves, face shield and N95 face mask when entering R90's isolation room. LPN5 stated R90 was a new admission and tested positive for COVID at the hospital before transferring to the facility. Observation on [DATE] at 11:55AM revealed the Dietary Manager (DM) was wearing a blue face mask, donned gown and gloves. The DM did not perform hand hygiene before donning the gloves. The DM took R90's lunch in Styrofoam dishes into the resident's room. During an interview on [DATE] at 12:03 PM, the DM revealed staff should wear gowns, mask, and gloves when entering R90's room. According to the DM staff may wear the blue mask if they have been vaccinated. If a staff member is unvaccinated, they must wear the N95 mask. During an interview on [DATE] at 9:00 AM, the Assistant Director of Nursing /Infection Preventionist (ADON/IP) revealed new admissions testing positive for COVID were placed in droplet/contact isolation. The ADON/IP stated staff should wear N95 masks, face shields or goggles, gowns, and gloves. The ADON/ICP was unaware of the airborne precautions signage posted on R90's room. Observation on [DATE] at 9:10 AM revealed the signage on R90's room door still read airborne precautions. Certified Medication Technician/Certified Nursing Assistant (CMA/CNA) 7 was observed to perform hand hygiene and donned an N95 mask, face shield, gown, and gloves under the direction of the Assistant Director of Nursing/Infection Control Nurse (ADON/ICP). At this time the ADON/ICP did not change the signage on the door. Observation on [DATE] at 9:53AM revealed Housekeeper (HSK) 1 donning a blue face mask, gown, and gloves. HSK 1 did not perform hand hygiene and did not don an N95 face mask and face shield or goggles. During an interview on [DATE] at 9:53AM, HSK 1, as the employee donned the PPE, revealed even though the signage on the door directed the staff to wear only N95 face mask and face shield, the employee felt it was necessary to wear everything to prevent the spread of infection. Observation on [DATE] at 2:15 PM revealed the signage on R90's room door now read droplet/contact precautions. The signage directed the staff to perform hand hygiene; must wear N95 face mask, face shield, gowns, and gloves. CMT/CNA7 was observed donning the appropriate PPE according to the signage. A family member (F90) of R90 was observed in the resident's room wearing a blue face mask and no other PPE. The CMT/CNA7 did not inform the visitor about wearing the correct PPE. Interview on [DATE] at 2:30 PM with F90 revealed the daily visits with the resident. F90 stated that no one had ever said anything about what was needed to be worn before entering the resident's room. Review of R90's ''Face Sheet'' found in the resident's electronic medical record (EMR) section titled ''Face Sheet'' revealed the resident was admitted to the facility on [DATE] with diagnoses that included COVID. Review of R90's Physician's Orders dated [DATE] located in the resident's EMR section titled Orders revealed the resident was to be droplet precautions isolation unit [DATE]. 2. Review of the facility's undated policy titled ''Water Management'' read in part ''.lt is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems . A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance, employees, safety officers, risk and quality management staff, and Director of Nursing . The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder .'' During an interview on [DATE] at 10:25AM, the facility's Water Management Notebook was reviewed with the Maintenance Director (MD). The notebook did not contain any documentation of the facility's water management program. The Water Management Notebook contained only examples of documentation. The MD stated he was hired two weeks ago and has not received any training regarding the water management program. The MD was unable to locate any documentation completed the previous MD for the water management program. The MD stated the Administrator might the water management documentation of the previous MD. During an interview on [DATE] at 12:05 PM, the Administrator revealed the previous maintenance director died a few weeks ago. Since then the Administrator has only monitored the water temperatures. The Administrator stated the regional corporate person was assisting with maintaining the water management program. The Administrator stated it was possible to access the previous MD documentation of the program. During an interview on [DATE] at 2:29 PM, the Administrator stated he was still looking for the previous maintenance director's water management program records. The Administrator stated there had been no testing of the facility's water level for Legionella disease. The Administrator stated that to his knowledge there had never been an outbreak of Legionella disease in the area. The Administrator did not provide any documentation of the facility's water management program by the end of the survey.

Based on observations, interviews, and review of facility policy, the facility failed to ensure that two of two medication carts and one of two treatment were locked and secured on two of two resident halls. This failure creates a risk of medications being misappropriated or tampered with. The census was 38. Findings include: Review of the facility's policy titled ''Medication Storage'' with a revision date of June 2023 read, ''All drugs and biologicals will be stored in in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During a medication pass the medication cart must be under direct observation of the person administering medications or locked in the medication storage area/cart.'' 1. Observation on 11/29/23 at 8:39 AM revealed the 100 Hall medication cart parked across from the Physical Therapy department and nurses' station unlocked. There were no medications on top of the cart. Non-nursing facility staff members (physical therapy and dietary) were nearby. At 8:43AM, the Assistant Director of Nursing (ADON) passing by noticed the medication cart was unlocked and secured the cart. Interview on 11/29/23 at 9:00 AM with the ADON confirmed the medication cart on the 100 Hall was unlocked and unattended. The ADON stated the cart should be always locked when the nurse was not at the cart. The ADON stated the treatment carts also are to be locked since the cart contains creams, gels, and supplies. 2. Observation on 11/29/23 at 8:46 AM revealed the treatment cart unlocked in front of a resident's room with the door closed. The top drawer of the treatment cart contained residents insulin pens and glucometers. The second drawer on the treatment cart contained wound care products such as wound cleanser, nystatin powders, and Voltaren gel (arthritis pain gel). The cart was out of the sight of Licensed Practical Nurse (LPN) 7. Interview on 11/29/23 at 8:51 AM with LPN7 revealed the treatment cart was left unlocked and out of her line of sight. LPN7 stated the treatment cart probably should be locked but was not necessary since there were no narcotics stored on the treatment cart. 3. Observation on 11/29/23 at 9:37 AM revealed Certified Nursing Assistant (CNA)7 (a certified medication technician) setting up the medication for Resident (R) 83. CNA7 entered R83's room leaving the medication cart unlocked. The medication cart was out of the line of sight on the person administering the medications. During an interview on 11/29/23 at 9:45AM, CNA7 acknowledged the medication was left unlocked. CNA7 also confirmed the medication cart could not be visualized. 4. Observation on 11/29/23 at 11:37 AM revealed LPN7 preparing insulin injections for R18. LPN7 entered the resident's room leaving the treatment cart unlocked. LPN7's back was turned to the door and the unlocked treatment cart was out of sight of LPN7.

Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; and using speech, language or other functional communication systems; -The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy Resident Rights, dated 6/2023, showed the following: -The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice; -The resident has a right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has the right to be informed of, and participate in, his or her treatment, including the right to participate in the development and implementation of his or her person-centered plan of care; -The resident has the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 1. Review of the facility's undated Shower Schedule Sheet showed the following: -Resident #8's shower days were Mondays and Thursdays; -Resident #9's shower days were Wednesdays and Saturdays; -Resident #10's shower days were Sundays and Wednesdays; -Residents have the right to choose to shower, bathe, or have a bed bath; -Residents have the right to choose the day and time most convenient for themselves; -Residents may bathe as frequently or infrequently as they choose; -The director of nursing (DON) may adjust the schedule to accommodate individual resident needs; -If no preference is made, then the proposed schedule should be followed. 2. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Care Plan for Rehabilitation Services dated 1/18/24 showed the following: -The resident requires rehabilitation services at this time: -The resident will meet therapy goals for improved functional status; -Assist the resident with completing ADLs and encourage to be as independently as safely possible. -No evidence of documentation of preferences for shower/bath day or frequency noted. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/24/24 showed the following: -The resident admitted to the facility on [DATE]; -Diagnoses of fractured hip, neurogenic bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), and arthritis; -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Preference for bathing, taking a shower or a tub bath, very important; -Dependent upon staff for bathing; -Requires maximum assistance of staff for turning side to side; -Has an indwelling catheter (a tube placed in the bladder to drain urine to a bag) and frequently incontinent of bowel. During an interview on 1/31/24 at 9:27 A.M. Resident #10 said the following: -He/She has been at the facility for over a week and yesterday was the first day that he/she has had a bed bath; -He/She would prefer to have a shower, but has sutures in his/her right leg that cannot get wet; -His/Her last bath was 1/12/24, which was at home prior to him/her falling and breaking his/her hip; -He/She would prefer to have a bath at least every other day, but knew that would not be possible due to the facility not having enough help, so he/she would settle on at least two per week. Review of the resident's medical record from 1/18/24 through 1/31/24 showed no documentation staff assisted the resident with a bed bath or shower. 2. Review of the Resident #8's face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident was his/her own responsible person; -The resident had diagnoses that included fracture of left humerus (left upper arm) , and cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of the left upper limb. Review of the resident's entrance tracking record MDS dated [DATE], did not show any pertinent information regarding the resident. Review of the resident's care plan, dated 1/29/24, showed the following: -The resident was at risk for altered activities of daily living (ADL) function secondary to left elbow surgical procedure; -Assist in completing ADL tasks each day; -No evidence of documentation of preferences for shower/bath day or frequency noted. During an interview on 1/30/24 at 11:04 A.M. and 1/31/24 at 1:55 P.M. and 3:25 P.M., the resident said the following: -On 1/30/24, the resident said he/she had not had a shower since admitting to the facility, but was supposed to get one this afternoon; -He/she was worried about body odors; -On 1/31/24 At 1:55 P.M., the resident said he/she did not get a shower yesterday and had not had a shower yet today; -He/She should be able to get a shower regularly; -On 1/31/24 at 3:25 P.M., staff asked the resident if he/she wanted a shower but but the resident was too tired at that time due to therapy. Review of the resident shower sheets showed no documentation the resident received a bed bath or shower from 1/26/24 through 1/31/24. 3. Review of Resident #9's initial MDS dated [DATE], showed the following: -The resident admitted to the facility on [DATE]; -The resident was cognitively intact; -The resident did not reject cares; -The resident required substantial/maximum assistance from two or more staff for bathing, rolling side to side, rising from a sitting to standing position and toileting; -The resident made himself/herself understood and understood others; -The resident had diagnoses that included chronic kidney disease, kidney transplant, klebsiella pneumonia (healthcare associated pneumonia), respiratory failure, cystitis with hematuria (bladder infection with blood in the urine), and bacteremia (bacteria in the blood). Review of the resident's care plan, dated 1/16/24, showed the following: -The resident required rehabilitation services to complete activities of daily living and encourage to be as independent as safely possible; -The resident was at risk for altered ADL function secondary to deconditioning, history of falls, and decreased endurance. Assist in completing ADL tasks each day; -No evidence of documentation of preferences for shower/bath day or frequency noted. During an interview on 1/30/24 at 2:43 P.M. the resident said the following: -He/She has only had two showers since being admitted on [DATE]; -He/She would like at the very least one shower a week. Review of the resident shower sheets showed no documentation the resident received a bed bath or shower from 1/13/24 through 1/31/24. During an interview on 1/31/24 at 2:16 P.M. Certified Nurse Aide (CNA) B said the following: -Residents have designated shower days; -If a resident refused a shower the resident signed their shower sheet. During an interview on 1/31/24 at 2:03 P.M. Licensed Practical Nurse (LPN) A said the following: -The CNAs are to completed a shower sheet and give it to the nurses; -There is a schedule for what rooms get a shower each day on the day shift and the evening shifts; -Once the shower is complete, the CNAs give the shower sheets to the nurses to check and sign that the shower is complete and any issues are addressed; -He/She does not verify the shower sheets to the schedule to ensure that everyone has had a shower. During an interview on 1/31/24 at 2:15 P.M. the Director of Nursing said the following: -The CNAs are to complete a shower sheet and give to the nurses when they complete a shower; -There is a shower schedule set for each hall with assigned rooms; -Resident's in each room should be given a shower at least two times a week; -Showers should be given at least two times a week. -She would expect the staff to provide a shower or bath according to the resident's preferences; -The nurses are to check the shower sheets daily to verify that the resident's have received their showers. MO229329

Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; and using speech, language or other functional communication systems; -The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy Resident Rights, dated 6/2023, showed the following: -The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice; -The resident has a right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has the right to be informed of, and participate in, his or her treatment, including the right to participate in the development and implementation of his or her person-centered plan of care; -The resident has the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 1. Review of the facility's undated Shower Schedule Sheet showed the following: -Resident #8's shower days were Mondays and Thursdays; -Resident #9's shower days were Wednesdays and Saturdays; -Resident #10's shower days were Sundays and Wednesdays; -Residents have the right to choose to shower, bathe, or have a bed bath; -Residents have the right to choose the day and time most convenient for themselves; -Residents may bathe as frequently or infrequently as they choose; -The director of nursing (DON) may adjust the schedule to accommodate individual resident needs; -If no preference is made, then the proposed schedule should be followed. 2. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Care Plan for Rehabilitation Services dated 1/18/24 showed the following: -The resident requires rehabilitation services at this time: -The resident will meet therapy goals for improved functional status; -Assist the resident with completing ADLs and encourage to be as independently as safely possible. -No evidence of documentation of preferences for shower/bath day or frequency noted. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/24/24 showed the following: -The resident admitted to the facility on [DATE]; -Diagnoses of fractured hip, neurogenic bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), and arthritis; -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Preference for bathing, taking a shower or a tub bath, very important; -Dependent upon staff for bathing; -Requires maximum assistance of staff for turning side to side; -Has an indwelling catheter (a tube placed in the bladder to drain urine to a bag) and frequently incontinent of bowel. During an interview on 1/31/24 at 9:27 A.M. Resident #10 said the following: -He/She has been at the facility for over a week and yesterday was the first day that he/she has had a bed bath; -He/She would prefer to have a shower, but has sutures in his/her right leg that cannot get wet; -His/Her last bath was 1/12/24, which was at home prior to him/her falling and breaking his/her hip; -He/She would prefer to have a bath at least every other day, but knew that would not be possible due to the facility not having enough help, so he/she would settle on at least two per week. Review of the resident's medical record from 1/18/24 through 1/31/24 showed no documentation staff assisted the resident with a bed bath or shower. 2. Review of the Resident #8's face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident was his/her own responsible person; -The resident had diagnoses that included fracture of left humerus (left upper arm) , and cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of the left upper limb. Review of the resident's entrance tracking record MDS dated [DATE], did not show any pertinent information regarding the resident. Review of the resident's care plan, dated 1/29/24, showed the following: -The resident was at risk for altered activities of daily living (ADL) function secondary to left elbow surgical procedure; -Assist in completing ADL tasks each day; -No evidence of documentation of preferences for shower/bath day or frequency noted. During an interview on 1/30/24 at 11:04 A.M. and 1/31/24 at 1:55 P.M. and 3:25 P.M., the resident said the following: -On 1/30/24, the resident said he/she had not had a shower since admitting to the facility, but was supposed to get one this afternoon; -He/she was worried about body odors; -On 1/31/24 At 1:55 P.M., the resident said he/she did not get a shower yesterday and had not had a shower yet today; -He/She should be able to get a shower regularly; -On 1/31/24 at 3:25 P.M., staff asked the resident if he/she wanted a shower but but the resident was too tired at that time due to therapy. Review of the resident shower sheets showed no documentation the resident received a bed bath or shower from 1/26/24 through 1/31/24. 3. Review of Resident #9's initial MDS dated [DATE], showed the following: -The resident admitted to the facility on [DATE]; -The resident was cognitively intact; -The resident did not reject cares; -The resident required substantial/maximum assistance from two or more staff for bathing, rolling side to side, rising from a sitting to standing position and toileting; -The resident made himself/herself understood and understood others; -The resident had diagnoses that included chronic kidney disease, kidney transplant, klebsiella pneumonia (healthcare associated pneumonia), respiratory failure, cystitis with hematuria (bladder infection with blood in the urine), and bacteremia (bacteria in the blood). Review of the resident's care plan, dated 1/16/24, showed the following: -The resident required rehabilitation services to complete activities of daily living and encourage to be as independent as safely possible; -The resident was at risk for altered ADL function secondary to deconditioning, history of falls, and decreased endurance. Assist in completing ADL tasks each day; -No evidence of documentation of preferences for shower/bath day or frequency noted. During an interview on 1/30/24 at 2:43 P.M. the resident said the following: -He/She has only had two showers since being admitted on [DATE]; -He/She would like at the very least one shower a week. Review of the resident shower sheets showed no documentation the resident received a bed bath or shower from 1/13/24 through 1/31/24. During an interview on 1/31/24 at 2:16 P.M. Certified Nurse Aide (CNA) B said the following: -Residents have designated shower days; -If a resident refused a shower the resident signed their shower sheet. During an interview on 1/31/24 at 2:03 P.M. Licensed Practical Nurse (LPN) A said the following: -The CNAs are to completed a shower sheet and give it to the nurses; -There is a schedule for what rooms get a shower each day on the day shift and the evening shifts; -Once the shower is complete, the CNAs give the shower sheets to the nurses to check and sign that the shower is complete and any issues are addressed; -He/She does not verify the shower sheets to the schedule to ensure that everyone has had a shower. During an interview on 1/31/24 at 2:15 P.M. the Director of Nursing said the following: -The CNAs are to complete a shower sheet and give to the nurses when they complete a shower; -There is a shower schedule set for each hall with assigned rooms; -Resident's in each room should be given a shower at least two times a week; -Showers should be given at least two times a week. -She would expect the staff to provide a shower or bath according to the resident's preferences; -The nurses are to check the shower sheets daily to verify that the resident's have received their showers. MO229329

Based on interviews, record review, and review of facility policy the facility failed to ensure that baseline care plans were developed and/or presented to the resident and/or the responsible party within 48 hours of admission for 13 residents (Resident (R) 1, R83, R90, R14, R15, R20, R30, R3, R4, R18, R29, R134, and R135) reviewed for baseline care plans. The census was 38. Findings include: Review of the facility policy titled ''Base Line Care Plans'' with a revision date of [DATE] read in part ''.To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The resident and their representative will be provided a summary of the baseline care plan .'' 1. Review of R1's undated ''Face Sheet,'' located in the resident's electronic medical records (EMR) section titled ''Face Sheet,'' revealed the resident was admitted on [DATE] with diagnoses that included displaced fracture of right lower leg, diverticulitis of large intestine, morbid obesity, chronic obstructive disease, chronic embolus, and urinary tract infection. Review of R1's ''Five Day Minimum Data Set'' (MDS) with an Assessment Reference Date (ARD) [DATE] revealed R1 had Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident's cognition was intact and able to make decisions regarding care. Review of R1's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence a baseline care plan was developed and shared with the resident within the first 48 hours of admission. During an interview on [DATE] at 4:15 PM, R1 did not recall receiving a care plan within 48 hours of admission to the facility. 2. Review of R83's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed R83 was admitted to the facility on [DATE] with diagnoses that included left artificial hip joint replacement surgery; acute resp failure with hypoxia, chronic obstructive pulmonary disease, and urinary tract infection. Review of the resident's admission 'MDS'' with an ARD of [DATE] located in the resident EMR section titled ''MDS revealed the resident had a BIMS score of 13 out of 15 indicating the resident's cognition was intact. The resident required supervision to partial assistance with ADLs; continent B&B; no falls or PUs, surgical wound; resident takes opioid, antibiotic, diuretic, anticoagulant medications. Review of R83's ''Care Plan'' located in the resident's EMR section titled ''Care Plan'' revealed the care plan was initiated [DATE] identifies the resident had a nutritional deficit problem. The care plan was later revised on [DATE] to reflect the following concerns memory/recall problems related to environmental changes interventions included ensure assistive devices available and in good working condition; ensure resident's area is free of environmental hazards. Further review of the EMR lacked evidence that a baseline care plan including healthcare information necessary to properly care for R83 was developed and shared with the resident within the first 48 hours of admission. During an interview on [DATE] at 11:10 AM, R83 revealed she was admitted two weeks ago but did not remember receiving a care plan that detailed her identified care needs within the first two days of her admission. R83 stated she attended a care plan meeting a few days ago but the facility never gave her a copy of her care plan to keep. 3. Review R90's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed R90 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, COVID acute resp disease, anxiety disorders, mitral valve insufficiency, chronic kidney disease and fall history. Review R90's admission MDS'' located in the resident's EMR section titled ''MDS'' revealed the MDS was not yet completed. Review of R90's ''Functional ''Abilities Assessment '' dated [DATE] located in the resident's EMR section titled ''Observations'' revealed R90 was alert and oriented; was incontinent of bladder and continent of bowel; resident required isolation due to positive COVID currently asymptomatic; dependent on staff for toileting with setup and supervision with other ADLs. Review of R90's ''Care Plan'' initiated [DATE] located in the resident's EMR section titled ''Care Plans'' identified potential discharge to the community and resident at risk for psychosocial issue secondary to change in condition/inability to return home/life change and other. The care plan did not address the resident being in isolation and the affect it would have on his diagnosis of anxiety. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. During an interview on [DATE] at 2:15 PM, with R90 and family member (F90), R90 stated he was not sure about the base line care plan. F90 stated they had not received a copy of the care plan for R90. 4. Review of R14's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed R14 was admitted to the facility on [DATE] with diagnoses that included fracture to neck of the femur, hemiplegia and hemiparesis, seizures, emphysema, peripheral vascular disease, chronic obstructive disease, moderate protein calorie malnutrition and chronic viral hepatitis C, and urinary retention. Review of R14's admission MDS'' with an ARD of [DATE] located in the resident's EMR section titled ''MDS'' revealed R14 had a BIMS score of nine out of 15 which indicated the resident had impaired cognition and some difficult making decisions. Review of R14's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 5. Review of R15's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed R15 was admitted to the facility on [DATE] with diagnoses that included non-displaced fracture of the right acetabulum; multiple rib fractures, fracture right pubis; right clavicle fracture, Parkinson disease, chronic kidney disease stage III; urinary retention, urinary tract infection, adult failure to thrive, and fall history. Review of the resident's admission MDS'' with a ARD of [DATE] located in the resident's EMR section titled ''MDS'' revealed the resident had a BIMS score of nine out 15 indicating the resident had impaired cognition and difficulty making some decisions. The resident was totally dependent on staff for all areas of care. The resident had a foley catheter and was incontinent of bowel. The resident did not have pressure ulcers on admission but was at risk for pressure ulcer development. The resident had falls with fractures prior admission to the facility. Review of R15's ''Care Plan'' dated [DATE] located in the resident's EMR section titled ''Care Plan'' identified the resident at risk for pressure ulcers related to immobility. Care plan dated [DATE] resident has catheter secondary to urinary retention. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 6. Review of R20's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed the resident was admitted to the facility on [DATE] with diagnoses that included displaced fracture of lateral malleolus of left fibula and open fracture; post hemorrhagic anemia. diabetes mellitus type II; morbid obesity; anxiety disorder; chronic kidney disorder; bladder neck obstruction; and dysphagia. Review of R20's admission MDS'' with an ARD of [DATE] located in the resident's EMR section titled ''MDS'' revealed the resident had a BIMS score of 13 out 15 indicating the resident's cognition was intact and was able to make decision regarding care. The resident required assistance with ADLs, incontinent of bladder and bowel. The resident sustained falls before and after admission to the facility. The resident had one unstageable pressure ulcer upon admission; the resident received daily insulin injections and received daily antidepressant, antipsychotic, and opioid medications. Review of R20's ''Care Plan'' with an initiated date of [DATE] located in the resident's EMR section titled ''Care Plans'' revealed the resident was identified at risk for falls; skin breakdown; dementia; use of psychotropic medications, nutritional status and use of indwelling catheter. The care plan was revised to reflect a recent fall. Further review of the EMR lacked evidence that a baseline care plan was developed and shared with the resident or responsible party within the first 48 hours of admission. 7. Closed record review of R30's undated ''Face Sheet,'' located in the resident's EMR section titled ''Face Sheet,'' revealed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal bleed; atrial fibrillation; diabetes mellitus, coronary artery disease, end stage renal disease with dialysis, anxiety disorder and dislocated right hip. R30 expired on [DATE]. Review of R30's admission MDS'' located in the resident's EMR section titled ''MDS'' revealed the assessment of the MDS was still progress. Review of R30's ''Nurses Notes,'' dated [DATE] and located in the resident's EMR section titled ''Progress Notes,'' documented the resident returned to the facility with a foley catheter and was placed on hospice. Review of R30's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 30347 8. Review of R3's undated ''Face Sheet,'' located in the electronic medical record (EMR) under the ''Face Sheet'' tab, revealed R3 was admitted to the facility on [DATE] with diagnoses which included right femur fracture, retention of urine, protein-calorie malnutrition. Review of R3's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 9. Review of R4's undated ''Face Sheet,'' located in the EMR under the ''Face Sheet'' tab revealed R4 was admitted to the facility on [DATE] with diagnoses which included acute cystitis, type 2 diabetes mellites, heart disease. Review of R4's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 10. Review of R18's undated ''Face Sheet,'' located in the EMR under the ''Face Sheet'' tab, revealed R18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, type one diabetes mellitus, anemia, acute kidney failure. Review of R1's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 11. Review of R29's undated ''Face Sheet,'' located in the EMR under the ''Face Sheet'' tab, revealed R29 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, adult failure to thrive, altered mental status, chronic diastolic heart failure. Review of R1's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 12. Review of R134's undated ''Face Sheet,'' located in the EMR under the ''Face Sheet'' tab, revealed R134 was admitted to the facility on [DATE] with diagnoses which included right femur fracture, anemia, anxiety, lymphedema, asthma. Review of R1's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. 13. Review of R135's undated ''Face Sheet,'' located in the EMR under the ''Face Sheet'' tab, revealed R135 was admitted to the facility on [DATE] with diagnoses which included cardiac arrhythmia, occipital neuralgia, type 2 diabetes mellitus, acute kidney failure. Review of R1's EMR section titled ''Care plan revealed a care plan with an initiated date of [DATE]. Further review of the EMR lacked evidence that a baseline care plan was shared with the resident or responsible party within the first 48 hours of admission. During an interview on [DATE] at 2:20 PM, the Director of Nursing (DON) revealed the base line care plans were completed by the floor nurse. The DON stated the base line care plan was reviewed with the resident and/or resident's responsible party in a ''Welcome Meeting'' that was held 72 hours after the resident's admission to the facility. The DON stated the base line care was to be offered to the resident in the meeting. Sometimes the resident or representative will take the copy and sometimes they will refuse it. The DON stated there was no documentation of the ''Welcome Meeting,'' or other documentation to show families/residents were given the baseline care plans.

Based on observation, interview, and review of facility policy the facility failed to maintain a clean environment for one of two residents (Resident (R )90) in contact isolation from a sampled 15 residents. The census was 38. Findings include: Review of the facility policy titled ''Handling Soiled Lined'' with a revision date June 2023 stated ''. Used or soiled linen shall be collected at the bedside (or point such as dining room) and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed and securely placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.'' Observation on 11/29/23 at 9:10 AM of R90's room revealed R90 in droplet/contact isolation for positive COVID diagnosis. In the resident's bathroom one large yellow plastic bag filled with dirty linen and a large blue bag also filled with dirty stained linen was sitting on the floor next to the shower. There was a strong urine and fecal odor in the bathroom. The trash can by the resident's room door was overflowing with used personal protective equipment (gowns, gloves, blue face masks, and N95 face mask). Interview on 11/29/23 at 9:53 AM with Housekeeper (HSK)1 revealed housekeeping staff emptied resident's trash cans daily. However, the nursing staff were responsible for removing the dirty linen from the resident's room every shift. Interview on 11/29/23 at 8:30AM with Certified Nursing Assistant (CNA)7 revealed the nursing staff was responsible for removing dirty linen each shift from the resident's room. Interview on 11/29/23 at 9:00 AM with the Infection Preventionist (IP) revealed the nursing staff was responsible for removing the dirty linen from the resident's room. IP confirmed the accumulation of dirty linen in R90's room.

Based on interview and record review the facility failed to ensure one resident (Resident #1) in a review of three sampled residents, was free from abuse when Certified Nurse Aide (CNA) A picked the resident up out of bed with his/her arms and aggressively transferred the resident from the wheelchair to the toilet, causing the resident to hit his/her back and head. The resident reported pain at the time and continued pain after the incident. The resident reported feeling helpless and was afraid of CNA A. The facility census was 29. Review of the facility policy for Abuse, Neglect and Exploitation dated 10/22 showed: -It is the policy of this facility to provide protections fro the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; -Neglect means failure to the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of Resident #1's baseline care plan dated 6/6/23 showed: -The resident requires physical assistance of one staff member for toileting; -Requires extensive assistance of two staff members for transferring. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 6/8/23 showed: -Resident was admitted to the facility on [DATE]; -Alert and able to answer questions appropriately; -Able to make self understood and understand others; -Diagnoses of periprosthetic fracture (A periprosthetic hip fracture is a broken bone that occurs around the implants of a total hip replacement); -Requires extensive assistance of one staff person for bed mobility, dressing and personal hygiene; -Requires extensive assistance of two staff persons for transfers and toilet use; -Balance is not steady moving from a seated to standing position, transfer between the bed and chair to wheelchair; -Has an impairment of the lower extremities on one side; -Uses a wheelchair and walker for mobility; -Has severe pain and requires medication. During an interview on 6/14/23 at 10:30 A.M. the resident said the following: -Sometime during the evening on 6/9/23, between 7:00 P.M. and 10:00 P.M. or so, he/she rang his/her call light to go to the bathroom. CNA A came into his/her room and seemed rushed and angry and was mumbling under his/her breath; -When CNA A moved him/her from the bed to the wheelchair, CNA A wrapped his/her arms around his/her shoulders, picked him/her up and sat him/her hard down into the wheelchair; -CNA A took him/her into the bathroom and put his/her hand on his/her upper arm area, picked him/her up and threw him/her onto the toilet; -As a result, he/she hit his/her back and the back of his/her head; -He/She still has some pain in his/her back from this; -When CNA A threw him on the toilet, he/she called out in pain and said You are too rough!, the aide just shrugged his/her shoulders and said Oops and walked out the room; -He/She rang his/her call light to get off the toilet, CNA A came back into the room and picked him/her up by his/her arms and put him/her in the wheelchair, then picked him/her up by the arms and put him/her back in bed; -He/She has a lot of pain in his/her leg due to a broken bone in the hip that cannot be repaired; -CNA A hurt his/her arms and back; -CNA A did not use a gait belt to transfer him/her, he/she grabbed him/her by the arms; -He/She does not want CNA A back in his/her room and is afraid of CNA A; -He/She did not say anything when it happened, as he/she was afraid of CNA A and does not want any retaliation against him/her or his/her family; -On 6/10/23 when CNA B came in and said he/she was going to take care of him/her, he/she was relieved and told CNA B that he/she was glad CNA A was not working; -He/She told CNA B that CNA A had been rough with him/her the night before and hurt him/her. During an interview on 6/14/23 at 10:30 A.M. the resident's Family Member A said: -Resident #1 called him/her on 6/9/23 after the incident happened; -The resident was very upset and said that he/she was afraid of CNA A and did not want him/her to take care of him/her again; -He/She and the resident reported the incident on 6/10/23 to CNA C, who told him/her that he/she needed to file a report with management and that he/she had received several complaints about CNA A being rough with other residents; -On 6/11/23 the Director of Nurses (DON) came to see them and talk with them about what happened on 6/9/23. During an interview on 6/14/23 at 1:30 P.M. CNA B said the following: -On 6/10/23 the resident said he/she did not want CNA A to take care of him/her again; -The resident said CNA A was very rough with him the night before, the aide had transferred him/her very aggressively and slammed him/her into the toilet and hit his/her back. During an interview on 6/15/23 at 11:15 A.M. Licensed Practical Nurse (LPN) A said the following: -On 6/10/23 CNA B told him/her that Resident #1 did not want CNA A taking care of him/her; -The resident said CNA A had manhandled him/her, threw him/her onto the toilet and hurt him/her; -When LPN A went to the resident' room to make a report, the resident was sitting on the side of the bed and said he/she felt helpless and did not want CNA A to take care of him/her again; -LPN A considered what the resident told him/her described abuse. During an interview on 6/14/23 at 10:00 A.M. the DON said the following: -She had come in to relieve LPN A from duty on 6/11/23 around 7:00 A.M.; -LPN A told him/her Resident #1 told CNA B on 6/10/23 on the evening shift CNA A had thrown him/her onto the toilet on 6/9/23; -She interviewed the resident who said that sometime after 7:00 P.M. and before midnight, he/she had rang his/her call light to ask for assistance from the bed to the bathroom. CNA A came into him/her room to assist the resident. CNA A seemed rushed and angry, CNA A roughly transferred the resident into the wheelchair without using a gait belt, then threw the resident onto the toilet causing the resident to hit his/her back and the back of his/her head. The resident said CNA A said whoops and left the bathroom. The resident put his/her call light on when he/she was finished. CNA A returned and in a rushed manner put the resident back to bed. When she asked the resident what he/she meant by throw onto the toilet, the resident said CNA A bear hugged him/her and threw him/her onto the toilet; -At the time that the incident was reported, she felt this was a customer service concern. She was unaware that the resident said he/she was afraid of CNA A. During an interview on 6/14/23 at 9:36 A.M. the Administrator said the following: -Resident #1 alleged CNA A threw him/her onto the toilet; -The incident occurred on the night shift on 6/9/23; -He would have expected the staff to report the incident to the DON or himself immediately. MO219823

Based on interview and record review the facility failed to provide treatment and monitoring to promote healing for one resident with pressure ulcers and wounds (Resident #5). Resident #5 was admitted to the facility with a Stage III pressure ulcer on 1/27/21. The facility did not obtain or provide treatment to the pressure ulcer until 2/4/21. The wound deteriorated. The resident was hospitalized on [DATE] with deep tissue, unstageable, wounds to the right heel, right buttocks, right lateral foot, right leg and thigh, left mid spine, and left ankle. The resident also had unstageable wounds to the right ankle. These wounds were not identified or treated by the facility. A sample of five residents and six closed records were selected for review. The facility census was 16. Review of the facility's policy titled, Wound and Skin Care, revised 3/24/21, showed the following: -Purpose: To prevent injury formation by identifying those residents who are at risk for pressure ulcer injury and to develop appropriate interventions. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of pressure injury in a cost efficient and timely manner; -The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure injury, and identify related causes and complications; -A Braden Scale should be completed for all residents upon admission, readmission, then weekly times four weeks and as needed when a significant change of condition occurs; -Identified risk factors should be discussed and addressed in the resident's plan of care to assure appropriate interventions to manage the risk are implemented; -Residents with a Braden Score of 12 or less should be considered at high risk for pressure ulcer injury development; -Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure injury; -Nurse aides should assess residents' skin when providing bath/shower and performing routine cares and report any impairments to the charge nurse for appropriate follow up; -Any skin impairments, including pressure injury, non-pressure injury ulcers, surgical wounds, skin tears, abrasions, etc, should be assessed and documented weekly by a licensed nurse, or designee on the weekly skin assessment form. Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, a description of any drainage, eschar, necrosis, odor, tunneling or undermining; -The physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment; -Residents with wounds should be reviewed during the weekly Risk Management Committee meetings for progress, interventions, and care plan revision as appropriate; -A weekly wound report should be completed by the Director of Nursing, or designee, on a weekly basis for review and monitoring by the Interdisciplinary Team to assure the objectives of this policy and procedure are being met. 1. Review of Resident #5's admission skin assessment, dated 1/27/21, showed the following: -The resident had an alteration in skin integrity; -Open area to left buttock, 3.2 cm by 4.0 cm. The wound was beefy red. Review of the resident's admission progress note, dated 1/27/21 at 1:20 P.M., showed the resident had altered skin integrity to his/her left buttock, an open area that measured 3.2 cm by 4.0 cm. The wound was beefy red. Review of the resident's Braden Score, dated 1/27/21, was 13, indicating moderate risk for pressure ulcer development. Review of the resident's Physician Order Sheet (POS) for January 2021 showed no treatment orders for the resident's pressure ulcer. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 2/3/21, showed the following: -admitted [DATE]; -Diagnoses included heart disease, diabetes, malnutrition, and septicemia (the clinical name for blood poisoning by bacteria); -Cognition was intact; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling urinary catheter; -Frequently incontinent of bowel; -At risk for pressure ulcers; -One Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) (Staff identified this wound on admission as an open area to the resident's left buttock) present on admission.) Review of the resident's skin assessment, dated 2/3/21, showed the resident had a wound to his/her coccyx that measured 5.4 cm by 4.2 cm (Staff identified this wound on admission as an open area to the resident's left buttock). There was no documentation in the resident's record the physician was notified of the resident's deteriorating wound or of orders being obtained to treat the wound. Review of the resident's POS for February 2021 showed an order dated 2/4/21 to cleanse the open area on the buttock with wound cleanser and cover with a dry dressing every night. Review of the resident's nutritional assessment, dated 2/4/21, showed the following: -Wounds were present; -Nutrition risk triggers related to increased energy and protein needs associated with chronic illness, pressure ulcers and wounds on feet; -Continue with current diet and monitor intake. There was no documentation found on the resident's record regarding wounds to his/her feet as mentioned in the nutritional assessment on 2/4/21. Review of the resident's care plan, dated 2/6/21, showed the following: -The resident was admitted with a pressure injury to the buttock related to immobility and weakness; -Administer treatments as ordered and monitor for effectiveness; -Braden Scale weekly for four weeks; -Follow facility protocols/policies for the prevention/treatment of skin breakdown; -The resident had actual impairment to skin integrity of the buttocks and was at risk for other skin breakdown; -Pressure relieving/reducing mattress to protect the skin while in bed; -Pressure relieving/reducing mattress to protect the skin while up in chair; -The care plan did not identify any wounds on the resident's feet or treatment for the wounds on the feet. Review of the resident's progress note, dated 2/9/21 at 3:54 P.M. showed the resident had a urinary catheter and was incontinent of bowel. The resident had a wound on his/her coccyx (tailbone) and the dressing was changed that day. Review of the resident's skin assessment, dated 2/10/21, showed the resident had a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) Staff identified this wound on admission as an open area to the resident's left buttock and was identified on the resident's admission MDS as a Stage III pressure ulcer. There was no documentation showing the pressure ulcer to the resident's coccyx was healing and it had increased in size considerably and was darker in color since it was first identified. There was no documentation found in the resident's record the physician was notified of the resident's deteriorating wound or any other newly acquired wounds. Review of the resident's Braden Score, dated 2/10/21, was 13, indicating moderate risk for pressure ulcer development. Review of the resident's progress note, dated 2/12/21 at 6:15 P.M. showed the Nurse Practitioner (NP) was in the facility and gave a new order to cleanse the open area to the buttock with wound cleanser, apply hydrogel (wound dressing, when applied to dry wounds, can make and keep them clean by promoting the removal of infected or necrotic tissue) and foam-type dressing three times a week. Review of the resident's progress note, dated 2/13/21 at 1:48 P.M. showed the resident's wound on his/her coccyx was cleansed with wound cleanser and Medihoney (a mixture of two honeys containing compounds which contribute to its antibacterial activity) was applied with a dry dressing. The nurse would have the NP look at the wound to see if he/she wanted to change the order for a new dressing. Review of the resident's record showed there was no order in place for Medihoney to the resident's coccyx wound. There was no documentation found in the resident's record he/she had any wounds, other than the wound to his/her coccyx. There was no evidence found in the resident's record the facility followed their policy of completing a weekly wound report for the resident. Review of the resident's progress note, dated 2/16/21 at 9:00 A.M. showed the resident was sent to the emergency room for evaluation and treatment due to change in condition. Review of the resident's history and physical from the hospital, dated 2/16/21, showed the following: -The resident presented from the nursing home with complaints of hypotension (low blood pressure); -The resident arrived to the emergency room with blood pressure of 49/32 (normal blood pressure for an adult is 120/80) and required intravenous Levophed (a vasoconstrictor, similar to adrenaline, used to treat life-threatening low blood pressure; -Assessment and Plan: low blood pressure secondary to sepsis. Continue intravenous fluids and admit to the Intensive Care Unit; -Sepsis with septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention) with acute organ dysfunction. Continue intravenous fluids and Levophed drip. Blood cultures pending. Start intravenous vancomycin and cefepime (antibiotics). Review of the resident's wound consult from the hospital, dated 2/17/21, showed the following: -The wound Registered Nurse (RN) was consulted for the resident's multiple wounds which were present on admission; -The resident had multiple wounds to his/her back, buttocks, and bilateral lower extremities; -Most wounds appeared new as deep tissue injuries that were still evolving; -These wounds may develop into Stage III or Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers as they evolve; -The resident's entire buttock was broken down and both posterior thighs have linear markings, possibly from a bed pan; -Deep tissue injury (When there isn't an open wound, but the tissues beneath the surface have been damaged, the sore is called a deep tissue injury (DTI). The area of skin may look purple or dark red, or there may be a blood-filled blister) to the resident's middle back; -Both feet with multiple pressure injuries; -Triad cream (Zinc-oxide based hydrophilic paste for light-to- moderate levels of wound exudates. Helps maintain an optimal wound healing environment) applied to buttock wound; -Feet in boots for offloading; -Pressure redistribution mattress; -On frequent turning schedule; -Care concerns discussed with Social Service. Review of the resident's wound assessment, completed in the hospital, dated 2/17/21 at 3:00 P.M., showed the following: -Unstageable pressure ulcer (The base of the wound is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The base of the wound cannot be visualized to determine the stage) to the resident's right lateral ankle. With black eschar (Necrotic tissue or eschar consists of an accumulation of dead cells, tissue and cellular debris. Removal of wound eschar through appropriate debridement techniques (surgical or medical) is a prerequisite for the wound healing processes to start). The wound measured 1.5 centimeters (cm) in length by 1.5 cm in width and zero depth; -Suspected deep tissue injury pressure ulcer to the resident's right heel that measured 2.0 cm by 2.0 cm by zero depth. The wound bed was black and deep purple. The surrounding skin was boggy. The wound was dressed with a silicone dressing (dressings coated with soft silicone as an adhesive or a wound contact layer. These are designed to absorb exudate and maintain a moist wound bed to facilitate fast healing); -Suspected deep tissue injury pressure ulcer to the resident's buttocks that measured 15 cm by 15 cm by zero depth. The wound bed was deep pink, burgundy, and yellow. The wound was dressed with a hydrophilic dressing (hydrophilic wound dressing is indicated for the local management of pressure and venous stasis ulcers, dermal lesions/injuries, superficial wounds, scrapes, first-and second-degree burns, partial-and full-thickness wounds); -Suspected deep tissue injury pressure ulcer to the resident's right lateral foot that measured 2.0 cm by 2.0 cm by zero depth. The wound bed was burgundy and the wound was left open to air; -A second suspected deep tissue injury pressure ulcer to the resident's right lateral foot that measured 1.5 cm by 1.5 cm by zero depth. The wound bed was burgundy and the wound was left open to air; -An unstageable pressure ulcer to the resident's left ankle that measured 1.0 cm by 1.0 cm by zero depth. The wound bed was black eschar. The wound was dressed with a silicone dressing; -A suspected deep tissue injury pressure ulcer to the resident's right lateral leg that measured 4.0 cm by 1 cm by zero depth. The wound bed was burgundy. The wound was dressed with a silicone dressing; -A suspected deep tissue injury pressure ulcer to the resident's upper back that measured 6.0 cm by 3.0 cm by zero depth. The wound bed was burgundy. The wound was dressed with a foam dressing. Review of the resident's hospital discharge summary, dated 3/1/21, showed the resident arrived to the hospital from the nursing home on 2/16/21 with multiple medical problems and was admitted to the Intensive Care Unit for septic shock. The resident was found to have enterococcus fecalis (bacterium inhabiting the gastrointestinal tracts of humans) bacteremia (the presence of bacteria in the blood), likely source was urinary with multiple urinary tract infections over the last six months and possibly from the wounds the resident had. During an interview on 3/30/22 at 2:15 P.M. Licensed Practical Nurse (LPN) A said if a resident was admitted with wounds or a wound was found for a resident, facility staff obtain measurements and document an assessment of the wound. Specialized Wound Management (SWM) does see the resident's with more severe wounds weekly. The facility staff complete weekly wound rounds as well and keep and document their own assessments and measurements. During an interview on 4/12/22 at 11:15 A.M. the Director of Nurses (DON) said she expected staff to call and get an order for treatment if they identify a resident has a wound. Staff should complete and document a full assessment of the wound, including measurements, weekly. Staff should notify the physician if a wound was not improving. During an interview on 4/18/22 at 4:21 P.M. Resident #5's physician said he/she would have expected staff to obtain treatment orders for Resident #5's buttock pressure ulcer as soon as it was identified and to complete the treatment as ordered. The physician would have expected facility staff to have identified any additional wounds and to have completed assessments of these wounds to include measurements for Resident #5. The physician did not find any additional documentation for Resident #5's wounds, other than the pressure ulcer to his/her buttocks. Resident #5's multiple wounds could have contributed to his/her diagnosis of septic shock, but the resident was clinically complex and had multiple contributing factors related to his/her decline in addition to his/her skin issues. Resident #5 had been septic in the past prior to admission to the facility. During an interview on 4/25/22 at 9:30 A.M. the administrator said she expected staff to conduct a skin assessment for residents upon admission and to obtain treatment orders for any identified skin issues from the physician and to complete the treatments as ordered. Staff should complete weekly skin assessments for all residents and document assessments of any skin issues to include descriptions and measurements of any wounds. The administrator expected staff to identify any newly developed skin issues and to document an assessment and to obtain treatment orders and complete the treatments as ordered. Staff, whether it be an aide or therapy staff, who identify a skin concern should report this to the charge nurse right away so a full assessment could be completed and treatment orders obtained.