Every finding on record at Truman Lake Manor Inc

Based on observation, interview, and record review, the facility failed to an effective program to identify areas of possible resident entrapment when the facility failed to ensure the side rail gap measurements were within acceptable standards to protect the safety of residents when the zone one (within the rail) measurements for the side rails of three residents (Residents #63, #2, and # 7) were greater than the maximum allowed to prevent entrapment of a body part. The facility census was 64.Review of the United States Food and Drug Administration (FDA) document titled, Guidance for Industry and FDA staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/06, showed the following:-The head, neck, and chest are the three key body parts at risk for life-threatening entrapment in the seven zones (within the rail, under the rail between the rail supports or next to a single rail support, between the rail and the mattress, under the rail at the ends of the rail, between split bed rails, between the end of the rail and side edge of the head or foot board, and between the head or foot board and the mattress end) of a hospital bed system;-The bed system should not allow entrapment of the widest part of a small head (head breadth measured across the face from ear to ear);-A maximum head breadth gap measurement of 4 3/4 inches (in);-The bed system should not allow entrapment of the neck;-A maximum neck gap measurement of 2 3/8 in;-The bed system should not allow entrapment of the chest through split rails;-A maximum chest gap measurement of 12 1/2 inches. Review of a facility policy titled, Bed Safety and Bed Rails, dated 2001, showed the following information:-The interdisciplinary team (IDT) should evaluate the resident sleeping environment with considerations given for resident safety, medical conditions, comfort, freedom of movement, and input from the resident and family regarding sleeping habits;-Staff should check bed frames, mattresses, and bed rails for compatibility and size prior to use;-Mattresses regardless of type, width, length, or depth cannot leave gaps wide enough for entrapment of the resident's head or body;-Staff should ensure all gaps are within the safety dimensions established by the FDA;-Maintenance staff should inspect all beds and equipment routinely for entrapment risk;-Maintenance staff should provide copies of inspections to the Administrator and report results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action;-The Administrator should maintain copies of the inspections and QAPI committee recommendations. Review of the facility policy titled, Restraints: Bed Rail Safety Check, undated, showed the following:-Facility staff should regularly inspect each of the seven areas of a bed with restraints for entrapment;-The seven areas include: within the rail, under the rail between the rail supports or next to a single rail support, between the rail and the mattress, under the rail at the ends of the rail, between split bed rails, between the end of the rail and side edge of the head or foot board, and between the head or foot board and the mattress end;-The spacing within bed rails should be small enough to prevent a resident's head from passing through the openings;-The mattress to bed rail interface should prevent entrapment and suffocation risk. Review of a facility Bed Rail Safety Check Form, dated April 2009, showed the following:-A zone one (within the rail) maximum gap measurement of 4 3/4 in;-A zone two (under the rail between the rail supports or next to a single rail support) maximum gap measurement of 4 3/4 in;-A zone three (between the rail and the mattress) maximum gap measurement of 4 3/4 in;-A zone four (under the rail at the ends of the rail) maximum gap measurement of 2 3/8 in and less than 60-degree angle;-The form did not identify gap measurement allowances for zone five (between split bed rails), zone six (between the end of the rail and side edge of the head or foot board, or zone seven (between the head or foot board and the mattress end). 1. Review of Resident #63's face sheet (basic information sheet), dated 05/22/26, showed the following:-admission date of 06/04/22;-Diagnoses included Bell's Palsy (sudden weakness in muscles on one side of the face), history of falls, lack of coordination, reduced mobility, and cognitive impairment involving function and awareness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/21/26, showed the following:-Cognitively intact;-No impairment;-Independent mobility. Review of the resident's informed consent for bed rails, dated 05/05/22, showed verbal consent given by the resident's responsible party and signed by the Director of Nursing (DON) for bilateral upper 1/2 rails for assistance with repositioning and independence with bed mobility. Review of the resident's Physician Order Sheet (POS), dated 05/22/26, showed an order, dated 1/24/24, for one or two 1/2 siderails to aid in independence with bed mobility. Review of the resident's quarterly bed rail safety check, dated 02/18/26, showed the following:-Zone one (within the rail) measured 7 inches for each side of the bed (exceeding allowed maximum by 2 1/4 inches). Observation on 05/19/26, at 11:08 A.M., showed the following:-The resident lay in bed with the right upper side rail in the upright position;-The mattress lay crooked on the frame, separated from the bedrail, and exposing the bare metal frame underneath;-The bedrail had a large square opening in the middle. During an interview on 05/19/26, at 11:08 A.M., the resident said the following:-He/She had the bedrail for a few years;-He/She utilized one of the two upper bedrails to support him/herself while standing from bed;-The mattress slides sometimes when getting in bed, but he/she adjusts it back to normal. Observation on 05/21/26, starting at 3:25 P.M., showed the Housekeeping Supervisor assessed the resident's bedrail gap measurements. The bed had one bedrail in the upright position. The rail had a large square opening in the rail measuring 7 in by 7 in. 2. Review of Resident #2's face sheet showed the following:-admission date of 11/21/24;-Diagnoses included cellulitis of left lower limb, Alzheimer's disease, dementia, osteoarthritis in both knees, violent behaviors, muscle weakness, fracture to right tibia (one of the lower leg bones), and reduced mobility. Review of the resident's annual MDS, dated [DATE], showed the following:-Severely impaired cognition for decision making;-Functional limitation on range of motion: lower limbs, one side impaired;-Required substantial/maximal assistance for rolling left/right, sitting to lying down, lying to sitting on side of bed, sitting to standing, and chair/bed transfers. Review of the resident's care plan, updated 03/24/26, showed the following:-Activities of Daily Living (ADL) self-care performance deficit related to dementia and right leg fracture;-Resident needed maximum assistance from one staff for repositioning and turning in bed at least every two hours and as necessary;-Half side-rails up x 2 per physician orders for safety during care provision to assist with bed mobility; observe for injury or entrapment related to side rail use; and reposition at least every two hours and as necessary to avoid injury. Review of the completed form titled Restraints: Bed Rail Safety Check, dated 03/02/26, showed the following:-Zone 1 - Pass if less than 4 3/4 inches;-Measurements for the bed rails on each side of the bed documented as 7 inches (exceeding allowed maximum by 2 1/4 inches);-Pass/fail not indicated. Review of the resident's POS, current as of 05/22/26, showed an order, dated 03/17/26, for resident may have one to two 1/2 siderails up to aid in independence with bed mobility. Observation on 05/20/26, at 7:17 A.M., showed the resident rested in bed with his/her eyes closed. The side rail on each side of the bed was in the raised position. Each side rail had a large square opening in the middle. During an interview on 05/20/26, at 4:00 P.M., the resident said he/she used the side rails to help reposition him/herself in bed. Observation on 05/21/26, at 10:29 A.M., showed the resident rested in bed. The side rail on each side of the bed was in the raised position. Observation on 05/21/26, starting at 3:25 P.M., showed the Housekeeping Supervisor assessed the resident's bedrail gap measurements. The bed had bedrails on each side in the upright position. Both rails had one large square opening in each upper rail measuring 7 in by 7 in. 3. Review of Resident #7's face sheet showed the following:-admission date of 11/20/25;-Diagnoses included quadriplegia (the partial or total loss of sensory and motor function in all four limbs (both arms and legs) and the torso), anxiety, and depression. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact for decision making;-Functional limitation on range of motion: lower limbs, one side impaired;-Substantial/maximal assistance required for rolling left/right, sitting to lying down, lying to sitting on side of bed, sitting to stand, and chair/bed transfers. Review of the resident's care plan, last updated 02/21/26, showed the following:-ADL self-care performance deficit related to quadriplegia;-Resident needed maximum assistance from one staff for repositioning and turning in bed at least every two hours and as necessary;-Half side-rails up x 2 as per physician orders for safety during care provision to assist with bed mobility; observe for injury or entrapment related to side rail use and reposition at least every two hours and as necessary to avoid injury. Review of the resident's Informed Consent for Use of Bed Rails, dated 11/21/25, showed the following:-Half partial rail to be used at all times when the resident is in bed;-Both the left and right side approved but only one used at a time, as the resident preferred his/her bed up against the wall. Review of the resident's POS, current as of 05/22/26, showed an order, dated 01/18/26, for 1/2 siderails up x 2 to aid in independence with bed mobility related to a diagnosis of quadriplegia. Review of a completed form titled, Restraints: Bed Rail Safety Check, dated 02/18/26, showed the following:-Zone 1 - Pass if less than 4 3/4 inches: measurements for the bed rail on the left side of the bed documented as 7 inches (exceeding allowed maximum by 2 1/4 inches); pass/fail not indicated. Observation on 05/19/26, at 2:45 P.M., showed the following:-The resident's bed was pushed up against his/her wall;-There was a 1/2 bedrail on the left side of the bed and none on the side against the wall. Observation on 05/21/26, starting at 3:25 P.M., showed the Housekeeping Supervisor assessed the resident's bedrail gap measurements. The bed had one bedrail in the upright position. The rail had a large square opening in the rail measuring 7 in by 7 in. During an interview on 05/21/26, at 4:25 P.M., the resident said the following: -He/she used the side rails every night to help reposition him/herself in bed;-Someone comes into his/her room every so often to take measurements. 4. During an interview on 05/21/26, at 3:50 P.M., Certified Nursing Assistant (CNA) N, said the following:-He/she did not know who took measurements of the bedrails but thought it was maintenance;-He/she did not know what the measurements should be but knew there could be harm if there was too much of a gap. During an interview on 05/21/26, at 4:05 P.M., Certified Medication Technician (CMT) O, said the Housekeeping Supervisor was the one taking the gap measurements. During an interview on 05/19/26, at 3:52 P.M., Licensed Practical Nurse (LPN) F said maintenance installs side rails and the laundry/housekeeping supervisor was responsible for doing the safety gap measurements on installed side rails. During an interview on 05/21/26, at 4:15 P.M., Registered Nurse (RN) B said housekeeping completed all the measurements. There was a book where all the measurements were kept. During an interview on 05/21/26, at 4:46 P.M., the MDS Coordinator said the following:-The Housekeeping Supervisor completed gap rail assessments quarterly and on installation;-The Housekeeping Supervisor gave him the completed assessments, and he placed them in a binder;-He did not know the gap requirements for siderails;-He had not reviewed the gap rail assessments for issues;-He was responsible for compliance. During an interview on 05/21/26, at 4:45 P.M., the Assistant Director of Nursing (ADON) said the following:-Once the measurements are completed by the housekeeping supervisor, they are given to the ADON;-These are placed into the black book, where they are kept;-He/she looked at the national standards and found that the gap between bedrail and mattress should be 2.375 inches or less, and the bedrail gaps should be 4.75 inches or less. During an interview on 05/21/26, at 3:34 P.M., the Housekeeping Supervisor said the following:-She completed gap rail assessments on initial implementation and quarterly;-She gave the completed gap rail assessment forms to the MDS Coordinator;-She did not know the specific gap requirements. She thought it was around 4 in maximum;-The facility has bedrails measuring around 7 in;-She followed the check sheet form and assessed the zones indicated;-Some of the hospital beds were old and did not meet requirements;-She did not know who was responsible for compliance. During an interview on 05/21/26, at 4:32 P.M., the Administrator said the following:-The facility had old hospital beds;-He did not know the gap allowance for bedrails;-The Housekeeping Supervisor assessed the bedrails quarterly and gave the completed form to nursing;-Staff should report issues with bedrails to maintenance for repair;-The bedrails should not have gaps large enough for a resident to become entrapped;-The MDS Coordinator, Director of Nursing (DON), and himself were responsible for compliance.

Based on record review and interview, the facility failed to ensure nurse aides (NA) were not used more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in one NA (NA A) working longer than four months in the facility without completing the CNA training course. The facility census was 64.Review of the facility policy, entitled Nurse Aide Qualifications and Training Requirements, revised October 2017, showed the following:-Nurse aides must undergo a state-approved training program;-Nurse aide is defined as any individual providing nursing or nursing-related services to residents in our facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay;-Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless:-That individual is competent to provide designated nursing care and nursing related services; and -That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or -That individual has been deemed competent as provided in section 483.150(a) and (b) of the Requirements of Participation;-Our facility will not use any individual as a nurse aide who has worked less than four months unless the individual: -Is a full-time employee and participating in a state-approved training and competency evaluation program; -Has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; or -Has been determined competent as provided in section 483.150(a) and (b) of the Requirements of Participation;-Inquiries concerning nurse aide training should be referred to the Personnel Director or to the Director of Nursing Services (DNS). 1. Review of NA A's personnel file showed the following:-Date of hire on 01/12/26 (4 1/2 months prior);-Staff did not have documentation NA A completed the nurse aide training program. Review of the facility's online CNA class schedule and sign-in sheet showed NA A started classes on 04/27/26. During an interview on 05/22/26, at 1:22 P.M., NA A said the following:-He/she started working at the facility in early January 2026, but the facility did not have a CNA instructor available;-The facility said there wasn't sufficient time to find an instructor, take the classes, and get certified within the required time limit of four months;-They agreed to terminate NA A and rehire him/her on a part-time basis while he/she completed the online class;-He/she started the online class in mid to late April and worked part-time at the facility to complete the required clinical hours. During an interview on 05/20/26, at 9:35 A.M., the Administrator said the following: -The facility hired NA A in January 2026, but the facility could not arrange for a CNA instructor soon enough for NA A to complete the classes and certification within the required four months;-The NA agreed to have the facility terminate him/her for about one week and rehire him/her on a part time basis;-The facility then enrolled NA A and three other new NAs in online classes offered through the State. During an interview on 05/21/26, at 10:49 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said the following: -The facility could not enlist a certified CNA instructor in time for NA A to complete the classes, clinical training, and certification within the required four months;-NA A was now enrolled in the online CNA training class;-The ADON monitored the NAs for completion of the online modules and knowledge tests;-After the aides completed all modules, the facility would arrange for the NAs to take their certification tests.

Based on interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to initiate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits) for one resident (Resident #45) after an unwitnessed fall and failed to complete neurological assessments for two residents (Residents #56 and #61) after each resident sustained a fall with potential for head injury. The facility census was 64.Review of the facility policy titled, Neurological Assessment, revised October 2010, showed the following:-Neurological assessments are indicated when ordered by a physician, following an unwitnessed fall, following a fall involving head injury, or when indicated by resident condition;-Neurological assessments include frequent vital signs;-Neurological assessments include the initial assessment, assessment every 15 minutes x 4, every 30 minutes x 2, every hour x 4, every shift x 5. 1. Review of Resident #45's face sheet (a form that provides resident details) showed:-admission date of 11/06/23;-Diagnoses included cerebral infarction (a disruption to blood supply that is severe enough and long enough in duration to result in tissue death), dementia (a progressive neurological condition affecting memory, and decision making), lack of coordination, muscle weakness, and repeated falls. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/28/26, showed him/her as cognitively impaired. Review of the resident's current care plan, revised on 04/28/26, showed the following: -Cognitively impaired due to disease process (dementia);-At risk of falls. Review of resident's nursing progress notes, dated 05/19/26, showed the following:-Resident had an unwitnessed fall;-Staff did not start document the start of neurological assessments. Review of resident's nursing progress notes, dated 05/19/26 to 05/21/26, showed staff did not document regarding fall follow-up assessments. During an interview on 05/20/26, at 12:20 P.M., Registered Nurse (RN) I said the following:-Neuro checks should be started on all unwitnessed falls or falls with head injuries or unless the resident can tell staff they did not hit their head;-The resident could not tell staff if he/she hit their head and staff should start neuro assessment if he/she fell. 2. Review of Resident #56's face sheet showed the following:-admission date of 03/31/26;-Diagnoses include dementia, unsteadiness on feet (lack of balance), and reduced mobility. Review of the resident's admission MDS, dated [DATE], showed him/her ascognitively intact. Review of the resident's current care plan, revised on 04/14/26, showed him/her at risk for falls and communication problems related to disease process (dementia). Review of resident's nursing progress note dated 04/23/26, at 3:05 A.M., showed the staff found resident sitting on floor, right leg tucked under left leg, with bruising and discoloration to face and arms from previous falls. Staff noted initiation of neurological checks. Review of resident's neurological assessment form, dated 04/23/26, showed staff did not document the initial assessment or neurological assessments for final three shifts of the assessment timeframe. Review of the resident's nursing progress note dated 04/25/26, at 1:05 A.M., showed the resident had a hematoma (bruise) to forehead and face from previous fall. Review of the resident's nursing progress note dated 04/25/26, at 1:48 A.M., showed the nurse documented the resident had complaints of head pain. 3. Review of Resident #61's face sheet showed the following:-admission date of 04/17/26;-Diagnoses included dementia. Review of the resident's admission MDS, dated [DATE], showed he/she ascognitively impaired. Review of the resident's current care plan, revised on 05/06/26, showed he/she had impaired cognitive function and communication related to neurological symptoms. Review of a resident's progress note dated 04/25/26, at 6:32 P.M showed the resident was observed on the floor with a hematoma over the right eye. Staff noted neuro checks were initiated. Review of resident's neurological assessment form, dated 04/25/26, showed staff did not document completion of three neurological assessments due every hour and five neurological assessments due every shift. Review of a resident's progress note dated 04/27/26, at 4:32 A.M, showed the nurse documented the resident had complaints of pain related to large hematoma to right eyebrow. Ibuprofen was given for pain. 4. During an interview on 05/20/26, at 12:20 P.M., Registered Nurse (RN) I said neurological assessments were important to identify possible complications of head injuries, like brain bleeds. During an interview on 05/20/26, at 1:40 P.M., RN B said the following:-Staff should start neurological checks on all residents with an unwitnessed fall or fall with head injury;-Neurological assessments should continue for 72 hours unless the resident is cleared by a physician. During an interview on 05/21/26, at 9:30 A.M., Licensed Practical Nurse (LPN) C said the following:-Staff should begin neurological checks on all unwitnessed falls;-Neurological checks continue for 72 hours unless the resident is cleared by a physician;-Neurological checks are important to identify changes in a resident. During an interview on 05/21/26, at 9:45 A.M., the Assistant Director of Nursing (ADON) said the following:-Neurological assessments should be started on residents who have an unwitnessed fall;-Neurological assessments continue for 72 hours and help identify brain injuries. During an interview on 05/21/26, at 9:55 A.M., the Director of Nursing (DON) said she expected staff to start and complete all neurological assessments for residents who have an unwitnessed fall. During an interview on 05/21/26, at 12:30 P.M., the Administrator said he expected nursing staff to initiate and continue all neurological assessments in accordance with the policy of the facility.

Based on observation, record review, and interview, the facility failed to ensure food was protected from possible contamination at all times when staff failed to keep all food-contact areas clean and when staff failed to air dry dishes. The facility had a census of 64.1. Review of the Food & Drug Administration (FDA) 2022 Food Code showed the objective of cleaning focuses on the need to remove organic matter from foodcontact surfaces so that sanitization can occur and to remove soil from non-foodcontact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. Review of the facility policy titled Cleaning Rotation, Guideline and Procedure Manual, dated 2016, showed the following:-Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions;-Items cleaned after each use include the can opener and small food preparation equipment;-Items cleaned daily include the toaster. Review of the facility kitchen cleaning schedule showed the following: -Staff to clean the can opener twice daily;-The toaster was not on the cleaning schedule. Observation on 05/18/26, beginning at 11:00 A.M., showed the following:-The can opener was dirty with food crumbs and a grease/lint mixture:-The toaster was dirty with food crumbs, and a grease/lint mixture:-The prep table, to the right of the stove, was dirty with a grease/lint mixture. During an interview on 05/22/26, at 12:50 P.M., Dietary Aide (DA) D said the following: -The cleaning schedule was based on what staff does and if they work in an area, they are expected to clean that same area;-The can opener, toaster, or any appliances the cook used should be cleaned daily, by the cook. During an interview on 05/22/26, at 1:10 P.M., [NAME] F said the following: -He/she followed a cleaning list, but gets busy so there are days some things do not get done;-He/she was responsible to clean the toaster and can opener. During an interview on 05/22/26, at 1:25 P.M., [NAME] G said he/she cleaned up the area he/she was working at. During an interview on 05/22/26, at 1:55 P.M., the Dietary Manager (DM) said the following: -There was a cleaning schedule;-Staff were expected to follow the cleaning schedule;-If something was not on the actual schedule, he/she expected staff to clean their own area and anything that they may notice that needed cleaning;-If he/she noticed something needed cleaning, he/she will often do it. During an interview on 05/22/26, at 1:05 P.M., the Administrator said there was a cleaning schedule, and staff was expected to follow it. 2. Review of the FDA 2022 Food Code showed the following: -Items must be allowed to drain and to air-dry before being stacked or stored;-Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow;-Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. Review of the facility policy titled Dishwashing: Manual, Guideline & Procedure Manual, 2016 Edition, showed the following:- All pots and pans shall be cleaned by washing, rinsing, and sanitizing, according to the following guidelines.-The pots and pans will be drained and air-dried on the drain counter. Observation on 05/18/26, beginning at 11:00 A.M., showed the following:-A small room in the dining room and next to the kitchen, held the ice machine and two rolling carts;-The first cart had 62 large plastic water glasses, sitting upside down and with no air flow and water trapped inside;-The second cart had 46 large plastic water glasses, sitting upside down and with no air flow and water trapped inside. Observation on 05/20/26, beginning at 8:50 A.M., showed the following:-Twelve plastic coffee mugs, stacked upside down and with no air flow and water trapped inside;-Twelve plastic plate covers, stacked upside down and with no air flow and water trapped inside;-Seventeen white plastic bowls, stacked upside down and with no air flow and water trapped inside;-Twenty clear drinking glasses, stacked upside down and with no air flow and water trapped inside. Observation on 05/21/26, beginning at 9:55 A.M., showed the following:-Ten plastic coffee mugs, stacked upside down and with no air flow and water trapped inside;-Fourteen clear drinking glasses, stacked upside down and with no air flow and water trapped inside;-Eighteen plastic plate covers, stacked upside down and with no air flow and water trapped inside. During an interview on 05/22/26, at 12:50 P.M., DA D said dishes were supposed to sit and dry for a few minutes, before being put away. During an interview on 05/22/26, at 1:10 P.M., Dishwasher (DW) E said staff should leave the dishes on the drying rack until they are dry. During an interview on 05/22/26, at 1:10 P.M., [NAME] F said if there was not time to towel dry the dishes, then they should sit in a tray to be air dried. During an interview on 05/22/26, at 1:05 P.M., the Administrator said he expected dishes to be completely dry before being put away and the kitchen staff have been trained to do this.

Based on observation, interview, and record review, the facility failed to ensure a process was in place to clearly and consistently documented each resident's code status preference (if resident wished to receive cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when a person's heartbeat or breathing stops)) when two resident's records (Residents #9 and #8) had inconsistent code status documentation. A sample of 22 was reviewed in a facility with a facility census of 64.Review of the facility's policy entitled Advance Directives (2001 MED-PASS, Inc.), showed the following:-Do not resuscitate (DNR) indicates in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no CPR or other life-sustaining treatments or methods are to be used;-The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings;-The plan of care for each resident is consistent with their documented treatment preferences and/or advance directive;-The interdisciplinary team (IDT) will review annually with the resident their advance directives to ensure such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record;-The IDT will be informed of changes and/or revocations so that appropriate changes can be made in the resident's medical record and care plan; Review of the facility's policy entitled Emergency Procedures - Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) (2001 MED-PASS, Inc.), showed the following:-If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare providers/BLS will administer CPR unless it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual;-If the resident's CPR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order not to administer CPR. Review of the facility's policy entitled Do Not Resuscitate (DNR) Order (2001 MED-PASS, Inc.), showed the following:-Facility staff will not initiate DPR or related emergency measures on a resident when there is a DNR order in effect;-The DNR orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record;-The DNR order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed at the front of the resident's medical record;-Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital;-DNR orders remain in effect until the resident (or legal representative) provides the facility with a signed and dated request to end the DNR order. 1. Review of Resident #9's electronic face sheet (gives basic profile information at a glance), dated [DATE], showed the following:-admission date of [DATE];-A DNR code status. Review of the resident's comprehensive/significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated [DATE], showed the resident as cognitively intact. Review of the resident's current electronic physician order sheet (POS) showed an order, dated [DATE], for DNR code status. Observation on [DATE], at 12:01 P.M., showed a green dot (indicating resident wished to receive CPR) on the wall mounted nameplate next to the entrance of the resident's room. Review of the resident's care plan, as of [DATE], showed staff care planned he resident as a full-code status with interventions to administer life-saving measures if found without a pulse or respiration. Observation on [DATE], at 9:40 A.M., showed a green dot on the wall mounted nameplate next to the entrance of the resident's room. Observation and review on [DATE], at 10:00 A.M., of the resident's physical chart located in the nurses' station medication room showed the following:-A green sticker with Full Code (wished to receive CPR) written on the spine of the binder;-A signed DNR sheet dated [DATE];-A POS, dated [DATE], showed an order, dated [DATE], for full code. During an interview on [DATE], at 10:23 A.M., Certified Nursing Assistant (CNA) K said the resident's code status recently changed from a full code to DNR. He/She did not know when the code status changed. During an interview on [DATE], at 12:44 P.M., Registered Nurse (RN) I said the resident #9's code status recently changed to DNR, but he/she did not know when this change occurred. During an interview on [DATE], at 12:16 P.M., Hospice RN J said the following: -The resident was DNR status as required for hospice admission;-The resident re-admitted to hospice services when he/she returned from the hospital on [DATE];-He/She did not know of any discrepancies in code status in the resident's record. During an interview on [DATE], at 12:29 P.M., the Activity Director said she did not know of the resident's change in code status until identified by surveyors. During an interview on [DATE], at 2:25 P.M., the Social Worker (SW) said the following:-The resident's code status changed to DNR in [DATE];-She did not know why staff did not update the resident's code status documentation for each area. 2. Review of Resident #8's face sheet showed the following:-admission date of [DATE];-Code status of DNR. Review of the resident's POS, current as of [DATE], showed an order, dated [DATE], for DNR. Review of the resident's annual MDS, dated [DATE], showed the resident had severely impaired cognition for decision making. Review of the resident's care plan, last updated [DATE], showed the following:-Resident wished to be a DNR; -Wishes will be honored through next review;-If found without pulse or respiration notify the nurse and do not initiate CPR. During an observation and interview on [DATE], at 3:47 P.M., the SW said the binder that contained all residents' DNR documentation did not have a copy of the resident's DNR documentation. The SSD located a copy of the resident's signed DNR card in his/her admission packet. During an observation and interview on [DATE], at 3:50 P.M., LPN F could not locate a signed DNR card in the resident's hard chart binder. The binder had a green Full Code label on its spine. LPN F said if the resident was in medical crisis he/she would refer to the binder. He/she would provide CPR since there was no indicator for DNR. 3. During an interview on [DATE], at 10:23 A.M., CNA K said the following:-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-Nursing staff document the code status in the electronic record and physical chart;-The Activity Director places the code status stickers outside the resident rooms;-The code status should be the same for all areas;-He/She did not know who was responsible for verifying all areas reflected the correct code status. During an interview on [DATE], at 11:56 A.M., CNA M said the following:-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-The Activity Director places the code status stickers outside resident rooms;-He/She did not know who documented code status in the physical chart or electronic chart;-Code status should be the same for the physical chart, electronic chart, and match the sticker outside the resident's room;-He/She did not know who was responsible for overall compliance;-He/She would report conflicts in code status to the charge nurse immediately. During an interview on [DATE], at 11:33 A.M., Certified Medication Technician (CMT) L said the following:-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-Resident code status is in the physical chart, electronic record, and color sticker outside their room;-Code status should be the same for all areas;-The Director of Nursing (DON) was responsible for compliance;-He/She did not know how often the DON checked resident code status for accuracy;-He/She would report discrepancies in code status immediately to the charge nurse and DON. During an interview on [DATE], at 12:29 P.M., the Activity Director said the following:-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-She places the stickers outside the resident's room on admission and replaces as needed with changes;-Department heads discuss code status changes daily Monday through Friday;-Nursing staff document code status in the face sheet, POS, and attachments in the electronic charting;-Administrative staff were responsible for monitoring resident code status and ensuring accuracy for all areas reflecting code status. During an interview on [DATE], at 1:06 P.M., LPN C said the following:-Nursing staff document code status in the electronic face sheet and physical chart;-He/She did not know what specific locations of code status documentation in the electronic and physical records;-He/She did not know how often staff checked code status documentation;-The Activity Director places a code status sticker outside the resident rooms when they admit;-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-He/She would report discrepancies in code status to the DON immediately;-The DON was responsible for checking code status. During an interview on [DATE], at 12:44 P.M., RN I said the following:-Nursing staff document the code status based on the code sheet;-Nursing staff document the code status on the face sheet in the electronic medical record, electronic POS, save the code sheet in the attachments tab of the electronic medical record, and physical chart;-Nursing staff place the code sheet in the physical chart;-The Activity Director places a code status sticker outside resident rooms;-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-Code status should be the same for the physical chart, electronic chart, and match the sticker outside the resident's room;-Nursing staff were responsible for compliance. During an interview on [DATE], at 2:25 P.M., the SW said the following:-She obtains resident code status on admission, gives to the physician to sign, makes copies, and saves copies in the electronic and physical chart;-She saves the electronic code status on the face sheet and in the attachments;-She places a copy of the code status in the physical chart and places a code status sticker on the spine of the physical chart;-She or the Activity Director place a code status sticker outside the resident's room;-The green door sticker outside the resident's room indicated full code status;-The red door sticker outside the resident's room indicated DNR status;-Her, the DON, and Activity Director were responsible for verifying accuracy of resident code status and addressing changes as needed. During an interview on [DATE], at 2:44 P.M., the DON said the following:-Nursing staff should document resident code status in the face sheet, POS, attachments tab, and care plan of the electronic medical record;-Nursing staff should document resident code status on the spine of the physical chart and advanced directive section of the physical chart;-The Activity Director or SW place a code status sticker outside the resident's room;-The green door sticker outside the resident's room indicates full code status;-The red door sticker outside the resident's room indicates DNR status;-The SW checks code status on admission;-Department heads verify code status during quarterly care plan meetings and MDS assessments. During an interview on [DATE], at 1:45 P.M., the Administrator said the social worker starts the code status preference process when a resident is admitted . After the resident or resident representative signs the DNR card, it is given to the physician for signature. Medical Records then scans the signed card into the electronic medical record (EMR) and puts the signed card into the resident's hard chart. The Activities Director places the code status indicator dot on the resident's room nameplate; green for Full Code or red for DNR. Staff can check the code status on the EMR, in the facility DNR binder kept by the social worker, or in the resident's hard chart. A copy of the DNR card should be sent with EMS if the resident is sent to the hospital.

This citation is uncorrected. For prior examples, please see event ID 1DFDCA-H1, exit date 01/07/26, for details. 1.Please refer to event ID 1DFDCA-H2, exit date 03/09/26, for details. Complaint #2787573

This citation is uncorrected. For prior examples, please see event ID 1DFDCA-H1, exit date 01/07/26, for details. Please refer to event ID 1DFDCA-H2, exit date 03/09/26, for details. Complaint #2787573

Based on observation, interview and record review, the facility failed to protect residents on the memory care unit from sexual and physical abuse. Resident #1 exhibited repeated behaviors against others, including touching breasts, forceful kissing, unwanted hugs, slapping of the leg. The attempts at unwanted contact impacted four residents (Resident #2, #3, #4, and #5) who exhibited signs of being upset with the contact. The facility did not notify Resident #1's physician of the behaviors or implement new interventions on the care plan to protect residents. The facility census was 67. Review of the facility's Abuse and Neglect policy, revised 03/2017, showed the following:-Each resident has the right to be free from all types of abuse, neglect and misappropriation of resident property;-Residents must not be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, agency staff, family members, legal guardians, friends or other individuals;-Each resident has the right to be free from abuse neglect and misappropriation of property this includes identification of residents whose personal histories render them a risk for abusing other residents and development of intervention strategies to prevent occurrences monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis;-To achieve this purpose, we have adopted the following policies and procedures for screening and training new employees' protection of residents and for the prevention identification investigation and reporting of abuse and allegations of abuse neglect and misappropriation of resident property;-To assist in recognizing incidents abuse the following definitions are provided;-Abuse: the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish, deprivation by and individual including a caretaker of goods or services that are necessary to attain or maintain physical mental or psychosocial well-being;-Sexual abuse: defined as but not limited to sexual harassment sexual coercion or sexual assault;-Physical abuse: hitting, slapping, pinching, kicking, etc. and controlling behavior through corporal punishment. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following:-The resident was admitted [DATE];-The resident had a responsible party;-Diagnoses included dementia (progressive cognitive decline-including memory loss, language difficulties, and impaired reasoning-that disrupts daily life), diabetes, and high blood pressure. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 02/16/26, showed the following:-The resident had severe cognitive impairment;-The resident had physical and verbal behaviors directed at others 4 to 6 days, but less than daily, and other behavioral symptoms not directed at others, daily. Review of the resident's care plan, revised 10/07/25, showed the following:-The resident was an elopement risk and wanderer related to dementia and looking for his/her significant other;-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, or television or a book. He/she liked word searches and crossword puzzles;-Attempt to identify the pattern of wandering;-The resident had a history of being verbally aggressive toward staff and peers during redirection related to his/her diagnosis of dementia and poor impulse control;-He/she had a history of being intrusive to peers' space, rooms and belongings. He/she had been observed being sexually aggressive to staff and peers. He/she thought they were his/her significant other;-If these behaviors are observed, administer medications as ordered and monitor and document effectiveness. Analyze key times, places, circumstances, triggers and what deescalates the behavior and document;-If the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation and, if response is aggressive, staff should walk calmly away and approach later;-Psychiatric and psychogeriatric consult as indicated;-The resident has a history of physically aggression towards staff and peers related to his/her dementia;-When the aggression is observed, administer medications as ordered and monitor and document effectiveness. Analyze times of day, places, circumstances, triggers and what deescalates the behavior and document. Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior and encourage seeking out of staff member when agitated;-Monitor, document and report, as needed, any signs and symptoms of him/her posing a danger to self and others. When the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation and if response is aggressive, staff should walk calmly away and approach later. Psychiatric and psychogeriatric consult as indicated. Review of the resident's nurses progress notes showed the following:-A note dated 02/13/26, at 3:08 A.M., showed the resident demonstrated aggression and was initiating conflict with others by pulling and yanking on them, grabbing, smothering through close affection and, on one occasion, attempted to pull his/her pants down in front of another resident of the opposite sex. He/she targeted a resident of the opposite sex, calling that resident his/her significant other, pulling on the resident to go home with him/her, taking the resident's walker, and causing the other resident to retaliate by yanking the walker back escalating Resident #1's agitation and aggression. At one point, he/she attempted to strike the other resident with a glass vase and staff intervened. Resident #1 attempted to expose himself/herself towards another resident of the opposite sex and cozied up to a third resident of the opposite sex as well. Resident #1 demonstrated no impulse control, and all actions were spontaneous with no sense of purpose. When not targeting residents of the opposite sex, he/she walked the halls, looked into other resident's rooms, helped himself/herself to other residents' things all while he/she believed everything he/she saw belonged to him/her. This resident received an intramuscular injection of Ativan (a medication used for short-term anxiety relief, insomnia, and seizures) in the left buttocks which allowed him/her to calm, lay down in his/her room, and rest until he/she fell asleep;-A note, dated 02/20/26, at 6:20 A.M., the resident was hard to redirect last night. He/she talked with word salad and his/her words did not make any sense when responding to simple questions. He/she woke up every hour and came out of his/her room, still rubbing his/her eyes, and the aide walked him/her back to his/her bed every time. He/she was hateful to the other residents in the dining room with his/her body language and tone of voice. He/she took the walkers from two residents in the dining room and placed them outside the dining room away from them. When asked why he/she was doing that, he/she showed his/her teeth and rolled his/her eyes and refused to leave the walkers alone. Will continue to monitor him/her for behaviors;-A note, dated 02/20/26, at 11:00 P.M., this evening the resident initiated conflict within the unit against several of the residents of the opposite sex. He/she was interrupted in the act of climbing into another resident's bed while that resident slept. Staff intervened during this act which ignited Resident #1's temperament and he/she began screaming at the other resident to get up, that the other resident was his/her significant other. Staff guided the resident out of the other resident's room all while he/she made attempts at lunging at the staff with verbal aggression and physical gestures. The resident then entered Resident #5's room confronting Resident #5 face to face at bedside. Resident #5 yelled for help and told Resident #1 to leave them alone and leave the room. Staff entered the room an intervened between the residents to keep them from physical contact all while Resident #1 began a list of verbal aggression toward Resident #5. Resident #1 was guided out of the room all while being aggressive. Resident #1 then targeted Resident #3 in the lounge area after the evening meal activity. Resident #1 made statements that Resident #3 was his/her significant other. He/she sat next to Resident #3 agitating the resident whereby the resident got up and moved to another chair. This went on up until Resident #1 sat next to Resident #3 on the lounge sofa really agitated and yelling at Resident #3 about Resident #3 being his/her significant other. Resident #1 made a fist with his/her right hand and struck Resident #3 on the dorsal side of the left thigh. Resident #3 got up from the sofa and moved to a rocking chair between two other residents. Resident #1 remained on the sofa fuming over Resident #3's rejection;-A note, dated 02/21/26, at 3:26 P.M., the resident continued to have increased behaviors, pacing the hallways, going in and out of other residents' rooms upsetting the other residents and then got agitated and started yelling. The nurse redirected him/her and would continue the plan of care;-A note, dated 02/22/26, at 10:10 P.M., the resident presented with several inappropriate episodes of touching of residents of the opposite sex this evening. This included staff members of the opposite sex when their backs were turned. The resident frequently said he/she was in love or that he/she loved whoever he/she targeted at that moment. He/she made attempts to hug on two residents who pushed him/her away. The resident was also aggressive with others as well, grabbed arms and attempted to tug on them to follow him/her. The resident entered other residents' rooms, removed their bedding and personal items and took away items directly from residents who held the item or were working on a craft project. Redirection of the resident by staff did not improve his/her actions. The resident was opportunistic towards other residents' personal things;-A note, dated 02/23/26, at 2:57 A.M., the resident presented with several inappropriate touching of residents of the opposite sex this evening. This included staff of the opposite sex when their back was turned. This resident frequently stated he/she was in love or stated I love you to whom he/she targeted at that moment of time. He/she made attempts to hug two residents of the opposite sex who pushed him/her away. This resident was also aggressive with others, grabbed arms attempting to tug on them to follow him/her. This resident entered other residents' rooms, removed their bedding, personal belongings and took away items directly from residents who held the item or worked on a craft project coloring book. Redirection of this resident does not improve his/her actions. The resident was opportunistic towards others personal things. The resident this evening was stopped by staff while climbing on to another resident's rolling walker. He/she climbed over this supportive equipment backwards where his/her buttocks was on the seat and legs hanging over the top of the walker with his/her feet dangling. The walker was prevented from tipping over by the other resident holding it to the floor. The nurse had to support Resident #1 under his/her armpits and assist him/her off the equipment into a high back rocking chair. Throughout the night, during the hours of sleep, the resident woke every hour or so where staff aided him/her to his/her room and assisted in covering him/her up. At times this occurred during rounds where the resident would enter residents' rooms of the opposite sex while staff performed personal care. The resident was oppositional to redirection from the rooms of opposite sex residents. The resident presented himself/herself as a bully when staff redirected him/her;-A note, dated 02/23/26, at 2:32 P.M., witnessed the resident walking down the hallway, go into Resident #5's room, and kiss Resident #5 on the top of the head. The resident was redirected out of the room easily;-A note, dated 02/24/26, at 4:28 A.M., the resident was being rude and hateful towards other residents and staff last night. He/she was going in and out of the other residents' rooms and refused to leave the room when cares were being done. The nurse practitioner (NP) was contacted and gave an order for lorazepam (a medication used for short-term anxiety relief, insomnia, and seizures), 1 milligram (mg.), by mouth every 8 hours as needed (PRN) for agitation. One tablet was administered at 7:45 P.M. with effective results. The resident rested in bed with his/her eyes closed the rest of the shift;-A note, dated 02/24/26, at 1:40 P.M., the resident was going around trying to kiss peers and staff. The resident was redirected before this happened. The resident paced the halls and got upset when staff redirected him/her. The resident had a PRN medication that worked for a while. Will continue plan of care;-A note, dated 02/25/26, at 3:12 A.M., the resident invaded others personal space and was sexually aggressive towards residents of the opposite sex. The resident forced himself/herself onto Resident #2, grabbed Resident #2's head and neck with both hands and forced his/her tongue into Resident #2's mouth. Resident #2 pulled away by pulling down on Resident #1's arms to get him/her to release his/her hold on Resident #2. A second attempt was made again by Resident #1 that failed due to Resident #2 stepping back just as staff intervened. Resident #1 attempted to swing but was blocked. The resident entered Resident #4's room and was removed from this room when he/she became physically aggressive towards Resident #4. Resident #4 said Resident #1 was attempting to make sexual advances towards him/her, but was unsuccessful in his/her attempts. The resident attempted to enter Resident #5's room while the nurse was providing care. Resident #1 would not willingly leave this room, attempted to sidestep the nurse and reach Resident #5. Resident #1 was redirected out of the room by staff. He/she made two fisted swings while yelling at staff. Both swings were unsuccessful and blocked. The resident was directed from the fire egress doors on East Hall and at the nurse station where he/she was observed pushing on the doors attempting to open them. Observed the resident attempting to open secured storage doors twice on East Hall, including the dirty utility room. Observed the resident removing bed linens from other residents' rooms and carry the item back toward the lounge area. He/she destroyed his/her own room, throwing his/her bedding into the hallway. Observed the resident carrying personal items from other rooms claiming he/she just purchased these items and now they were his/hers. The resident was resistant in giving up items so staff could return them. The resident was in perpetual state of hyperactivity during the first six hours of the shift and would not sit for any length of time. After midnight, the resident wore himself/herself out and fell asleep. Staff assisted the resident to his/her room where he/she remained until this entry, resting in bed with his/her eyes closed;-A note, dated 02/26/26, at 2:30 A.M., observation showed the resident consistently invaded others interpersonal space, exhibited ongoing, inappropriate sexual aggression toward others such as touching the private areas of residents of both sexes. The resident laid in bed with others. The resident scavenged others personal belongings, removing these items from residents' rooms, claiming those items were now his/hers. He/she took food items from other residents and drank other residents' liquids. This resident was exit seeking at the East egress door and lounge fire doors. The resident pushed on these doors setting off alarms. The resident does not redirect well, and quickly escalates to verbal and physical aggression towards staff or other higher functioning residents. He/she remained in a nonstop state of hyperactivity. The resident remained hyper up until around 9:00 PM., when he/she stated he/she was getting tired and staff directed him/her to his/her room where he/she readily climbed into bed. At 2:30 A.M., the resident remained in his/her room resting in bed with his/her eyes closed;-A note, dated 02/26/26, at 3:31 P.M., showed the resident was on skilled care. He/she recently went to a hospital wellness unit. He/she did not speak very clearly at times and this was attributed to medication. However, the resident was constantly up every 30 seconds to pace the halls or raid someone's room. When this nurse met him/her walking in the hall, the resident purposefully bumped into the nurse and kept on going. He/she has been pleasant with cares at times for treatment and toileting. He/she had a shower by two bath aides this morning and the aides came out scratched up. The resident was currently messing with people trying to play checkers. The resident was disruptive to the entire memory care unit today;-A note, dated 03/01/26, at 9:53 P.M., the resident finally went to his/her room. He/she wandered up and down the hall going into random rooms of the opposite sex. Staff were unable to redirect the resident. The resident got verbally aggressive at times;-A note, dated 03/02/26, at 1:07 P.M., showed the resident had been pacing the halls, exit seeking, and being verbally aggressive towards staff and residents since 11:00 A.M. The resident was currently walking up and down the hallway. Staff made multiple attempts of redirection and tried to give him/her something to do to occupy his/her time, but were not effective;-A note, dated 03/03/26, at 8:36 P.M., the resident continued to wander in the hallway and also continued to invade others space and enter other resident rooms and remove items.-The resident's nurse's progress notes showed no documentation of the facility reported incident of Resident #1 kissing Resident #2 on 02/24/26. 2. Review of Resident #2's face sheet showed the following:-admitted on [DATE];-The resident had a responsible party;-Diagnoses including depression, dementia, and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had severe cognitive impairment;-The resident had behaviors of wandering daily. Review of the resident's care plan revised 11/10/25, showed the following:-At risk for wandering and elopement. Distract the resident if he/she was showing signs for elopement. Engage the resident in purposeful activity. Monitor him/her for wandering times increasing as this may be a sign that the resident may want to elope from the facility. Monitor the resident's whereabouts throughout the day to ensure residents safety;-Potential to be physically aggressive related to poor impulse control. He/she would exit seek often. He/she did not redirect easily. Administer medications as ordered and monitor and document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers and what deescalates behavior and document. Assess and address for contributing sensory deficits. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior and encourage seeking out of staff member when agitated. Monitor, document and report as need any signs and symptoms of the resident posing a danger to self and others. Psychiatric and psychogeriatric consult as indicated. When the resident became agitated: intervene before agitation escalated; guide away from the source of distress; engage calmly in conversation; if the resident's response was aggressive, staff to walk calmly away and approach later;-History of a behavior problem related to sexually inappropriate behaviors with a peer of the opposite sex. Administer medications as ordered and monitor and document for side effects and effectiveness. Intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner. Divert the resident's attention. Remove the resident from the situation and take to an alternate location as needed. Minimize potential for the resident's disruptive behaviors by offering tasks which divert his/her attention. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. During an interview on 03/05/26, at 10:46 A.M., the resident's next of kin said the following:-He/She was unaware of the actions of Resident #1 towards Resident #2;-The resident started losing his/her short-term memory in 2007;-Prior to the resident losing his/her memory, the actions of Resident #1 against Resident #2 would have upset Resident #2 and he/she would have tried to defend himself/herself. 3. Review of Resident #3's face sheet showed the following:-admitted on [DATE];-The resident had a responsible party;-Diagnoses included Alzheimer's disease, dementia, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors. Review of the resident's care plan, revised 11/21/25, showed the following:-The resident had impaired cognitive function and dementia related to Alzheimer's disease. Administer medications as ordered and monitor and document for side effects and effectiveness. Cue, reorient and supervise the resident as needed. Monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding, level of consciousness and mental status. Review of the resident's nurse's progress notes, dated 02/01/26 through 03/09/26, showed no documentation or assessment of the resident related to the incident on 02/20/26 with Resident #1. Staff did not document notification of the responsible party of the incident. During an interview on 03/04/26, at 12:28 P.M., the resident said a resident of the opposite sex went into everyone's rooms. 4. Review of Resident #4's face sheet showed the following:-admitted on [DATE];-The resident had a responsible party;-Diagnoses included depression, dementia, and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors. Review of the resident's care plan, revised 10/03/25, showed the following:-The resident was an elopement and wanderer risk related to dementia. Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Provide structured activities such as toileting, walking inside and outside and reorientation strategies including signs, pictures and memory books;-The resident was at risk for falls related to confusion, psychoactive drug use and he/she was unaware of safety needs. Staff should anticipate and meet the resident's needs. Encourage him/her to participate in activities that promote exercise and physical activity for strengthening and improved mobility. Review of the resident's nurse's progress notes, dated 02/01/26 through 03/09/26, showed no documentation or assessment of the resident related to the incident on 02/25/26 with Resident #1. During an interview on 03/04/26, at 12:20 P.M., the resident said the following:-Resident #1 comes into his/her room, touches his/her arm and attempts to kiss him/her;-He/she would not let Resident #1 kiss him/her;-Resident #1 followed him/her around and staff was aware of this;-He/she said when Resident #1 attempted to kiss him/her, it bothered him/her because he/she was married and his/her significant other lived at the facility. 5. Review of Resident #5's face sheet showed the following:-admitted on [DATE];-The resident had a responsible party;-Diagnoses included schizophrenia (a mental health illness), dementia, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors. Review of the resident's care plan, revised 07/15/25, showed the following:-The resident had a behavior problem related to schizophrenia. The resident had been rude to peers and staff. He/she at time would call others names. He/she had been attempting to inappropriately touch peers of the same sex. Staff to complete 15 minute checks until further notice. Administer medications as ordered and monitor and document for side effects and effectiveness. Staff should anticipate and meet the resident's needs. If reasonable, discuss his/her behavior. Explain and reinforce why the behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner. Divert the resident's attention and remove the resident from the situation and take to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Monitor the resident's whereabouts in the unit until further notice. Review of the resident's nurse's progress notes, dated 02/01/26 through 03/09/26, showed no documentation or assessment of the resident related to the incidents on 02/20/26, 02/23/26, and 02/25/26 with Resident #1. During an interview on 03/04/26, at 12:25 P.M., the resident said a resident of the opposite sex was on his/her bed. 6. During interviews on 03/06/26, at 12:46 P.M. and 2:29 P.M., Certified Nursing Assistant (CNA) B said the following:-Types of abuse included sexual, physical, mental, verbal, and emotional;-If he/she witnessed a resident kiss or inappropriately touch another resident sexual abuse he/she would separate the residents; -Resident #1's behaviors had been getting worse;-Resident #1 was redirectable at times, but if the resident was not redirectable, he/she walked away and reapproached the resident. During an interview on 03/06/26, at 12:54 P.M., CNA C said the following:-Types of abuse included physical, verbal, sexual, and mental;-If a resident inappropriately touched another resident, he/she considered that sexual abuse. He/she would separate the residents. During an interview on 03/04/26, at 12:59 P.M., Certified Medication Technician (CMT) said the following:-Types of abuse included financial, emotional, physical, involuntary seclusion, and sexual;-He/she witnessed Resident #1 kiss Resident #2 in the hall on 02/24/26;-He/she witnessed Resident #1 attempt to kiss other residents before;-In each case, he/she separated the residents;-He/she considered this incident and the other incidents between Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 sexual assault and abuse. During interviews on 03/04/26, at 1:12 P.M. and 3:50 P.M. and 03/09/26, at 10:40 A.M., Registered Nurse (RN) E said the following:-Types of abuse included physical, verbal, sexual, financial, and neglect;-He/she considered a resident being sexually inappropriate, inappropriate touching, and a resident forcing their tongue into another resident's mouth to be abuse;-The documented incidents between Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 on 02/20/26, 02/22/26, 02/23/26, 02/24/26, 02/25/26, and 02/26/26 were abuse;-Resident #1's behaviors had worsened, and he/she had no idea the behaviors had gotten this bad;-Resident #1 was sent out for psychiatric evaluation two to three times in the past;-Resident #1 periodically followed other residents and staff;-Resident #1 was redirectable and would forget what he/she was doing;-He/she did not consider Resident #1 kissing Resident #5 on the forehead abuse, but if this happened to him/her, he/she would feel uncomfortable;-The receptionist reported witnessing Resident #1 kiss Resident #5 on the top of the head to the RN. None of the other incidents were reported to him/her. During an interview on 03/06/26, at 11:52 A.M., Receptionist J said the following:-Types of abuse included sexual, verbal, physical, and mental;-On 02/23/26, he/she witnessed Resident #1 kiss Resident #5 on the top of the head;-He/she reported to RN E and then left the unit after he/she redirected the resident out of Resident #5's room;-He/she considered this incident to be sexual abuse. During an interview on 03/04/26, at 1:37 P.M., RN A said the following:-Types of abuse included verbal, sexual, and physical;-Resident #1 had been pulling residents out of bed, kissing other residents, and touching other residents on the chest;-The residents tell Resident #1 to leave them alone;-Resident #3 did not want to be touched and attempted to get away from Resident #1;-Resident #1 grabbed Resident #2 and forced his/her tongue in Resident #2's mouth and the RN considered this abuse;-Resident #1's behaviors had gone on for months. They had tried redirection and sending the resident out for evaluation;-Resident #1 was sent out for evaluation in the past;-Staff attempted to monitor Resident #1, but the resident was impossible to contain;-He/she considered the incident between Resident #1 and Resident #3 on 02/20/26 to be physical abuse;-Resident #1's actions of hugging, putting his/her neck on another resident's neck, attempting to kiss other residents, and following other residents to be abuse. The other residents did not want this attention from Resident #1;-When he/she documented sexual aggression, he/she was referring to Resident #1 kissing other residents and the RN considered this abuse;-When he/she documented inappropriate touching, he/she was referring to Resident #1 touching other resident's chest and breast area;-Everyone knew about it and he/she passed the information along at shift change. He/she would try and redirect Resident #1. During an interview on 03/04/26, at 2:35 P.M., Licensed Practical Nurse (LPN) F said the following:-Types of abuse included verbal, physical, sexual, and neglect;-He/she had not witnessed abuse, but heard that Resident #1 was physically and verbally aggressive, attempted to kiss staff and other residents, and was exit seeking;-He/she considered a resident kissing another resident sexual abuse and a resident hitting another resident physical abuse;-Interventions included redirection, 15 minute checks and medication;-Most of the time, Resident #1 was not redirectable and got aggressive with staff;-Staff would walk away and reapproach later;-He/she reported abuse immediately to the DON or Administrator;-He/she did not notify the responsible party. During an interview on 03/04/26, at 2:51 P.M., Nursing Assistant (NA) G said the following:-Types of abuse included financial, physical, sexual, and emotional;-He/she was told in report that Resident #1 aggressively kissed another resident and he/she considered this sexual abuse;-Interventions included redirection and to give Resident #1 an activity to complete;-Resident #1 was hard to redirect;-He/she believed Resident #1's behaviors were unchanged;-Resident #1 followed other residents of the opposite sex around and thought the other residents were his/her significant other and called them by his/her significant others name. During an interview on 03/06/26, at 11:36 A.M., Housekeeper (HK) I said the following:-Types of abuse included physical, verbal, sexual, and financial;-He/she witnessed Resident #1 attempt to hug other residents and the resident would follow him/her. During an interview on 03/06/26, at 12:48 P.M., CNA K said the following:-If he/she witnessed a resident kiss, touch inappropriately or hug another resident, he/she would consider it sexual abuse;-If he/she witnessed a resident hit another resident, he/she considered this physical abuse;-He/she separated the residents and reported to the charge nurse immediately. During an interview on 03/06/26, at 1:00 P.M., CNA L said the following:-Types of abuse included physical, verbal, misappropriation, and sexual;-He/she witnessed Resident #1 approach Resident #2 and kiss the resident;-He/she separated the residents and re

Based on interview and record review, the facility failed to ensure all nurse aides (NA) completed the required competency and certified process within four months of beginning work as an NA, when one NA (NA G) worked nine months as a NA without obtaining the required certification. The facility census was 67.Review of the facility's policy titled Nurse Aide Qualifications and Training Requirements, revised 10/2017, showed the following:-Nurse aides must undergo a state-approved training program;-Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay;-In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities;-Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in S483.1 S0(a) and (b) of the Requirements of Participation;-Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non -nursing related services.Review of NA G's personnel file showed the following:-The NA's first date of employment as a NA was [DATE];-The NA began certified nursing assistant (CNA) classes on [DATE] and completed the classes on [DATE];-As of [DATE], staff did not have documentation of NA completing the CNA certification process. Review of the CNA registry on [DATE], showed NA G did not have an active CNA certification in Missouri. Review of the facility's nurse staffing sheets, dated [DATE] through [DATE], showed the following:-On [DATE], the NA worked from 6:00 P.M. to 6:00 A.M.;-On [DATE], the NA worked from 6:00 P.M. to 6:00 A.M.;-On [DATE], the NA worked from 6:00 P.M. to 6:00 A.M.;-On [DATE], the NA worked from 6:00 P.M. to 6:00 A.M.;-On [DATE], the NA worked from 6:00 P.M. to 6:00 A.M During interviews on [DATE], at 2:51 P.M., and on [DATE], at 10:49 A.M., NA G said the following:-He/she started work at the facility in [DATE];-He/she started CNA classes in [DATE];-He/she was not certified;-He/she did not know how much time he/she had to get certified;-He/she did not complete the classes within four months;-He/she worked as a NA since he/she was hired at the facility and had not been terminated or moved to a different department;-He/she took and passed the written test in [DATE] and the practical exam was scheduled for February 2026, but was cancelled;-He/she was unable to take the test earlier due to not having valid unexpired identification;-The former CNA Instructor and the Director of Nursing (DON) reminded him/her regularly that he/she needed to complete the tests.During an interview on [DATE], at 10:18 A.M., the CNA Instructor said the following:-The former CNA instructor quit about a month ago;-The NAs had 120 days or four months to get certified;-If a NA was not certified at the end of the four months, the NA should be moved to another department such as dietary or housekeeping until they passed their test or have their employment terminated;-He/she thought NA G was certified;-NA G should have been certified within four months.During an interview on [DATE], at 11:56 A.M., the DON said the following:-NAs had four months to get certified;-If a NA was not certified within four months, they should be terminated or moved to another department;-NA G started work on [DATE] and started CNA classes in [DATE];-NA G should have been certified in [DATE];-NA G worked as a NA since his/her start date and had not been moved to another department or terminated;-NA G should not have worked as a NA past [DATE];-NA G passed his/her written test, but had not taken his/her clinical test;-NA G went for his/her clinical test, but did not take a valid identification with him/her;-He/she was responsible for ensuring NAs were certified within the required four month time frame.During an interview on [DATE], at 12:25 P.M., the Administrator said the following:-The facility had four months to get NAs certified;-If a NA was not certified within the four-month time frame, they should be moved to another department or terminated;-NA G worked as a NA since [DATE] and should have been certified by [DATE];-NA G was not moved to another department and was not terminated;-He/she should not have allowed NA G to continue working as a NA past [DATE];-NA G passed his/her written exam and scheduled his/her clinical exam;-He/she was ultimately responsible for ensuring NAs were certified by the required four month time frame.

Based on interview and record review, the facility failed to all allegations of abuse were investigated timely and steps taken to protect residents were documented when the facility did not complete a timely documented investigation with steps taken to protect the resident documented after an allegation of abuse was made by one resident (Resident #1). The facility had a census of 71.Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management;-The Administrator will assign the investigation of an incident or suspected incident of resident abuse or injury of unknown source to an appropriate individual;-The individual conducting the investigation will, at a minimum, review the completed documentation forms; review the resident's medical record; interview the person reporting the incident; interview any witness to the incident; and interview the resident; interview the resident's physician as needed to determine the resident's current cognitive level and medical condition; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family, and visitors; interview other residents to whom the accused employee provides care for; and review all events leading up to the alleged incident;-Interviews will be conducted separately in private location;-Witness reports will be obtained in writing, signed, and dated.1.Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 10/10/25;-Diagnoses included paranoid schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/16/25, showed the resident had moderate cognitive impairment, delusions, and verbal behavioral symptoms directed at others.Review of the resident's progress note dated 12/23/25, at 11:21 P.M., showed Licensed Practical Nurse (LPN) F documented the resident had been yelling and screaming since his/her return from the emergency room. Resident was heard yelling That N word, next door is putting his penis in my butthole. The resident referred to was unable to get up out of bed unassisted and was sleeping at the time. This nurse asked the resident what he/she was talking about, and he/she made a ring with his finger and thumb and moved his index finger of the other hand in and out of the ring and stated he is putting his penis in my butthole. This nurse explained to resident that it was impossible, and the facility did not tolerate racial slurs and name calling. Resident resting in bed at this time. (The LPN did not document any steps taken to begin an investigation or steps taken to protect the resident during an investigation.)Review of the resident's electronic medical record showed staff made no additional entries related to an assessment, notifications, or further information related to sexual abuse allegation.Review of the Department of Health and Senior Services (DHSS) records, on 01/02/26 showed the facility had not submitted an investigation of the incident completed by facility. During an interview on 01/07/25, at 10:20 A.M., LPN F said the following:-The resident was heard yelling for help on 12/23/25;-He/she checked on the resident and he/she stated the n***** next door put his penis in my butthole;-He/she told the resident that the other resident was asleep in his/her bed;-LPN F thought the other resident was unable to walk but was later informed that he/she was ambulatory;-LPN F did not think the other resident could do anything to Resident #1;-LPN F made a progress note about the incident and reported it to the oncoming nurse in report;-LPN F did not complete an assessment of the resident after allegation;-He/she would have moved the resident to a safer location and continued to monitor the resident if he/she thought it was a credible abuse allegation.During an interview on 01/07/26, at 12:00 P.M., the Assistant Director of Nursing (ADON) said he/she was involved in abuse investigations, and they should consist of staff and resident interviews. The Administrator was responsible for documenting an investigation. During interviews on 01/02/26, at 1:45 P.M. and 2:50 P.M., and on 01/07/26, at 1:20 P.M., the Administrator said the following:-He/she was unaware of the allegation of sexual abuse;-A resident assessment should have been completed after the allegation was made;-He/she would begin an investigation. -An abuse report should result in an investigation being started;-The nurse should complete an assessment of the resident, notify family, physician, and responsible party, and document all information in a progress note;-A resident should be monitored after an abuse report;-An abuse investigation would consist of staff and resident interviews and a review of the resident chart, including diagnosis and medications;-Investigation should be completed within five days of allegation.

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible abuse made by one resident (Resident #1). The facility census was 71.Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management;-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source will be reported by the facility Administrator to the state licensing agency responsible for surveying the facility; the local ombudsman; the resident's representative; the resident's attending physician; and the facility medical director;-An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source) will be reported immediately, but not later than two hours for abuse or serious bodily injury and 24 hours if it does not involve abuse and had not resulted in serious injury.1.Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 10/10/25;-Diagnoses included paranoid schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/16/25, showed the resident had moderate cognitive impairment, delusions, and verbal behavioral symptoms directed at others.Review of the resident's progress note dated 12/23/25, at 11:21 P.M., showed Licensed Practical Nurse (LPN) F documented the resident had been yelling and screaming since his/her return from the emergency room. Resident was heard yelling That N word, next door is putting his penis in my butthole. The man the resident referred to was unable to get up out of bed unassisted and was sleeping at the time. This nurse asked the resident what he/she was talking about, and he/she made a ring with his finger and thumb and moved his index finger of the other hand in and out of the ring and stated he is putting his penis in my butthole. This nurse explained to resident that it was impossible, and the facility did not tolerate racial slurs and name calling. Resident resting in bed at this time. (The LPN did not document notifications related to the allegation of possible abuse.) Review of DHSS records showed the facility did not report the allegation of possible abuse on 12/23/25. During an interview on 01/07/26, at 10:20 A.M., LPN F said the following:-Types of abuse would include mental, physical, isolation, and neglect;-Staff should report to the DON and Administrator immediately any allegation of abuse; -The facility should call the state immediately with an allegation of abuse;-The resident was heard yelling for help on 12/23/25;-He/she checked on the resident and he/she stated the n***** next door put his penis in my butthole;-He/she told the resident that the other resident was asleep in his/her bed;-LPN F thought the other resident was unable to walk, but was later informed that he/she was ambulatory;-LPN F did not think the other resident could do anything to Resident #1;-LPN F made a progress note about the incident and reported it to the oncoming nurse in report;-LPN F did not think the allegation should be reported due to the resident's diagnosis of paranoid schizophrenia and thought it was a hallucination;-LPN F did not notify the Administrator of the abuse allegation.During an interview on 01/07/26, at 8:45 A.M., Certified Nurse Assistant (CNA) D said the following:-Types of abuse would include neglect, isolation, or physical;-He/she would report any abuse to the charge nurse and Administrator immediately;-An allegation of abuse should be reported to the state within 24 hours.During an interview on 01/07/26, at 10:05 A.M., CNA E said the following:-Types of abuse would include verbal, physical, and sexual;-He/she would advise the nurse immediately of any abuse;-The state should be notified within two hours of any abuse allegations.During an interview on 01/07/26, at 5:00 A.M., Certified Medication Technician (CMT) A said the following:-Types of abuse would include physical, mental, financial, and sexual;-He/she would make sure the resident was safe if abuse was observed and report it to the charge nurse as soon as possible;-The facility should contact the state within two hours with an allegation of abuse.During an interview on 01/07/26, at 5:30 A.M., LPN B said the following:-Types of abuse would include neglect, physical, mental, and financial; -He/she would report abuse to the Director of Nursing (DON) and Administrator immediately;-The facility should contact the state within two hours with an allegation of abuse;-He/she was unaware of any resident-to-resident abuse reported by Resident #1;-He/she would report any allegation as soon as possible and make sure the residents were separated.During an interview on 01/07/26, at 8:10A.M. LPN C said the following:-Types of abuse would include neglect, physical, verbal, and mental; -He/she would report abuse to the administrator immediately;-The facility should contact the state within two hours with an allegation of abuse;-He/she heard about the incident of abuse reported by Resident #1 in report from another nurse;-He/she did not know if the incident had been reported to the Administrator;-The allegation should have been reported to the administrator, but he/she was unsure if it should be reported to the state.During an interview on 01/07/26, at 12:00 P.M., the Assistant Director of Nursing (ADON) said the following:-Types of abuse would include physical, sexual, and financial;-Staff should notify administration immediately;-State should be notified of an abuse allegation within two hours;-The resident's abuse allegation should be taken seriously;-The allegation from the resident should have been reported to the state and investigated. During an interview on 01/07/26, at 1:20 P.M., the Administrator said the following:-An allegation of abuse should be reported to the administrator or on-call staff as soon as possible;-The facility had two hours to report an abuse allegation to the state;-The resident's allegation should have been treated as possible abuse and reported to administration and the state.

Based on interview and record review, the facility failed to employee a medical director who was actively involved in the implementation of care policies and assisted with coordination of medical care when the facility had not entered into a contract with the medical director and ensured he/she was aware of his/her medical director responsibilities and when when the facility failed to ensure the medical director participated and was involved in completing/updated the facility assessment and attended the Quality Assessment and Assurance (QAA) Committee meeting. The facility census was 70. Review of the facility policy titled Medical Director, dated July 2016, showed the following: -Physician services shall be under the supervision of the Medical Director; -The Medical Director is a licensed physician in this state and is responsible for ensuring adequate and appropriate physician services; reviewing practitioner credentials and overseeing physicians and those who perform physician-delegated tasks; reviewing physician performance and provide feedback to try to improve performance; overseeing and helping develop and implement care-related policies and practices; participating in efforts to improve quality of care and services; serving as the liaison with the community; and serving as a source of education, training, and information; -The Medical Director functions also included, but were not limited to acting as a liaison between administration and attending physicians; acting as a consultant to the director of nursing services in matters related to resident care services; helping assure that residents receive adequate services appropriate to meet their needs; helping assure that the resident care plan accurately reflects the medical regimen; participating in staff meetings concerning infection prevention and control, quality assurance and performance improvement, antibiotic stewardship, pharmaceutical services, resident care policies, etc.; assisting with employee health issues and concerns; and assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, showed the following: -This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI program; -The primary goals of the QAPI Committee were to establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services; promote the consistent use of facility systems and processes during provision of care and services; help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems; help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members; -The committee has the full authority to oversee the implementation of the QAPI Program, including, but not limited to establishing performance and outcome indicators for quality of care and services delivered in the facility; choosing and implementing tools that best capture and measure data about the chosen indicators; appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility; and communicating the information gathered and their interpretation to the owner/governing board; The Committee Chairperson, Administrator, Director of Nursing Services, Medical Director, Dietary Representative, Pharmacy Representative, Social Services Representative, Activities Representative. Environmental Services Representative, Infection Control Representative, Rehabilitative/Restorative Services Representative, Staff Development Representative, Safety Representative, and Medical Records Representative will service on the committee: -The committee with meet monthly at an appointed time; -Special meetings may be called by the coordinator as needed to address issues that cannot be help until the next regularly scheduled meeting. 1. During an interview on 11/06/24, at 12:45 P.M., Physician A said the following -He/she had not signed a written contract to be the Medical Director; -He/she agreed to be the Medical Director on 07/01/24; -He/she had not done much yet, as he/she was new; -There had not been any meetings yet for him/her to attend, including QAPI meetings. During an interview on 11/06/24, at 11:10 A.M., the Director of Nursing said the following: -Physician A was the new Medical Director; -The Medical Director had not yet attended a QAPI committee meeting; -He/she was unsure of the date that he/she started as the Medical Director and thought it had been about two months. During an interview on 11/06/24, at 11:20 A.M., the Administrator said the following: -Physician A had not signed a formal contract to be the Medical Director; -Physician A and the Administrator shook hands on the Medical Director agreement; -Physician A agreed to be the Medical Director on 07/01/24; -The Medical Director had not yet attended a QAPI committee meeting. MO00244644

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when medications when one resident (Resident #1) had an almost full bottle of medication in his/her room, on the memory care unit, unsecured and unattended by authorized personnel. The facility had a census of 70. Review of a facility policy titled Storage of Medication, dated April 2019, showed the following: -The facility stored all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls; -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received; -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Hazardous drugs shall be clearly marked as such and shall be stored separately from other medications; -Only persons authorized to prepare and administer medications have access to locked medications; -Access to controlled medications is limited to authorized personnel. Personnel access to controlled medications is recorded. Review of a facility policy titled Administering Medications, dated April 2019, showed the following: -Medications are administered in a safe and timely manner and as prescribed; -Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so; -The Director of Nursing Services supervises and directs all personnel who administer medication and/or have related functions; -Residents may self-administer their own medications only if the Attending Physician, in conjunction with the interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the prescribing information for Brukinsa (zanubrutinib - prescription drug used to treat certain types of blood cancers in adults), dated June 2024, showed the following: -It is a prescription medicine used to treat adults with chronic lymphocytic leukemia (CLL - type of cancer that causes the bone marrow to produce too many lymphocytes, or white blood cells); -Recommended dosage of 160 milligram (mg) orally twice daily or 320 mg orally once daily. Patient to swallow whole with water and with or without food; -Advise patients not to open, break, or chew capsules; -Side effects can include fatal and serious hemorrhage (bleeding) in patients with hematological malignancies (blood cancers) treated with Brukinsa; fatal and serious infections (including bacterial, viral, or fungal infections) and opportunistic infections in patients with hematological malignancies; -Store the medication in the original, labeled container at room temperature and in a dry location; -Keep containers out of reach of children and pets; -If a caregiver prepares the dose, they should consider wearing gloves or pour the pills directly from their container into the cap, a small cup, or directly into the patient hand. They should avoid touching the pills. They should always wash their hands before and after giving the medication. 1. Review of Resident #1's face sheet (a brief information sheet about the resident), showed the following: -admitted [DATE]; -Self-responsible; -Diagnoses included osteomyelitis (serious bone infection that causes inflammation and swelling of the bone tissue) of vertebra thoracic region, chronic lymphocytic leukemia of B-Cell type (type of white blood cell that makes antibodies) not having achieved remission, and cognitive social or emotional deficit following other cerebrovascular disease (conditions that affect blood flow to your brain). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/26/24, showed the following: -Cognitively intact; -Staff supervision for oral hygiene, toileting hygiene, personal hygiene, and transfers; -Partial to moderate assistance of staff for showering and dressing. Review of the resident's care plan, dated 09/20/24, showed the following: -The resident had an alteration in hematological (refers to blood) status related to lymphocytic leukemia; -Staff would give medications as ordered and monitor for side effects and effectiveness; -Staff would provide medications as ordered and assist to follow up appointments as needed; -Resident was on antibiotic therapy (IV - into the vein) related to osteomyelitis; -Staff should administer antibiotic as ordered by physician. Review of the resident's physician orders, current as of 11/06/24, showed the following: -An order, dated 09/20/24, for Sodium Chloride solution 0.9% (solution containing sodium chloride (salt) in water for injection intended for IV administration), use 10 milliliter (ml) intravenously every six hours for flush, flush before and after antibiotic. -An order, dated 10/01/24, for Brukinsa (zanubrutinib) oral 80 milligram (mg), give two capsules by mouth twice daily for cancer. Observation on 11/06/24, at 9:20 A.M., showed the following: -The resident's room was located in the secured care unit (SCU - intentionally designed space that helps people with dementia live in a safe environment); -The room door was closed and not secured with no information on the door; -The resident was not in the room; -The room was cluttered with papers on the floor; -The sink counter contained a unsecured box of medication with a pharmacy prescription label. The medication was bottle was for Brukinsa 80 mg capsule; -Licensed Practical Nurse (LPN) B did not know where the resident was. He/she knew the resident had taken a shower and then thought he/she went to his/her room. Observation and interview on 11/06/24, at 9:28 A.M., showed the following: -Two residents were ambulating up and down the hall; -Resident #3 was confused and asked if he/she could go down the hall. LPN B advised he/she could go down the hall, but not out the end door. The resident ambulated down the hall; -LPN B spoke with shower aide in hall and determined Resident #1 went to a doctor's appointment with his/her family; -LPN B said that Resident #1 was admitted after back surgery and wanted a private room, that was why he/she was located on the secured care unit. He/she did not have a diagnosis of dementia. Observation and interview on 11/06/24 showed the following: -At 10:45 A.M., Resident #1 was not in his/her room. The door was closed and there was no lock on the door. The room connected to an empty resident room through the shared bathroom. On the counter in the room, next to the sink, was a nearly full bottle of Brukinsa 80 mg caplets with a pharmacy labeled dated 10/01/24. The bottle read take one tablet four times per day, quantity 120 tablets. There was also approximately 50 empty sodium chloride solution 10 ml syringes on the counter in a clear plastic bag and two full unopened 10 ml syringes; -At 10:50 A.M., two residents (Resident #5 and #6) were ambulating up and down hall past the room; -At 10:55 A.M., two residents were observed in a resident room three doors down from Resident #1's room. One resident was resting under the covers in the bed and the second resident was standing and touching the curtains in the room; -At 10:55 A.M., LPN B said that Resident #3 did not belong in the room and then noted that Resident #4, that was in the bed, also did not belong in the room. Staff re-directed both residents out of the room. The room belonged to Resident #2 and he/she was seated in a wheelchair in the common area propelled by staff; -LPN B said that generally Resident #1 stayed in his/her room; -Resident #3 frequently wandered in and out of rooms; -Many of the residents will open a closed door and peek in, but then close the door and not go in; -Many of the residents will wander into a room if the door was open; -When passing morning medications, he/she did not see the bottle of medication in the room; -He/she was going to talk to the Administrator about the medication at bedside but had not done that yet; -A resident would require a physician's order to have medications at bedside; -If one of the wandering residents got the medication he/she was unsure what the possible side effects could be. During an interview on 11/06/24, at 11:10 A.M., the Director of Nursing (DON) said Resident #1 wanted a private room and no rooms were available other than in the SCU. The resident was always in his/her room unless out for an appointment. The residents on the SCU did tend to wander and open doors. Resident #1 was difficult and wanted to do things his/her way. The bottle of pills should not have been in the room. The resident wanted to keep the empty sodium chloride vials to use on his/her farm. There was no known risk for the empty syringes to other residents. There was concern for risk of chemo drug being possibly accessible to the other residents. During an interview on 11/06/24, at 11:20 A.M., the Administrator said the following: -Any resident should have an order and have an evaluation to determine if it was safe to have medications at bedside; -There was a potential risk to all other residents with medication left in a resident room; -Resident #1 had not been diagnosed with dementia. He/she was in the SCU by choice for a private room.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to seal and date stored food in refrigerator and freezer; failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; failed to follow proper hand hygiene while serving food; failed to wash dishes properly between the preparation of separate food items; and failed to keep ice machine free of white substances. The facility's census was 62. 1. Review of the facility's policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 2016, showed the following: -Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; -Leftover contents of can and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Wrap food properly. Never leave any food item uncovered and not labeled. Observation on 03/17/24, at 3:27 P.M., of the kitchen refrigerator showed the following: -One quart size zipper bag containing french toast sticks. The bag was not labeled or dated; -One quart size zipper bag containing sausage patties. The bag was not labeled or dated; -One quart size zipper bag containing a ground meat. The bag was not labeled or dated; -One gallon size zipper bag containing sliced American cheese. The bag was not labeled or dated; -One gallon size zipper bag containing what appeared to be a turkey breast. The bag was not labeled or dated; -An unsealed and undated stick of margarine. Observation on 03/17/24, at 3:44 P.M., of the freezer showed one 20 lb. box of beef patties and one bag of approximately 15 chicken breasts unsealed and undated. Observation on 03/18/24, at 9:26 A.M., of the kitchen refrigerator showed the following: -One gallon size zipper bag containing sliced American cheese. The bag was not labeled or dated; -One gallon size zipper bag containing what appeared to be a turkey breast. The bag was not labeled or dated. Observation on 03/18/24, at 9:33 A.M., of the freezer showed one 20 lb. box of beef patties and one bag of approximately 15 chicken breasts unsealed and undated. Observation on 03/19/24, at 11:07 A.M., of the kitchen refrigerator showed the following: -One gallon size zipper bag containing sliced American cheese. The bag was not labeled or dated: -One gallon size zipper bag containing what appeared to be a turkey breast. The bag was not labeled or dated. During an interview on 03/19/24, at 1:55 P.M., Dietary Aide (DA) M said the following: -Kitchen staff are responsible for dating and identifying food prior to putting in refrigerator/freezer; -Items in the refrigerator not dated should be thrown away; -All items in the refrigerator and freezer should be in sealed containers. During an interview on 03/19/24, at 2:14 P.M., Cook O said the following: -Staff putting away food are responsible for dating and identifying food prior to putting in the refrigerator; -Items in the refrigerator not dated or identified should be thrown away; -All items should be stored in sealable containers and not open to air. During an interview on 3/19/24, at 2:38 P.M., Dietary Manager (DM) said the following: -He/She expects staff to date and label food prior to putting it in the refrigerator; -All food should be stored in sealable containers and not open to air; -Food in refrigerator not dated or identified should be discarded. During an interview on 03/20/24, at 2:10 P.M., the Administrator said the following: -He/She expects food to be dated and identified prior to storing in the refrigerator; -He/She expects all food to be stored in sealable containers. 2. Review of the facility's policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 2016, showed dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. Review of the Food and Drug Administration (FDA) 2022 Food Code showed rusted, pitted, or dented cans may also present a serious potential hazard. Observation on 03/17/24, at 3:00 P.M., of the dry food storage area showed the following: -Three dented 50-ounce (oz) cans of cream of mushroom soup; -One dented 112 oz. can apple fruit filling; -One dented 108 oz. can tapioca pudding; -One dented 6 pound (lb.) 12 oz. can black beans; -One dented 6 lb. 6 oz. can of whole potatoes. Observation on 03/17/24, at 5:20 P.M., of dinner serve out showed the tapioca pudding being served to residents for dessert. Observation on 03/17/24, at 5:20 P.M., of the food storage area showed all 108 oz. cans of tapioca pudding, including the one dented can, was gone. During an interview on 03/17/24, at 6:20 P.M., DA L said the following: -All staff are responsible for stocking items when they arrive; -Dented cans do not go on the shelf. If he/she finds a dented can he/she tells the DM; -Dented cans go on a separate shelf in the DM's office; -The food from the dented cans can make the residents sick. During an interview on 03/17/24, at 6:22 P.M., DA M said the following: -All staff are responsible for unloading the truck and putting away items; -All staff are to look for dented cans when putting items away; -If staff find dented cans, they go in a separate room to be sent back to the driver; -The food in the dented cans may be contaminated and could make residents sick. During an interview on 03/17/24, at 6:25 P.M., the DM said the following: -Staff are to look for dented cans when putting away items; -Dented cans should not be put on the shelf, they should be put in separate store room; -Dented cans can be contaminated and cause food poisoning and sickness in the residents; -The DM used the dented 108 oz can of Tapioca pudding for dinner. He/she would not have had enough tapioca pudding for dinner if not used. Observation on 03/18/24, at 9:18 A.M., of the kitchen and food storage area showed the following: -Three dented 50 oz cans of cream of mushroom soup; -One dented 112 oz. can apple fruit filling; -One dented 6 lb. 12 oz. can black beans; -One dented 6 lb. 6 oz. can whole potatoes. During an interview on 03/19/24, at 2:14 P.M., Cook O said the following: -Dented cans should not be put on shelf or used; -Dented cans can be contaminated and make resident sick. During an interview on 03/20/24, at 2:10 P.M., the Administrator said he expects dented cans to be sent back with the driver when delivered and not used. 3. Review of the facility's policy titled, Proper Hand Washing and Glove Use, dated 2016, showed the following: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines; -Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident; -Gloves are to be used whenever direct food contact is required with the following exception: bare hand contact is allowed with foods that are not in ready to eat form that will be cooked or baked; -Hands are washed before donning gloves and after removing gloves; -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform or other non-food contact surface, such as door handles and equipment; -Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. Review of the FDA 2022 Food Code showed the following: -Food employees shall clean their hands and exposed portions of their arms as immediately before engaging in food preparation including working with exposed food, clean equipment, and utensils; -Food employees shall clean their hands after handling soiled equipment or utensils; -Food employees shall clean their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -Food employees shall clean their hands before donning gloves to initiate a task that involves working with food; -Single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observation on 03/19/27, at 11:12 A.M., of the puree process showed the following: -Cook N washed his/her hands and donned gloves; -Cook N placed chicken and broth in blender bowl, pureed the chicken, and poured the purred chicken into a metal pan; -Without washing hands or changing his/her gloves, Cook N placed rice and broth in the blender bowl and pureed the rice; -Cook N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender; -Cook N did not doff his/her gloves or wash his/her hands; -Using the same gloves, Cook N used his/her gloved hands to scoop cooked broccoli into the blender bowl, pureed the broccoli, and poured the puree in a metal pan; -Cook N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender; -Cook N did not doff his/her gloves or wash his/her hands; -Using the same gloves, Cook N placed five pieces of cake and milk in the blender bowl and pureed it. The cook then poured pureed cake into three separate serving dishes. Observation on 3/19/24, at 11:49 A.M., of lunch serve out showed the following: -Cook N washed hands and donned gloves; -Cook N went from serving food with serving utensils to the refrigerator, retrieved a bag of hot dogs, and opened the bag. The cook used his/her hands and retrieved one hot dog, opened the microwave and placed hot dog directly on glass microwave plate to cook; -Cook N did not doff his/her gloves or wash his/her hands; -Cook N retrieved a bag of hot dog buns, opened the bag, using his/her hands retrieved one hot dog bun, set on plate, then used tongs and placed hot dog in bun. Cook N then sent plate to be served to resident; -Cook N did not doff his/her gloves or wash his/her hands; -Cook N returned to serving food with serving utensils; -Cook N retrieved a bag of sliced cheese from the refrigerator, opened the bag, with his/her hands retrieved a slice of cheese, and placed it on a hamburger patty and returned to serving; -Cook N did not doff his/her gloves or wash his/her hands; -Cook N retrieved a bag of hamburger buns, with his/her hands he/she retrieved a hamburger bun from the bag and placed it on a plate; -Cook N using his/her hands then placed a hamburger patty and slice of cheese on the bun and sent the tray to be served to resident; -Cook N repeated this process two times; -Cook N did not doff his/her gloves during the lunch serve out process. During an interview on 03/19/24, at 1:55 P.M., DA M said the following: -Staff should wash hands when entering the kitchen; -Staff should wash their hands prior to donning gloves; -Staff should don gloves prior to direct food contact; -Staff should change gloves when going from non food items to direct food items. During an interview on 03/19/24, at 2:14 P.M., Cook O said the following: -Staff should always wash hands and wear gloves; -Staff should change gloves between preparing food and washing dishes; -Staff should probably change gloves prior to direct food contact. During an interview on 03/19/24, at 2:38 P.M., the DM said the following: -Staff should wash hands when entering the kitchen, between preparing food items, and after taking trash out; -Staff should wear gloves during direct food contact; -Staff should change gloves, when going between direct food contact and no food item contact. During an interview on 03/20/24, at 2:10 P.M., the Administrator said he/she expected staff to use proper hand hygiene while preparing and serving food. 4. Review of the facility policy titled, Cleaning Rotation, dated 2016, showed the following: -Equipment and utensils will be cleaned according to the facility guidelines or manufacturer's instructions; -Items cleaned after each use include small food preparation equipment (e.g. blender, food processor), kettles and utensils and mixers. Review of the 2022 FDA Food Code showed the following: -Equipment food-contact surfaces and utensils shall be clean to sight and touch; -Equipment food-contact surfaces and utensils shall be cleaned before each use with a different type of raw animal food; -Equipment food-contact surfaces and utensils shall be cleaned each time there is a change from working with raw food to working with ready-to-eat-foods; -Equipment food-contact surfaces and utensils shall be cleaned between uses with raw fruits and vegetables and with time/temperature control for safety food; -Equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred; -Equipment food-contact surfaces and utensils shall be effectively washed to remove or completely loosen soils by using the manual or mechanical means necessary such as the application of detergents containing wetting agents and emulsifiers; acid, alkaline, or abrasive cleaners; hot water; brushes; scouring pads; high-pressure sprays; or ultrasonic devices; -Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning' -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining. Observation on 03/19/27, at 11:12 A.M., of the puree process showed the following: -Cook N placed chicken and broth in blender bowl, pureed the chicken, then poured the puree into a metal pan; -Cook N placed rice and broth in the blender bowl, without washing/sanitizing it, and pureed the rice; -Cook N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -Cook N scooped cooked broccoli into the blender bowl, pureed broccoli, and poured in metal pan; -Cook N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -Cook N placed five pieces of cake and milk in the blender bowl and pureed it. The cook then poured pureed cake into three separate serving dishes. The blender bowel, wet from removing food debris, dripped off the bowl into the serving dishes. During an interview on 03/19/24, at 1:55 P.M., DA M said the following: -All dishes having food contact should be washed with soap and sanitized; -Dishes should be dry prior to use. During an interview on 03/19/24, at 2:14 P.M., Cook O said the following: -The food processor should be washed with soap and sanitized between pureeing of foods; -The processor should be dried prior to use; -Dishes should not have water dripping from them while in use. During an interview on 03/19/24, at 2:38 P.M., DM said the following: -The DM expects staff to clean the bowl, blade, and lid of the processor between pureeing of foods; -Staff should use soap and sanitizer when washing dishes; -All dishes should be dry prior to use. During an interview on 03/20/24, at 2:10 P.M., the Administrator said the following: -He/She expected staff to wash dishes with soap and sanitize them; -He/She expected staff to wash the processor between the pureeing of separate food items; -He/She expected dishes to be air dried prior to use. 5. Review of the facility's Daily AM and Daily PM cleaning logs showed the following: -Mop ice room; -Delime ice machine. Review of the FDA 2022 Food Code showed the following: -Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms Observation on 03/17/24, at 3:51 P.M., on 03/18/24, at 9:35 A.M., and on 03/19/24, at 12:29 P.M., showed the following: -The inside of the ice machine, above the ice and around the hinges, has a white substance present; -The deflector shield on the inside of the ice machine had six black spots and a pinkish substance along most of the bottom of the deflector shield. During an interview on 03/19/24, at 1:55 P.M., DA M said the following: -Staff are given a daily cleaning schedule with assigned task; -Kitchen staff are responsible for cleaning the inside and outside of the ice machine; -The ice machine is cleaned every shift. During an interview on 03/19/24, at 2:14 P.M., Cook O said DA's are responsible for cleaning the ice machine. During an interview on 03/19/24, at 2:38 P.M., the DM said the following: -The ice machine is delimed daily; -Kitchen staff are responsible for cleaning the outside of the ice machine; -Maintenance staff are responsible for cleaning the inside of the ice machine. During an interview on 03/20/24, at 12:30 P.M., the Maintenance Supervisor said the following: -Maintenance staff are responsible for cleaning and sanitizing the inside of the ice machine; -Maintenance staff clean the inside of the ice machine once a month; -Maintenance staff have not been documenting when the ice machine was cleaned. During an interview on 03/20/24, at 2:10 P.M., the Administrator said there should not be calcium/lime build up on the ice machine.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program, based on facility policy and standards of practice, when multiple staff did not wear face coverings and appropriate personal protective equipment (PPE) while assisting/conversing with 14 residents on the designated hall during a coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) outbreak in the facility. The facility census was 62. Review of the facility's policy titled Covid-19 Prevention, Response and Reporting, revised 01/01/24, showed the following: -It is the policy of the facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance; -Source control options for health care personnel (HCP) include the following: -A NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher; -A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirator; -A well-fitting facemask; -Source control can be used for an entire shift unless they become soiled, damaged, or hard to breathe through; -Source control is recommended for individual in healthcare settings who have suspected or confirmed SARS-CoV-2 infection or other respiratory infection; had close contact (residents and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infections, for 10 days after their exposure; -Source control is recommended more broadly in the following circumstances: -By residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection universal use of source control could be discontinued as a mitigation measure once the outbreak is over (no new cases of SARS-CoV-2 infection have been identified for 7 days) or; -Facility-wide or, based on facility risk assessment, targeted toward higher risk areas or resident populations during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission; -The facility may consider designating entire units within the facility, with dedicated HCP to care for residents with SARS-CoV-2 infection when the number of residents with SARS-CoV-2 infection is high; -HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters, or higher, gown, gloves and eye protection. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 03/18/24, showed the following: -The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency; -Source control is recommended for individuals in healthcare settings who have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure; -Source control is recommended more broadly by those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromised) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission. 1. Observation and interviews on 03/17/24, beginning at approximately 4:00 P.M., showed the following: -An isolation cart on the outside of the COVID unit which contained PPE; -Certified Nurse Aide (CNA) H and CNA I worked on the designated COVID hall and were not wearing PPE; -The Administrator entered the back door of the COVID wearing an N95 mask. He said he did not have any symptoms except he was tired and out of breath after his run today. The Administrator had tested positive for COVID; -CNA I said he/she was positive for COVID and did not have COVID symptoms; -The Administrator said the staff working the COVID hall are positive and did not have to wear PPE. Observation and interview on 03/17/24, at 5:30 P.M., on the COVID unit showed the following: -CNA J said he/she tested positive for COVID on 03/16/24; -His/her symptoms included nauseous, headache, and he/she was a little tired; -He/she worked on the COVID unit; -He/she did not wear mask or PPE while working on the COVID unit; -CNA I, CNA H, CNA J, and the Administrator served the dinner meals to the residents on the COVID unit. The staff did not wear PPE. During an interview on 03/18/24, at 12:22 P.M., Licensed Practical Nurse (LPN) K said staff did not need to wear PPE if they are positive for COVID and work the COVID unit. Staff should wear PPE if they are negative for COVID and work on the COVID unit. During an observation and interview on 03/18/24, at 12:21 P.M., CNA H wore an N95 mask on the COVID unit. He/she tested negative for COVID that morning. He/she said staff did not wear PPE if COVID positive and worked on the COVID unit. The DON informed staff of this information. During an interview on 03/19/24, at 3:20 P.M., Registered Nurse (RN) G said the following: -He/she did not believe COVID positive staff who work on the COVID unit had to wear PPE; -Staff should wear PPE if working with residents on the COVID unit and then they work out of the COVID unit with residents. During an interview on 03/19/24, at 3:37 P.M., LPN A said as far as he/she knew, if staff are positive for COVID, they can wear just a N95. During an interview on 03/19/24, at 3:51 P.M., the Director of Nursing/Infection Preventionist said the following: -Staff should isolate the resident to their room if positive for COVID; -On 03/12/24, the facility had multiple residents test positive for COVID; -She called the Administrator to inform him. The facility made a COVID unit instead of isolating each resident to his/her room; -Staff monitor the residents daily; -Residents are on isolation until a negative COVID test; -The facility policy is when COVID in the building, staff test daily and wear N95 masks throughout the facility; -Staff who are negative for COVID and work the COVID hall should wear shoe covers, gown, N95, face shield, and gloves; -Staff who are positive did not have to wear PPE if they worked on the COVID unit. During an interview on 03/21/24, at 12:23 P.M., the Administrator said the following: -Staff who are positive for COVID and work on the COVID unit did not have to wear PPE; -COVID positive staff are not at a higher risk of spreading COVID; -Staff should wear PPE if they are negative for COVID.

Based on observation, interview, and record review, the facility failed to maintain an environment free of safety hazards when staff failed follow the care plan when transferring one resident (Resident #52) of two sampled residents who was care planned to need a mechanical lift for transfers and when the staff failed to implement planned fall intervention for one resident (Resident #46), assessed as a fall risk, when staff did not have a fall mat in place when the resident was in bed. The facility census was 62. 1. Review of the facility policy Safe Lifting and Movement of Residents, revised July 2017, showed the following: -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with rehabilitation staff shall assess resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan and shall included resident's mobility (degree of dependency), weight-bearing ability, and cognitive status; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of Resident #52's face sheet (admission information at a glance) showed the following: -admitted [DATE]; -Diagnoses included dementia (brain is damaged by injury or disease and involved progressive impairments in memory, thinking, and behavior which negatively impacts a person's ability to function and carry out every day activities), and psychotic disorder with delusions (mental illness where you can't tell what's real from what was imagined and main symptom of delusions which belief that is not true or based on reality). Review of the resident's care plan, dated 05/24/23, showed the following: -Activities of daily living (ADL) self-care performance deficit related to aggressive behavior, confusion, dementia, and limited mobility; -The resident required two staff for total assistance with transfers with a hoyer lift (mechanical lift often use for residents who are non-weight bearing) to move between surfaces at least every two hours and as necessary. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/22/24, showed the following: -Severely impaired cognition; -No behaviors; -Sit-to-stand (ability to come to a standing position from sitting in a chair or wheelchair or side of the bed) - not attempted due to medical condition or safety concerns; -Chair/bed-to-chair transfer (the ability to come to a standing position from sitting in a chair, wheelchair) - dependent, helper does all the effort. Resident does none of the effort to complete the action. Observation and interview on 03/19/24, at 9:19 A.M., showed Certified Nurse Aide (CNA) B and CNA C pushed the resident's wheelchair into the his/her room, put their hands under the resident's arms on each side of the resident without putting a gait belt (an assistance safety device used to help a patient sit, stand, or walk around to steady them) on the resident's waist and transferred the resident from the wheelchair to the bed. The resident said, Oh loudly as they stood him/her up. The resident's lower legs remained stiff and straight as they transferred him/her to the bed (not bearing weight). CNA C said the resident did not need a hoyer transfer since he/she will stand and bear weight, but did not always bear his/her weight. During interviews on 03/19/24, at 9:26 A.M., and on 03/21/24, at 9:36 A.M., CNA C said he/she did have a gait belt and should have used a gait belt to transfer the resident. He/she did not have the gait belt with him/her at the time. They can find how to transfer a resident by looking at his/her care plan in the resident's medical record. If changes were made with the resident's transfer, the charge nurse or CNAs would tell him/her. He/she knew the resident was a hoyer lift, but knew the resident could stand. The resident had been a hoyer lift for a while. During interviews on 03/20/24, at 10:21 A.M., and 03/21/24, at 10:13 A.M. CNA D said the resident was a hoyer lift transfer. The resident did not bear his/her weight and they would not try to stand him/her. The resident was very stiff and was not safe to transfer with a gait belt either. When a resident was admitted , therapy comes in and makes the decision of the type of transfer. If they notice a change in the resident's mobility, whether it is better or worse, they have therapy evaluate them again. This resident was a two person transfer when admitted . Now, the resident was a hoyer lift for months due to stiffness in his/her whole body. They could find this information in the resident's care plan book but CNAs don't look in this. He/she gets information from the nurses or therapy. For a two person assistance transfer, they were to use a gait belt. There were too many shoulder issues with residents which could pop their shoulder out of place. During an interview on 03/20/24, at 4:20 P.M., CNA E said they were to transfer the resident with the mechanical lift since the resident was not weight bearing. They were not to transfer him/her with a gait belt. The resident's legs were stiff and it would be unsafe to stand him/her. They were never to go under the resident's arms to transfer the resident since it could pull a shoulder out of place and/or cause a tear. During an interview on 03/21/24, at 9:55 A.M., CNA B said the residents' medical records and care plans say how the residents are transferred. There were care plan books at the nurses' desk. The CNAs can get information from the kiosks and the CNA can ask other aides or the nurse especially if resident was new at the facility. The resident was a hoyer lift, but was weight bearing. They have told the nurses and therapy this. They normally transfer the resident with a two person assist with a gait belt. Staff were aware of this. The resident has strength in his/her legs and will lose it, if he/she doesn't use it. The staff did an evaluation and said the resident was a hoyer lift. They were never to transfer a resident under his/her arms. They were to always use a gait belt. He/she did not know if there was a gait belt in the resident's room. They would have been expected to use a hoyer lift to transfer this resident. During an interview on 03/21/24, at 10:30 A.M., Licensed Practical Nurse (LPN) A said if a resident was unable to bear his/her weight, they would use a mechanical lift to transfer them. If a resident was not safe or could hurt themselves or staff hurt themselves to transfer the resident, the CNAs use a hoyer lift until therapy can assess the resident. If a resident was care planned as a hoyer lift, CNAs would not transfer the resident with a gait belt, but transfer with a hoyer lift. They keep information in the resident's care plans on how to transfer the resident and will notify aides if there was a change in their transfer. This resident was a hoyer lift and does not bear much weight most of the time. The resident was transferred by hoyer lift for both his/her safety and staff safety. At times, the resident was more stiff in his/her extremities. During interview on 03/21/24, at 8:50 A.M., the Director of Nursing (DON) said staff were to use a gait belt to transfer a resident because they were not to tug on arms or let a resident put their arms around their necks which was unsafe. Staff were never to lift underneath the resident's arms. Staff were to look in the resident's care plan and they do use word of mouth to know how to transfer a resident. The resident was a hoyer lift transfer and never transfers with a gait belt with his/her stiffness. She tells the staff if they haven't been here to work for a while, they were to ask them how to transfer a resident. The care plan books were usually up at the nurse's desk. During interview on 03/21/24, at 12:22 P.M., the Administrator said he would expect staff to transfer a resident according to their care plan and/or assessment. He would expect staff to transfer the resident according to the care plan which said a hoyer lift. 48534 2. Review of the facility's policy titled, Falls and Fall Risk, Managing, revised March 2018, showed the following: -Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (i.e., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -Resident conditions that may contribute to the risk of falls include delirium and other cognitive impairment, lower extremity weakness, functional impairments, neurological disorders, and balance and gait disorders; -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls; -If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once); -If falling recurs despite initial intervention, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling; -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified; -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of Resident #46's face sheet (resident's information at a quick glance) showed the following: -Readmitted [DATE]; -Diagnoses included conversion disorder with seizures or convulsions (a psychiatric illness in which psychological conflicts are manifested as physical symptoms), muscle weakness, lack of coordination, and reduced mobility. Review of the resident's March 2024 Physician Order Summary (POS) report showed the following: -An order, dated 05/26/23, for fall mats while in bed, every day and night shift, related to unsteadiness on feet, other reduced mobility, and muscle weakness. Review of the resident's progress note dated 11/9/23, at 10:53 A.M., showed the following: -The resident was observed lying on his/her left side on floor next to bed with legs tangled in the blankets; -The resident said he/she rolled out of bed and hit his/her head; -Staff were educated regarding floor mat being down while the resident is in bed. Review of the resident's fall risk evaluation, completed on 03/07/24, showed the following: -Resident had three or more falls in past three months; -Resident is ambulatory; -Balance problem while walking and decreased muscular coordination; -Resident has one to two predisposing diseases present; -The resident is at risk for falls. Review of the resident's quarterly MDS, dated [DATE], and showed the following information: -Severe cognitive impairment; -Resident has had two or more falls since prior assessment. Observation on 03/17/24, at 4:07 P.M., showed the resident lying in bed, bed in lowered position, with fall matt folded up leaning against the roommate's recliner. Review of resident's care plan, updated 03/20/24, showed the following information: -The resident is at risk for falls related to decline in condition; -Assist resident with bed positioning as needed; -Resident is now on a low bed, close to the nurses' station, and fall mat beside bed; -Ensure bed is in lowest position; -If resident is a fall risk, initiate fall risk precautions. Observation on 03/20/24, at 10:21 A.M., showed the resident in bed, bed lowered, with fall mat folded up beside roommate's recliner. During an interview on 03/21/24, at 8:10 A.M., CNA J said the following: -Staff are made aware of residents who are fall risk in report; -Staff can find fall interventions on care plans; -The resident is a fall risk: -The resident has fall interventions in place, including a fall mat to be used when the resident is in bed. Observation on 03/21/24, at 8:12 A.M., showed the resident in bed, bed lowered, with resident's feet hanging off bed. The resident's fall mat was folded up beside roommate's recliner. Observation on 3/21/24, at 8:33 A.M., showed the following: -The resident was on his/her knees on the floor next to his/her bed, bed lowered, with no fall mat in place; -The resident was assisted to recliner by two staff members; -The resident was assessed/vitals taken by LPN P; -The resident was assisted back to bed and fall mat was placed on floor next to bed. During an interview on 03/21/24, at 8:43 A.M., LPN P said the following: -Fall interventions are found on the resident's care plan; -The resident is a fall risk; -The fall mat should be used anytime the resident is in bed; During an interview on 03/21/24, at 8:59 A.M., CMT Q said the following: -Interventions for residents that are fall risk include fall mats; -The resident is a fall risk; -Fall mats should be in place anytime the resident is in bed. During an interview on 03/21/24, at 9:12 A.M., the DON said the following: -All staff have access to the resident's care plan; -Fall interventions are listed in the resident's care plan; -The resident is a fall risk; -The fall mat should be used when the resident is in bed; -The DON would expect all staff to follow interventions listed on the care plan for residents who are at risk of falling. During an interview on 03/21/24, at 12:33 P.M., the Administrator said that he/she would expect all staff to follow fall interventions put in place for residents.

Based on interview and record review, the facility failed to notify residents' physicians of all changes in condition when when staff failed to ensure one resident's (Resident #29) physician was aware of the death of the resident's spouse prior to discontinuing an antianxiety medication and failed to report changes in the resident's condition after the discontinuation of the anti-anxiety medication. The facility census was 62. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction (GDR), revised [DATE], showed when a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms. Review of the facility's policy titled, Change in a Resident's Condition or Status, revised [DATE], showed the following: -Staff shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -The nurse will notify the resident's attending physician or physician on call when there has been a(an) significant change in the resident's physical/emotional/mental condition; -A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); -Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. 1. Review of Resident #29's face sheet (resident's information at a glance) showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, type two diabetes (a chronic condition that affects the way the body processes blood sugar), and depression. Review of the resident's annual Minimum Data Sheet (MDS - a federally mandated assessment tool completed by facility staff), dated [DATE], showed the resident had severe cognitive impairment. Review of the resident's care plan, revised [DATE], showed the following: -The resident has impaired cognitive function and impaired thought process related to Alzheimer's; -Staff should monitor/document/report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of the resident's progress notes, dated [DATE] to [DATE], showed staff did not document regarding the resident's spouse passing away in the same facility on [DATE]. Review of the note to attending physician/prescriber regarding the residents GDR review, dated [DATE], showed the following: -An recommendation to stop an order, dated [DATE], for buspirone (an anti-anxiety medication), 5 milligrams (mg), by mouth, one time a day; -Physician/Prescriber response, dated [DATE], showed agree, discontinue buspirone. Review of the resident's progress notes, dated [DATE] to [DATE] showed the following: -On [DATE], at 9:19 A.M., a new order received from the physician related to GDR of buspirone. The physician agreed to discontinue; -On [DATE], at 7:26 P.M., the nurse was checking the resident's blood glucose, and the resident became tearful, when asked what was wrong the resident voiced everything. When the resident was asked if he/she was having a bad day the resident voiced every day is a bad day, just leave me alone. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.); -On [DATE], at 2:30 A.M., the resident was yelling out, saying that he/she knows someone is outside of his/her room watching him/her. The resident became tearful voicing that the nurse was calling him/her a liar. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.); -On [DATE], at 7:34 P.M., the nurse responded to the resident crying out, the resident said that it was a bad day, when the nurse asked what happened the resident said that he/she had already told the nurse and the nurse didn't care enough to remember. The resident continued to cry saying he/she doesn't want to be in the building anymore. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.); -On [DATE], at 5:47 P.M., the resident refused to eat any dinner. The resident usually has a good appetite. The resident said that he/she was not hungry and if he/she didn't want to eat, he/she didn't have to. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.); -On [DATE], at 11:45 P.M., the resident was yelling out at 7:00 P.M., and wanted to go to bed. The resident was crying out and when asked why he/she was crying he/she said they didn't know. The resident continued to cry out with cares and fell asleep at 1:15 A.M. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.); -On [DATE], at 11:02 P.M., the resident was yelling out while in bed. When the resident was asked how he/she was doing, the resident said, just leave me alone because he/she wants to go to sleep. (Staff did not document notification of the resident's physician of the resident's change of condition and statements.) During an interview on [DATE], at 8:10 A.M., Certified Nursing Assistant (CNA) J said the following: -He/she is not always made aware of resident's medication changes; -If he/she notices changes in a resident, he/she would report the information to a charge nurse; -The resident has had changes in his/her behavior recently including hollering out and being more paranoid; -The resident's spouse recently passed away; -He/she was not aware that the resident has a recent medication change. During an interview on [DATE], at 8:43 A.M., Licensed Practical Nurse (LPN) P said the following: -Staff are made aware of medication changes when report is given; -If the resident has a negative change in behavior after a medication change, the physician should be notified; -The resident has had changes in his/her behavior recently; -The resident has been hollering out more; -LPN P was not aware that the resident had any medication changes recently; -LPN P said the resident's spouse passed away recently. During an interview on [DATE], at 8:59 A.M., Certified Medical Technician (CMT) Q said the following: -He/she is made aware of medication changes for residents; -The resident has been yelling out more, but denies any pain. During an interview on [DATE], at 9:12 A.M., the Director of Nursing (DON) said the following: -All staff are not made aware of medication changes; -Staff should notify him/her when there is a change in the resident's behavior; -The physician should be notified of a change in the resident's behavior; -It should be documented in the resident's chart that the resident's spouse had recently passed away; -The physician should have been notified of the changes in the resident's behavior. During an interview on [DATE], at 9:42 A.M., the Social Service Director (SSD) said the following: -Staff should document in the resident's chart a life event that had potential to affect the resident's behavior; -Staff should notify him/her of changes in the resident's behavior; -The resident has had a recent change in behavior; -The resident's change in behavior should be reported to the physician. During an interview on [DATE], at 12:23 P.M., the Administrator said the following: -He would expect staff to document in the resident's chart a significant life event that could affect the resident's behavior; -He does not know if the physician was made aware that the resident's spouse had recently died ; -He would expect staff to notify the physician of a change in the resident's behavior following a medication change. 34871

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to repair floors in resident rooms for two residents (Resident #1 and Resident #7) out of a sample of 20 residents. The facility census was 62. Review of the facility's policy titled, Maintenance Service, revised December 2009, showed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to, maintaining the building in good repair and free from hazards. 1. Review of Resident 1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included paraplegia (paralysis of the legs and lower body) and delusional disorders. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/05/24, showed the following: -Cognitive skills intact; -Independent with oral hygiene; -Substantial/maximal assistance with toileting. Observations on 03/19/24, at 1:51 P.M., showed the resident's floor contained cracked and missing floor tiles around the resident's bed. The area with missing floor tiles had black underneath and was a non cleanable surface. During an interview on 03/18/24, at 9:45 A.M., the resident said that the tiles in his/her room had been broken and missing for longer than two years. He/she had an electric wheelchair and the foot rests were so heavy that they messed up the floor. He/she would like to have the floor replaced and is concerned that the floor is not able to be properly cleaned. He/she saw the maintenance staff strip and wax other rooms and would like his/her room stripped and waxed, but has been told that because he/she had so many broken tiles that they are not able to strip and wax his/her floor. During an interview on 03/18/24, at 9:55 A.M., Housekeeping (HK) R said he/she sweeps and mops daily in the resident's room. He/she noticed the missing floor tiles and reported it to maintenance staff. He/she did not remember how long ago it had been when he/she reported it, but said its been several months. Maintenance is currently working on changing tiles in residents' rooms and is not sure when he will get to the resident's room. During an interview on 03/18/24, at 11:55 A.M., HK S said that he/she strips and waxes the floors. If there are missing tiles or tiles that need replaced, maintenance will replace them. He/she is aware of the broken tiles in the resident's room and said they need replaced. Maintenance is aware and he/she is waiting for maintenance to replace them. After the tiles are replaced he/she will be able to strip and wax the resident's floor. During an interview on 03/21/24, at 8:36 A.M., the Maintenance Supervisor said he cannot buy the tile in the resident's room anymore. The tile was made back in the 1980's. He will have to relocate the resident to repair the floor. During an interview on 03/21/24, at 9:34 A.M., Certified Nurse Aide (CNA) C said staff report any broken tiles to maintenance. He/she noticed broken tiles in the resident's room. CNA C had not reported the broken tiles to maintenance and said that he/she should had reported them. During an interview on 03/21/24, at 10:13 A.M., CNA D said he/she reported the resident's floor tile to maintenance staff and did not remember how long ago that was. CNA D did not see anyone fixing any of the broken tiles. During an interview on 03/21/24, at 12:23 P.M., the Administrator said the resident will have to go in with another resident in order for maintenance staff to fix the missing/broken tile. 2. Review of #7's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty in breathing) and obsessive-compulsive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitive skills intact; -Supervision or touching assistance required with toileting hygiene. Observations on 03/19/24, at 1:29 P.M., showed the resident's bathroom floor contained cracked and missing floor tiles. The area with missing floor tiles had black underneath and that was a non cleanable. During an interview on 03/21/24, at 8:36 A.M., the Maintenance Supervisor said he did not know about the missing tiles in the resident's bathroom. It looks like it had been there awhile. During an interview on 03/21/24, at 11:20 A.M., the resident said his/her bathroom floor is all torn up. The floor had been like that for a while. He/she did not like it. He/she would love for it to be fixed if they can. 3. During an interview on 03/19/24, at 3:20 P.M., Registered Nurse (RN) G said staff report to maintenance staff if they find any broken tiles in a resident room. Staff fill out requests in the book at the nurses' station. 4. During an interview on 03/21/24, at 10:13 A.M., CNA D said there are a lot of rooms with broken floor tiles. Staff report the broken floor tiles to maintenance staff. 5. During an interview on 03/21/24, at 8:36 A.M., the Maintenance Supervisor said the following: -Staff should write in the maintenance request book if any damages or repairs needed for resident room floors; -He looks at the book every morning and schedules the repairs. 6. During an interview on 03/21/24, at 10:28 A.M., the Director of Nursing (DON) said the following: -The facility is an old building and staff are slowly working on it; -Facility staff complete repairs in stages; -She knows the Maintenance Supervisor and Administrator are aware about the broken/missing tiles in the resident rooms. 7. During an interview on 03/21/24, at 12:23 P.M., the Administrator said the following: -Facility staff have replaced some of the tiles in the resident rooms; -He talked to a company for the floors. He wants to do an epoxy pour for the bathrooms instead of re-tiling them; -He talked with a company representative three weeks ago for the bathroom tiles. 48187

Based on interview and record review, the facility failed provide care in accordance with standards of practice when staff failed to document an order change and complete dressing changes as ordered for one resident (Resident #59) resulting in the resident having routinely saturated dressing. A sample of 20 residents was reviewd in a facility with a census of 62. 48187 Review of the facility policy titled Telephone Orders, undated, showed the following: -Verbal telephone orders may only be received by licensed personnel; -Orders must be recorded in the resident's medical record; -The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 1. Review of Resident #59's face sheet (a brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included chronic pancreatitis (the organ becomes permanently damaged from inflammation), gastrostomy (a surgical incision into the stomach), chronic kidney disease stage 2 (mild kidney damage), chronic obstructive pulmonary disease (COPD - a group of lung diseases making it difficult to breathe), and hypertension (high blood pressure). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/05/24, showed the following information: -Cognition intact; -Required setup or cleanup assistance with bathing, dressing and personal hygiene. Review of the resident's care plan, revised 03/15/24, showed the following information: -Required tube feeding (G-tube and J-tube) related to pancreatitis infection; -Monitor/document/report as needed any signs and symptoms of fever, shortness of breath, tube dislodged, tube dysfunction or malfunction, pain, tenderness, or infection at tube site; -Provide care to G-tube and J-tube sites as ordered and monitor for signs and symptoms of infection. Review of the resident's physician order sheet (POS), current as of 03/20/24, showed an order, dated 01/29/24, to change dressing to G/J tube daily. Review of the resident's Nurse Progress Note, dated 03/16/24, showed the following information: -The resident called nurse to room regarding G/J-tube site; -The resident said he/she was concerned regarding the amount of drainage coming from around his/her G/J-tube and was uncomfortable. The resident requested to be sent to the emergency room to be evaluated; -The nurse documented green drainage around the tube site and thick brown drainage under the tube site. The resident's skin appeared red and inflamed; -Nurse notified physician and received new orders to change dressing twice per day to help keep skin clean and dry and received orders for Tylenol as needed for pain. Review of the resident's POS, current as of 03/20/24, showed the following information: -An order, dated 03/16/24, to give extra strength Tylenol every six hours as needed for pain. (Staff did not document a new order to change the resident's dressing twice per day.) Review of the resident's March 2024 Treatment Administration Record (TAR) showed the following information: -An order, dated 01/29/24, to change dressing to G/J tube daily; -Staff documented completion of the daily dressing changes were documented. Observations on 03/17/24, at 5:40 P.M., on 03/18/24, at 9:15 A.M., and on 03/19/24, at 2:00 P.M., showed the G/J-tube dressing to be saturated. During an interview on 03/17/24, at 5:40 P.M., the resident said that he/she is upset that the staff has not kept his/her dressing changed. The dressing keeps getting his/her clothing wet. The resident was concerned that the G/J-tube site was infected. During an interview on 03/18/24, at 9:15 A.M., the resident said that he/she cannot remember if his/her dressing had been changed last night. The resident said that the staff do not change the dressing during the day shift, only the night shift and they only change the dressing if he/she tells someone that it needs to be changed. During an interview on 03/19/24, at 2:10 P.M., Certified Nurse Aide (CNA) B said that he/she has seen the resident's dressing saturated several times while assisting him/her with showers. The resident has complained about the drainage getting his/her clothing wet. CNA B said that he/she will remove the dressing prior to the shower and always notifies the nurse of the saturated dressing. During an interview on 03/18/24, at 2:25 P.M., Licensed Practical Nurse (LPN) A said that the resident had orders for daily dressing changes. The resident drains a lot and has redness and pain around the site. During an interview on 03/20/24, at 9:34 A.M., CNA C said that he/she has not noticed that the resident had any dressings that were saturated, but would tell the charge nurse is he/she did notice. During an interview on 03/20/24, at 1:45 P.M., Registered Nurse (RN) G said that the resident does sometimes saturate his/her dressing. The resident will usually let the staff know and the staff will change the dressing. RN G said that if licensed staff receive telephone orders, that staff should immediately add the order to the electronic medical record so that it will pop up on your to do task list. During an interview on 03/21/24, at 9:48 A.M., the Director of Nursing (DON) said that he/she called the physician to get the order changed from daily dressing changes to twice per day due to it being saturated and causing redness to the skin. The drainage was yellow and green and it appeared to be infected. The DON said that he/she forgot to put the order in the electronic medical record and that it was his/her fault that the dressings did not get done. The DON said that he/she expected staff to put the orders into the electronic medical record immediately after receiving them. During an interview on 03/21/24, at 10:09 A.M., the Administrator said that he/she expected staff to follow physician orders. The Administrator said he/she also expected staff to follow through with verbal and telephone orders. If staff received orders via telephone, the Administrator expects staff to put those orders in the electronic medical record. 48534

Based on interview and record review, the facility failed to ensure incontinent residents received care and appropriate treatment to prevent and treat urinary tract infections when staff failed to follow-up with the physician regarding hi/her response to a positive urine culture for one resident (Resident #32) resulting in a delay of care. A sample of 20 residents was reviewed in a facility with a census of 62. 1. Review of Resident #32's face sheet showed the following: -admitted [DATE]; -Diagnoses included bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), vascular dementia, and reduced mobility. Review of the resident's laboratory results, reported on 02/06/24, showed the following: -Clarity-hazy (reference range:clear); -Nitrite (abnormal presence in urine) - positive (reference range: negative); -Leukocytes (high levels of white blood cells) - one plus (reference range: negative); -Red blood cells 6-20 microscopic high power field (HPF) (reference range less than six); -White blood cells 21-50 HPF (reference range less than six); -Bacteria moderate (reference range negative); -Culture indicated; -Urine culture showed greater than 100,000 colony forming unit (CFU)/milliliters (ml) Kluyvera Ascorbata (a bacteria that indicated infection.) Review of the resident's nurse's note dated 02/06/24, at 3:49 P.M., showed Licensed Practical Nurse (LPN) A documented the resident's urinalysis results (UA) results came in for the resident. The culture stated the resident had Kluyvera Ascorabata. Staff faxed the results of the UA to the physician. Staff awaiting response from physician for new order. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/13/24, showed the following: -Moderately impaired cognitive skills; -No behaviors; -Required partial moderate assistance for toilet transfer; -Always incontinent. Review of the resident's medical record, dated 02/06/24 to 02/15/24, showed staff did not document a response regarding the abnormal lab or new orders obtained from physician to treat the UA. Review of the resident's February 2024 Physicians' Order Sheet, dated 02/14/24 to 02/29/24, showed the following: -An order, dated 02/16/24, for amoxicillin-potassium clavulanate (an antibiotic) tablet 875-125 milligrams (mg), give one tablet by mouth (PO) every 12 hours for UTI (urinary tract infection) until 02/23/24. Review of the resident's care plan, revised 02/16/24, showed the following: -Resident had an UTI; -Staff to administer the antibiotic as ordered for seven days; -Staff to encourage fluids; -Staff to monitor the resident for any further signs and symptoms of infection and notify the physician and family. Review of the resident's nurse's note dated 02/17/24, at 1:17 A.M., showed a nurse documented the initial dose of antibiotic given without any noted or reported adverse reactions. During an interview on 03/20/24, at 9:34 A.M., LPN A said the following: -The resident's physician did not like the nurses calling his cell and wants results faxed; -He/she expects the order for an antibiotic sooner than 10 days after staff receive UA results. It should only be a few days to receive an order for an antibiotic. During an interview on 03/20/24, at 10:13 A.M., LPN P said the following: -The facility had a hard time at times getting in touch with the resident's physician; -The best time to get in touch with the resident's physician is 6:30 A.M.; -It normally did not take that long to receive a response from the physician and start an ordered antibiotic. During an interview on 03/20/24, at 10:13 A.M., the Assistant Director of Nursing (ADON) said the following: -Staff collected the resident's UA on 02/02/24 and staff received the laboratory results on 02/06/24; -Nurses faxed to the resident's physician on 02/06/24 and he/she did not see an order until 02/16/24; -Nurses should continue to call the physician if no response; -He/she expected the antibiotic to not take that long; -He/she reviews the progress notes daily and it fell through the cracks. During an interview on 03/20/24, at 10:34 A.M., the Director of Nursing (DON) said she expects the antibiotic order before 10 days later. She expected nurses to contact the physician the next day if no response or order obtained for abnormal UA. The nurses should call the physician everyday to receive a response of laboratory results. Nurses should communicate between nurses and if no response from the physician, continue to call. During an interview on 03/21/24, at 12:23 P.M., the Administrator said he expected nurses to follow up with the physician if there was no response back regarding lab results. He expected an antibiotic to be started sooner than 10 days after laboratory results.

Based on observation, interview, and record review, the facility failed to assess one resident's pain status, failed to offer prescribed pain medication prior to a wound treatment, failed to notify the physician of the resident's pain timely with the wound treatment, and failed to provide adequate pain control for one resident (Resident #3) who showed verbal and nonverbal signs of significant pain. The facility failed to complete periodic comprehensive assessments and monitoring for multiple stasis/[MEDICAL CONDITION] for one resident (Resident #3). The facility failed to follow infection control standards while providing the ulcer treatments. The ulcers declined to dry gangrene toe ulcers. Seventeen residents were selected for review in facility with a census of 42. 1. Record review of Resident #3's face sheet and physician order [REDACTED]. -Initial admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/04/16, showed the following information: -Severely impaired cognitive status; -Dependent on staff for bed mobility, transfers, toilet use, and locomotion; -Received scheduled and as needed (PRN) pain medication; -Frequent complaints of pain in past five days; -Pain does not affect sleep patterns; -Pain does not affect day to day activities; -Resident is unable to rate level of pain. Record review of the resident's current care plan, dated 01/17/17, showed the following information: -Watch for increased pain or discomfort, medicate per orders; -Watch for nonverbal cues to ensure his/her needs are being met; -Watch for signs of pain and address needs PRN; -Watch complaints of pain and report to charge nurse; -Notify physician PRN; -Medications as ordered; -Watch for signs and symptoms of pain. Record review of the current physician order [REDACTED]. -On 02/09/17, the physician ordered Tylenol 500 mg daily; -On 02/09/17, the physician ordered [MEDICATION NAME] (medication used to treat pain associated with diabetic nerve damage) 100 mg capsules, two capsules three times daily. -On 3/23/17, the physician ordered [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg ([MEDICATION NAME], pain medication for mild to moderate pain) one tablet every four hours as needed for pain; -On 03/29/17, the physician ordered staff to cleanse the right heel with wound cleanser; apply Silver Alginate (pad containing silver polymers to aid in the prevention or management of a wound infection) and cover daily. Record review of facility form, Pain Assessment Quarterly Review, dated 03/31/17, showed the following information: -Resident complains of almost constant severe pain in right heel; -The pain affects his sleep at night and his day to day activities; -The resident continues with scheduled pain management; -Due to resident's complaints of severe pain during this assessment, resident was administered [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligrams (mg) one tablet; -Resident was educated to request pain medication or tell staff of discomfort before pain becomes severe; -Educated resident two times during assessment to inform staff of pain levels; -Resident receiving restorative therapy for non-pharmacological interventions for pain. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: - Severely impaired cognitive status; - Dependent on staff for bed mobility, transfers, toilet use, and locomotion; -Received scheduled and PRN pain medication along with non-medication intervention for pain during last five days. -Five venous and arterial ulcers (painful, open wounds on lower extremities caused by poor circulation); -Resident reported almost constant presence of severe pain causing difficulty with sleeping at night and limiting of day to day activities during the resident interview: Record review of the physician progress notes [REDACTED]. Record review of the current physician order [REDACTED]. Record review of nurse's note for 05/23/17 at 3:00 P.M. states: -Resident medicated with [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg one tablet for increased complaints of pain; -Effective relief of pain. Record review of the physician progress notes [REDACTED]. -Third right toe, dry and black; -Dry gangrene (infection where tissue dies) to right third toe. Record review of the June 2017 Medication Administration Record [REDACTED] -Staff administered [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg on an as needed basis on the following dates: -On 6/3/17, at 8 A.M., staff documented the medication to treat the toe pain was effective; -On 6/4/17, at 6:40 A.M. staff documented the medication to treat the toe pain was effective; -On 6/5/17, at 5:45 A.M. staff did not document any follow up assessment regarding if the pain medication helped the foot pain; -On 6/6/17, at 6:00 P.M., staff documented a follow up assessment showing the medication was effective for the foot pain. During an interview on 06/05/17, at 11:10 A.M. Registered Nurse (RN) F said the following: -Resident # 3 has gangrene in toes of right foot; -Resident has no routine pain medication; -If resident complains of pain during his wound treatment, he/she would give him/her something for pain after the treatment. Record review of the physician progress notes [REDACTED]. Record review of the facility's dermal wound assessments, dated 11/12/16 through 5/30/17, did not show any pain assessments. Record review of the June 2017 MAR indicated [REDACTED] -Staff administered one tablet of Tylenol 500 mg during the time period of 6/1/17 through 6/12/17; -Staff administered [MEDICATION NAME] 100 mg, two capsules, three times daily 6/1/17 through 6/12/17. Observation and interview on 6/8/17, at 9:50 A.M., showed the resident lay in bed. The resident had a tearful expression to his/her face. When questioned if he/she was sad, the resident nodded, yes. The resident became tearful and began to cry. When questioned why the resident was sad, the resident said his/her heel hurt. It was unclear if staff had administered anything for the resident's pain. Observation on 6/8/17, at 10:16 A.M., showed Nursing Assistant (NA) C and NA D entered the room to provide care. The aides provided incontinent care. The right great toe had an eschar (dead tissue) area along the outer edge of the toe. The resident's second toe tip had eschar covering it for approximately 1/3 of the toe area. The resident's third toe had a dry, shriveled black eschar necrotic (dead tissue, which usually results from an inadequate local blood supply) appearance. The resident's right heel also had an ulcer. The aides transferred the resident from the bed to the geri chair. At 11:34 A.M., Licensed Practical Nurse (LPN) J brought the treatment cart into the resident's room. The nurse said he/she was going to put a new bandaid on the resident's foot. When the nurse removed a heel protector boot (protective foam device) from the resident's right foot, the resident flinched and drew his right foot back. The nurse sprayed gauze with Dermal Wound Cleanser (nontoxic solution for cleansing of the wound) and wiped the heel ulcer. The resident grimaced and jerked his foot away from the nurse during the cleaning of the heel ulcer. LPN J reported the resident does not like the treatment. LPN J continued with treatment. The nurse said the heel ulcer was a stasis ulcer. Observation showed the ulcer with a dark eschar center with a yellow slough (dead tissue) around the perimeter edges of the ulcer. The nurse applied [MEDICATION NAME] to the ulcers on the top of the foot. The completed the treatment on the heel ulcer. The nurse removed his/her gloves and sanitized his/her hands. The nurse asked the resident if he/she hurt. The resident held up one finger and made a zero with other finger to indicate pain level was at a ten ( pain scale from zero to ten with zero being no pain and ten being the worst possible pain) for him/her during the treatment. The nurse said he/she would get the resident something for pain. The resident jerked his/her foot and the resident confirmed it hurt and tickled. The nurse used Dermal Wound Cleanser and gauze and cleansed all the necrotic areas of the toes and foot. The nurse sprayed wound cleanser and asked if the resident was okay. The resident shook his/her head, no. The nurse continued to clean the foot ulcers. Resident continued to flinch, draw his foot away, and cry throughout the treatment. The nurse asked the medication technician if the resident could have his/her strong pain pill. The nurse wiped the resident's great toe ulcer with the [MEDICATION NAME] wipe. The nurse got a new [MEDICATION NAME] wipe and wiped the top of the foot. The nurse cleansed the second toe ulcer and the resident gasped and made a low groan noise. The nurse placed the heel protector boot back on the right foot. When the nurse completed the treatment, the resident had tears in the corners of his/her eyes. At 11:45 A.M., Certified Medication Technician (CMT) U administered [MEDICATION NAME] to the resident after the nurse completed the treatments on the resident's right foot. Record review of the June 2017 MAR, showed on 6/8/17, at 11:40 A.M., showed CMT U administered one [MEDICATION NAME] 5/325 mg to the resident for complaints of foot pain. Staff documented the pain medication results/response as effective . Staff did not document the time of the follow-up assessment and staff did not document their initials or signature as the staff person who completed the follow up assessment. Observation and interview on 06/8/17, at 11:46 A.M., showed the following: -LPN J said this is the usual way for the resident's treatment to progress. The resident does not like the treatment because it hurts him/her. The resident does have routine pain medication. The treatment hurts less when he/she is in bed. -At 11:49 A.M., staff wheeled the resident to the dining room. -At 12:09 P.M., the resident asked about pain medication and staff told him/her LPN J administered pain medication ten minutes prior and the resident needed to let it kick in Observation of 06/08/17, at 2:30 P.M. showed the following: -At 2:30 P.M., The resident lay in the geri chair and rated his/her pain level at a ten when asked; -At 2:36 P.M., NA C and NA D entered the room to transfer the resident to bed. The aides placed a gait belt on the resident's waist. NA C said, I know baby, I know your leg hurts. -The resident cried, It hurts! It hurts! -NA C told the resident, I'll tell nurse. We will stand up real quick; -The aides transferred the resident to the bed. The resident continued to cry and say, it hurts! NA C said, I know. -Resident continued reporting in a repetitive pattern, It hurts! -At 2:44 P.M., NA C asked the resident if he/she was okay. The resident shook his/her head, no. The aide asked if the resident's leg hurt and the resident said, yes and nodded his/her head. Record review of the June 2017 MAR indicated [REDACTED] -Staff administered [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg ([MEDICATION NAME]) on an as needed basis on the following dates: -Staff did not document administering any additional [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg on 6/8/17 after 11:40 A.M. -On 6/9/17, at 6:45 A.M., staff documented the pain medication as effective for treatment of [REDACTED]. -On 6/9/17, at 11:45 A.M., staff did not document any follow up assessment to determine if the pain medication helped the resident's foot pain. Observation and interview on 6/9/17, at 12:39 P.M., showed staff wheeled the resident to his/her room. CMT V removed the heel protector boot from the resident's right foot. The resident yelled, Hurt!. At 12:48 P.M., LPN J asked if the resident could have anything else for pain. CMT V said, No, and listed what the resident had for pain that morning. CMT V said, I don't know why the physician will not put the resident on something routine for pain. At 12:57 P.M., the Director of Nursing (DON) asked the resident if he/she was feeling better. The resident shook his/her head, no. At 1:18 P.M., NA D and Certified Nursing Assistant (CNA) I entered the resident's room. The aides transferred the resident to bed and provided incontinent care for the resident. CNA I said the resident used to stand and pivot during the transfer, but now the resident does not because his/her toe and foot hurts. CNA I said the resident's feet hurt all the time. Observation on 06/12/17, at 2:45 P.M. showed the following: -RN F entered the resident's room to complete the wound treatments to the resident's right foot; -The resident jerked his/her foot when the nurse removed the dressing; -The resident complained of severe pain when the nurse touched the resident's toes; -The nurse applied [MEDICATION NAME] to the resident's toes; -The resident showed increased jerking and moaning throughout the completion of the treatment; -The nurse did not stop the treatment and administer pain medication or notify the physician of the resident's pain during the treatment. During an interview on 06/14/17, at 10:45 A.M., NA C said the following: -He/she would report any resident complaining of pain to the nurses; -Resident #3 kicks a lot during his/her wound treatments; -Resident #3's foot hurts all the time; -The resident's foot has to hurt. His/her toes are black and have been black for a long time. During an interview on 06/14/17, at 10:15 A.M., LPN J said the following: -Resident # 3 has very sensitive feet; -Resident is complaining of less pain during wound treatment than he/she had in past; -He/She would assess for pain during wound treatments; -If resident complained of pain during wound treatment, he/she would ask the CMT to administer something for pain when treatment was completed; -He/she would reassess for pain after administering medication; -He/she would monitor for nonverbal signs and symptoms of pain such as moaning, grimacing, or guarding; -The CNAs let the licensed nurses know if anyone is hurting; -If a resident had pain, he/she would document pain in nursing notes; -He/she would notify the physician if pain was not relieved; -The MDS nurse does a pain assessment, but not sure how often. Observation on 06/14/17, at 10:29 A.M., showed a sign at the nurses' station for charge nurses to focus on the following guidance of what to include in the weekly documentation. This list included pain management. During an interview on 06/14/17, at 2:45 P.M. LPN B said the following: -He/she looks at all wounds or skin problems in facility weekly; -He/she documents all measurements and changes in wounds weekly: -He/she does not document pain as part of his/her wound assessment; -If a resident complains of pain, during wound assessment, he/she would inform the CMT of this; -No routine pain assessments are done during wound assessments; -Resident #3 does pull away his/her foot during treatment on occasion; -Resident #3 is very ticklish on his/her feet; -If he/she is not in facility during the week, wound documentation is not completed. During an interview on 06/14/17, at 5:50 P.M., the DON said the following: -Facility does not have a policy and procedure for pain management; -No daily assessment of pain is a part of the resident's medical record; -The only routine pain assessment is the quarterly pain assessment completed by the MDS Coordinator; -CNAs should report any pain observed during cares to their charge nurses; -Any staff member who sees a resident in pain should report pain to the charge nurse; -If a resident is in pain, they should be administered pain medication they have ordered; -Their pain levels should be documented on their MARs; -The effectiveness of the pain medication should be followed up within an hour of being administered; -If a resident is having pain during a wound treatment, she would have the CMT administer pain medication after the wound treatment; -Pain medications should be given an hour before painful wound treatments; -Pain medications should be routine prior to wound treatments if pain is consistent for two or more treatments; -Pain assessment is not a part of the routine weekly wound documentation; -Pain levels should be documented in the weekly routine nursing documentation. 2. Record review of Resident #3's face sheet and physician order [REDACTED]. -Initial admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the nurses' notes, dated 12/29/16, showed the nurse documented the resident's right second toe noted to have purulent (pus filled) drainage. The nurse notified the physician and received an order for [REDACTED]. Record review of the quarterly MDS, dated [DATE], showed the following information: -No venous/arterial ulcers; -[MEDICAL CONDITION]; -Application of dressings to feet. Record review of the nurses' notes, dated 1/16/17, showed the nurse documented the resident's toenail detached from the nail bed on the right great toe. Nail bed appears pink and intact. Record review of the resident's current care plan, dated 01/17/17, showed the following information: -Watch skin during routine cares and baths, reporting any potential areas or actual areas of breakdown to charge nurse; -Keep bed and wheelchair linens wrinkle free, clean, and dry; -Keep him/her clean, dry, and odor free, providing incontinence care after each episode; -Clean ulcers per physician orders; -Wound supplements for wound healing; -Weekly wound assessment; -Wound clinic appointments as ordered by physician. Record review of the nurses' notes, dated 1/18/17, showed the nurse documented to see the treatment administration record (TAR) for skin issues. Record review of the facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the resident's permanent medical record) showed the following information: -On 03/01/17, staff documented areas on right foot as diabetic/stasis ulcers,with the largest ulcer top of right foot measuring 0.6 cm x 0.7 cm with no change in appearance. Staff did not document any further assessment; -On 03/09/17, staff documented areas on the right foot as stasis ulcers, with the largest measuring 1.1 cm x 0.9 cm. Staff documented stable, no new ulcers. Staff did not document any further assessment; -On 03/14/17, staff documented areas on the right foot as stasis ulcers, with the largest measuring 1 cm x 0.8 cm and scabbed over, appears stable. Staff did not document any further assessment; -On 03/21/17, staff documented areas on right foot as stasis ulcers ,with the largest measuring 1.1 cm x 1.0 cm and scabbed over, appears stable. Staff did not document any further assessment; -On 03/28/17, staff documented areas on the right foot as stasis ulcers, with the largest measuring 0.9 cm x 1.1 cm and scabbed over. Staff did not document any further assessment. -Staff did not document the color or type of tissue in the wound base or any further description of the wounds. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely impaired cognitive status; -Dependent on staff for bed mobility, transfers, toilet use, and locomotion; -Five venous/arterial ulcers (painful, open wounds on lower extremities caused by poor circulation); -[MEDICAL CONDITION]; -Other open lesion on feet; -Application of dressings to feet. Record review of facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed the following information: -On 04/04/17, staff documented the areas on the right foot as stasis ulcers, with the largest measuring 1.9 cm x 1.3 cm and scabs intact; -On 04/11/17, staff documented the areas on the right foot as stasis ulcers, intact scabbed, with the largest measuring 1.0 cm x 1.2 cm; Record review of the nurses' notes, dated 4/12/17, showed the nurse documented in the weekly summary, the necrotic areas on the resident's right foot did not show any improvement. Record review of the nurses' notes showed the following information: -On 4/16/17, the podiatrist saw the resident and is okay with the present treatment, stating foot is looking improved since last visit. No new orders; -On 4/18/17, the nurse documented a weekly summary and to see TAR for skin issues. Record review of facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed the following information: -On 04/18/17, staff documented the areas on the right foot as stasis ulcers, with the largest measuring 0.7 cm x 0.9 cm and scabbed; -Staff did not document any further assessment or description of the wounds, such as the wound bed color, type of tissue, or individual measurements of the ulcers. Record review of the physician progress notes [REDACTED]. -Patient has multiple ulcers on the right foot with large one on heel and second toe of right foot scabbed and occasional drainage; -The physician did not document any new orders on this date. Record review of the nurses' notes, dated 4/25/17, showed several necrotic areas on the right foot, mostly on the toes, treated with [MEDICATION NAME] twice a day. The resident also had areas of redness on the right foot. Record review of facility form, Weekly Skin Report, (an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed, on 04/26/17, staff documented areas on the right foot as stasis ulcers, with the largest measuring 0.7 cm x 0.9 cm, no signs and symptoms of infection. Staff did not document any description of the wound bases. Record review of the nurses' notes, dated 4/26/17, showed resident's right foot is slowly improving, some of scabbed areas are healing with [MEDICATION NAME] treatment. Record review of facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed the following information: -On 05/02/17, staff documented the areas on the right foot as stasis ulcers, with the largest measuring 1.0 cm x 0.9 cm, scabbed, no drainage; -On 05/09/17, staff documented the areas on the right foot as stasis ulcers, with the largest measuring 1.9 cm x 1.0 cm, scabbed, no signs or symptoms of infection; -On 05/16/17, staff documented the areas on the right foot as stasis ulcers, stable, remains scabbed, no signs or symptoms of infection. Staff did not document any measurements or description of the ulcers. Record review of the June 2017 POS showed the physician ordered, on 5/20/17, staff to apply [MEDICATION NAME] to ulcers on right foot and toes daily. Record review of the nurses' notes, dated 5/23/17, showed the resident's second and third toes had increased redness and dusky at the tips. The third and fourth toes' underside had dusky color. The resident's foot was warm to touch. The nurse notified the physician and received order for [MEDICATION NAME]. [MEDICATION NAME] applied to toes as usual, with loose conform bandage put over foot to keep air to foot, toes appear moist now, where previously had been dry. Record review of the nurses' notes, dated 5/26/17, showed the nurse documented middle toe on the right foot blue and cold. Resident complained of pain. The nurse did not document notification of the physician regarding the change in the toe. Record review of the nurses' notes, dated 5/29/17, showed the physician assessed the resident. The right foot, third toe appears 3/4 necrotic, with [DIAGNOSES REDACTED]. Record review of physician progress notes [REDACTED]. -Third right toe, dry and black; -Dry gangrene (infection where tissue dies) to right third toe; -The physician ordered to decrease the [MEDICATION NAME] treatment to the toes to once daily. Record review of the facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed, on 05/30/17, staff documented the areas on the right foot as stasis ulcers, third toe necrotic (dead, black tissue), no odor or drainage, other ulcers appear stable. Staff did not document any measurements or further descriptions of the ulcers. Record review of the nurses' notes, dated 6/4/17, showed resident has issues with right foot, third toe is dry and black, bottom ball of foot has changed to dark deep blue to black. During an interview on 06/05/17, at 11:10 A.M., RN F said the following: -Resident has gangrene in his/her toes; -The toes are being treated with [MEDICATION NAME] and a light dressing; -He/she has had the skin concern for a long time, at least six months; -He/she has heel protectors; -They want the toes to be open to the air. Record review of the June 2017 TAR showed the following information: -Apply [MEDICATION NAME] to ulcers of right foot daily; -Staff did not document completion of the [MEDICATION NAME] treatment to the right foot ulcers on 6/6/17; -Staff did not document an assessment of the resident's skin or ulcers. Observation on 6/8/17, at 10:16 A.M., showed NA C and NA D entered the room to provide care. The aides provided incontinent care. The right great toe had an eschar area along the outer edge of the toe. The resident's second toe tip had eschar covering it for approximately 1/3 of the toe area. The resident's third toe had a dry, shriveled black eschar necrotic appearance. The resident's right heel also had an ulcer. The aides transferred the resident from the bed to the geri chair. At 11:34 A.M., LPN J brought the treatment cart into the resident's room and completed the wound treatment. The nurse applied [MEDICATION NAME] to the ulcers on the top of the foot. The nurse completed the treatment on the heel ulcer. The nurse used Dermal Wound Cleanser and gauze and cleansed all the necrotic areas of the toes and foot. The nurse sprayed wound cleanser and continued to clean the foot ulcers(physician order [REDACTED]. The nurse did not change gloves or wash hands before applying [MEDICATION NAME] wipes to the toe ulcers on the right foot. The nurse wiped the resident's great toe ulcer with the [MEDICATION NAME] wipe. The nurse got a new [MEDICATION NAME] wipe and wiped the top of the foot. The nurse cleansed the second toe ulcer. The nurse placed the heel protector boot back on the right foot. During an interview on 6/9/17, at 2:00 P.M., the Director of Nursing said non-pressure ulcers are documented on the multi-resident log. There is not any documentation in the resident's medical record. The wound assessment sheets are mainly just for pressure ulcers. Occasionally, non-pressure ulcers are documented on those sheets. Record review of the June 2017 TAR showed the following information: -Staff did not document completion of the [MEDICATION NAME] treatment to the right foot ulcers on 6/10/17 and 6/11/17; -Staff did not document the reason treatments not administered as ordered. Record review of the nurses' notes, dated 6/11/17, showed the nurse documented a weekly summary and to see TAR for skin issues. Record review of facility form, Weekly Skin Report, ( an in house report listing multiple residents,which is not part of the residents' permanent medical record) showed no assessments or documentation after 5/30/17 through at least 6/12/17. During an interview on 06/14/17, at 10:45 A.M., NA C said the resident's toes of his/her right foot have been black for a long time. During an interview on 06/14/17, at 10:15 A.M., LPN J said the following: -If the resident developed any new areas on skin, he/she would refer to wound nurse, Director of Nursing (DON), or physician; -The charge nurses inform the wound nurse of any changes in skin conditions; -If the wound nurse is not available, he/she would inform the DON or physician of changes; -Wound nurse completes weekly measurements and documentation on all wounds; -He/she is not sure who does weekly documentation if the wound nurse is not available. -Staff must follow the treatment orders on the TAR; -TAR should follow the POS; -Wound nurse documents weekly on the heel and toes of Resident #3; -Any changes in treatment orders, the charge nurse would let the treatment nurse know; -Wound nurse takes pictures and measures wounds every week; -He/she is not sure who would complete weekly wound assessments if wound nurse unavailable; -They really rely on the aides to notify the nurses of skin conditions; -Aides document any skin condition on bath sheets and turn those in at the end of the shift. During an interview on 06/14/17 at 2:45 P.M. with LPN B, he/she said the following: -All residents with wounds are documented weekly with measurements of length, width, and depth; -He/she looks at all wounds or skin problems in the facility weekly; -He/she documents all measurements and changes in wounds weekly: -If he/she is not in facility during the week, wound documentation is not completed; -She only measures the largest of Resident #3's foot and toe ulcers, because there are too many to measure individually on his/her toes. -They document appearance of the wound bed, type of tissue, tunneling, undermining, and drainage; -They document on pressure, stasis, and diabetic ulcers; -They take pictures weekly of wounds; -The report for the DON has name of resident, type of skin condition, and type of treatment ordered; -The report is a tracking tool for the DON; -Staff keep the most recent three months of wound documentation for pressure and diabetic ulcers in the treatment record book; -They count on the aides to let the nurses know of any changes in skin condition. During an interview on 06/14/17, at 11:45 A.M., the MDS coordinator said the following: -The charge nurse should perform a skin assessment when a resident is admitted to the facility; -The initial skin assessment should be documented on the admission nursing assessment; -The wound care nurse performs weekly wound assessments and documents on the dermal tracking sheets; -Wound assessments are not performed if the wound care nurse is not working in the facility; -Every resident should have a skin assessment performed by a nurse, she is not sure of the frequency of the skin assessments; -Skin assessments should include tissue color changes, bruises, condition of the resident's toenails, skin tears and any shearing or friction concerns. During an interview on 06/14/17, at 5:50 P.M., the DON said the following: -She would expect the nurses to follow the orders for treatments as written; -Treatment documentation should occur when the treatment is done; -The only

Based on observation, interview, and record review, the facility failed to perform routine skin assessments, failed to routinely assess, identify and implement physician ordered treatments and interventions for pressure ulcers on three residents (Resident #1, #2 and #3). Resident #1 developed two Stage II pressure ulcers, one of which closed and reopened. Resident #3 developed an unstageable pressure ulcer on the right heel. Resident #2 developed two Stage II pressure ulcers. The facility staff failed to reposition two residents (Resident #3 and Resident #8) for several hours. Facility staff failed to follow infection control standards during pressure ulcer treatments for three residents (Resident #1, Resident #2, and Resident #3). The facility failed to follow up and implement nutritional recommendations for one resident (Resident #3). Seventeen residents were reviewed in a facility with a census of 42. Record review of the Prevention and treatment of [REDACTED]. -Stage I pressure ulcer is nonblanchable [DIAGNOSES REDACTED] (a persistent area of skin redness without a break in the skin, that is nonblanchable). Intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage II pressure ulcer - Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough (non-viable tissue), may also present as an intact or open/ruptured blister; -Stage III pressure ulcer - Full thickness tissue loss. Subcutaneous fat (under the skin) may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (opening underneath the lip of the ulcer border) or tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation); -Stage IV pressure ulcer - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable-Slough and/or eschar (dead tissue), known but not stageable due to coverage of wound bed by slough and/or eschar. Record review of the facility's policy titled, Pressure Ulcer Stage II, dated 09/11/13, showed the following information: -Interventions included pressure relieving devices, inspection of the resident's skin when dressing or changing, repositioning in bed or chair every two hours, dietary interventions (protein, vitamin C and nutritional supplements and increased fluid intake), educating the resident and/or family to shift the resident's weight, notifying the physician and family/responsible party upon onset, weekly and with any significant change; -Additional interventions include documenting an initial assessment of the pressure ulcer using a wound assessment report form and using the same form for reassessing the wound every week; -Treatments ordered by the physician should be performed on the pressure ulcers; -Pressure should be relieved from the affected areas; -The goals of treatment include promoting healing, maintain moist wound environment and protection; -Procedures should be performed by the registered nurse (RN) or licensed practical nurse (LPN). Record review of the facility's policy titled, Wound Care, dated 09/12/13, showed the following precautions when care is given for open wounds of any kind: -Staff will wash hands before and after completing wound care procedures; -Dressings will be handled with aseptic (clean) technique; -Wound care supplies should not be placed on the bed. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by the facility staff, dated 09/05/16, showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -No pressure ulcers upon admission to the facility. Record review of the resident's discharge MDS, completed by the facility staff when the resident discharged from the facility to the hospital, dated 10/17/16, showed the resident had one Stage II pressure ulcer, not present on the resident's previous MDS assessment. Record review of the resident's initial nursing assessment, completed by the facility staff, dated 10/24/16, showed the following information: -Skin as pink, dry, warm and smooth, no [MEDICAL CONDITION] identified; -[MEDICAL CONDITION] (surgical opening of the colon onto the abdominal surface) noted for bowel elimination; -Indwelling catheter in place for urinary elimination; -Lower legs flaccid (without muscle tone); -Non-ambulatory, mechanical lift required for all transfers; -Extensive assistance required from staff for all position changes; -Body diagram showed a scar present on the resident's tailbone area and two open areas noted on the right lower buttocks region; -Staff did not document a description for the two open areas. Record review of the resident's physician order [REDACTED]. Record review of the resident's wound culture, obtained on 02/15/17, showed the following information: -Heavy growth of Proteus Mirabilis (bacteria normally found in the intestinal tract) was identified; -Moderate growth of Pseudomonas Aeruginosa (bacterial infection often spread by the hands of healthcare workers); -Moderate growth of [MEDICAL CONDITION] Resistant Staphyloccus Aureus (bacterial infection resistant to broad spectrum antibiotics). Record review of the resident's POS showed the following information: -On 02/19/17, the physician ordered an antibiotic based upon the results of the wound culture; -On 02/21/17, the physician ordered antibiotic injections twice a day for seven days based on the wound culture results; -On 02/21/17, the physician ordered the staff to cleanse the buttocks with Dawn dish soap and water and cover with thick gauze pad twice a day; -On 02/24/17, the physician ordered staff to Skin Prep to the resident's bony prominences twice a day. Record review of the resident's March 2017 POS showed the physician referred the resident to a wound clinic for evaluation of his/her open wounds on buttocks on 03/14/17. Record review of the wound clinic's POS showed the following information: -On 03/16/17, the wound clinic's order sheet showed the resident had a [DIAGNOSES REDACTED]. The wound clinic ordered the ulcer to be cleansed with normal saline (solution of sodium chloride and distilled water) and apply a zinc based barrier ointment every eight hours. The wound clinic ordered the resident to be up in the chair for meals and one hour after his/her meals only, to avoid pressure on the identified ulcer. The resident needed to be turned from side to side every two hours until the resident returned to the wound clinic in two weeks. The resident should perform wheelchair pushups every 15 minutes while in his/her chair. The wound clinic only provided treatment orders for the right gluteal thigh pressure ulcer. Record review of the resident's Dermal Wound Assessment Report, dated 03/21/17, completed by the facility staff showed the following information: -The resident had two pressure ulcers identified on his/her right buttocks; -Staff first identified the ulcers on 11/23/16 and the ulcers as not present on admission; -The staff described the two ulcers as Stage II pressure ulcers; -The first pressure ulcer measured 0.5 centimeters (cm) in length by 6.3 cm in width, with red tissue surrounding the ulcer; -The second pressure ulcer measured 1.2 cm in length by 1.0 cm in width; -Staff listed the treatment order as to cleanse the ulcers with normal saline and apply zinc oxide barrier cream. Record review of the facility's Weekly Pressure Sore Log showed the following information: -On 3/21/17, staff identified only one pressure ulcer on the resident's right buttock; -The resident originally developed the pressure ulcer on 11/23/16. Record review of the resident's Dermal Wound Assessment Reports completed by the facility staff showed the following information: -On 04/04/17, the resident had a Stage II pressure ulcer on his/her right buttock. The ulcer measured 2.0 cm in length and 1.3 cm in width. The treatment included cleansing the ulcer with wound cleaner and the application of zinc oxide barrier cream. The report did not address the second pressure ulcer previously identified on 03/21/17; -On 04/11/17, the resident's right buttock ulcer had enlarged to 3.8 cm in length by 2.5 cm in width and the depth of the ulcer had increased to 0.2 cm. The ulcer had a light amount of clear drainage. The skin surrounding the ulcer was macerated (skin that had softened and thinned). The treatment of [REDACTED]. Staff did not identify a second pressure ulcer on this report. The treatment nurse notified the physician due to the increased size of the ulcer this week; Record review of the resident's care plan, completed by the facility staff, last reviewed on 04/12/17, showed the following information: -Pressure ulcer treatments should be performed as ordered; -Staff to complete weekly skin assessments; -The resident required extensive assistance with repositioning; -Staff to monitor the resident's skin closely during his/her baths and during delivery of personal care. Record review of the resident's Dermal Wound Assessment Reports completed by the facility staff showed the following information: -On 04/18/17, the resident's right buttock Stage II pressure ulcer had enlarged to 3.3 cm in length and 4.0 cm in width. The ulcer treatment included cleansing the ulcer with wound cleaner and the application of [MEDICATION NAME]. Record review of the resident's April 2017 Treatment Administration Record (TAR) showed the following information: -The treatment order from the wound clinic, dated 03/16/17, directed staff to cleanse the right thigh/gluteal ulcer with normal saline and apply a zinc based barrier ointment to the ulcer every eight hours and as needed; -Staff provided this treatment twice a day from 04/01/17 through 04/12/17, (instead of three times a day as the treatment order directed); -The treatment, dated 02/24/17, directed staff to apply Skin Prep (topical wipe used to protect and strengthen the skin's integrity) to the resident's bony prominences twice a day; -The resident received the Skin Prep application only once a day for the month of April (instead of twice a day as the treatment order directed). Record review of the resident's April POS showed the following information: -The treatment order with a start date of 03/01/17, directed staff to cleanse the wound/ulcer on buttocks with Dawn soap and water, then cover with ABD pad (thick absorbent gauze pad) twice daily until healed; -On 04/11/17, the physician ordered a wound culture of the right gluteal fold ulcer; -On 04/14/17, the physician prescribed [MEDICATION NAME] ointment (over the counter topical antibiotic ointment) to be applied to the right thigh/gluteal (area between the buttocks and thigh) twice a day; -On 04/14/17, the physician prescribed an oral antibiotic for ten days for the infected pressure ulcer. Record review of the resident's right gluteal fold (area between the buttock and thigh) wound culture report, dated 04/16/17, showed the following information: -Moderate amount of [MEDICATION NAME] Faecalis (intestinal bacteria, found in human stool); -Moderate amount of Proteus Mirabilis (an intestinal tract bacteria); -Moderate amount of [MEDICAL CONDITION]-Resistant Staphylcoccus Aureus (bacteria resistant to multiple antibiotics). Record review of the resident's May 2017 POS showed the following information: -Continuing order from 04/14/17, cleanse the ulcer on the buttocks with Dawn soap and water and apply [MEDICATION NAME] until healed; -Continuing order from 02/24/17, staff to apply Skin Prep to bony prominences twice a day; -On 05/02/17, the physician ordered the staff to cleanse the right thigh/gluteal ulcer with wound cleanser (spray solution for cleaning pressure ulcers), then apply silver alginate (pad containing silver polymers to aid in the prevention or management of a wound infection) twice a day. If the wounds do not improve in one week, send the resident to the wound clinic; -On 05/11/17, the physician referred the resident to the wound clinic for evaluation of his/her right gluteal ulcers; Record review of the resident's May 2017 treatment administration record (TAR) showed the following treatment: -Cleanse the right thigh/gluteal area with wound cleaner; -Apply Hydrogel dressing to the ulcers until silver alginate dressing back in stock; -Treatment to be performed daily; -The staff performed this treatment to the right gluteal area twice a day; -Staff to apply Skin prep to the resident's bony prominences twice a day. Staff provided the Skin Prep treatment twice a day on 12 out of the 31 days in May; -Facility staff did not provide the wound clinic's prescribed treatment. Record review of the resident's Dermal Wound Assessment Reports, dated May, 2017, showed the following information: -On 05/02/17, the right buttock Stage II pressure ulcer measured 3.0 cm in length and 3.1 cm in width. The ulcer had blood-tinged drainage. The treatment included the use of wound cleaner and [MEDICATION NAME] ointment; -On 05/02/17, staff identified a new left buttock Stage II pressure ulcer measuring 3.0 cm in length and 3.1 cm in width. This ulcer had a light amount of blood-tinged drainage. The treatment included the use of wound cleaner and [MEDICATION NAME] ointment; Record review of the resident's nurses' notes for May, 2017 showed the the weekly summary, dated 05/03/17, did not contain any information related to the resident's skin condition or pressure ulcers. Record review of the resident's Dermal Wound Assessment Reports, dated May, 2017, showed the following information: -On 05/09/17, the right buttock/gluteal Stage II pressure ulcer measured 5.0 cm in length and 4.0 cm in width. The ulcer had a light amount of clear drainage. The treatment included the use of wound cleaner and the application of silver alginate dressing; -On 05/09/17, staff reported the left buttock pressure ulcer as closed with fragile tissue. Record review of the resident's nurses' notes for May, 2017 showed the the weekly summary, dated 05/10/17, did not contain any information related to the resident's skin condition or pressure ulcers; Record review of the resident's Dermal Wound Assessment Reports, dated May, 2017, showed the following information: -On 05/16/17, the right buttock Stage II pressure ulcer had enlarged and measured 5.5 cm in length and 1.3 cm in width, with a light amount of bloody drainage. The treatment included the use of wound cleaner and the application of silver alginate and covering the ulcer with a dressing; -On 05/16/17, the left buttock pressure ulcer reopened and measured 2.0 cm in length and 0.9 cm in width. The ulcer had a light amount of blood-tinged drainage. The treatment included the use of wound cleaner and silver alginate and covering the ulcer with a dressing; -The resident had an appointment scheduled for 05/17/17 at the wound clinic. Record review of the resident's nurses' notes for May, 2017 showed the following information: -The weekly summary of 05/17/17 did not contain any information related to the resident's skin condition or pressure ulcers; -An entry dated 05/17/17 at 12:30 P.M. showed the resident left the facility to go to the wound clinic; -An entry dated 05/17/17 at 2:30 P.M. showed the resident returned to the facility. The resident will continue with the current orders and should return to the clinic on 06/07/17. Record review of the wound clinic's treatment order, dated 05/17/17, directed the staff to perform the following treatment: -Cleanse the ulcers with normal saline; -Apply [MEDICATION NAME] dressings (wound/ulcer dressings containing silver for infection management) to two ulcers on the resident's gluteal area; -Cover the [MEDICATION NAME] dressings with [MEDICATION NAME] dressings (adhesive absorbent pad); -Change this dressing once a day; -Return to the wound clinic in three weeks. Record review of the resident's May 2017 POS did not contain the wound clinic's pressure ulcer treatment prescribed on 05/17/17. Record review of the resident's Dermal Wound Assessment Reports dated May, 2017, showed the following information: -On 05/25/17, the right buttock Stage II pressure ulcer measured 1.5 cm in length and 0.8 cm in width. The ulcer had a light amount of clear drainage. The treatment included wound cleaner and the application of silver alginate dressing and covered with an additional dressing; -On 05/25/17, the left buttock Stage II pressure ulcer measured 1.7 cm in length and 1.5 cm in width. The ulcer had a light amount of clear drainage. The treatment included wound cleaner followed by silver alginate and cover with a dressing; -On 05/30/17, the right buttock Stage II pressure ulcer was documented as closed with fragile tissue. The area was reddened and measured 8.4 cm in length and 7.0 cm in width; -On 05/30/17, the left buttock Stage II pressure ulcer measured 1.0 cm in length and 0.3 cm in width. The ulcer had a light amount of bloody drainage. The treatment included wound cleaner followed by silver alginate and covered with a dressing. Record review of the resident's May 2017 TAR showed the following treatment: -Cleanse the right thigh/gluteal area with wound cleanser; -Apply Hydrogel dressing to the ulcers until silver alginate dressing back in stock; -Treatment to be performed daily; -The staff performed this treatment to the right gluteal area twice a day, from 05/02/17 through 05/31/17; -Staff to apply Skin Prep to the resident's bony prominences twice a day. Staff provided the skin prep treatment twice a day on 12 out of the 31 days in May; -The facility staff did not enter the wound clinic's prescribed treatment on the TAR, nor did the staff perform the wound clinic's prescribed treatment to include cleaning the ulcers with normal saline, application of [MEDICATION NAME] dressing, and cover with the [MEDICATION NAME] dressing, once a day from 05/17/17 through 05/31/17 when the treatment order changed. Record review of the resident's POS, dated 05/29/17, showed the physician approved the use of Hydrogel dressing (dressing used to keep the wound moist) for buttocks ulcer as replacement of silver alginate until the silver alginate is restocked in the facility. Record review of the resident's nurses' notes for May, 2017 showed no additional documentation found in the nurse's notes pertaining to the resident's skin condition or pressure ulcers after 05/17/17 through the end of the month. Record review of the resident's June 2017 POS showed the continuing physician order, dated 02/27/17, for Skin Prep to be applied to the resident's bony prominences twice a day. Record review of the resident's June 2017 TAR showed staff applied the Skin Prep on the resident's skin a total of six times from 06/01/17 through 06/08/17. The staff should have applied the skin prep a total of 16 times during this time period. Record review of the resident's June 2017 POS showed the following information: -On 06/13/17, the physician discontinued the silver alginate dressing on the right buttock ulcer. The physician changed the treatment order to Skin Prep to be applied to the right buttock fragile tissue area twice a day; -On 06/13/17, the physician ordered the treatment on the resident's left buttock to include cleansing the ulcer with wound cleaner and then apply triple antibiotic ointment (over the counter medicated ointment) and cover with a dressing daily until the ulcer was healed. Record review of the resident's June 2017 TAR showed the following information: -Treatment to cleanse the ulcer on buttocks with wound cleanser and apply silver alginate and cover with a dressing twice a day; -This treatment was performed ten times from 06/01/17 through 06/09/17, staff did not perform one half of the treatments on this pressure ulcer. During an interview on 06/08/17, at 2:15 P.M., LPN J said the facility did not have any silver alginate dressings so the staff had been using Hydrogel dressings on the resident's pressure ulcers. Observations on 06/08/17, at 2:15 P.M., showed the following: -LPN J placed the dressing supplies on the resident's bed in preparation of his/her treatment to the buttocks pressure ulcers (potentially contaminating the supplies); -The resident had an open, reddened, dime-sized pressure ulcer on his/her left buttock; -The resident had an open, 0.25 cm in width by 2.0 cm in length pressure ulcer on his/her right buttock; -LPN J cleansed the ulcers with wound cleaner and gauze; -LPN J placed calcium alginate dressings on the pressure ulcers, followed by [MEDICATION NAME] (non-adherent dressings) and taped in place; -The resident had a visibly healed skin flap on his/her coccyx from prior surgery. During an interview on 06/09/17, at 2:55 P.M., the Director of Nursing (DON) said the facility had not performed any assessments on the resident's pressure ulcers in June. The last assessments completed on the resident's pressure ulcers was on 05/30/17. Observation on 06/12/17, at 1:55 P.M., showed the following: -Certified Nursing Assistant (CNA) E rolled the resident on to his/her right side; -CNA E removed the dressings from the resident's buttocks pressure ulcers; -RN F poured Dawn dish soap into a medicine cup; -RN F soaked gauze under running water from the resident's sink; -RN F submerged the gauze into the medicine cup with dish soap; -RN F dabbed the open pressure ulcer on the resident's left buttock with soap and water causing water to run in between the resident's buttocks; -RN F used the same gauze to wipe down between the resident's buttocks then dabbed the open pressure ulcer on the resident's right buttock, using the same surface of the gauze; -RN F used a dry gauze to dab the left buttock's pressure ulcer, wiped down between the resident's buttocks then dabbed the open right pressure ulcer with the same surface of the gauze; -RN F placed a Hydrogel dressing over the left buttock's pressure ulcer, covered the ulcer with [MEDICATION NAME] and taped the dressing in place; -RN F placed a Hydrogel dressing on the resident's right buttocks open ulcer, CNA E placed his/her finger on top of the Hydrogel causing the dressing to become twisted and in poor placement over the open ulcer. The aide's gloved finger slid off the Hydrogel and went into the open wound. -RN F removed his/her gloves, obtained a new Hydrogel dressing to place over the open ulcer and cut the dressing to cover the open ulcer, put new gloves on and placed the Hydrogel dressing over the open right pressure ulcer, covered this with [MEDICATION NAME] and taped the dressings in place. During an interview on 06/12/17, at 2:15 P.M., RN F said the following: -The staff usually do it once or twice a day referring to the resident's dressing changes; -My friend was sticking his/her glove in the resident's wound, referring to CNA E placing his/her finger in the resident's pressure ulcer; -I just continue to use Dawn soap because it is there, referring to the dish soap found next to the resident's sink; -We don't have any silver or calcium alginate dressings to use. Observation and interview on 06/12/17, at 2:30 P.M. showed RN F initialed the resident's TAR treatment record for 06/06/17, 06/10/17, 06/11/17 and 06/12/17, indicating RN F had completed the pressure ulcer treatments on these multiple previous days. The surveyor asked RN F why he/she just initialed treatments as being performed on the three prior days. RN F said my pen just went crazy. RN F said he/she thought another nurse did the resident's treatment on Saturday 06/10/17. During an interview on 06/14/17, at 11:15 A.M., the resident said the following: -The resident is supposed to be turned from side to side every two hours while he/she is in bed; -The staff are supposed to place at pillow behind the resident's back to position him/her up on his/her side; -Some of the staff turn the resident onto his/her side, it depends on the aide working if the resident gets repositioned. During an interview on 06/14/17, at 1:45 P.M., LPN J said Resident #1's right gluteal ulcer healed on 06/13/17. The resident's current treatment order includes the use of wound cleaner then the application of triple antibiotic ointment and the placement of a [MEDICATION NAME] dressing on the left buttock's pressure ulcer. 2. Record review of Resident #3's annual MDS, dated [DATE], showed the following information: -Short and long term memory problem; -Moderately impaired decision-making skills; -Required extensive assistance for bed mobility, transfers, and toilet use; -Total dependence on staff for personal hygiene; -Frequently incontinent of bowel and bladder; -At risk for pressure ulcer development; -No current unhealed pressure ulcers; -The resident had pressure-relieving devices for chair and bed. Record review of the nutritional evaluation, dated 10/18/16, showed the registered dietitian (RD) recommended to discontinue the resident's low concentrated sweets (LCS) diet. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -No current unhealed pressure ulcers; -Infection of the foot; -[MEDICAL CONDITION]. Record review of the resident's care plan, with start date of 1/17/17, showed the following information: -Required extensive assisstance with all cares; -Watch skin closely during cares/baths for redness, skin breakdown, and irritation. Report tany potential areas or actual areas of breakdown to the charge nurse. -Provide perineal care and barrier cream as needed after each incontinent episode; -Resident would like to lay down between meals most times, rather than sitting up in the wheelchair for long periods of time; -Reposition in the chair/bed for safety and to help prevent skin breakdown at least every two hours and as needed; -Dietitian consult monthly and as needed; -At risk for other skin breakdown and pressure ulcer related to impaired mobility and incontinence of bowel and bladder. Currently has abrasions on toes, treatment in progress. -Monitor for repositioning while in wheelchair or bed at least every two hours; -Resident had unstageable decubitus ulcer located on the right outer ankle. Treatment in progress; -Clean ulcers as per physician orders. Treatment as ordered. -Float heels while in bed to prevent pressure; -Weekly wound assessment per policy and procedure; Record review of the dietary progress notes, dated 1/24/17, showed the dietitian recommended the resident take multivitamin with minerals, [MEDICATION NAME] twice a day, and one scoop of protein powder twice a day. Record review of the dietary progress notes, dated 2/21/17, showed resident treated for [REDACTED]. The RD recommended to discontinue the LCS diet due to weight loss. The RD recommended to add one scoop protein powder twice a day (second time recommended). Record review of the dermal wound assessment report, dated 3/9/17, showed the right heel ulcer, measured 1.9 cm x 1.7 cm, with unknown depth. The wound nurse documented the ulcer's initial stage as necrotic/no stage, with the initial cause as diabetic. The nurse documented the ulcer as not present on admission. The nurse documented ulcer healing visual stage as necrotic (unable to stage). Tissue is necrotic with surrounding skin as red. The treatment documented as cleansed with wound cleanser and [MEDICATION NAME] medication. The nurse did not document a dressing for the ulcer. The nurse did not assess the resident's pain with the ulcer or treatment. Record review of the dermal wound assessment report, dated 3/14/17, showed the right heel ulcer measured 1.7 cm x 0.8 cm, with unknown depth. with necrotic (eschar) tissue in the wound and surrounding skin as red. The nurse did not assess the resident's pain with the ulcer or the treatment. The nurse documented the ulcer cleansed with [MEDICATION NAME]. No other treatment documented as provided or ordered by the physician. Record review of the dietary progress notes, dated 3/20/17, showed the resident had a 7% weight loss in the previous six months. Staff assisted the resident to eat a LCS diet. The resident currently receiving treatment for [REDACTED]. The RD recommended to discontinue the LCS diet due to weight loss (second time recommended). Record review of the nurses' notes, dated 3/21/17, showed the nurse documented a weekly summary. The resident was dependent with transfers and ADLs. The resident sat in a geri chair and staff assisted the resident with eating. The resident was incontinent of bowel and bladder. The nurse did not document a skin assessment. Record review of the dermal wound assessment report, dated 3/21/17, showed the right heel ulcer measured 1.5 cm x 1.7 cm, with no depth documented. The nurse documented the tissue type as granulation tissue with adherent slough, adipose. The wound nurse documented the wound base color as brown, red, and white with serosanquinous drainage with red skin surrounding the ulcer. The nurse did not document an assessment of the resident's pain. The wound nurse documented the treatment as wound cleanser, silver alginate, and cover. The nurse documented the treatment changed on 3/21/17 due to the scab falling off. Record Review of the POS [REDACTED]. Record review of the dermal wound assessment report, dated 3/29/17, showed the right heel ulcer measured 1.1 cm x 1.2 cm, with unknown depth. The ulcer had a light serosanquinous drainage with a red and yellow wound base color. The skin surrounding the ulcer was red. The nurse did not document a pain assessment of the ulcer or treatment. The nurse documented the treatment as wound cleanser, silver alginate, and cover. Record review of the resident's malnutrition risk assessment, dated 3/31/17, showed the resident as high risk for malnutrition, which directed staff to initiate a prevention plan. Record review of the pressure ulcer development risk assessment, dated 3/31/17, showed the resident as at a moderate risk of pressure ulcer development. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -No unhealed pressure ulcers; -Five venous/arterial ulcers present; -[MEDICAL CONDITION]; -Other open lesion on the foot. Record review of the dermal wound assessment report, dated 4/4/17, showed the right heel ulcer measured 1.9 cm x 1.3 cm, with unknown depth. The ulcer current healing visual stage was necrotic (unable to stage). The nurse documented the tissue type as adherent slough and necrotic tissue, with the wound base color as gray and black with serous drainage. The surrounding skin was red. The nurse documented the treatment as wound cleanser and silver alginate. The nurse did not document a pain assessment of the ulcer or treatment. Record review of the dermal wound assessment report, dated 4/11/7, showed the right heel ulcer measured 1.5 cm x 1.4 cm, with unknown depth. The healing visual stage was necrotic (unable to stage). The nurse documented the wound base color as yellow with s

Based on interview and and record review, the facility failed to initiate cardio-pulmonary resuscitation (CPR) for one resident (Resident #15), who did not have a "Do Not Resuscitate" (DNR) order, in a facility with a census of 52. 1. Record review of Resident #15's hospital emergency department nursing record, dated [DATE], showed the resident arrived to the emergency room by ambulance at 3:30 P.M. The resident asked to go to the (VA) Veteran's Administration in Kansas City. The resident said his/her defibrillator went off this morning and the resident had been drinking vodka ever since. The resident said to "get me outta here as soon as possible". The resident had a strong odor of alcohol present. At 4:23 P.M., the resident refused the EKG, labs, and x-ray. The resident wanted a ride to the VA. At 4:40 P.M., the resident said he/she would go to the nursing facility. Record review of the emergency room physician record, dated [DATE], showed the resident had recurrent cardiac shocks from his/her defibrillator. The symptoms started in [DATE]. The resident said it feels like the pacemaker with the defibrillator went off twice today, so the resident drank two ounces of vodka each time. The resident did not have any more shocks since drinking the vodka. The resident was at the VA hospital one week ago and the pacemaker was okay. The (EKG) electrocardiogram showed a regular rhythm rate of 79. The resident refused laboratory tests and x-rays. The resident refused further evaluation. The resident agreed to go to the skilled nursing facility tonight. The clinical impression was chest discomfort with history of cardiac arrhythmia and [MEDICAL CONDITION]. The resident transferred to the skilled nursing facility per nursing facility van. Record review of the National Heart, Lung, and Blood Institute website, showed the following information: -An implantable cardioverter defibrillator (ICD) is a small device that's placed in the chest or abdomen. Doctors use the device to help treat irregular heartbeats called arrhythmias. -An ICD uses electrical pulses or shocks to help control life-threatening arrhythmias, especially those that can cause sudden [MEDICAL CONDITION] (SCA). SCA is a condition in which the heart suddenly stops beating. If the heart stops beating, blood stops flowing to the brain and other vital organs. SCA usually causes death if it's not treated within minutes. -ICDs use electrical pulses or shocks to treat life-threatening arrhythmias that occur in the ventricles (the heart's lower chambers). -When ventricular arrhythmias occur, the heart can't pump blood well. You can pass out within seconds and die within minutes if not treated. -To prevent death, the arrhythmia must be treated right away with an electric shock to the heart. This treatment is called defibrillation. -An ICD has wires with [MEDICATION NAME] on the ends that connect to the heart chambers. The ICD will monitor the heart rhythm. If the device detects an irregular rhythm in the ventricles, it will use low-energy electrical pulses to restore a normal rhythm. -If the low-energy pulses don't restore your normal heart rhythm, the ICD will switch to high-energy pulses for defibrillation. The device also will switch to high-energy pulses if the ventricles start to quiver rather than contract strongly. The high-energy pulses last only a fraction of a second, but they can be painful. -Pacemakers give off only low-energy electrical pulses. They're often used to treat less dangerous heart rhythms, such as those that occur in the upper chambers of your heart. Most new ICDs can act as both pacemakers and defibrillators. Record review of the admission physician order [REDACTED]. The orders did not include a DNR order. The resident's [DIAGNOSES REDACTED]. Record review of the nurses' notes showed the following information: -On [DATE], at 7:00 P.M., the resident arrived at the facility. The nurse documented the resident smelled of alcohol and appeared to show signs of intoxication. The resident did not complain of defibrillator shock at this time as this was the chief complaint on going from home to the hospital and the stated reason for the alcohol use. At this time, the resident is oriented to self only. -On [DATE], at 5:15 P.M., the nurse documented the resident alert and oriented with no complaints of defibrillator shocks this shift. Record review of the [DATE] POS did not include a DNR order. Record review of the social services progress notes, dated [DATE], showed the following information: -The facility admitted the resident from the emergency roiagnom on [DATE]. This is the third admission to the facility. The resident previously stayed at the facility from February 4, 2012 to February 6, 2012. At that time, the resident had not wanted to stay here but decided on [DATE] to come and stay at the facility permanently. The resident is alert and oriented. The resident eats without staff assistance in the dining room or resident room per his/her choice. On [DATE], Adult Protective and community service worker talked to the resident and determined that since the resident had decided on his/her own to stay at the facility, the resident was not in danger. On [DATE], the social services director assisted the resident to mail an application for Medicaid. Record review of the admission and social information data sheet, dated [DATE], showed the resident responsible for his/her own self. Social services documented the resident's code status as "full code" (indicating the resident would want CPR provided in the situation where his/her heart stopped beating and/or he/she stopped breathing). During interview on [DATE], at 12:50 P.M., the social services director said the resident was a full code. The resident did not request a no code status (DNR). This was the resident's third time at the facility. The resident did not have a power of attorney or advance directive. When asked on admission, the resident wanted to be full code. The resident decided he/she was going to stay here and applied for Medicaid. The director thought Medicaid had been approved before his/her death. Someone had called the adult protective services and told him/her the resident was going to stay at the facility. The resident had a drinking problem. When the resident died , the facility was not expecting that. Record review of the resident's admission Minimum Data Set (MDS) a federally mandated comprehensive assessment instrument, completed by facility staff, dated [DATE], showed the following information: -Cognitively intact; -Required supervision for bed mobility; -Required extensive assistance for transfers, dressing, and toilet use; -Always continent of bowel and bladder. Record review of the nurses' notes, showed the following information: -On [DATE], at 7:30 P.M., the nurse documented the resident as alert and oriented and performs most of his/her own activities of daily living (ADLs). The resident is able to voice needs and concerns. -On [DATE], at 3:40 P.M., the nurse documented the resident eats in room per his/her request. The resident had a poor appetite and fair fluid intake. Record review of the care plan, dated [DATE], showed the following information: -The resident needs assist with most ADLs related to generalized weakness secondary to several cardiac related problems. The resident is a smoker. -Staff to notify the physician of any significant changes; -Continent of bowel and bladder. Staff assists the resident with transfers and emptying the urinal. The resident is independent with perineal care; -The resident eats meals in his/her room; -At risk for falls related to generalized weakness, use of oxygen, and use of diuretics. The resident is alert and oriented, uses his/her call light appropriately, and asks for assistance with transfers. -The resident is not at nutritional risk at this time. The resident eats a majority of his/her meals and the resident's weight is stable. -At risk for acute shortness of breath and activity intolerance related to effects of [MEDICAL CONDITION]. -Watch for episodes of acute shortness of breath and activity intolerances; -Assess lung sounds, watch for cough, and production of sputum, fever, or acute respiratory distress as needed; -Notify physician as needed; -Administer medications and oxygen as ordered; -Potential for acute signs and symptoms of impaired peripheral blood flow associated with effects of [MEDICAL CONDITION] (disease of the arteries and veins of the extremities that interfere with adequate flow of blood to or from the extremities); -Observe for acute shortness of breath or change in mental status. Record review of the nurses' notes, showed the following information: -On [DATE], at 4:15 P.M., the nurse documented the resident had decreased appetite. The resident does not even attempt some meals. The nurse documented receipt of an order from the physician for [MEDICATION NAME] (appetite stimulant) twice a day. -On [DATE], the nurse documented the resident continued with poor appetite. The resident wanted milk. The nurse gave the resident milk upon repeated demand for it. During interview on [DATE], at 11:50 A.M., licensed practical nurse (LPN) H said the resident had not been eating well and the facility tried an appetite stimulant. The resident had constant diarrhea. The staff tried to hold milk products. The resident just would not eat and would not go to the dining room. The resident preferred to stay in his/her own room. The resident did not complain of not feeling well. The physician knew about the eating situation. The physician ordered the appetite stimulant and a medication for the diarrhea. The resident was his/her own responsible party. Record review of the nurses' notes, showed the following information: -On [DATE], at 7:50 A.M., LPN I documented he/she was called to the room. Upon arrival, the resident was very pale, no response, and bilateral lower extremities appear to be mottling. The resident's skin was cool to touch. Upon assessment of vital signs, the resident did not have a blood pressure, apical pulse, or respirations noted. Two different nurses auscultated for an apical pulse for a minute. At 7:56 A.M., the nurse notified the physician. During interview on [DATE], at 1:13 P.M., certified medication technician (CMT) W said he/she entered the resident's room at about 7:00 A.M. on [DATE] to administer medications to the resident. The CMT said he/she needed to check the resident's pulse for one of the medications. The resident would not let him/her. The resident pulled his/her arm away when the CMT tried to check his/her pulse. The resident refused the medications. The resident said he/she "didn't want them, because they didn't do any good". The CMT asked the resident what was wrong because he/she did not normally act like that. The resident was usually very nice. The resident said "don't want the damn medicine" and rolled over in bed towards the window. The CMT asked the resident if he/she was having a hard time breathing and the resident said he/she was fine. CMT W said he/she just thought the resident had a bad night. CMT W said the resident was not gasping for air when he/she talked, but would take a minute to catch his/her breath when talking. At approximately 7:10 A.M., CMT W told LPN I, the charge nurse, the resident refused his/her medications. The medication technician said he/she noticed on the MAR the resident had refused his/her medications some in the previous few days and wanted to let the nurse know. The resident did not normally refuse his/her medications. CMT W said when he/she was almost finished with the medication pass, at approximately 8:15 A.M., the nurses, LPN H and LPN I came to him/her and said to get the resident's MAR and medications together because the resident had "passed". The nurses said they were trying to get ahold of the family and they had already talked to the physician. During interview on [DATE], at 1:50 P.M., certified nursing assistant (CNA) E said he/she came on shift on [DATE], at 6:45 A.M. and received shift report. The night shift CNA said the resident had diarrhea all night long. After report, the aide checked rooms and went to get hall trays. When he/she walked into the resident's room to deliver the breakfast tray, the resident lay on his/her side facing toward the window. The resident's water, cell phone, and inhaler lay on the floor. The aide spoke to the resident. The resident did not respond. The resident's eyes were open looking at the aide, like he/she was saying, "help me". The resident was breathing hard and fast, gasping for air. The aide went to get LPN I. When LPN I got there, he/she could not find a pulse and wanted LPN H to check for a pulse. The aide said he/she did not remember how LPN H got involved. The aide said it all happened very fast and he/she was "freaked out" because the aide had never seen someone die. LPN H said the resident had a lot of mottling (condition that is marked by discolored areas). At this point, the resident was taking a breath about every two minutes. LPN H was watching how fast the breaths were. LPN H tried the left arm and CNA E tried the right arm. The aide said he/she felt a very faint pulse on the right arm. Then, LPN H came over to the right arm, but could not feel the pulse. They were not able to obtain a blood pressure. The aide said a couple days before this, the resident was fine, going on smoke breaks. The resident was still eating and drinking. The resident just did not want to go to the dining room. The resident was not pale except when he/she took off the oxygen, sometimes he/she would get pale. The staff would tell the resident he/she needed to put the oxygen back on and the resident would pink back up again. When the aide entered the resident room that morning, the resident was very pale. The aides do not chart vital signs. The nurse or certified medication technician (CMT) charts the vital signs. There was no CMT in the room, so it would have been LPN H or LPN I who documented the vital signs. The aide said no one called the ambulance and no one attempted CPR. During interview on [DATE], at 11:50 A.M., LPN H said he/she was present at the time of the resident's death on [DATE]. At approximately 7:30 A.M., the CNA (CNA E) came out of the resident's room and said the resident was not right and got LPN H. LPN I and LPN H went to the room and saw the resident. When LPN H entered the room, the stuff on the bedside table had been knocked off. LPN H did not know if the resident reached out and knocked the stuff off, or what. LPN H checked the resident's vital signs and was able to get them at the time. The resident's vital signs were awful, noticeably bad. Usually, the nurse writes vitals on something. LPN I usually keeps his/her own notes in situations like that. If it is documented in the chart, it would be in the nurses' notes. After checking the vital signs, LPN H came back and said they needed to call the physician and the family. Normally, the staff document in the nurses' notes regarding a change in condition. The orange stickers marked with "No code" are on the medical records of residents who have DNR orders. If the medical record does not have an orange sticker, staff considers the resident full code. When questioned what the resident's code status was, LPN H said he/she did not know about this resident's code status without looking at the medical record. After checking the resident's vital signs, the nurse said he/she was just involved with the phone calls to the physician and resident's family. The nurse said he/she was not aware of anyone attempting CPR on the resident. The nurse said he/she knew he/she did not. During interview on [DATE], at 12:50 P.M., LPN I, the charge nurse said, on [DATE], nothing had been passed on in report about any condition change for the resident. The medication technician came up and said the resident refused morning medications that morning and the day before. About ,[DATE] minutes after the medication technician reported the refusal, the aide went to pass breakfast trays and hollered out for help. LPN H and LPN I went to the room. The resident did not appear to be breathing at all. The resident was very pale. The nurse left the room to get the vital sign equipment. The nurse began trying to contact the family. The nurse called the family but was not able to get a hold of him/her yet when LPN H came back and said they were barely able to get a blood pressure. LPN I went to the resident room and LPN H said he/she could not get a blood pressure, pulse, or respirations at that point. LPN I listened for an apical pulse for one minute and then contacted the physician. LPN I said he/she told the physician the resident had no respirations or blood pressure and the assessment of the two nurses. When the nurse called the physician, the other staff told the nurse the resident was already gone. LPN I said it did not cross his/her mind to check the resident's code status. He/she did not know why it did not occur to him/her. Usually, the nurse writes on the report sheet if a resident is full code or he/she writes it on a scrap of paper. The orange sticker on the outside of the chart that is marked "No code" indicates a DNR order. If a resident is full code, there is no sticker. LPN I said he/she did not attempt CPR on the resident. During interview on [DATE], at 1:25 P.M., the administrator said he asked the nurse (the administrator did not clarify which nurse he talked to) about the incident and called the physician about the incident. The administrator asked the physician about the nurse calling him. The physician said the nurse told him the resident had already passed. The administrator told the physician CPR had not been started. The physician said he might have told the nurse not to start CPR because it was too late. The administrator said he talked to the nurse and he/she did not start CPR because the resident was mottled and was absent of vital signs. The administrator said the nurse would start CPR the next time. The administrator said if a resident is full code, he would have started CPR, called the ambulance and let the ambulance crew decide what to do from there. That is what he would have expected to happen. The administrator said he bought an AED machine (automated external defibrillator that automatically [DIAGNOSES REDACTED]. The MDS nurse is going to in-service the nurses on the machine and what is expected for full code residents next week. At 2:55 P.M., the administrator said no in-service had been completed yet. He just talked to the nurse involved and told him/her what he would have done. LPN J is going to re-do the policy. During an interview on [DATE], at 2:38 P.M., the resident's physician said the nurse told him they entered the room and found the resident passed away, kind of cool and starting to mottle a little bit. The resident was already cool to touch. After describing the account from the two staff regarding finding the resident gasping for air and the faint pulse, the physician said he did not remember any gasping breathing being reported. The physician said he would hate to pass judgment because he was not there. It is easy to make comments afterwards. When questioned who decided when CPR was too late for a full-code resident, the physician said the highest licensed staff would determine if CPR should be done. The physician said he did not know what the facility policy said. If the highest licensed staff in the building was an registered nurse (RN), then the RN should determine if CPR should be done. Record review of the facility's Cardiopulmonary resuscitation (CPR) policy (undated), showed the following information: -Objective: To provide ventilator and circulatory support until respiration's and pulse resume or until an ambulance arrives; -When caring for a resident with a terminal illness, always verify if the resident is to be resuscitated. A "do not resuscitate" order must be written by and signed by a physician. -If a resident is lying silently with no apparent respirations, shake the resident and ask if the resident is okay. If no response, alert a staff member to assist you. -Look, listen, and feel for breathing for five seconds. If no breathing is noted, cover the resident ' s mouth and nose with ventilation mask and give two full breaths. -Have someone call for an ambulance (staff drew a line through the instruction); -Check for pulse be feeling on side of trachea (neck); -If pulse is present and respirations are still absent, continue rescue breathing by giving one full breath every five seconds; -If there is no pulse, begin chest compressions 100 times per minute; -Give two breaths after every 30 compressions. After four cycles, stop and check for respiration and pulse; -If pulse and respirations do not resume, continue with CPR until ambulance arrives; -CPR to be performed by CPR certified personnel only; -Chart in nurses' notes the resident's respiration and circulatory status, the resident's response to the CPR intervention, vital signs after CPR, and the time loss of consciousness and/or arrest was noted. Staff should document the time CPR was started and the time the ambulance arrived. **At the time of the abbreviated survey, dated [DATE], the violation was determined to be at the immediate and serious jeopardy level "J". On [DATE], based on interview and record review, the facility had implemented corrective action to address and lower the violation at this time. The facility staff had counseled the charge nurse and explained the policy and procedure of what to do when a resident is found nonresponsive and not breathing. Licensed staff on duty were inserviced prior to starting their shift regarding proper CPR protocol. The facility staff has additional nursing staff to inservice. The facility updated their written policy regarding "Determining Resident's Code Status". Staff will be inserviced on the new written policy. All licensed nursing staff will be CPR trained. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.