Every finding on record at Sunterra Springs Springfield

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner to prevent possible contamination when staff failed to wash hands and change gloves appropriately during food prep and service, and when staff failed to cover food on a rack. The facility was census was 37. 1. Review of the facility's policy titled, Maintaining a Sanitary Tray Line, revised April 2025, showed the following: -This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness; -During tray assembly, staff shall use utensils such as tongs and serving spoons to handle food as much as possible; -Wear gloves when handling food items, particularly when direct contact between the hands and food occurs or when handling ready-to-eat foods such as salads, fruits, sandwiches, bread; -Use gloves that fit properly; -Wash hands before and after wearing or changing gloves; -Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the work station; -Change gloves after sneezing, coughing, or touching face, hands, or hair with gloved hand. Review of the facility's policy titled, Handwashing Guidelines for Dietary Employees, revised April 2025, showed the following: -Handwashing was necessary to prevent the spread of bacteria that may cause food borne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in sinks used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste; -Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles; after hands have touched anything unsanitary such as garbage, soiled utensils/equipment, dirty dishes, etc.; and before donning gloves for working with food; Review of the facility's policy titled, Dietary Employee Personal Hygiene, revised April 2025, showed the following: -It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by food service employees; -Hands must always be washed after using the restroom, eating or drinking, using tobacco products, coughing, sneezing, blowing nose, before putting on gloves, after removing gloves and after engaging in other activities that contaminate the hands; -Employees should never use bare hand contact with any foods, read-to-eat or otherwise. Observation on 05/27/25, at 11:49 A.M., showed the following: -The Dietary Manager (DM) donned gloves, picked up a scoop to serve chicken salad on a plate, used his/her gloved hands to pick up crackers, touched the diet card, and picked up lettuce by hand and placed it on the plate; -The DM picked up a scoop for the chicken salad and placed it on a plate, opened a bag of crackers, and placed several crackers by hand on the plate; -The DM picked up a small bowl, used a scoop and spooned out mandarin oranges, and picked up a spatula to pick up a cookie; -The DM used his/her gloved hands to open up the cooler by the handle, pick up a diet card, pick up a spoon to serve oranges, and then picked up lettuce by hand and placed it on a plate; -The DM used his/her same gloved hand to pick up a scoop and spoon out chicken salad. The DM picked up several crackers by hand and placed them on a plate; -DM used his/her same gloves hands to open the warmer by the handle, took out a bowl, picked up lettuce by hand, and placed the lettuce on a plate. The DM scooped up chicken salad and placed it on a plate. The DM picked up several crackers by hand and placed them on a plate. Observations on 05/27/25, at 12:15 P.M., showed the following: -Dietary Aide (DA) S donned gloves and picked up lettuce by hand and placed it on a plate, used a scoop to pick up chicken salad and placed it on a plate, and picked up several crackers by hand and placed them on a plate; -The DA used his/her same gloved hands and picked up a plate, picked up lettuce, scooped chicken salad and placed them on a plate. The DA picked up several crackers by hand, scooped oranges, touched a cookie with his/her hand, and placed them on a plate; -The DA used the same gloved hands and picked up a plate, picked up lettuce by hand and placed it on the plate, picked up a scoop to get chicken salad, picked up several crackers by hand, scooped oranges into a bowl, and picked up a diet card and placed, the diet card and plate in the serving window; -The DA used the the same gloved hands and touched the warmer handle, took a food item out, opened the cooler to get out a cold item, wiped his/her pants with his/her gloves, and touched a plate, diet card. The DA then picked up lettuce by hand and placed it on a plate, scooped chicken salad, picked up crackers by hand, and placed them on on plate, scooped oranges into a bowl and placed the plate and diet card in the serving window; -The DA used the same gloved hands to open the warmer by the handles, picked up a grilled cheese sandwich by hand, with his/her gloves picked a cookie, and placed them on the plate; -The DA used the same gloved hands and picked up lettuce by hand and placed it on a plate, scooped chicken salad and placed it on plate, opened a package of crackers and picked up several crackers by hand, and placed them on a plate. Observations on 05/28/25, at 11:46 A.M., showed the following: -DA Q donned gloves and picked up a plate and hamburger bun by hand and placed on a plate. He/she used tongs to pick up a hamburger and placed on the bun; -The DA used his/her gloved hands and picked up lettuce, onion, and tomato by hand and placed them on the hamburger. He/she picked up a bowl and used tongs to scoop cole slaw into the bowl; -The DA used his/her same gloved hands and picked up a plate warmer lid, a plate, and a hamburger bun by hand. The DA used tongs and picked up a hamburger and placed on the bun. He/she used the same gloved hands to pick up lettuce, onion, tomato, a diet card, and placed them vegetables on the plate and the card in the serving window; -The DA used his/her gloved hands to open the warmer and got out a bowl of soup, picked up a hamburger bun by hand, used tongs to pick up a hamburger, picked up lettuce, tomato, and onion by hand, and placed them on the hamburger; -The DA used his/her gloved hands to open the warmer and shut the door with a food item, picked up a plate, picked up a hamburger bun by hand, used tongs to pick up a hamburger, and placed it on the hamburger bun. The DA then picked up lettuce, tomato and onion by hand and placed them on the hamburger. Observations on 05/29/25, at 8:34 A.M., showed the following: -DA Q stood at the dishwasher. He/she donned gloves and dumped water from a pan and ran the a rack through the dishwasher. He/she doffed gloves, did not wash his/her hands, and touched clean covers for plates and placed them on the rolling cart; -The DA did not have gloves on and placed dirty dishes on the dishwasher rack. He/she washed his/her hands and donned gloves. He/she moved the rack through the dishwasher and placed his/her hands on the dirty dishes on the rack. He/she doffed his/her gloves and did not wash his/her hands, picked up a clean tray, and placed it on the counter. The DA then picked up two clean cookie sheets and took them to the back preparation area. -The DA donned gloves and dumped a tub with dish soap and placed rack in the dishwasher, doffed his/her gloves, did not wash his/her hands, and put away clean plate covers. During an interview on 05/29/25, at 11:47 A.M., Dietary Aide R said the following: -Staff wear gloves the entire time during serving the first hall and staff change into a new pair of gloves after serving the first hall; -Staff should change gloves from dirty to clean tasks; -Staff should hand wash in between changes of gloves and in between ready to eat food and touching other items. During an interview on 05/29/25, at 02:23 P.M., [NAME] P said staff should wash hands before and after donning gloves and when touching food. During an interview on 05/29/25, at 12:50 P.M., DA Q said the following: -Staff should change gloves between serving each hall; -Staff wear the same gloves during meal serving times; -Staff wear the same gloves after touching the warmer handle and ready to eat food; -Staff should wash hands after changing gloves before putting away clean dishes. During an interview on 05/29/25, at 12:35 P.M., the DM said the following: -Staff should wash hands before serving food and before and after glove changes; -Staff should change gloves after serving the first hall trays; -Staff should change gloves when they touch the handle of an equipment and then touch ready to eat food; -It would take several hours if staff washed hands and changed gloves in between, but should not wear gloves the whole time of serving. During an interview on 05/30/25, at 8:47 A.M., the Administrator said the following: -She excepted staff to change gloves in between dirty to clean tasks; -She expected staff to wash hands after removing gloves; -She expected staff to wash hands when working with dirty and clean dishes. 2. Review of the facility's policy titled Food Preparation Guidelines, revised April 2025, showed the following: -It was the policy of the facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status; -Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This included, but is not limited to storing food in a manner to minimized exposure to light and air. Observation and interview on 05/28/25, at 11:46 A.M., showed the following: -A large pan on a rack in between the back area preparation station and serving area with a dessert on it that was not covered; -DA S said the dessert on the rack was apple cobbler that he/she made it yesterday. He/she put it on the cooling rack and sometimes places parchment paper on it. He/she leaves the cobbler open to air and to cool; -The dessert was left to cool on the rack until the next day. Observation on 05/29/25, at 8:26 A.M., showed approximately eight cookies on a pan on a rack not covered. At 9:38 A.M., showed the cookies remained uncovered. Observations on 05/29/25, at 9:45 A.M., showed the following: -Two large rectangular pans of macaroni sat on the two vat sink uncovered in the back preparation area; -A pan of chicken sat in the back area on the preparation table uncovered in a shallow pan on top of ice. At 11:40 A.M. showed the chicken remained uncovered. During an interview on 05/29/25, at 11:47 A.M., DA R said the following: -Staff should cover desserts and it should not be left uncovered on the rack all night; -Food should be covered. During an interview on 05/29/25, at 02:23 P.M., [NAME] P said the following: -He/she did not cover the macaroni and chicken in the pans because they were cooling; -The apple cobbler was not covered and it sat out on the rack overnight; -Staff should cover the dessert if it is out all night. During an interview on 05/29/25, at 12:50 P.M., DA Q said staff prepare desserts the day ahead and leave them out on the rack uncovered to keep down the moisture. During an interview on 05/29/25, at 12:35 P.M., the DM said the following: -Food code says to cover food, but leave a corner open for cooling; -The cookies on the rack should be covered. The desserts were on the rack all night. During an interview on 05/30/25, at 8:47 A.M., the Administrator said she expected staff to cover food.

Based on record review and interview, the facility failed to ensure the facility implement their abuse and neglect policies when staff failed to complete a criminal background checks (CBCs) for one of ten sampled employees prior to their hire/start date in a facility with a census of 37. Review of the facility's policy, Abuse, Neglect and Exploitation, revised April 2025, showed the following: -It is the policy of this facility to provide protections for 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; -Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property; -Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants; -Screenings may be conducted by the facility itself, third-party agency, or academic institution; -The facility will maintain documentation of proof that the screening occurred. 1. Review of Licensed Practical Nurse (LPN) O's employee record showed his/her hire date and start date was 02/22/24. The facility did not documentation of a CBC check completed for the LPN. During an interview on 05/29/25, at 9:23 A.M., the Administrator said the following: -She started at the facility March 2024; -The staff member who was responsible for the CBCs was no longer employed with the facility and was not available for interview; -Facility staff interview potential employees and enter information in the corporate system; -When staff interview a potential employee, they send information to corporate human resource staff who complete the required background checks and it is maintained in the employee file; -The new hired employee should not start until all background checks are completed and in the system; -She did not find LPN O's CBC. During interviews on 05/30/25, at 10:00 A.M., and on 06/02/25, at 10:06 A.M., the Director of Nursing (DON) said the following: -New employees should not start working on the floor until all background checks are completed; -The facility did not not have LPN O's CBC.

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to follow Enhanced Barrier Precautions (EBP-infection control measures used to reduce transmission of resistant organisms) while providing wound care for three residents (Resident #2, #197, and #14) and when staff failed to place a protective barrier beneath supplies in two resident rooms (Resident #197 and #14). The facility census was 37. Review of a facility policy titled Enhanced Barrier Precautions, dated April 2025, showed the following: -It is the facility policy to implement EBP for the transmission of multi-drug resistant organisms (MDRO); -All staff receive training on EBP upon hire and at least annually, and are expected to comply with all designated precautions; -An order for EBP will be obtained for residents with wounds, medical devices, and infection with an MDRO; -Personal protective equipment (PPE) for EBP is only necessary when performing high-contact activities; -The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine need for additional training and education; -High-contact resident activities include dressing, bathing, transferring, hygiene care, changing linens or briefs, device care or use, and wound care; -EBP should be used until resolution of the wound or discontinuation of the indwelling medical device. Review of the Centers for Disease Control and Prevention's Implementation of PPE Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of PPE (personal protective equipment) and the availability of PPE and hand hygiene supplies at the point of care; -MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities; -Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs; -Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, and tracheostomy/ventilator, and wound care of any skin opening requiring a dressing. Review of the facility policy titled Standard Precautions Infection Control, dated April 2025, showed all staff are to assume that all residents are potentially infected with an organism that could be transmitted while providing resident care services. All staff should adhere to standard precautions to prevent the spread of infection to residents, staff, and visitors. 1. Review of Resident #2's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 05/02/25; -Diagnoses included atrial fibrillation (irregular heart beat), hematuria (blood in urine), pleural effusion(buildup of fluid between the tissues that line the lungs and the chest), and high blood pressure. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 05/06/25, showed the following: -Resident's cognition was in tact and resident was interviewable; -Resident had one Stage 2 (partial thickness loss of dermis) pressure ulcer upon admission. Observations on 05/28/25, at 9:25 A.M., showed the resident in bed. The Licensed Practical Nurse (LPN) H (wound nurse) entered the resident's room, laid two paper towels down on the resident's bedside table, used hand sanitizer, and put on gloves. The LPN did not put on a protective gown for EBP. The LPN proceeded to remove the dressing on the resident's coccyx (tailbone), where there was a Stage II pressure ulcer. He/she did the wound care and then provided incontinence care to the resident before washing hands, removing gloves, and leaving the room. During an interview on 05/29/25, at 4:28 P.M., LPN H said the following: -He/she had EBP training last year; -Staff were to wear a gown with gloves in the rooms for residents with foley urinary catheters, wounds, IV's, and a mask if on respiratory isolation; -He/she should have worn a gown for any treatments of wounds and pressure ulcers like the resident's. 2. Review of the Resident #197's face sheet showed the following: -An admission date of 04/24/25; -Diagnoses included intestinal obstruction (blockage that prevents normal bowel movement) and diabetes mellitus (chronic condition that results in too much sugar in the blood). Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact and had a surgical wound. Review of the resident's care plan, revised 05/06/25, showed the resident had a wound to the abdomen and was on EBP. During an observation on 05/28/25, at 2:42 P.M., LPN H enter the resident's room to provide wound care. LPN H set a basket containing supplies on the resident's bedside table without placing a protective barrier underneath. LPN H then placed paper towels on the bedside table and removed supplies from the basket to place on top. LPN H sanitized hands and applied gloves but did not don a gown. LPN H provided wound care and then removed gloves. After removing gloves and throwing trash away, LPN H sanitized his/her hands and picked up supply basket. LPN H then exited the room and placed the basket of supplies on top of the treatment cart without sanitizing the basket. The resident did not have an enhanced barrier precautions sign posted outside of the room door. 3. Review of the Resident #14's face sheet showed the following: -An admission date of 05/02/25; -Diagnoses included multiple sclerosis (disorder in which the body's immune system attacks the nerve cells), Parkinson's disease (a movement disorder of the nervous system that worsens over time), and retention of urine. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact and had an indwelling catheter. Review of the resident's care plan, revised on 05/05/25, showed the resident had a suprapubic catheter and was on EBP. During an observation on 05/29/25, at 1:25 P.M., LPN I entered the resident's room to provide catheter care. LPN I placed supplies on the resident's bedside table without placing a protective barrier. LPN I then sanitized his/her hands and placed gloves on but did not don a gown. LPN I provided catheter care to resident and threw supplies in trash. LPN I then removed gloves, sanitized hands, and left the room. The resident had an EBP sign outside the room. 4. During an interview on 05/29/25, at 3:02 P.M., Certified Nursing Assistant (CNA) J said he/she was unsure what EBP was, but there were signs in front of the resident rooms for it. EBP would be for residents on chemotherapy or with an infection. The sign outside the door would let someone know what type of PPE to use. During an interview on 05/29/25, at 3:16 P.M., CNA E said EBP were used for any resident with a catheter, IV, or wound. There was a sign on the front of the resident's room that indicated EBP, and the nurse advised which residents were on EBP in report. Staff should wear a gown and gloves when providing personal care to a resident on EBP. Residents #14 and #197 were both on EBP. During an interview on 05/29/25 at 3:24 P.M., Registered Nurse (RN) C said EBP was for a resident with an infection, catheter, or a wound. Staff should wear a gown and gloves for personal resident contact. There should be an EBP sign on the resident door. Staff should wear a glove and gown for any wound or catheter care. Supplies should be placed on a barrier in the resident room during wound care. During an interview on 05/30/25, at 10:12 A.M., the Assistant Director of Nursing (ADON) said EBP was for residents with wounds and tubes. Staff should wear gloves and gowns when caring for residents on EBP. There should be a sign on the door that indicated EBP. During an interview on 06/02/25, at 8:45 A.M., LPN G said EBP was used for residents with catheters, wounds, or ports. EBP was used to prevent bacteria from entering the body. Staff should wear gloves and gowns when in close contact with a resident on EBP. Would care supplies should be placed on a barrier in resident's room. During an interview on 06/02/25, at 10:22 A.M., the Director of Nursing (DON) said EBP were for residents with an infection or medical device. Medical devices wound include a drain, catheter, or intravenous (IV) line. Residents should have a sign on the door indicating EBP. There should be an order for EBP, and it should be included on care plan. Staff should wear a gown and gloves when coming into direct contact with the resident on EBP. Wound care supplies should be placed on some type of barrier in the resident room. During an interview on 06/02/25, at 12:20 P.M., the Administrator said staff should follow infection control guidelines including EBP.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment when staff failed to keep non-food contact surfaces of the floor, stove, warmer, and can opener clean and well maintained in the kitchen. The facility census was 37. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -The physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled, Sanitation Inspection, revised April 2025, showed the following: -It is the policy of the facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations; -All food service areas shall be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. 1. Observations on 05/27/25, at 11:49 A.M., on 05/28/25, at 8:50 A.M., and on 05/29/25, at 8:26 A.M., of the kitchen showed the following: -The sides of the stove and oven had a black and brown greasy substance present; -The sides of the grill had an accumulation of grease; -The warmer by the steam table had a hard substance on the top and bottom handles and brown splatters on the front and sides; -The floor underneath the steam table had crumbs present; -The rack with pots and pans by the exit door had crumbs and a black substance under it and along the wall and corner; -The can opener had a black sticky substance around the bottom; -The floor in the back preparation area, under the preparation table, had crumbs, four dishes, and small pieces of paper present; -Along the walls of the kitchen by the dry storage door and walk in refrigerator to the back preparation area had a black substance around the wall areas; -The floor behind the ice machine had a black substance and crumbs present. During an interview on 05/29/25, at 12:23 P.M., [NAME] P said the following: -Dietary staff have assignments of cleaning duties; -Staff should sweep and mop the kitchen floors. During an interview on 05/29/25, at 12:50 P.M., Dietary Aide S said the following: -Staff clean the warmer weekly; -The cook cleans the oven one time per week. During an interview on 05/29/25, at 12:35 P.M., the Dietary Manager said the following: -Kitchen staff use the cleaning schedule; -Staff clean the oven and warmer weekly; -Staff mop twice per day; -Staff should clean the can opener in the dishwasher everyday; -The floors had a black substance; -The can opener had a black substance around the bottom of it; -The floor in the back preparation area had a black substance and crumbs. During an interview on 05/30/25, at 8:47 A.M., the Administrator said the following: -Staff should mop and sweep the kitchen floor; -Staff should clean the appliances in the kitchen; -The can opener should be cleaned.

Based on interview, and record review, the facility failed to ensure each resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record when staff did not update the care plan for one resident (Resident #36) and when the physician did not date the code status form for one resident (Resident #140) out of a sample of two residents. The facility census was 37. Review of the facility's policy titled, Communication of Code Status, revised [DATE], showed the following: -It was the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -When an order is written pertaining to a resident's presence or absence of an advance directive, the directions will be clearly document in designated sections of the medical record. Review of the Missouri Transportable Physician Orders for Patient Preferences (TPOPP) form showed the following: -Area for resident's name, resident's signature or resident representative's signature, address, and phone number; -Area for authorized healthcare provider's signature with date, phone number, and physician printed name. 1. Review of Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of [DATE]; -Diagnoses included congestive heart failure (CHF - chronic condition in which the heart does not pump blood as well as it should), high blood pressure, and diabetes mellitus; -The resident's code status was not listed. Review of the resident's TPOPP form showed the following: -Do not attempt resuscitation marked; -The resident signed the form; -The physician signed and dated the form on [DATE]. Review of the resident's current Physician Order Sheet (POS) showed an order, dated [DATE], for Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped)). Review of the resident's care plan, revised on [DATE], showed the resident wished to be a full code (receive CPR). During an interview on [DATE], at 12:20 P.M., Licensed Practical Nurse (LPN) G said the resident signed the code status form on [DATE] for a DNR code status and was a full code status on [DATE]. The resident's care plan showed full code and should match throughout the medical record. During an interview on [DATE], at 12:27 P.M., the Care Plan Coordinator said the resident's care plan should had been changed from a full code status to a DNR code status. 2. Review of Resident #140's face sheet showed the following: -admission date of [DATE]; -readmission date of [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease that blocks airflow and makes it difficult to breathe) and essential hypertension (high blood pressure). Review of the resident's TPOPP form showed the following: -Do not attempt resuscitation was marked; -Comfort-focused treatments was marked; -The resident signed the form; -The resident's physician's signed the form. The physician did not date the form. Review of the resident's current POS, dated [DATE], showed the resident's code status as DNR. Review of the resident's care plan, dated [DATE], showed a code status of DNR. During an interview on [DATE], at 03:00 P.M., the Director of Nursing (DON) said the physician should date the code status form. The physician's signature is already on the code status copies and it is a wet signature. Staff make copies of it to have for residents to sign. The physician reviews code status forms when he comes to the facility. During interviews on [DATE], at 2:35 P.M., and on [DATE], at 12:20 P.M., LPN G said the physician did not electronically sign the resident's code status yet. 3. During an interview on [DATE], at 02:07 P.M., Registered Nurse (RN) F said the following: -The admitting nurse completed the code status with new admissions; -Residents or representatives mark CPR or DNR on the form; -Full code means give CPR and DNR means do not resuscitate; -The code status book is located at the nurses' desk; -He/she thought staff sent the form to the physician for signature. He/she did not know for sure how the physician received the form to review and sign; -DNR is considered a physician order and the physician should sign and date the form; -The date showed the physician acknowledged the code status form. During interviews on [DATE], at 2:35 P.M., and on [DATE], at 12:20 P.M., LPN G said the following: -The admitting nurse completed the code status with new admissions; -Full code status meant staff initiated CPR if a resident stopped breathing or the heart stopped; -DNR code status meant staff did not resuscitate and allow natural death; -The code status form had an option for CPR or DNR and comfort type measures; -The resident or representative signed the form and the admitting nurse placed the form in the code status book; -The physician came to the facility weekly for rounds and signed the form; -Staff give the physician a list of all new admissions and the physician reviews the code status book and signs the forms for any new admissions since his last visit; -The code status form is considered a physician order; -Corporate enters physician orders of new admissions which the facility nursing staff will review; -Code status should match throughout the medical record; -The form should be dated. It is a physical representation of what is in the computer; -Any staff can update the care plan; -The Care Plan Coordinator checks the filter on care plans for updates. During an interview on [DATE], at 3:16 P.M., Certified Nurse Aide (CNA) E said the following: -A resident was full code when they are admitted until the code status papers are signed; -Staff have a resident code status book at the nurses' station that staff refer to; -The nurse advised the aides if a resident code status changes. During interviews on [DATE], at 3:24 P.M., and on [DATE], at 2:37 P.M., Registered Nurse (RN) C said the following: -A resident's code status was listed in the chart and on the report sheet; -The DNR order should have a resident and physician signature and should be dated; -The form should indicate a date for accuracy. Some of the ones at the facility are dated and some are not. During an interview on [DATE], at 3:57 P.M., the Director of Nursing (DON) said the following: -The admitting nurse reviewed the code status with residents upon admission; -Residents were admitted as a full code status unless they come with a DNR order; -Staff check a resident's code status which in the the binder located at the nurses' station or in the computer system if a resident is found unresponsive; -The form should be dated to know the residents' current wishes; -The code status forms in the binder are suppose to be a quick visual when staff check a residents' code status. During an interview on [DATE], at 12:27 P.M., the Care Plan Coordinator said the following: -She reviewed the computer dashboard/communications every morning for any changes and reviews the last 24 hours and updates the care plan; -She reviews the code status book and current physician orders if a code status has changed and changes the care plan once she finds all are correct; -A resident's code status should match throughout the medical record; -She reviews code status with residents during care plans to verify their current code status wishes; -Residents or a representative talks to the nurse if they want a code status changed; -Nurses can update care plans also and staff communicate daily in morning meetings of any changes to a resident's plan of care. During an interview on [DATE], at 4:15 P.M., the Physician said the form should be dated to show current wishes for a resident's code status. During an interview on [DATE], at 12:48 P.M., the Administrator said the following: -She expected the physician to date the code status form to represent the most updated code status; -She expected staff to update the care plan if a resident's code status changed from full code to DNR; -The resident's code status should match throughout the medical record.

Based on observation, record review, and interview, the facility failed to ensure care was provided in accordance with standards of practice when staff failed to consistently document full assessments of a wound, failed to document physician notification of wound deterioration and resident refusals of treatment, failed to maintain a current and accurate wound care plan, and failed to fully document regarding new wounds and failed to document physician notification of new wounds for one resident (Resident #37). The facility also failed to failed to monitor blood glucose level four times daily per physician's order for one resident (Resident # 197). The facility census was 37. 1. Review of the facility's policy titled, Documentation of Wound Treatments, revised April 2025, showed the following: -The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment; -Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates; -The following elements are documented as part of a complete wound assessment; -Type of wound (pressure injury, surgical, etc) and anatomical location; -Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury), or the degree of skin loss if non-pressure (partial or full thickness); -Measurements including height, width, depth, undermining (destruction of tissue or ulceration extending under the skin edges (margins)), and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Description of wound characteristics including color of the wound bed, type of tissue in the wound bed (granulation, slough (non-viable, yellow, tan, gray, green or brown tissue), eschar (dead tissue that is hard or soft in texture), epithelium (thin tissue forming the outer layer of a body's surface)), condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated), presence, amount, and characteristics of wound drainage/exudate, presence or absence of odor, and presence or absence of pain; -Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (clean, dry, intact); -Additional documentation shall include, but is not limited to, date and time of wound management treatments, weekly progress towards healing and effectiveness of current intervention, any treatment for pain, if present, modifications of treatments or interventions and notifications to physician and/or responsible party regarding wound or treatment changes. Review of the facility's policy titled, Wound Treatment Management, revised April 2025, showed the following: -To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record. Review of the facility's policy titled, Notifications of Changes, revised April 2025, showed the following: -The purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification. Review of Resident #37's face sheet (admission data) showed the following: -admission date of 12/06/24; -Diagnoses included cellulitis (skin infection) of groin, malignant neoplasm of vulva (type of cancer on the outer surface area of genitals) and essential hypertension (high blood pressure). Review of the resident's admission orders from the discharging hospital, dated 02/27/25, showed the following: -Active hospital problems included wound cellulitis and squamous cell carcinoma of vulva; -An order for lidocaine 4% cream (anesthetic cream), apply to affected area two times daily as needed (PRN). Review of the resident's progress note dated 02/27/25, at 4:10 P.M., showed Licensed Practical Nurse (LPN) G documented the following -The resident was transferred from the hospital; -Foley catheter (a flexible tube used for various medical purposes, most commonly to drain urine from the bladder) required due to cancerous lesion to the right groin; -Dressing to right groin changed during skin assessment. Moisture associated skin disorder (MASD-skin breakdown) noted to buttocks. Review of the resident's Physician Order Sheet (POS), dated 02/27/25, showed the following: -An order, dated 02/27/25, for staff to apply lidocaine-prilocaine (to cause numbness or loss of feeling before certain medical procedures or prevent pain) external cream 2.5-2.5%, apply to around right groin lesion topically every 12 hours as needed for wound care; -An order, dated 02/27/25, for lidocaine external cream 4% apply to around right groin lesion topically every 12 hours PRN for pain. Review of the resident Admit/Readmit assessment dated [DATE], at 4:15 P.M., showed LPN G documented the following: -Open areas and MASD; -Coccyx had MASD; -Groin had cancer lesion; -Cancerous lesion to right groin with open deep wound to area. MASD to buttocks. Barrier applied as needed; -Treatments as prescribed. Review of the resident's Care Plan, initiated 02/27/25, showed the following: -The resident had an actual skin impairment/wound to his/her right groin; -In house wound care provider to assess and treat; -Treatments as prescribed. (Staff did not document regarding the identified MASD to buttocks) Review of the resident's nurses note dated 02/28/25, at 12:33 A.M., showed a nurse documented daily skilled assessment completed. The resident's dressing to the right groin wound was dry and intact. The resident was on Cefidinir (can treat bacterial infections) for cellulitis to right groin wound. Review of the resident's skilled evaluation dated 02/28/25, at 6:35 A.M., showed a nurse documented the following: -Skin warm and dry; -Skin color within normal limits; -Right groin open area oozing yellowish discharge. (Staff did not document notification of the physician regarding the discharge of the wound.) Review of the resident's telehealth physician visit, dated 02/28/25, showed the following: -New admission for skilled nursing services following hospitalization for cellulitis of groin wound; -The resident is currently being treated by oncology for vulvar cancer; -Groin wound secondary to vulvar cancer; -Continue current treatment, reports resident is well managed. (The visit did not address the new drainage from the wound or the areas of MASD identified.) Review of the resident's skilled evaluation dated 03/03/25, at 3:35 A.M., showed a nurse documented the resident's right groin had moderate amount of serous (clear, watery fluid found in the body) drainage and treatment in place. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitive skills intact; -The resident was dependent on staff with toileting, shower/bathing, sit to stand, and transferring from chair to bed; -Surgical wound; -MASD. Review of the resident's physician visit, dated 03/04/25, showed the resident was seen for oral sores post chemotherapy. The resident was in the facility to regain strength then will continue chemotherapy/radiation as managed by oncology/gynecology. Staff to continue current wound care. (The visit notes did not address the wound drainage or the MASD previously identified.) Review of the resident's skin only evaluation dated 03/05/25, at 3:09 A.M. and noted as a late entry, showed LPN H (wound nurse) documented the following: -Skin warm and dry; -Skin color within normal limits (WNL); -Mucous membranes moist, turgor (the skin's elasticity) was normal; -Surgical wound to right groin (no measurements documented) with serosanguineous (thin, watery, pale, red/pink drainage) wound exudate; -Peri wound condition noted as maceration (the softening and breakdown of the skin due to prolonged exposure to moisture); -Dressing saturation was moderate 26-75%; -No odor present; -No tunneling; -No undermining; -Tissue was painful, mushy and cool; -Surgical wound healing, intact, and well approximated; -Right groin cavity deep from surgical cyst removal. Review of the resident's nurses note dated 03/05/25, at 3:22 A.M., showed it was labeled as completed and showed the resident on alert charting for antibiotic treatment for cellulitis to the right groin wound bed. Staff completed the dressing change after it got soiled during an incontinent episode. Staff irrigated the resident's right groin open area with sterile normal saline (NS) and sterile abdominal (ABD) gauze pads (used to absorb discharges from abdominal and other heavily draining wounds) and placed over the site to assist with containing the drainage. (Staff did not document the physician notification regarding the condition and new order.) Review of the resident's nurse's note dated 03/05/25, at 10:44 P.M., showed a nurse documented the resident was on alert charting for antibiotic treatment until 03/09/25 for cellulitis to the right groin cancerous lesion. The resident was to start on Diflucan every other day (QOD), three doses for the yeast build up in the wound and surrounding perineal areas. Review of the resident's skilled evaluation dated 03/06/25, at 4:10 A.M., showed a nurse documented the resident had an open lesion to his/her right groin that continuously drained yellow to brown discharge. Mild irritation and redness to buttocks. Resident currently on antibiotics for cellulitis to the right groin. Review of the resident's physician order dated 03/06/25, at 11:41 A.M., showed an order for wound care to cleanse and irrigate wound to right groin with wound cleanser and pat dry. Apply nystatin cream to peri wound, and cover area with ABD and tape. Review of the resident's March 2025 TAR showed an order, dated 03/06/25, for wound care to cleanse and irrigate wound to right groin with wound cleanser and pat dry. Apply nystatin cream to peri wound. Cover area with ABD and tape every shift. Review of the resident's nurse's note dated 03/06/25, at 11:09 A.M., showed Registered Nurse (RN) C documented an antibiotic note. Wound to right groin was red with increased warmth to surrounding area and inflamed. Nystatin cream applied related to yeast around and in wound bed. The resident also received Diflucan every other day, three doses to treatment yeast build up. Staff irrigated the resident's wound cavity. (Staff did not document regarding notification of the physician regarding the wound change.) Review of the resident's nurses note dated 03/07/25, at 12:00 A.M., showed a nurse documented the resident was on alert charting for antibiotic for right groin cancerous lesion. Staff changed the resident frequently due to the right groin lesion continuously draining yellowish brown discharge. (Staff did not document regarding notification of the physician regarding the wound drainage.) Review of the resident's physician's visit, dated 03/07/25, showed the following: -Resident continued on skilled nursing services for weakness and cellulitis of groin wound; -The resident currently treated by oncology for vulvar cancer; -Recent aggressive chemotherapy. The resident at the facility to regain strength, then will continue chemotherapy/radiation as managed by oncology/gynecology. Groin wound to continue current wound care. (The physician not did not address the wound drainage or yeast.) Review of the resident's nurses note dated 03/08/25, at 12:57 P.M., showed a nurse documented redness noted to peri-wound and moderate amount of clear drainage noted in the wound bed with tenderness to touch noted. (Staff did not document regarding notification of the physician regarding the wound drainage) Review of the resident's infection note dated 03/09/25, at 11:26 A.M., showed a nurse documented continued antibiotic for cellulitis to right groin wound bed with decreased redness noted to peri-wound and clear drainage noted in wound bed. Tenderness to touch noted. Review of the resident's March 2025 TAR showed the following: -An order, dated 03/06/25, for wound care to cleanse and irrigate wound to right groin with wound cleanser, ad pat dry. Apply nystatin cream to peri wound. Cover area with ABD and tape every shift; -Staff did not document the treatment completed on 03/10/25 (night shift). Review of the resident's medical record showed staff did not document notification of the physician regarding the treatment not administered. Review of the resident's nurse's note dated 03/12/25, at 2:17 P.M., showed a nurse documented the resident returned from his/her oncology/infusion appointment. The resident's family member related next follow up appointment with oncology and no new orders. Review of the weekly wound rounds dated 03/12/25, at 4:45 P.M., showed a nurse documented stable surgical incision of 8.2 cm in length by 3.1 cm in width by 5 cm in depth. (The nurse did not document any additional description of the wound.) Review of the resident's nurses note dated 03/13/25, at 12:09 A.M., showed a nurse documented the resident's wound to groin had quite a lot of green exudate. The resident was post antibiotic, but the wound was not cleared from infection. The nurse made doctors note. Review of the residents physician's visit, dated 03/14/25, showed the following; -Non resolving inguinal (groin) wound and Omnicef (cefdinir-antibiotic to treat infections) for cellulitis; -Right inguinal wound had mild serous drainage, no erythema (redness) or purulence noted; -Will order wet to dry dressing two times per day (BID) and continued Valacyclovir (treats infections), to follow up with oncology. Review of the resident's March 2025 TAR showed the following: -An order, dated 03/14/25, to cleanse and irrigate wound to right groin with wound cleanser, pat dry, pack cavity with dakins (topical antiseptic to clean and debride wounds) soaked gauze, and cover with ABD. Wet to dry dressing, every shift for wound care. Review of the resident's alert note dated 03/15/25, at 2:48 P.M. showed Registered Nurse (RN) C documented the following: -The resident refuses to follow orders for his/her wound care; -The resident did not want wet to dry dressing order; -The resident stated the doctor said to flush the wound out with tap water and then leave it open; -LPN educated the resident on wound care orders and accurate protocol for the wet to dry dressing order; -The resident was argumentative and agitated and stated he/she knew what to do. The resident said his/her other doctor said he/she could leave the wound open as well if he/she wanted; -The resident has ABD pads in reach for when he/she wants to cover the wound. (Staff did not document notification of the physician of the resident's refusal of the ordered treatment) Review of the resident's skilled evaluation dated 03/15/25, at 2:05 A.M., showed a nurse documented a skin note of groin wound to right of groin with wound bed white and yellow with serous drainage that soaks through ABD pads. The resident had fresh dressing this shift. (Staff did not document regarding notification of the physician of the wound drainage.) Review of the resident's March 2025 TAR showed the following: -On 03/16/25, (night) shift, staff did not document completion of the ordered treatment of the wound; -On 03/17/25, (day) shift, staff did not document completion of the ordered treatment of the wound. Review of the resident's medical record showed staff did not document notification of the physician regarding the treatment not administered. Review of the resident's current POS showed an order, dated 03/21/25, for right groin flush with NS, cover with ABD and secure two times a day for wound date. Review of the resident's March 2025 TAR showed an order, dated 03/21/25, for right groin to flush with NS, cover with ABD and secure as needed for wound care. Review of the resident's skilled evaluation dated 03/22/25, at 1:11 A.M., showed a nurse documented large wound to right groin with dressing changes daily. Buttocks, vulva, and groin all have yeasted skin. Resident currently on antibiotic amoxicillin for wound infection. (Staff did not document regarding notification of the physician of the resident's skin) Review of the resident's nurse's note dated 03/22/25, at 1:37 A.M., showed a nurse documented the resident returned to the facility as a new admission. The resident had a groin wound to his/her right groin. Review of the resident's admit/readmit assessment dated [DATE], at 4:02 A.M.,. completed by LPN G, showed the following: -Groin had opened are of 3 inches inches length by 2 inches in width by 5 inches in depth from cancer. -Resident expected to have surgery; -Followed by outside wound care provider; -Treatments as prescribed. Review of the resident's March 2025 TAR showed the following: -An order, dated 03/21/25, for right groin to to flush with NS, cover with ABD, and secure two times a day for wound care; -On 03/23/25, at 06:00 P.M., staff did not document treatment of the wound. Review of the resident's medical record showed staff did not document notification of the physician regarding the treatment not administered. Review of the resident's skin only evaluation dated 03/24/25, at 5:28 P.M., and noted as a late entry, showed LPN H documented the following: -Skin warm and dry; -Skin color WNL; -Mucous membranes moist, turgor normal; -Surgical wound; -Location: right groin; -No measurements; -No description of wound bed, wound exudate, peri wound condition, dressing saturation; -No odor present; -No tunneling; -No undermining; -Painful; -Tissue mushy and cool; -Surgical wound healing, intact, and well approximated; -Right groin cavity deep/moist buttocks red. Review of the resident's physician's telehealth visit, dated 03/25/25, showed the following: -Resident seen today for admission to the facility after recent hospitalization; -An MRI pending for left groin lymph node inflammation; -Cellulitis groin wound continues on antibiotic, resolving per patient; -Groin wound secondary to vulvar cancer, continue current treatment, reports patient is well managed. Review of the resident's March 2025 TAR showed on 03/27/25, at 06:00 P.M., staff did not document treatment of the wound. Review of the resident's medical record showed staff did not document notification of the physician regarding the treatment not administered. Review of the resident's physician's telehealth visit, dated 03/25/25, showed the following: -New admission following hospitalization -The resident was being treated by oncology for vulvar cancer; -Groin wound, secondary to vulvar cancer, continue treatment; -The resident reports it is well managed. Review of the resident's skilled evaluation dated 03/27/25, at 12:37 A.M., showed a nurse documented a skin note of maceration to the resident's bilateral buttocks has improved since start of zinc ointment. The cancer lesion to right groin oozing yellow drainage.(Staff did not document regarding physician notification of the wound drainage) Review of the resident's skilled evaluation dated 03/28/25, at 8:54 A.M., showed a nurse documented the following: -Skin note of right groin lesion with white slough in the wound bed. Staff irrigated the wound but the resident will not let staff touch anything on the inside. (Staff did not document regarding notification of the physician of the resident refusing treatment of the wound.) Review of the resident's March 2025 TAR showed on 03/30/25, at 6:00 P.M., staff did not document treatment of the wound. Review of the resident's medical record showed staff did not document notification of the physician regarding the treatment not administered. Review of the resident's skin only evaluation dated 03/31/25, at 4:49 P.M. and noted to be a late entry, showed LPN H documented the following: -Skin warm and dry; -Skin color WNL; -Mucous membranes moist, turgor normal; -Skin issue #1: surgical wound; -Location: right groin cavity; -No measurements; -Wound bed: slough; -Wound exudate serosanguineous (thin, watery, pale, red/pink drainage); -Peri wound condition: WNL; -Dressing saturation moderate: 26-75%; -No odor present; -No tunneling; -No undermining; -Firm, tissue cool; -Surgical wound healing and intact, well approximated. Review of the resident's March 2025 TAR showed on 03/31/25, at 6:00 P.M., staff did not document treatment of the wound. Review of the resident's skilled evaluation dated 04/02/25, at 2:18 A.M., showed a nurse documented skin note of the right groin open area with slight drainage. (Staff did not document regarding notification of the physician of drainage to the wound or any other details regarding the wound.) Review of the resident's nurse's note dated 04/03/25, 1:18 A.M., showed a nurse documented alert charting for antibiotic for wound groin. Surgery scheduled for 04/15/25 for debridement of the wound. Review of the resident's skilled evaluation dated 04/04/25, at 2:00 A.M., showed a nurse documented skin note of open wound to right groin. Staff changed the dressing. Wound is red around outside of wound. The resident limits how staff irrigates the wound. Staff applied the ABD to the wound. (Staff did not document regarding notification of the physician of the resident refusing wound treatments.) Review of the nurse practitioner's service notes, dated 04/04/25, showed the following: -Skin was pink, warm, and dry with dressing on right groin; -Medications, orders, notes, and chart reviewed; -The resident was on Cefdinir for cellulitis of his/her groin; -Wound care provider on board and wound had improved. Review of the resident's skin only evaluation full assessment dated [DATE], at 4:43 P.M., showed LPN H nurse documented the following: -Skin warm and dry; -Skin color WNL; -Mucous membranes moist, turgor normal; -Skin issue-surgical wound; -Location of right groin; -No measurements; -No odor present; -No tunneling; -No undermining; -Tissue was painful, firm, and cool; -Surgical wound healing intact and well approximated; -Skin issue #2 of MASD to both buttocks; -No odor present; -Tissue was mushy and cool; -Right groin open cavity from surgery and buttocks moisture from sweating on air mattress. Open spots to right buttock and shearing to left buttock. (Staff did not document physician notification of the open areas to right buttock and did not document measurement of the new areas.) Review of the resident's nurses note dated 04/08/25, at 2:54 A.M., showed a nurse documented the resident was alert and able to make his/her needs know. Staff changed the resident's dressing and an odor was noted from the wound. The resident refused irrigation of wound and will only allow the nurse to change the ABD pads. (Staff did not document regarding notification of the physician of the resident refusing treatment to the wound and an odor of the wound.) Review of the resident's nurse's note dated 04/08/25, at 2:56 A.M., showed a nurse documented resident alert and able to make needs known. Continued antibiotic for wound infection, dressing change, and odor noted from wound. Resident refuses irrigation of wound and only allows this nurse to change the ABD pads. (Staff did not document regarding notification of the physician of the resident refusing wound treatment or the odor.) Review of the resident's nurse practitioner's service notes, dated 04/08/25, showed the following: -Follow up visit for nausea and diarrhea; -Skin pink, warm dry, and dressing on the resident's right groin; -Resident is on cefdinir for cellulitis of groin, is improving. (The note did not address the open areas identified on the resident's buttocks.) Review of the resident's skilled evaluation dated 04/09/25, at 2:27 A.M., showed a nurse documented the following: -Skin issue #1-location vulva; -Groin issue type of cancer lesion deteriorating; -Wound characteristics deteriorated; -Partial or complete separation of the outer layers of the joined incision; -Red and bleeding surface or granulation tissue; -Odor increased; -Non healing; -Increased exudate; -Size has increased; -Slough 100%; -Exudate amount moderate; -Mixture of purulent and serous usually watery, yellow, green, tan or brown; -Nurse irrigated the resident's right groin wound, large amount of debris from wound yellow and white, thick, and foul smelling; -Resident could not tolerate to assess depth of wound. Cover with dry dressing. (Staff did not document regarding notification of the physician of the the decline of the wound or resident refusal of measurement of the wound.) Review of the resident's April 2025 nurse's note dated 04/10/25, at 1:49 A.M., a resident refused to have wound flushed with NS. (Staff did not document regarding notification of the physician of the resident refusing the wound treatment.) Review of the resident's skilled evaluation dated 04/10/25, at 2:40 A.M., showed a nurse documented the following: -The resident refused wound care treatment; -Skin issue #1-location vulva; -Groin issue type of cancer lesion deteriorating; -Wound characteristics deteriorated; -Partial or complete separation of the outer layers of the joined incision; -Odor increased; -Non healing; -Increased exudate; -Size has increased; -Slough 100%; -Exudate amount moderate; -Mixture of purulent and serous usually watery, yellow, green, tan, or brown; -Irrigated right groin wound, large amount of debris from wound yellow, green, tan or brown. Noted change in wound condition. (Staff did not document regarding notification of the physician of the wound condition change.) Review of the resident's nurse's note dated 04/10/25, at 12:15 P.M., showed Registered Nurse (RN) C documented the resident only allowed gentle flushing of wound and does not let staff clean out wound cavity. A foul odor noted to the wound. (Staff did not document regarding notification of the physician of the wound condition.) Review of the resident's nurse note dated 04/10/25, at 2:31 P.M., showed Licensed Practical Nurse (LPN) G documented the resident's family member informed staff of the resident's surgery date. On 04/14/25, the resident will have his/her left groin cancer lesion removed. The resident also had surgery date on 04/25/25 for his/her right groin cancerous lesion removed and open wound closed. Review of the resident's skilled evaluation dated 04/11/25, at 1:17 A.M., showed a nurse documented the following: -Skin issue #1-location vulva; -Groin issue type of cancer lesion deteriorating; -Wound characteristics deteriorated; -Partial or complete separation of the outer layers of the joined incision; -Smell increased; -Red and bleeding surface or granulation tissue; -Non healing; -Increased exudate; -Size has increased; -Slough 100%; -Exudate amount moderate; -Mixture of purulent and serous usually watery, yellow, green, tan or brown. (Staff did not document regarding notification of the physician of the wound condition.) Review of the resident's nurses note dated 04/11/25, at 11:52 A.M., showed RN C documented the resident had a cancerous wound to his/her right groin that was being treated twice daily. The resident only allowed staff to flush the area with saline and refused to let staff clean out the wound cavity. (Staff did not document regarding notification of the physician of the wound or resident refusal of full treatment.) Review of the resident's nurse practitioner's (NP) note dated 04/11/25, at 3:29 P.M., showed the following: -Staff asked the NP to see the resident due to white blood cell count. The resident did not let staff clean his/her wound. The wound was odiferous and looked like cauliflower. The wound seemed to be worsening. No increased erythema (redness of the skin or mucous membranes) down his/her leg but did have purulent drainage; -The resident is on Cefdinir; -The resident refuses to allow staff do anything but wash out the wound with saline. Wound care had recommended vashe (wound cleanser) cleanser twice a day but the resident again refused to allow staff to clean or pack the wound. Review of the resident's April 2025 nurse's note dated 04/12/25, at 4:52 P.M., showed RN C documented a foul odor noted to the resident's wound. The resident only allowed staff to flush the wound cavity. Large amounts of yellow discharge flushed out of the wound cavity. (Staff did not document regarding notification of the physician of the resident refusing wound treatment.) Review of the resident's nurses note dated 04/13/25, at 11:01 A.M. showed RN C documented the resident started Cipro (antibiotic) on 04/11/25 with end date of 04/21/25. Foul odor noted to wound. The resident only allowed staff to flush the wound cavity. Large amount of yellow discharge continuous to be flushed out of cavity. (Staff did not document regarding notification of the physician of the resident refusing wound treatment.) During an interview on 05/30/25, at 2:27 P.M., RN C said the following: -The resident had a large open cancerous wound. The only thing the resident allowed the staff to do was irrigate the wound and every once in awhile apply gauze and scrub with Q-tips; -On 04/10/25, he/she notified the physician or informed the wound nurse of the nurse's note on 04/10/25; -He/she informed the physician that the resident refused to let him/her use wound cleanser; -The resident said every time he/she went for an appointment, the wound was doing better and keep doing what the staff did; -The resident allowed him/her to put gauze on the wound and cover but the resident did not like it, had pain and wanted it left alone; -The wound nurse texted the providers with changes of the wound; -The resident's wound stayed consistent and got a little narrower; -The wound nurse completed a weekly skin assessment on residents; -Nurses should assess a resident's skin with the wound treatment and document assessment; -Nurses review the wound order and documents if any drainage and size of the wound; -Nurses should notify the physician or NP of any signs of infection; -Nurses should document in the computer of any notifications to the physician or NP; -The wound nurse is responsible for measuring wounds weekly; -Nurses complete the wound care treatments when the wound nurse is not at the facility; -Nurses should document on the wound assessment if a surgical wound, approximate of areas, drainage, signs of an infection, typically nurses do not measure every time a wound is assessed. During an interview on 05/29/25, at 2:53 P.M., and on 06/02/25, at 8:48 A.M., LPN H (wound nurse) said the following: -The resident had a surgical wound on his/her right groin and would not let staff touch it. The resident would not allow staff to clean it, or measure it for the depth. He/she kept an eye on the redness and how much the wound drained. -He/she did not document that the resident refused wound measurements or wound treatments. He/she informed the charge nurse and they should had informed the Director of Nursing (DON) and it goes from there; -The care plan sh

Based on record review and interview, the facility failed to obtain ensure catheter (a tube inserted into the bladder, allowing your urine to drain freely) use per standards of practice when staff failed to obtain a complete order indicating the size of the catheter used and a corresponding diagnosis and when staff failed to document monitoring and care of the catheter as ordered for one resident (Resident #14) out of a sample size of 13 residents. The facility census was 37. Review of a facility policy titled, Appropriate Use of Indwelling Catheters, dated May 2025, showed the following: -An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary; -It is the policy of the facility to ensure a resident admitted with a urinary catheter will be assessed for removal of the catheter unless the resident's clinical condition indicates catheterization is necessary; -The use of an indwelling catheter will be in accordance with physician orders and include the diagnosis or clinical condition making the use of a catheter necessary, size of the catheter and frequency of change. Review of the facility policy titled, Catheter Care, dated May 2025, showed the following: -Facility policy is to ensure 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; -Staff should document care and report any concerns noted. 1. Review of Resident #14's face sheet showed the following: -admission date of 05/02/25; -Diagnoses included multiple sclerosis (disorder in which the body's immune system attacks the nerve cells), Parkinson's disease (a movement disorder of the nervous system that worsens over time), and retention of urine. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/06/25, showed the resident was cognitively intact and had an indwelling catheter. Review of the resident's care plan, revised on 05/05/25, showed the following: -Resident had a suprapubic catheter secondary to multiple sclerosis; -Catheter care every shift and as needed; -Change catheter as prescribed; -Enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); -Monitor and document signs or symptoms of a urinary tract infection (UTI) and notify physician if present. Review of resident's current Physician Order Sheet (POS) showed the following orders: -An order, dated 05/02/25, to monitor urine for abnormal color, clarity, and odor, and if abnormal notify the physician, every shift; -An order, dated 05/02/25, to change the suprapubic catheter as needed (no diagnosis, size of catheter or balloon indicated); -An order, dated 05/02/25, for urinary catheter care every shift; -An order, dated 05/02/25, to apply a split sponge to suprapubic catheter every day shift. Review of resident's May 2025 Treatment Administration Record (TAR) showed the following: -Staff did not document catheter care provided as ordered on 05/04/25, 05/05/25, 05/12/25, and 05/17/25; -Staff did not document monitoring urine for abnormal color, clarity, and odor on 05/04/25, 05/05/25, 05/12/25, and 05/17/25. Observation and interview on 05/28/25 at 12:45 P.M. with Resident #14 showed a catheter in which the drainage bag was below waist level and placed in a dignity bag. Resident reported he/she used the catheter due to urine retention related to multiple sclerosis diagnosis. He/she was admitted to the facility from the hospital with the catheter in place. During an interview on 05/29/25, at 3:16 P.M., Certified Nurse Assistant (CNA) E said catheter care was completed every shift. CNA's do not chart catheter care. There is no area to chart catheter care is completed in CNA charting. During an interview on 05/29/25, at 3:24 P.M., Registered Nurse (RN) C said catheter orders should include type of catheter, diagnosis, size of catheter, and balloon size. The catheter should have an order to be changed every 30 days and as needed. During an interview on 05/30/25, at 10:12 A.M., the Assistant Director of Nursing (ADON) said there should be an order to change a resident's catheter every thirty days and as needed. A catheter order should include size of balloon and size. During an interview on 06/02/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said catheter orders should include type, size of catheter, and the milliliter (ml) size of the balloon. Corporate has an order set for residents with catheters, but nurses can change the orders to personalize per resident. Catheters are usually changed every 30 days, but it depends on if the urologist (physician that specializes in diseases related to the urinary system) indicates different orders. During an interview on 06/02/25, at 10:22 A.M., the Director of Nursing (DON) said catheter orders should include the size and indication for use. There should also be an order for catheter care. Most residents are not at the facility long enough to need the catheter changed. During an interview on 06/02/25, at 12:20 P.M., the Administrator said catheters should include all aspects of care in the order.

Based on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for one resident (Resident #142) out of a sample of four residents. The facility census was 37. Review of the facility's policy titled Oxygen Administration, revised April 2025, showed the following: -Oxygen is administered to residents who need it consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; -Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control; -Personnel authorized to initiate oxygen therapy include physicians, registered nurses, licensed practical nurses, and respiratory therapists. 1. Review of Resident #142's face sheet (a brief resident profile) showed the following: -admission date of 05/20/25; -Diagnoses include chronic obstructive pulmonary disease (COPD - lung disease that blocks airflow and makes it difficult to breathe) and essential hypertension (high blood pressure). Review of the resident's Physician Order Sheet (POS), dated 05/20/25, showed a current order for staff to assess oxygen every shift and administer oxygen at 0 to five liters per minute via nasal cannula. Staff may titrate flow to keep oxygen saturations above 90% every shift. Review of the resident's care plan, dated 05/20/25 showed the following: -The resident required respiratory support at this time secondary to pneumonia; -Notify provider of changes in respiratory status; -Oxygen as prescribed. Review of the resident's May 2025 Medication Administration Record (MAR) showed an order, dated 05/20/25, for staff to assess oxygen every shift and oxygen at 0 to 5 liters per minute via nasal cannula. Staff may titrate flow to keep oxygen saturations above 90% every shift. Review of resident's admission Minimum Data Set (MDS - federally mandated assessment tool completed by staff), dated 05/23/25, showed the resident's cognitive skills intact and resident received oxygen therapy. Observation and interview on 05/29/25, at 10:45 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident received oxygen per nasal cannula; -The resident said he/she was on continuous oxygen at six liters of oxygen per minute; -The concentrator was set at six liters of oxygen per minute;. Observation and interview on 05/30/25, at 10:32 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident said he/she had not been short of breath and is on six liters of oxygen; -Resident received oxygen per nasal cannula; -The resident said he/she was on continuous oxygen at six liters of oxygen per minute; -The concentrator was set at six liters of oxygen per minute During an interview on 05/30/25, at 10:45 A.M., the Care Plan Coordinator said the following: -Staff should notify the physician if a resident's oxygen is increased; -Physician orders should match what liters the oxygen is set on. During an observation and interview on 05/28/25, at 2:07 P.M., Registered Nurse (RN) F said the following: -Nurses receive report from the hospital of a resident's oxygen orders; -Nurses enter the order in the computer for how many liters of oxygen a resident is on; -The resident said the resident's oxygen was set at six liters. He/she received report from the hospital that the resident's order was six liters. During an interview on 05/30/25, at 9:45 P.M., RN C said the resident's oxygen orders should be for six liters if the resident is on six liters. During an interview on 06/02/25, at 10:06 A.M., the Director of Nursing said the following: -Nurses enter oxygen orders in the computer system; -The resident has an order for 0 to 5 liters; -Staff should have notified the physician to get an oxygen order for six liters; -The facility has standing orders for 0 to 5 liters. During an interview on 06/02/25, at 10:00 A.M., the Administrator said she expected staff to communicate to the physician if the resident's oxygen liters was on six liters and not 0 to 5 liters.

Based on interview and record review, the facility failed ensure pain services provided per standards of practice when staff failed to document providing appropriate pain medication to address pain in a timely manner for one resident (Resident #93) admitted from the hospital after knee replacement surgery. The facility census was 37. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders; -The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission; -The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Review of the facility's policy Pain Management, revised 04/2025, showed the following: -Acute pain refers to pain that is usually sudden in onset and time-limited with a duration of less than one month and often is caused by injury, trauma, or medical treatments such as surgery; -Chronic pain refers to pain that typically lasts greater than three months and can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or unknown cause; -Subacute pain refers to pain that has been present for one to three months; -Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; -Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs; -Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences; -Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to change in gait (e.g. limping), skin color, vital signs (increased heart rate, respirations, and/or blood pressure), perspiration; loss of function or inability to perform activities of daily living (ADLs); fidgeting, increased or recurring restlessness; facial expressions (grimacing, frowning, fright, or clenching of the jaw); behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities; difficulty eating or loss of appetite; weight loss; difficulty sleeping (insomnia); negative vocalizations (groaning, crying, whimpering, or screaming); decline in activity level; and skin conditions; -Facility staff will be aware of verbal descriptor a resident may use to report or describe their pain. Descriptors include but are not limited to heaviness or pressure, stabbing, throbbing, hurting or aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles, feeling rough, tearing, or ripping; -The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information as applicable to the resident such as history of pain and its treatment; asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual de scriptor that is appropriate and preferred by the resident; reviewing the resident's current medical conditions (pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post CVA (stroke), venous and arterial ulcers, and multiple sclerosis); identifying key characteristics of the pain: duration of pain, frequency, location, timing, pattern (constant or intermittent), radiation of pain; -Obtaining descriptors of the pain (stabbing, aching, pressure, spasms); identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain; impact of pain on quality of life (sleeping, functioning, appetite, and mood); current prescribed pain medications, dosage and frequency; and the resident's goals for pain management and his/her satisfaction with the current level of pain control; -Based upon the evaluation, the facility in collaboration with the attending physician, other health care professionals, and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -Factors influencing the choice of treatments include cause, location and severity of resident's pain, current medical condition, current medications, resident's desired level of relief and tolerance for adverse consequences (partial pain relief for fewer significant adverse consequences), potential benefits, risks and adverse consequences of medications; -Non-pharmacological interventions will include, but are not limited to environmental comfort measures(adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning), loosening any constrictive bandage, clothing or device, applying splinting (pillow or folded blanket), physical modalities (cold compress, warm shower/bath, massage, turning and repositioning), cognitive/behavioral interventions (music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain); -Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following general principles the facility will utilize for prescribing analgesics: -Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain; -Consider administering medication around the clock instead of PRN (on demand) or combining longer acting medications with PRN medications for breakthrough pain; -Use lower doses of medication initially and titrate slowly upward until comfort is achieved; -Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects; -Opioid treatment for acute pain, subacute pain, and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences; -Opioid treatment should be individualized for each resident with consideration by the prescriber of utilizing immediate-release opioids instead of extended-release and long-acting forms of opioids; -Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. 1. Review of Resident #93's face sheet (admission information at a glance) showed the following: -admission date of 05/25/25; -Diagnoses included aftercare following joint replacement surgery, osteoarthritis (degeneration of joint cartilage and underlying bone which causes pain and stiffness, especially in hip, knees, and thumb joints), anxiety disorder, fibromyalgia (widespread body pain and tiredness), and neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Review of the resident's care plan, initiated 05/25/25, showed the following: -At risk for acute pain related to right total knee replacement; -Goal to have no unaddressed pain with current pain interventions; -Interventions included monitor pain as prescribed, offer non-pharmacological approaches to pain management (massage, ice, reposition), monitor for side effects of pharmacological pain interventions, and notify physician with positive signs or symptoms of side effects; -Administer medications as prescribed. Review of the resident's Physician's Orders (POS), dated 05/25/25, showed the following: -Complete and document pain assessment using numeric/facial/[NAME] pain scale every shift; -Non-pharmacological interventions for pain include 1=repositioning, 2=cool pack, 3=warm pack, 4=dim light/quiet environment, 5=relaxation, 6=distraction, 7=music, and 8=massage every shift; -Acetaminophen (for mild pain) oral tablet 500 milligrams (mg) two tablets by mouth every eight hours as needed for mild pain; -Hydromorphone HCL (opioid narcotic to treat moderate to severe pain) tablet, 2 mg tablet, give one tablet by mouth every four hours as needed for pain (maximum daily amount 12 mg); -Tramadol HCL (narcotic medication for moderate to severe pain) 50 mg tablet give one tablet by mouth every six hours as needed for moderate and severe pain. Review of the resident's progress note dated 05/25/25, at 1:11 P.M., showed Registered Nurse (RN) C did a pain assessment that showed the resident had frequent moderate pain making it hard to sleep at night, limited participation in rehabilitation therapy sessions, limited day-to-day activities, pain intensity of five with worst pain moderate, and resident vocalized complaints of pain. Location was the right knee with aching, spasm, stiffness, cramping, nonradiating, and multiple times a day. Cool compresses applied. Non-medication interventions provided relief. PRN medication provided. Review of the resident's pain level summary sheet dated 05/25/25, at 1:12 P.M., showed a pain level of 5 (moderate pain). Review of the resident's Medication Administration Record (MAR), dated 05/25/25, showed an order for acetaminophen oral tablet 500 mg, give two tablets every eight hours as needed for mild pain. Staff did not documentation administration of the resident's acetaminophen on 05/25/25. Review of the resident's pain level summary sheet dated 05/26/25, at 1: 08 A.M., showed a pain level of moderate pain. Review of the resident's progress notes dated 05/26/25, at 9:07 A.M., showed Registered Nurse (RN) F documented the resident was very upset this morning about not having any pain medications. RN F called the pharmacy and the pharmacy said they would STAT (immediately send) them to the facility. Review of the resident's pain level summary sheet dated 05/26/25, at 2:26 P.M., showed Certified Medication Tech (CMT) A documented pain level 5 (moderate pain). Review of the resident's medical records showed staff did not document administration of pain medication to address the resident's pain. Review of the resident's pain level summary sheet dated 05/26/25, at 8:40 P.M., showed Licensed Practical Nurse(LPN) N documented resident's pain level was 6 (moderate pain). Review of the resident's MAR, dated 5/26/25, showed at 8:40 P.M., LPN N administered hydromorphone 2 mg and documented the medication was effective for treatment of the resident's pain. Review of the resident's pain level summary sheet dated 05/26/25, at 9:51 P.M., showed LPN N documented pain level of 4 (less pain but moderate level). Review of the resident's MAR, dated 5/27/25, showed the following: -At 12:40 A.M. and 12:51 A.M., (2 1/2 hours after hydromorphone administered), LPN N administered another hydromorphone 2 mg tablet and the pain level was 5 (moderate). The LPN document the medication was effective in treating the resident's pain; -At 5:41 A.M., the resident's pain level was 6 (moderate pain) and LPN administered hydromorphone 2 mg; -At 7:10 A.M., the resident's pain level was 5 (moderate pain); -At 12:11 P.M., the resident's pain level was 7 (moderate to severe pain) and staff administered hydromorphone 2 mg tablet. Review of the resident's medical record showed staff did not notify the physician of the increased pain level. During an interview on 05/30/25, at 9:25 A.M., RN C said the following: -He/she worked days from 6:30 A.M. to 7:00 P.M. usually. Last weekend, 05/24/25 and 05/25/25, there were lots of new admissions. He/she will go over paperwork, do a head-to-toe assessment, make progress note when a new admission arrived at the facility, how they arrived, put on a regular diet, if they were on O2 (oxygen), chart vital signs, do their 1st step tuberculin tine (tuberculosis) test, go over their paper work with the resident and/or family, and get something for them to drink. -The residents are upset when they get there. They expect all their medications to be there and their pharmacy is in Lenexa, Kansas which takes 3 to 4 hours to deliver medications. If they have a common medication, they may have the medication there in the facility. Monday to Friday, the pharmacy made a 5:00 P.M. delivery. On weekends, they deliver later; -f a resident requested pain medication, they can give Tylenol (for mild pain); -If they don't have a physician's prescription, they won't get the narcotic medications; -Narcotic medications were the biggest things. It has been taking too long for the physician to sign the hard (written) prescription and the staff were unable to get an electronic code to pull the narcotics. -They do try to get them Tylenol (a medication for mild pain); -The hospitals were to send the prescription with the resident or send an electronic prescription directly to the pharmacy; -RN C admitted the resident in the afternoon. The resident's family brought him/her there. The resident had a recent knee replacement surgery. They assisted the resident in a wheelchair to a room. The resident didn't want to sign any paperwork, but the family member signed it. RN C got ice water for the resident who wanted to lie down in bed. -They did not have signed physician's orders for pain medicines for the resident yet and he/she had not asked for any pain medications. The resident came from the hospital and had an order for Valium (for anxiety). RN C thought the resident was angry and not necessarily in pain. The resident was frustrated. The hospital staff was supposed to administer pain medication before the resident discharged such as a narcotic pain medication like hydromorphone or Dilaudid (for moderate to severe pain). They would have needed the hard prescription order or an electronic prescription there at the facility to give pain medications to the resident. They did have Tylenol they could administer every 8 hours; -On admission, he/she did a pain assessment and he/she put a 5 for a little bit of pain from the ride over from the hospital. This was what the resident said. The resident did not ask for any pain medication. During an interview on 05/30/25, at 12:13 P.M., Certified Nurse Aide (CNA) K said the resident's family came in with the resident. RN C helped toilet the resident and he/she helped transfer the resident to bed and put an ice bag on the resident's right knee. Later, the resident mentioned having pain to him/her after the Assistant Director of Nursing (ADON) had been in the resident's room. When he/she helped toilet the resident later, the resident said his/her leg was hurting. They had to wait for the pharmacy medications to come in. The ADON did bring pain medicine to the resident after 5:00 P.M. During an interview on 05/30/25, at 8:22 A.M., CMT B said she/he worked last Saturday (05/24/25) and Sunday (05/25/25) on the day shift. They had several new admissions which was normal at this facility. They usually did not get the new resident's medications orders until the second day for the medication cart. They usually have to pull medications for the resident the first day. A majority of new admissions come in the afternoon and early evening. As soon as they get a signed physician's order, such as a hard copy from the physician, they will pull medications such as blood pressure, diabetic and pain medications from the emergency kit. Sometimes there was a delay getting a signed order from the physician. The nurses talk to the physician. He/she did not remember administering any medications or any pain medication to the resident that first day the resident was admitted on [DATE]. During interview on 06/02/25, at 2:15 P.M., Licensed Practical Nurse (LPN) M said the following: -He/she worked as charge nurse on the 200 hall on Sunday night (05/25/25). He/she began work around 5:30 P.M. since this was the first time to work at this facility. He/she remembered the resident because the resident turned his/her call light on frequently all night. The resident complained of not getting his/her medication and had not received them for the second day. LPN M said the resident had admitted to the facility that day and felt the resident was confused. -The resident did not complain of pain and was in bed and covered up. The main thing the resident asked was to get a hold of his/her family member; -LPN M did not remember giving any medications to the resident including any pain medications. He/she did assess for pain and the resident said he/she had no pain. The resident didn't show any signs of severe pain. He/she said Tramadol was delivered for the resident early and he/she put the medication in the narcotic drawer on the shared narcotic cart; -He/she did not administer Tramadol or any pain medication to the resident. During an interview on 06/02/25, at 8:40 A.M., LPN L said the following: -If they have an admission early, like mid-day or in the week, and know the resident is coming, the physician signs the orders. The delay can be on the weekend or at night. They do have an on-call pharmacy for urgent meds; -If a resident needed pain med, they can get it out of the emergency kit. They can give a code and make sure the doctor signed the order. -If a resident had a knee replacement, he/she would expect a lot pain and hope the pain is more manageable by the time they come to the facility; -Tylenol would not be a drug of choice for moderate and severe pain, but for mild pain; -He/she would assess pain and pain was subjective. If he/she saw grimacing, withdrawing, not getting up to transfer to toilet, or verbalized pain, it could be a higher level of pain; -Nonverbal pain can be with assessed with facial expressions; -He/she would be looking at higher doses of medication if pain was at a severe level. During an interview on 05/29/25, at 3:30 P.M., LPN G (unit manager) said the following: -Usually they knew beforehand of a new admission. admission information was faxed, emailed, or scanned from the hospital beforehand; -There was a 5:00 P.M. cut off time for the pharmacy. If a resident admitted to the facility before noon, they would receive their medications before 5:00 P.M. If they were admitted in the afternoon, they received their medications at night; -Physician's orders were only activated when resident was in the building. There was an emergency supply kit. The kit contained vital medications for blood pressure and pain; -The hospital was to send a medications-electronic script or hard script (written copy) to send with the resident. The hospitals were different with how they sent the information. Then the facility will contact the physician and get temporary approval of medication until the physician can see the resident. They have to go to their facility physician and get a temporary approval until the physician can see the resident; -If this resident was admitted on Sunday in the evening, they can get local medications. They don't get many Sunday admissions. They would pull the medication from their kit if it was available. Their pharmacy medications come from Lenexa, Kansas. During interviews on 05/30/25, at 10:11 A.M. and 10:42 A.M., the ADON said the following: -He/she came in on Sunday (05/25/25). The resident sat in his/her wheelchair eating a meal when he/she talked to him/her. The ADON was there from noon to the 6:30 P.M. shift change. -The resident said he/she felt like he/she was dropped off there and left and no one in to see him/her. The ADON explained what type of facility they were and talked about rehabilitation from his/her surgery. It seemed to satisfy him/her. The resident brought up about having pain in her right knee and asked if he/she could have any pain medication; -The resident gave a pain level above a 5. The resident had moderate pain and would have needed something for pain, like a narcotic medication. The resident had just gotten to the facility and his/her medication list wasn't there yet. The physician has a standing order for Tylenol and he/she asked and the resident said yes; -The ADON went to get a soda for the resident and let CMT B know that the resident needed something for pain. He/she got a Tylenol 325 milligrams (mg) per the physician's standing orders. When he/she came back with the soda, the resident was in bed and he/she administered the Tylenol 325 mg two tablets by mouth; -Since this was on the weekend, the staff didn't add the physician's orders into the electronic medical record (EMR). Their corporate staff had a process for this. The corporate office was in the state of Utah and the pharmacy didn't deliver until later after the physician signed orders; -He/she would expect the pharmacy to deliver the resident's medications by 5:00 P.M. even on a weekend; -The resident's admission note said admitted on [DATE], at 12:35 P.M. Someone looks at the paperwork at the corporate and puts in the medication orders and it goes to the pharmacy. During an interview on 05/30/25, at 11:05 A.M., Corporate Staff said a for a new admission, they would get physician's orders from the hospital. The hospitals fax, email, or send through an electronic portal. The corporate intake nurse entered the orders and then will double checks the orders. The second corporate nurse reviewed again and orders go into a queue to triple check. The nurse in the facility gets the physician's orders, and they review the pending status and then activate the orders to send to the pharmacy. Nurses were available 24/7 for new intakes. They will reconcile all the orders. Sometimes hospitals arrange transportation for the patient to the facility and the patient gets there before the orders come. When the corporate has the orders, the time to double check takes 25 minutes. The resident's orders from the hospital were in their corporate queue at 11:37 A.M. on 05/25/25. During interviews on 06/02/25, at 9:28 A.M. and 11:24 A.M., the Director of Nursing (DON) said the CMTs can't go into the regular progress notes on the electronic medical record and chart, but if they document in the MAR and it should show up in the progress notes. They should have documented they administered Tylenol to the resident on 05/25/25. She would expect the staff to assess residents for pain. They won't have controlled substances until signed by physician. There was a Tramadol (for mild to moderate pain) order on the MAR. The pharmacy delivered the Tramadol the first night after 5:00 P.M. and the physician would have signed for this. RN C was responsible for putting the narcotic medication in the narcotic drawer for the resident. The resident had allergies and could only have Dilaudid which is hydromorphone (he/she was allergic to codeine). RN F would have handled the Dilaudid, but had to track it down to get it for the resident. The physician did order this and released this, but it takes the pharmacy three hours to deliver the medication. They do have a local pharmacy if need medication. During an interview on 06/02/25, at 12:49 P.M., the Administrator said pain medications should be administered timely. Upon a resident's admission, she would expect to get the resident's medications from pharmacy by the evening pharmacy delivery and if admission was later in the day, the pharmacy would deliver at 1:00 AM. If the physician signs the orders, like for narcotic pain medications, they should get it by early morning. The physician has to sign the orders for the pharmacy to send the medications. MO00254937

Based on record review and interview, the facility failed to provide pharmacy services per standards of practice when staff failed to administer medications after receipt for one newly admitted resident (Resident #93) and when staff failed to properly document the removal of Fentanyl patches (a narcotic pain medication) for one resident (Resident # 197). The facility census was 37 residents. 1. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders. Review of Resident #93's face sheet (admission information at a glance) showed the following: -admission date of 05/25/25; -Diagnoses included aftercare following joint replacement surgery, osteoarthritis (degeneration of joint cartilage and underlying bone which causes pain and stiffness, especially in hip, knees, and thumb joints), Type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (COPD - lung disorder that blocks airflow making it difficult to breathe), anxiety disorder, hypothyroidism (low thyroid hormone), anemia (low red blood cells that leads to reduced oxygen flow to body organs), recurrent major depressive disorder, fibromyalgia (widespread body pain and tiredness), and neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Review of the resident's progress notes showed the resident was admitted on [DATE] at approximately 12:35 P.M. Review of the resident's physician's orders (POS), dated 5/25/25, showed the following orders: -Celecoxib capsule (non-steroid antinflammatory medication) 200 milligrams (mg), give one capsule by mouth two times a day for inflammation for 28 days. The medication was scheduled for 6:00 A.M. and 2:00 P.M. administration; -Dexamethasone tablet (steroid medication for inflammation) 4 mg, give one tablet by mouth two times a day for rheumatoid arthritis (RA - causes joint pain, stiffness, swelling, and inflammation) for 10 days. The medication was scheduled for 6:00 A.M. and 2:00 P.M. administration; -Duloxetine HCL (for depression and anxiety and also used for pain caused by nerve damage associated with diabetes and peripheral neuropathy) oral capsule delayed release particles 40 mg, give one capsule by mouth one time a day for depression; -Propranolol HCL tablet (for high blood pressure) 10 mg to give one tablet by mouth two times a day for hypertension (high blood pressure); -Primidone tablet (for seizures) 50 mg, to give one tablet by mouth two times a day for seizure. Review of the pharmacy shipping manifest dated 05/25/25, at 5:42 P.M., showed the following medications for the resident were received: -Celecoxib 200 mg capsule, quantity 30; -Dexamentasone 4 mg capsule, quantity 20; -Duloxetine HC 40 mg capsule, quantity 15; -Propranolol 10 mg tablet, quantity 30; -Primidone 50 mg tablet, quantity 30. Review of the resident's Medication Administration Record (MAR) showed the following: -On 05/26/25, at 6:00 A.M., staff documented a 9 (other/see progress note) for the dose of celcoxib, dexamentasone, duloxetine, propranolol, and primidone. Review of the resident's progress notes, dated 05/26/25, showed staff did not document regarding the missed doses of medications. During an interview on 05/30/25, at 8:22 A.M., Certified Medication Technician (CMT) B said the following: -There was one medication technician for the building; -He/she worked last Saturday (05/24/25) and Sunday (05/25/25) on day shift. They did have new admissions and usually do not get the resident's medication orders usually until the second day on the medication cart. They usually have to pull medications the first day for the resident; -The majority of new admissions come in afternoon and early evening; -He/she didn't remember administering any medications for the resident that night; -As soon as they get signed orders, a hard copy, from the physician, they will pull meds from the e-kit like blood pressure, diabetic and pain meds. Sometimes there is a delay getting a signed order from physician. During an interview on 05/29/25, at 3:30 P.M., Licensed Practical Nurse (LPN) G said the following: -When they received information from the hospital for a new admission, it would depend when the resident arrived when they would get their medications delivered from the pharmacy. If they arrived prior to noon, they will get their medications before 5:00 P.M. and if after noon time, they will receive the pharmacy medications at night. The medication orders were only activated when the resident arrived in the building -They have an emergency supply with their emergency kit for vital medications such as blood pressure medications; -They have to get their physician to give a temporary approval of medication orders until they do see the resident. If there was a Sunday admission in the evening, they can get medications from a local pharmacy since their medications are delivered from Kansas. During an interview on 05/30/25, at 9:25 A.M., Registered Nurse (RN) C said the following: -He/she worked day shift last Saturday (05/25/25) and Sunday (05/26/25). There were many new admissions; -He/she does go over the paperwork and the admission medications; -Residents are normally upset when they get to the facility. They expect all their medications to be there and there pharmacy was in Kansas and it took 3 to 4 hours to get medications delivered to the facility; -If they had a physician's order for a common medication, they may have it on hand there at the facility; -It had been taking awhile long for the physician to sign the hard prescription; -The local hospitals send either the written prescriptions or electronic prescriptions directly to the pharmacy; -During Monday to Friday, the pharmacy delivers medications around 5:00 P.M. On weekends, they deliver later. During an interview on 06/02/25, at 12:49 P.M., the Administrator said the following: -All medications should be administered timely; -She would expect to get the resident's medications in from the pharmacy when admitted by the evening delivery and at 1:00 A.M. delivery for a late admission; -When the physician signs the medication orders, they should receive the medications by early morning. The physician had to sign the orders for the pharmacy to send the medications. 2. Review of a facility policy titled Controlled Substance Administration and Accountability, dated April 2025, showed the following: -The facility will have safeguards in place in to prevent loss, diversion, and accidental exposure; -All controlled drug patches removed from patients are disposed of in such a manner as to prevent diversion; -After removing the patch, the used patch is folded in half so that the sticky side sticks to itself and placed in a drug enforcement agency (DEA) compliant drug disposal system so that the controlled substance is not retrievable. A sharps container does not meet this requirement; -Disposal of patches is witnessed and cosigned on the MAR in the blanks provided with each controlled patch order; -Two signatures are required for documentation of controlled drug patch disposal. Review of a facility policy titled Documentation in Medical Record, dated May 2025, showed the following: -Each resident's medical record shall contain an accurate representation of the resident and include enough information to provide a picture of the resident progress through complete, accurate, and timely documentation; -Staff shall document all assessments, observations, and services provided in the resident medical record; -Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident care. Review of the Resident #197's face sheet showed the following: -An admission date of 04/24/25; -Diagnoses included intestinal obstruction (blockage that prevents normal bowel movement), high blood pressure, and diabetes mellitus (chronic condition that results in too much sugar in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/28/25, showed the resident was cognitively intact and on opioid (medication to reduce moderate to severe pain) medication. Review of the resident's care plan, revised on 04/25/25, showed the following: -Resident was at risk for acute pain related to a bowel obstruction and a new ileostomy (an opening in the abdomen to divert waste from the small intestines through the skin); -Resident will have no unaddressed pain; -Monitor pain as ordered; -Offer non-pharmacological approaches to pain management; -Monitor for side effects of pharmacological pain interventions. Review of resident's current POS showed an order, dated 05/03/25, for a Fentanyl (opioid pain medication) patch 72 hour, 12 micrograms (mcg) per hour, apply 1 patch transdermal (absorption through the skin into the bloodstream) every 72 hours for pain. Rotate the site and remove per schedule. Review of the residents MAR, dated May 2025, showed 05/0625, 05/09/25, 05/12/25, 05/15/25, 05/18/25, 05/21/25, 05/24/25, and 05/27/25 staff document a Fentanyl patch applied but did not show documentation for removal of the patch as ordered. During an interview on 06/02/25, at 10:22 A.M., the Director of Nursing (DON) said a fentanyl patch should be documented upon removal and should be placed in medication destroyer. During an interview on 06/02/25, at 12:20 P.M., the Administrator said staff should be documenting medication administration and removal of a medication patch. MO00254937

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made 4 errors out of 45 opportunities resulting in an 8.8% error rate affecting one resident (Resident #142). The facility had a census of 37. Review of a facility policy titled Medication Administration, dated April 2025, showed the following: -Medications are administered as ordered by the physician and in accordance with professional standards of practice; -Obtain and record vital signs per physician orders; -Hold medication for those vital signs outside the physician's prescribed parameters; -Ensure the six rights of medication administration are followed which are right resident, right drug, right dosage, right route, right time, and right documentation; -Administer within sixty minutes prior to or after scheduled time unless otherwise ordered by a physician; -Sign Medication Administration Record (MAR) after administered and record vital signs on the MAR. 1. Review of Resident #142's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 05/20/25; -Diagnoses included pneumonia (lung inflammation caused by bacteria or a virus), chronic obstructive pulmonary disease (COPD - lung disease that causes persistent airflow obstruction and breathing problems), and diabetes mellitus (chronic condition that results in too much sugar in the blood). Review of the resident's current Physician Order Sheet (POS) showed the following: -An order, dated 05/20/25, for digoxin (medication to treat heart failure and irregular heartbeat) 125 microgram (mcg) tablet, give one tablet once daily for heart failure. Check apical pulse (a pulse site on the left side of the chest over the pointed end of the heart auscultated (examined by listening to the sounds from the heart) with a stethoscope) for one full minute. Hold medication for pulse less then 60 beats per minute (bpm) or greater than 100 bpm; -An order, dated 05/20/25, for bumetanide (medication to treat fluid retention) 2 mg, give 1 tablet two times a day for fluid retention; -An order, dated 05/20/25, for midodrine (medication to treat low blood pressure) 10 mg, give 1 tablet by mouth every eight hours for hypotension (low blood pressure); -An order, dated 05/20/25, for metoclopramide (medication to treat nausea and vomiting) 5 mg, give 1 tablet before meals and at bedtime for Angi ectasia (dilated blood vessels) of gastrointestinal tract. Observation of medication pass on 05/28/25, at 10:30 A.M., showed the following: -Certified Medication Technician (CMT) A was unable to obtain resident's blood pressure with electronic blood pressure machine. Registered Nurse (RN) F obtained resident's blood pressure manually and reported a result of 132/70 milligrams of Mercury (mm/Hg). Staff did not attempt to obtain an apical pulse prior to or during medication pass. -CMT A sanitized hands and prepared medication for administration. CMT A reported he/she would not administer midodrine due to resident blood pressure being high. (The resident's order had no perimeters for holding medication.) CMT A entered resident room and administered medications. -CMT A administered the digoxin without obtaining an apical pulse prior to administration as ordered; -CMT A administered the bumetanide 2 mg, scheduled for 7:00 A.M., and at 10:30 A.M. (next dose ordered at 1 P.M.); -CMT A administered the metoclopramide 5 mg, 6 A.M. dose administered at 10:30 A.M. after breakfast completed. During interviews on 05/28/25, at 10:45 A.M., and on 05/30/25, at 12:47 P.M., CMT A said the following: -There is an indicator on the MAR that requests vital signs entered when medication is administered; -Certified nurse assistants (CNAs) obtain resident vital signs around 6:30 A.M. to 7:00 A.M. and provide a list to the CMT's for medication administration; -He/she used the vital signs obtained by aides to pass morning medications, but takes his/her own in the afternoon; -There are four medication pass times and he/she can pass an hour before or after those times; - The medication times are 6:00 A.M. to 10:00 A.M., 10:00 A.M. to 2:00 P.M., 2:00 P.M. to 6:00 P.M., and 6:00 P.M. to 10:00 P.M.; -Medications that are on flex time schedule are indicated on the MAR; -Most medication is administered during flex medication times except if indicated at a specific time; -It is difficult to pass medications that are due at a specific time or with meals; -He/she uses a pulse oximeter that is applied to the resident finger to obtain the pulse rate for digoxin administration; -He/she is not aware an apical pulse is required prior to administering digoxin. The apical pulse is the pulse found on the forearm; -The midodrine was not given during the medication pass observation due to the resident blood pressure was too high. There are no perimeters to hold the midodrine in the order. During an interview on 05/28/25, at 11:17 A.M., CNA D said he/she takes vital signs on all residents between 7:00 A.M. and 9:00 A.M The vital sign sheet is placed on a clipboard and given to the CMT. He/she has not used a stethoscope to check a resident pulse. A pulse oximetry machine is used to obtain pulse. During an interview on 05/30/25, at 8:22 A.M., CMT B said a resident's pulse should be taken immediately before administering digoxin. Apical pulse means to take the pulse at the wrist for one minute. CNA's complete vital signs when they come in at 6:30 A.M Medication should be given no more than 30 minutes after vital signs are taken. During an interview on 06/02/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said there are flex administration parameters for most medications. Medications are scheduled at a set time if they are given with or before meals. The CMT should give medications on a set time prior to giving flex administration time medications. CMT's should notify the nurse and not make the decision on when to hold or administer medications. Medications should not be held without parameters. Digoxin should have an apical pulse prior to administration. Vital signs should be documented on the MAR. During an interview on 05/30/25, at 9:45 A.M., Registered Nurse (RN) C said he/she had not checked the resident's apical pulse. He/she was unaware the resident required an apical pulse prior to administering medication. Apical pulse is more accurate than the pulse obtained with a machine. A machine does not pick up an irregular heart rate. He/she would obtain an apical pulse with a stethoscope. Digoxin could cause the pulse to drop dangerously low if given when pulse is below 60. A CMT cannot hold medication if there are no perimeters listed. During an interview on 05/29/25, at 1:05 P.M., the Nurse Practitioner (NP) said the nurse should check an apical pulse for one minute if stated in the order. Midodrine does not usually have parameters and should be administered as ordered. During an interview on 05/30/25, at 10:12 A.M., the Assistant Director of Nursing (ADON) said staff have a four-hour flex period with one hour before and after to pass medications. The four-hour flex period should be indicated on the MAR and if not there is a designated time. Digoxin should have an apical pulse taken before administering. A CMT should take vital signs 15 minutes prior to administering medications. The CMT should notify a nurse if they feel a medication should be held. Vital signs should be taken and entered in the MAR if requested. During an interview on 06/02/25, at 10:22 A.M., the Director of Nursing (DON) said the CMT's should not be holding medications without ordered parameters. CMT's should notify a nurse if they feel a medication should be held. The CMT should document nurse notification, and that the medication was held. Digoxin required an apical pulse before administration and CMT's were trained to do this. Medications indicating administer before or with meals should be given at a specific time. CMT's should notify the nurse if a medication dose is held due to late administration of the previous dose. During an interview on 06/02/25 at 12:20 P.M., the Administrator said staff should follow physician orders.

Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers (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) when the facility staff failed to document a full assessment of wounds upon admission, failed to obtain physician's orders for treatment and interventions of wounds, and failed to update the care plan regarding skin breakdown intervention changes for one resident (Resident #1) out of 7 sampled residents. The facility census was 37. Review of the facility's policy titled, Skin Assessment, dated 07/21, showed the following information: -A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse (RN) 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; -The following should be documented: date and time of the assessment, staff members name and position title, observations, type of wound, measurements, if the resident refused the assessment and why; and any other information as indicated or appropriate. Review of the facility's policy titled, Wound Treatment Management, dated 07/21, showed the following information: -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; -Treatment decisions will be based on the following: etiology of the wound, characteristics of the wound, and location of the wound, and goals and preferences of the resident; -Treatments will be documented on the Treatment Administration Record (TAR) inside the resident's Electronic Medical Record (EMR); -The effectiveness of treatments will be monitored through ongoing assessment of the wound; -Considerations for needed modifications include lack of progression towards healing, changes in the characteristics of the wound. And changes in the resident's goals and preferences. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included malignant neoplasm of the spinal cord (a cancer containing tumor within the spinal cord), severe protein-calorie malnutrition ( a condition that occurs when an adult doesn't get enough protein, calories, and other nutrients), and diabetes. Review of the resident's care plan, initiated on 02/17/25, showed the following information: -Staff to encourage and assist with frequent repositioning to alleviate areas of pressure; -Staff to provide skin and incontinence care as needed; -Standard facility pressure reduction mattress; -Staff to complete weekly skin checks per facility schedule and notify physician of alterations for prompt/proper intervention; -Wound to the sacrum (a large, triangular bone at the base of the spine that forms the back wall of the pelvis). Staff to use enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes); -In house wound care provider to assess and treat; -Treatments as prescribed. Review of the resident's admission orders from the discharging hospital, dated 02/17/25, showed the following information: -Coccyx (a small triangular bone at the base of the spinal column) and gluteal (buttock) wounds; Cleanse wounds with normal saline and pat dry. Apply Mepilex border (a foam dressing used for treating low to medium exudating (draining) wounds). Change every three days and as needed per soiling. If the resident is frequently incontinent, discontinue using Mepilex and apply barrier cream instead; -Low loss air mattress with repositioning every two hours; -Float heels off the bed with pillows. Review of the resident's February 2025 Physician Order Sheet (POS) showed the following: -An order, dated 02/17/25, for pressure relieving cushion to wheelchair; -An order, dated 02/17/25, for pressure reduction mattress; -An order, dated 02/17/25, for outside wound clinic to evaluate and treat. (staff did not transcribe the hospital orders for wound treatment or floating heels on 02/17/25.) Review of the residents admission assessment, dated 02/17/25, showed the following: -Wound to sacrum with type documented as other; -Staff did not document a description and measurements; -Staff did not indicate the resident had wounds to the buttocks as noted on the hospital summary; -Staff did not note any current treatment orders. Review of the resident's progress notes, dated 02/17/25, showed staff did not document regarding the resident's wounds and or treatment. Review of the resident's Braden Scale assessment (an assessment filled out by facility staff to determine a resident's likely hood of developing pressure ulcers), dated 02/17/25, showed staff assessed the resident at moderate risk for developing pressure ulcers. Review of the resident's February 2025 POS showed an order, dated 02/18/25, for wound to sacrum. Staff to cleanse with vashe (a wound cleanser that contains hypochlorous acid, which helps remove debris and microorganisms) , pat dry, apply calcium alginate (a highly absorbent wound dressing made from alginate, a natural polymer derived from the cell walls of brown seaweed), and cover with bordered dressing every day shift. (Staff did not document treatment orders for the resident's buttock wounds.) Review of the resident's February 2025 Treatment Administration Record (TAR) showed the following information: -An order, dated 02/18/25, for sacrum. Staff to wash with vashe, pat dry, apply calcium alginate and Mepilex daily; -Staff did not document completion of the treatment on 02/18/25. Review of the resident's progress notes, dated 02/18/25 through 02/21/25, showed staff did not document regarding the resident's wounds and/or treatment. Review of the resident's wound assessment, dated 02/21/25, showed the following: -Pressure ulcer to the right buttock measuring 1.8 centimeters (cm) by 1 cm with a depth of 0.1 cm; -Pressure ulcer to the left buttock measuring 1.5 cm by 1.2 cm with a depth of 0.1 cm; -Pressure ulcer to left buttock measuring 2.6 cm by 1.9 cm with a depth of 0.1 cm; -Wounds were worsening and have outside wound clinic to evaluate and treat; -Supplementary healing included, air mattress, offloading, cushion in wheelchair, and supplements. Review of the resident's progress note, dated 02/23/25, showed the resident utilized the call light frequently, did not participate in self-cares, and refused to assist staff. The resident's buttocks wounds were extensive and causing pain to the resident despite frequent repositioning by staff. Review of the resident's February 2025 TAR showed the following information: -Staff did not document completion of the ordered treatment to the sacrum wound on 02/24/25 through 02/26/25; -An order, dated 02/24/25, for buttocks. Staff to wash with vashe, pat dry, apply calcium alginate and Mepilex on Monday, Wednesday, Friday, and as needed. Staff did not document completion of the ordered treatment on 02/24/25 and 02/26/25. Review of the resident's care plan, initiated on 02/17/25, showed staff did not update the care plan to reflect the resident's additional identified wounds and/or treatments. Review of the resident's progress notes, dated 02/24/25 through 02/26/25, showed staff did not document regarding the residents' wounds, treatments, or why treatments were not completed. The resident discharged from the facility on 02/26/25. Review showed the facility did not provide shower sheets for the resident from 02/17/25 through 02/26/25. During an interview on 02/28/25, at 1:38 P.M., Certified Nursing Assistant (CNA) A said the following: -If he/she noticed a new area of concern on a resident's skin, he/she reported it to the charge nurse; -Areas of concern are also found during showers, documented on shower sheets, and turned into the charge nurse; -The charge nurse will assess and measure the wound and decide on an appropriate treatment if the wound nurse was not on shift that day. The wound nurse works Monday, Wednesday, and Friday; -The charge nurse would notify the wound nurse of the new area of concern. During an interview on 02/28/25, at 2:23 P.M., Certified Medication Technician (CMT) B said the following: -If he/she noticed a new area of concern on a resident's skin, he/she reports it to the wound nurse, if the wound nurse was not here that day, he/she would notify the charge nurse; -The nurse that was at the facility, will assess and measure the wound, notify the physician, and obtain orders for treatment; -The resident did have wounds upon admission;. During an interview on 02/28/25, at 2:37 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident was admitted to the facility with really bad wounds to both buttocks and the sacrum; -He/she was the resident's nurse the day after he/she admitted to the facility. On that day, 02/18/25, the resident's wound beds had slough (a non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) and eschar (a dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.); -He/she spoke with the facility wound nurse regarding the residents' wounds, the wound nurse then completed her own assessment of the wounds; -The admission skin assessment should be completed within 48 hours of the resident's admission to the facility; -Wound treatment should be initiated immediately upon discovering of the wounds, and should be documented in the progress notes, and care planned; -There should be documentation of the wounds and treatment in the progress notes and care plan. During an interview on 03/24/25, at 10:24 A.M., Registered Nurse (RN) D said the following: -The admitting nurse should do a full head to toe assessment of the resident. If the wound nurse is on shift during the admission, she can do the skin assessment; -If concerns are found during the head-to-toe assessment, the nurse on staff gets into contact with the wound nurse and initiates an appropriate treatment; there are standing orders that can be used until the wound nurse assesses the wound herself; -Floor nurses were responsible for looking at the resident's skin weekly and the wound nurse does weekly wound documentation as well; -The resident had wounds upon admission, and he/she believes the hospital he transferred from sent orders for wound treatment; -Wound care was not due on any of the shifts he/she worked. He/she did see a Mepilex pad on the wounds during repositioning; -Wounds and treatment of wounds should be documented in the progress notes, notifications should be made to the physician, and the resident's responsible parties, and should also be care planned. During an interview on 03/04/25, at 12:36 P.M., LPN E said the following: -He/she was the admitting nurse for the resident; -The resident had open wounds on both buttocks, and a reddened sacrum upon admission; -The resident admitted to the facility with treatment orders from the discharging hospital; -Nurses should perform skin assessments daily and should document their findings in the progress notes. Findings should also be reported to the wound nurse; -The wound nurse does wound assessments weekly. During an interview on 03/04/25, at 10:45 A.M., the Wound Nurse said the following: -The admitting nurse should do a full head to toe assessment of the resident as well as initiate a treatment, if she is not there that day; -She does wound assessments on Mondays and measures wounds on Wednesdays or Fridays; -She documents her wound assessments in the EMR, under assessments; -Aides will bring her their shower sheets if there is a concern with skin, and she also has a book on her desk that staff can fill out when she is not on shift; -The resident admitted with a reddened sacrum and stage two (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) wounds to both buttocks; -A couple days after the resident admitted , a nurse had reported to her that the wounds appeared to be worsening, initially the staff were applying barrier cream; -During her assessment of the wounds, on 02/21/25, she noticed the wounds needed more attention and ordered an air mattress, an outside wound clinic to evaluate and treat, and initiated a new treatment; -When an area of concern is found or is found to be worsening, the finding nurse should notify her, as well as document that in the progress notes, and the care plan. During an interview on 03/24/25, at 11:09 A.M., the Director of Nursing (DON) said the following: -She expected staff that find new and/or worsening wounds to notify the nurse. The nurse would then go and assess the wound, decide an appropriate treatment, and document in the progress notes, update the care plan, and notify the Wound Nurse; -The admitting nurse is responsible for obtaining a full head to toe assessment on the residents, if areas of concern are found they should also initiate treatment, the wound nurse should complete the measurements of the wounds and document her assessment; -The resident had wounds to his/her sacrum and both buttocks; -The resident refused repositioning and care often, which should also be documented. During an interview on 03/04/25, at 11:57 A.M., the Administrator said the following: -She expected head to toe assessments to be completed upon admission; -She expected all staff members who notice a area of concern or worsening of the skin to notify the nurse on duty and the wound nurse. The nurse should assess the wound and initiate a treatment; -Nurses should be laying eyes on resident's skin daily and should be documenting and care planning any concerns. MO00250192

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported timely when staff failed to report an allegation of abuse involving one resident (Resident #3) to the state survey agency (Department of Health and Senior Services (DHSS)) within the required two hour time frame. The facility census was 36. Review of the facility's policy Abuse, Neglect and Exploitation, revised 06/2023, which showed the following: -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 altercations; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property; -The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies such as law enforcement when applicable within specified timeframes; -The facility reports immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or -The facility reports not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Review of Resident #3's face sheet (admission information at a glance) showed the following: -admitted [DATE]; -Diagnoses that included left arm fracture, depression, and generalized anxiety disorder. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/29/24, showed the resident was cognitively intact. Review of the resident's progress note dated 07/24/24, at 8:41 A.M., showed the Social Services Director (SSD) met with the resident to discuss a complaint regarding two nurses in the facility. The resident wanted to leave the facility after being recently admitted . The resident responded, Two nurses came in here and absolutely humiliated me. They pulled down my pants, smacked my ass, and then ran both of their fingers up my ass. The SSD reiterated that it was a nurse's responsibility to check the buttocks area of residents. The resident responded, It's like they were on something, ya know? I couldn't smell nothin', like marijuana or [NAME]. But, they acted like they were on something. During an interview on 08/01/24, at 10:52 A.M., the SSD said when he/she talked to the resident on 07/24/24, at 8:17 A.M., the resident kept bringing up his/her home situation. The home kept trying to reach a specified family member several times and when they talked to this family member, he/she said he/she would not come pick up the resident until 07/30/24. On 07/31/24, the resident said he/she was going home and this was when the SSD hotlined DHSS for adult protective services regarding concerns with him/her going home. The Administrator was responsible for making self reports of abuse and neglect. Review of the resident's record showed staff did not document reporting the resident's allegation of abuse involving facility staff to DHSS. Review of DHSS records showed the facility reported the allegation of abuse on 07/31/24 (seven days after the allegation was made). During an interview on 08/01/24, at 11:33 A.M., Licensed Practical Nurse (LPN) A said he/she admitted the resident. Certified Nurse Aide (CNA) C assisted LPN during the assessment process. The resident did not make an allegation of abuse at that time. Staff were to report any allegation of abuse/neglect within two hours to the on-call nurse first. Then the on-call nurse was to report to the Director of Nursing (DON) who reported to the Administrator. The Administrator was to report to the state. During an interview on 08/01/24, at 1:14 P.M., CNA C said the resident was in the recliner in the room when he/she and LPN A went in to check the resident's skin. The resident was already agitated. Both he/she and LPN A explained that they were going to do a skin assessment on the resident. The resident did not make any allegation of abuse during or right after the skin assessment. CNA C knew to report any allegation of abuse to the charge nurse and said they were to do this right away and staff were to report any allegation of abuse to the state within two hours of incident. During an interview on 08/01/24, at 10:35 A.M., the Assistant Director of Nursing (ADON) said the Administrator called him/her at the facility on 07/24/24, about 7:00 A.M., and asked him/her to talk to the resident regarding the allegation. He/she asked the resident if he/she had any care concerns. The resident said, when two nurses came in and did assessment they pulled up his/her gown, pulled his/her underwear down, and one of them patted his/her butt and said It's a cute butt and then put their finger in his/her butt. The resident knew who he/she was and where he/she was but seemed off. He/she talked to LPN A and CNA C and got their statements. The Administrator was to call the state for abuse and neglect. During interviews on 08/01/24, at 10:05 A.M. and 5:12 P.M., the DON said the resident had concerns with LPN A who admitted the resident. The resident said LPN A had the resident drop his/her pants, swatted him/her on the butt, and said he/she had a nice butt, and stuck his/her finger in it. At first, the resident seemed lucid (thinking clearly), but when speaking more with the resident, the story grew. When the admitting nurse does the initial skin assessment, they try to have two staff go into the room to do the assessment. If the nurse had been the only one to go do the initial skin assessment on the resident and they felt it was possible abuse, they would have reported this to the state. They thought with two staff in the room who described what they did, that there was no abuse. The resident did not make any allegation of abuse then. During interviews on 08/01/24, at 10:10 A.M. and 11:20 A.M., the Administrator said the night shift nurse called him/her at 6:11 A.M. on 07/24/24 and said the resident asked the night CNA if it was normal for a nurse to stick her finger in his butt. The Administrator called the ADON to start an investigation to talk to the resident. The resident did not report this until hours later to the night CNA. The staff that did the skin assessment were LPN A and CNA C. The resident never said he/she was abused, neglected, or harmed or she would have reported this to DHSS within the two hour time frame. She was on the fence about calling the state. She had two witnesses in the room at the time (the nurse and the aide), but she should have made a self report to the DHSS state survey agency. MO00239812

Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document a full assessment of wounds upon admission; failed to document on-going full assessments of wound to assist with monitoring and possible decline of wound; failed to obtain physician's orders for treatment and failed to follow ordered treatments of pressure ulcers; and failed to care plan and update care plans regarding actual skin breakdown and intervention changes for two residents (Residents #1 and #2) of six sampled residents. The facility census was 36. Review of the facility policy Skin Assessment, revised 7/2024, showed the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter; -The assessment may also be performed after a change of condition or after any newly identified pressure injury; -Procedure included begin head to toe and thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath of medical devices; -Remove any dressings, unless contraindicated ordered to remain in place, and note findings; -Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions; -Consider the general status of the resident's skin such as color, temperature, moisture status, sensory perception, and skin texture/turgor (firmness); -Documentation included observations of the skin conditions, type of wound, wound measurements, color, type of tissue in wound bed, drainage, odor, and pain. Review of the facility policy Wound Care Best Practice Guidelines, undated, showed the following: -Upon admission and readmission (during 24 hour chart check) all new admissions will be carefully examined for any wounds. It is very important that any wounds received prior to admission are documented as such. Additionally, any factors which contribute to a wound such as boggy heels, non-blanchable areas, etc should be documented also; -Each time a new wound is found, it should be assessed by the nurse designated for wound management. The Wound Nurse will add each wound to resident Wound Management Documentation or the facility wound report. The Wound Nurse will complete a new Braden assessment (scale developed to identify patients at risk for forming pressure sores) and update the at risk for skin impairment care plan; -Every wound will be measured and assessed weekly in the facility. This included resident receiving hospice or palliative care (comfort measures); -The assessment will be documented in electronic medical record Wound Management and will include date of assessment, measurements, description of wound and peri-wound, wound bed, current treatments/interventions, pain, wound status, and physician notification, etc.; -Any time a wound is not improving or worsening, showing signs and symptoms of infection, or has uncontrolled pain associated with it, the physician will be notified, and new orders obtained; -The care plan will be updated as needed with assessment/new orders for the wound, and interventions. 1. Review of Resident #1's face sheet (admission information at a glance) showed the following: -admitted [DATE]; -Diagnoses included right femur (lower leg) fracture, atrial fibrillation (abnormal heart rhythm), peripheral vascular disease (PVD - reduced circulation of blood to a body part due to a narrowed or blocked blood vessel), chronic obstructive pulmonary disease (COPD - lung disease that blocks air flow and makes it difficult to breathe), high blood pressure, history of abnormal weight loss, and pain. Review of the resident's care plan, dated 07/19/24, showed the following: -At risk for alteration to skin integrity secondary to surgical wounds as well as other open area to skin, thin fragile skin, and decreased meal intake due to poor appetite. Patient frequently refuses protein supplement or meal alternatives; -Approaches included air mattress applied to bed, dietitian/nutritional evaluation as needed, provide skin and incontinence care assistance as needed, weekly skin check per facility schedule, and notify physician of alterations for prompt/proper intervention. Review of the resident's admission assessment, dated 07/20/24, showed the following: -Right knee and leg fracture; -Lifted manually; -Limitation on one side; -Occasionally incontinent of bladder and usually continent of bowel; -Mild pain daily; -DTI (deep tissue injury - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to resident's coccyx (tailbone). (Staff did not document a description or complete assessment of the DTI.) Review of the resident's Braden scale (a risk assessment tool that helps identify residents at risk of developing pressure ulcers or injuries), dated 07/20/24, showed staff assessed the resident as at mild risk for developing pressure ulcers. Review of the resident's physician's orders, dated 07/20/24, showed a treatment order for the DTI to coccyx. Staff to cleanse with vashe (a wound cleanser), pat dry, and apply calmoseptine (a moisture barrier ointment) every shift on the DTI to coccyx. Review of the resident's progress note, dated 07/20/24, showed a DTI to coccyx with dark purple/black and open area. Staff obtained treatment orders. (Staff did not document a full and complete assessment of the area.) Review of the resident's current care plan, last reviewed 07/19/24, showed staff did not address the resident's DTI on the care plan. Review of the resident's daily skilled charting, dated 07/21/24, showed the resident had moisture associated skin damage (MASD) on the resident's buttocks. (Staff did not document regarding the resident's DTI to the coccyx.) Review of the resident's daily skilled charting, dated 07/22/24, showed the resident had multiple skin tears on his/her bottom. (Staff did not document regarding the resident's DTI to the coccyx.) Review of the resident's weekly skin assessment, dated 07/22/24, and completed by the wound nurse showed the following: -Skin turgor was fair, warm, dry, and pale; -Open lesions; -DTI to coccyx; -New skin tears over weekend were measured, and treatment put in place. (The wound nurse did not document a full and complete assessment of the resident's DTI on the coccyx.) Review of the facility's wound report, dated 07/24/24, showed the wound nurse measurements as follows: -The wound nurse documented measurements of three skin tears on the resident's left buttock, the right buttock, and the right rear thigh; -The unspecified ulcer on the top of the coccyx was 4 cm (centimeters) by 4 cm width by 4 cm length by 0.1 cm depth (depth would indicate this area was open). (The wound nurse did not document any further description of the open area or the DTI on the coccyx) Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/25/24, showed the following: -Cognitively intact; -Required substantial/maximum assistance to shower, toilet, and dress, transfer, and change position in bed; -Occasionally incontinent of urine and bowel; -admitted for fracture and malnutrition; -At risk for developing pressure ulcers/injuries; -Has one or more unhealed pressure ulcers/injuries; -One unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) pressure injury present upon admission. During an interview on 07/30/24, at 9:05 A.M., the resident said he/she had an open sore on his/her behind and staff put ointment on it. He/she said his/her skin was sensitive and he/she had lymphedema (swelling in the tissues). Observation on 07/30/24, at 9:28 A.M., showed the resident told Licensed Practical Nurse (LPN) B that his/her pain level was 10 (10 is severe pain on a level from 1 to 10). The resident told LPN B that the crack in his/her butt was hurting. Observation on 07/30/24, at 12:15 P.M., showed the following: -The resident was in bed and said his/her bottom was hurting and kept trying to raise up off his/her bottom and his/her hand underneath his/her right leg; -The Director of Nursing (DON) and Certified Nurse Aide (CNA) C assisted the resident to his/her side. There was a dressing on the sacrum (the large triangular bone at the base of the spine) at the top of the buttocks on the coccyx with a darker color drainage beneath the dressing. The DON removed the undated mepilex foam dressing (foam dressing to treat pressure ulcers) and the pressure ulcer was red, open, with a scant to moderate amount of darker color drainage with a slight odor. The DON measured the pressure ulcer as 3.5 cm by 6 cm by 0.2 cm depth. She removed a small piece of calcium alginate (dressing for moderate to heavy drainage) from the wound bed on the upper coccyx/sacrum. (The resident's physician's order did not address use of a dressing.) During interviews on 07/30/24, at 1:30 P.M. and 4:04 P.M., LPN A said for the resident the physician's order was to cleanse and put calmoseptine ointment over the pressure wound on the coccyx. The physician's order did not say to put a dressing over this. During interviews on 07/30/24, at 2:10 P.M. and 4:06 P.M., LPN B said for the resident, LPN A notified the physician to put the resident on antibiotics for the wound. When he/she changed the resident's dressing on the coccyx, he/she just followed the order to put calmoseptine ointment on the wound. He/she did not cover the wound with a dressing. Review of the resident's physician's order, dated 07/30/24, showed the following: -Cephalexin (antibiotic for skin infection) 500 mg (milligrams) three times a day for wound to coccyx and leg; -Staff to cleanse wound to coccyx with vashe, pat dry, and cover wound with bordered optifoam (an absorbant foam dressing) dressing or equivalent once a day. Review of the resident's wound care companys progress notes, dated 7/31/24, showed the resident had very fragile skin exacerbated by fluid overload which made his/her skin susceptible to tearing and once an opening was there. H e/she may weep heavily from the wound because of the fluid. They cleansed the open pressure ulcer injury and applied santyl (debrides the skin) to wound bed with dressing changes. During an interview on 08/01/24, at 2:33 P.M., LPN E (wound nurse) said the resident had calmoseptine ointment for his/her bottom which wasn't too bad. Calmoseptine can be used for for reddened skin and when the wound is not real deep like sheering. The resident wanted to sit in bed and the wound physician told him/her to get up for one hour a day. The wound physician debrided the coccyx and other areas on the resident and then gave orders for the foam dressing with calcium alginate (absorbs wound fluid). 2. Review of Resident #2's hospital progress note, dated 07/01/24, showed the following: -Deep tissue pressure injury (DTI), unstageable pressure ulcer, on the left buttock; -Non-blanchable purple, red appearance that measured 1.5 cm length by 4.5 cm width. Review of the resident's face sheet showed the following: -admitted [DATE] from the hospital; -Diagnoses included surgical wound/colostomy (a piece of colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon) with colostomy complication and peritoneal abscess (a collection of pus or infected fluid within the abdomen). Review of the resident's care plan, dated 07/05/24, showed the following: -At risk for infection secondary to multiple wounds. Staff to use universal precautions and notify physician of signs and symptoms of infection; -At risk for alteration to skin integrity secondary to moisture. Staff to provide skin and incontinence care assistance as needed, dietitian/nutritional evaluation as needed, standard facility pressure reduction mattress, weekly skin check per facility schedule, and notify physician of alterations for prompt/proper intervention; -Resident has actual skin impairment/wound to midline abdomen and left buttock. In house wound care provider to assess and treat, followed by outside wound care provider, enhanced barrier precautions, supplements to promote wound healing as prescribed, and treatments as prescribed. Review of the resident's nursing admission assessment, dated 07/05/24, showed a small area to buttock noted. Staff cleansed area and applied a dressing. (Staff did not document a full and complete description of the wound.) Review of the resident's Braden scale, dated 07/05/24, showed staff assessed the resident as not at risk for developing pressure ulcers. Review of the resident's skin assessment, dated 7/5/24, showed left buttock shearing and MASD. (Staff did not document a full and complete description of the wound.) Review of the resident's physician's orders showed no documented treatment orders put in place on 07/05/24 for the shearing and MASD. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Supervision for activities of daily living such as toileting, dressing, transfers, rolling left to right in bed; -At risk for developing pressure ulcers; -Had a surgical wound. Review of the resident's skin assessment, dated 07/08/24, showed the following: -A pressure ulcer to the left buttock, pale in color with fair skin turgor and cool to touch. Dry skin and area on left buttock measured 5.5 cm width by 2 cm length and depth 0.4 cm. Resident reports as painful. Large amount of drainage without dressing (soaked through patient's pants); -Cleaned with wound cleanser, pat dry, and cover with foam dressing. Nurse notified the wound care nurse. Resident reported pain with touch or pressure. Nurse recommended pressure cushion in chair. (There was no order in the record for this treatment.) Review of the resident's physician's orders, dated 07/05/24, showed no treatment ordered for the resident's left buttock. (There was a delay in treatment from the resident's admission on 07/5/24 to when a treatment was ordered on 7/10/24) Review of the resident's daily skilled charting, dated 07/10/24 and 07/12/24, showed open lesions, MASD, and other with wound to left buttocks and inner buttocks MASD. (Staff did not document any further description of the wound.) Review of the facility wound report for the resident, dated 7/17/24, showed unspecified ulcer on left buttock, present on admission. Staff identified on 07/10/24, the wound measured 1.2 cm length by 1.8 cm width by 0.1 cm depth. Review of the resident's physician orders, dated 07/10/24, showed a treatment order for the left buttock . Staff to wash with vashe, pat dry, santyl (an enzymatic debridement ointment) to eschar (dark dead tissue on wound), calcium alginate (absorbs wound fluid), border mepilex (a protective foam dressing) once a day every other day and as needed if soiled. (This was the first ordered treatment after admission on 07/05/24.) Review of the resident's current care plan showed the staff did not update the resident's care plan with new or change in interventions for prevention and treatment of pressure ulcers. Review of the resident's daily skilled charting, dated 07/14/24, showed open areas to buttocks. (Staff did not document any further description.) Review of the resident's weekly skin assessment, dated 07/15/24, showed an ulcer to the left buttock, MASD and the wound care company to see the resident on Wednesday (07/17/24). (Staff did not document any further description.) Review of the resident's daily skilled charting, dated 07/17/24, showed an ulcer to left buttock. (Staff did not document any further description.) Review of the resident's wound management charting, dated 07/17/24, showed the following: -Unspecified ulcer identified on 07/10/24 on left buttock 1.2 cm by 1.8 cm ; -Unspecified ulcer identified on 07/17/24, sacrum both sides, present on admission, 7.2 cm X 10 cm . During interview on 08/07/24, at 2:23 P.M., LPN E said the following; -He/she did assess the resident's skin day the resident was admitted on [DATE]. He/she observed the left buttock which was black with red around it like it was a big bruise. It was blackish/purple DTI in the middle. He/she measured it as 4.2 cm length by 4 cm width, but it was not open and had no depth. The resident would not lie down, but stayed up in the recliner because he/she said it was hard to breathe lying down. -He/she does measurements on Wednesdays and measured the resident's wounds on 07/10/24. The left buttock measured 6.3 cm length by 4.5 cm width by 0.1 cm depth with pinhole drainage. He/she called the physician and the wound care physician to see this resident. He/she did put a dressing of calcium alginate with Santyl on the left buttock; -The wound care physician saw the resident on 07/17/24 and the left wound pressure injury measured 7.2 cm length by 10 cm width by 0.2 cm depth and had opened up. The wound care physician debrided the wound and then the resident went to the hospital that night. 3. During interviews on 07/30/24, at 1:30 P.M. and 4:04 P.M., LPN A said when they have a new admission to the facility, the admitting nurse does the skin assessment from head to toe. The former DON, did not want them to measure wounds, but just say what it looked like in the documentation. They recently found out from the DON that they were to measure any wound, describe the appearance, location, drainage, and any odor. They have a full time wound nurse who works Monday, Wednesday, and Friday. The wound nurse does the weekly skin assessments. They were to notify the physician for any wound treatments. 4. During interviews on 07/30/24, at 2:10 P.M. and 4:06 P.M., LPN B said when they admit a new resident to the facility, they were to do a head to toe skin assessment and look for wounds and pressure areas. He/she did not measure any wounds, but was taught like quarter size and dime size as describing sizes and would describe its appearance. The wound nurse comes in on Monday, Wednesday, and Friday and they were to look at wounds and document any changes. 5. During an interview on 08/01/24, at 12:55 P.M., Registered Nurse (RN) D said when they admitted a new resident, they were to do a head to toe skin assessment which included their bottom, for redness and breakdown. If the wound nurse was here that day, he/she would go with him/her to catch anything he/she might miss. They look at the size and appearance of wounds, but since there was a discrepancy with measuring wounds, they would just document drainage, odor, color, how much drainage, temperature, and would notify the physician. They have training for staging pressure wounds, but they were to describe them. Calmoseptine is a barrier cream and they do use a foam dressing when needed. DTI-coccyx is not a skin assessment. The wound nurse does the weekly skin assessments. 6. During interviews on 08/01/24, at 2:33 P.M., and on 08/07/24, at 2:23 P.M., LPN E said the following: -He/she worked at the facility on Monday, Wednesday, and Friday and usually worked 7:30 A.M. to 5:30 P.M. He/she did not work on his/her days off or weekends; -He/she does all wound measurements on Wednesdays at the facility and documents all measurements in a wound book kept at the nurses' station; -He/she will try to get all this documentation in the residents' wound management in their electronic medical record, but it takes a long time; -He/she has the wound book to check if something was missed in the resident's electronic medical record for wounds; -Staff were to assess any wounds and leave a note for him/her. They were to call the wound physician for treatment orders. LPN A was the only nurse who calls him/her about residents' wounds; -He/she expected staff to measure any open area, bruise, and pressure and see what was going on with this; -Staff were to do daily treatments on wounds, but not always getting done; -They did stage wounds and the physician was to measure and/or stage wounds for him/her. He/she will let the physician and the wound physician know when the resident's wounds have changed in condition; -For the wound description of Coccyx-DTI, this could be an area that was badly bruised and could be open but would need more description of this; -He/she would expect staff to daily look at the residents' coccyx, heels, and when staff do daily cares and showers/baths. During interviews on 07/30/24, at 10:55 A.M., and on 08/01/24, at 12:06 P.M., the DON said the following: -The nurses were not describing or measuring wounds upon admission. They were dependent on the wound nurse to do the skin assessments; -Nurses were to measure all wounds and observe for odor, signs and symptoms of infection, appearance of the wound but were not to stage any wounds; -They were to call the physician or the physician's nurse practitioner for wound orders; -Calmoseptine was a barrier cream; -There were no standing orders for wound treatments and dressings; -If a small wound was stable and had a treatment and they were on supplements, they would not contact the wound company physician unless interventions were not working and the wounds became worse; -They were to update the care plan with any changes and new interventions. During an interview on 08/06/24, at 1:37 P.M., the Administrator said the following: -Staff were to do a full skin assessment on a resident and document this assessment; -They were to describe, measure all pressure injuries and wounds and notify physician of open areas for treatment; -If there was no dressing on an open pressure injury or wound, he/she would expect staff to call the physician and ask what was best for this; -She would expect staff to update the care plan with new interventions for any new pressure injuries and wounds with changes. During an interview on 08/05/24, at 3:38 P.M., the Medical Director said the following: -Prevention is the biggest factor for skin breakdown; -A resident's skin can have breakdown within three hours due to being partially immobile, too weak, and incapacitated. Healing wounds were difficult and staff need to prevent wounds developing and getting worse; -When a resident comes in the door, staff need to identify issues with skin breakdown and what factors could cause skin breakdown and attempt to prevent them. MO00239551 and MO00240004

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers, when staff stacked dishes while still wet, and when staff failed to ensure the dishwasher rinsed the dishes at the recommended temperature. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 37 residents. 1. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Observations of the kitchen on 11/06/23, at 8:45 A.M., showed the following: -An opened bag of parmesan cheese in the walk in refrigerator with a binder clip on it. The bag was not sealed and was partially opened to the air; -A large steel container in the walk in freezer with aluminum foil covering the top labeled chicken rice soup. The aluminum foil had several holes in it leaving it exposed to the air ; -Boxes of frozen broccoli, chopped spinach, and cauliflower in plastic with the plastic opened. The vegetables were exposed to the open air. Observations of the kitchen on 11/07/23, at 10:25 A.M., showed the following: -A large steel container in the walk in freezer with aluminum foil covering the top labeled chicken rice soup. The aluminum foil had several holes in it leaving it exposed to the air; -Boxes of frozen broccoli, chopped spinach, and cauliflower in opened plastic bags that were not sealed. The vegetables were exposed to the open air; -A box of individual frozen rolls in a plastic bag, opened and not sealed. Observations of the kitchen on 11/08/23, at 12:29 P.M., showed the following: -A large steel container in the walk in freezer with aluminum foil covering the top labeled chicken rice soup. The aluminum foil had several holes in it leaving it exposed to the air; -Boxes of frozen broccoli, chopped spinach, and cauliflower in opened plastic bags that were not sealed. The vegetables were exposed to the open air; -A box of individual frozen rolls in a plastic bag, opened and not sealed. During an interview on 11/09/23, at 10:17 AM, Dietary Aide G said the following: -Staff should ensure opened food packages are sealed; -Soup should be stored in plastic with a lid; -Staff should seal opened frozen vegetables and rolls. Unsealed food in freezer can become freezer burnt; -Bags of opened food, such as parmesan cheese, should be placed in a zip lock bag, sealed. During an interview on 11/09/23, at 10:32 A.M., Cook H said the following: -Staff should seal food; -A bag of opened parmesan cheese should be stored in a sealed zip lock bag; -Plastic bags of vegetables and rolls in the freezer should have the bag tied for sealing to protect from freezer burn; -Soup should stored in plastic and sealed. During interviews on 11/09/23, at 10:45 A.M. and 12:30 P.M., the Dietary Manager said the following: -All opened foods should be sealed; -An opened bag of parmesan cheese should be placed in a plastic container with a lid or original bag by rolling it and placing a black clip on it or bread tie; -Soup should not be stored in a metal container in the freezer with aluminum foil covering. Soup should be stored in a plastic container with a lid and be labeled. During an interview on 11/09/23, at 2:00 P.M., the Administrator said the following: -All opened foods should be sealed; -A bag of opened parmesan cheese should be sealed; -Bags of opened frozen vegetables and rolls should be sealed; -Soup should be stored in plastic and sealed. 2. Review showed the facility did not provide a policy regarding drying, stacking, and storing dishes. Review of the Missouri Food Code, published 2013, showed dishes are required to be air dried before being stacked and stored. Observations of the kitchen on 11/06/23, at 8:45 A.M., showed the following: -Multiple plastic cups stacked upside down with moisture visible trapped inside; -Multiple water cups stored upside down with visible moisture trapped inside. Observations of the kitchen on 11/07/23, at 10:25 A.M., showed the following: -Multiple water cups stored upside down with visible trapped moisture inside; -Multiple small cups stacked upside down with visible trapped moisture inside. Observations of the kitchen on 11/08/23, at 9:30 A.M., showed multiple water cups stored upside down with visible trapped moisture inside. During an interview on 11/09/23, at 10:17 A.M., Dietary Aide G said the following: -Dishes should be air dried on dish rack before storing; -Staff should never store cups containing moisture, which can cause bacteria or mold. During an interview on 11/09/23, at 10:32 A.M., Cook H said the following: -Dishes should be air dried on racks before being stored for use; -Cups never be stacked with moisture, which can cause bacteria and mold. During interviews on 11/09/23, at 10:45 A.M. and 12:30 P.M., the Dietary Manager said the following: -Dishes should be air dried before storing; -Cups should be checked for moisture before stacking or storing as moisture can cause bacteria. During an interview on 11/09/23, at 2:00 P.M., the Administrator said the following: -Dishes should be air dried prior to storing; -Cups should not contain moisture before storing/stacking. 3. Record review of the facility policy titled, Dishwasher Temperature, showed the following: -It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures; -Manufacturer's instructions shall be followed for machine washing and sanitizing; -For high temperature washers the wash temperature for a stationary rack, dual temperature machine 150 degrees Fahrenheit (F); -The final rinse shall be 180 degree F; -Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. Observations of the kitchen and record review of the dishwasher temperature logs on 11/08/23, at 1:19 P.M. showed the following: -The rinse cycle showed a temperature of 177 degrees F during the first observation; -The rinse cycle showed a temperature of 172 degrees F during four subsequent cycles; -The temperature logs for the rinse cycle from 11/01/23 to 11/07/23 showed the highest temperature documented to be 167 degrees F. During an interview on 11/09/23, at 10:17 A.M., Dietary Aide G said the following: -Manufacture recommendations for the dishwasher temperatures are 150 degrees for the wash cycle and 180 degrees for the rinse cycle; -Staff should document temperatures in the log book two times per day, morning and evening; -Staff should notify maintenance immediately if the temperatures are not meeting 150 degrees during the wash cycle and 180 degrees during the rinse cycle. During an interview on 11/09/23, at 10:32 A.M., Cook H said the following: -Dishwasher temperatures should be documented daily in the temperature log; -The dishwasher temperatures should 160 degrees for the wash cycle and 180 degrees for the rinse cycle; -Staff should notify the Dietary Manager or maintenance immediately if the dishwasher is not running at the appropriate temperatures. During an interview on 11/09/23, at 10:45 A.M. and 12:30 P.M., the Dietary Manager said the following: -Staff should document dishwasher temperatures in the morning and evening in the temperature log; -Manufacture recommendations for dishwasher temperatures are 150 degrees for wash cycle and 180 degrees for rinse cycle; -Staff should notify the Dietary Manager or maintenance immediately if the temperatures are not running at manufacturer's recommendations. During an interview on 11/09/23, at 2:00 P.M., the Administrator said the following: -Staff should document the dishwasher temperatures in the temperature log daily; -Manufacture recommendations for the dishwasher temperatures are 150 for the wash cycle and 180 for the rinse cycle; -Staff should notify the Dietary Manager if the temperatures are not hot enough.

Based on record review and interview, the facility failed to ensure a resident's choice of code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) was accurate and matched throughout the record when three residents' (Resident #135, #133, & #132) code statuses (do not resuscitate (DNR - the resident did not wish to received cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions often combined with artificial ventilation) or CPR (full code status)) failed matched through the medical record. A sample of 13 residents was selected for review out of a facility census of 37. Review of the facility policy titled Communication of Code Status. dated [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; -In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -The facility will follow policy regarding a resident's right to request, refuse and/or discontinue medication or surgical treatment and to formulate an Advance Directive; -When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medication record; -Examples of directions to be documented include, but are not limited to full code, do not resuscitate, do not intubate, and do not hospitalize; -The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record; -In the absence of an Advance Directive or further direction from the physician, the default direction will be full code; -The presence of an Advance Directive or any physician directives relate to the absence or presence of an Advance Directive shall be communicated to Social Services; -The Social Services Director (SSD) shall maintain a list of residents who have an Advance Directive on file; -The resident's code status will be reviewed at least quarterly and documented in the medical record. 1. Review of Resident #135's face sheet showed the following information: -admitted [DATE]; -Diagnoses included non-rheumatic aortic valve stenosis (thickening and narrowing of the valve between the heart's main pumping chamber and the body's main artery), congestive heart failure (CHF - a condition in which the heart doesn't pump blood as efficiently as it should), chronic kidney disease state 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of the blood), history of malignant neoplasm (cancer) of large intestine (portion of the digestive system most responsible for absorption of water from the indigestible residue of food); -DNR status. Review of the resident's physician's order sheet, up to date as of [DATE], showed an order, dated [DATE], for full code status. Review of the facility binder titled Code Book at the nursing station showed a purple signed sheet titled Outside the Hospital DNR Order, dated [DATE], signed by the resident. Review of the resident's care plan, dated [DATE], showed the following: -Resident had a do not resuscitate form signed and in place; -The resident code status will be honored during their stay in the facility; -If the patient's heart stops or patient stops breathing, CPR will not be initiated; -The patient may change their code status any time. 2. Review of Resident #133's face sheet showed the following information: -admitted [DATE]; -Diagnoses included asthma (respiratory condition causing difficulty in breathing, usually from an allergic reaction) with acute exacerbation (sudden worsening of symptoms), chronic obstructive pulmonary disease (COPD, condition involving constriction of the airways and difficulty or discomfort in breathing), pneumonia (lung inflammation caused by bacterial or viral infection), shortness of breath, acute and chronic respiratory failure (a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (deficiency in the amount of oxygen reaching the tissues), chronic kidney disease stage 3 (kidneys have mild to moderate damage, and are less able to filter waste and fluid out of your blood), cardiomyopathy (chronic disease of the heart muscle), atrial fibrillation, and heart failure (lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen); -DNR code status. Review of the physician's order sheet, up to date as of [DATE], showed an order, dated [DATE], for full code status. Review of the resident's care plan, dated [DATE], showed the following: -Resident has a full code post signed and in place; -The resident code status will be honored during their stay in the facility; -If the patient's heart stops or patient stops breathing, CPR will be immediately initiated per protocol; -The patient may change their code status any time. Review of the binder titled Code Book at the nursing station showed a purple signed sheet titled Outside the Hospital DNR Order, dated [DATE], signed by the resident. 3. Review of Resident #132's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnosis included cerebral infarction (stroke), acute kidney failure (kidneys suddenly become unable to filter waste products from the blood), gastrointestinal hemorrhage (any type of bleeding that starts in the digestive tract), type 2 diabetes mellitus (problem in the way the body regulates and uses sugar as a fuel), atrial fibrillation (irregular and often very rapid heart rhythm), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), and other signs and symptoms involving cognitive function following cerebral infarction; -DNR code status. Review of the resident's physician's order sheet, up to date as of [DATE], showed an order, dated [DATE], for full code status. Review of the binder titled Code Book at the nursing station showed. a purple signed sheet titled Outside the Hospital DNR Order, dated [DATE], signed by the resident. Review of the resident's care plan, dated [DATE], showed the following: -Resident has a full code post signed and in place; -The resident code status will be honored during their stay in the facility; -If the patient's heart stops or patient stops breathing, CPR will be immediately initiated per protocol; -The patient may change their code status any time. 4. During an interview on [DATE], at 9:30 A.M., Certified Nurse Aide (CNA) D said code status is discussed during shift report and can be found on the resident profile in the EMR and in a book at the nurse station. He/she said it should match at each area. 5. During an interview on [DATE], at 9:45 A.M., CNA J and CNA E said that resident code status is found on the face sheet in the EMR and is on the printed ADL sheets. It should match on all areas. 6. During an interview on [DATE], at 9:55 A.M., Certified Medication Tech (CMT) A said that code status is in the resident electronic medical record and in the code book at the nurse desk and should match. He/she would notify the nurse if it did not match. 7. During an interview on [DATE], at 10:20 A.M., Licensed Practical Nurse (LPN) I said that code status should be on the resident's face sheet, physician orders, care plan, and the code status book and it should all match. He/she thought the Assisted Director of Nursing (ADON)/Director of Nursing (DON) audit charts. When he/she entered information into the care plan, he/she checked that it matches the orders. 8. During an interview on [DATE], at 11:20 A.M., Registered Nurse (RN) B said that code status can quickly be found in the EMR on the resident's face sheet and there is also a signed copy in the code book at the nurse desk. There will also be a physician order, but it was quickest to check the face sheet and code book. He/she said the information should match throughout the chart. 9. During an interview on [DATE], at 1:35 P.M., the DON said that code status was located on the resident's face sheet in the EMR and in the physician orders and that it should match throughout chart. The DON and ADON audit resident charts within 48 hours of admission for accuracy. The offsite central intake from corporate enters the physician orders, which included the code status, and should be auditing the chart as well. 10. During an interview on [DATE], at 2:00 P.M., the Administrator said that a resident's code status can be found in EMR on the face sheet, the physician orders, and the care plan. The code status should match throughout the record.

Based on observation, record review, and interviews, the facility failed to ensure the interdisciplinary team approved all self-administration of medication, obtained orders for the self-administration of medication, and care planned the self-administration for two residents (Resident #182 and #87) with a medication at bedside. The facility census was 37. Review of the facility policy titled Resident Self-Administration of Medication, dated June 2023, showed the following information: -It is the policy of this facility to support each resident's right to self-administer medication; -A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; - Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team; -Resident's preference will be documented on the appropriate form and placed in the medical record; -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the medications appropriate and safe for self-administration; the resident's physical capacity to swallow without difficulty, open medication bottles, administer injections; the resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; the resident's comprehension of instructions for the medications they are taking, including dosing, timing, and signs of side effects, and when to report to staff; the resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to education when this occurs; and the resident's ability to ensure the medication is stored safely and securely; -The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Form, which is placed in the resident's medical record; -Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the Medication Administration Record (MAR); -Only one signature per shift is required when documenting the resident's report of self-administration; -Bedside medication storage is permitted only when it does not present a risk to confused resident who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication; -All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage; -Unauthorized medications are given to the charge nurse for return to the family or responsible party; -Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary; -Medications stored at the bedside are re-ordered in the same manner as other medications; -Diabetic resident with attached insulin pumps for glucose control will follow the physician's orders for basal rates and/or bolus doses, blood glucose checks, and changing of infusion sets/tubing, cartridges, reservoirs, or syringes for the insulin and will notify staff of any changes in glucose reading, skin changes at the site of insertion or pain at the delivery site; -The care plan must reflect resident self-administration and storage arrangements for such medications; -Medication errors occurring with residents who self-administer will not be counted in the facility's medication error rate; -A re-assessment for safety at a minimum should be considered by the interdisciplinary team for signification change in resident's status and medications errors. 1. Review of Resident #182's face sheet included the following: -admitted [DATE]; -Diagnoses included asthma (respiratory condition causing difficulty in breathing, usually results from an allergic reaction). During observation and interview on 11/08/23, at 11:34 A.M., an albuterol inhaler (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung disease) was on the resident's bedside table. The resident said he/she required the inhaler for use as needed due to history of asthma. Review of the resident's physician order sheet, current as of 11/09/23, showed the following: -An order, dated 11/03/23, for albuterol sulfate HFA aerosol inhaler, 90 mcg (micrograms)/actuation (dose of medication), two puffs every four hours as needed for wheezing; -No order for the resident to have the inhaler at bedside. Review of the resident's care plan, dated 11/07/23, showed staff did not care plan related to the resident keeping a medication at bedside and self-administering medication. 2. Review of Resident #87's face sheet included the following information: -admitted [DATE]; -Diagnosis included congestive heart failure (CHF - the heart can't pump enough blood), pneumonia (lung inflammation caused by bacterial or viral infection), chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), acute respiratory failure (the inability of the respiratory system to meet the oxygen requirements) with hypoxia (reduction in the normal level of oxygen available to cells or tissues that arises when oxygen demand exceeds oxygen supply), and generalized muscle weakness. During observation and interview on 11/08/23, at 3:26 P.M., an albuterol inhaler was on the resident's bedside table. The resident said he/she required the inhaler for use as needed due occasional shortness of breath. Review of the resident's physician order sheet, current as of 11/09/23, showed the following: -An order, dated 10/26/23, for albuterol sulfate HFA aerosol inhaler, 90 mcg/actuation, two puffs every six hours as needed for shortness of breath; -No order for the resident to have the inhaler at bedside. Review of the resident's care plan, dated 11/07/23, showed staff did not care plan related to the resident keeping a medication at bedside and self-administering medication. 3. During an interview on 11/09/23, at 9:55 A.M., Certified Medication Tech (CMT) A said that medications, including inhalers, should not be in a resident room without a physician order. He/she would remove the medication if seen in a resident's room without an order and notify the nurse. 4. During an interview on 11/09/23, at 10:10 A.M., Registered Nurse (RN) C said that if he/she saw a medication in a resident room, he/she would check for an order for the medication to be at bedside and if there was not an order he/she would notify the Director of Nursing (DON). 5. During an interview on 11/09/23, at 11:20 A.M., RN B said medications, including inhalers, should be left in the medication cart to ensure the resident is receiving the medication at the right time and the right amount of times per day. Occasionally, there will be a doctor's order that medication may be left at bedside, but staff would want to ensure the resident is cognitively intact. Even if a resident was on isolation precautions the inhaler could be kept in a baggy and put away from the resident in the resident's room. 6. During an interview on 11/09/23, at 1:35 P.M., the DON said that inhalers should not be in resident rooms unless there is a physician order. Some families will bring in from home even when advised against policy. 7. During an interview on 11/09/23, at 2:00 P.M., the Administrator said that medications should not be left in the resident room without an order. If a family/resident wants a medication in the room, staff should request an order from the physician.

\\ Based on record review and interview, the facility failed to complete a discharge Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident #6) in a timely manner. The facility census was 37. Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #6's face sheet showed an admitted [DATE]. Review of the resident's electronic medical record (EMR), census tab, showed the following: -admitted [DATE]; -discharge date of [DATE] with return not anticipated. Review of the resident's EMR progress notes showed the following: -On 06/29/23, at 5:00 P.M., Social Services documented the resident planned to discharge home with family and any needed services and/or equipment were in place. Family planned to pick up the resident at 4:00 P.M. on 06/30/23; -On 06/30/23, at 8:39 A.M., nursing staff documented the resident plan was to discharge this date. Review of the resident's EMR, MDS tab, showed the following: -Entry MDS dated [DATE]; -Five-day MDS dated [DATE]; -Admission MDS dated [DATE]; -No discharge MDS in the EMR (greater than 120 days since discharge). During an interview on 11/08/23, at 1:46 P.M., the MDS Coordinator said he/she started in the current position in early September. He/she runs a report daily to every other day to determine what MDS need to be completed. He/she ran the report back to September. During an interview on 11/08/23, at 1:49 P.M., the Administrator said the expectation is for staff to run reports and complete MDS as scheduled in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 27 opportunities resulting in an error rate of 7.4% when staff failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: -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, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Compare medication card with MAR to verify the resident name, medication name, form, dose, route, and time; -Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects; -Administer medication as ordered in accordance with manufacturer specifications. Review of the facility policy titled Insulin Pen, dated June 2023, showed the following information: -It is the policy of this facility to use insulin (hormone that lowers the level of glucose (a type of sugar) in the blood) pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare resident for self-administration of insulin therapy upon discharge; -Insulin pens contain multiple doses of insulin, but are used for a single resident only; -Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date; -A new needle will be used for each injection; -Monitor blood sugar as ordered by physician; -Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; -Always review physician orders prior to administering any medication; -Remove the pen cap from the insulin pen, wipe the rubber seal with an alcohol pad, screw the pen needle onto the insulin pen, twist open, and remove outer cover from the pen needle; -Prime the insulin pen by dialing pen to two units by turning the dose selector clockwise, with the needle pointing up. Push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop of insulin appears; -Set the insulin dose by turning the dose selector to ordered dose. Check the dose a second time; -Administer the insulin; -Document the dosage, site, and time in the medication record. Record review of the insulin aspart (generic for Novolog - rapid acting insulin) flexpen manufacturer's website, dated February 2023, showed the following information: -This product is a rapid acting human insulin indicated to improve glycemic (measure of how quickly a food causes our blood sugar levels to rise) control in adults and children with diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)); -Instruction for use include: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Give an air shot before each injection. Turn the dose selector to select two units, hold the pen with the needle pointing up, tap the cartridge gently a few time to make any air bubbles collect at the top; -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and report the procedure no more than six times; -Turn the dose selector to select the number of units you need to inject. The pointer should line up with the dose. Record review of the insulin lispro (generic name for Humalog - short acting insulin) last revised December 2021, showed the following: -Insulin lispro injection products are short-acting, man-made version of human insulin. It works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy; -Instruction for use include; -Pull off the pen cap and wipe the rubber seal with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If the pen is not primed before each injection, may get too much or too little insulin; -To prime the pen, turn the dose selector to select two units, hold the pen with the needle pointing up, and tap the cartridge gently a few times to make any air bubbles collect at the top; -Continue holding the pen with the needle pointing upwards, press the dose knob all the way in and count to five slowly. Insulin should appear at the tip of the needle. If not, repeat priming, no more than four times; -Turn the dose selector to select the number of units needed to inject. The dose indicator should line up with the dose; -Always check the number in the dose window to ensure the dialed dose is correct; -Give the injection. 1. Record review of Resident #132's face sheet showed to the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with hyperglycemia (excess of glucose in the bloodstream). Review of the resident's physician orders sheet (POS), current as of 11/09/23, showed the following: -An order, dated 10/31/23 with discontinued date of 11/07/23, for insulin lispro (Humalog) solution 100 unit/milliliter (ml), give per sliding scale before meals and at bedtime; -If resident's blood sugar is less than 70 milligrams/deciliter (mg/dL), call the physician; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. -An order, dated 11/07/23, for insulin aspart (insulin mixture) U-100 cartridge, 100 unit/ml, give per sliding scale before meals and at bedtime due to type 2 diabetes mellitus; -If resident's blood sugar is less than 70 mg/dL, call the physician; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. Observation on 11/08/23, at 11:10 A.M., showed Licensed Practical Nurse (LPN) K prepared the resident's insulin. He/she removed an insulin lispro pen from the medication cart with the resident's name on it, removed the cap from the insulin Lispro pen, and put on a new needle. Without priming the pen, the LPN turned the dial to the 4 indicator mark for a blood glucose ready of 137 mg/dL. He/she entered the resident's room and used an alcohol wipe to clean the resident's left upper arm. The LPN injected the 4 units of insulin lispro. He/she the returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record and put the pen back into the medication cart. (The order for insulin lispro ended on 11/07/23.) 2. Review of Resident #134's face sheet showed to the following: -admitted on [DATE]; -Diagnosis included type 2 diabetes mellitus with hyperglycemia. Review of the resident's POS, current as of 11/09/23, showed the following: -An order, dated 10/27/23, for Humalog Kwikpen Insulin (insulin lispro) insulin pen, 100 unit/ml, give seven units subcutaneous (administered under the skin), three times per day with meals; -An order, dated 10/27/23, for Humalog Kwikpen Insulin (insulin lispro) insulin pen, 100 unit/ml, give per sliding scale due to type 2 diabetes mellitus, four times per day before meals and at bedtime; -If blood sugar is less than 70 mg/dL call the physician; -If resident's blood sugar is 70 mg/dL to 130 mg/dL, administer zero units of insulin; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. Observation on 11/08/23, at 11:20 A.M., showed Licensed Practical Nurse (LPN) K removed an insulin Lispro pen from the medication cart with the resident's name on it, removed the cap and applied a new needle. Without priming the pen the LPN turned the dial to '15' indicator mark for a blood glucose of 193. He/she entered the resident's room and used an alcohol wipe to clean the resident's right upper arm. The LPN injected the 15 units of insulin Lispro. He/she the returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record and put the pen back into the medication cart. 3. During an interview on 11/09/23, at 10:10 A.M., Registered Nurse (RN) C said that staff should follow the manufacturer instructions when administering insulin pens. Nursing staff should check the blood sugar, then follow physician orders for dose and type of insulin. The nurse should remove the lid, turn the dose to the unit to administer, put on a needle, and proceed with administration including alcohol wipe to the resident skin site. The nurse should then document and dispose of supplies appropriately and store the pen in the medication cart. 4. During an interview on 11/09/23, at 10:20 A.M., LPN I said that when staff are preparing to administer insulin from an insulin pen, they should take off pen cap, apply needle after wiping the stopper with alcohol wipe. Staff should turn to two units to prime the pen and remove any air bubbles. Then they should dial to the dose to administer per the physician orders. 5. During an interview on 11/09/23, at 11:20 A.M., RN B said that nursing staff should take the cap off the appropriate insulin pen, take off the cap, wipe with alcohol wipe, and apply a new needle. Staff should prime with two units to remove air bubbles and then dial to the total dose ordered. Staff should ensure to have the correct medication according to physician orders. 6. During an interview on 11/09/23, at 1:35 P.M., the Director of Nursing (DON) said that staff should ensure they use the correct insulin pens per physician orders, they should prime the pen with two units prior to turning the dose to the physician ordered dose. Staff should always follow physician orders for name and dose of medication. Staff should not give insulin lispro if order is for insulin aspart, they are different medications. 7. During an interview on 11/09/23, at 2:00 P.M., the Administrator said that staff should follow the physician orders for medication administration and staff should prime the pen. Staff should follow the physician orders for medication name and dose.

Based on observation, interview, and record review, the facility failed to ensure resident were free of significan medication erros when failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: -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, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Compare medication card with MAR to verify the resident name, medication name, form, dose, route, and time; -Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects; -Administer medication as ordered in accordance with manufacturer specifications. Review of the facility policy titled Insulin Pen, dated June 2023, showed the following information: -It is the policy of this facility to use insulin (hormone that lowers the level of glucose (a type of sugar) in the blood) pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare resident for self-administration of insulin therapy upon discharge; -Insulin pens contain multiple doses of insulin, but are used for a single resident only; -Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date; -A new needle will be used for each injection; -Monitor blood sugar as ordered by physician; -Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; -Always review physician orders prior to administering any medication; -Remove the pen cap from the insulin pen, wipe the rubber seal with an alcohol pad, screw the pen needle onto the insulin pen, twist open, and remove outer cover from the pen needle; -Prime the insulin pen by dialing pen to two units by turning the dose selector clockwise, with the needle pointing up. Push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop of insulin appears; -Set the insulin dose by turning the dose selector to ordered dose. Check the dose a second time; -Administer the insulin; -Document the dosage, site, and time in the medication record. Record review of the insulin aspart (generic for Novolog - rapid acting insulin) flexpen manufacturer's website, dated February 2023, showed the following information: -This product is a rapid acting human insulin indicated to improve glycemic (measure of how quickly a food causes our blood sugar levels to rise) control in adults and children with diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)); -Instruction for use include: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Give an air shot before each injection. Turn the dose selector to select two units, hold the pen with the needle pointing up, tap the cartridge gently a few time to make any air bubbles collect at the top; -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and report the procedure no more than six times; -Turn the dose selector to select the number of units you need to inject. The pointer should line up with the dose. Record review of the insulin lispro (generic name for Humalog - short acting insulin) last revised December 2021, showed the following: -Insulin lispro injection products are short-acting, man-made version of human insulin. It works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy; -Instruction for use include; -Pull off the pen cap and wipe the rubber seal with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If the pen is not primed before each injection, may get too much or too little insulin; -To prime the pen, turn the dose selector to select two units, hold the pen with the needle pointing up, and tap the cartridge gently a few times to make any air bubbles collect at the top; -Continue holding the pen with the needle pointing upwards, press the dose knob all the way in and count to five slowly. Insulin should appear at the tip of the needle. If not, repeat priming, no more than four times; -Turn the dose selector to select the number of units needed to inject. The dose indicator should line up with the dose; -Always check the number in the dose window to ensure the dialed dose is correct; -Give the injection. 1. Record review of Resident #132's face sheet showed to the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with hyperglycemia (excess of glucose in the bloodstream). Review of the resident's physician orders sheet (POS), current as of 11/09/23, showed the following: -An order, dated 10/31/23 with discontinued date of 11/07/23, for insulin lispro (Humalog) solution 100 unit/milliliter (ml), give per sliding scale before meals and at bedtime; -If resident's blood sugar is less than 70 milligrams/deciliter (mg/dL), call the physician; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. -An order, dated 11/07/23, for insulin aspart (insulin mixture) U-100 cartridge, 100 unit/ml, give per sliding scale before meals and at bedtime due to type 2 diabetes mellitus; -If resident's blood sugar is less than 70 mg/dL, call the physician; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. Observation on 11/08/23, at 11:10 A.M., showed Licensed Practical Nurse (LPN) K prepared the resident's insulin. He/she removed an insulin lispro pen from the medication cart with the resident's name on it, removed the cap from the insulin Lispro pen, and put on a new needle. Without priming the pen, the LPN turned the dial to the 4 indicator mark for a blood glucose ready of 137 mg/dL. He/she entered the resident's room and used an alcohol wipe to clean the resident's left upper arm. The LPN injected the 4 units of insulin lispro. He/she the returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record and put the pen back into the medication cart. (The order for insulin lispro ended on 11/07/23.) 2. Review of Resident #134's face sheet showed to the following: -admitted on [DATE]; -Diagnosis included type 2 diabetes mellitus with hyperglycemia. Review of the resident's POS, current as of 11/09/23, showed the following: -An order, dated 10/27/23, for Humalog Kwikpen Insulin (insulin lispro) insulin pen, 100 unit/ml, give seven units subcutaneous (administered under the skin), three times per day with meals; -An order, dated 10/27/23, for Humalog Kwikpen Insulin (insulin lispro) insulin pen, 100 unit/ml, give per sliding scale due to type 2 diabetes mellitus, four times per day before meals and at bedtime; -If blood sugar is less than 70 mg/dL call the physician; -If resident's blood sugar is 70 mg/dL to 130 mg/dL, administer zero units of insulin; -If resident's blood sugar is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If resident's blood sugar is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If resident's blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If resident's blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If resident's blood sugar is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If resident's blood sugar is 451 mg/dL to 500 mg/dL, administer 30 units of insulin; -If resident's blood sugar is greater than 500 mg/dL, call the physician. Observation on 11/08/23, at 11:20 A.M., showed Licensed Practical Nurse (LPN) K removed an insulin Lispro pen from the medication cart with the resident's name on it, removed the cap and applied a new needle. Without priming the pen the LPN turned the dial to '15' indicator mark for a blood glucose of 193. He/she entered the resident's room and used an alcohol wipe to clean the resident's right upper arm. The LPN injected the 15 units of insulin Lispro. He/she the returned to the medication cart, removed the needle, and entered the required information into the resident's medication administration record and put the pen back into the medication cart. 3. During an interview on 11/09/23, at 10:10 A.M., Registered Nurse (RN) C said that staff should follow the manufacturer instructions when administering insulin pens. Nursing staff should check the blood sugar, then follow physician orders for dose and type of insulin. The nurse should remove the lid, turn the dose to the unit to administer, put on a needle, and proceed with administration including alcohol wipe to the resident skin site. The nurse should then document and dispose of supplies appropriately and store the pen in the medication cart. 4. During an interview on 11/09/23, at 10:20 A.M., LPN I said that when staff are preparing to administer insulin from an insulin pen, they should take off pen cap, apply needle after wiping the stopper with alcohol wipe. Staff should turn to two units to prime the pen and remove any air bubbles. Then they should dial to the dose to administer per the physician orders. 5. During an interview on 11/09/23, at 11:20 A.M., RN B said that nursing staff should take the cap off the appropriate insulin pen, take off the cap, wipe with alcohol wipe, and apply a new needle. Staff should prime with two units to remove air bubbles and then dial to the total dose ordered. Staff should ensure to have the correct medication according to physician orders. 6. During an interview on 11/09/23, at 1:35 P.M., the Director of Nursing (DON) said that staff should ensure they use the correct insulin pens per physician orders, they should prime the pen with two units prior to turning the dose to the physician ordered dose. Staff should always follow physician orders for name and dose of medication. Staff should not give insulin lispro if order is for insulin aspart, they are different medications. 7. During an interview on 11/09/23, at 2:00 P.M., the Administrator said that staff should follow the physician orders for medication administration and staff should prime the pen. Staff should follow the physician orders for medication name and dose.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer insulin as ordered for two days for one resident (Resident #1,) out of a sample of one resident, resulting in the resident being hospitalized with hyperglycemia (high blood sugar). The facility census was 33. On 07/15/23, at 12:30 P.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 07/10/23. On 07/14/23, the facility notified the Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, started having the corporate office enter all new orders for admissions, began doing multiple checks of all new orders, and in-serviced all facility staff involved in new orders prior to working the floor. The IJ was removed and corrected on 7/14/23. Review of the facility's policy titled Administering Medications, dated December 2012, showed the following: -Medications shall be administered in a safe and timely manner and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included Type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and chronic kidney disease stage 3 (moderate kidney damage). Review of the resident's hospital discharge summary, dated 07/10/23, showed the following: -Finger stick blood glucose check before meals and at bedtime; -Insulin aspart 100 unit/milliliter (a short acting insulin), 5 units with meals plus sliding scale. Maximum dose of 50 units daily; -Insulin degludec (a long acting insulin) 100 units/milliliter (ml) solution, 20 units by subcutaneous (beneath the skin) injection daily; -The discharge summary did not show parameters for a sliding scale. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/12/23, showed the resident was severely cognitively impaired. Review of the resident's care plan, updated 07/12/23, showed the following: -The resident had impaired cognition secondary to Alzheimer's; -The resident was a diabetic; -Monitor blood sugar levels as prescribed. Review of the resident's physician orders, dated 07/01/23 to 07/15/23, showed facility staff did not enter insulin orders or blood sugar checks for the resident. Review of the resident's Medication Administration Record (MAR), dated 07/01/23 to 07/15/23, showed staff did not document performing insulin administration or glucose checks. Review of the resident's nursing note dated 07/13/23, at 12:26 A.M., showed the resident had been lethargic and belly breathing (using abdominal muscles to assist breathing) according to the off-going nurse. Labs and a chest x-ray were ordered. A nurse aide expressed concern of resident being sweaty and lethargic. The nurse assessed the resident to see Kussmaul breathing (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace. It is a sign of a medical emergency, usually occurring with diabetes-related ketoacidosis (a condition that occurs when there is not enough insulin in the body), which can affect people with diabetes) and the resident was sweaty. An accu-check (glucose test) was performed and read hi with no number. Resident did not respond to the finger stick or sternal rub (a firm rub on the flat part of the chest to see if there is a reaction). The nurse called 911 and Emergency Medical Services (EMS) instructed staff to get the defibrillator (devices that apply an electrical charge or current to the heart to restore a normal heartbeat). The crash cart was brought to the room while EMS was on the way and the resident was being prepared for transport. The nurse prepared the paperwork for transport and observed the lack of insulin orders, though insulin pens were present with the resident's name on them. The resident left the facility at approximately 10:20 P.M., on 7/12/23 to the hospital via EMS. Review of the facility self report dated 07/14/23, at 3:01 P.M., showed the following: -The resident was admitted to the facility on [DATE]; -He/she went to the hospital on 07/12/23 late at night with hyperglycemia (high blood sugar) and was admitted ; -The hospital had been in contact with the facility to clarify insulin orders. The resident had insulin orders on a sliding scale on admission to the facility, but was not given the insulin. During an interview on 07/20/23, at 12:45 P.M., hospital Registered Nurse (RN) E said the resident had been admitted to the Intensive Care Unit (ICU) with high blood sugar and had to have dialysis (a treatment to clean blood when the kidneys are unable). During an interview on 07/15/23, at 12:12 P.M., Licensed Practical Nurse D said he/she enters some of the orders for new admissions and after the physician makes rounds. He/she did the admission orders for the resident and just missed the insulin orders. During an interview on 07/15/23, at 11:30 A.M., RN A said he/she would expect a diabetic resident to get glucose checks and medications for diabetes. The nurse managers were responsible for entering the medications for new residents until recently, when the central office took over the admission orders. If he/she feels like there is a medication missing, or an error, he/she would look at the hospital discharge orders and put the concern in the physician's notebook for them to look at on the rounding days of Monday, Wednesday, or Thursday. If the need was emergent, he/she would email the physician. It is not appropriate for a resident to go without a needed medication. The nurse said he/she remembered the resident and knew he/she was diabetic because the resident was missing toes. The nurse remembered the resident having insulin in the medication cart, but it came in after his admission orders were entered. The nurse would have expected the resident to receive glucose checks and insulin. During an interview on 07/15/23, at 11:45 A.M., RN B said the unit managers were responsible for entering the orders until recently, but the central office had taken over. The nurses were responsible for performing checks for accuracy. If the nurses feel there is an error or medication missing, they should contact the physician and get clarification. It is not appropriate for a resident to go without medication due to an error. Diabetics usually get glucose checks and either oral or injectable medications. During an interview on 07/15/23, at 11:55 A.M., RN C said central office will now be doing the admission order entries, and the nurses will be checking for accuracy. The unit managers were doing the entries when they had time, but the nurses ended up doing a lot of them. He/she would expect a diabetic to have glucose monitoring and medication. If the nurse found a medication missing or suspected an error, he/she would call the physician or the pharmacy. If the resident had an order for a medication, it is not appropriate to not give the medication. During an interview on 07/15/23, the Director of Nursing and Administrator said they expect staff to enter a complete set of orders on the resident's admission. If the floor staff notice medications that do not match the orders, or see diagnoses that don't match the medications, they expect the staff to clarify. The residents should have the correct medications. It is not appropriate for a resident to not get the correct medications. MO00221451, MO00221467, and MO00221797