Every finding on record at Valley View Health & Rehabilitation

Based on interview and record review, the facility failed to ensure three residents (Resident #10, #9, and #13), in a review of 13 sampled residents, were treated with dignity and respect. Certified Medication Technician (CMT) F was rude and rough during care for one resident, (Resident #10) and the resident said it hurt his/her feelings and made him/her feel angry. CMT F was rough and forceful with Resident #9's care and the resident said it made him/her feel like he/she wasn't worth anything. Resident #13 reported CMT F was condescending and liked to show his/her authority; the resident said it made him/her so angry he/she wanted to punch CMT F in the face. The facility census was 76. Review of the facility's policy Resident Rights, revised December 2016, showed all employees should treat all residents with kindness, respect, and dignity. Review of the facility's policy Conduct and Behavior, revised May 2019, showed examples of conduct and behavior that were considered inappropriate and therefore prohibited included failure to treat all residents with kindness, respect and dignity, being discourteous to residents or any behavior that was deemed offensive or unsafe 1. Review of Resident #10's Care Plan, dated 11/12/24, showed the following: -The resident had a self-care deficit related to impaired balance and limited mobility; -Encourage resident to participate in the fullest extent possible with each interaction; -Encourage the resident to use the call bell for assistance; -The resident needs prompt response to each call for assistance; -The resident required partial to moderate assistance with personal hygiene, toileting, transfers, bathing, bed mobility, and dressing. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/14/25, showed the following: -Moderate cognitive impairment; -Upper extremity impairment on one side of the body; -The resident required supervision or touching assistance moving from a lying position to sitting on the side of the bed; -The resident required substantial to maximum assistance with toileting hygiene, showering and lower body dressing; -The resident required partial to moderate assistance with personal hygiene, moving from sitting to standing position, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer and walking 10 feet; -Mobility devices of walker and wheelchair; -Diagnoses included cancer, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), arthritis and depression. During an interview on 2/20/25 at 2:45 P.M. the resident said the following: -Certified Medication Technician (CMT) F was very rude during care; -Last week when he/she turned on his/her call light, CMT F said four staff had just been in his/her room and said he/she (the resident) should have asked the other staff instead of turning on the call light again; -CMT F was rough when he/she pulled the resident up in bed and made comments that he/she would push the resident through the wall when the resident complained about him/her being rough with care; -CMT F hurt the resident's feelings and made the resident angry. CMT F acted like he/she was the boss; -The resident was afraid to report CMT F because he/she could retaliate against him/her. 2. Review of Resident #9's annual MDS assessment, dated 11/17/24, showed the following: -The resident was cognitively intact; -The resident was dependent on staff for toilet hygiene and lower body dressing and with transfers; -The resident required substantial to maximal assistance with personal hygiene and bathing; -Partial to moderate assistance needed with upper body dressing; -Always incontinent of bowel and bladder; -Diagnoses included multiple sclerosis (a chronic disease where the body's immune system attacks the protective coating around nerves in the brain and spinal cord, causing damage that disrupts signals and can lead to muscle weakness, vision problems and difficulty walking). Review of the resident's Care Plan, revised 2/20/25 showed the following: -The resident had an activities of daily living (ADL) performance deficit related to multiple sclerosis; -Allow sufficient time for dressing and undressing; -The resident had limited physical mobility related to ataxia (impaired balance or coordination) and multiple sclerosis; -The resident was dependent on a manual wheelchair for locomotion; -The resident refused showers at times. Caregivers to provide opportunity for positive interaction and attention; -Explain all procedures to the resident before starting and allow the resident time to adjust to the changes; -Approach and speak in a calm manner. During an interview on 2/25/25 at 10:18 A.M. the resident said the following: -CMT F was rough and forceful with care; -CMT F wanted to do everything his/her way and if the resident complained about it, CMT F said you just need to fucking get used to it; -This made the resident feel like he/she was not worth anything; -He/She just let it go, because it could get worse if he/she reported CMT F. 3. Review of Resident #13's Care Plan, dated 11/20/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to a stroke with hemiplegia (weakness on one side of the body); -The resident required extensive assistance with dressing; -The resident required limited assistance with transfers, bed mobility and toilet use; -The resident was independent with personal hygiene with setup assistance; -Encourage the resident to participate to fullest extent possible with each interaction; -Encourage the resident to use his/her call bell for assistance; -The resident had impaired cognitive function/dementia or impaired thought processes; -With communication, identify yourself with each interaction, reduce any distractions, the resident understands simple directive sentences. Provide the resident with necessary cues and stop and return if agitated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Functional limitation in range of motion affecting one side of the body; -The resident required partial to moderate assistance with toileting hygiene, bathing, personal hygiene, upper body dressing and chair/bed-to-chair transfer and the ability to come to a standing position from a sitting position; -The resident required substantial/maximal assistance with lower body dressing; -Mobility device used was a wheelchair; -Diagnoses included a stroke, aphasia (a language disorder that affects how you communicate), hemiplegia and depression. During an interview on 2/24/25 at 8:40 A.M. the resident said the following: -CMT F was rude and talked down to him/her; -CMT F was condescending and liked to show his/her authority; -The resident said CMT F made him/her so angry he/she wanted to punch CMT F in the face! During an interview on 2/24/25 at 10:00 A.M. Certified Nurse Assistant (CNA) C said the following: -Many of the residents said CMT F was rough, hateful, and rude during care; -CMT F said things like, get up yourself, I'm not doing it for you, or you can do it yourself; -CMT F's tone was harsh, and it upset the residents; -He/She had reported the residents' complaints to different charge nurses, but nothing was ever done. During an interview on 2/24/25 at 1:45 P.M. the Director of Nursing (DON) said the following: -CMT F didn't have a gentle approach; -He had received a couple of complaints regarding CMT F in the past couple of years and one recently about his/her tone; -All residents should be treated with dignity and respect. During an interview on 2/24/25 at 3:30 P.M. the Administrator said the following: -CMT F was too gruff and had been written up before for not providing good customer service to one of the residents; -She would expect staff to treat all residents with dignity and respect. MO248667

Based on observation, interview, and record review, the facility failed to ensure staff provided assistance with Activities of Daily Living (ADLs) for two residents (Resident #1 and #7) in a review of 13 sampled residents, to maintain proper grooming to include nail care and personal hygiene. The facility census was 76. Review of the facility's policy Activities of Daily Living (ADL), Supporting, revised March 2018, showed the following: -Resident's will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); -If a resident with cognitive impairment or dementia resists care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining the care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. Review of the facility policy titled, Fingernail/Toenail Care, dated February 2018, showed the following: -Nail care includes daily cleaning and regular trimming; -If the resident refuses nail care, document the reason why and the intervention taken. 1. Review of Resident #1's Care Plan, last revised 2/24/25, showed the following: -The resident had an ADL self-care performance deficit related to impaired mobility; -The resident refused showers and nail care. The resident had been educated on the risks of refusing care and the importance of proper hygiene; -The resident will refuse hand hygiene and had been educated on the risks and benefits; -If possible, negotiate a time for ADLs so that the resident participates in the decision-making process; -If the resident resists ADLs, reassure resident, leave, and return five to 10 minutes later and try again; -Provide consistency in care to promote comfort in ADLs; -Provide resident with opportunities for choice during care provision. -Check nail length and trim and clean on bath day and as necessary; -The resident required extensive assistance with bathing/showering; -Provide a sponge bath when a full bath or shower cannot be tolerated; -The resident will hoard feces in his/her clothing. If reasonable, discuss the resident's behavior. Explain and reinforce why the behavior was inappropriate or unacceptable to the resident; -The resident had impaired cognitive function/dementia or impaired thought process. Cue, reorient and supervise as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/10/25, showed the following: -The resident was cognitively intact; -No rejection of care exhibited; -Functional limitation in range of motion (ROM) impairment on both sides of lower extremities; -Partial/moderate assistance needed with showering/bathing; -Independent with upper and lower body dressing, personal hygiene and toileting; -Occasionally incontinent of urine and frequently incontinent of bowel; -Received Hospice care: Review of the resident's shower sheets requested for the past 30 days showed the following: -The resident received a shower on 1/22/25, 1/29/25, and 1/31/25; -The resident received a shower on 2/5/25, 2/7/25, 2/12/25, and 2/19/25; -There was no documentation that nail care was offered or provided on days staff provided showers. Observation on 2/20/25 at 10:00 A.M. in the resident's room showed the following: -The resident sat in his/her electric wheelchair; -A strong odor of urine and feces was noted in the room; -The resident's hands were dirty with brown debris and there was also brown debris under the resident's fingernails. The resident's fingernails were long and uneven; -The resident's shirt was soiled with brown debris along the bottom of the shirt; -There was a white hand towel soiled with brown debris by his/her feet on the foot rest of his/her electric wheelchair. Observation on 2/20/25 at 2:06 P.M. in the outside smoking area showed the following: -The resident had dark brown debris under his/her nails and the nails remained long and uneven; -The resident's hooded jacket had brown debris along the bottom of the jacket. Review of the resident's shower sheets showed the resident received a shower on 2/21/25. There was no documentation staff offered or provided nail care. Observation on 2/25/25 at 10:15 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair, brown debris was noted under his/her fingernails. The resident's nails remained long and uneven; -The resident had an odor of urine and feces; -The back of the resident's hooded jacket had brown debris along the bottom. During an interview on 2/20/25 at 10:18 A.M. the resident said he/she refused showers at times and that was his/her right. During an interview on 2/24/25 at 10:00 A.M. Certified Nurse Assistant (CNA) C said the following: -The resident often had feces under his/her fingernails. Staff could only educate him/her if he/she refused; there was nothing else that could be done; -The resident often refused showers; -The resident's room had feces everywhere and needed to be cleaned daily. During an interview on 2/20/25 at 11:30 A.M. Certified Medication Technician (CMT) D said the following: -The resident often had feces on his/hands, under his/her fingernails and on his/her clothes. The resident refused to shower and clean up; -There was not much that could be done. Staff couldn't force the resident to shower. 2. Review of Resident #7's Care Plan, revised 11/15/24, showed the following: -The resident had an ADL performance self care deficit related to Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors); -Check nail length and trim and clean on bath day and as necessary; -The resident had a communication problem related to deafness, anticipate, and meet needs. Review of the resident's annual MDS dated [DATE] showed the following: -The resident had moderate cognitive impairment; -No rejection of care exhibited; -The resident required substantial to maximum assistance with bathing; -The resident required partial to moderate assistance with personal hygiene; -Diagnoses included Parkinson's disease. Observation on 2/25/25 at 3:25 P.M. in the resident's room showed the resident's nails were approximately 1/4 inch long, uneven, with brown crusted debris under the nails. During an interview on 2/25/25 at 3:30 P.M. the Assistant Director of Nursing (ADON) said Resident #7 probably refused to have his/her nails trimmed, he/she often refused care. During an interview on 2/24/25 at Director of Nursing (DON) said the following: -Resident #1 often had diarrhea and was fixated on his/her bowels; the physician had addressed this multiple times by adjusting laxatives; -Staff tried to assess the resident and offer a shower, but he/she often refused; -Resident #7 would allow only certain staff to trim his/her nails. He was not aware the resident's nails were that long. During an interview on 2/20/25 at 4:30 P.M. the Administrator said the following: -Many of the resident's complained about Resident #1's odor, because the resident didn't shower routinely and was often dirty; -Resident #1 refused to wash the dirty sweatshirt he/she wore, he/she seldom ever took it off so it was very dirty; -The resident often had fecal matter under his/her nails and would refuse to shower or clean up; -She would expect each resident to have a shower at least two times a week or per their preference. She would expect nails to be trimmed on shower days or as needed; -Staff should make multiple attempts to provide a shower or a partial bath if nothing else. MO249168 MO248667

Based on interview and record review, the facility failed to provide protective oversight to ensure one resident (Resident #1), did not obtain a lighter and cigarettes within the facility on multiple occasions. The resident was also observed smoking in his/her room wearing oxygen and admitted to staff he/she was smoking in the facility. Staff educated the resident not to smoke in the building and on the smoking policy. There was no documentation any other interventions were put in place or the resident's smoking assessment was updated until 2/19/25. On 2/20/25 during the night, the resident was observed smoking and admitted to smoking in the facility on more than one occasion and was found with two lighters and a half pack of cigarettes. The facility census was 76. Review of the facility's policy titled, Smoking Policy, dated 10/2/24, showed the following: -When the resident requested to smoke, the interdisciplinary team (IDT) will assess the resident's capabilities and deficits to determine appropriate supervision and assistance. Smoking will only be allowed in designated areas at designated times in the facility that are not near flammable substances or where oxygen is in use. Residents, resident representatives, and visitors will be informed of the facility smoking policy; -The objective of this policy is to complete an assessment when a resident requests to smoke, determine the level supervision, assistance and individualized approaches required for safety. In addition, the smoking policy outlines the designated areas, notices, education, and requirements for smoking on the facility property to ensure precautions are taken for resident's individual safety as well as the safety of others in the facility; -Smoking will only be permitted in marked designated areas ONLY. Smoking is prohibited in all other areas; -No residents with oxygen are permitted in the designated smoke areas; -Any resident choosing to smoke will be assessed by a member of the IDT utilizing the Smoking Evaluation Assessment. The assessment will be completed upon admission, annually, with change of condition and as needed. Individualized approaches and directions for safety and assistance will be documented in the resident's plan of care and communicated to direct care staff. Documentation will detail situations when the resident is not allowed to smoke; -Education about the policy will be provided to the resident/resident representative; -Residents who can sign out per responsible party, may ask for their smoking materials after signing out and must leave the property to smoke at will. The residents must return smoking materials to nurse ' s station upon returning to the facility; -Failure to comply or act in accordance with facilities smoking policy can result in the loss of smoking privileges due to severe possibility of harm and/or damages that may be caused from non-compliance; -First violation will result in a 2-day suspension of smoking privileges; -Second violation of our smoking policy will result in permanent revocation of smoking privileges and the resident will be offered smoking cessation products and education; -Continued non-compliance will result in a 30-day discharge from the facility; -All residents who smoke need to be supervised by a facility staff member or personal family member at designated smoke areas; -Smoke breaks are in the designated areas; -Smoke breaks are limited to one cigarette per resident; -All cigarettes will be extinguished in the appropriate receptacles; -Residents are not permitted to have smoking materials on their possession or in their room. All smoking materials such as lighters, matches and cigarettes are to be kept in the designated cabinet and passed out by the designated staff member; -The facility may conduct room searches for smoking materials, during which time the resident and or representative may be present; -Absolutely no smoking inside the facility. Violation of this rule may result in discharge. 1. Review of the Resident #1's Care Plan, initiated on 1/16/23 showed the following: -Educate the resident on smoking risks and hazards. Encourage the resident to participate in a smoking cessation program; -If the resident wears oxygen ensure the resident does not take the tank or tubing with him/her to smoke; -Educate the resident on the risks of smoking around/near oxygen; -Educate the resident on smoking with a compromised lung function; -Educate the resident on smoking times, rules and safe smoking practices; -Notify the Social Service Director (SSD)/Administrator if it is suspected the resident had violated the facility smoking policy; -Observe clothing for cigarette burns. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 1/10/25, showed the following: -admitted to the facility 1/3/23; -The resident was cognitively intact; -No behavioral symptoms exhibited; -Functional limitation in range of motion in lower extremities, impairment on both sides; -Independent with chair/bed-to-chair- transfer, toilet transfers; -The resident used a motorized scooter independently, can wheel at least 150 feet once in the scooter; -Diagnoses included arthritis, chronic pain syndrome (persistent pain that lasts for weeks to years), adult failure to thrive (a condition that commonly affects the elderly, especially those with multiple chronic medical conditions), unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence (an emotional and behavioral issue with the onset being as a child or adolescent. Symptoms can include anger and aggression towards others or self, impulsivity, difficulty handling frustration, refusing to follow rules) and cognitive communication disorder (trouble reasoning and making decisions while communicating and sometimes have trouble responding in an appropriate or a socially acceptable manner). Review of the resident's Physician Order Sheets (POS) dated February 2025, showed an order for oxygen to titrate to keep oxygen saturation above 90% (the measure of how well the body is delivering oxygen to tissues and organs in the body, a normal oxygen saturation level is between 95% to 100 %)) and as needed for dyspnea (shortness of breath). Review of the resident's smoking assessment dated [DATE] showed the following: -The resident was a smoker; -The resident had no visual or cognitive deficit and no dexterity problems; -The resident was an independent smoker and could light his/her own cigarettes; -The facility will store the resident's cigarettes and lighter; -The resident was to utilize an apron when smoking. Review of the resident's Nurse's Note, dated 2/7/25 at 11:20 P.M.,. showed the following: -The resident asked the Certified Nurse Assistants (CNAs) to let him/her out to smoke, they were busy with bed check and said they would as soon as they were finished. The resident went to charge nurse requesting to go out and was told the same thing; -After a few minutes a CNA from Unit 2 came down and let the resident outside. The resident was outside for five minutes and then came back inside. The resident immediately came out of his/her room and asked to go outside to smoke again. Staff told the resident they would let him/her out as soon as possible; -Unit 1 aide let the resident out after a few minutes The resident was outside for less then five minutes and came back in and went to his/her room. In less then five minutes the resident came out again requesting to go out and smoke. Staff told the resident they would let him/her out as soon as possible; -The resident went to the dining room to wait for aides to let him/her outside. The aides went to the dining room and there was a strong cigarette smoke odor. The resident denied smoking but there was a partially smoked cigarette by his/her feet. The resident said the cigarette was not his/her's, but no other residents smoke this type of cigarette, only this resident; -On call was notified and social services. The resident was educated to not smoke in the building and on the smoking policy. The resident verbalized an understanding. Review of the resident's record showed his/her Care Plan was not updated to show staff smelled a strong cigarette odor or noted a partially smoked cigarette by the resident's feet or any new interventions for supervision. There was no evidence staff updated the resident's smoking assessment. Review of the resident's Nurse's Note, dated 2/11/25 at 9:26 A.M., showed the following: -The resident said staff were not quick enough to let him/her out at night to smoke and that was why he/she sometimes propped (the resident would leave the door propped open to the outside smoke area off the dining room after he/she smoked so he/she could come and go as he/she wanted) the door open. The resident said he/she had to smoke to be able to have a bowel movement; -Staff educated the resident on not propping the doors as it was a potential danger to other residents. The resident agreed to attempt to be patient so staff could let him/her through locked doors at night to smoke. Review of the resident's record showed no update to the resident's Care Plan to show the resident admitted to propping the facility door open to smoke on occasion or any new interventions for increased supervision and no evidence the resident's smoking assessment was updated. Review of the resident's Nurse's Note, dated 2/13/25 at 4:09 P.M., showed the following: -The nurse along with the Director of Nursing (DON), Social Service Director, Housekeeping Supervisor, and the Administrator were requested to come to the resident's room. The resident requested staff look for missing money in his/her room; -Upon going through the resident's room, staff found half smoked cigarettes, multiple piles of opened boxes of cigarettes, some half empty, and some that had been opened but had no cigarettes removed. Review of the resident's Care Plan showed it was not updated to show staff found the resident with half smoked cigarettes in his/her room along with multiple boxes of cigarettes or any new interventions for increased supervision. Review of the resident's social service note dated 2/18/25 at 11:32 P.M. showed the following: -An aide was walking down the hall and smelled smoke; -The aide knocked on the resident's door and the resident answered the door; - Staff asked the resident if he/she was smoking as smoke was coming out the room; - Charge nurse notified and staff educated the resident on the smoking policy. Review of the resident's Care Plan showed it was not updated to show staff smelled smoke and observed smoke coming out of the resident's room or any new interventions for increased supervision. Review of the resident's smoking assessment showed it was not updated after the resident was found with cigarettes Review of the resident's Nurse's Note, dated 2/19/25 at 12:30 A.M., showed the following: -The charge nurse and aide went to the resident's room to administer medications. The resident's door was closed; -Upon entering the resident's room, it smelled strongly of smoke and the room was hazy from smoke; -Staff questioned the resident about smoking and he/she denied it. Staff educated the resident on the smoking policy and the dangers of smoking around oxygen. Review of the resident's Care Plan showed it was not updated to show that the resident's room smelled strongly of smoke and the room was hazy from smoke. There were no new interventions for increased supervision and no evidence the smoking assessment was updated at the time of the incident on 2/19/25 at 12:30 A.M. Review of the resident's Progress Note, dated 2/19/25 at 12:40 A.M., showed the following: -Aides went down the hall to answer a call light. The resident's door was closed but the hallway was smokey and there was a strong odor of cigarettes; -Aides attempted to open the door, however the resident was in front of the door in his/her wheelchair; -Aides opened the door about six inches and were able to see the resident put his/her cigarette out on his/her wheelchair. The resident admitted he/she was smoking in his/her room; -The resident gave the aide around ten cigarette butts and two lighters. Staff left the resident's room and he/she followed them in his/her wheelchair. Aides reported the situation to charge nurse; -Staff educated the resident on the smoking policy and dangers of smoking around oxygen. The Social Service Director notified the on-call Administrator. Review of the resident's Nurse's Note, dated 2/19/25 at 5:34 A.M., showed the following: -The resident said he/she could not have a bowel movement unless he/she smoked. Offered medications for constipation and the resident refused; -The resident said he/she only had diarrhea and needed to smoke every time he/she had the urge to have a bowel movement. Review of the resident's Nurse's Note, dated 2/19/25 at 6:48 A.M., showed the following: -The resident was at the nursing station demanding to go out and smoke; -Staff told the resident he/she could not go out to smoke until supervised smoke time and that the facility was following the current smoking policy. Review of the resident's Nurse's Note, dated 2/19/25 at 7:24 A.M., showed the following: -The resident was going out to smoke break and asked for a pack of cigarettes; -The Social Service Director observed the resident had a hidden pack in his/her pocket. The resident had been redirected several times and staff had no success redirecting him/her; -The resident continued to argue with staff about why he/she was smoking in the facility. Review of the resident's medical record showed there was no documentation to show the Administrator was notified of the resident being found with cigarettes in his/her pocket and continuing to argue about smoking in the facility. Review of the resident's Nurse's Note, dated 2/19/25 at 8:39 A.M., completed by the Social Service Director showed the following: -The resident was made a supervised smoker due to the resident hunched over and asleep numerous times with his/her electric wheelchair in drive several times through the night and because of smoking in the facility; -The resident had been educated on the risks of smoking in the facility and had signed a new smoking policy that came out at the beginning of the year; -The resident was supposed to have a smoking apron which he/she did not wear properly. The resident was educated on the risks of not wearing the apron properly; -Staff completed a new smoking assessment due to the resident falling asleep in his/her electric wheelchair and smoking in the facility. Review of the resident's Smoking Assessment, dated 2/19/25, showed the following: -The resident was a smoker; -The resident had no visual or cognitive deficit; -The resident had a dexterity problem; -The resident was to be a supervised smoker and could light his/her own cigarettes; -The facility was to store the resident's cigarettes and lighter; -The resident was to utilize an apron when smoking. Review of the resident's Nurse's Note, dated 2/19/25 at 9:39 A.M., showed the following: -The resident was called to an Interdisciplinary Team (IDT) meeting to discuss the resident being caught in his/her room smoking; -The Administrator asked the resident if he/she was smoking in his/her room and the resident said yes, yes, he/she had been smoking in his/her room, he/she needed to have a bowel movement and couldn't wait and was at his/her wits end; -The resident was offered a nicotine patch and he/she declined. The Administrator explained that the resident would be supervised because he/she had been caught multiple times smoking inside the facility. Review of the resident's Care Plan, last revised on 2/20/25, showed on 2/19/25 the resident required supervised smoking. Review of the resident's Nurse's Note, dated 2/20/25 at 12:55 A.M., showed the following: -The resident went to the dining room and the aides reported a strong smell of cigarette smoke coming from the dining room; -The resident went back to his/her room and admitted to the Social Service Director he/she was smoking in the dining room; -The resident gave the SSD two lighters and a half of a pack of cigarettes. The resident said he/she could not have a bowel movement without a cigarette; -The resident was educated on the smoking policy and the Administrator on call was notified. Review of the resident's Care Plan showed no updated interventions of increased supervision/monitoring of the resident while in the facility after the resident was found with two lighters and a half of a pack of cigarettes and admitted to smoking in the dining room of the facility. Review of the resident's Nurse's Note, dated 2/20/25 at 2:40 A.M., showed the following: -The SSD was called down to Unit 1 due to smelling cigarette smoke in the dining room while the resident was coming out of the dining room; -The resident denied smoking at first, but later admitted he/she had been smoking due to not being able to have a bowel movement; -Staff educated the resident on the risks of smoking in the building and the smoking policy for the facility. Review of the resident's care plan showed no evidence the care plan was updated with any new interventions of increased supervision/monitoring of the resident while in the facility after smelling cigarette smoke while the resident was in the dining room and the resident admitted to smoking in the dining room of the facility. Review of the resident's Nurse's Note, dated 2/20/25 at 8:57 A.M., showed the following: -The Social Service Director called the nurse down the resident's room around 7:40 A.M., after the resident was caught smoking in his/her room; -Staff questioned the resident if he/she had any other smoking materials and the resident denied. The resident emptied his/her pockets; -Staff educated the resident on the smoking policy and dangers of smoking in his/her room especially with oxygen in his/her room; -The resident denied having oxygen on. Observation on 2/20/25 at 2:06 P.M., during the resident's smoke break outside the facility in the designated smoke area showed over 20 cigarette butts scattered on the ground. During an interview on 2/20/25 at 10:00 A.M. the resident said the following: -Staff took all his/her cigarettes out of his/her room around two hours ago because he/she was found smoking in his/her room; -He/She stored cigarettes in his/her room in his/her safe; -Smoking helped the resident relax and have a bowel movement. He/She had to smoke to be able to have a bowel movement; -He/She didn't smoke with his/her oxygen on. During an interview on 2/25/25 at 1:00 P.M. Certified Nurse Aide (CNA) D said the following: -He/She caught the resident smoking in his/her room recently. CNA D could not recall the exact date but it was when he/she was working on the evening shift; -He/She was across the hall and smelled smoke. The resident was in his/her room wearing his/her oxygen with it turned on, smoking a cigarette; -He/She turned the oxygen off and reported it to the charge nurse; -All residents are now supervised during smoking times. Staff hand out one cigarette to each resident and the staff were to hold the lighter and light each resident's cigarette; -The residents were to give the cigarette butts to staff and they would throw them away in the receptacle. During an interview on 2/20/25 at 2:00 P.M. and 2/25/25 at 10:22 A.M. the Social Services Director said the following: -He/She worked a split shift and worked at the facility at night, he/she was also a CNA; -There were a lot of places in the facility the resident had been found smoking in the past month and a half. The resident said he/she had to smoke to have bowel movement; -The resident's family brought cigarettes into the resident, and the resident hid cigarettes in his/her room; -Staff found cigarette packs all over his/her room and cigarette butts everywhere. The resident had 32 open packs of cigarettes in his/her room; -On 2/19/25, the resident changed to a supervised smoker. The SSD was normally always up and down the halls of the facility at night checking on the residents, but there was nothing specific put in place regarding supervision of the resident on 2/19/25 or 2/20/25 while he/she was in the facility; -On 2/20/25 staff found the resident smoking in his/her room; -Since the resident was now a supervised smoker, his/her cigarettes were accounted for, the issue with smoking inside had been addressed; -Staff didn't complete any room searches or provide increased supervision when the resident was inside the facility. Review of the resident's Care Plan, revised on 2/24/25, showed the following: -The resident will keep multiple packs of tobacco on his/her person in his/her room and will accuse staff of stealing them; -The resident had been educated on the proper storing of tobacco and refused to abide by the facility rules; -The resident will refuse to wear his/her smoking apron and had been educated on the risks and benefits and the importance of wearing the apron to avoid burns. During an interview on 2/24/25 at 1:45 P.M. the DON said the following: -In December of 2024, the facility put in place a strict policy regarding smoking and all residents had to be supervised with specific smoke times; -Prior to this resident coming to the facility he/she had been homeless for a long period. The resident would probably pick up cigarette butts; -The resident never denied smoking in his/her room. The facility had an IDT meeting regarding smoking on 2/20/25 and also had a meeting prior to that regarding the resident smoking in the facility; -There were no problems with the resident smoking in the facility until the new policy was put in place. The resident was independent prior to that; -The facility had never had problems with residents smoking in the facility prior to the new policy being implemented. During an interview on 2/24/25 at 3:30 P.M. the Administrator said the following: -Staff found a large amount of cigarettes in the resident's safe the day he/she reported some missing money on 2/13/25. Staff were searching for the money and found all of the cigarettes. Those items were brought up to front office;-On 2/18/25, the facility had a group meeting with all the residents that smoked, reviewed the smoking policy and had each resident who smoked sign the policy after it was reviewed; -Facility staff notified her by phone the resident was smoking inside the facility once around 1:00 A.M. to 2:00 A.M. the morning of 2/20/25; -The other times staff thought the resident was possibly smoking, but wasn't sure as the resident may have a strong odor of smoke and it could have been because the resident just came back inside from smoking outside; -He/She would have expected to be notified of any incident of the resident suspected of smoking or found smoking inside the facility; -She instructed staff to do 15 minute checks on the resident after he/she was found smoking inside his/her room, he/she did not instruct staff to document the checks; -She hadn't decided if the resident would continue on 15 minute checks; -Staff searched the resident's room on 2/24/25 for any smoking contraband after the resident's family left and nothing was found; -She would expect staff to place all cigarette butts in the appropriate receptacles. MO249513

Based on interview and record review, the facility failed to ensure staff adequately documented assessments and monitoring of pressure ulcers (any lesion caused by unrelieved pressure, resulting in damage to underlying tissue that usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed) for one resident (Resident #333), in a review of 22 sampled residents; failed to maintain documentation of communication with the resident's physician on the changes to the resident's pressure ulcers to ensure appropriate treatment and care of the pressure ulcers; failed to ensure the resident's physician or designee followed facility policy to examine the resident's pressure ulcers upon readmission to the facility and to evaluate and document the progress of the pressure ulcers during resident visits; and failed to re-evaluate the need for ordered interventions, including a low air loss mattress, when the condition of the resident's pressure ulcers worsened. The pressure ulcers on the resident's buttocks, originally developed during hospitalization , worsened while in the facility, resulting in a Stage IV pressure ulcer (a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur). The facility census was 84. Review of the facility's policy, Wound Care, dated (revised) October 2010, showed the following: -Documentation: the following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The position in which the resident was placed; -The name and title of the individual performing the wound care; -Any change in the resident's condition; -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; -How the resident tolerated the procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: Notify the supervisor if the resident refuses the wound care; report other information in accordance with the facility policy and professional standards of practice. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister, and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body, which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage, or bone are not exposed; -Stage IV pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury (DTPI) is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage III or stage IV pressure injury). Review of the facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated (revised) April 2018, showed the following: -Assessment and Recognition: -The nurse shall describe and document/report the following: -a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissues; -b. Pain assessment; -c. Resident's mobility status; -d. Current treatments, including support surfaces, and: -e. All active diagnoses; -3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; -4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer; -5. The physician will help identify and define and complications related to pressure ulcers; -Monitoring: -1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly healing wounds. 1. Review of Resident #333's undated medical diagnoses record showed the resident's diagnoses included transverse myelitis (a neurological disorder that results in inflammation of both sides of one section of the spinal cord, which can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction), diabetes mellitus (too much sugar in the bloodstream), and peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs-usually the legs). Review of the resident's Care Plan, dated 06/19/24, showed the following: -The resident has potential/actual impairment to skin integrity. The resident refused wound care, turning/repositioning every two hours, and hygiene cares to promote wound healing; -Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to the physician; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the resident's progress notes, dated 07/14/24 at 2:16 P.M., showed the resident had experienced emesis (vomiting) all day and was discharged to the hospital where he/she was admitted . Review of the resident's progress notes, dated 07/24/24 at 5:53 P.M., showed the resident was readmitted to the facility from the hospital. Review of the resident's Weekly Wound Assessment, dated 07/25/24 at 9:00 A.M., showed Registered Nurse (RN) N documented the following: -Date of onset: 07/25/24; -The resident had an unstageable pressure ulcer located on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 0.5 centimeters (cm) length by 0.5 cm in width by 0.1 cm in depth; -No undermining (separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface) or tunneling (a wound that has progressed to form passageways underneath the surface of the skin); -Wound bed color- pink and red; -Granulation (the development of new tissue and blood vessels in a wound during the healing process) 100 percent; -Amount of drainage (exudate) small, less than 25 percent (%); -Type of drainage (exudate) serosanguinous (thin, watery, pale, red/pink drainage); -No odor; -Wound edges- macerated (a softening and breaking down of skin resulting from prolonged exposure to moisture) and red; -Periwound tissue (tissue surrounding a wound) macerated, redness; -No pain related to wound; -Wound healing progression-new. Review of the resident's Weekly Wound Assessment, dated 07/25/24 at 9:00 A.M., showed Registered Nurse (RN) N documented the following: -Date of onset: 07/25/24; -The resident had a Stage III pressure ulcer located on his/her left buttock that was present on admission to the facility; -The pressure ulcer was 3.6 cm in length by 4.3 cm in width by 0.1 cm in depth; -No undermining or tunneling -Wound bed color- red; -Granulation 100 percent; -Amount of drainage: small, less than 25 percent (%); -Type of drainage: serosanguinous; -No odor; -Wound edges- red; -Periwound tissue was macerated, redness; -No pain related to wound. -Wound healing progression-new. Review of the resident's Care Plan, last dated 06/19/24, showed no documentation staff updated the care plan to include the resident had pressure ulcers on his/her left and right buttocks and no goals or interventions to address these areas. Review of the resident's Nursing Progress Notes, dated 7/29/24, showed staff documented the resident was lethargic (sleepy), had a low level of consciousness and confused, with a low blood pressure. He/She was discharged to the hospital on 07/29/24. Review of the resident's progress notes, dated 08/05/24 showed the resident was readmitted to the facility from the hospital. Review of the resident's Hospital Discharge Orders, dated 08/05/24, showed the following orders for skin/wound care: -Bilateral sacral gluteal (base of the spine/buttocks) - cleanse with Theraworx (a hygiene and barrier system foam) daily. Apply triad cream (an antibiotic cream) daily dime thick (approximately 2 millimeters (ml)) to open lesions. Apply mixture of triad cream and petroleum jelly to surrounding skin and gluteal/perineal region for barrier cream. Use petroleum jelly as needed with incontinence care after daily application of petroleum jelly. Do not scrub barrier/wound cream away with repeated care, wipe away top (soiled) layer only and then reapply; -Please do the following for the best care of the patient: IsoAir low air loss mattress (a special mattress that helps prevent and treat pressure injuries and manages moisture)-please implement! Review of the resident's physician orders showed an order, dated 08/06/24 at 7:00 A.M., to cleanse the resident's bilateral buttocks with cleanser, pat dry, apply thick layer of zinc/collagen mixture (topical treatment for cell repair) every shift until healed every day for wound healing. (Review showed no evidence staff obtained an order for a low air loss mattress.) Review of the resident's weekly wound assessment, dated 08/06/24 at 7:53 A.M., showed Registered Nurse (RN) N documented the following: -The resident had a stage II pressure ulcer on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 4 cm in length by 5 cm in width by 0.1 cm in depth. (The size of the pressure ulcer increased from the previous assessment on 7/25/24 when it measured 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. Staff identified the pressure ulcer on 7/25/24 as unstageable.) -No undermining or tunneling; -Wound bed color- pink and red; -Granulation 100 percent; -Amount of drainage: small, less than 25% -Type of drainage: serosanguinous; -No odor; -Wound edges- macerated and red; -Periwound tissue: macerated, redness; -No pain related to wound. Review of the resident's weekly wound assessment, dated 08/06/24 at 8:01 A.M. showed RN N documented the following: -The resident had a pressure ulcer on his/her left buttock that was present on admission to the facility. He/She classified the wound as a deep tissue injury (DTI); -The pressure ulcer measured 5.5 cm in length by 4 cm in width, by 0.1 cm in depth. (The size of the pressure ulcer increased from the previous assessment on 7/25/24 when it measured 3.6 cm in length by 4.3 cm in width by 0.1 cm in depth. Staff identified the pressure ulcer changed from a stage III pressure ulcer on 7/25/24 to a DTI on 8/6/24.) -No undermining or tunneling; -Wound bed color- red and black; -Necrosis (the death of the cells in your body tissues which can occur due to injuries, infections, or diseases) 100%. (Staff's assessment on 7/25/24 showed the pressure ulcer had 100% granulation tissue.) -Amount of drainage-none; -No odor; -Wound edges- red; -Periwound tissue macerated, redness; -No pain related to wound. Review of the resident's medical record showed no documentation RN N notified the resident' physician or primary care NP of the condition of the resident's pressure ulcers or the changes to the resident's pressure ulcers identified on the weekly skin assessment completed on 08/06/24. Review of the Interdisciplinary Team (IDT) meeting notes, dated 08/06/24 at 9:45 A.M., showed the Social Worker documented the following: -The resident said his/her goal was to work with therapy to go home; -The Director of Therapy explained to the resident that he/she was only able to use the slide board for transfers; -The IDT team discussed with the resident the pros and cons of an air mattress as per the resident's hospital paperwork; -The resident verbalized understanding and said he/she wanted to continue working with therapy to get stronger and go home; -The Director of Therapy explained that in the resident's best interest, therapy would continue to work on slide board transfers, but the resident would remain a mechanical lift for nursing staff until therapy cleared him/her; -The resident was in agreement with goal to go home and to work with therapy to do so; (Review of the IDT meeting notes showed no documentation the primary care NP or resident's physician were in attendance.) During an interview on 10/04/24 at 2:00 P.M., RN N said the following: -A low-air loss mattress was not obtained for the resident when he/she returned to the facility on [DATE]. He/She and the therapy team decided during an IDT meeting that since the resident's goal was to return home and therapy was working with the resident on slide board transfers, they would hold off on the low-air loss mattress for the time being. A slide board could not be used with a low-air loss mattress; -He/She was pretty sure he/she discussed why nursing and therapy decided not to implement a low air loss mattress as ordered on the hospital discharge on 08/05/24 with the resident's primary care NP and the NP concurred. During an interview on 10/07/24 at 9:45 A.M., the Director of Physical Therapy said the following: -The IDT met regarding the resident's return to the facility on [DATE]; -She recalled the conversation during the IDT meeting about the resident's hospital discharge orders on 08/05/24 for a low-air loss mattress; -The resident's goals at that time were to return home, so the team opted to continue to work with the resident on slide board transfers; -A slide board cannot be used on a low air loss mattress; -She was not aware the resident had any worsening of his/her pressure ulcers on the buttocks from his/her recent hospitalization and upon his/her return to the facility on [DATE]; -If a resident's wound involved the buttocks, a slide board could potentially cause worsening of the wound. Review of the resident's medical record showed no documentation staff notified the resident's physician or primary care NP of the IDT's discussion to not utilize a low air loss mattress on the resident's bed or consulted with the physician to determine if a slide board was appropriate for transfers when the resident had pressure ulcers on his/her buttocks. Review of the resident's progress notes, dated 08/08/24, showed the primary care NP documented the following: -History of present illness (HPI): the resident was seen in follow-up for his/her readmission to the facility from the hospital on 08/05/24; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's five-day prospective payment system (PPS) Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 08/11/24, showed the following: -Cognitively intact; -Dependent for toileting; -Partial to moderate assistance for chair/bed-to-chair transfer; -Had an indwelling urinary catheter; -Always incontinent of bowel; -At risk for developing pressure ulcers; -Had one or more unhealed pressure ulcers at stage I or higher; -Skin and ulcer treatments did not include pressure reducing device for bed. Review of the resident's progress notes, dated 08/15/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's weekly wound assessment, dated 08/16/24 at 1:11 P.M., showed RN N documented the following: -The resident had a stage II pressure ulcer on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 3.0 cm in length by 3.8 cm in width and 0.1 cm in depth. (The size of the pressure ulcer decreased from the previous assessment on 08/06/24 when it measured 4 cm in length by 5 cm in width by 0.1 cm in depth.); -No undermining or tunneling; -Wound bed color- pink and red; -Granulation 100%; -Amount of drainage: small, less than 25% -Type of drainage: serosanguinous; -No odor; -Wound edges- macerated and red; -Periwound tissue: macerated, redness; -No pain related to wound. Review of the resident's weekly wound assessment, dated 08/16/24 at 1:14 P.M., showed RN N documented the following: -The resident had a pressure ulcer on his/her left buttock that was present on admission to the facility; -He/She classified the wound as a suspected deep tissue injury (DTI); -The pressure ulcer measured 5.5 cm in length by 4.0 cm in width and 0.1 cm in depth. (The size of the pressure ulcer stayed the same from the previous assessment on 08/06/24); -No undermining or tunneling; -Wound bed color- red and black, (unchanged from staff assessment on 08/06/24); -Necrosis 100% (unchanged from staff assessment on 08/06/24); -Amount of drainage-none; -No odor; -Wound edges- red; -Periwound tissue macerated, redness; -No pain related to wound. Review of the resident's progress notes, dated 08/19/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's Physician's Orders, dated 8/20/24, showed a new order to cleanse the resident's bilateral buttocks with cleanser, pat dry and apply calcium alginate (a type of dressing that accelerates wound healing) to affected areas, then cover with sacral silicone border foam dressing (an absorbent dressing) daily and as needed for soiling/dislodgement until healed. Review of the resident's progress notes, dated 08/21/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's weekly wound assessment, dated 08/23/24 at 9:53 P.M., showed RN N documented the following: -The resident had an unstageable pressure ulcer on his/her bilateral buttocks that was present on admission to the facility; -The pressure ulcer measured 6.4 cm by 5.4 cm by 0.1 cm; -No undermining or tunneling; -Wound bed color pink and red; -Granulation 100%. (RN N identified the unstageable pressure ulcer had 100% granulation tissue, however, an unstageable pressure ulcer is identified as a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. RN N did not identify any slough or eschar on the skin assessment.) -Amount of drainage: moderate, 25 to 75 percent; -Type of drainage: serosanguinous; -No odor; -Wound edges macerated and red; -Periwound tissue macerated, redness; -No pain related to wound; -Wound healing progression- worsened. Review of the resident's medical record showed no documentation staff notified the resident's physician or primary care NP of the worsening condition of the resident's pressure ulcer on 8/23/24. Review of the resident's progress notes, dated 08/25/24 at 3:43 P.M., showed facility staff documented the resident's left foot was red and warm to touch and he/she was lethargic (sleepy) and hard to arouse. The resident was discharged from the facility to the hospital where he/she was admitted . Review of the resident's hospital records, dated 08/27/24 (four days after the facility's weekly wound assessment completed on 8/23/24), showed the hospital skin care team (SCT) documented the following: -Sacrum/coccyx and bilateral gluteal unstageable pressure injury measures 11.5 cm by 14.5 cm. (a worsening in measurements from 6.4 by 5.4 cm by the facility). This large wound bed covers the sacrum, coccyx and extends on both the right and left gluteal with greater than 50% of the wound bed covered in adherent yellow-black slough (a specific type of nonviable tissue that occurs as a byproduct of the inflammatory process, it can delay healing and increase the risk of infection). Additionally, there is incontinence associated dermatitis (skin inflammation) noted to the periwound, with generalized bright red erythema with partial thickness skin loss and small areas of erosion; -Recommendations: consult a surgical team to evaluate for debridement (a surgical procedure by which dead skin tissue is removed). Review of the resident's hospital records, dated 08/28/24, showed the SCT documented the resident's sacrum and coccygeal stage IV pressure injury, post-debridement. ACS debrided some of the eschar (dead tissue that forms over healthy skin) and slough today noting this is a stage IV as this probes to bone. During an interview on 10/04/24 at 2:00 P.M., RN N/Wound Nurse said the following: -He/She was the wound care nurse for the facility; -He/She received wound care training from a wound care certified nurse practitioner (NP) who previously cared for the resident at the facility; -He/She was not wound care certified; -The resident's primary care nurse practitioner (NP) oversaw the resident's pressure ulcers after the wound care certified NP left a couple of months ago; -RN N saw the resident and provided wound care to him/her daily and as needed; -The primary care NP did not always see the resident's wounds with RN N, but RN N was always in communication with the primary care NP, either while the NP was in the building making rounds on residents or by phone, about how the wounds were looking and what treatment changes might need to be made. (Review of the resident's medical record showed no documentation of the communication between RN N and the primary care NP); -He/She documented his/her findings on the weekly skin assessment flow sheet and in the nurses' progress notes if he/she needed to; -He/She completed skin assessments weekly unless there was a change in the wound; -If a wound was not improving or worsened, he/she notified the primary care NP. Sometimes he/she spoke to the NP when the NP was making rounds at the facility or he/she could always call the NP; -The resident sometimes refused wound care and to turn; -If a resident refused care, staff should document that in the progress notes. He/She wasn't sure why that had not been documented. (Review of the resident's progress notes showed no evidence the resident refused care.) -He/She did not exactly recall how the resident's pressure ulcers looked on 08/20/24 when the wound care orders were changed to a calcium alginate product for the buttocks, but he/she would have gotten the wound care order from the primary care NP; -His/Her last assessment of the resident's pressure ulcers was on 08/23/24, two days prior to the resident being discharged to the hospital; -He/She could not recall how the resident's pressure ulcers looked on 08/23/24, but remembered the buttocks did not have any depth, and that he/she was still comfortable with the current treatment orders. During an interview on 10/08/24 at 11:00, the primary care NP said the following: -She was not wound care certified; -She oversaw wound care for her residents after the previous wound certified NP left the facility, about two months ago; -She did not make rounds with RN N, who was the wound care nurse, but she was in contact with RN N as she was in the facility at least one to two times each week seeing other residents; -The resident had been in and out of the facility for hospital admissions and had been seen by other specialists while hospitalized and on an outpatient basis; -She thought the resident's pressure ulcers were managed by other specialists, to include infectious disease (ID), vascular (blood flow specialists) and orthopedics (bone specialists), so she would typically not change any wound care orders. (Review of the resident's progress and consultation notes showed no documentation that other medical specialists who saw the resident, including vascular and orthopedics, evaluated or ordered treatment specific to the resident's buttocks/sacral wounds.); -She thought she last saw the resident's pressure ulcers after the resident's vascular appointment, maybe in July; -If the wound nurse did not communicate any concerns about the resident's pressure ulcers not improving or worsening, she would not have changed any orders; -She may have given the order to change the wound treatment for the buttocks to a calcium alginate product on 08/20/24. She was not sure and could not recall what changes had been reported to prompt the new orders. (Review of the resident's progress notes showed no documentation regarding the condition of the resident's pressure ulcers on 08/20/24 or evidence staff notified the NP regarding the resident's pressure ulcers on this date.); -She thought she remembered staff said they were not going to use a low-air loss mattress when the resident returned to the facility on [DATE] because therapy wanted to still work on transfers with the slide board; -Not using a low-air loss mattress could have contributed to worsening of the resident's wounds, however, the resident had several other medical issues that likely also contributed to her lack of wound healing or wound deterioration; -She could not speak to the discrepancy of the pressure ulcer assessment by the wound care nurse in the facility on 08/23/24 to the hospital assessment of the pressure ulcer on 08/27/24 which determined the resident had a stage IV sacral pressure ulcer; -She expected nursing staff to follow the facility policy for wound care; -She expected nursing staff to document wound care, verbal orders, or other communications about the resident with the primary care team (physician/NP) in the progress notes. During an interview on 10/08/24 at 4:15 P.M., the Director of Nurses (DON) said the following: -The facility's wound nurse was trained by the previous certified wound care NP who was no longer at the facility; -The primary care NP oversaw the residents with wounds while the facility looked for a new wound care provider; -The primary care NP was in communication with the wound care nurse at least one to two times weekly as the NP was in the building making rounds on her residents; -He was not sure if the primary care NP saw Resident #333's pressure ulcers when she was in the facility; -He was aware therapy was still working on slide board transfers when the resident was readmitted on [DATE] and that the low-air loss mattress, as ordered on hospital discharge, was not obtained at that time, and that the resident's PCP was also aware; -He was not aware the pressure ulcers on the resident's buttocks had worsened from 08/05/24 through 08/25/24; -He was unable to speak to the discrepancies and worsening of the pressure ulcer on the resident's buttocks from the wound nurse's weekly skin assessment on 08/23/24 to the resident's hospital evaluation of the pressure ulcer on 08/27/24 which showed a stage IV sacral pressure ulcer; -If he had known the pressure ulcer had gotten so bad, they would have done things differently such as stopping the slide board transfers and started using a low-air loss mattress; -He expected nursing staff to follow facility policy for wound care; -He expected the wound care nurse to report and document any changes of a resident's pressure ulcers and any communication or new orders about wound care with the primary care NP or physician in the progress notes; -He expected the wound care nurse to report any changes or worsening of a resident's pressure ulcers to the DON and document those changes and communication in the progress notes. During an interview on 10/08/24 at 5:00 PM, the Administrator said the following: -She expected nursing staff, including the wound care nurse, to report changes or worsening of a resident's pressure ulcers to the DON and the PCP; -She expected nursing staff, including the wound care nurse, to document any chan

Based on observation, interview and record review, the facility failed to ensure staff safely transferred two residents (Residents #133 and #21), in a review of 22 sampled residents and one additional resident (Resident #30), who required assistance with transfers. Staff failed to utilize proper transfer technique when transferring Resident #133, when staff did not use a gait belt and did not ensure the resident wore proper foot wear during a transfer which resulted in a fall with injury. The resident sustained a displaced fracture of the tibia/fibula (ankle) as a result of the fall. The facility census was 84. Review of the facility policy, Managing Falls and Fall Risk, revised [DATE], showed the following: -Based on previous evaluations 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 Minimum Data Set (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 (e.g., a resident pushes another resident). An episode were 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. -Environment factors that contribute to the risk of falls include: wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs, and footwear that is unsafe or absent. Review of the facility's policy, Safe Lifting and Movement of Residents, revised [DATE], showed the following: -In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: resident's preferences for assistance; resident's mobility (degree of dependency); resident's size; weight-bearing ability; cognitive status; whether the resident is usually cooperative with staff; the resident's goals for rehabilitation, including restoring or maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #133's discharge Minimum Data Set (MDS), a federally mandated assessment to be completed by a previous facility, dated [DATE], showed the following: -His/Her cognition was intact; -The resident required partial to moderate assistance (helper provided less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), with position changes from sitting to standing and transferring from chair to chair and/or chair to bed; -The resident required supervision/touch assistance with toilet transfers; -The resident required supervision or touch assistance with walking ten feet. Review of the resident's undated discharge documents from a previous facility showed the following: -The resident weighed 415 pounds; -The resident could ambulate and transfer to the toilet. Review of the resident's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's physician's orders, dated [DATE], showed the resident used a walker and wheelchair. Review of the resident's admission fall assessment, dated [DATE], showed the following: -He/She was at risk for falls; -He/She was not steady and only able to stabilize with physical assistance while standing, sitting, and during transfers. Review of the resident's care plan, initiated on [DATE], showed the following: -The resident had an activity of daily living (ADL) self-care performance deficit related to limited mobility; -The resident required substantial/maximum assist with transfers. -The resident was at high risk for falls related to deconditioning; -Ensure the resident wore appropriate footwear (non-skid socks) when ambulating. Observation on [DATE] at 6:25 A.M. showed the following: -The resident requested to use the bedside commode; -Certified Nursing Assistant (CNA) M assisted the resident to prepare for the transfer from the bed to the bedside commode; -The resident did not wear socks or shoes. CNA M did not assist the resident to put on proper footwear prior to the transfer; -CNA M did not put a gait belt on the resident. The resident held onto his/her walker and stood while CNA M provided stand-by assistance. The resident said the floor was wet. The resident's left foot began to slide. The resident told CNA M to place his/her foot next to his/her (the resident's) left foot to prevent it from sliding. CNA M placed his/her foot next to the resident's foot and the resident started to pivot to the bedside commode. As the resident pivoted, his/her right foot slid, and he/she said he/she was going to fall. CNA M attempted to assist the resident to the floor by attempting to hold onto the resident's arm, but the resident fell to the floor. During an interview on [DATE] at 8:25 A.M., the resident said the following: -He/She stood up and his/her right knee buckled which caused his/her left leg/foot to slide; -Staff never used a gait belt on him/her; -His/Her feet were too swollen for socks and his/her slippers were too big for him/her to wear so he/she did not wear footwear. During an interview on [DATE] at 4:10 P.M., CNA M said the following: -He/She did not use a gait belt when transferring this resident because the resident had told him/her (in the past) that he/she could transfer by himself/herself; -During the transfer, the resident said there was water on the floor, but the floor was usually shiny and cold. He/She did not see anything wet on the floor prior to the transfer. If he/she had noted the floor was wet, he/she would not have transferred the resident; -He/She worked with the resident a couple of times and was directed (did not specify who provided this direction) that the resident required stand by assist with transfers; -The resident had never had any problems with previous transfers; -He/She should have assisted the resident to sit down and asked for assistance when the resident asked him/her to place his/her foot next to the resident's foot to prevent it from sliding. Review of the resident's nursing progress note, completed by Registered Nurse (RN) H, dated [DATE] at 7:15 A.M., showed the following: -The resident had a witnessed fall during a pivot transfer with one assist; -Assessment completed and x-ray of the right ankle/foot ordered. Review of the resident's right ankle x-ray report, dated [DATE], showed an acute displaced fracture of the tibia/fibula (ankle). During an interview on [DATE] at 7:00 A.M., the Assistant Director of Nursing (ADON) said the resident normally required a one person stand/pivot transfer. During an interview on [DATE] at 3:25 P.M., RN H said the resident may only require standby assistance if he/she was having a good day, but staff should always use a gait belt when transferring the resident. During an interview on [DATE] at 3:40 P.M., the Director of Nursing (DON) said the following: -The resident transferred to the facility from another facility; -The discharging facility's staff, who transported the resident to the facility, demonstrated how the resident transferred which was one person pivot transfer with a gait belt; -He expected staff to use a gait belt with transfers; -When the resident said the floor was wet and was sliding, the CNA should have stopped the transfer, sat the resident down, and assessed the situation; -The CNA should not have used his/her foot as a wedge for the resident's foot during the transfer. 2. Review of Resident #30's care plan, dated [DATE], showed the following: -The resident had an activity of daily living (ADL) self-care deficit performance deficit related to weakness; -Staff were to transfer the resident with a mechanical lift; -The resident was a risk for falls related to gait/balance problems. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Upper and lower extremity impairment on one side; -Required partial to moderate assistance chair/bed-to-chair transfers; -Medical diagnoses included stroke. During an interview on [DATE] at 4:10 P.M., the resident said the following: -He/She had a stroke that left his/her left side weak, so it was hard for him/her to get out of bed without help; -Usually just one staff helped him/her to get out of bed; -Sometimes the staff used a gait belt when they helped him/her up, but not always; -He/She did not always feel steady on his/her feet when he/she was up. Observation on [DATE] at 4:20 P.M. showed the following: -The resident lay in bed and was barefoot; -CNA C did not put a gait belt on the resident; -CNA C assisted the resident to sit on the side of the bed, then assisted the resident to stand at the bedside by lifting up under the resident's left arm/underarm area; -The resident held onto the walker with his/her right hand while he/she attempted to steady himself/herself to stand; -The resident tottered to his/her left side briefly while standing; -CNA C steadied the resident by holding onto the resident's left arm; -The resident put his/her left hand onto the walker and used both hands to hold on and steady himself/herself as he/she stood at the walker. During an interview on [DATE] at 5:00 P.M., the resident said the following: -He/She felt very unsteady when CNA C helped him/her up earlier and did not use a gait belt; -He/She was afraid of falling. During an interview on [DATE] at 9:05 A.M., CNA C said the following: -The resident required stand-by assistance from one staff for transfers; -He/She didn't use a gait belt because the resident usually did pretty well with transfers; -He/She did not realize the resident was barefoot. The resident probably should have worn gripper socks. During an interview on [DATE] at 3:00 P.M., the Restorative Nurse Aide (RNA) said the following: -The resident was on restorative therapy and transferred with assistance from one staff; -He/She was not sure why the care plan indicated the resident needed a mechanical lift; -Staff should always use a gait belt for all transfers. 3. Review of Resident #21's face sheet showed the resident's diagnoses included hemiplegia and hemiparesis (weakness on one side of the body) following a stroke, affecting the left non dominant side, morbid obesity, unsteadiness on feet, cognitive communication deficit, difficulty walking and need for assistance with personal care. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -The resident had limited range of motion on one side of his/her upper body and lower body; -The resident required partial assistance from bed to chair transfer and for sit to stand assistance. Review of the resident's visual bedside Kardex report (a facility document that directed staff how to care for a resident) showed the following: -Mobility: The resident was weight bearing; -Transfer: Maximum one staff assist; -Dressing: The resident required extensive assistance; -No documentation of gait belt use. Observation on [DATE] at 12:33 P.M., showed the following: -A gait belt hung on the towel rack in the resident's room; -CNA C assisted the resident to sit on the side of his/her bed; -CNA C did not put a gait belt around the resident; -CNA C placed his/her left arm under the resident's right arm, placed his/her right hand around the resident's waist, and assisted the resident to a standing position. CNA C then pivoted the resident and assisted the resident to sit in a wheelchair; -The resident was able to stand briefly for the transfer. During an interview on [DATE] at 12:40 P.M., CNA C said the resident required one staff to help him/her stand and pivot to his/her wheelchair. Staff did not use a gait belt to assist the resident with his/her transfers. The resident did not like the staff to use a gait belt during his/her transfers. During an interview on [DATE] at 9:06 A.M., Licensed Practical Nurse (LPN) C said the resident was able to stand to transfer. Staff should use a gait belt when helping with transfers. During an interview on [DATE] at 2:34 P.M., the Director of Rehabilitation said the resident had a stroke and had improved with therapy. He/She required one staff to help him/her stand and pivot to his/her wheelchair. Staff had been educated to use a gait belt when doing a one person transfer with the resident. No one had ever mentioned the resident refused the use of a gait belt during transfers. 4. During an interview on [DATE] at 6:00 P.M., the DON said he expected staff to use gait belts with all stand by transfers. During an interview on [DATE] at 6:05 P.M., the Administrator said she expected staff to use gait belts with all stand by transfers. 47246

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served to residents in a safe and sanitary manner when staff failed to utilize proper hand hygiene and gloving techniques, hair restraint usage, surface sanitation, food storage, and dish handling and storage. The facility census was 84. 1. Review of the facility policy, Food Preparation and Service, revised ,d+[DATE], showed the following: -Food and nutrition services employees will prepare and serve food in a manner that complies with safe food handling practices; -Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays; -Gloves are worn when handling food directly and changed between tasks. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised ,d+[DATE], showed the following: -Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Employees must wash their hands: -After personal body functions (i.e. toileting, blowing/wiping nose, coughing, sneezing); -Whenever entering or re-entering the kitchen; -Before coming in contact with any food surfaces; -After handling raw meat, poultry or fish; -When switching between working with raw food and working with ready-to-eat food; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -After engaging in other activities that contaminate the hands; -Food services employees will be trained in the proper use of utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent foodborne illness; -Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. Observation on [DATE] at 11:07 A.M., in the kitchen, showed the following: -The Dietary Manager put on gloves, separated frozen raw beef patties with her gloved hands, and laid the raw patties out on a pan; -Without changing her gloves or washing her hands, she used her gloved hands to pick up lids (grasping the inner and outer portions of the lids) for three pitchers that were full of beverages and placed the lids onto the beverage pitchers; -She used her same gloved hands to grasp the handles of the convection oven, put food items in the oven, closed the oven door, and touched the handle of a food thermometer. Observation on [DATE] at 11:07 A.M., in the kitchen, showed the Dietary Manager picked up two small bowls by extending her bare fingers inside the bowls and touched the eating surface of the bowls. She then served soup into the bowls for residents at the lunch meal service. Observation on [DATE] at 11:29 A.M., in the kitchen, showed the following: -Cook I used his/her gloved hands to grasp the handle of a spoon to stir a food item on the stove; -Without washing his/her hands or changing his/her gloves, he/she used his/her same gloved hands to grasp the inner eating surface of a bowl and moved the bowl to the food preparation counter; -He/She used his/her same gloved hands to open the reach-in cooler door and obtained bags of shredded lettuce and cheese; -He/She moved the bowl (that sat on the preparation counter) with one gloved finger inside the bowl and used his/her gloved fingers to reach into the bags of lettuce and cheese and place the food items into the bowl. Observation on [DATE] at 11:39 A.M., in the kitchen, showed the following: -Dietary Aide J used his/her gloved hands to grasp the handle of and open the reach-in cooler; -He/She obtained a jug of milk from the cooler and picked up a cup with his/her gloved finger located on the inside drinking surface of the cup; -He/She poured milk into the cup and placed it on a tray with other cups of beverages being prepared for the lunch meal service. Observation on [DATE], from 12:19 P.M. to 1:15 P.M., in the kitchen, showed the following: -Cook I served residents' meals at the steam table during the lunch meal service; -He/She used his/her gloved hands to grasp the handles of serving utensils to serve food, opened the reach-in cooler to obtain food items, and used potholders to obtain plate warmers from the oven; -Without washing his/her hands or changing his/her gloves, he/she grasped chips, buns, and sliced cheese with his/her gloved hands and placed the items onto a resident's plate. Observation on [DATE], from 7:37 A.M. to 7:58 A.M., in the kitchen, showed the following: -Cook L served residents' meals at the steam table during the breakfast meal service; -He/She used his/her gloved hands to grasp the handles of serving utensils to serve food, opened the reach-in cooler to obtain food items, and touched meal tickets; -Without washing his/her hands, he/she changed his/her gloves and grasped hard boiled eggs and toast with his/her gloved hands and placed the items onto residents' plates. Observation on [DATE] at 7:49 A.M., in the kitchen, showed the following: -The Dietary Manager used his/her gloved hands to place pieces of bread in the toaster, turned on the toaster, touched her clothing, touched the handle of a cart, and left the kitchen through the dining room/kitchen door; -She re-entered the kitchen, and without washing his/her hands or changing his/her gloves, used his/her gloved hands to take the toast from the toaster to serve during the breakfast meal service. During an interview on [DATE] at 11:48 A.M., the Dietary Manager said the following: -Staff should wash their hands anytime they leave the kitchen, prior to touching food items, after switching tasks, after changing gloves, and after completing dirty tasks or touching dirty items; -Staff changing their gloves was not a substitute for washing their hands; -Staff should not use soiled gloves to touch ready-to-eat food items; -Staff should handle bowls, cups, pitchers, and other dishes by the non-eating surfaces of those items. 2. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised ,d+[DATE], showed hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Observation on [DATE] at 11:02 A.M., showed [NAME] I prepared pureed food items at the food preparation counter in the kitchen. He/She wore a hair restraint but his/her hair was not completely contained within the hair restraint and several strands of hair, measuring approximately six inches in length, were exposed. Observation on [DATE] at 11:07 A.M., in the kitchen, showed the Dietary Manager placed frozen beef patties onto a pan for the lunch meal service. Approximately 25% of her hair was exposed and not contained within a hair restraint. During an interview on [DATE] at 11:48 A.M., the Dietary Manager said staff should properly wear hair restraints that fully covered their hair. 3. Review of the facility policy, Food Preparation and Service, revised ,d+[DATE], showed appropriate measures used to prevent cross contamination included the following: -Sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution; -Cleaning and sanitizing work surfaces and food-contact equipment between uses. Observation on [DATE] at 10:51 A.M., in the kitchen, showed the following: -A moist white cloth, soiled across 50% of the cloth's surface, sat on the counter by the microwave; -The cloth was not submerged in sanitizing solution. Observation on [DATE], from 12:02 P.M. to 12:17 P.M., in the kitchen, showed the following: -The Dietary Manager obtained a bag of hot dogs from the reach-in cooler and spilled liquid from the bag onto the preparation counter; -She used a dry cloth to wipe up the spill from the counter; -Without placing the dry cloth in sanitizing solution, she wiped another spill located on another preparation counter, placed the cloth on the counter, and left the area; -She returned to the area, picked up the soiled cloth and used it to wipe a three-tiered plastic cart located by the three-compartment sink and placed the cloth in the bucket of sanitizing solution in the sink with approximately 25% of the cloth not submerged in the sanitizing solution; -The Dietary Manager left the area then returned and obtained the cloth from the sanitizing solution; -She wiped a preparation counter with the cloth, left the cloth on the counter, and left the area. Observation on [DATE] at 11:27 A.M., in the kitchen, showed a moist white cloth hung on the edge of a sanitizing solution bucket located in the three-compartment sink. Approximately 75% of the cloth was not submerged in the sanitizing solution. During an interview, on [DATE] at 11:48 A.M., the Dietary Manager said the following: -Staff should properly sanitize cleaning cloths that have been used to wipe up spills, such as meat juices, prior to wiping other surfaces; -Sanitizing cloths should be stored fully submerged in sanitizing solution between uses. 4. Review of the facility policy, Food Receiving and Storage, revised ,d+[DATE], showed all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Review of the facility policy, Refrigerators and Freezers, revised ,d+[DATE], showed the following: -This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines; -All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened; -Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Observation of the chart, Labeling and Dating System Protocol, revised [DATE], posted on the reach-in freezer in the kitchen, showed the following: -Follow manufacturer's expiration date on all unopened or opened product. If there is no printed manufacturer's date on the product, follow below dating protocol: -Hard boiled eggs: three days; -All fresh and frozen foods must be dated with the date it was received into the kitchen. Observation of the Cold Storage Chart, revised ,d+[DATE], posted on the reach-in freezer in the kitchen, showed fully cooked ham slices could be stored in the freezer (0 degrees Fahrenheit) for one to two months. Observation on [DATE] at 9:04 A.M., in the reach-in coolers and freezer, showed the following: -An opened 10-pound box of frozen ground beef patties did not have the inner plastic sealed and the patties were exposed to air; -An opened 15-pound box of bacon did not have the inner plastic sealed and the bacon was exposed to air; -An opened 16-ounce stick of butter was not securely sealed and was exposed to the air; -A clear drink pitcher with a green lid contained a red liquid and was not labeled or dated; -A gallon zipper top bag of four hard boiled eggs was labeled with a marker and read 'Eggs ,d+[DATE];' -A small fluted bowl of pears and a small fluted bowl of chocolate pudding were undated; -Ten cups of white milk and two cups of chocolate milk, located on a tray, were undated. Observation on [DATE] at 9:10 A.M., in the kitchen on a three-tiered wire cart, showed an opened bag of bread, containing approximately ten slices. The bag was loosely folded over and not securely sealed. Observation on [DATE] at 9:12 A.M., in the dry storage room adjacent to the kitchen, showed a zipper-top bag contained a 2-pound open bag of powdered sugar and was not closed or securely sealed. The lid on an opened, 10-pound box of dry lasagna noodles was loosely closed and was not securely sealed. Observation on [DATE] at 9:23 A.M., on a three-tiered plastic cart by a small reach-in cooler in the kitchen, showed an open bag of potato chips, an open bag of hamburger buns and an open bag of sliced bread. The bags were loosely folded over and were not securely sealed. Observation on [DATE] at 9:26 A.M., in the dry storage room located near the kitchen, showed the following: -Three opened, approximately half-full 16-ounce bottles of snow cone syrup sat on the shelf unrefrigerated. The labels on the bottles read 'Refrigerate After Opening;' -In the reach-in freezer, a zipper-top gallon bag of sliced ham had an excess accumulation of ice crystals and had a handwritten marker date of ,d+[DATE]. One large open bag of mixed vegetables and one large open bag of broccoli was not sealed and was open to the air. Observation on [DATE] at 7:17 A.M., in the kitchen on a three-tiered plastic cart, showed two opened bags of chips had their tops loosely folded over and were not securely sealed. During an interview, on [DATE] at 11:48 A.M., the Dietary Manager said the following: -Opened food items should be properly sealed, labeled, dated, and stored per the manufacturer's instructions; -Staff should refer to the chart posted on the reach-in freezer for guidance on how long to store and when to dispose of food items. 5. Observation on [DATE] at 9:23 AM, in the kitchen showed the clean dishes cart, located between the small and large reach-in coolers, contained dishes that were not inverted or covered. The top plate, in a stack of approximately 15 plates, had bits of brown-colored dried debris on the surface. Observation on [DATE] at 10:51 AM, in the kitchen, showed the following: -One red and one clear beverage pitcher sat in a two-compartment sink near the steam table. The interior surface of the red picture was scratched across 75% of the surface and the clear pitcher had an approximate 0.25-inch by 2-inch chip out of the rim near the pour spout; -On a three-tiered metal cart, located behind the reach-in cooler by the three-compartment sink, showed several non-inverted plastic containers. Three of the containers were damaged and not smooth across approximately 50% of the interior surface. Observation on [DATE] at 11:57 A.M., in the kitchen, showed the following: -Cook I obtained a metal mesh screen colander and placed it over the two-compartment sink; -The colander was discolored brown across 50% of the screen' s surface; -He/She strained the juice from cooked carrots through the colander. Observation on [DATE] at 11:29 A.M., in the kitchen, showed a clear plastic bowl with visible water droplets on the interior surface of the bowl, was stacked inside another bowl on a three-tiered metal cart located behind the reach-in cooler and the three-compartment sink. During an interview on [DATE] at 11:48 A.M., the Dietary Manager said dishes should be stored clean, dry, inverted, and be in good condition.

Based on observation, interview, and record review, the facility failed to provide care to prevent the development and transmission of diseases and infections for four residents (Residents #21, #40, #283, and #31), in a review of 22 sampled residents, and four additional residents (Resident #71, #38. #79 and #50). Staff failed to perform appropriate hand hygiene during personal care for Residents #21 and #71; failed to utilize Enhanced Barrier Precautions (EBP) during personal care for Resident #71 who had a gastrostomy tube (a flexible tube that is surgically inserted through the abdominal wall and into the stomach that allows for the delivery of nutrition and medication directly into the stomach); failed to ensure Resident #40's urinary catheter (tube inserted into the bladder to excrete urine from the body) drainage bag was stored off the floor; failed to ensure Resident #283's wound vac (a treatment device that uses pressure to help close wounds and increase healing) was kept up off the floor while in use; and failed to ensure staff used proper technique and hand hygiene during a medication pass for Residents #31, #38, #79 and #50. The facility census was 84. Review of the facility's handwashing/hand hygiene policy, dated August 2019, showed the following: -All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: -Before and after direct contact with residents; -Before preparing or handling medications; -Before handling clean or soiled dressings, gauze pads, etc; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc; -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace handwashing/hand hygiene.; -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's undated guidance on Enhanced Barrier Precautions (EBP) showed the following: -EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities; -EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing; -EBP are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies; -For residents for whom EBPs are indicated, EBP is employed when performing the following high-contact resident care activities including dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care and wound care. Review of the facility policy, Urinary Catheter Care, dated September 2014, showed the following: -The purpose was to prevent catheter-associated urinary tract infections; -Keep the urinary catheter tubing and drainage bag off the floor. 1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/23/24, showed the following: -The resident was incontinent of bowel and bladder; -The resident required substantial assistance for toileting hygiene; -The resident required moderate assistance for personal hygiene. Review of the resident's visual bedside Kardex report (a facility document instructing staff how to care for the resident) showed the following: -Toileting: Clean peri-area with each incontinence episode; -Personal Hygiene: The resident required extensive assistance; -Dressing: The resident required extensive assistance. Observation on 09/30/24 at 12:29 P.M., showed the following: -Certified Nurse Assistant (CNA) C cleaned the resident's perineal area using a wet wipe, removed his/her gloves and washed his/her hands; -With his/her bare hands, CNA C folded up a urine soaked disposable pad from under the resident and placed it in a plastic bag; -CNA C did not wash his/her hands with soap and water and did not use hand sanitizer after handling the urine soiled pad; -CNA C grabbed the handles of the resident's wheelchair to reposition the wheelchair in the resident's room, cleaned the resident's glasses and put them on the resident's face, and brushed the resident's hair with soiled hands; -CNA C washed his/her hands before leaving the resident's room; -CNA C held onto the soiled handles of the wheelchair and pushed the resident out of his/her room to the dining room. During an interview on 10/03/24 at 2:45 P.M., CNA C said he/she should not have touched soiled linens with his/her bare hands. After he/she touched the dirty linens, he/she should have washed his/her hands with soap and water before touching any other items with his/her dirty hands. During an interview on 10/03/24 at 9:20 A.M., the Infection Preventionist (IP) said staff should wash their hands with soap and water before entering a resident's room, before putting on gloves, in between cares and when leaving a resident's room. Staff should not touch any items that have urine on them with their bare hands. During an interview on 10/09/24 at 9:41 A.M., the Director of Nursing (DON) said he expected staff to wear gloves if they touched any items that were soiled with urine. Staff should wash their hands with soap and water after touching an item that was soiled with urine. During an interview on 10/09/24 at 10:00 A.M., the Administrator said staff should not touch any soiled items with their bare hands. If a staff member used their bare hands to pick up a soiled item, they should wash their hands with soap and water. 2. Review of Resident's #71's quarterly MDS, dated [DATE], showed the following: -Always incontinent of bowel and bladder; -Dependent on staff for personal hygiene; -Maximum assistance to roll left and right; -Resident had a gastrostomy tube (g-tube). Review of the resident's Care Plan, revised 06/18/24, showed the following: -The resident was incontinent of bowel and bladder; -Clean peri-area after each incontinence episode; -The resident received all nutrition/fluids through a g-tube; -The plan did not identify the need for or use of enhanced barrier precautions (EBP) when providing care to the resident. Review of the resident's October 2024 Physician Order Sheet (POS) showed the resident received Jevity (nutritional supplement) 1.5 cal via g-tube at 75 cc/hr (cubic centimeters per hour) for 20 hours and off for four hours. Observation on 10/1/24 at 9:40 A.M. showed the following: -EBP signage on the resident's door indicated that a gown and gloves were required in the resident's room and PPE, including gowns and gloves, were in a cart in the corner of the hallway; -The resident lay in bed and had a g-tube with Jevity running at 75 cc/hr; -Certified Nurse Assistant (CNA) C was in the resident's room. CNA C wore a mask and gloves but did not wear a gown; -CNA C unfastened the resident's urine soiled incontinence brief, pushed it down between the resident's legs, and cleaned the resident's peri area with incontinence wipes; -While wearing the same gloves, CNA C touched and moved the blanket off the resident's feet and rolled the resident to his/her right side, touching the resident's right hip, with his/her soiled gloves; The resident's upper body touched CNA C's clothing; -CNA C cleaned the resident's buttocks with incontinence wipes, pulled the incontinence brief from under the resident, and rolled the urine soiled bed pad to the right side, then rolled the resident to his/her left side and removed the bed pad; -CNA C removed his/her soiled gloves, scooped up the soiled linens using the outside of a trash bag, tied the bag and sat the bag on the floor; -CNA C washed his/her hands, left the room to get a clean bed pad and returned to the room; -CNA C donned new gloves, rolled the resident to his/her right side and placed the clean bed pad and incontinence brief under the resident, then rolled the resident to his/her left side and pulled the incontinence brief and bed pad through; -CNA C rolled the resident to his/her back, covered him/her with a blanket, elevated the head of the bed, and placed a call light in reach; -CNA C doffed his/her gloves, put the trash in the trash bag, and took the bags of trash and soiled linen to the soiled utility room. CNA C did not wash his/her hands prior to leaving the resident's room. During an interview on 10/8/24 at 3:25 P.M., CNA C said the following: -For EBP precautions, staff should put on a gown and gloves before entering a resident's room; -Staff should use proper hand hygiene, which included washing hands before gloving and after removing gloves; -Staff should put on clean gloves when going from dirty to clean objects; -Staff should remove gloves and wash hands when leaving a room; -He/She forgot to put a gown on that day (when he/she provided care to the resident) and did not perform proper hand hygiene; -The storage container for the PPE was outside the resident's room and pushed back in the corner, so it did not catch his/her attention when entering the room to provide care. During an interview on 10/03/24 at 9:20 A.M., the Infection Preventionist (IP) said she expected staff to wear gowns and gloves and use appropriate hand hygiene when providing personal cares to residents on EBP. During an interview on 10/8/24 at 6:00 P.M., the DON said he expected staff to wear gowns and gloves and use appropriate hand hygiene when providing personal cares to residents on EBP. During an interview on 10/8/24 at 6:05 P.M., the Administrator said she expected staff to wear gowns and gloves and use appropriate hand hygiene when providing personal cares to residents on EBP. 3. Review of Resident #40's Care Plan, dated 04/18/23, showed the resident had a urinary catheter (tube inserted into the bladder to drain urine) related to obstructive uropathy (condition in which the flow of urine is blocked). (The resident's care plan did not direct staff on where the catheter or catheter drainage bag should be positioned.) Review of the resident's Physician's Orders, dated October 2024, showed an order for a urinary catheter. Observation on 09/30/24 at 11:50 A.M. showed the following: -The resident lay in his/her bed which was in the lowest position; -His/Her urinary catheter drainage bag hung from the bed frame and touched the floor. Observation on 10/01/24 at 3:30 P.M. showed the following: -The resident lay in his/her bed which was in the lowest position; -His/Her urinary catheter drainage bag hung from the bed frame and touched the floor. Observation on 10/02/24 at 6:00 A.M. showed the following: -The resident lay in his/her bed which was in the lowest position; -His/Her urinary catheter drainage bag hung from the bed frame and touched the floor. Observation on 10/2/24 11:45 A.M. showed the following: -The resident lay in bed which was in the lowest position; -His/Her urinary catheter drainage bag hung from the bed frame and rested on the floor. During an interview on 10/02/24 at 1145 A.M., CNA R said the following: -Urinary catheter drainage bags should not touch the floor; -The resident's urinary catheter drainage bag should not be on the floor. The resident's bed was so low, he/she didn't know where the drainage bag should be positioned to keep it from touching the floor. During an interview on 10/02/24 at 11:50 A.M., CNA P said the following: -Urinary catheter drainage bags should not touch the floor; -He/She was not sure where to position the resident's catheter drainage bag in order to keep it off the floor because of the resident's bed was in the lowest position. Observation on 10/3/24 9:20 A.M. showed the following: -The resident lay in bed with the bed in the lowest position; -His/Her urinary catheter drainage bag hung from the bed frame and rested on the floor. During an interview on 10/08/24 at 6:00 P.M., the DON said urinary catheter drainage bags should be kept off the floor at all times to prevent infection. During an interview on 10/08/24 at 6:05 P.M., the Administrator said urinary catheter drainage bags should be kept off the floor at all times to prevent infection. 4. Review of Resident #283's admission record, dated 09/20/24, showed the resident's diagnoses included non-pressure, chronic ulcer of buttock with necrosis (tissue death) of muscle and paraplegia (paralysis of lower body). Review of the resident's Physician Orders, dated September 2024, showed an order for negative pressure therapy (wound vac; medical treatment that uses a vacuum to help wounds heal) to wound site, set unit to 125 millimeters of mercury (mmHg) (a unit used to measure pressure) continuously. Review of the resident's wound evaluation and management summary, dated 09/30/24, showed the following: -The resident had a wound on his/her sacrum (large, triangular bone at the base of the spine); -The wound was a Stage 4 pressure wound (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur.); -The wound measured 4.5 centimeters (cm) in length by 4.0 cm in width by 2.0 cm in depth; -The wound had moderate serous exudate (a clear or pale yellow, watery, thin plasma that leaks from a wound during the body's healing process) (an increase in exudate may indicate an infection); -The wound was over 97 days old; -The wound had previously undergone autolytic debridement (a natural process where the body's enzymes and cells break down dead tissue in a wound); -The wound treatment plan included negative pressure wound therapy using a pump set at 125 mmHg low continuously for 23 days. Observation on 09/30/24 at 12:11 P.M. and 3:30 P.M., showed the resident's wound vac sat on the floor next to the left side of the resident's bed. The pump was running and connected to the resident's wound site. Observation on 10/02/24 at 6:50 A.M. and 7:44 A.M., showed the resident's wound vac sat on the floor next to the left side of the resident's bed. The pump was running and connected to the resident's wound site. Observation on 10/03/24 at 8:23 A.M., showed the resident's wound vac sat on the floor next to the left side of the resident's bed. The pump was running and connected to the resident's wound site. During an interview on 10/03/24 at 9:02 A.M., the Wound Nurse said the resident's wound vac should not be on the floor. The resident had an increased risk of infection if the wound vac was on the floor. The wound vac should be on a chair beside the resident's bed. During an interview on 10/03/24 at 9:20 A.M., the IP said the wound vac should not be on the floor. The resident had an increased risk of infection if the wound vac was on the floor. The wound vac was normally attached to an intravenous (IV) pole. She did not know why the wound vac was on the floor. During an interview on 10/09/24 at 9:41 A.M., the DON said the wound vac should not be on the floor. He was not aware the wound vac was on the floor. The wound vac should be attached to an IV pole or should be on a bed side table. During an interview on 10/09/24 at 10:00 A.M., the Administrator said the wound vac should not be on the floor. The wound vac should be hung up. There were bags that attached to the back of wheelchairs which could hold the wound vac. 5. Review of Resident #38's POS for October 2024 showed an order for Timolol (medicated eye drop used to treat glaucoma) 0.5% eye drops; instill one drop in the right eye once a day. Observation on 10/02/24 at 8:15 A.M., showed the following: -Certified Medication Technician (CMT) P entered the resident's room to administer Timolol 0.5 % (medicated eye drop); -Without washing and/or sanitizing his/her hands, CMT P put on gloves, pulled down the resident's lower right eyelid, instilled one drop of the medication into the resident's eye, removed his/her gloves, and exited the room. CMT P returned to his/her medication cart, opened the medication cart, and placed the medication into the cart before sanitizing his/her hands. 6. Review of Resident #31's Physician Order Sheet (POS) for October 2024, showed an order for acidophilus lactobacillus (a probiotic that is used to help maintain the number of healthy bacteria in your stomach and intestines) oral capsule; one capsule by mouth daily. Observation on 10/02/24 at 7:50 A.M. showed CMT P removed the resident's medication cards from the medication cart, popped medications into a medicine cup, placed the medications in a small plastic bag, crushed the medications with the medication crusher, and without sanitizing and/or donning gloves, picked up the acidophilus capsule from a medication cup, opened it, placed the contents of the capsule into applesauce, and administered it to the resident. 7. Observation on 10/02/24 at 8:20 A.M., showed the following: -CMT P administered Symbicort inhaler (steroid inhaler used to treat chronic lung conditions) to Resident #79; -Without washing and/or sanitizing hands, CMT P exited Resident #79's room, returned to the medication cart, opened the cart, removed Resident #50's medications, and punched the medications into a medication cup before he/she sanitized his/her hands. During an interview on 10/02/24 at 8:30 A.M., CMT P said the following: -He/She was supposed to wash and/or sanitize his/her hands before and after administering resident's medications; -He/She should not have touched clean items with contaminated hands and/or gloves; -He/She did not wash and/or sanitize like he/she should have because he/she forgot. During an interview on 10/08/24 at 6:00 P.M., the Director of Nursing (DON) said the following: -He expected staff to perform hand hygiene before providing care, after providing care, and as needed during care; -Staff should not touch clean items with contaminated hands and/or gloves; -Staff should not touch medications with their bare hands. During an interview on 10/08/24 at 6:05 P.M., the Administrator said the following: -She expected staff to perform hand hygiene before care, after care, and as needed during care; -Staff should not touch clean items with contaminated hands and/or gloves; -Staff should not touch medications with their bare hands. 47008 47246 49528

Based on observation, interview, and record review, the facility failed to provide oral hygiene for two residents (Residents #41 and #48), who required assistance with oral care, in a review of 22 sampled residents. The facility census was 84. Review of the facility's policy, Mouth Care, revised February 2018, showed the following: -Purpose of the procedure was to keep the resident's lips and oral tissues moist, to cleanses and freshen the mouth, and to prevent oral infection; -The following should be documented in the resident's medical record; -1. The date and time the mouth care was provided along with the name and title of the individual who provided the mouth care; -2. Complaints of pain or discomfort of the mouth; -3. If the resident refused the treatment, the reason why, and the intervention taken; -4. The signature and title of the person recording the data. (The facility policy did not direct staff on how often they should provide oral care.) 1. Review of Resident #41's undated medical diagnosis record showed his/her diagnoses included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's Care Plan, dated 10/05/23, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to impaired mobility; -The resident required extensive assistance with personal/oral hygiene (initiated on 06/16/24). (The resident's care plan did not provide any specific instructions related to personal/oral hygiene care and did not identify the resident had natural teeth and dentures.) Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/15/24, showed the following: -Moderate cognitive impairment; -Did not refuse care; -Required supervision or touching assistance for oral hygiene; -Required partial/moderate assistance for mobility; -Obvious or likely cavities or broken natural teeth. During an interview on 10/01/24 at 9:15 A.M., the resident said the following: -He/She did not get his/her teeth brushed regularly; -He/She could not remember when his/her teeth were brushed last; -He/She had upper dentures and did not remember when or if they had ever been soaked or cleaned; -He/She needed help to brush his/her teeth and to clean/soak his/her upper denture; -The staff did not assist him/her with oral care; -He/She did not think the staff knew he/she even had upper dentures; -Not getting his/her teeth brushed or cleaned made him/her feel dirty. Observation on 10/01/24 at 9:25 A.M. showed the following: -The resident had yellow colored tartar (a hardened, discolored build-up of plaque, formed when the natural occurring bacteria in the mouth mixes with food particles to form a sticky, adherent film) along the front of his/her bottom natural teeth and had food debris along the lower gum line; -The resident had upper dentures in his/her mouth and had food debris along the center top of the denture plate; -The resident had a toothbrush (sealed in unopened plastic wrap) and a new tube of toothpaste (the tube was intact and had never been squeezed; the top opening had not toothpaste on it) in a clean, pink emesis basin on his/her nightstand; -The resident did not have a denture cup in his/her room. During an interview on 10/02/24 at 6:10 A.M., the resident said the following: -The night shift staff got him/her up and out of bed to go to the dining room this morning; -The staff did not offer oral care, but just got him/her dressed to go to the dining room for breakfast; -He/She would have liked to have his/her teeth brushed and his/her upper denture cleaned. Observation on 10/03/24 at 9:20 A.M. showed the following: -The resident had yellow colored tartar build-up along the front of his/her bottom natural teeth and had food debris along his/her lower gum line; -The resident had upper dentures in his/her mouth and had food debris along the top of the denture plate; -The unopened toothbrush and new tube of toothpaste sat in a clean, pink emesis basin on his/her nightstand; -The resident did not have a denture cup in his/her room. During an interview on 10/03/24 at 9:20 A.M., Certified Nurse Assistant (CNA) S said the following: -It was the responsibility of either the night shift or day shift staff, whoever got the resident up first in the morning, to offer oral care to a resident. Staff were also to offer oral care after meals or when the resident requested; -He/She had provided care to the resident in the past, but not this morning; -He/She did not think the resident had dentures; -He/She was not sure why the resident's toothbrush and toothpaste had not been opened; -If a CNA needed to know about the resident's oral care routine, he/she could look at the resident's care plan or ask the charge nurse. Observation on 10/03/24 at 9:30 A.M. showed the following: -The resident removed his/her top denture and showed it to CNA S; -There was food debris stuck along the inside of the upper denture; -The resident showed CNA S his/her bottom teeth; -CNA S could not locate a denture cup in the room that had been used for the resident. During an interview on 10/03/24 at 9:32 A.M., CNA S said the following: -It did not appear the resident had been receiving routine oral care by the way the resident's mouth/teeth looked; -He/She was not sure why the resident did not have a denture cup, but he/she did not realize the resident had an upper denture; -It was important to offer oral care to the residents to help them feel good and to prevent the development or worsening decay of the teeth. 2. Review of Resident #48's admission diagnoses dated 07/21/23, included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). Review of the resident's Care Plan, initiated on 08/10/23, showed the following: -He/She had oral/dental health problems related to poor dentition; -He/She had an ADL self-care performance deficit related to impaired mobility; -He/She was dependent on staff for performance of personal hygiene, including oral care. Review of the resident's annual MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She had obvious broken natural teeth and/or cavities; -He/She required substantial/maximum assistance with oral hygiene. Review of the resident's Kardex, dated 10/03/24, showed he/she was dependent on staff for personal hygiene. (The Kardex did not specifically address the resident's oral hygiene needs.) Observation on 10/01/24 at 3:10 P.M. showed the following: -The resident had poor dentition; -His/Her upper teeth appeared to have obvious cavities and black stubs for teeth; -He/She had a white film over his/her lower teeth and black spots on the back lower teeth. Observation on 10/02/24 at 12:30 P.M. showed the following: -The resident had poor dentition; -His/Her upper teeth appear had obvious cavities and black stubs for teeth; -He/She had a white film over his/her lower teeth and black spots on back lower teeth. During an interview on 10/02/24 at 12:30 P.M., the resident said the following: -Staff did not assist him/her with brushing his/her teeth and he/she was unable to do it for himself/herself; -Poor oral hygiene was probably why his/her teeth were sometimes painful; -His/Her mouth felt icky and he/she would like for staff to assist him/her with brushing them. 3. During an interview on 10/08/24 at 6:00 P.M., the Director of Nursing (DON) said he expected staff to assist with oral care every morning and after meals. During an interview on 10/08/24 at 6:05 P.M., the Administrator said she expected staff to assist with oral care every morning and after meals. 47246

Based on interview and record review, the facility failed to ensure the Medical Director or his/her designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. The facility census was 84. Review of the facility's QAPI Plan, dated March 2020, showed the following: -The Quality Assessment and Assurance (QAA) committee was designed to address quality deficiencies through analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level; -QAA committee was responsible for analyzing identified problems, establishing, corrective actions, measuring progress against the established goals and benchmarks, and communicating information to staff and residents and reporting findings to the administrator and governing board; -The QAA committee consisted of the Administrator, all department heads, Medical Director, and Pharmacist. 1. Review of the QAA meeting attendance log, dated 07/30/24, showed no documentation the facility's Medical Director and/or designee attended the meeting. Review of the QAA meeting attendance log, dated 08/22/24, showed no documentation the facility's Medical Director and/or designee attended the meeting. Review of the QAA meeting attendance log, dated 09/20/24, showed no documentation the facility's Medical Director and/or designee attended the meeting. During an interview on 10/03/24 at 4:25 P.M., the Administrator verified the Medical Director did not attend any of the QAA committee meetings. The Medical Director had previously been told when the meetings were held each month, but she did not contact the Medical Director every month to remind him/her of the meetings. The Medical Director did not send a designee to the meetings.

Based on observation, interview, and record review, the facility failed to ensure one resident, in a review of seven sampled residents (Resident #2), who had an indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder), and who had a history of urinary tract infections (UTI), was provided with urinary incontinence care and indwelling catheter care in a manner to prevent the spread of bacteria that cause infections. The facility had 12 residents with indwelling urinary catheters. The facility census was 84. Review of the facility policy Urinary Catheter Care dated September 2014, showed the following: -The purpose was to prevent catheter-associated urinary tract infections; -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag; -Do not clean the periurethral area with antiseptics to prevent catheter-associated urinary tract infections while the catheter was in place. Routine hygiene (cleansing the meatal surface, insertion site, during daily bathing or showering) was appropriate; -Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. Cleanse around the meatus using circular strokes from the meatus (urinary opening) outward, change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the same technique; -Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 1. Review of Resident #2's Physician Order Sheet (POS) dated 6/20/24 showed the following: -Diagnoses included stroke with paralysis of the right side; -Indwelling urinary catheter; -Catheter care every shift; -Macrobid (antibiotic medication) 100 milligrams two times daily for five days for urinary tract infection. Review of the resident's care plan, dated 6/26/24, showed the following: -The resident had an indwelling urinary catheter. Staff should cleanse the urinary catheter with soap and water, rinse, pat dry every shift and as needed if soiled. Staff should report any signs or symptoms of urinary tract infection such as pain, burning, blood tinged urine, cloudiness, deepening of urine color, decreased or not output, foul smelling urine, altered mental status or change in behavior. Review of the resident's POS, dated 7/4/24, showed an order to send the resident to the emergency department for evaluation and treatment of elevated blood pressure and dysuria (decreased urine output). Review of the resident's emergency room discharge instructions, dated 7/4/24, showed the following: -Diagnosis of urinary tract infection; -Start Bactrim DS (antibiotic medication) 160 mg every 12 hours for 14 days. Review of the resident's Significant Change Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 7/18/24 showed the following: -Severely impaired cognition; -Dependent on staff for personal hygiene; -Required an indwelling urinary catheter (a sterile tube inserted into the bladder used to drain the bladder of urine); -Always incontinent of bowel. Observation on 7/25/24 at 9:45 A.M. showed the resident lay in bed. He/She had an indwelling urinary catheter that contained brown colored urine in the tubing. Observation on 7/25/24 at 11:32 A.M. showed the following: -Certified Nurse Assistant (CNA) B and Nurse Assistant (NA) C removed the resident's gown. Soft, loose feces was noted between the resident's legs and perineal skin folds and around the urinary catheter insertion site. Dried feces was noted between the resident's upper thighs. CNA B wiped both sides of the resident's upper thighs and perineal skin folds with wet wipes removing loose feces. CNA B did not clean around the resident's catheter insertion site or tubing; -CNA B and NA C turned the resident to his/her side. The resident's buttocks, hips and perineal skin folds were soiled with loose feces extended up into the thighs and skin creases between the resident's legs; -CNA B repeatedly wiped the resident's feces soiled buttocks, skin folds and open abraded areas with wet wipes. The resident yelled out with each wipe; -CNA B and NA C repositioned the resident on his/her back and wiped the resident's upper thighs and the indwelling urinary catheter tubing below the level of the insertion site with wet wipes. Staff did not cleanse the urinary catheter insertion site. Feces was noted near the urinary catheter insertion site. During an interview on 7/25/24 at 11:50 A.M. CNA B said the following: -CNA B had not changed the resident or checked on the resident since 7:30 A.M. Feces was dried on the resident. He/She did not provide perineal care correctly and had not cleansed the resident's urinary catheter tubing or insertion site. He/She should make sure the resident's urinary catheter was kept clean and cleanse feces from the tubing and insertion site to prevent infection. During an interview on 7/26/24 at 9:45 A.M. the Director of Nursing (DON) said staff should follow the residents care plans and provide all necessary care to keep residents clean, dry and comfortable. Staff should provide the resident catheter care every shift and as needed to prevent infections. Staff should keep the urinary catheter clean and cleanse the catheter tubing from the meatus down the tubing. Feces should not be left on the urinary catheter tubing or around the meatus potentially causing a urinary tract infection. The resident had urinary tract infections in the past and was treated with antibiotics. During an interview on 7/26/24 at 2:30 P.M. the Administrator said staff should follow the resident's care plans and provide the resident catheter care as needed and every shift to prevent urinary tract infections. He/She expected staff to meet and provide for the residents' needs and care. MO 238672

Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for one resident (Residents #2), in a review of seven sampled residents. The facility census was 84. Review of the facility policy Handwashing/Hand Hygiene, dated August 2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap and water when the hands were visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol based hand rub or alternatively soap and water for the following situations; -Before and after direct contact with residents; -Before performing any non-surgical invasive procedures; -Before donning gloves; -Before handling clean or soiled dressings; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids, -After removing gloves; -Hand hygiene was the final step after removing and disposing of personal protective equipment; -The use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections; -Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids and when in contact with a resident or the equipment or environment of a resident who was on contact precautions. 1. Review of Resident #2's care plan, dated 6/26/24, showed the following: -Diagnoses of stroke with paralysis of the right side, aphasia (difficulty communicating due to damage to the parts of the brain that control language), apraxia (difficulty with skilled movement caused by brain disease or damage), restlessness and agitation, generalized arthritis, and muscle weakness; -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility, physical limitation; -The resident had an Activity of Daily Living (ADL) self-care deficit related to a stroke and was dependent on staff for bathing, bed mobility, dressing, toileting, transfers, eating, and personal hygiene. Staff should allow sufficient time for dressing and undressing and provide simple comfortable clothing. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/18/24, showed the following: -Severely impaired cognition; -Functional limitation in range of motion, impairment on one side to upper and lower extremity; -Dependent on staff for toileting, bathing, dressing, personal hygiene and transfers; -Required substantial or maximal staff assistance with bed mobility; -Required an indwelling urinary catheter (a sterile tube inserted into the bladder used to drain the bladder of urine); -Always incontinent of bowel. Observation on 7/25/24 at 11:32 A.M. showed the following: -Certified Nurse Assistant (CNA) B and Nurse Assistant (NA) C applied gloves without washing hands and removed the resident's gown. Soft, loose feces was noted between the resident's legs and perineal skin folds and around the urinary catheter insertion site. Dried feces was noted between the resident's upper thighs. CNA B wiped both sides of the resident's upper thighs and perineal skin folds with wet wipes removing loose feces. Feces were noted on CNA B's gloved hands; -CNA B, with the same feces soiled gloves, touched the resident's electronic bed controller and lowered the resident's bed. CNA B, without changing his/her feces soiled gloves, and NA C turned the resident to his/her side. The resident's buttocks, hips and perineal skin folds were soiled with loose feces that extended up into the thighs and skin creases between the resident's legs; -CNA B, with the same feces soiled gloves, repeatedly wiped the resident's soiled buttocks, skin folds and open abraded areas with wet wipes. CNA B wiped feces directly from his/her gloved hands with wet wipes and did not change his/her soiled gloves or wash his/her hands; -CNA B, with the same feces soiled gloves, applied clean linens to the resident's bed, applied skin barrier cream to his/her feces soiled gloved hands and rubbed the skin barrier cream into the resident's open abraded buttock areas and onto intact skin; -CNA B, with the same feces soiled gloves, and NA C repositioned the resident on his/her back touching the resident's arms, legs, hips, and bed linens. During an interview on 7/25/24 at 11:50 A.M. CNA B said the following: -He/She was responsible for the resident's hall along with NA C. The resident needed lots of help, was unable to turn to his/her side and required two staff to provide cares; -Feces were dried on the resident. He/She did not wash his/her hands or change gloves correctly. He/She should wash his/her hands when entering a resident's room and before putting on gloves. He/She should change gloves anytime the gloves were soiled and not attempt to wash feces off the soiled gloves with wet wipes. He/She should have changed gloves and washed his/her hands when the gloves were soiled and before applying clean linens and touching other items in the resident's room. He/She should not apply skin barrier cream on the resident's open abraded skin and intact skin with feces soiled gloves; -Handwashing prevented infections. He/She should provide resident care with clean hands and clean gloves. During an interview on 7/26/24 at 9:45 A.M. the Director of Nursing (DON) said staff should follow the resident's care plans and provide all necessary care to keep residents clean, dry and comfortable. Staff should wash hands and apply gloves prior to providing resident cares and change gloves any time the gloves were soiled. Staff should wash hands or use hand sanitizer every time gloves were changed to prevent the spread of infections. During an interview on 7/26/24 at 2:30 P.M. the Administrator staff should follow the facility policy regarding hand washing and gloving to prevent infections. MO 239243

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #2 and #7) in a review of seven sampled residents, who the facility identified as dependent on staff for Activities of Daily Living (ADLs), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to ensure Resident #2 was kept clean and dry, repositioned in bed, provided access to a call light, and had access to water and fluids. Staff also failed to provide incontinence care to Resident #7 for over seven hours when the resident had informed staff. Instead of providing care, staff covered the resident's soiled bed linens with a towel. The facility census was 84. Review of the facility policy, Activities of Daily Living (ADL), Supporting, dated March 2018, showed the following: -Residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal hygiene; -Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care), mobility, (transfer and ambulation), elimination (toileting ), dining (meals and snacks) and communication; -Care and services to prevent and /or minimize functional decline would include appropriate pain management, as well as treatment for depression; -A resident's ability to perform ADLs would be measured using clinical tools, including the Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff). Extensive assistance, the resident performed part of the activity, staff provided weight-bearing support. Total dependence, full staff performance of an activity with no participation by the resident for any aspect of the ADL activity. 1. Review of Resident #2's care plan, dated 6/26/24, showed the following: -Diagnoses of stroke with paralysis of the right side, aphasia (difficulty communicating due to damage to the parts of the brain that control language), apraxia (difficulty with skilled movement caused by brain disease or damage), restlessness and agitation, generalized arthritis, muscle weakness, palliative care (end of life care); -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility, physical limitation. Staff should converse with the resident while providing care, encourage family involvement; -The resident had an ADL self-care deficit related to a stroke. Staff should provide bed rails (metal bars attached to the bed) to aid in bed mobility, avoid scrubbing and pat sensitive skin dry, check nail length and trim as necessary. The resident was dependent on staff for bathing, bed mobility, dressing, toileting, transfers, eating, and personal hygiene. Staff should allow sufficient time for dressing and undressing and provide simple comfortable clothing. Staff should encourage the resident to use the call light for assistance; -The resident had limited physical mobility. Staff should provide gentle range of motion as tolerated with daily care; -The resident had communication problems related to aphasia and stroke. Staff should anticipate and meet the resident's needs, allow adequate time for the resident to respond. Ensure and provide a safe environment with the call light in reach; -The resident had right sided paralysis and weakness related to stroke. Staff should provide range of motion with morning and evening care daily, reposition the resident as tolerated and at least every two hours; -The resident had potential and actual impairment to skin integrity. Staff should avoid the resident scratching and keep hands and body parts from excessive moisture. Keep the resident's fingernails short. Prevent skin injury, encourage good nutrition and hydration to promote healthier skin, use a draw sheet or lifting device to move the resident and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface; -The resident received hospice (end of life) services. Staff should establish routine with facility and hospice care, collaborate with the plan of care. Provide maximum comfort for the resident. Review of the resident's Significant Change Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 7/18/24, showed the following: -Severely impaired cognition; -Functional limitation in range of motion, impairment on one side to upper and lower extremity; -Dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene and transfers; -Required substantial or maximal staff assistance with bed mobility; -Required an indwelling urinary catheter (a sterile tube inserted into the bladder used to drain the bladder of urine); -Always incontinent of bowel; -Resident had Moisture Associated Skin Damage (MASD, incontinence associated dermatitis, perspiration, drainage caused from wet or soiled skin); -Skin treatments included a turning and positioning program and application of ointments and medications; -Received hospice care. Observation on 7/25/24 from 9:45 A.M. to 10:15 A.M. showed the following: -The resident lay in bed wearing a facility gown pulled down to his/her mid chest. The resident's right arm was flaccid (unable to move) and dangled off the side of the bed with a pillow wedged between the mattress and positioning bedrail and under the resident's right elbow. The resident's right hand and lower right arm was swollen, and appeared shiny and taut (tight, bulging, filled to capacity), his/her right hand was clenched in a fist; -He/She had matted long hair and facial hair. His/Her head rested partially on the mattress and partially on a pillow; -The resident's call light lay on the bed above the resident's left elbow. The resident was unable to reach the call light; -A bedside table was positioned across the resident's knees and upper legs and had two drink cups with handles and an open plastic individual container of juice with no straw or lid. The resident could not reach the drink cups or the open juice container. Observation on 7/25/24 at 10:15 A.M. showed the following: -The resident remained in bed with no change in position, his/her right arm dangled off the side of the bed with a pillow wedged between the mattress and positioning bedrail and under the resident's right elbow. The resident's right hand and lower right arm remained swollen, shiny and taut in appearance with his/her right hand clinched in a fist; -The resident's call light lay on the bed above the resident's left elbow. The resident tried to move his/her left arm to reach the call light. The call light was out of reach; -The bedside table remained across the resident's knees and upper thighs. The resident was unable to reach the drink cups or open juice container; -Housekeeping staff entered the room and arranged the closet, then left the room. Observation on 7/25/24 from 10:16 A.M. to 10:40 A.M. showed the resident remained in bed with no change in position and no staff entered the room. The resident reached for the drinking glass on the bedside table across his/her knees and upper thighs, his/her left hand reached the edge of the bedside table. The resident was unable to reach the drinking glass or obtain a drink. Observation on 7/25/24 from 10:40 to 11:32 A.M. showed the following: -Certified Medication Technician (CMT) A walked into the room and past the resident, adjusted the room air conditioner controls, provided the resident's roommate (Resident #6) a blanket, fresh ice and a soda then left the room. CMT A did not speak to or check on Resident #2; -The resident remained in bed with no change in position, his/her right arm continued to dangle off the side of the bed with a pillow wedged between the mattress and positioning bedrail under the resident's right elbow. The resident's right hand and lower right arm remained swollen, shiny and taut in appearance with his/her right hand clinched in a fist; -The resident's call light lay on the bed out of reach above the resident's left elbow and the resident's head rested partially on the mattress and partially on a pillow; -The bedside table remained across the resident's knees and upper thighs. The resident was unable to reach the drink cups or open juice container. Observation on 7/25/24 at 11:32 A.M. showed the following: -Certified Nurse Assistant (CNA) B and Nurse Assistant (NA) C removed the resident's gown. Soft, loose feces was noted between the resident's legs and perineal skin folds, dried feces was noted between the resident's upper thighs. CNA B and NA C turned the resident to his/her side. The resident's buttocks, hips and perineal skin folds were soiled with loose feces. Four abraded, open areas were noted on the resident's buttocks and tailbone area. Each open area was soiled with feces. Barrier cream was dried and appeared brown in sections, containing feces; -CNA B repeatedly wiped the resident's feces soiled buttocks, skin folds and open abraded areas with wet wipes. The resident yelled out with each wipe; -CNA B applied skin barrier cream over the feces soiled barrier cream and rubbed the cream over the resident's entire buttocks, skin folds and open abraded areas. The resident moaned; -CNA B and NA C repositioned the resident on his/her back and placed the call light in the resident's left hand. CNA B elevated the resident's swollen, shiny and taut right hand on a pillow. The resident's right hand remained clenched in a fist. CNA B and NA C did not provide the resident range of motion or open the resident's right hand and fingers. CNA B and NA C did not offer the resident a drink. The bed side table with the resident's drink cups was out of reach and left against the wall in front of the window. During an interview on 7/25/24 at 11:50 A.M. CNA B said the following: -He/She was responsible for the resident's hall along with NA C. There was no additional CNA staff on the hall; -The resident needed lots of help, was unable to turn to his/her side and required two staff to provide cares. The resident could drink fluids with supervision but required staff to feed him/her. The resident's right hand was swollen, and staff should keep the resident's right hand elevated on a pillow; -CNA B had not changed the resident or checked on the resident since 7:30 A.M. Feces were dried on the resident. He/She had not provided the resident a drink or any fluids that morning since breakfast; -CNA B and NA C were busy, started rounds at 9:00 A.M. and had not gotten to the resident since 7:30 A.M. The hall was busy, and they had not gotten to the resident any earlier; -The call light was not in reach and the resident was unable to reach his/her drink cups all morning; -He/She should check on the resident at least every two hours, keep the resident clean and dry, reposition the resident and offer a drink. The resident had open wounds and required frequent care. He/She had not provided the resident's care, he/she had not had time earlier in the morning. Observation on 7/25/24 at 12:35 P.M. showed the following: -The resident remained in bed on his/her back, his/her right arm remained elevated on a pillow with his/her right hand clenched in a fist. The resident's right hand and lower right arm remained swollen, shiny and taut in appearance; -The bedside table remained against the wall in front of the window out of the resident's reach. The resident's drink cups remained on the bedside table, untouched; -The resident's mouth appeared dry, flies were noted on the resident's gown, hands and face. Feces were noted on the bottom edge of the resident's gown. Observation on 7/25/24 at 1:45 P.M. showed Licensed Practical Nurse (LPN) D removed the resident's lunch tray. The resident ate a container of ice cream and drank some juice. The resident's gown remained soiled with feces on the bottom edge. His/Her right hand remained swollen, shiny and taught in appearance and was elevated on a pillow with right hand clenched in a fist. The resident's call light was wrapped around the bedrail and hung down the side of the bed out of the resident's reach. Observation on 7/25/24 at 3:30 P.M. showed the resident's family member opened the resident's right hand. The palm of the resident's hand was moist and soiled with three open slits noted in the skin of the resident's palm. The resident's call light remained wrapped around the bedrail and hung down the side of the bed out of the resident's reach. The resident's family member applied a hard plastic right arm splint (a positioning device used to prevent contractures or tightening of the muscles and tendons, caused the fingers to bend to the palm of the hand in a fist) and secured the straps around the back of the resident's right hand near the knuckles and around the resident's forearm. The splint held the resident's right hand in an open position and extended from the resident's fingers to the forearm. The family member elevated the resident's right hand and arm on a pillow. The resident's nails were long with tan debris under the nails. Observation on 7/26/24 at 8:50 A.M. showed the following: -The resident laid in bed on his/her back, leaning to the right, with his/her right arm secured in a splint, dangling off the edge of the bed. A positioning pillow was tucked under the resident's right elbow and hung off the side of the bed. The right hand and lower arm were swollen, shiny and taut in appearance with the right-hand splint in place. The lower hand strap located at the knuckle was secured tightly and a deep indentation was noted in the swollen hand near the little finger and across the knuckle area; -The resident's call light hung off the side of the resident's bed out of the resident's reach. During an interview on 7/26/24 at 9:10 A.M. the Physical Therapy Assistant (PTA) said the resident previously received therapy services and staff should provide range of motion exercises daily. The resident's right-hand splint was intended to prevent contractures. Staff should keep the resident's right hand elevated on a pillow to reduce the swelling. 2. Review of Resident #7's care plan, dated 7/23/24, showed the following: -admitted [DATE]; -Diagnoses of morbid obesity, lymphedema (excessive swelling of the legs caused by blockage of the lymphatic system), and necrotizing fascitis (a serious bacterial infection that destroys tissue under the skin, flesh-eating disease); -The resident had an ADL self-care deficit related to limited mobility. Staff should provide extensive assistance with bathing, bed mobility, and dressing. Staff should provide total assistance with toileting, and transfers; -The resident had potential for and actual impaired skin integrity. Staff should avoid scratching and keep hands and body parts from excessive moisture, keep skin clean and dry, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface, and use a draw sheet or lifting device to move the resident. During an interview on 7/25/24 at 9:50 A.M. the resident said he/she came to the facility a few days ago. The evening and night shift were usually slow to answer the call light. He/She was incontinent of bowel and bladder because he/she was in bed. Staff were either too slow or too late answering the call light or the bed pan spilled and the bed became soiled. He/She required a mechanical lift to get out of bed and he/she had a large lower abdominal wound that required dressing changes twice daily. Staff had not changed his/her soiled linens since 5:00 A.M. that morning. He/She had notified multiple staff his/her bed was wet. Observations on 7/25/24 showed the following: -At 12:15 P.M. LPN E changed the resident's left lower abdominal wound dressing. The resident said he/she wanted to get up for lunch, his/her bed was wet and had not been changed since 5:00 A.M. that morning. A large brown ring was noted on the bottom sheet extending from under the resident to the resident's right side from mid back to below the knees. A strong urine odor was noted; -At 12:45 P.M. NA C and the physical therapy assistant (PTA) changed the resident's gown, the resident said he/she was wet and needed cleaned up before getting up in the chair, staff had not cleaned him/her up that morning. NA C and PTA turned the resident to the left side, the resident's bed, bottom sheet, two washable bed protectant pads and turn sheet were saturated with urine. A wadded wet saturated towel lay partially over the urine saturated bed protectant pads. The resident said the night shift covered the wet bed linens with a towel instead of changing the soiled bed protectant pads and sheets in the night. That was about 4:00 A.M. or 5:00 A.M.; -NA C asked if the resident wanted his/her knees wiped. The resident said yes, wash from the knees up, back of his/her legs and all the areas between his/her legs. A red rash was noted between the resident's legs, perineal area skin folds and buttocks; -NA C and PTA provided incontinence care, and a mechanical lift transfer to the wheelchair. 3. During an interview on 7/26/24 at 9:45 A.M. the Director of Nursing (DON) said the following: -Resident #2 had a stroke and had moisture associated skin breakdown on his/her buttocks and tailbone. Staff should apply barrier cream to the open areas and intact skin after providing perineal care and incontinence care. Staff should check the resident every two hours at a minimum and check more frequently if needed. Staff should make sure the resident was clean and dry at all times. The resident's right arm and hand was swollen, and staff should elevate the resident's right arm and hand on a pillow. The resident's right arm and hand should not dangle off the side of the bed. This caused more swelling. Staff should remove the resident's right arm splint and check the resident's skin condition. The splint was new. Staff should provide range of motion to the right arm and hand daily. The DON was not aware the resident had open slits in the palm of his/her right hand from his/her fingernails. Staff should keep the resident's right hand clean and monitor the resident's skin condition. The resident's hand should be kept open with a soft positioning device kept in the palm of the resident's hand to prevent the hand from forming a fist. The resident could get a drink independently if the drink cup was within reach of the resident's left hand and he/she had a lid and straw. The drink cups should always be within the resident's reach; -Staff should check residents frequently, at least every two hours and ensure all residents were kept clean and dry. Residents should not have dried feces between their legs or remain soiled for extended periods of time. Staff should follow the residents care plans and provide all necessary care to keep residents clean, dry and comfortable. Staff should never leave a resident soiled with urine or feces and never cover a urine soiled bed with a towel. Residents call lights should be within reach at all times. During an interview on 7/26/24 at 2:30 P.M. the Administrator said resident should be clean and dry and all Activities of Daily Living met. Staff should complete rounds on all residents at least every two hours and as needed for those who required more frequent care. If staff were behind, they should call for assistance from other halls. There was plenty of staff. Staff should never delay providing cares, should follow the resident's care plans and should avoid leaving residents wet or soiled. Staff should make sure the resident's call light was in reach and the resident was able to use the call light. Staff should provide fluids routinely and offer fluids to those who could not drink or eat independently. He/She expected staff to provide care to meet the residents' needs. MO 238446 MO 238672 MO 238666

Based on observation, interview and record review, the facility failed to prevent misappropriation of three residents' (Resident #1, #2 and #3) narcotic pain medication when certified medication technician (CMT) A removed one hydrocodone-acetaminophen (a combination medication used to relieve pain containing an opioid pain reliever and a non-opioid pain reliever) 5 milligrams (mg)/325 mg pill from Resident #1's and #3's narcotic medication card and removed two hydrocodone 10 mg/325 mg pills from Resident #2's narcotic medication card and admitted to ingesting them while on duty. The facility census was 81. The administrator was notified on 3/6/24 of the past non-compliance which occurred on 2/27/24. On 2/27/24 the consulting pharmacist was at the facility conducting a random spot check of medications. The pharmacist counted narcotics with CMT A and found medications that were missing from three residents' narcotic cards. The pharmacist asked what happened to them and CMT A admitted to ingesting the medications. Upon discovery, the administrator suspended CMT A, assessed all residents for pain and counted all narcotic medications. CMT A was terminated on 2/28/24. The facility conducted in-services on abuse, neglect, and misappropriation. Staff corrected the deficient practice on 2/28/24. Review of the facility policy, Abuse Prevention Program, dated December 2016, showed the following: -The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation; -The administration will protect the residents from anyone including, but necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/3/24, showed the following: -The resident's cognition was moderately impaired; -The resident took scheduled and as needed pain medication; -The resident had occasional pain; -The resident had diagnoses that included chronic kidney disease, hereditary lymphedema (a genetic condition characterized by chronic swelling of certain parts of the body), non-pressure chronic ulcer of unspecified part of left and right lower legs limited to breakdown of the skin (ulcers that are caused by poor circulation and can be painful), chronic venous hypertension with ulcer and inflammation of right lower extremity. Review of the resident's physician order sheet for February 2024 showed an order for hydrocodone-acetaminophen tablet 10 mg/325 mg; give one tablet by mouth three times a day for pain (start date 11/8/22). Review of the resident's medication administration record (MAR) for February 2024 showed hydrocodone-acetaminophen 10 mg/325 mg give one tablet three times a day at 8:00 A.M., 2:00 P.M. and 8:00 P.M. Review of the resident's controlled medication utilization record (narcotic count sheet) for hydrocodone-acetaminophen 10/325 mg, one tablet three times a day, dated 2/22/24, showed the following: -On 2/27/24 at 8:00 A.M., CMT A signed out one hydrocodone-acetaminophen 10 mg/325 mg leaving the count at 17 pills remaining; -On 2/27/24 at 2:00 P.M., CMT A signed out one hydrocodone-acetaminophen 10 mg/325 mg leaving the count at 16 pills remaining; -On 2/27/24 (no time noted) a master count was completed by the assistant director of nursing (ADON) and CMT I for a count of 15 pills remaining, leaving one pill unaccounted for. 2. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/24/24, showed the following: -The resident's cognition was severely impaired; -The resident had frequent pain; -The resident's pain occasionally effected his/her sleep; -The resident had diagnoses that included apraxia (unable to make voluntary movements or gestures even though you have the physical ability), aphasia (unable to communicate effectively with others), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), unspecified dementia with behavioral disturbances, cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), history of traumatic brain injury and history of malignant neoplasm (cancerous tumor) of the brain. Review of the resident's physician order sheet for February 2024 showed an hydrocodone-acetaminophen tablet 5 mg/325 mg; give two tablets by mouth three times a day for pain (start date of 11/8/22). Review of the resident's MAR for February 2024 showed hydrocodone-acetaminophen 5 mg/325 mg give two tablets three times a day at 8:00 A.M., 2:00 P.M. and 8:00 P.M. Review of the resident's controlled medication utilization record (narcotic count sheet) for hydrocodone-acetaminophen 5/325 mg, dated 2/22/24, showed the following: -On 2/27/24 at 8:00 A.M., CMT A signed out two hydrocodone-acetaminophen 5 mg/325 mg leaving the count at 11 pills remaining; -On 2/27/24 at 2:00 P.M., CMT A signed out two hydrocodone-acetaminophen 5 mg/325 mg leaving the count at 9 pills remaining; -On 2/27/24 (no time noted) a master count was completed by the ADON and CMT I for a count of 7 pills remaining, leaving two pills unaccounted for. 3. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/2/24, showed the following: -The resident's cognition was severely impaired; -The frequency of the resident's pain and the effect the resident's pain had on his/her sleep was left blank; -The resident had diagnoses that included osteoarthritis (pain and stiffness from the wearing down of the protective tissue at the ends of bones and worsens over time) of the right knee, heart failure and other heart-related complications, chronic pulmonary edema (a condition caused by too much fluid in the lungs), and chronic obstructive pulmonary disease (COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems). Review of the resident's physician order sheet for February 2024 showed an order for hydrocodone-acetaminophen 5/325 mg; give one tablet four times a day for pain (start date of 11/8/22). Review of the resident's MAR for February 2024 showed hydrocodone-acetaminophen 5 mg/325 mg give one tablet four times a day at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the resident's controlled medication utilization record (narcotic count sheet) for hydrocodone-acetaminophen 5/325 mg give one tablet four times a day, dated 2/20/24, showed the following: -On 2/27/24 at 8:00 A.M., CMT A signed out one hydrocodone-acetaminophen 5 mg/325 mg leaving the count at 50 pills remaining; -On 2/27/24 at 2:00 P.M., CMT A signed out one hydrocodone-acetaminophen 5 mg/325 mg leaving the count at 49 pills remaining; -On 2/24/24 at 4:00 P.M., CMT A signed out one hydrocodone-acetaminophen 5 mg/325 mg leaving the count at 48 pills remaining; -On 2/27/24 (no time noted) a master count was completed by the ADON and CMT I for a count of 47 pills remaining, leaving one pill unaccounted for. 4. During an interview on 3/18/24 at 12:58 P.M., the pharmacy consultant said the following: -He/She was at the facility to do a check of the facility medication counts for accuracy; -He/She began a count with CMT A; -The first card the pharmacy consultant pulled to count was for Resident #1; -When he/she counted the pills on the card for Resident #1 the number of actual pills in the card (15) did not match the ending number (17) on the resident's narcotic count sheet; -He/She told CMT A the count in the card was 15 and the count on the narcotic count sheet was 17; -CMT A said he/she forgot to sign out the 2:00 P.M. administration to Resident #1. CMT A then signed the narcotic count sheet in front of the pharmacy consultant. The ending count was then 16; -He/She again told CMT A the count did not match. CMT A began to act nervous and flipped through the narcotic count sheets; -CMT A then asked to speak to the pharmacy consultant in private; -They both went into the medication room where CMT A told the pharmacy consultant he/she had consumed the medication that was unaccounted for; -The pharmacy consultant asked CMT A if any of the other resident's counts would be inaccurate and CMT A said yes; -CMT A said counts would also be off for Residents #2 and #3; -At that point the pharmacy consultant took CMT A to the Director of Nursing (DON). CMT A told the DON that he/she had taken one hydrocodone-acetaminophen 5/325 mg from Resident #3, two hydrocodone-acetaminophen 5/325 mg from Resident #2 and one hydrocodone-acetaminophen 10/325 mg from Resident #1 and ingested them all. During an interview on 3/6/24 at 3:00 P.M. and 3/18/24 at 12:53 P.M., the DON said the following: -On 2/27/24 the pharmacy consultant and CMT A came to his office and CMT A told him he/she had taken narcotic medications from three residents; -CMT A said he/she ingested three hydrocodone-acetaminophen 5/325 mg and one hydrocodone-acetaminophen 10/325 mg; -The DON immediately took CMT A to the administrator's office; -CMT A was escorted from the building and was terminated on 2/28/24 for misappropriation of resident narcotic medications. During an interview on 3/6/24 at 3:00 P.M. the administrator said the following: -On 2/27/24, the DON brought CMT A to her office and let her know there was a problem with CMT A diverting narcotics; -CMT A admitted to ingesting three residents' (Residents #1's, #2's and #3's) hydrocodone-acetaminophen pills (three hydrocodone-acetaminophen 5/325 mg and one hydrocodone-acetaminophen 10/325 mg); -The local police department was called and the incident was reported; -CMT A was escorted from the building at 3:15 P.M. on 2/27/24; -Staff completed a count of all narcotics on 2/27/24, after CMT A was escorted from the building. There were no further discrepancies found. MO232430

Based on interview and record review, the facility failed to protect one resident (Resident #3), in a review of five residents, from physical abuse when Licensed Practical Nurse (LPN) B witnessed Certified Nurse Assistant (CNA) A pushing down and holding Resident #3's arms that were crisscrossed on the resident's chest while the resident hollered out with a red face. LPN B noted red marks on the resident's wrist and forearm following the incident. The facility census was 85. On 1/11/24 at 2:00 P.M., the administrator was notified of the past noncompliance which occurred on 12/31/23. On 12/31/23, the administrator identified CNA A physically abused Resident #3. Upon discovery, staff suspended CNA A, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff members were educated on the facility abuse and neglect policies. CNA A was terminated from employment. The deficiency was corrected on 1/2/24. Review of the facility policy, Abuse Prevention Program, dated December 2016, showed the following: -The residents had the right to be free from abuse including verbal, mental or physical abuse; -Administration would protect residents from abuse by anyone including facility staff, other residents, staff from other agencies, family members, legal representatives, friends, visitors or any other individual; -Administration would require staff training/orientation programs that included abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. Review of the facility policy, Recognizing Signs and Symptoms of Abuse/Neglect dated January 2011 showed the following: -The facility would not condone any form of resident abuse, all personnel were to report any signs and symptoms of abuse to their supervisor or to the Director of Nursing Services immediately; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 1. Review of Resident #3's Care Plan, updated 5/8/23, showed the following: -Diagnoses of dementia, anxiety, muscle weakness, cognitive communication deficit, abnormal weight loss, and unsteadiness on feet; -The resident had difficulty completing Activities of Daily Living (ADLs) related to weakness. Staff should provide assistance with bed mobility, dressing, personal hygiene, toileting, transfers and encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts in self-care; -The resident was resistive to care and would spit out medications at times. Staff should allow the resident to make decisions about treatment regimen to provide sense of control, encourage as much participation/interaction by the resident as possible during care, give clear explanation of all care activities prior to and as they occurred during each contact. Praise the resident when behavior was appropriate. Staff should provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine as much as possible; -The resident would holler out and could become combative during care due to dementia. Staff should anticipate and meet the resident's needs. If reasonable, discuss the resident's behavior and intervene as necessary to protect the rights and safety of others. Staff should approach and speak in a calm manner, divert attention, remove from the situation, and take to alternate location as needed. Staff should communicate and provide physical and verbal cues to alleviate anxiety; -The resident had impaired cognitive function and communication due to dementia. Staff should provide supervision with all decision making, keep the resident's routine consistent and try to provide consistent care givers as much as possible. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 10/15/23, showed the following: -Diagnoses included heart disease, dementia, malnutrition, and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing); -Severely impaired cognition; -No physical or verbal behaviors; -Made self-understood and sometimes understood others, responded to simple direct communication only; -Required substantial/maximal staff assistance with eating and dressing lower body; -Required partial/moderate staff assistance with dressing the upper body, personal hygiene, rolling left to right, movement from lying flat on the bed to sitting on the side of the bed and standing from a sitting position; -Required staff supervision or touch assistance with movement from sitting on the side of the bed to a lying down position and transfers to and from bed to chair. Review of the facility Abuse Investigation report, dated 12/31/23 at 5:27 P.M.,. showed the following: -LPN B heard the resident hollering and LPN B went to the resident's room. The resident said, I am going to kill you to Certified Nurse Aide (CNA) A. CNA A had the resident's arms crisscrossed over the resident's chest and held the resident's hands to the resident's chest. CNA A said the resident was trying to hit him/her. LPN B instructed CNA A to leave the room; -CNA A said he/she was trying to get the resident up for supper and the resident began swinging at CNA A. The resident said he/she was going to kill CNA A. CNA A held the resident's arms to keep from getting hit. During an interview on 1/10/24 at 2:45 P.M. LPN B said on 12/31/23 he/she was the charge nurse on the resident's hall. He/She heard the resident hollering, and he/she walked in the resident's room and saw CNA A pushing the resident's arms across the resident's chest, crisscrossed, and was pushing down on the resident's chest. The resident yelled get out, get out, get out and the resident's face was red. CNA A continued to hold the resident's crisscrossed arms down and push down on the resident's chest. LPN B told CNA A to leave the resident's room. The resident said he/she was going to kill CNA A and CNA A said oh no you are not. Then CNA A released the resident's arms. LPN B noted a red spot on the top of the resident's left wrist and the right forearm from CNA A holding pressure on the resident's arms. CNA A physically abused the resident. The resident had dementia and limited arm reach. The resident could not have tried to harm CNA A. During an interview on 1/10/24 at 4:25 P.M., CNA A said he/she worked on 12/31/23. The resident screamed and started yelling when staff provided his/her care. CNA A was getting the resident up for supper. The resident yelled and screamed and was irate. He/She put the resident's pants on first and planned to find some additional staff to help get the resident dressed and out of bed. The resident screamed and hit him/her. CNA A grabbed the resident's arms and told the resident to stop it. During interview on 1/11/24 at 2:00 P.M. the administrator said CNA A abused the resident by holding the resident's arms down and pushing on the resident's chest while the resident hollered out. All staff were educated on abuse upon hire including CNA A. Staff should not abuse residents. CNA A was suspended immediately on 12/31/23 and terminated on 1/2/24 for physical abuse of Resident #3. All staff abuse education was started immediately on 12/31/23 and completed on 1/2/24. MO#00229560

Based on interview and record review, the facility failed to protect one resident (Resident #2), in a review of six sampled residents, from abuse when Certified Nurse Assistant (CNA) A threatened to break the resident's hands if the resident hit him/her. The facility census was 79. The administrator was notified of the past non-compliance which occurred on 5/7/23. On 5/8/23, the administrator became aware of the violation. The facility suspended CNA A upon notification of abuse allegation on 5/8/23 and started an investigation. Staff and residents were interviewed for further concerns related to abuse. CNA A was terminated on 5/12/23. A mandatory in-service was conducted for all staff on 5/8/23 which included resident abuse/neglect. The non-compliance was corrected on 5/8/23. Review of facility policy Signs and Symptoms of Abuse/Neglect, dated January 2011, showed the following: -Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Facility would not condone any form of resident abuse. Review of the facility policy Abuse Prevention, dated December 2016, showed the following: -Residents had the right to be free from abuse, including verbal and mental; -The facility would protect residents from abuse by anyone, including facility staff. 1. Review of Resident #2's care plan, revised on 6/22/22, showed the following: -The resident required extensive assistance with bed mobility, dressing, personal hygiene, toilet use, and transfers; -The resident was resistive to care; -Allow the resident to make decisions about treatment regimen to provide a sense of control; -Encourage as much participation/interaction by the resident as possible during care activities; -Give clear explanation of all care activities prior to and as they occur during each contact. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/14/23, showed the following: -His/Her cognition was severely impaired; -His/Her diagnoses included dementia; -He/She was sometimes understood; -He/She sometimes understood others (responded adequately to simple direct communication only); -He/She did not have a history of rejecting cares; -He/She did not experience physically and verbally aggressive behaviors affecting others in the previous seven-day look back period; -He/She required extensive physical assistance from two or more staff with bed mobility and transfers; -He/She required extensive physical assistance from one staff with toileting and personal hygiene. Review of facility's investigation report showed on 5/8/23 at 2:06 P.M., Resident #1 (Resident #2's roommate), went to the nursing office to file a complaint about how Certified Nurse Assistant (CNA) A had treated his/her roommate (Resident #2). Review of Resident #1's signed written statement provided by the facility, dated 5/8/23, showed that on the evening of 5/7/23, CNA A assisted Resident #2 to bed. CNA A did not explain what he/she was going to do, and Resident #2 started to scream and yell. Resident #2 continued to scream as CNA A assisted Resident #2 from his/her wheelchair to the bed. CNA A began to mock the resident while Resident #2 screamed. CNA A started to change Resident #2's brief, but Resident #2 told CNA A to leave him/her alone, but CNA A ignored the resident. Resident #2 told CNA A to leave him/her alone two more times, but CNA A continued to ignore Resident #2 and continued to change the resident's brief. Resident #2 hit CNA A in the side when he/she would not leave Resident #2 alone. CNA A became mad at Resident #2 and told Resident #2 if he/she ever hit him/her again, CNA A would break Resident #2's hands, call the police, and have him/her arrested for assault. (According to Resident #1's admission MDS, dated [DATE], the resident's cognition was intact.) During an interview on 5/30/23 at 11:25 A.M., Resident #1 said his/her roommate (Resident #2) had dementia. Resident #2 had panic attacks and would scream occasionally, but was cooperative with staff when they explained what they were doing step by step. He/She witnessed Resident #2 begin to yell when CNA A pulled down the resident's covers to check the resident without explaining what he/she was doing. Resident #2 continued to scream/yell and told CNA A to leave him/her alone, but CNA A continued to provide care. Resident #2 punched CNA A in the side and CNA A told the resident, you touch me one more time and I will break both of your hands, call the police, and file abuse charges. Resident #2 tried to apologize to CNA A, but CNA A told Resident #2 that he/she didn't want to hear apologies because he/she heard that all of the time, and you people don't stop. Review of CNA A's undated written statement provided by the facility, showed on Saturday night (no date provided), Resident #2 become agitated and combative with staff. Staff asked Resident #2 to not place his/her hands on them as they were just trying to help change him/her. Review of facility's written statement dated 5/8/23 at 5:00 P.M. showed Resident #2 was unable to answer if he/she remembered about being put to bed the night before due to severely impaired cognition. During an interview on 5/31/23 at 11:30 A.M., the administrator said she expected staff to be respectful and kind to all residents. Staff and residents were interviewed for further concerns related to abuse after the alleged incident. After the investigation, CNA A was suspended on 5/8/23 and terminated on 5/12/23 for verbal abuse. A mandatory in-service was conducted for all staff on 5/8/23 which included resident abuse/neglect. MO00218131

Based on observation, interview and record review, the facility failed to follow appropriate infection control procedures to prevent or reduce the risk of spreading COVID-19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2/SARS-CoV-2), when facility staff failed to separate two negative residents (Resident #2 and #4) from their roommates (Resident #1 and #3) who tested positive for COVID-19. The facility also failed to test two residents timely (Residents #3 and #22) for COVID-19 in accordance with their policy when the residents displayed signs and symptoms of the disease. Resident #22 required hospitalization on [DATE] where he/she was found to be positive for COVID-19 and required treatment for COVID-19 pneumonia and respiratory failure. The facility census was 70. The administrator was notified on 12/29/22 at 11:33 A.M., of the Immediate Jeopardy (IJ), which began on 12/23/22. The IJ was removed on 12/29/22, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic), updated on 9/23/22, showed the following: -Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room; -The door should be kept closed (if safe to do so) and ideally the patient should have a dedicated bathroom; -If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Review of the facility policy, COVID-19 - Identification and Management of Ill Residents, revised September 2021, showed the following: -Residents with signs and/or symptoms of COVID-19 are identified and isolated to help control the spread of infection to other residents, staff and visitors; -Strategies used for the rapid identification and management of COVID-19 infected residents are consistent with current recommendations from the CDC; -The infection preventionist is responsible for establishing and overseeing screening and monitoring efforts; -A COVID-19 care unit (which may be a dedicated floor, unit, wing or cluster of rooms at the end of a hallway)/or room has been established to cohort and manage the care of residents with confirmed SARS-CoV-2 infection/or exposed roommate; -The location of the COVID-19 unit/or room is physically separated from other rooms or units housing residents without confirmed SARS-CoV-2 infection and/or exposure; -A resident with suspected SARS-CoV-2 infection/and or exposed roommate is isolated to a semi-private room with a private bathroom while test results are pending; -The door to the room remains closed to reduce transmission of SARS-CoV-2; -Unvaccinated residents who have had close contact with someone with SARS-CoV-2 infections are placed in quarantine for ten days after their exposure, even if viral testing is negative. Review of the CDC's, Infection Control Guidance for Long Term Care: Testing Overview, updated 9/28/22, showed the following: -Symptoms of COVID-19 included fever, chills, shortness of breath, fatigue, sore throat, runny nose, congestion, nausea and vomiting, and diarrhea; -Screening can provide important information to limit transmission and outbreaks in high risk congregate settings; -People who have symptoms of COVID-19 or known exposure to someone with COVID-19 should be tested . Review of the CDC's, Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating, last reviewed 11/22/22, showed the following: B) Properly manage residents with SARS-CoV-2 infection. -Treatment should be administered as soon as possible for nursing home residents with mild-to-moderate COVID-19 because they are at high risk of progression to severe COVID-19. 1. Review of Resident #1's undated diagnoses list showed the following: -Diabetes mellitus (a group of diseases that result in too much sugar in the blood), end stage renal disease (the last stage of long-term kidney disease, when the kidney's can no longer support the body's needs), and hypertension (high blood pressure). Review of the resident's rapid COVID test lab results, dated 12/23/22, showed he/she tested positive for COVID. 2. Review of Resident #2's undated face sheet showed he/she was his/her own responsible party. Review of the resident's diagnosis list showed the following diagnoses: -Diabetes mellitus, heart failure (a chronic condition in which the heart does not pump blood as well as it should), history of Covid-19, hypertensive heart disease (heart problems that occur because of high blood pressure), and cerebral infarction (also called a stroke, occurs as a result of disrupted blood flow to the brain). Review of the resident's rapid COVID test lab results, dated 12/22/22, 12/23/22 and 12/26/22, showed he/she tested negative for COVID-19. Review of the facility provided census report for 12/26/22 showed Resident #1 and Resident #2 were roommates. Observation on 12/27/22 at 12:48 P.M., showed the resident room had PPE (personal protective equipment) outside of the room with a plastic curtain zipped up and secured around the door frame. The door to the room was open and a TV was on. The name plaque outside of the room indicated the room was occupied by Resident #1 and Resident #2. Staff reported Resident #1 was currently at dialysis and Resident #2 was in the room. 3. Review of Resident #3's diagnoses list in the electronic health record, dated 10/11/22, showed the following: -Pulmonary hypertension (condition where the pressure in the blood vessels leading from the heart to the lungs is too high), acute and chronic respiratory failure, heart disease, and shortness of breath. Review of the resident's nurse's notes showed the following: -On 12/21/22 at 7:20 A.M., the resident had a sore throat, weak voice, malaise (general feeling of discomfort, illness, or uneasiness), weakness, and generally not feeling well; -On 12/21/22 at 7:52 A.M., the resident had an infrequent cough. Staff called the dialysis center and was told the resident would skip treatment today and would come for treatment on Friday; -On 12/22/22 at 10:22 A.M., the resident had complaints of cough, congestion, runny nose, and malaise. Temperature of 98.6 degrees Fahrenheit (normal). No shortness of breath. The resident was coughing up white sputum. Review of Resident #3's rapid COVID test lab results, dated 12/23/22, showed he/she tested positive for COVID. During an interview on 12/27/22 at 10:15 A.M., the Director of Nursing (DON) said Resident #3 had gone to the hospital that morning not feeling well. 4. Review of Resident #4's face sheet showed he/she is his/her own responsible party. Review of the resident's diagnosis list showed the following diagnoses: -Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), breast cancer, unspecified convulsions (rapid involuntary muscle contractions that often occur during a seizure), and history of Covid-19. Review of the resident's rapid COVID test lab results dated 12/23/22 and 12/26/22, showed he/she tested negative for COVID-19. Review of the facility provided census report for 12/26/22 showed Resident #4 and Resident #3 were roommates. Observation on 12/27/22 at 11:42 A.M., of the residents room showed the door open with a plastic curtain secured around the door frame. The plastic curtain was zipped shut. A cart with PPE was located outside the the room door with gloves, face shields, gowns and N95 masks available for use. A sign on the door said please see charge nurse before entering. A PPE sequence sign for donning (putting on) and doffing (taking off) all PPE noted. Resident #4 was present in the room alone. (Resident #3 was not present in the room as he/she had been transferred to the hospital earlier that morning for evaluation.) 5. During an interview on 12/29/22 a 3:05 P.M. 3:30 P.M. the Infection Preventionist (IP) said he/she was aware of the guidance from the Centers for Disease Control and Prevention (CDC), but felt the information was contradictory. Resident #2 and #4 were quarantined in their room with their roommates who were positive for COVID-19 due to already being exposed to their roommates. Rooming a COVID-19 positive resident and a negative resident together did increase the negative resident's risk of contracting COVID-19. During an interview on 12/27/22 at 10:15 A.M., the Director of Nursing (DON) said there were two COVID positive residents currently, Resident #1 and Resident #3. Resident #3 had gone to the hospital that morning not feeling well. Both of the positive residents were dialysis residents and were isolated to their room unless going to dialysis. Both residents' roommates (Resident #2 and #4) remained in the room in isolation due to already being exposed by the positive residents and had been tested negative. During an interview on 12/27/22 at 10:15 A.M. and 4:15 P.M., the administrator said there were two COVID positive residents, Resident #1 and Resident #3, and Resident #3 went to the hospital this morning not feeling well. The positive residents had been quarantined in their room once a positive result was noted, and only come out to go to dialysis. Their roommates (Resident #2 and #4) were quarantined in their room with their positive roommates due to already being exposed. 6. Review of Resident #22's diagnoses list in the electronic health record, dated 11/30/22, showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing), pulmonary hypertension (condition where the pressure in the blood vessels leading from the heart to the lungs is too high), heart failure, and anxiety. Review of the resident's COVID-19 Respiratory Assessment, dated 12/19/22 and 9:50 P.M., showed the following: -The resident had diminished lung sounds on both sides; -The resident did not have signs or symptoms of COVID-19. Review of the resident's COVID-19 Respiratory Assessment, dated 12/20/22 and 9:50 A.M., showed the following: -Temperature of 100 degrees Fahrenheit (normal is 98.6 degrees); -The resident had wheezes in his/her lungs on both sides; -The resident was short of breath with rest; -The resident had difficulty breathing. Review of the resident's nurse's note, dated 12/20/22 at 4:38 P.M., showed the resident complained of having difficulty breathing due to having a productive cough. Oxygen saturation level was 90% (measures the percentage of oxygen-bound hemoglobin in the blood which indicated how much oxygen is delivered to tissues in the body, normal is 97 to 100%) on supplemental oxygen at three liters/minute per nasal cannula (tubing that provides supplemental oxygen therapy to people who have lower oxygen levels). Staff repositioned the resident and elevated the head of his/her bed. Oxygen saturation increased to 94%. The resident said he/she felt better, but would like some cough syrup for his/her cough. The nurse contacted the physician who ordered a STAT (meaning immediately) chest X-Ray (produces images of the heart, lungs, blood vessels, airways, and the bones of the chest and spine). Review of the resident's chest X-Ray results, dated 12/20/22 at 7:30 P.M., showed bilateral lower lobes (the lower lobes of the lungs on both sides) infiltrates (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs) with pleural effusions (a buildup of fluid between the layers of tissue that line the lungs and chest cavity) and pulmonary vascular congestion (obstruction of the normal flux of blood within the blood vessel network of the lung resulting in engorgement of pulmonary vessels). Follow up examination recommended. Review of the resident's nurse's notes showed the following: -On 12/21/22 at 1:20 A.M., the resident complained of difficulty breathing with noted wheezing in the right lung. As needed inhaler administered. Temperature of 100 degrees Fahrenheit. As needed Tylenol administered as ordered. The nurse practitioner was notified and gave orders for doxycycline (antibiotic) 100 milligrams (mg) twice a day for seven days. Probiotic (a mixture of live bacteria and/or yeast that lives in your body) daily for ten days. The physician was informed of the resident's chest X-Ray results; -On 12/21/22 at 4:44 P.M. the resident complained of shortness of breath. Oxygen saturation of 91%, diminished lung sounds to the lower lobes on both sides, worsening cough, using abdominal muscles to breath. The resident requested to go to the hospital. The resident refused a breathing treatment, saying he/she had already had four breathing treatments and they hadn't done any good. The physician was contacted and the resident was sent to the emergency room . Review of the resident's medical record from December 2022, showed the resident was not tested for Covid-19 at the facility. Review of the resident's emergency room physician documentation, dated 12/21/22, showed the following: -The resident arrived at the emergency department at 5:17 P.M.; -At 7:30 P.M. the resident was found to be positive for COVID-19; -The resident was admitted to the hospital for further management of respiratory failure, pneumonia, and COVID-19; -The resident was started on Remdesivir (an antiviral agent that is administered intravenously and inhibits viral replication) for treatment of COVID-19. During an interview on 12/29/22 at 2:35 P.M. Registered Nurse (RN) G said he/she did recall Resident #22 having diminished lung sounds and RN G documented the resident's respiratory assessment on 12/19/22. RN G said the nurses could use their discretion to test a resident for COVID-19. There were plenty of the rapid COVID-19 swab testing kits available for staff to use. RN G did not consider testing Resident #22 for COVID-19 as he/she attributed the resident's symptoms to his/her COPD. The resident's X-ray results were reported to the physician. During an interview on 12/30/22 at 8:00 A.M. RN H said he/she completed Resident #22's respiratory assessment on 12/20/22. RN H called the resident's physician on 12/20/22 and the physician gave orders to start the resident on an antibiotic and reviewed the results of the resident's chest X-Ray. RN H said he/she had been instructed to test residents for COVID-19 if they show signs and symptoms such as fever or shortness of breath. The facility nurses could test resident's for COVID-19 at their discretion and there were plenty of supplies available to do so. RN H did not test Resident #22 for COVID-19, because the resident was new to him/her and RN H attributed the resident's symptoms to COPD. RN H was most concerned with the resident's X-Ray results which showed pneumonia. During an interview on 12/20/22 at 11:05 A.M., Licensed Practical Nurse (LPN) I said he/she had not worked with Resident #22 before, but he/she was the resident's nurse on 12/21/22. The resident did have a cough, wheezing, and shortness of breath. Nurses can test residents in the facility for COVID-19 if they have respiratory symptoms and there are plenty of tests available to do so. LPN I did not consider testing Resident #22 for COVID-19 as he/she had a chronic respiratory illness. LPN I said he/she was more focused on getting the resident sent to the hospital as the resident needed emergent treatment. 7. During an interview on 12/29/22 a 3:05 P.M. 3:30 P.M. the Infection Preventionist (IP) said nurses could test residents in the facility for COVID-19 anytime a resident was symptomatic. The main symptoms that would indicate testing for COVID-19 to be conducted were fever and increased or productive cough. Resident #22's respiratory assessment on 12/20/22 where he/she had a fever should have prompted the nurse to conduct a COVID-19 test. Resident #3's documented symptoms in the nurse's notes on 12/21/22 should have prompted nursing staff to conduct COVID-19 test. During an interview on 12/29/22 at 3:50 P.M. the DON said nurses could use their discretion to determine when to test residents in the facility for COVID-19. There were plenty of supplies available. Nursing staff should have tested Resident #22 for COVID-19 on 12/20/22 when he/she exhibited respiratory signs and symptoms. Nursing staff should have tested Resident #3 for COVID-19 on 12/21/22 when he/she exhibited respiratory signs and symptoms. Symptoms that would prompt testing for COVID-19 were fever, shortness of breath, cough, and diarrhea. The facility had not tested residents for COVID-19 for quite some time prior to 12/23/22. The DON felt facility staff had become complacent because the facility had not had a positive case of COVID-19 for over a year. 8. During an interview on 1/16/23 at 4:00 P.M. Resident #1, #3, and #22's physician said he/she expected facility staff to test residents with respiratory symptoms for COVID-19 and expected staff to separate residents who were positive for COVID-19 from their roommates who were negative to limit the exposure. The physician could not say if a delay in the facility testing of Resident #22 for COVID-19 and obtaining treatment had any detrimental effect on the resident. MO00211719 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility (briefly state what the facility did to remove the immediacy/imminent danger and what the facility still has to do before it can be corrected.) A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the 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 violation(s).

U4413 Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 14 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #23). The facility census was 70. 1. Record review of the facility's maintained Accounts Receivable Report for the period 12/01/21 through 12/15/22, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #1 $1,981.00 #2 $1,703.00 #3 $1,916.00 #4 $1,612.00 #5 $ 317.46 #6 $4,463.13 #7 $4,403.00 #8 $8,975.00 #9 $1,026.72 #10 $1,950.00 #11 $2,438.00 #12 $1,225.00 #13 $ 547.00 #23 $5,456.87 Total $38,014.18 During an interview on 12/13/22 at 2:17 P.M., the Regional Business Office Manager said the facility is working on the Accounts Receivable, but only have access to files from 08/2022 to current. The facility changed management companies in 08/2022. During email correspondence on 12/16/22 at 1:40 P.M., the Regional Business Office Manager told the Administrator the credit balances have not been refunded because of the change of management and the facility is unsure if there are credits due to the residents.

Based on interview and record review, the facility failed to ensure one resident (Resident #6), in a review of 3 sampled residents, was free from misappropriation of his/her property, when hospitality aide (HA) A misappropriated the resident's money. The facility census was 67. The administrator was notified on 12/29/22, of the Past Non-Compliance which occurred prior to 12/13/22. On 11/30/22, the facility became aware of the noncompliance when the issue was reported to the facility. Facility staff immediately started an investigation, completed disciplinary action, began in-servicing all staff and residents on 12/01/22. Facility staff also notified Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 12/01/22. Review of the facility's Abuse and Neglect Policy, revised 9/2016, showed the following: -Employees are trained through orientation and ongoing training on issues related to abuse/neglect and misappropriation of resident property; -This facility desires to prevent abuse, neglect, and theft by establishing a resident secure environment. 1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, 9/22/22, showed the resident was cognitively intact. Review of the resident's face sheet showed the resident was his/her own responsible party and did not list any additional source of income. During an interview on 12/13/22 at 1:40 P.M., Resident #6 said he/she received a dividend check in the amount of $1806.60. Resident #6 did not tell the facility about receiving dividend checks as he/she did not feel it was any of facility business. Resident #6 said he/she told HA A about the dividend check he/she received. Resident #6 said he/she trusted HA A and HA A was going to help find him/her a handicapped accessible apartment. Resident #6 said he/she gave HA A the check on 11/16/22 to cash for him/her. Resident #6 said HA A and his/her friend came to the facility on [DATE] and said HA A was unable to cash the check. Resident #6 said HA A was going to try and cash the check at his/her friends bank in another town and gave Resident #6 $100.00. Resident #6 said HA A's friend was a fast talker. Resident #6 said he/she reported to Certified Medication Technician A on 11/30/22 he/she had given HA A the check. Resident #6 called the company, with the Director of Nursing (DON) present on speaker phone, and was informed the check was cashed on 11/16/22 by HA A. Resident #6 said he/she did receive a cashier's check for $600.00 that was brought to facility by someone for HA A. The resident said the police came and took his statement and he/she wanted to press charges as HA A needed to be checked for taking advantage of him/her. Review of the facility's self report, sent to the state agency on 11/30/22, showed the following: -Resident #6 reported on 11/30/22, he/she gave HA A dividend check to cash for him/her and only received a $100.00 back. -Resident #6 with DON present called the company that issued the dividend check and verified HA A signed and cashed the check on 11/16/22. -On 12/01/22 HA A admitted to taking the check for Resident #6. HA A stated Resident #6 asked him/her to cash it stating people were stealing Resident #6's money. HA A said he/she took the check and had a friend cash it and put it in his/her savings account. HA A stated he/she did bring Resident #6 $100.00. HA A said he/she was holding on to Resident #6's money so the resident could get his/her own place. HA A said he/she would bring in the remaining money to the facility 12/02/22. HA A suspended pending investigation. HA A never brought in the money on 12/02/22 and has been terminated. Facility attempts made to call/contact HA A without success. -Facility contacted police who came and took report. Resident wants to press charges. -On 12/07/22, HA A had someone drop off a $600.00 cashier's check for Resident #6. Facility staff took resident to the bank to cash the check and purchased a lock box for the resident. During an interview on 12/13/22, at 1:00 P.M., the DON said the following: -Resident #6 had not reported receiving a dividend check or giving check to HA A until 11/30/22. The DON sat in on phone call the resident made to the company regarding the dividend check. The company representative verified the check was signed and cashed by HA A. The company provided a copy of the signed check to facility. During an interview on 12/13/22 at 1:00 P.M., the administrator said the following: -HA A admitted to taking the dividend check to cash for the resident and said he/she gave the resident $100.00. HA A said he/she put the money in his/her saving account to hold for the resident to get his/her own place. -HA A immediately put on suspension; -Police were notified and came out to take statement from the resident. During an interview on 1/6/23 at 3:20 P.M., HA A said he/she took a check from Resident #6 for $1806.00 and cashed it for the resident. He/She had a friend cash the check and deposit it in the friend's account. HA A said the friend gave him/her $600.00. HA A said he/she sent the resident a $600.00 cashier's check. He/She said the check was on a ten day hold. MO00210543

Based on observation, interview, and record review the facility failed to follow physician orders for one resident (Resident #16) of 23 sampled residents. The facility failed to administer a scheduled antibiotic or notify the on-call physician for order clarification as per policy for Resident #16. The facility census was 70. Review of the facility policy, Medication Unavailable Policy, dated 12/20/19, showed the following: -This policy is put into effect to give the licensed nursing staff direction on how to obtain medications and document effectively; -If medications are not available for administration: search medication cart, obtain from emergency box if medication is stocked, if medication is not stocked immediately call the pharmacy to obtain medication; -If pharmacy cannot deliver or if the medication cannot be delivered within the ordered time frame, notify the physician; -Notify physician if medication cannot be given in the time frame ordered and document physician response; -The Director of Nursing (DON) or designee should be notified when there is a medication that continues to be unavailable. 1. Review of Resident #16's census report showed the resident admitted to the facility on [DATE]. Review of the resident's December 2022 physician order sheet showed an order to administer ceftriaxone sodium (an antibiotic used to treat bacterial infections) 2 grams intravenously (IV) every 12 hours at 8:00 A.M. and 8:00 P.M. for seven days with a start date of 12/23/22. Review of the resident's December 2022 medication administration record (MAR) showed the resident did not receive his/her 8:00 P.M. dose of ceftriaxone on 12/23/22. Review of the resident's nursing progress notes, dated 12/24/22 at 12:35 A.M., showed ceftriaxone sodium solution 2 grams IV every 12 hours for infection x 7 days, waiting on arrival from pharmacy. Review of the list of medications available in the facility emergency medication kit showed ceftriaxone 1 gram injectable, two vials, were available for use. Review of the resident's December 2022 progress notes showed no documentation the physician was notified of the missed dose of antibiotic. During an interview on 12/27/22 at 12:34 P.M., the resident said the following: -I am only here to get IV antibiotics and then I can go home; -I don't know how long I will have to stay now that I have missed some of my antibiotics; -It makes me stressed to know that I have missed some of my antibiotics; -The doctor told me it was absolutely necessary to receive all of my antibiotics, it worries me that I have not. During an interview on 12/29/22, at 2:40 P.M., Licensed Practical Nurse (LPN) B said the following: -He/She took care of the resident on 12/23/22 during the evening shift; -Pharmacy had not delivered the IV antibiotic for the resident at the time it was scheduled to be administered; -He/She did not have staff check the emergency medicine kit to see if the antibiotic was available; -He/She did not administer the resident's IV antibiotic at 8:00 P.M. on 12/23/22; -He/She was not aware the physician needed to be called for a missing antibiotic since the medication was on its way from the pharmacy; -He/She did not call the physician on call to make them aware the antibiotic was not available to administer and ask for additional direction; -He/She did not call the DON to make him aware the medication was not available to administer at 8:00 P.M. During an interview on 12/29/22 at 3:33 P.M., the DON said the following: -He entered the medication into the system for Resident #16; -By history the pharmacy deliveries usually occur around 6 P.M. and around midnight; -If an IV antibiotic was not available to be given as scheduled he would expect nursing staff to notify the physician for further orders; -To his knowledge the physician was not notified to receive additional orders related to the unavailable antibiotic for resident #16. During an interview on 12/29/22 at 4:15 P.M., the administrator said the following: -IV antibiotics are delivered in the pharmacy runs and it depends on what time the medication is ordered as to what delivery it will arrive in; -If any medication is unavailable, the emergency medication kit should be checked and if unavailable the physician should be notified for a hold order. During an interview on 1/3/23 at 10:59 A.M., Resident #16's physician said the following: -He/She would expect to be notified if an antibiotic was unavailable for administration for a new admission or new order; -He/She would expect medications to be given as ordered; -He/She would expect physician orders to be followed as written; -He/She did not see any indication the facility had notified the on-call physician for clarification of orders related to missing antibiotic for Resident #16. MO00211719

U4413 Based on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for two residents (Resident #14 and #15) out of a sample of two. The facility census was 70. 1. Record review of the Admission/discharge date s provided by the administrator on 12/13/22 at 2:51 P.M., showed Resident #14 admitted on [DATE] and Resident #15 admitted on [DATE] and both residents discharged on [DATE]. Record review of the facility maintained Room and Board Statement, dated 09/30/22, showed Resident #14 had a credit balance of $3,202.66 and Resident #15 had a credit balance of $3,082.71. Record review of the facility maintained Accounts Receivable Report, dated 12/15/22, showed Resident #14 had a Medicaid pending credit in the amount of $3,202.66 and Resident #15 had a Medicaid pending credit in the amount of $3,082.71 as of 12/15/22 (99 days after both Residents #14 and #15 discharged ). Record review of the Missouri HealthNet Vendor Notice, dated 08/24/22, showed both Resident #14 and #15 became Medicaid approved retroactive to 03/01/22. During an interview on 12/13/22 at 2:17 P.M., the Regional Business Office Manager said the facility was working on the credits, but only had access to files from 08/2022 to current. The facility changed management companies in 08/2022. During email correspondence dated 12/28/22 at 10:09 A.M., the administrator provided a copy of check #740 in the amount of $3,791.47 that brought the balance to zero for both Residents #14 and #15. The check was received by Residents #14 and #15's Financial Power of Attorney (POA) on 12/23/22, (107 days after both Residents #14 and #15 discharged .) MO00211085

Based on observation, interview and record review, the facility failed to implement interventions consistent with one resident's (Resident #1's), plan of care to address the resident's behaviors and psychosocial needs. The resident made statements he/she molested residents, wandered throughout the facility without wearing clothing, and provoked his/her roommate to hit him/her. Staff failed to consistently identify the root cause for the resident's behaviors and implement interventions to meet the resident's psychosocial needs. On 8/18/22, staff documented multiple incidents where the resident wandered without his/her clothing, and also made a request to speak to his/her physician regarding his/her concern about his/her mental health. On the evening of 8/18/22, the resident wandered into another resident's (Resident #2's), room and hit the resident while the resident lay in bed. Resident #2 sustained injuries including a fractured nose and a laceration requiring sutures above his/her eye. The facility census was 67. Review of the facility's policy Dementia-Clinical Protocol, revised November 2018, showed the following: -Physician will identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition on the initial assessment; -Staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments; -For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life; -Nurse assistants will receive initial training in the care of residents with dementia and related behaviors. -In-services will be conducted at least annually thereafter; -Performance reviews will be conducted annually and in-service education will be based on the results of the reviews; -IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise; -Staff will monitor the individual with dementia for changes in condition and decline in functional and will report these findings to the physician; -The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements; -Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time, unless a clinical rationale for higher doses or longer-term use is documented; -IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors; -The physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral psychiatric symptoms and will adjust, stop or change such medications as indicated. 1. Review of Resident #1's nurses notes, dated 7/22/22 at 8:38 P.M., showed the resident was admitted to the facility from the hospital. Review of the resident's baseline care plan, revised 7/22/22, showed the following: -The resident was cognitively impaired; -The resident could easily communicate with and understand staff; -The resident was independent with bed mobility, transferring, toileting, eating, ambulating, locomotion and did not use any mobility assistive devices; -The resident was taking anti-psychotic/psychotropic medications. Review of the resident's physician's orders for July 2022 showed the following: -Diagnoses included unspecified dementia with behavioral disturbances, anxiety disorder, recurrent depressive disorder, encephalopathy (a brain disease that alters brain function or structure), and cognitive communication deficit; -Donepezil (cognition enhancing medication) 10 milligrams (mg), give two tabs in the evening for dementia (ordered 7/22/22); -Quetiapine (antipsychotic medication) 50 mg at bedtime for mood (ordered 7/22/22). Review of the resident's nurses notes, dated 7/23/22 at 11:41 A.M., showed orders obtained to give Seroquel (brand name for quetiapine) 50 mg one time now for increased behaviors and Ativan (anti-anxiety medication) 1 mg three times a day (TID). (Review of the nurses notes showed no documentation the resident exhibited behaviors on 7/22/22 or 7/23/22.) Review of the resident's physician's orders for July 2022 showed the following: -Ativan (antianxiety medication) 1 mg three times a day (TID) for anxiety (ordered 7/23/22); -Sertraline HCL (antidepressant medication used to treat depression and mood disorders) 100 mg daily (ordered 7/23/22). Review of the resident's care plan, revised 7/26/22, showed the following: -The resident had impaired cognitive function/dementia or impaired thought processes/communication related to dementia; -Staff were to communicate with the resident/family/caregivers regarding resident's capabilities and needs; -Staff were to use the resident's preferred name, identify themselves at each interaction, face the resident when speaking and make eye contact, ask yes/no questions in order to determine the resident's needs; -The resident understood consistent, simple, directive sentences. Staff were to provide the resident with necessary cues, stop and return if agitated, cue, reorient, and supervise as needed; -Staff were to review medications and record possible causes of cognitive deficits. Review of resident's admission Minimum Data Set (MDS), a federally required assessment instrument, dated 7/28/22, showed the following: -Resident was admitted on [DATE]; -Severe cognitive impairment; -Diagnosis of dementia; -Sometimes understand others; -Other behavioral symptoms not directed toward others one to three days in the seven day look back period. -Significantly disrupts living environment; -Wandering occurred one to three days in the seven day look back period; does not intrude. -Independent with bed mobility, transfers, dressing, and ambulation; -Received antipsychotic medications on a routine basis. Review of the resident's nurses notes showed no documented behaviors, including wandering, as indicated on the resident's admission MDS, from admission on 7/22/22 through 7/28/22. Review of the resident's Skilled Nurse's Note, dated 7/28/22 at 3:14 P.M., showed the following: -The resident's mood/affect was cooperative, anxious, short temper/easily annoyed; -No behaviors of wandering, verbal or physical behaviors, socially inappropriate, or rejected evaluation or care noted. Review of the resident's care plan, revised 7/28/22, showed the following: -The resident is at risk for elopement/wandering related to impaired cognition; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book; -Identify patterns of wandering and intervene as appropriate; -Provide the resident with a program of activities that was of interest and empowers the resident, and provide materials for individual activities; -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of the resident's nurses notes, dated 7/29/22 at 11:41 A.M., showed the resident walked down to Unit #2 to tell staff he/she exposed himself/herself in front of other residents. (Review showed no documentation of interventions staff implemented to address the resident exposing himself/herself to other residents on this date.) Review of the resident's Nurse's Notes, dated 7/30/22 at 7:38 P.M., showed the following: -At approximately 2:03 P.M., the resident told staff, I'm thinking of molesting some of the people here.; -Staff discussed with the resident the inappropriate behavior and that it was not allowed in the facility; -A few minutes later, the resident said, I'm going to molest some people here. It's going to happen.; -The resident was crying and said, You can call them for what I did last night. I molested those two old ladies.; -Management was notified and a verbal order was received to send the resident to the hospital for evaluation. Review of the resident's Nurse's Notes, dated 7/30/22 at 7:51 P.M., showed the following: -Hospital staff contacted facility staff to report the resident's urine and lab work were okay, and the resident was not belligerent and was remorseful; -The physician said there was nothing wrong with the resident and said the resident was not a threat to residents or staff. Review of the resident's Nurse's Notes, dated 7/30/22 at 8:35 P.M., showed the following: -Management onsite to meet with the resident and family. Resident and family instructed that any obscene behaviors could not be tolerated if the resident wished to stay in this facility. All involved voiced understanding; -The resident was interviewed and voiced remorse for his/her statements. His/Her mood was sad and tearful. He/She said he/she wanted someone to talk to and wanted to get their attention; -Discussed more appropriate ways of calling attention to himself/herself. Voices understanding; -Physician made aware of all findings, order given to continue current medication regimen. During an interview on 8/29/22, at 6:56 P.M., Registered Nurse (RN) F said the following: -On 7/30/22, Resident #1 told an Licensed Practical Nurse (LPN) he/she wanted to molest someone, then 30 minutes later, the resident said he/she was going to molest someone; -He/She went to speak with the resident around 2:30 P.M. and the resident said he/she molested two old ladies last night; -He/She placed the resident on one-on-one supervision; -Staff called the resident's physician and got orders to send the resident to the emergency room ; -When the resident was sent back to the facility, he/she placed the resident on one-on-one supervision for 24 hours. (Review of the resident's nurses notes showed no documentation staff placed the resident on one-on-one supervision after he/she returned from the hospital in the evening on 7/30/22. Review of the nurses notes on 7/31/22 at 12:39 P.M. showed the resident was walking in the halls without any clothing. Further review of the notes on 7/31/22 showed the resident was out of his/her room on multiple occasions without clothing on this date. The notes do not indicate the resident was on one-on-one during these incidents.) Do we have interviews with staff regarding the 1:1 supervision? Review of the resident's Nurse's Notes, dated 7/31/22 at 12:39 P.M., showed the following: -The resident was walking in wing 1 naked, this is the second or third time today he/she was walking in the halls naked; -The nurse called out to him/her by name and asked him/her to stop, then called out a little louder; the resident did not stop; -The nurse reached for the resident and touched the resident on the arm. The resident pulled away from nurse; -Staff instructed the resident he/she could not be out of his/her room naked. The resident said, I do not and why; -Staff walked him/her to his/her room and instructed him/her to get dressed; -Staff went into the resident's room two minutes later and he/she was trying to remove his/her wanderguard (a device worn on a resident's wrist that alerts caregivers when the resident approaches a monitored door to help protect the resident against elopement); -The resident asked staff to just call the police and have him/her arrested for being naked; -Staff reinforced the resident was not to be out of his/her room without being appropriately clothed. (Review showed no evidence staff attempted to identify the root cause for the resident's behavior or implement behavioral/psychosocial interventions to address the cause of the behavior.) Review of the resident's nurses notes, dated 7/31/22 at 12:45 P.M., showed this event was the third such event today. The resident was in the halls earlier. The resident's family member arrived for a visit and found the resident walking out of his/her room naked. Review of the resident's Nurse's Notes, dated 7/31/22 at 9:01 P.M., showed staff interviewed the resident about behaviors in past 24 hours. Confusion was noted in the resident and his/her mood was labile throughout the interview. The resident had little recall of events in last 24 hours. The resident's physicians were notified and orders given to again continue current medication regimen. Staff were informed that resident's primary physician would be conducting rounds in the morning and would address any issues. Review of the resident's history and physician, completed by the resident's physician on 8/1/22, showed the following: -Diagnoses: Alzheimer's disease, dementia with behavioral disturbances, and inappropriate sexual behavior; -Problem: The resident has made trouble by exposing himself/herself in the hallways and making advances at residents of the opposite gender in the facility. He/She remembers this and has dementia. He/She needs psychiatric (psych) consult. The resident walks the hallways and then seems to become more anxious; -Plan: Decrease Zoloft (sertraline) to 50 mg daily for seven days then discontinue. Depakote 250 mg twice daily and psych consult. Review of the resident's care plan, revised 8/1/22, showed the following: -The resident seeks attention by coming out of his/her room naked and reporting he/she wants to 'molest' someone and then requests for others to call the police on him/her. He/She has been educated on appropriate ways to get attention and behaviors that are appropriate versus inappropriate and he/she states understanding; -The resident will put himself/herself on the floor at times; -Anticipate and meet the resident's needs; -Caregivers provide opportunity for positive interaction and attention. Stop and talk with the resident as passing by; -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident; -Intervene as necessary to protect the rights and safety of others. Divert the resident's attention. Remove the resident from the situation and take to an alternate location as needed; -Monitor behavior episodes and attempt to determine the underlying cause. Document the resident's behavior and the potential causes. Review of resident's care plan, revised 8/2/22, showed the following: -Staff were to encourage social interactions and participation in activities with others that have similar interests; -Staff were to provide community resources to the resident and/or family/caregiver as needed/requested; -Staff were to provide emotional and spiritual support for resident and/or family/guardian decisions as needed; -The resident used psychotropic medications related to behaviors, anxiety, and depression; -The resident was to remain free of psychotropic drug related complications, including cognitive/behavioral impairment; -Staff were to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift; -Staff were to discuss with medical physician and family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; -Staff were to monitor/document/report as needed any adverse reactions of psychotropic medications: behavior symptoms not usual to the person. Review of the resident's physician's orders, dated 8/2/22, showed the following: -A new order for Depo-Provera suspension (a hormone suppressing medication which lowers testosterone levels), inject 150 mg intramuscularly (in the muscle) once per day; -A new order for divalproex sodium (a medication used to treat seizures and certain psychiatric conditions) delayed release 250 mg twice a day for mood. Review of the resident's Progress Note from Heartland Geriatrics, dated 8/8/22, showed the following: -On 8/8/22, the resident was seen for an initial evaluation using telemedicine (care was provided from a remote location separate from where the patient resided); -The resident was seen for wandering halls, confusion, dementia, and evaluation for medication management; -The resident's review of systems showed he/she had mild restlessness at times, cognitive impairment, confusion, and disorientation; -The resident's mental status examination showed he/she was calm, confused, unfocused, and maintained poor eye contact, speech was slow, and his/her concentration, insight, and judgment were limited/poor; -The resident's diagnoses included dementia with behavioral disturbance, unspecified dementia type; -Recommendations for the resident's plan of care included continue offering activities, social events and group initiatives as well as personal one-on-one time; continue being flexible with resident's mood and validate concerns and feelings with acknowledgment and empathy; offer concise, clear, slowly stated directions to assist with and prevent confusion; ensure regular physical activity as tolerated; offer supportive environment, calm redirection efforts, and anticipate needs; -Recommend not giving scheduled benzodiazepines for long-term usage unless severe anxiety/agitation is persistent due to its propensity to increase confusion, sedation, respiratory depression, disinhibition, orthostasis/hypotension, increased risk for falls, recommend writing a 14-day parameter for any benzodiazepine PRNs with required physician review as well as behavior documentation by floor staff to evaluate further necessity of its use after the 2 week period; -Modifications for inappropriate behaviors: offer redirection and education when verbally or sexually inappropriate; recommend male staff working with this resident; offer slow, concise and understandable explanation to resident why behavior is unacceptable when it occurs; offer snacks, exercise/walks, crafts/activities for distraction and redirection efforts; if conservative management is ineffective, can evaluate for paroxetine, mirtazapine, trazodone or other psychopharmacologic intervention in future if these instances continue to occur. Review of the resident's physician's orders, dated 8/10/22, showed the order for Sertraline HCL was discontinued. Review of the resident's nurses notes showed no documented behaviors, including wandering, from 8/1/22 through 8/10/22. Review of the resident's Skilled Nurse's Note, dated 8/11/22 at 1:01 A.M., showed the following: -The resident's mood/affect was cooperative, anxious, short temper/easily annoyed, little interest in doing things, negative feelings about self/life; -Wandering behavior noted. Review of the resident's Nurse's Notes, dated 8/13/22 at 9:57 P.M., showed the following: -The resident was struck by his/her roommate (Resident #6); -The resident had scant blood from right nostril and swelling beginning around his/her nose and both eyes; -The resident said he/she was irritated by his/her roommate hollering out, and approached his/her roommate and told his/her roommate to hit him/her; -The resident said he/she stood over his/her roommate's wheelchair and repeatedly asked to be struck until his/her roommate struck him/her; -The resident said he/she then went to the hallway and hollered out for staff's assistance; -When staff asked the resident why he/she did this, he/she said he/she didn't think his/her roommate could reach him/her from his/her wheelchair and he/she just wanted his/her roommate to be quiet; -The resident said he/she regretted starting an argument and denied anger; -The resident was shown his/her new room and was oriented to the hall; -Physician notified, x-ray and lab orders received; -Staff placed the resident on 15 minute safety checks. During an interview on 8/24/22 at 3:50 P.M., Resident #6 said the following: -Resident #1 kept asking him/her (Resident #6) to hit him/her because he/she did something bad, and he/she felt bad for what he/she was doing; -He/She hit Resident #1 because Resident #1 asked him/her to; -The whole situation made him/her feel bad because it was a bad deal; -Resident #1 told him/her that he/she took his/her clothes off because he/she wanted attention. Review of the resident's care plan, revised 8/15/22, showed the resident was educated to not ask peers to hit him/her for any reason and to remove himself/herself from the area if a peer is irritating him/her. (Review showed no interventions were identified for staff to implement to address the resident's request for physical aggression. The care plan showed staff educated the resident, who has been identified as having severe cognitive impairment and has exhibited repeated compulsive behaviors, to remove himself/herself from the situation.) Review of the resident's Nurse's Notes, dated 8/17/22 at 2:20 A.M., showed the following: -At approximately 7:30 P.M. on 8/16/22, the resident was walking up the hallway naked carrying his/her clothes in both hands covering his/her genitals; -Staff asked the resident to please go to his/her room if he/she did not want to wear clothes. The resident said, I'm sorry repeatedly; -The resident returned a few minutes later fully dressed, and staff educated the resident again on wearing clothes in common areas. The resident said, okay, I'm sorry.; (Review showed no evidence staff attempted to identify the root cause for the resident's behavior or implement behavioral/psychosocial interventions to address the cause of the behavior.) Review of the resident's Nurse's Notes, dated 8/17/22 at 10:01 A.M., showed the following: -At 9:00 A.M., the resident was in the activity area and started taking off his/her clothes; staff redirected him/her; -Staff noted the resident coming up the hall from unit 1 naked. The resident was taken to room and dressed. (Review showed no evidence staff attempted to identify the root cause for the resident's behavior or implement behavioral/psychosocial interventions to address the cause of the behavior.) Review of the resident's Nurse's Notes, dated 8/18/22 at 10:07 A.M., showed the following: -The resident was found laying on the floor in the activities room with no shirt on, his/her pants half down his/her legs, and no underwear on facing the door; -Staff instructed the resident to put on his/her clothes and get off of the floor. Staff redirected the resident back to his/her room where he/she could lay down and take a nap; -The resident told the nurse he/she was concerned about his/her mental health and would like to speak to a doctor regarding his/her mental state; -The nurse notified the DON and will pass along in report. (Review showed no evidence staff notified the resident's physician of the resident's comments concerning his/her mental health. Review showed no evidence staff attempted to identify the root cause for the resident's behavior or implement behavioral/psychosocial interventions to address the cause of the behavior.) Review of the resident's Nurse's Notes, dated 8/18/22 at 11:00 A.M., showed the following: -The resident was walking down the 500 hall completely naked; -Staff instructed the resident to go back into his/her room and put on his/her clothes; -The resident said,, Okay, I'm sorry. (Review showed no evidence staff attempted to identify the root cause for the resident's behavior or implement behavioral/psychosocial interventions to address the cause.) Review of the resident's Nurse's Notes, dated 8/18/22 at 2:52 P.M., showed the following: -The resident was found walking around in the activities room completely naked; -The nurse instructed the resident to put on his/her clothes; -The resident said, I understand. Review of the resident's Nurse's Notes, dated 8/18/22 at 3:00 P.M., showed the following: -Staff spoke with the resident. The resident denied any anger or hostilities toward any staff or residents, and denied physical pain or discomforts; -The resident said he/she was unsure why he/she continued to undress in inappropriate places; -The resident said he/she would like to go home but understands his/her family cannot meet his/her current needs. Discussed alternative placements and the resident declined wanting to seek any other placements. The resident said he/she felt that staff care for him/her and he/she appreciates what they do for him/her; -Staff encouraged the resident to go to daily activities; -Staff asked the resident if he/she feels his/her current medication regimen was appropriate and helping him/her. He/She responded to the affirmative and said he/she was at times confused but better than it was before admission; -Staff told the resident he/she would be put on doctor's rounds for Friday morning (8/19/22). -Staff educated the resident that if he/she had any needs, to seek out staff and make his/her needs known. Review of the facility's investigation, dated 8/18/22, showed the following: -On 8/18/22 at 7:23 P.M., the administrator was notified Resident #2 had been hit; -Certified Nurse Assistant (CNA) I said he/she was in Resident #2's room giving care at around 7:00 P.M.; -CNA I came out of the bathroom in Resident #2's room, saw Resident #1 in Resident #2's room, and then saw Resident #1 leave Resident #2's room and go into the dining room; -CNA I returned to Resident #2's room around 7:15 P.M. to answer the resident's call light; -Resident #2 had blood on his/her face and the right side of his/her face was swollen; -Resident #8 reported seeing Resident #1 walk out of Resident #2's room at 7:15 P.M. and walk back down the hallway towards his/her room; -Resident #1 admitted to going into Resident #2's room and hitting him/her; -Resident #1 said he/she did not know why he/she hit Resident #2, but was apologetic; -Resident #2 was sent to the hospital for evaluation and returned to the facility with three stitches to a laceration above his/her eye and a fractured nose; -Staff monitored Resident #1 until he/she was discharged from the facility to his/her family at 11:50 P.M. During an interview on 8/24/22 at 1:05 P.M., CNA I said the following: -While performing care in Resident #2's room on 8/18/22, he/she came out of the bathroom in Resident #2's room and saw Resident #1 hovering over Resident #2's head. Resident #1 had his/her hands behind his/her back; -She thought Resident #1 knew Resident #2, and it looked like Resident #1 was checking on Resident #2; -Resident #1 didn't say anything while he/she was in the room; -He/She bumped into a chair in the room, and then Resident #1 left Resident #2's room and went to the dining room; -He/She finished performing care in Resident #2's room and left the room to assist another staff perform care in another resident's room; -He/She came back to Resident #2's room a few minutes later to answer the call light that had been activated for Resident #2's room, and saw that Resident #2 was injured and bleeding from his/her head. He/She called out for help from nearby staff; -He/She then saw Resident #1 walking down the hall in the distance toward Unit #2 of the facility; -Staff came to assist in caring for Resident #2's injuries and Resident #1 was placed on one-on-one observation; -He/She began employment at the facility on 8/15/22 (three days prior to the incident involving Resident #2) and did not receive dementia, abuse, or neglect training when he/she was hired; -He/She was not aware of Resident #1's behaviors or his/her past statements regarding wanting to molest someone; -He/She was told Resident #1 walked around naked sometimes and staff would redirect him/her; -He/She did not know how to find out about a resident's behaviors or past history in the resident's chart. Review of the resident's Nurse's Notes, dated 8/18/22 at 11:30 P.M., showed Resident #1 was escorted out of the facility and left with family. Review of Resident #1's Nurse's Notes, dated 8/19/22 at 10:25 A.M. (documented after the resident was discharged from the facility), showed the following: -Staff received a call that the resident had struck another resident; -The resident admitted to striking another resident but refused to give any indication as to the motivation or anything that would have precipitated a violent outburst. The resident denied any anger or resentment towards staff or peers, mood flat, speech stunted and slow; -The resident remained one-on-one with staff until family arrival at approximately 11:30 P.M. and departure from property noted at 12:10 A.M. Observation on 8/24/22 at 4:14 P.M., showed the right side of Resident #2's face had yellow and blue colored bruising in an approximately 4 inch by 5 inch area that extended below the resident's eye and up into his/her hairline approximately 1 inch. The total surface area of the bruising was the size of a small dinnerplate. The resident's nose had small scabbed areas and areas of healing bruising. During an interviews on 8/24/22 at 3:54 P.M. and 8/26/22 at 12:41 P.M., Resident #1's representative said the following: -The resident would strip down and walk down the halls naked. He/She was unsure where this behavior came from since the resident did not do this prior to coming to the facility; -He/She did not believe the resident had received any psychiatric evaluation while at the facility; -Prior to coming to the facility, the resident was having increased confusion and memory issues, but did not have any past history of physical aggression or of mentioning sexual assault. -He/She felt like there was not enough oversight or staff to monitor the resident, especially during the evenings. During an interview on 8/24/22, at 11:50 A.M., Resident #4 said the following: -Resident #1 would walk down the hall without a stitch of clothing on; -Resident #1 would walk all the way from his/her room without clothing to the nurses desk and back to his/her room a couple of times before any staff would see him/her or intervene; -Resident #1 made all the residents feel uncomfortable; -The facility did not have enough staff for a resident like that; -If staff were in a room cleaning someone up, there was no one to watch Resident #1 who wandered around the facility. During an interview on 8/24/22 at 11:54 A.M., Resident #10 said the following: -He/She felt uncomfortable when Resident #1 would constantly stop at his/her doorway and stare into his/her room; -One time, he/she saw Resident #1 walking with no clothes on in the hallway; -He/She did not feel safe at the facility when Resident #1 resided at the facility. During an interview on 8/24/22, at 11:55 A.M., Resident #5 said the following: -Resident #1 would walk up and down the hall without any clothing on; -This made him/her feel uncomfortable; -There was not enough staff to keep up with Resident #1. During an interview on 8/24/22, at 12:20 P.M., Resident #7 said the following: -Resident #1 would follow him/her; -Sometimes Resident #1 would stare at him/her from the hallway into his/her room; -Often Resident #1 would not have any clothes on when he/she would stare at him/her; -Resident #1 was often without clothing in the hallway; -It made him/her so uncomfortable, so he/she asked the staff to keep Resident #1 away from him/her. During an interview on 8/24/22, at 11:20 A.M., CNA A said the following: -The resident would take off all of his/her clothing and lay on the floor or walk down the hall; -He/She did not know if the resident went in and out of other residents' rooms; -The facility did not have enough staff to keep up with the resident to know if he/she went in and out of other residents' rooms; -The resident also had sexual behavior

Refer to event ID 22T312 Based on interview and record review, the facility staff failed to ensure one resident (Resident #3) with a diagnosis of hypothyroidism (underactive thyroid, a condition in which your thyroid gland doesn't produce enough of certain crucial hormones), received his/her levothyroxine (a synthetic thyroid hormone used as a thyroid hormone replacement medication) from 12/31/21 through 2/8/22 as ordered on his/her hospital discharge instructions on 12/30/21. The resident required hospitalization again on 2/8/22 and per the hospital record the resident's presentation was presumed to be secondary to myxedema coma (severe hypothyroidism). The facility also failed to obtain the follow up laboratory blood work as ordered related to this diagnosis and medication. A sample of six residents was selected for review. The facility census was 66. On 3/1/22 at 3:35 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 2/6/22. On 2/8/22, the administrator identified Resident #3 had not received his/her thyroid replacement medication from 12/31/21 through 2/8/22. The facility conducted an internal investigation and reviewed physician orders on all new admissions/readmissions from December 2021 to present. On 2/8/22, the facility re-educated the administrative staff (nurse responsible for transcribing orders) regarding physician's orders and began having a second administrative nurse double check the orders. Since 2/8/22, the administrative nurse is reviewing all admission/readmission orders the next day following admission to ensure accuracy. The IJ was removed on 2/8/22. Review of the facility's policy on Medication and Treatment Orders, revised July 2016, showed the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Orders for medications must include the name and strength of the medication, number of doses, start and stop dates, and/or specific duration of therapy, dosage and frequency of administration, clinical condition or symptoms for which the medication is prescribed, and any follow up requirements (pending reports, repeat labs, medication monitoring, etc.); -Labs will be ordered and placed on the Medication Administration Record (MAR)/Treatment Administration Record (TAR) for the nurse to sign off when due. The nurse will enter lab orders, print requisition, and place in the designated lab folder for the lab upon arrival. 1. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included diabetes, morbid obesity, and hypothyroidism. Review of the resident's physician orders for November 2021 showed an order dated 11/20/21 for levothyroxine 175 micrograms (mcg) by mouth daily. Review of the resident's Medication Administration Record (MAR) from 11/20/21 through 12/12/21 showed documentation staff administered the levothyroxine 175 mcg daily as ordered. Review of the resident's medical record showed he/she was admitted to the hospital on 12/12/21 and was readmitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated 12/30/21, showed the following: -Discharge diagnoses included unstable angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart), acute on chronic heart failure, acute respiratory failure, lung infection, chronic kidney disease, diabetes, and hypothyroidism; -Noted elevated thyroid stimulating hormone (TSH, stimulates the release of thyroid hormone) of 52 (normal levels 0.5 to 5.0) upon admission with questionable medication compliance; -Endocrine specialist following with recommendation for levothyroxine 175 mcg every morning. Repeat TSH levels in four weeks; -Discharge medication orders included levothyroxine 175 mcg by mouth every morning; -Obtain TSH and free thyroxine (T4 is the main hormone produced by the thyroid gland. A laboratory test can be done to measure the amount of free T4 in your blood. Free T4 is the thyroxine that is not attached to a protein in the blood) between 1/23/22 and 1/31/22. Review of the resident's physician orders from 12/30/21 through 2/8/22 showed the resident did not have an order for levothyroxine. Review of the resident's MAR from 12/31/21 through 2/8/22 showed the resident did not receive levothyroxine. Review of the resident's record showed the facility had not obtained the ordered TSH and T4 laboratory work as ordered on his/her discharge instructions dated 12/30/21. Review of the resident's record showed he/she was hospitalized on [DATE] and was readmitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated 2/15/22, showed the following: -Hospital course: The resident presented from the nursing home on 2/8/22 with altered mental status for two days, reduced urine output, and reduced oral intake for the past two weeks. On admission the resident's labs were concerning. The TSH level and his/her presentation was presumed to be secondary to myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate). Some medications were missing from the resident's medication list so the facility was called. On questioning the facility, the nurse said the resident had not been on levothyroxine at the facility. Endocrinology was consulted and the resident was initially started on intravenous levothyroxine, which was switched to oral on 2/13/22. It was unclear why the resident had not received levothyroxine replacement, per the facility it was not on his/her medication list; -Discharge diagnoses included altered mental status, likely secondary to myxedema coma, hypothyroidism, malnutrition, and diabetes; -Discharge medications included levothyroxine 150 mcg by mouth every morning. During an interview on 2/24/22 at 11:20 A.M. the Registered Nurse Clinical Consultant said Resident #3's levothyroxine order and follow up lab orders for TSH and T4 were missed on his/her readmission orders from 12/30/21. The facility became aware the orders were missed about two weeks ago when the hospital called and asked about the medication. During an interview on 2/23/22 at 4:12 P.M. and 2/24/22 at 11:15 A.M. the Director of Nursing (DON) said the administrative nurses tried to complete the admission and readmission orders for residents so the floor nurses can complete their other duties. The administrative nurses just recently began double checking new admission and readmission orders to ensure nothing was missed. The nurse completing the admission was responsible for ordering any lab work. During an interview on 3/1/22 at 2:03 P.M. Resident #3's physician said she would expect the resident to receive the ordered levothyroxine and lab work. She could not say for certain that not receiving the levothyroxine contributed to the resident being hospitalized because she was not there with the resident. If the hospital physicians felt it was a contributing factor, she could not argue with that. MO197131

Based on interview and record review, the facility staff failed to ensure one resident (Resident #3) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required hospitalization again on 2/8/22 and per the hospital record the resident's presentation was presumed to be secondary to myxedema coma (severe [CONDITION(S)]). The facility also failed to obtain the follow up laboratory blood work as ordered related to this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 66. On 3/1/22 at 3:35 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 2/6/22. On 2/8/22, the administrator identified Resident #3 had not received his/her [CONDITION(S)] replacement medication from 12/31/21 through 2/8/22. The facility conducted an internal investigation and reviewed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/8/22, the facility re-educated the administrative staff (nurse responsible for transcribing orders) regarding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Since 2/8/22, the administrative nurse is reviewing all admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ was removed on 2/8/22. Review of the facility's policy on Medication and Treatment Orders, revised July 2016, showed the following: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Orders for medications must include the name and strength of the medication, number of doses, start and stop dates, and/or specific duration of therapy, dosage and frequency of administration, clinical condition or symptoms for which the medication is prescribed, and any follow up requirements (pending reports, repeat labs, medication monitoring, etc.); -Labs will be ordered and placed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse will enter lab orders, print requisition, and place in the designated lab folder for the lab upon arrival. 1. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed he/she was admitted to the hospital on 12/12/21 and was readmitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated 12/30/21, showed the following: -Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Noted elevated [CONDITION(S)] stimulating hormone (TSH, stimulates the release of [CONDITION(S)] hormone) of 52 (normal levels 0.5 to 5.0) upon admission with questionable medication compliance; -Endocrine specialist following with recommendation for [MEDICATION(S)] 175 mcg every morning. Repeat TSH levels in four weeks; -Discharge medication orders included [MEDICATION(S)] 175 mcg by mouth every morning; -Obtain TSH and free [MEDICATION(S)] (T4 is the main hormone produced by the [CONDITION(S)] gland. A laboratory test can be done to measure the amount of free T4 in your blood. Free T4 is the [MEDICATION(S)] that is not attached to a protein in the blood) between 1/23/22 and 1/31/22. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MAR from 12/31/21 through 2/8/22 showed the resident did not receive [MEDICATION(S)]. Review of the resident's record showed the facility had not obtained the ordered TSH and T4 laboratory work as ordered on his/her discharge instructions dated 12/30/21. Review of the resident's record showed he/she was hospitalized on [DATE] and was readmitted to the facility on [DATE]. Review of the resident's hospital discharge records, dated 2/15/22, showed the following: -Hospital course: The resident presented from the nursing home on 2/8/22 with altered mental status for two days, reduced urine output, and reduced oral intake for the past two weeks. On admission the resident's labs were concerning. The TSH level and his/her presentation was presumed to be secondary to myxedema coma (severe [CONDITION(S)] leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate). Some medications were missing from the resident's medication list so the facility was called. On questioning the facility, the nurse said the resident had not been on [MEDICATION(S)] at the facility. Endocrinology was consulted and the resident was initially started on intravenous [MEDICATION(S)], which was switched to oral on 2/13/22. It was unclear why the resident had not received [MEDICATION(S)] replacement, per the facility it was not on his/her medication list; -Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Discharge medications included [MEDICATION(S)] 150 mcg by mouth every morning. During an interview on 2/24/22 at 11:20 A.M. the Registered Nurse Clinical Consultant said Resident #3's [MEDICATION(S)] order and follow up lab orders for TSH and T4 were missed on his/her readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/23/22 at 4:12 P.M. and 2/24/22 at 11:15 A.M. the Director of Nursing (DON) said the administrative nurses tried to complete the admission and readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrative nurses just recently began double checking new admission and readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/1/22 at 2:03 P.M. Resident #3's physician said she would expect the resident to receive the ordered [MEDICATION(S)] and lab work. She could not say for certain that not receiving the [MEDICATION(S)] contributed to the resident being hospitalized because she was not there with the resident. If the hospital physicians felt it was a contributing factor, she could not argue with that. MO 1

Based on observation, interview, and record review, the facility failed to provide adequate monitoring to prevent falls, and failed to consistently implement and modify care plan interventions as necessary to reduce the risk of falls for two residents (Residents #3 and #8), in a review of 19 sampled residents. Resident #8 sustained injuries from multiple falls which required hospitalization and/or medical intervention beyond first aid, including a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and sutures (surgical threads used to close a wound). The facility census was 57. Review of the facility's Falls - Clinical Protocol Policy, dated March 2018, showed the following: -The physician will help identify individuals with a history of falls and risk factors for falling; -The nurse shall assess and document/report the following: -Vital signs; -Recent injury, especially fracture or head injury; -Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; -Change in cognition or level of consciousness; -Neurological status; -Pain; -Frequency and number of falls since last physician visit; -Precipitating factors, details on how fall occurred; -All current medications, especially those associated with dizziness or lethargy; -All active diagnosis. -The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events; -Falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate and other circumstances such as sliding out of a chair or rolling from a low bed to the floor; -Falls should be identified as witnessed or unwitnessed events; -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall; -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable; -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling; -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for it continuation; -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling; -If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions. 1. Review of Resident #8's undated face sheet showed the resident's diagnoses included the following: -Unspecified dementia with behavioral disturbance; -[CONDITION(S)] brain damage (a condition caused by a complete lack of oxygen being provided to the brain that results in the death of brain cells); -Personality change due to known physiological condition; -Traumatic subarachnoid hemorrhage without loss of consciousness; -[CONDITION(S)] (a sudden, involuntary muscle jerk, shake, or spasm). Record review of the resident's admission Minimum Data Sheet (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/20, showed the following: -The resident was admitted to the facility on [DATE]; -The resident had short-term and long-term memory problems; -The resident's cognitive skills for daily decision making were severely impaired; -The resident had trouble concentrating; -The resident was totally dependent on two or more staff for bed mobility and transfers; -The resident was not steady moving from a seated to a standing position and could only perform this activity with staff assistance; -The resident used a walker; -The resident had falls in the last month. Review of the resident's Fall Risk Evaluation, dated 5/12/20, showed the following: -The resident's fall risk score was 20 (a score of 10 or higher indicates the resident is at risk for falls); -When a resident's total score of 10 or more, interventions should promptly be put in place. Review of the resident's care plan, dated 6/10/20, showed the following: -The resident had a [CONDITION(S)] and suffered brain damage. The resident can move himself/herself (although it's not always intentional). Sometimes his/her arms and legs jerk; he/she cannot control this. Physical therapy is working with the resident. He/She does not stand much, instead he/she relies on a wheelchair. He/She has had falls in the facility and has a poor safety awareness; -The resident had trouble staying on track and following conversation topics; -The resident was unable to make reasonable decisions and his/her memory was quite poor; -The resident may be found on the fall mat next to his/her bed, but nursing cannot tell if he/she fell or put himself/herself there; -The resident needs assistance to transfer; -It would be a good idea for staff to check on the resident frequently and to make sure he/she is positioned properly in his/her chair and bed; -Staff will notice the resident tends to have frequent movement and that it often looks as if he/she is sliding out of his/her chair or bed; -The resident needs a wheelchair to get around and one staff to push him/her. Review of the resident's Fall Investigation Worksheet, dated 6/18/20 at 6:00 A.M., showed the following: -The resident fell in his/her room; -The resident was found on the floor next to his/her bed with his/her head resting on the bed frame; -The fall was unwitnessed; -The bed was in a low position; -The call bell was in reach; -The resident did not call for help; -The resident did not require supervision; -The resident had two falls in the last 30 days. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 6/18/20. Review of the resident's Fall Investigation Worksheet, dated 6/20/20 at 3:00 P.M., showed the following: -The resident had been observed propelling himself/herself in the hallway; -The resident was sitting in his/her wheelchair near his/her room; -The resident appeared to have slid out of his/her wheelchair; -The fall was unwitnessed; -There was no injury to the resident; -The resident did not require supervision. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 6/20/20. Review of the resident's Fall Investigation Worksheet, dated 6/21/20 at 11:20 A.M., showed the following: -The resident attempted to get out of his/her wheelchair in the hallway; -The resident was lying on the floor in the hallway; -The fall was unwitnessed; -Foot pedals were on the wheelchair; -There was no injury. Review of the resident's Fall Investigation Worksheet, dated 6/21/20 at 5:45 P.M., showed the following: -The resident was found on the floor, face down on the fall mat next to his/her bed; -The fall was unwitnessed; -The resident did not call for help; -The resident had a small cut/scrape on top of his/her nose. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's two falls on 6/21/20. Review of the resident's Fall Investigation Worksheet, dated 6/30/20 at 11:30 A.M., showed the following: -The resident was found on the floor in his/her room; -The resident was agitated and restless at the time of the fall; -The fall was unwitnessed; -The call bell was in reach -The resident did not call for help; -The resident had a laceration to the left side of his/her head; -The bed was in a low position and a fall mat was on the floor next to the bed. Review of a daily skilled nurse's note, dated 6/30/20 at 11:30 A.M., showed the following: -The resident was found on floor lying on his/her left side; -The left side of the resident's head was bleeding and was against the over-the-bed table leg; -Pressure applied to 1.5 inch laceration; -The resident was alert and crying; -The resident complained of left sided rib pain; -The resident was transferred to the hospital. Review of a night shift daily skilled nurse's note, dated 6/30/20, showed the hospital notified the facility the resident would be admitted with a diagnosis of a small brain bleed. Review of the resident's nursing progress notes, dated 7/2/20, showed the following: -The resident was readmitted to the facility from the hospital; -The resident had a small laceration on his/her left forehead and bruising on his/her right arm and on both ankles. Review of the resident's discharge summary from the hospital, dated 7/2/20, showed the following:-The results of the CT scan (computed tomography scan is a medical imaging technique that uses computer-processed combinations of multiple X-ray measurements taken from different angles to produce tomographic images of a body, allowing the user to see inside the body noninvasively) showed the resident had a small right frontal subarachnoid hemorrhage and minimal left frontal subarachnoid hemorrhage; -Fall precautions: assess fall risk score every day (orientation/clarity/mental status; patient stability during ambulation/transfer) and effectiveness of safety interventions. Review of the resident's care plan, updated 7/6/20, showed sensory pillows were provided to the resident in hopes if his/her hands were kept busy, he/she might be less restless. Review of the resident's physician progress notes, dated 7/7/20, showed the following: -The visit was conducted via telemedicine; -The resident was readmitted after a fall at the nursing facility and a subarachnoid hemorrhage; -The resident required frequent redirection due to episodes of confusion at baseline; -Nursing reported no deficits from the hemorrhage; -The plan for the resident; -Follow up with psychiatry; -Fall precautions; -Medication reconciliation completed. Record review of the resident's significant change MDS, dated [DATE], showed the following: -The resident was readmitted from an acute stay at the hospital; -The resident had unclear speech; -The resident was short tempered and easily annoyed; -The resident had been fidgety, restless and moved around more than usual; -The resident showed physical behaviors directed toward others on a daily basis; -The resident showed verbal behavioral symptoms directed toward others on a daily basis; -The resident showed other behavioral symptoms (physical symptoms such as hitting or scratching self, disrobing in public, or verbal/vocal symptoms like screaming or disruptive sounds) directed toward others on a daily basis; -The resident's behavior put the resident at risk for physical illness or injury; -The resident's behavior had a significant interference with the resident's care; -The resident's behavior had a significant interference with the resident's participation in activities/social interaction; -The resident's behavior had a significant disruption of care and the living environment; -The resident's behavior significantly intruded on the privacy and activities of other residents; -The resident did not exhibit wandering; -The resident's behavior worsened since his/her assessment on 5/12/20; -The resident was unable to move from a seated to standing position; -The resident started physical and occupational therapy on 7/3/20; -The resident had a diagnosis of a traumatic subarachnoid hemorrhage with loss of consciousness. Review of a social services progress note, dated 7/16/20, showed therapy reports the resident is not making progress with therapy. At this point, the resident is a max assist with activities of daily living. Staff discussed discontinuation of therapy services with the resident's family. The facility provided the resident with a sensory pillow for the resident to manipulate. The family expressed not liking the pillows provided and expressed wanting the facility to provide a different kind. The resident refuses many activities offered, but enjoys looking at pictures of his/her family and enjoys country music. Review of the resident's physician progress notes, dated 7/16/20, showed the following: -The visit was conducted via telemedicine; -The resident was seen for agitation, restlessness, combative behavior, and to be evaluated for medication management for psychiatric conditions; -The resident was confused but cooperated; -The resident could not respond meaningfully to physician assistant's (PA) questions; -The resident did not seem to understand how to function his/her nursing light, he/she would scream for staff in lieu of using his/her call light; -The resident had cognitive impairment, confusion and disorientation; -The resident's judgment was limited/poor; -The PA recommended to be flexible with the resident's mood and validate concerns and feelings with acknowledgement and empathy; -The PA offered education to the staff. Review of the resident's physician progress notes, dated 7/17/20, showed the following: -The visit was conducted via telemedicine; -The resident was readmitted after a fall at the nursing facility and a subarachnoid hemorrhage; -The resident required frequent redirection due to episodes of confusion at baseline; -No falls reported this week; -The resident's judgement/insight was inappropriate. Review of the resident's Fall Investigation Worksheet, dated 7/17/20 at 1:50 P.M., showed the following: -The resident was in the hallway between the MDS office and the nurse's station on Unit II; -The resident was sitting in a high back wheelchair, stood up and fell to his/her buttock; -The resident was restless at the time of the fall; -The resident did not call for help; -Three staff witnessed the resident fall; -The resident had no injury due to the fall; -The resident did not require supervision but staff were to keep a watchful eye on the resident; -No recent change in the resident's medical condition. Review of the resident's nursing progress notes showed no documentation of the fall on 7/17/20. Review of the resident's care plan, updated 7/17/20, showed the following: -A foam helmet was provided to the resident to be worn as needed for the prevention of head injury during falls; -If restless, try to distract the resident with his/her favorite music, try to talk with his/her family on his/her tablet, or look at his/her photos. Review of the resident's Fall Investigation Worksheet, dated 7/19/20 at 6:00 P.M., showed the following: -The resident was found on the floor in his/her room on the fall mat; -The fall was unwitnessed; -A wedge was in the bed at the time of the fall; -The call bell was in reach; -The resident did not call for help; -The resident has a bump on top of his/her head, not sure if it was from the fall; -The resident required supervision; -No recent change in the resident's medical condition. Review of the resident's nursing progress notes showed no documentation of the resident's fall on 7/19/20. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 7/19/20. Review of the resident's physician progress notes, dated 7/24/20, showed the following: -The visit was conducted via telemedicine; -The resident was readmitted after a fall at the nursing facility and a subarachnoid hemorrhage; -The resident required frequent redirection due to episodes of confusion at baseline; -No recent falls reported; -The resident's judgement/insight was inappropriate; -Nursing reported the resident received his/her helmet and wore it at times. Review of the resident's Fall Investigation Worksheet, dated 7/24/20 at 10:30 P.M., showed the following: -The resident sat in his/her wheelchair at Unit II nurse's station; -The resident attempted to stand up out of his/her wheelchair without assistance and fell landing on his/her left side; -The resident was restless at the time of the fall; -The resident did not call for help; -A staff member witnessed the resident fall; -A skin tear was noted on the left outer elbow; -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 7/24/20. Review of the resident's Fall Investigation Worksheet, dated 7/27/20 at 5:30 P.M., showed the following: -The resident sat in his/her wheelchair in the hallway; -The resident attempted to stand up out of his/her wheelchair without assistance and fell landing on his/her left side; -The resident fell over in the wheelchair to his/her right side and was lodged up against the wall; -The resident was restless at the time of the fall; -The resident did not call for help; -Two staff members were at the nurse's station and saw the resident fall; -A skin tear was noted on the resident's left outer elbow; -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 7/27/20. Review of the resident's physician progress notes, dated 7/28/20, showed the following: -The visit was conducted via telemedicine; -Nursing staff requested the visit due to the resident having a fall on 7/27/20; -The nurse reported the resident hit his/her head but had soft helmet in place; -No change in mental status; -The resident's judgement/insight was inappropriate; -The resident required frequent redirection due to episodes of confusion. Review of the resident's care plan, updated 8/1/20, showed one side of the resident's bed had been placed up against the wall per family's wishes to reduce the frequency of falls out of bed. A fall mat is was placed on the floor on the other side of the bed to reduce the risk of injury when he/she fell out of bed. Review of the resident's Fall Investigation Worksheet, dated 8/3/20 at 4:15 P.M., showed the following: -The resident sat in his/her wheelchair in the hallway so he/she could be watched more closely; -When the nurse was in the medication room, the resident fell forward out of the wheelchair; -The fall was unwitnessed; -The resident was restless at the time of the fall; -The resident was leaning in his/her wheelchair; -The resident did not call for help; -The resident opened an old scar; -The resident had three falls in the last 30 days; -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/3/20. Review of the resident's Fall Investigation Worksheet, dated 8/6/20 at 3:20 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident fell out of the wheelchair while in his/her room; -The fall was unwitnessed; -The resident was restless at the time of the fall; -The call bell was in reach; -No documentation to show if the resident called out for help; -The resident had no injury from this fall; -The resident had three falls in the last 30 days. -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/6/20. Review of the resident's Fall Investigation Worksheet, dated 8/8/20 at 12:30 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident fell out of the wheelchair; -The fall was unwitnessed; -The resident was agitated and restless at the time of the fall; -No documentation to show if the resident called out for help; -The resident had no injury from this fall. -No recent change in the resident's medical condition. Review of the nursing progress notes, dated 8/8/20 at 12:30 P.M., showed the following: -The resident was found on the floor in his/her room; -The resident fell out of the wheelchair; -Will continue with plan of care. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/8/20. Review of the resident's Fall Investigation Worksheet, dated 8/10/20 at 1:25 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident fell out of the wheelchair; -The nurse said the resident was found on the floor trying to pick cake up off the floor; -The fall was unwitnessed; -The resident was agitated and restless at the time of the fall; -No documentation to show if the resident called out for help; -The resident had no injury from this fall; -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/10/20. Review of the resident's record showed the resident fell from his/her wheelchair six times between 7/24/20 and 8/10/20. Review showed no evidence the facility evaluated or updated the resident's care plan with new interventions to address falls from his/her wheelchair during this time. Review of a Multidisciplinary Therapy Screen, dated 8/17/20, performed by a physical therapy assistant, showed the following: -No recent changes or decline; -No skilled therapy intervention indicated. Review of the resident's Fall Investigation Worksheet, dated 8/19/20 at 6:55 A.M., showed the following: -The resident was lying in the bed in his/her room; -The resident attempted to ambulate; -The resident was found on his/her back on the floor. The staff did not know if the resident fell out of bed or if he/she crawled out of bed; -The fall was unwitnessed; -The resident had the call bell in reach; -The resident did not called out for help; -The resident had no injury from this fall; -The resident was cognitively unable to relate circumstances; -Encouraged the resident to use his/her call light; -The resident required supervision; -No recent change in the resident's medical condition. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/19/20. Review of the resident's physician progress notes, dated 8/25/20, showed the following: -The visit was conducted via telemedicine; -The visit was a follow up to a fall on 8/19/20; -The plan for the resident was for fall precautions. Review of the resident's Fall Investigation Worksheet, dated 8/27/20 at 10:35 A.M., showed the following: -The resident sat in his/her wheelchair; -The resident was found on the floor; -The resident didn't know how he/she got on the floor, but said he/she must have been praying since he/she was kneeling on the mat beside the bed; -The fall was unwitnessed; -The resident had the call bell in reach; -The resident did not call out for help; -The resident had no injury from this fall; -No recent change in the resident's medical condition. Review of the nursing progress notes showed no documentation of the fall on 8/27/20. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 8/27/20. Review of the resident's Fall Investigation Worksheet, dated 9/4/20 at 12:45 P.M., showed the following: -The resident sat in his/her wheelchair in the dining room eating lunch; -The resident was unable to answer questions related to the fall; -The fall was unwitnessed; -The resident wore his/her helmet; -The resident had a 0.5 centimeter (cm) laceration injury to his/her forehead from this fall; -The resident did not call out for help; -The resident does not require supervision; -No recent change in the resident's medical condition. Review of the resident's nursing progress notes showed no documentation of the fall on 9/4/20. Review of the resident's care plan, updated 9/4/20, showed the resident was moved to another room where there was more staff traffic to better monitor his/her position. Review of the nursing progress notes, dated 9/10/20 at 5:45 P.M., showed the following: -The resident sat in his/her wheelchair in the Unit I TV room eating supper; -The nurse looked up from the desk and the resident was on the floor, face down, with arms and legs out; -The resident wore his/her helmet; -No injuries were noted. Review of the resident's Fall Investigation Worksheet, dated 9/10/20 at 5:45 P.M., showed the following: -The resident sat in his/her wheelchair near the nurse's desk; -Staff witnessed the resident falling toward the floor, face first; -The resident was restless and wandering at the time of the fall; -No recent change in the resident's medical condition. Review of the resident's care plan, updated 9/10/20, showed the resident was in constant motion, easily agitated and fell when agitated. The staff were to place the resident in the TV room across from the nurse's station when the resident became agitated so more staff could keep an eye on the resident. (Review of the resident's record showed the resident fell on [DATE] while in the TV room with staff nearby at the nurses station.) Review of the resident's care plan, updated 9/11/20, showed the resident was impulsive and lacked safety awareness related to cognitive deficits. Staff was to monitor the resident's position and assist with repositioning. Review of the nursing progress notes, dated 9/12/20 at 1:00 P.M., showed the following: -Staff found the resident on the floor in the hallway; -The resident opened a wound above his/her right eyebrow. The bleeding was easily controlled and staff applied a bandage; -Staff performed a Glasgow Coma Scale assessment (an assessment used to objectively describe the extent of impaired consciousness) at time of fall (12:30 P.M.); -At 1:00 P.M., staff performed a Glasgow Coma Scale assessment due to the resident only opened his/her eyes to speech; -The noted the resident likely had a concussion; -No nausea or vomiting noted; -The resident sat with the nurse at the nurse's station for 30 minutes, and then to bed to rest; -At 3:50 P.M., the resident's Glasgow Coma Scale steadily declined and the resident was difficult to arouse. New orders received to send the resident to the hospital for CT scan; -At 9:45 P.M., the resident returned to the facility. CT scan of head and neck was clear. Review of the resident's Fall Investigation Worksheet, dated 9/12/20 at 12:30 P.M., showed the following: -The resident was found lying in the hallway; -The fall was unwitnessed; -The resident did not call out for help; -The resident was restless and wandering at the time of the fall; -The resident wore his/her helmet; -The resident opened a wound from a previous fall; -The resident had multiple falls in the past 30 days; -No recent change in the resident's medical condition. Review of the resident's care plan, updated on 9/12/20, showed staff were to place the resident next to the nurses' station with a bedside table for meals when he/she was attempting to stand, so staff could monitor the resident more closely. Review of a Monthly Multidisciplinary Therapy Screen, dated 9/14/20, performed by a certified occupational therapy assistant, showed the following: -Referral from nursing for a change in falls; -The resident had a fall mat and bolster mattress; -The resident continued to be a high fall risk secondary to cognition and no safety awareness; -The resident tried to get up from his/her bed and wheelchair without being assisted; -An anti-thrust cushion (a cushion used to prevent sliding forward in a wheelchair) was recommended; -No skilled therapy intervention indicated. Review of the resident's Fall Investigation Worksheet, dated 9/16/20 at 4:50 P.M., showed the following: -The resident had been in his/her wheelchair; -The resident was found lying in the dining room; -The fall was unwitnessed; -The resident had no injury from this fall. There was no evidence in the nurses notes or fall investigation worksheet to show if the resident's anti-thrust cushion was in place at the time of the fall. Review of the resident's care plan, updated 9/16/20, showed a new cushion was placed in the resident's wheelchair. The cushion was a non-skid cushion, with a raised area in the front to hopefully prevent the resident from falling out of his/her wheelchair. Review of the resident's physician progress notes, dated 9/17/20, showed the following: -The visit was conducted via telemedicine; -Nursing staff requested the visit due to a fall; -The fall was unwitnessed; -The resident had a scab on his/her forehead; -The plan for the resident was for fall precautions. Review of the nursing progress notes, dated 9/20/20 at 5:00 P.M., showed the following: -The resident was found on the floor face down after falling from his/her wheelchair; -The resident had a new deep open area above his/her eyebrow; -The resident was lying on his/her left arm and staff noted a skin tear; -The resident was sent to the emergency room for treatment; -At 8:15 P.M., the resident returned to the facility. Review of the resident's Fall Investigation Worksheet, dated 9/20/20 at 5:00 P.M., showed the following: -The resident had been in his/her wheelchair wandering; -The resident was found in another resident's room; -The fall was unwitnessed; -The resident had an injury from this fall;; -The resident had six falls in the past 30 days; -No safety interventions were in use at the time of the fall. Review of the resident's care plan showed no evidence staff evaluated current interventions or updated the resident's care plan with new interventions following the resident's fall on 9/20/20. Review of the nursing progress notes, dated 9/22/20 at 12:20 P.M., showed the following: -The resident was found on the floor on his/her left side; -The nurse and Director of Nursing (DON) assessed the resident; -The resident complained of left hip, leg and lower back hurting; -The sites were observed with no bruising or abnormalities noted; -Healing area on forehead noted from previous falls; -No redness or hematomas on head; -The resident wore his/her helmet. -At 12:30 P.M., new orders received for x-ray. Review of the resident's Fall Investigation Worksheet, dated 9/22/20 at 12:00 P.M., showed the following:<

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR; an emergency procedure that is performed when a person's heartbeat or breathing has stopped) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 57. The administrator was notified on [DATE] of the Immediate Jeopardy (IJ) Past Non- Compliance which occurred on [DATE]. On [DATE], the administrator became aware of the violation of the facility cardio-pulmonary resuscitation policy. The staff member was suspended pending investigation. The facility started an investigation and inserviced facility staff on the cardio-pulmonary resuscitation policy and procedures. The IJ was removed and corrected on [DATE]. Review of the American Heart Association, Emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Signs of [CONDITION(S)]: -Sudden loss of responsiveness. The person doesn't respond, even if you tap him/her hard on the shoulders, or ask loudly if he/she is okay. The person doesn't move, speak, blink or otherwise react. -No normal breathing. The person isn't breathing or is only gasping for air. -If you have tried and failed to get the person to respond, and you think the person may be suffering [CONDITION(S)], here's what to do: -Yell for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an automated external defibrillator (AED), if there's one on hand. Tell them to hurry - time is of the essence. If you're alone with an adult who has these signs of [CONDITION(S)], call 911 and get an AED (if one is available). -Check breathing. If the person isn't breathing or is only gasping, administer CPR. -Give CPR: Push hard and fast. Push down at least two inches at a rate of 100 to 120 pushes a minute in the center of the chest, allowing the chest to come back up to its normal position after each push. -Use the AED as soon as it arrives. Turn it on and follow the prompts. -Continue administering CPR until the person starts to breathe or move, or until someone with more advanced training takes over, such as an emergency medical services (EMS) team member. Review of the facility's Emergency Procedure - CPR policy and procedure, last revised [DATE], showed if an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/basic life support (BLS) shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death (rigor mortis; recognizable sign of death, characterized by stiffening of the limbs of the body). 1. Review of Resident #1's face sheet showed the following: -The resident was less than [AGE] years old; -He/She had a guardian/public administrator; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated [DATE], showed the resident was a full code (all resuscitation procedures will be implemented if a person's heart stopped beating and/or they stopped breathing). His/Her request would be honored. Advanced directives of the resident's choice were completed and placed in his/her chart. Staff was to contact EMS if needed and CPR to be initiated if necessary. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed the following: -He/She was cognitively intact; -He/She was independent with bed mobility, transfers, walking, dressing, toilet use and personal hygiene; -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE] at 9:00 A.M., the director of nursing (DON) said the following: -A resident's code status was indicated on the spine of the resident's chart, on the resident's door, and on a single paper in the chart; -The color green behind the resident's name on the spine of the chart and on the resident's door meant the resident was a full code, and the color red meant the resident was a DNR. Review of the resident's medical chart showed the following: -The spine of the chart included the resident's name and a green backing behind the resident's name; -A single page within the chart was green in color and showed, Full code, start CPR, call 911. Review of the resident's [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital discharge paperwork, dated [DATE], showed the following: -Hospital admitted [DATE]; -Discharge [DATE]; -Admission and discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nursing notes showed on [DATE] at 5:45 A.M., the resident was found lying face down between the toilet and bathroom wall. No heartbeat or respirations, no response to verbal or physical stimulation. Licensed Practical Nurse (LPN) A was notified the resident's face was dark purple in color as well as fingers up to second knuckle. Physician after hours was immediately called. (Review showed no documentation staff initiated CPR or called 911.) Review of a release of body to the mortician form documented the resident's time of death to be 5:45 A.M. on [DATE]. During an interview on [DATE] at 10:20 A.M., LPN A said the following: -He/She was the night shift charge nurse responsible for the resident beginning the evening of [DATE] and into the morning of [DATE]; -He/She administered the resident his/her inhaler around midnight and saw the resident at 4:30 A.M. and had no concerns with the resident. The resident had oxygen on per nasal cannula at that time; -At 5:45 A.M., Hospitality Aide C alerted him/her to come to the resident's room; -Upon entering the resident's bathroom, he/she observed the resident was between the wall and the toilet with his/her left shoulder against the wall. The resident did not have on his/her oxygen; -The resident's face was black, his/her skin was cool, and he/she was not breathing; -He/She checked for a pulse in the resident's neck and right wrist and found no pulse; -He/She was unable to move the resident to begin CPR; -He/She did not get assistance from any other staff to move the resident so he/she could initiate CPR; -He/She did not perform CPR on the resident; -He/She left the resident's room and called the on-call physician. He/She reported to the on-call physician the resident was a full code status. The on-call physician asked LPN A when he/she knew the resident was last seen alive, and LPN A told him/her 5:00 A.M. The on-call physician told LPN A to call the funeral home; -He/She did not call 911 for help; -He/She was CPR certified; -CPR training taught him/her that if someone had declared a full code status and was found without a pulse and unresponsive, he/she should call for help or send someone for help and start CPR. During an interview on [DATE] at 11:23 A.M., Hospitality Aide C said the following: -On [DATE] at 5:40 A.M., he/she saw the resident sitting on his/her bedside with his/her oxygen on; -At 5:45 A.M., he/she found the resident in the bathroom, between the wall and toilet. The resident did not have his/her oxygen on. The resident's face and left arm were purple, his/her left shoulder was against the wall, and his/her right arm was on his/her side; -He/She ran into the hall to find help; -He/She first told Certified Nurse Assistant (CNA) B how he/she found the resident; -He/She and CNA B went back into the resident's bathroom. CNA B just looked at the resident, did not touch the resident or do CPR; -Later, LPN A and LPN D came to the resident's room; -He/She saw LPN A place his/her fingers on the resident's neck and wrist. He/She thought LPN A was checking for a pulse; -He/She did not see anyone perform CPR; -After LPN A checked for the resident's pulse, LPN A went to the nursing station to make a phone call; -He/She and CNA B moved the resident from the bathroom to his/her bed. The resident was flexible and was not cold or stiff. -He/She was not CPR certified; -He/She did not know how to identify what code status a resident had declared. During interview on [DATE] at 3:24 P.M. and [DATE] at 1:41 P.M., CNA B said the following: -He/She worked the night shift, beginning [DATE] through [DATE], and was responsible for the resident's care; -He/She last recalled seeing the resident at 5:30 A.M., lying in his/her bed with his/her nasal cannula oxygen in his/her nose. At that time, he/she left the unit to go assist on another hall; -Around 6:00 A.M., he/she was charting at the nursing station, when he/she saw LPN A come out of the resident's room, throw his/her pen on the desk, and said the resident had passed away; -LPN A got on the phone and he/she (CNA B) went to the resident's room; -When he/she entered the resident's room, the resident was in bed. CNA F, CNA E, LPN D and Hospitality Aide C were standing in the room; -He/She knew the resident was a full code because of the green coloring on his/her door; -He/She was CPR certified; -He/She knew if you found someone unresponsive who was a full code, you should call for help and begin CPR; -He/She did not try to perform CPR on the resident. He/She just did not think to do so. He/She felt like LPN A or others might have tried, and did not think to ask if staff had performed CPR. During an interview on [DATE] at 11:37 A.M., CNA E said the following: -He/She could recall last seeing the resident on [DATE] lying in his/her bed with oxygen on around 4:00 A.M.; -He/She recalled LPN A running down a resident hall adjacent to the resident's hall around 5:50 A.M., saying he/she needed LPN D because the resident was on the floor; -He/She later learned the resident had passed away; -At around 6:00 A.M., he/she went to the resident's room. He/She could recall LPN A was on the phone when he/she passed the nursing desk to get to the resident's room. -He/She saw the resident on the floor in the bathroom wedged between the wall and toilet. The resident was not wearing his/her oxygen; The resident's left arm was under him/her and he/she was face down; -CNA F and Hospitality Aide C were in the room. -He/She was able to move the resident's right arm and wrist. The resident's arm was flexible and not stiff, and the resident was cool to touch; -He/She checked the resident's right wrist for a pulse and did not feel one; -He/She was CPR certified, and knew to start CPR and get the nurse's attention if he/she found someone unresponsive who was a full code; -He/She knew the resident was a full code because of the green color on his/her door; -He/She did not think to start CPR, and did not ask if someone else had performed CPR. During an interview on [DATE] at 4:00 P.M., LPN D said the following: -He/She worked the evening of [DATE] into the morning of [DATE]; -He/She was assigned to another unit that night and was not responsible for the resident; -He/She was not familiar with the resident because he/she did not work the resident's unit; -He/She did not know the resident's code status, however, he/she knew the residents' code statuses could be found in their charts; -Around 6:10 A.M., CNA E told him/her the resident had passed away, and he/she went to the resident's room; -As he/she went to the resident's room, he/she passed the nursing desk where he/she saw LPN A on the phone; -Upon entering the room, he/she saw the resident on the floor in the bathroom, between the toilet and wall. The resident's face was down and he/she had a gray to bluish skin color; -He/She did not touch the resident or complete an assessment on the resident, because he/she thought one had been done; -He/She saw Hospitality Aide G, CNA E and CNA B move the resident from the bathroom to his/her bed, and then he/she left the resident's room; -The resident's body seemed to be dead weight, but flimsy; -As he/she returned to his/her unit, he/she walked by LPN A and asked if he/she needed anything. LPN A said, no. -He/She was CPR certified, and knew if someone was a full code and was found unresponsive and without a pulse, you should send for help and start CPR. During an interview on [DATE] at 9:10 A.M., LPN N said the following: -He/She was the facility nurse on-call for the weekend of [DATE] through [DATE]; -He/She received a call at 6:00 A.M. from LPN A who called to report the resident's death; -LPN A said he/she was just calling to let him/her know and everything had been taken care of; -He/She did not think to ask LPN A if CPR had been initiated; -He/She figured LPN A was the charge nurse and would have performed CPR on the resident if he/she was a full code status; -After the phone call, he/she texted the facility on-call group, which included the facility administrator and director of nursing (DON), to pass the reporting along. During interview on [DATE] at 9:00 A.M. and [DATE] at 4:48 P.M., the director of nursing (DON) said the following: -She received a text notification from the nurse on-call (LPN N) stating LPN A reported the resident had passed away; -She called the facility at that time and spoke with LPN A who told her he/she had not initiated CPR because the resident did not have any vital signs; -LPN A told the DON he/she knew the resident was a full code. During an interview on [DATE] at 7:30 A.M. and 10:00 A.M., the administrator said the following: -On [DATE] at 7:15 A.M., the DON called her to report the resident had passed away and that LPN A had not initiated CPR; -LPN A was CPR certified; -She would have expected LPN A to start CPR and have someone else call 911 when he/she found the resident unresponsive and without a pulse. During interview on [DATE] at 5:00 P.M. and [DATE] at 12:24 P.M., the administrator said the following: -When LPN A found the resident unresponsive and without a pulse, she would have expected LPN A to get help right away, to position the resident on his/her back, and to perform CPR because the resident was a full code; -She would have expected LPN A to have someone call 911 while he/she was performing CPR; -LPN A should not have called the on-call physician to notify him/her of the resident's death until after the ambulance crew called the hospital and talked to the hospital emergency room physician to pronounce the death; -Anytime a resident with a full code status was found without vital signs, staff must initiate CPR and call 911; -Staff should continue CPR until paramedics arrive and take over; -The facility did not have a policy that stated to call 911 when initiating CPR, however it is taught in CPR class. During an interview on [DATE] at 4:50 P.M., Nurse Practitioner R said the following: -He/She received a call from a nurse at the facility on [DATE] at 5:51 A.M. making him/her aware the resident had passed away; -The facility nurse said the resident had been found without a pulse and cold; -The facility nurse did tell him/her the resident was a full code status; -CPR classes teach to start CPR and instruct someone else to call for help; -If the resident was known to be alive at 5:30 A.M. or 5:40 A.M. and was found unresponsive at 5:45 A.M., staff definitely should have started CPR. During an interview on [DATE] at 2:00 P.M., the resident's physician said the following: -He/She expected staff to start CPR if they found a full code resident unresponsive; -Staff should call 911 or have someone call 911 while other qualified staff (CPR trained) perform CPR; -The ambulance crew should have arrived to assist if the resident was still not able to be moved; -EMS would have assisted with CPR; -It would have been EMS's responsibility to call or stop CPR if performed more than 20 minutes without success or they would have consulted with a physician to stop the process. During an interview on [DATE] at 9:06 A.M., the resident's guardian said the following: -The resident's code status had been identified as a full code; -She expected staff to perform CPR on the resident. Complaint #MO 131

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR; an emergency procedure that is performed when a person's heartbeat or breathing has stopped) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 57. The administrator was notified on [DATE] of the Immediate Jeopardy (IJ) Past Non- Compliance which occurred on [DATE]. On [DATE], the administrator became aware of the violation of the facility cardio-pulmonary resuscitation policy. The staff member was suspended pending investigation. The facility started an investigation and inserviced facility staff on the cardio-pulmonary resuscitation policy and procedures. The IJ was removed and corrected on [DATE]. Review of the American Heart Association, Emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Signs of [CONDITION(S)]: -Sudden loss of responsiveness. The person doesn't respond, even if you tap him/her hard on the shoulders, or ask loudly if he/she is okay. The person doesn't move, speak, blink or otherwise react. -No normal breathing. The person isn't breathing or is only gasping for air. -If you have tried and failed to get the person to respond, and you think the person may be suffering [CONDITION(S)], here's what to do: -Yell for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an automated external defibrillator (AED), if there's one on hand. Tell them to hurry - time is of the essence. If you're alone with an adult who has these signs of [CONDITION(S)], call 911 and get an AED (if one is available). -Check breathing. If the person isn't breathing or is only gasping, administer CPR. -Give CPR: Push hard and fast. Push down at least two inches at a rate of 100 to 120 pushes a minute in the center of the chest, allowing the chest to come back up to its normal position after each push. -Use the AED as soon as it arrives. Turn it on and follow the prompts. -Continue administering CPR until the person starts to breathe or move, or until someone with more advanced training takes over, such as an emergency medical services (EMS) team member. Review of the facility's Emergency Procedure - CPR policy and procedure, last revised [DATE], showed if an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/basic life support (BLS) shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death (rigor mortis; recognizable sign of death, characterized by stiffening of the limbs of the body). 1. Review of Resident #1's face sheet showed the following: -The resident was less than [AGE] years old; -He/She had a guardian/public administrator; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated [DATE], showed the resident was a full code (all resuscitation procedures will be implemented if a person's heart stopped beating and/or they stopped breathing). His/Her request would be honored. Advanced directives of the resident's choice were completed and placed in his/her chart. Staff was to contact EMS if needed and CPR to be initiated if necessary. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed the following: -He/She was cognitively intact; -He/She was independent with bed mobility, transfers, walking, dressing, toilet use and personal hygiene; -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE] at 9:00 A.M., the director of nursing (DON) said the following: -A resident's code status was indicated on the spine of the resident's chart, on the resident's door, and on a single paper in the chart; -The color green behind the resident's name on the spine of the chart and on the resident's door meant the resident was a full code, and the color red meant the resident was a DNR. Review of the resident's medical chart showed the following: -The spine of the chart included the resident's name and a green backing behind the resident's name; -A single page within the chart was green in color and showed, Full code, start CPR, call 911. Review of the resident's [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital discharge paperwork, dated [DATE], showed the following: -Hospital admitted [DATE]; -Discharge [DATE]; -Admission and discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nursing notes showed on [DATE] at 5:45 A.M., the resident was found lying face down between the toilet and bathroom wall. No heartbeat or respirations, no response to verbal or physical stimulation. Licensed Practical Nurse (LPN) A was notified the resident's face was dark purple in color as well as fingers up to second knuckle. Physician after hours was immediately called. (Review showed no documentation staff initiated CPR or called 911.) Review of a release of body to the mortician form documented the resident's time of death to be 5:45 A.M. on [DATE]. During an interview on [DATE] at 10:20 A.M., LPN A said the following: -He/She was the night shift charge nurse responsible for the resident beginning the evening of [DATE] and into the morning of [DATE]; -He/She administered the resident his/her inhaler around midnight and saw the resident at 4:30 A.M. and had no concerns with the resident. The resident had oxygen on per nasal cannula at that time; -At 5:45 A.M., Hospitality Aide C alerted him/her to come to the resident's room; -Upon entering the resident's bathroom, he/she observed the resident was between the wall and the toilet with his/her left shoulder against the wall. The resident did not have on his/her oxygen; -The resident's face was black, his/her skin was cool, and he/she was not breathing; -He/She checked for a pulse in the resident's neck and right wrist and found no pulse; -He/She was unable to move the resident to begin CPR; -He/She did not get assistance from any other staff to move the resident so he/she could initiate CPR; -He/She did not perform CPR on the resident; -He/She left the resident's room and called the on-call physician. He/She reported to the on-call physician the resident was a full code status. The on-call physician asked LPN A when he/she knew the resident was last seen alive, and LPN A told him/her 5:00 A.M. The on-call physician told LPN A to call the funeral home; -He/She did not call 911 for help; -He/She was CPR certified; -CPR training taught him/her that if someone had declared a full code status and was found without a pulse and unresponsive, he/she should call for help or send someone for help and start CPR. During an interview on [DATE] at 11:23 A.M., Hospitality Aide C said the following: -On [DATE] at 5:40 A.M., he/she saw the resident sitting on his/her bedside with his/her oxygen on; -At 5:45 A.M., he/she found the resident in the bathroom, between the wall and toilet. The resident did not have his/her oxygen on. The resident's face and left arm were purple, his/her left shoulder was against the wall, and his/her right arm was on his/her side; -He/She ran into the hall to find help; -He/She first told Certified Nurse Assistant (CNA) B how he/she found the resident; -He/She and CNA B went back into the resident's bathroom. CNA B just looked at the resident, did not touch the resident or do CPR; -Later, LPN A and LPN D came to the resident's room; -He/She saw LPN A place his/her fingers on the resident's neck and wrist. He/She thought LPN A was checking for a pulse; -He/She did not see anyone perform CPR; -After LPN A checked for the resident's pulse, LPN A went to the nursing station to make a phone call; -He/She and CNA B moved the resident from the bathroom to his/her bed. The resident was flexible and was not cold or stiff. -He/She was not CPR certified; -He/She did not know how to identify what code status a resident had declared. During interview on [DATE] at 3:24 P.M. and [DATE] at 1:41 P.M., CNA B said the following: -He/She worked the night shift, beginning [DATE] through [DATE], and was responsible for the resident's care; -He/She last recalled seeing the resident at 5:30 A.M., lying in his/her bed with his/her nasal cannula oxygen in his/her nose. At that time, he/she left the unit to go assist on another hall; -Around 6:00 A.M., he/she was charting at the nursing station, when he/she saw LPN A come out of the resident's room, throw his/her pen on the desk, and said the resident had passed away; -LPN A got on the phone and he/she (CNA B) went to the resident's room; -When he/she entered the resident's room, the resident was in bed. CNA F, CNA E, LPN D and Hospitality Aide C were standing in the room; -He/She knew the resident was a full code because of the green coloring on his/her door; -He/She was CPR certified; -He/She knew if you found someone unresponsive who was a full code, you should call for help and begin CPR; -He/She did not try to perform CPR on the resident. He/She just did not think to do so. He/She felt like LPN A or others might have tried, and did not think to ask if staff had performed CPR. During an interview on [DATE] at 11:37 A.M., CNA E said the following: -He/She could recall last seeing the resident on [DATE] lying in his/her bed with oxygen on around 4:00 A.M.; -He/She recalled LPN A running down a resident hall adjacent to the resident's hall around 5:50 A.M., saying he/she needed LPN D because the resident was on the floor; -He/She later learned the resident had passed away; -At around 6:00 A.M., he/she went to the resident's room. He/She could recall LPN A was on the phone when he/she passed the nursing desk to get to the resident's room. -He/She saw the resident on the floor in the bathroom wedged between the wall and toilet. The resident was not wearing his/her oxygen; The resident's left arm was under him/her and he/she was face down; -CNA F and Hospitality Aide C were in the room. -He/She was able to move the resident's right arm and wrist. The resident's arm was flexible and not stiff, and the resident was cool to touch; -He/She checked the resident's right wrist for a pulse and did not feel one; -He/She was CPR certified, and knew to start CPR and get the nurse's attention if he/she found someone unresponsive who was a full code; -He/She knew the resident was a full code because of the green color on his/her door; -He/She did not think to start CPR, and did not ask if someone else had performed CPR. During an interview on [DATE] at 4:00 P.M., LPN D said the following: -He/She worked the evening of [DATE] into the morning of [DATE]; -He/She was assigned to another unit that night and was not responsible for the resident; -He/She was not familiar with the resident because he/she did not work the resident's unit; -He/She did not know the resident's code status, however, he/she knew the residents' code statuses could be found in their charts; -Around 6:10 A.M., CNA E told him/her the resident had passed away, and he/she went to the resident's room; -As he/she went to the resident's room, he/she passed the nursing desk where he/she saw LPN A on the phone; -Upon entering the room, he/she saw the resident on the floor in the bathroom, between the toilet and wall. The resident's face was down and he/she had a gray to bluish skin color; -He/She did not touch the resident or complete an assessment on the resident, because he/she thought one had been done; -He/She saw Hospitality Aide G, CNA E and CNA B move the resident from the bathroom to his/her bed, and then he/she left the resident's room; -The resident's body seemed to be dead weight, but flimsy; -As he/she returned to his/her unit, he/she walked by LPN A and asked if he/she needed anything. LPN A said, no. -He/She was CPR certified, and knew if someone was a full code and was found unresponsive and without a pulse, you should send for help and start CPR. During an interview on [DATE] at 9:10 A.M., LPN N said the following: -He/She was the facility nurse on-call for the weekend of [DATE] through [DATE]; -He/She received a call at 6:00 A.M. from LPN A who called to report the resident's death; -LPN A said he/she was just calling to let him/her know and everything had been taken care of; -He/She did not think to ask LPN A if CPR had been initiated; -He/She figured LPN A was the charge nurse and would have performed CPR on the resident if he/she was a full code status; -After the phone call, he/she texted the facility on-call group, which included the facility administrator and director of nursing (DON), to pass the reporting along. During interview on [DATE] at 9:00 A.M. and [DATE] at 4:48 P.M., the director of nursing (DON) said the following: -She received a text notification from the nurse on-call (LPN N) stating LPN A reported the resident had passed away; -She called the facility at that time and spoke with LPN A who told her he/she had not initiated CPR because the resident did not have any vital signs; -LPN A told the DON he/she knew the resident was a full code. During an interview on [DATE] at 7:30 A.M. and 10:00 A.M., the administrator said the following: -On [DATE] at 7:15 A.M., the DON called her to report the resident had passed away and that LPN A had not initiated CPR; -LPN A was CPR certified; -She would have expected LPN A to start CPR and have someone else call 911 when he/she found the resident unresponsive and without a pulse. During interview on [DATE] at 5:00 P.M. and [DATE] at 12:24 P.M., the administrator said the following: -When LPN A found the resident unresponsive and without a pulse, she would have expected LPN A to get help right away, to position the resident on his/her back, and to perform CPR because the resident was a full code; -She would have expected LPN A to have someone call 911 while he/she was performing CPR; -LPN A should not have called the on-call physician to notify him/her of the resident's death until after the ambulance crew called the hospital and talked to the hospital emergency room physician to pronounce the death; -Anytime a resident with a full code status was found without vital signs, staff must initiate CPR and call 911; -Staff should continue CPR until paramedics arrive and take over; -The facility did not have a policy that stated to call 911 when initiating CPR, however it is taught in CPR class. During an interview on [DATE] at 4:50 P.M., Nurse Practitioner R said the following: -He/She received a call from a nurse at the facility on [DATE] at 5:51 A.M. making him/her aware the resident had passed away; -The facility nurse said the resident had been found without a pulse and cold; -The facility nurse did tell him/her the resident was a full code status; -CPR classes teach to start CPR and instruct someone else to call for help; -If the resident was known to be alive at 5:30 A.M. or 5:40 A.M. and was found unresponsive at 5:45 A.M., staff definitely should have started CPR. During an interview on [DATE] at 2:00 P.M., the resident's physician said the following: -He/She expected staff to start CPR if they found a full code resident unresponsive; -Staff should call 911 or have someone call 911 while other qualified staff (CPR trained) perform CPR; -The ambulance crew should have arrived to assist if the resident was still not able to be moved; -EMS would have assisted with CPR; -It would have been EMS's responsibility to call or stop CPR if performed more than 20 minutes without success or they would have consulted with a physician to stop the process. During an interview on [DATE] at 9:06 A.M., the resident's guardian said the following: -The resident's code status had been identified as a full code; -She expected staff to perform CPR on the resident. Complaint #MO 131

Based on interview and record review, the facility failed to develop policies and procedures to ensure an influenza and pneumococcal vaccine program was appropriately implemented for residents. Facility staff failed to administer pneumococcal vaccines when requested by the resident or the resident's responsible party for two residents (Resident #3 and Resident #30) who subsequently developed pneumonia. Staff failed to administer the pneumococcal vaccine after signed consent was given by the resident and/or the resident's responsible party for two residents (Resident #24 and #32) in a sample of 14 and three additional residents (Resident #4, #19,and #44). Staff obtained a signed refusal for the pneumococcal vaccine from one resident (Resident # 2) who was assessed to have severe cognitive impairment at the time of admission. Facility staff administered the influenza vaccine to one resident (Resident #11) without consent, failed to administer a second pneumococcal vaccine to one resident (Resident #5), did not offer the influenza vaccine to one resident (Resident #17) and did not offer the pneumococcal vaccine to three residents (Resident #17, #34 and #52). The facility census 53. 1. Review of the facility's Infection Prevention and Control Policies and Procedures revised (YEAR) showed the following: Influenza Vaccine Administration and Disease Control: Policy: The facility, in accordance with Centers for Disease Control and Prevention's guidelines and recommendations offers influenza immunization (MONTH) 1 through (MONTH) 31 annually, unless the resident or resident's representative refuses the immunization, the immunization is medically contraindicated or the resident has already been immunized during the current season; Procedures: 1. Influenza vaccine will be administered to all patients/residents unless medically contraindicated, or refused; 2. All patients/residents will be offered influenza vaccine when it becomes available upon admission during the vaccine season, (MONTH) 1 through (MONTH) 31 and each year thereafter; 3. Facility will review the resident's record of vaccination and immunization status, and complete an assessment of the resident for potential medical contraindications or if a medical condition is present that will delay the vaccination; 4. Risks and benefits of receiving the vaccine will be fully explained to the patient/resident, or their responsible party, prior to receiving the injection; 5. If a patient/resident refuses to accept the vaccine, they or their responsible part, will be asked to sign a declination form after all risks and benefits of taking/refusing the vaccine have been fully explained to them; 6. Documentation in the medical record should include: -Education provided concerning the risks/benefits of receiving the influenza vaccine; -The patient/resident's decision regarding whether to accept or decline the vaccine; -If there is a medical contraindication to receiving the vaccine; -If the vaccine is delayed due to a precaution; 7. Influenza Administration and Declination Logs will be maintained; 8. Refer to CDC and ACIP Clinical Guidelines; Pneumococcal Disease: Prevention and Control and Use of Pneumococcal [MEDICATION NAME] Vaccine: Policy: The facility, in accordance with Centers for Disease Control and Prevention's guidelines and recommendations offers pneumococcal immunization unless the resident or resident's representative refuses the immunization, the immunization is medically contraindicated or the resident has previously been immunized; Procedures: 1. Facility will review the resident's record of vaccination and immunization status, and complete an assessment of the resident for potential medical conditions that may present as a precaution and delay the vaccination; 2. Pneumococcal vaccine will be offered to all new patients/residents upon admission after determining whether they have previously received the vaccine or if they have a medical contraindication; 3. Risks and benefits of receiving the vaccine will be fully explained to the patient/resident, or their responsible party, prior to receiving the injection; 4. Patients/residents who refuse to accept the vaccine will be asked to sign a declination form after the risks and benefits of receiving the pneumococcal vaccine have been fully explained to them, or their responsible party; 5. Documentation in the medical record should include: -Education provided concerning the risks/benefits of receiving the pneumococcal vaccine; -The patient/resident's decision regarding whether to accept or decline the vaccine; -If there is reason to believe that the pneumococcal vaccine(s) was given previously, but the date cannot be verified; -If resident or resident's representative were able to identify which vaccine was received. (23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or 13-valent pneumococcal conjugate vaccine (PCV13) vaccine); -If there is a medical contraindication to receiving the vaccine; -If the vaccine is delayed due to a precaution; 6. Refer to CDC and ACIP Clinical Guidelines; Persons who should be vaccinated: -Persons aged > or equal to [AGE] years; -Persons aged 2-[AGE] years who have chronic illness; -Persons aged 2-64 who are living in special environments or social settings, e.g. patients/residents of nursing homes; -Immuno-compromised persons, although the vaccine is not as effective for immune-compromised patients/residents, the potential benefits and safety of the vaccine justify its use. 2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following: -Two pneumococcal vaccines are recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23); -One dose of PCV 13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV 23 and no doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. 3. Review of Resident #3's face sheet showed an admission date of [DATE]. Review of the resident's admission physician order [REDACTED]. -The resident had a [DIAGNOSES REDACTED]. A disease that attacks the body's immune system that can make it hard for the the body to fight off infections and other diseases) and [MEDICAL CONDITION] ([MEDICAL CONDITION]. progressive lung disease that characterized by long term breathing problems); -Orders to receive pneumococcal vaccine as indicated. Review of the resident's medical record showed the following: -The resident's responsible party gave staff written consent on 9/13/17 for staff to administer the pneumococcal vaccine; -No documentation facility staff administered the pneumococcal vaccine; -The resident was admitted to the hospital intensive care unit and treated for [REDACTED]. -The resident was hospitalized and treated for [REDACTED]. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/12/18, showed the following: -The resident was not up to date with the pneumococcal vaccine; -Staff did not offer the resident a pneumococcal vaccine. 4. Review of Resident #30's face sheet showed an admission date of [DATE]. Review of the resident's admission POS dated 8/17/17, showed orders to receive pneumococcal vaccine as indicated. Review of the resident's medical record showed the following: -The resident's responsible party signed consent for the resident to receive pneumococcal vaccine on 9/28/17; -No documentation facility staff administered the pneumococcal vaccine; -The resident was diagnosed and treated for [REDACTED]. Review of the resident's quarterly MDS dated [DATE], showed the following: -Severely impaired daily decision making; -No speech; -The resident was not up to date on his/her pneumococcal vaccine; -Staff did not offer the pneumococcal vaccine to the resident. 5. Review of Resident # 52's face sheet showed an admission date of [DATE]. Review of the resident's medical record showed no documentation staff obtained consent or refusal for the pneumococcal vaccine. Review of the resident's significant change MDS dated [DATE], showed the following: -BIMS score of 15 indicating cognition intact; -Staff documented the pneumococcal vaccine was up to date. During interview on 4/18/18 at 2:26 P.M., the resident said: -He/she was not offered the pneumococcal vaccine on admission; -He/she does not remember signing a consent or refusal for the vaccine; -He/she does not remember when or if he/she had the pneumococcal vaccine in the past. During interview on 4/18/18 at 2:30 P.M., the resident's family member said: -The resident was not offered the pneumococcal vaccine on admission; -He/she does not remember when the resident last had the vaccine. 6. Review of Resident #32's face sheet showed an admission date of [DATE]. Review of the resident's informed consent for pneumococcal vaccine dated 11/9/17 showed the following: -I hereby give the facility permission to administer a pneumococcal vaccination, unless medically contraindicated. To the best of my knowledge, I have not received a pneumococcal vaccination in the past five years; -Signed by the resident. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Pneumococcal vaccine not up to date; -Reason pneumococcal vaccine not received: not offered. Review of the resident's medical record showed no documentation of administration of the pneumococcal vaccine. During interview on 4/23/18 at 10:24 A.M. the resident said the following: -He/she signed consent on admission to receive the pneumococcal vaccine; -He/she wanted the pneumococcal vaccine on admission and expected it to be administered; -He/she has received no vaccines in the facility. 7. Review of Resident #24's face sheet showed an admission date of [DATE]. Review of the resident's informed consent for pneumococcal vaccine dated 10/3/17 showed the following: -I hereby give the facility permission to administer a pneumococcal vaccination, unless medically contraindicated. To the best of my knowledge, I have not received a pneumococcal vaccination in the past five years; -Signed by the resident's responsible party. Review of the resident's quarterly MDS dated [DATE] showed the following: -Short term and long term memory problem; -Severely impaired decision making; -Pneumococcal vaccine not up to date; -Reason pneumococcal vaccine not received: offered and declined. During interview on 4/17/18 at 1:33 P.M. the resident's family member said the following: -The resident is on hospice; -When the resident lived at home he/she was very susceptible to flu and pneumonia; -He/she signed the consent for the resident to receive the pneumonia vaccine; -He/she expected staff to administer the pneumonia vaccine to the resident unless medically contraindicated. Review of the resident's medical record showed no documentation of administration of the pneumococcal vaccine. 8. Review of Resident #5's face sheet showed an admission date of [DATE]. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severe cognitive impairment; -The resident had short term and long term memory problems; -The resident received the flu vaccine on 10/31/17; -The resident was up to date on pneumococcal vaccine. Review of the resident's medical record showed the following: -The resident received pneumococcal vaccine at the facility on 2/3/16; -The resident was to receive a second pneumococcal vaccine in (YEAR) but staff failed to document consent, education and administration and/or decline of the vaccine; -Staff administered the flu vaccine to the resident on 10/31/17; -No documentation facility staff educated the resident and/or responsible party or obtained consent prior to the administration of the flu vaccine. 9. Review of Resident #11's face sheet showed an admission date of [DATE]. Review of the resident's quarterly MDS dated [DATE], showed the following: -Moderate cognitive impairment; -The resident had short term and long term memory problems; -The resident received the flu vaccine; -The resident was up to date on pneumococcal vaccine. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED].>-Orders to receive flu vaccine yearly and pneumococcal vaccine as indicated; -Written note showed received flu 10/5/17. Review of the resident's medical record showed the following: -The resident's responsible party declined pneumococcal vaccine for resident on 10/12/15; -Staff failed to document if the resident ever received pneumococcal vaccine or the reason for declining the pneumococcal vaccine; -Staff administered the flu vaccine without consent from the resident or the resident's responsible party; -No documentation facility staff educated the resident and/or responsible party or obtained consent prior to the administration of the flu vaccine. 10. Review of Resident #17's face sheet showed an admission date of [DATE]. Review of the resident's physician order [REDACTED]. -The resident had a [DIAGNOSES REDACTED]. -Orders to receive flu vaccine yearly and pneumococcal vaccine as indicated. Review of the resident's admission MDS dated [DATE], showed the following: -[DIAGNOSES REDACTED].>-The resident was severely cognitively impaired; -The resident's was not offered the flu vaccine because the resident was not in the facility at time of flu season (the resident was admitted during flu season September-March according to CDC guidelines); -The resident was not up to date on his/her pneumococcal vaccine; -Staff did not offer the resident a pneumococcal vaccine. Review of the resident's medical record showed no documentation staff provided education, offered, obtained consent or declination and/or administered the flu and pneumococcal vaccine as ordered to the resident. 11. Review of Resident #19's face sheet showed an admission date of [DATE]. Review of the resident's Informed Consent for Pneumococcal Vaccine showed the following: -The consent box was checked to receive pneumococcal vaccine; -The resident's family member signed and dated the form on 10/9/17; -There was no date documented for the vaccine. Review of the resident's significant change MDS dated [DATE], showed the following: -Brief Interview for Mental Status (BIMS) score of zero indicating cognition severely impaired; -Staff documented the resident's pneumococcal vaccine was not up to date; -Staff documented the pneumococcal vaccine was offered and declined. -There was no date documented for the vaccine. 12. Review of Resident #44's face sheet showed an admission date of [DATE]. Review of the resident's Informed Consent for Pneumococcal Vaccine showed the following: -The consent box was checked to receive pneumococcal vaccine; -The resident's family member signed and dated the form on 9/26/17; -There was no date documented for the vaccine. Review of the resident's significant change MDS dated [DATE], showed the following: -BIMS score of zero indicating cognition severely impaired; -Staff documented the resident's pneumococcal vaccine was not up to date; -Staff documented the pneumococcal vaccine was offered and declined; -There was no date documented for the vaccine. 13. Review of Resident #4's face sheet showed an admission date of [DATE]. Review of the resident's immunization record showed the resident refused the pneumococcal vaccine on 10/25/16. Review of the resident's physician progress notes [REDACTED]. -Assessment: pneumonia, currently receiving [MEDICATION NAME] (oral antibiotic); -Plan: follow-up chest X ray in six weeks; -Schedule as needed (PRN) [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) x 10 days then back to previous PRN order; -Also started on [MEDICATION NAME] (oral decongestant). Review of the resident's informed consent for pneumococcal vaccine dated 9/23/17 showed the following: -I hereby give the facility permission to administer a pneumococcal vaccination, unless medically contraindicated. To the best of my knowledge, I have not received a pneumococcal vaccination in the past five years; -Signed by the resident's responsible party. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. Review of the resident's medical record showed no documentation of administration of the pneumococcal vaccine. 14. Review of Resident #34's face sheet showed an admission date of [DATE]; Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Pneumococcal vaccine not up to date; -Reason pneumococcal vaccine not received: not offered. Review of the resident's informed consent for pneumococcal vaccine was undated and blank. Review of the resident's medical record showed no documentation of administration of the pneumococcal vaccine. 15. Review of Resident #2's face sheet showed an admission date of [DATE]. Review of the resident's informed consent for pneumonia vaccine showed the following: -Signed by the resident 12/28/17; -He/she does not give facility permission to administer pneumococcal vaccine; - (Resident assessed with [REDACTED]. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Pneumococcal vaccine not up to date; -Reason pneumococcal vaccine not received: offered and declined. Review of the resident's medical record showed the following: -CT chest 2/23/18; -Left lower lobe pneumonia with pleural effusion. Review of the resident's physician progress notes [REDACTED]. -Family history: The resident is unable to provide any information, family is not available, and prior charts do not include family history; -Diagnosis: [REDACTED]. 16. During interview on 4/18/18 at 10:40 A.M., Licensed Practical Nurse (LPN) D said the following: -The charge nurse working was responsible for getting consents for pneumococcal and flu vaccine upon admission; -He/she did not educate the residents or responsible parties on pneumococcal and flu vaccines; -The assistant director of nursing (ADON) and director of nursing (DON) were responsible for tracking and administering the resident's pneumococcal and flu vaccines. During interview on 4/19/18 at 2:10 P.M., Registered Nurse (RN) K said: -Consents for pneumonia and flu vaccines are in the admission packets; -Charge nurse's get consents signed and lets ADON know to check consents; -He/she does not give pneumonia or flu vaccines; -He/she does not give out education to the residents on flu and pneumonia vaccines; -If the resident is not cognitively intact staff should contact the family for consent. During interview on 4/19/18 at 11:25 A.M., the ADON said the following: -The facility sent out the flu vaccine consent in the mail once a year to educate and get consent from the residents and the resident's responsible party; -The flu vaccine consent also had the pneumococcal vaccine information and consent on it and the residents and residents' responsible parties were filling it out at the same time or instead of the flu vaccine; -Staff were not reviewing pneumococcal vaccines because they were supposed to be flu vaccines consents; -Staff were missing pneumococcal vaccine consents; -The charge nurses were responsible for checking and administering flu and pneumococcal vaccine upon admission; -She was responsible for tracking residents' pneumococcal and flu vaccines consents and administration as ordered; -The charge nurse or she could give the vaccines as ordered and per consent; -There was not one staff responsible for administration, education, providing consent or denial for the flu or pneumococcal vaccines; -She nor anyone else were tracking the flu or pneumococcal vaccine to make sure if ordered, needed, or consented the residents or residents' responsible parties were educated and if appropriate and/or consent granted provided with the vaccines; -She was not current or familiar with the CDC or ACIP guidelines that were to be followed per the facility policy; -She expected the resident to receive a vaccine within one week of giving consent; -Every resident in the facility was at risk for contracting flu and pneumonia; -Individuals [MEDICAL CONDITION] at more risk for contracting flu or pneumonia because their immune system was compromised; -If the resident is not cognitively intact staff should contact the family for consent; -She expected staff to document flu and pneumococcal vaccines on the immunization form. During interview on 4/19/18 at 11:55 A.M., the DON said the following: -The ADON was responsible for overseeing staff administered flu and pneumococcal vaccines as ordered and indicated and education was provided; -Neither she or the ADON could find consents for vaccine administration for the individuals given a vaccine without consents in the medical record; -She expected the ADON to track pneumococcal and flu vaccine administration and education on admission; -The ADON could delegate to the charge nurses, but ultimately the ADON was responsible for the administration, education, and consent, denial and tracking of the flu and pneumococcal vaccines; -Resident #2 does not always express him/herself appropriately; -She doesn't know if Resident #2 would understand what he/she was signing, his/her family member signed all of the admission paperwork; -She expect the ADON to follow CDC, ACIP guidelines, physician orders, and consents for administration of pneumococcal and flu vaccines; -She expected the ADON to address the need for pneumococcal vaccine upon admission and then follow the CDC and ACIP and physician orders; -She expected the ADON to address the residents' needs for flu vaccine on a yearly bases during flu season which was (MONTH) to March; -She expected the flu vaccine education information that was updated yearly through the CDC to be giving along with the consent form yearly to the resident's and/or resident's responsible party; -The facility had residents that [MEDICAL CONDITION] were immunosuppressed living in the facility; -All individuals living in the facility were at risk for contracting flu and pneumonia. During interview on 4/19/18 at 2:57 P.M., Physician G, Resident #3's physician, said the following: -He/she expected staff to administer pneumococcal vaccine and flu vaccine as ordered and per the resident's or the resident's responsible party; -He/she expected staff to offer flu yearly to all residents along with education; -He/she expected staff to follow the Medical Director's set standards for administering pneumococcal vaccine; -Residents [MEDICAL CONDITION] at high risk for pneumonia and flu and should be offered the pneumococcal vaccine and flu vaccine as indicated and ordered. During interview on 4/25/18 at 11:15 A.M. the facility Medical Director said the following: -He would expect flu and pneumonia vaccine to be offered to all eligible residents; -Residents could potentially develop flu or pneumonia if they do not receive the flu or pneumonia vaccine; -He would expect staff to administer the flu and/or pneumonia vaccine if the resident/responsible party gave consent and there were no medical contraindications to receiving the vaccine; -He would expect education to be given regarding vaccine benefits/side effects when obtaining consent for vaccine administration.

Based on observation, interview and record review, the facility failed to provide adequate supervision to one resident (Resident #1) while drinking a hot liquid of four residents sampled. The resident had limited range of motion in both upper extremities and a history of throwing items including cups and plates. The resident utilized a specialized wheelchair with lateral supports due to leaning to one side. The resident's care plan showed the resident liked his/her coffee/tea lukewarm. On 8/9/15, the resident became upset and was yelling for hot tea. According to staff, the resident was not seated in his/her own wheelchair with the lateral supports and was not positioned correctly. Dietary staff fixed the resident a cup of hot tea and did not dilute it to make it lukewarm. The resident spilled the tea and sustained second degree burns (also known as partial thickness burns and involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful), on his/her left thigh, left abdomen and left hand. The facility census was 55. 1. Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment instrument required to be completed by staff dated 12/17/14 showed the resident: -The resident had severely impaired cognition; -He/she had verbal behavior directed at others; -Total assist of two persons for transfer; -Had range of motion impairment of both upper and lower extremities; -Required extensive assistance of one person with eating; -Used a wheelchair. Review of the resident's nurse's notes dated 1/24/15 through 1/25/15 showed: -On 1/24/15 at 12:00 P.M., the resident was very upset; -He/she was hollering, screaming and cursing at staff; -The resident hit a staff member on the arm; -The resident was throwing a blanket and applying brakes (on his/her wheelchair), while staff was trying to push the resident back to his/her room; -On 1/25/15 at 8:15 A.M., the resident was in the TV room; -He/she started cursing and threw Pepsi all over the floor; -Staff took the resident to his/her room; -The resident was applying the brakes on the wheelchair and screaming. Review of the resident's annual MDS dated [DATE] showed the resident: -Had severe cognitive impairment; -Had range of motion impairment of both upper and lower extremities; -Required extensive assistance of one person with eating: -Used a wheelchair. Review of the resident's care plan dated 4/7/15 and reviewed on 6/10/15 showed: -The resident had self-care performance deficit related to musculoskeletal impairment and limited mobility; -Occasionally assist with eating; -The care plan directed staff the resident used adaptive equipment to aide in the resident feeing him/herself; -The resident was totally dependant on staff for repositioning; -The resident used a tilt n space wheelchair for positioning; -The resident needed to be repositioned as required and as needed; -The resident enjoyed lukewarm decaffeinated coffee and tea; -The care plan directed staff to obtain the coffee or tea from the kitchen and offer it to the resident; -The resident had a communication problem related to cognition and inability to express him/herself at times; -The resident had a psychosocial well-being problem (actual or potential), related to [DIAGNOSES REDACTED]; -The resident angered easily and lashed out at others, cursing, screaming, grabbing and hitting; -Sometimes the resident would try to bite; -The care plan directed staff when conflict arises, remove the resident to a calm, safe environment and allow the resident to ventilate/share his/her feelings; -The resident had a behavior problem related to physical and verbal aggression at times; -The care plan directed staff to remove the resident from the area of disturbance and provide the resident with a calm quiet area in his/her own room to regain control; -If behavior occurs during meal service, the resident will eat in his/her room; -When the resident throws objects, food or fluids, staff are to remove the thrown objects from the resident's environment and provide the resident time out in his/her room; -The care plan directed staff to intervene as necessary to protect the rights and safety of others; -The resident used antipsychotic medications related to mood and behavior management (biting, hitting, throwing objects). Review of the resident's quarterly MDS dated [DATE] showed the resident: -Used a wheelchair; -Required extensive assistance of one person for eating; -Had range of motion impairment of both upper and lower extremities. Review of the resident's antipsychotic medication quarterly evaluation dated 6/16/15 showed: -The resident yelled/cursed, hit and bit every day; -The symptoms caused the resident to be a danger to him/herself and others and interfered with staff's ability to give care. Review of the resident's Occupational Therapy (OT) Plan of Care dated 6/30/15 showed: -Therapy needed for maximum wheelchair positioning; -The resident had a new lateral (side) support and foot wells for his/her wheelchair; -The therapist upon arrival, observed the resident with maximum lateral lean and maximum posterior tilt; -The resident required adjustment of the lateral support; -The assistive equipment was on crooked; -The therapist adjusted; -The resident continued with a right lateral lean; -The resident required increased width and depth of the support on the left side; -Long term goal-Nursing staff will independently position the resident in his/her wheelchair with adaptive equipment in good wheelchair position with the resident being able to maintain for two hours. Review of the resident's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -Medications included Seroquel (antipsychotic), 100 milligrams (mg) twice a day, Namenda XR (dementia), 14 mg, two daily and Paxil (depression), 10 mg every morning; -Adaptive equipment at meals; -Up in a tilt wheelchair during waking hours. Review of the resident's OT progress note dated 8/6/15 showed: -Long term goal-Nursing staff will independently position the resident in his/her wheelchair with adaptive equipment, in good wheelchair position; -The resident continued with decreased core stability impacting wheelchair positioning; -The resident attempted increased forward flexion out and around the lateral support; -OT increased the reline of the resident's wheelchair to 20 degrees to decrease the resident's ability and increase safety to reduce the amount of forward flexion which in turn keeps the resident in position for lateral (side) support, reducing the lateral lean as well; -Nursing staff educated on the amount of recline and cautioned increasing the reline increases the sliding of hip/fall from the wheelchair; -Nursing staff educated on the resident's hips being fully back in the wheelchair; -Treatment plan progression to include extensive nursing education to improve consistent positioning in the wheelchair. Interview on 9/29/15 at 2:29 P.M. showed physical therapy aide (PTA) I said the resident had lateral supports on his/her wheelchair. Interview on 9/29/15 at 2:29 P.M. showed certified occupational therapy aide (COTA) J said the resident had L shaped lateral supports for his/her wheelchair. The resident would lean at times if the lateral supports were not in his/her wheelchair. Review of the resident's nurse's notes dated 8/9/15 showed: -On 8/9/15 at 6:45 P.M., the resident had hot tea (cup), in his/her left hand; -The resident spilled the hot tea on his/her upper left leg, left abdomen and left hand; -Staff observed small blisters in these three areas. Review of the resident's POS showed an order dated 8/9/15 directing staff to apply Silvadene (anitbacterial ointment used in second- and third-degree burns) to burn areas two times a day until healed (left upper leg, left abdomen and left hand). Interview on 9/29/15 at 11:42 A.M. showed the Director of Nurses (DON) said: -A CNA (Certified Nurse Aide) gave the resident a cup of coffee and did not know it was way too hot; -The resident spilled the coffee when he/she went to take a drink. Review of the facility's investigation dated 8/10/15 showed: -The investigation was regarding the resident spilling hot tea on him/herself; -The resident had multiple [DIAGNOSES REDACTED]. -The resident wanted his/her usual cup of hot tea prior to leaving the dining room; -Cook A gave the resident his/her hot tea; -CMT (certified medication technician) B was taking the resident out of the dining room where he/she stopped to get his/her medications; -Housekeeping staff heard the resident holler out; -That's when it was discovered the resident resident had spilled hot tea on him/herself; -The resident's physician was notified and orders were received due to the blistering associated with the hot tea spill. Review of the resident's nurse's notes dated 8/10/15 showed: -The resident had blisters varying in size on his/her left leg, left abdomen and left hand; -At 10:45 A.M., staff dressed the resident's left hand; -The resident's face was flushed and hot to touch; -The resident's temperature was 103.3 (normal, 97.6 axillary, 98.6 oral and 99.6 rectal); -The resident was transferred by ambulance to the hospital; -The resident's lung sounds were diminished with a bark like cough; -At 2:00 P.M., staff notified the resident's guardian the resident had been admitted to the hospital with [REDACTED]. Review of the resident's Emergency Department Physician documentation from a local hospital at 8/10/15 showed: -On 8/10/15 at 11:55 A.M., the resident presented to the ED by ambulance: -The resident had received burns to his/her left abdominal wall and left thigh yesterday when some tea was spilled on him/her; -The resident had second-degree burns of his/her left lower abdominal wall and lateral left thigh; -There was also a second-degree burn over the radial (inner) side of his/her right hand; -The resident had multiple flaccid bolus lesions (blister-like lesions), at the sites of the burn with some surrounding [DIAGNOSES REDACTED] (redness). Review of the resident's history and physical from a local hospital dated 8/10/15 showed: -The resident had a past medical history of [REDACTED]. -The resident was sent to the hospital after he/she was found to have a wet cough and high-grade fever (103); -Reportedly, he/she burned his/her left hand, left upper thigh and left abdominal wall after he/she spilled some hot tea onto those areas; -The resident had superficial blisters on his left wrist and upper left thigh with superficial ulceration on his left abdominal wall; -The resident had significant contractures of his/her lower extremities and his/her right upper extremity with minimal rigidity of his left upper extremity; -Plan: treat the superficial burns with topical 1% gel with silver sulfadiazine (Silvadene) cream. Observation on 9/29/15 at 2:37 P.M. showed: -A glass coffee pot of hot water on the electric burner in the facility kitchen area; -Temperature of the hot water was 156 degrees Fahrenheit. During interview, Cook H said the hot water in the kitchen area was used for residents. Interview on 10/6/15 at 1:35 P.M. showed Cook A said: -On 8/9/15, one of the nurses asked him/her to make hot tea; -He/she was the cook and did not handle the drinks, so he/she asked another dietary staff how to make it; -Staff was leaving the dining room with the resident; -He/she fixed the tea and handed it to the nursing staff who gave it to the resident; -If he/she had of known the tea was for the resident, he/she would have asked more questions as the resident ate at the assisted table; -He/she did not know the resident was supposed to get his/her hot liquids half and half; -There was no sign posted in the kitchen area regarding this that he/she saw; -The kitchen kept the coffee pot of hot water on the burner; -He/she fixed the tea by pouring the hot water from the glass coffee pot in the kitchen into a mug with a tea bag; -He/she was told later the resident should get 1/2 hot tea and 1/2 cool water to cool it down. Interview on 9/29/15 at 1:00 P.M. showed the dietary supervisor said: -The resident was supposed to be served 1/2 cup of milk with 1/2 cup of coffee or tea; -There had been a note on the milk refrigerator in the kitchen instructing dietary staff to dilute Resident #1's hot liquids with milk, water or whipped topping; -He/she would expect dietary staff to follow the directions that had been placed on the milk refrigerator. Interview on 10/2/15 at 7:40 A.M. showed CNA K said: -The resident varied with his/her mood; -The resident could be fine one minute and cussing the next; -The resident threw things, he/she threw cups and plates; -The resident was supposed to be served 1/2 decaf and 1/2 milk so the drink would not be hot; -The resident had a wedge in his/her wheelchair; -The resident leaned in his/her wheelchair at times. Interview on 9/29/15 at 3:19 P.M. showed CNA F said: -At the time of the incident, he/she was in the dining room charting meals; -He/she heard a blood curdling scream; -The resident was holding something in his/her hand. Interview on 9/29/15 at 3:20 P.M. showed CNA G said: -He/she saw the resident's burns; -The resident had habit of dropping drinks; -The resident should not be given anything hot; -He/she watered coffee down so it not be so warm. Interview on 10/9/15 at 2:30 P.M. showed CNA D said: -He/she did not know who had given the resident the hot liquid; -He/she did not know if it had been cooled down; -If the liquid is too hot, staff were to put water in it to cool it down so the resident would not get burned; -The resident leaned to one side in his/her wheelchair and had things in the wheelchair to keep him/her from leaning. Interview on 9/29/15 at 12:10 P.M. showed CMT (Certified Medication Technician) B said: -On 8/9/15, he/she was passing medications; -Staff was assisting residents (pushing) out of the dining room; -Resident #1 was throwing a fit, wanting hot tea; -RN (Registered Nurse) C was assisting the resident out of the dining room in his/her wheelchair; -RN C sent CNA D to get the hot tea for the resident; -CNA D gave the tea to RN C who gave it to the resident; -The resident was not positioned well in the wheelchair; -The resident was not in his/her own wheelchair; -The wheelchair did not have the arm/side support and the resident was leaning more in the wheelchair; -The resident would throw a whole cup of coffee or tea; -The resident's tea was suppose to be diluted with milk; -Staff was not suppose to give the resident hot tea because the resident would throw the cup; -The resident was supposed to get 1/2 milk and 1/2 tea or coffee. Review of a written statement dated 9/29/15 showed CMT B showed: -While passing medications at mealtime (on 8/9/15), staff was assisting residents who had finished (eating), out of the dining room; -RN (Registered Nurse) C was pushing (wheelchair) Resident #1 out (of the dining room) when the resident began to have a behavior; -RN C stopped (pushing the wheelchair), asked the resident what he/she wanted; -The resident said he/she wanted some hot tea; -RN C asked CNA D to get the resident some tea; -CNA D went to the kitchen and asked for some tea and brought it back to RN C; -RN C gave the resident the tea and let him/her sit there and start drinking the tea; -RN C began pushing other residents out of the dining room; -After a few minutes, the resident began to scream again; -Initially, CMT B thought the resident was having another behavior but then noticed the resident had spilled hot tea on him/herself; -CMT B told the nurse (RN C) what had happened; -The nurse said the resident did not get hot drinks anymore and began assessing the resident. Interview on 9/29/15 at 12:10 P.M. showed LPN (Licensed Practical Nurse) E said the resident was suppose to get 1/2 milk and 1/2 tea or coffee. Interview on 10/9/15 at 1:15 P.M. showed RN C said: -On 8/9/15, he/she was standing by the medication cart talking with the CMT when he/she heard a blood curdling scream; -He/she could not get to the resident before he/she spilled hot liquid on him/herself; -RN C could see steam coming off the resident where the hot liquid had spilled; -The liquid had not been watered down; -The resident had burns on his/her left thigh, left abdomen and left hand/thumb; -The resident's thigh had two to three blisters, his/her abdomen had a white spot and his/her thumb had a little bigger blister; -The resident complained his/her hand hurt; -There were no stipulations on the resident's coffee or tea, it was just common sense to water the hot liquid down. Interview on 10/6/15 at 2:00 P.M. showed the resident's guardian said: -The resident had a history of [REDACTED]. -The resident liked tea and coffee; -Staff were supposed to serve the resident's tea/coffee 1/2 and 1/2 diluted so it was not hot; -On the evening of the incident, staff served the resident a hot beverage and did not dilute it; -The resident's hand was bubbled/blistered and red; -The blister was 1/2 to 1 inch wide and 1-2 inches long (from the knuckle to the thumb). Interview on 10/13/15 at 1:10 P.M. showed the DON said she would expect staff to make sure hot beverages were cool enough for the residents to drink. Interview on 10/13/15 at 1:10 P.M. showed the administrator said she would expect staff to follow the residents' plan of care. 2. Review of The Lippincott Manual of Nursing Practice 7th Ed Copyright 2001 showed -The very young and the elderly are at the greatest risk for burn injuries; -Burn depth is directly related to the temperature of the burning agent and the duration of contact with body tissue; -At 120 degrees F, it takes five minutes' exposure to create a full thickness burn; -At 125 degrees F, the time requirement is two minutes; -At 140 degrees F, only six seconds is required; -At 159 degrees F, it takes one second to create a full thickness burn in a healthy adult-less time or temperature in children or the elderly; -Second degree burn-superficial; -Blisters form; -Superficial layers of skin are destroyed; -Wound bed moist and painful; -Takes several weeks to heal and scarring may occur. MO# 4

Based on observation, interview, and record review the facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers from developing for one resident (Resident #3) of 12 sampled residents. The facility failed to notify the physician of a Stage II open area that was present on admission until nine days after the area was identified. The facility failed to obtain clear treatment orders and document consistent, timely assessments of the resident's pressure ulcers. The facility failed to provide ordered nutrition and maintain an adequate turning and repositioning schedule. The resident had one Stage II pressure ulcer on admission and had five Stage II and two Stage III pressure ulcers 18 days later. Facility census was 54. 1. Review of the RAI User's Manual (Long-term Care Facility Resident Assessment Instrument User's Manual) Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling. 2. Review of the facility's wound care policies and procedures, dated 12/2011, showed: -Evaluate the pressure ulcer initially for location, state, size (in centimeters/cm's), sinus tracts, undermining, tunneling, exudates (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and [MEDICATION NAME]; -Determine and record the date of onset for each pressure ulcer identified as Stage II or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed; -Pressure ulcer measurement should be obtained per RAI Manual 3.0 guidelines as follows: The length is based on the longest length from resident's head to toe. The width is the longest width perpendicular to the length forming a "+" side to side. The depth is measured from the deepest aspect of the ulcer to the skin surface. If the depth is uneven, the wound should have individual depth measurements identified as to their relative position to the wound. For the purpose of MDS 3.0 coding, the deepest measurement will be used; -Identify the most severe tissue type for any pressure ulcer on the appropriate forms as follows: [MEDICATION NAME] tissues-new skin that is light pink and shiny (even on darkly pigmented skin tones); granulation tissue-pink or red tissue with shiny, moist, granular appearance; slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous (containing a lot of mucus); necrotic tissue (eschar)-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin; -Re-evaluate pressure ulcers at least weekly. If the resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated; -If the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. 3. Review of the facility's nursing policy and procedure, physician communication grid, dated 9/2011 showed: -Pressure ulcers that are a new stage II or less should be reported to the physician within 24 hours; -Pressure ulcers that are a new stage III or higher, and break in skin associated with fever or signs of infection should be reported to the physician within four hours. 4. Review of the Pressure Ulcer Prevention and Treatment Quick Reference Guide dated 2009 showed the following: -Undernutrition is a reversible risk factor for pressure ulcer development; -Provide nutritional support to each individual with nutritional risk including provision of appropriate nutrition intervention, based on appropriate feeding route; -Provide sufficient calories for healing of existing pressure ulcers (recommendation of 30-35 kilocalories per kilogram of body weight for individuals under stress with a pressure ulcer). 5. Record review of Resident #3's care plan, dated 8/27/14 showed: -Diagnoses: [REDACTED]. -Potential/actual impairment to skin integrity related to fragile skin and moisture; -Red pannus (fold under abdomen); -Complete treatments as per orders. See TAR (treatment administration record); -Encourage to consume good nutrition and hydration in order to promote healthier skin; -Follow facility protocols/physician orders [REDACTED]. -Give extra fluids between meals; -Monitor/document the location, size and treatment of [REDACTED]. -Report any dry, red, weeping, or non-intact skin to the charge nurse. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/13 showed: -Usually makes self understood and sometimes understands others; -Severely impaired cognitive status; -Fluctuating inattention and disorganized thinking; -Did not reject care; -Requires extensive assistance of two for bed mobility, transfers, toilet use, personal hygiene and bathing; -Requires limited assistance of one for eating; -Always incontinent of bowel and bladder; -Received a diuretic (fluid pill) seven out of the last seven days. Record review of the resident's discharge summary from the hospital, dated 1/3/14 showed: -Diagnoses: [REDACTED]. -Consultation was obtained and PEG (percutaneous endoscopic gastrostomy) tube secondary to the resident's high risk of aspiration was recommended. Record review of the resident's hand written admission physician order [REDACTED]. -HOB (head of bed) up at least 30 degrees at all times; -[MEDICATION NAME] 1.5 calories (cal) (a calorically dense formula with fiber that provides complete, balanced nutrition for tube feeding), 380 ml (milliliters) bolus every eight hours; -NPO (nothing by mouth); -Gastrostomy tube (tube through the abdominal wall into the stomach) feeding of [MEDICATION NAME] 1.5 calories every eight hours and free water flushes every eight hours between feedings; -[MEDICATION NAME] topical (antifungal medication available in a powder, ointment and cream) 100,000 units BID (twice a day) (did not clarify which form to use or location for use). Record review of the resident's nursing data collection tool, dated 1/3/14 showed: -Nutritional approaches: PEG tube; -Oral problems (NPO); -Always incontinent of bowel and bladder; -Braden scale (used to predict pressure sore risk) equaled 9 (Total score of 18 or below are considered a risk); -Wounds present: Superficial open wound 0.5 x 0.3 buttocks (did not indicate unit of measurement or which buttock); -Other skin conditions: Reddened area/non-blanchable (did not indicate size or location of the area noted). Record review of the resident's weekly skin documentation, dated 1/3/14 showed: -Marked at resident's right inner mid-buttocks, circled with 0.5 x 0.3 (no unit of measurement indicated) open area written next to it; -Circles around bilateral forearms with "bruising" written next to it. Record review of the resident's care plan, dated 8/27/13 and updated 1/3/14 showed: -Right buttock open; buttocks excoriated (dated 1/3/14); -Staff failed to add additional interventions to the care plan to address the areas. Record review of the resident's daily skilled nurse's note for 1/4/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank; -Day shift: Extra large BM (bowel movement) noted with loose stool. Record review of the resident's daily skilled nurse's note for 1/5/14 showed bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank. Record review of the resident's daily skilled nurse's note for 1/6/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer and other open lesion left blank; -Day shift: Resident's physician's office notified of the resident having several loose stools daily; -Diarrhea checked on all three shifts. Record review of the resident's nurse's notes on 1/6/13 at 3:00 P.M. showed: -The resident's physician visited, said the resident's condition was poor, and advised to send the resident to the emergency room if the family agreed; -The family agreed and the resident was sent to the hospital emergency room . Record review of the resident's daily skilled nurse's note for 1/6/14 showed: -At 8:00 P.M. the resident returned with new orders to discontinue the 400 ml flush every eight hours and change to 200ml flush after each feeding; -Night shift: Calmo ([MEDICATION NAME]. Order not received until 1/13/14) to buttock. Record review of the resident's daily skilled nurse's note, dated 1/7/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank; -Skin WNL (within normal limits) checked on the day shift. Record review of the resident's daily skilled nurse's note, dated 1/8/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank; -Skin WNL checked on the day shift and night shift; -Hand written documentation on the night shift: One can of [MEDICATION NAME] 1.5 given as ordered with water flush ([MEDICATION NAME] 1.5 order was for 380 ml every eight hours. Each can of [MEDICATION NAME] 1.5 holds 237ml). Record review of the resident's daily skilled nurse's notes dated 1/9/14 - 1/11/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank; -Skin WNL checked on all three shifts. Record review of the resident's weekly skin documentation, dated 1/12/14 (Nine days after the last documentation/measurements) showed: -Right inner thigh 1.5 x 0.5cm (centimeter) open area; -Right buttock 0.5 x 0.9 (no unit of measurement) superficial open; -On body graph: fading bruise 6.8 x 3.8 (no unit of measurement) at resident's right hip; fading bruise 5.8 x 9.5 (no unit of measurement) at resident's left hip; excoriation inner buttocks 9 x 6.5 (no unit of measurement); hematoma 0.5 x 0.9 (no unit of measurement) marked at resident's right inner mid-buttocks). Record review of a facility fax to the resident's physician, dated 1/12/14 showed: -Weekly skin assessment: Buttocks excoriation with 0.5 x 0.7 superficial open area left buttock and 1.5 x 0.5 open area right inner thigh. Appears to be depend (disposable incontinent product) line. Two fading bruises on left and right lateral sides appears to be near waist line. May we have zinc oxide (Calmo) TID (three times a day) and PRN (as needed) for redness and open areas; -Physician responded with OK, dated 1/13/14. Record review of the resident's care plan, dated 8/27/13 showed: -Stage II right inner thigh (dated 1/12/14); -No additional interventions were added to the care plan. Record review of the resident's daily skilled nurse's notes dated 1/12/14 - 1/14/14 showed: -Bruising checked all three shifts. Rash, abnormal skin color, pressure ulcer, other open lesion and diarrhea left blank; -Skin WNL checked on all three shifts. Record review of the resident's turn/reposition record showed: -Staff failed to document prior to 1/13/14; -Staff failed to document on the evening and night shift for 1/13/14; -Staff failed to document on the day, evening and night shift on 1/14/14. Record review of the resident's daily skilled nurse's notes, dated 1/14/14 on the day shift, showed resident's coccyx noticed to have dark non-blanchable areas. Calmo applied; -Staff failed to document size or color. Record review of a facility fax to the resident's physician, dated 1/14/14 showed: -Resident's coccyx noted to have dark areas. Applied Calmo as ordered (Calmo was ordered for redness and open areas). Resident placed on turn schedule; -Physician responded with OK, dated 1/15/14. Record review of the resident's turn/reposition record showed: -On 1/15/14 staff failed to document repositioning on the evening and night shift; -On 1/16/14 staff failed to document repositioning on the day, evening and night shift; -On 1/17/14 staff failed to document repositioning on the evening and night shift; -On 1/18/14 staff failed to document repositioning on the day shift; -On 1/19/14 and 1/20/14 staff failed to document repositioning on the day, evening and night shift; -On 1/21/14 staff failed to document repositioning on the day and evening shift. Record review of the resident's treatment administration record (TAR) showed: -[MEDICATION NAME] topical 100,00 BID completed 1/4/14 - 1/20/14. Order did not include location or form of [MEDICATION NAME] used; -Calmo or equivalent to red or open area TID and PRN completed once on 1/13/14, twice on 1/14/14 and three times on 1/15/14 - 1/20/14. Order did not include location of red or open areas. Observation on 1/21/14 at 2/25 P.M. showed: -Resident lay on right side with a positioning wedge to his/her back; -Incontinence brief on. White cream noted on the resident's perineal area and buttocks; -Certified Nurse Aide (CNA) E and CNA F provided perineal care, washing the white cream off of the resident; -Large butterfly shaped red area noted across the resident's coccyx and upper buttocks region; -Multiple Stage II open areas noted right buttocks, beefy red in color; -Two Stage III open areas noted on left buttocks covered by a thin layer of yellow slough; -Entire perineal area and bilateral, upper inner thighs red and excoriated; -A tube of TENA protective cream with zinc (moisture repellant cream used for dry, chapped irritated skin) and a tube of [MEDICATION NAME] both at bedside; -CNA's did not apply any cream to the resident's buttocks or perineum; -Staff positioned the resident on his/her left side with a positioning wedge to his/her back. During an interview on 1/21/14 at 2:25 P.M. CNA E said: -The resident's sore areas have been present since the resident came back from the hospital and were not there when he/she left to go to the hospital; -The charge nurse puts the cream on the resident. The CNA's are not allowed to do treatments. Observation on 1/21/14 at 4:15 P.M. showed the resident had slipped off the wedge and lay on his/her back in bed. During an interview on 1/21/14 at 4:30 P.M. the Assistant Director of Nurses (ADON) said: -He/she worked on the weekend of 1/12/14; -He/she was not told about the open area on the resident until 1/12/14. Observation on 1/21/14 at 5:15 P.M. showed: -Resident lay supine in bed; -Bottom sheet, incontinent pad and incontinent brief wet with urine; -No visible barrier cream on the resident; -CNA G and CNA H performed perineal care; -CNA H washed the resident's buttocks with a handful of wipes. Without changing gloves or washing hands, took [MEDICATION NAME] from the bedside table, applied cream to the open areas on the resident's buttocks and coccyx region, returned the [MEDICATION NAME] to the bedside table and positioned the resident on his/her back; -CNA G applied [MEDICATION NAME] to the resident's perineal area; -Staff positioned the resident on his/her left side with a positioning wedge to his/her back; -CNA H elevated the head of the bed 45 degrees, placed a positioning wedge to the resident's left side, causing the resident to lay on his/her back. During an interview on 1/21/14 at 5:32 P.M. CNA H said: -A wedge is placed on both sides of the resident because he/she will try to get up; -He/she has seen the resident try to get up; -The wedges are placed on both sides to keep the resident from rolling out of bed. Record review of the resident's TAR, dated 1/21/14 - 2/20/14 showed: -[MEDICATION NAME] Cream 30 gm apply topically twice daily to affected area (order did not describe where the area was located); -Calmo or equivalent to red or open area TID and PRN. Record review of the resident's undated care plan showed: -I require tube feeding related to poor intake; -I am dependent with tube feeding, water flushes and medication. See physician orders [REDACTED]. Observation on 1/22/14 at 8:30 A.M. showed Licensed Practical Nurse (LPN) P administered [MEDICATION NAME] 1.5 cal, one can (237ml), by gravity via PEG tube (order was for 380ml every eight hours) and followed with a water flush. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. During an interview on 1/22/14 at 10:00 A.M. LPN P said: -The staff used the [MEDICATION NAME] powder on the resident's perineal/buttock wounds; -Then said no, staff use the [MEDICATION NAME] cream (after checking the order on the resident's TAR); -The [MEDICATION NAME] was for under the resident's breasts before he/she went to the hospital. Observation on 1/22/14 at 10:00 A.M. showed [MEDICATION NAME] powder and [MEDICATION NAME] cream were both available in the treatment cart for the resident. Observation on 1/22/14 at 11:30 A.M. showed: -The resident lay in bed; -The ADON completed measurements of the areas on the resident's perineal area and buttocks (Ten days after last measurements); -Inner thighs and genital areas deep red with a scattered red rash toward the edges; -Red area on right inner thigh 10 cm x 13cm; -Red area on left inner thigh 8.5cm x 15cm; -Five Stage II pressure ulcers, beefy red in color, on right buttocks measuring: one area 2cm x 2.4cm, two areas each measuring 0.3cm x 0.5cm, one area measuring 0.9cm x 1cm, one area measuring 0.3cm x 1.4cm; -One Stage III pressure ulcer, covered by yellow slough with red edges, on the resident's coccyx 2.3cm x 1.8cm; -One Stage III pressure ulcer, covered by yellow slough with red edges, on the resident's left buttocks 4cm x 1.8cm. During an interview on 1/22/14 at 11:30 A.M. the ADON said: -CNA's are not allowed to put the [MEDICATION NAME] on the resident. They have all been told this; -After perineal care they should tell the charge nurse and the charge nurse should reapply the [MEDICATION NAME]; -He/she was going to put [MEDICATION NAME] between the resident's legs and [MEDICATION NAME] on the resident's bottom; -The [MEDICATION NAME] order should have superceded the [MEDICATION NAME] order; -He/she would have to say the area on the resident's coccyx and left buttocks were Stage III's; -He/she would be asking for different treatment orders. Observation on 1/22/14 at 3:40 P.M. showed: -Resident lay supine in bed with a positioning wedge to both sides; -LPN O administered one can of [MEDICATION NAME] 1.5 cal (237ml) by gravity via PEG tube, opened a second can of [MEDICATION NAME] 1.5 cal, poured out 25ml into a plastic medicine cup (for a total of 262 ml, order was for the resident to receive 380 ml) and administered by gravity via PEG tube and followed with a water flush. During an interview on 1/22/14 at 3:40 P.M. LPN O said: -There were 355ml in a can of [MEDICATION NAME] 1.5 cal; -The resident's order was for 380ml. Observation on 1/23/14 showed the resident lay on his/her back with a wedge to the right side of the resident (but not on wedge) from 5:45 A.M. until 8:20 A.M., (a total of 2 hours and 35 minutes). Observation on 1/23/14 at 8:20 A.M. showed: -Two wet [MEDICATION NAME] pads covered the resident's pressure ulcers on his/her buttocks; -CNA F removed the wet [MEDICATION NAME] pads and threw them away; -CNA F and CNA Q performed perineal care to the resident; -CNA Q said the resident was on his/her back so the staff would position the resident on his/her left side. During an interview on 1/23/14 at 8:50 A.M. CNA T said the resident was on his/her back when he/she came in at 7:00 A.M. this morning and the resident was not repositioned at that time. During an interview on 1/24/14 at 3:30 P.M. the DON said: -When a resident comes from the hospital with an open area she expects staff to document, notify the physician, obtain treatment orders, place the resident on a turning schedule while using positioning devices and try to determine the cause; -Treatment orders should be specific to the location of the treatment; -[MEDICATION NAME] orders should specify if the staff is to use the cream or the powder; -She was unable to tell from the order on 1/3/14 if [MEDICATION NAME] powder or cream was to be used; -A resident's turning schedule depends on the resident. Some need to be turned as often as every 30 minutes but no more than every two hours.

Based on observation, interview, and record review, the facility failed accurately assess one resident's (Resident #5's) pressure ulcer risk, failed to monitor and conduct ongoing assessments of existing pressure ulcers, failed to inform the physician of new pressure ulcers and of increasing size and depth of existing pressure ulcers, failed to develop a care plan to address the resident's needs prior to the completion of the comprehensive assessment and care plan, failed to ensure the resident maintained positioning at an appropriate angle in bed according to manufacturer's directions for the resident's pressure relieving mattress, and failed to document provision of ordered treatments of 13 sampled residents. The resident was admitted to the facility with a 4.0 cm x 2.4 cm abrasion on his/her coccyx, on 3/3/13 staff documented the abrasion as a Stage II pressure ulcer measuring 10.5 cm x 13.5 cm, and on 3/27/13 staff documented the pressure ulcer measured 8.5 cm x 8 cm. with necrotic tissue in the wound bed. The resident required hospitalization at that time and the coccyx wound was assessed as a Stage IV pressure ulcer. The resident developed Stage II pressure ulcers on both left and right ankles, and a pressure ulcer covered with necrotic tissue, measuring 9 cm x 7 cm, on his/her right heel. The facility census was 67. 1. Review of the Wound and Skin Care Policy and Protocol, dated 11/12/10, showed it included the following: -Purpose: To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions, to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. to promote healing of pressure ulcers in a cost efficient and timely manner; -Residents should be examined thoroughly at least weekly by licensed nurse to identify existing pressure ulcers, findings from the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form; -Any skin impairments, including pressure ulcers, should be assessed and documented weekly by the Wound Nurse, or designee, on the Wound Evaluation Flow Sheet, documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissue, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; -The PUSH TOOL 3.0 (Pressure Ulcer Scale for Healing, serves as a framework for recording and tracking wound healing progression in an organized, systematic way) and Pressure Ulcer Healing Chart should be completed in conjunction with these weekly wound assessments. 2. Review of the facility's Wound and Skin Care Policy and Protocol, dated 11/12/10, showed the following: -Any risk factors identified by the Braden scale, MDS, or other assessment should be reviewed and addressed as determined appropriate through the RAI (resident assessment instrument) process, including the resident's care plan; -Nutritional consultation should be completed for residents who are at-risk for [MEDICAL CONDITION]; -Pressure reduction surfaces should be provided on beds and chairs for at-risk residents, unless intolerance or lack of need is noted and documented; -Interventions to prevent or treat a pressure ulcer may be limited in some situations; -The policy did not include guidance on turning/repositioning schedules or prevention of shearing. 3. Review of Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling. 4. Review of Resident #5's Hospital Discharge Summary, dated 2/15/13, showed the following: -Poorly controlled diabetes (deficiency in insulin production causing high blood sugar levels); -Peripheral [MEDICAL CONDITION] (complication of diabetes resulting in nerve damage of extremities); -Diabetic foot (complication related to diabetes) requiring amputation; -Osteo[DIAGNOSES REDACTED] (infection of the bone and bone marrow) and [MEDICATION NAME] abscess (an inflammation involving a collection of pus between the outer membrane that covers the brain/spinal cord and the bones of the skull or spine) of Lumbar (L) 4-L5/L5-Sacral (S) 1 requiring laminectomy (surgical removal of the bony arches of one or more vertebrae) November 2012; -Bilateral flaccid paralysis of lower extremities with sensory deficit up to [MEDICATION NAME] (T) 7 and paresis (motor weakness) of both hands due to cervical osteo[DIAGNOSES REDACTED] and abscess; -[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus - bacteria that is resistant to [MEDICAL CONDITION] and many other antibiotics) infection with multiple foci; -Chronic decubitus ulcer (pressure ulcer) in left lower quadrant (LLQ)/groin managed by wound team. Review of the resident's admission data collection sheet, dated 2/18/13, showed the following: -The resident was admitted to the facility on [DATE]; -The resident was dependent for personal hygiene and grooming; -The resident had a Foley catheter (catheter that is maintained within the bladder for the purpose of continuous drainage of urine); -Non-intact blister 2.5 centimeter (cm) x 1 cm below right elbow; -Left abdominal ulcer 6 cm x 12 cm x 0.3 cm; -Four cm x 0.2 cm drain tube site at mid-sacral region; -Shearing on right upper thigh 1 cm x 0.4 cm; -Shearing on coccyx (tail bone) 4 cm x 2.4 cm; -Bedrest; -Non-weight bearing requiring total assistance with transfers. Review of the resident's Braden scale (a scale used to predict pressure ulcer risk), dated 2/18/13, showed the following: -A total score of 14, indicating moderate risk for pressure ulcers; -A four marked for sensory perception, indicating no impairment; (discharge summary dated 2/15/13 showed sensory defect up to T 7). Review of the resident's February physician order [REDACTED]. Review of facility fax, dated 2/18/13, showed a note for a protective boot that the resident requested be switched from his/her left to right foot every two hours. The physician signed "ok", dated 2/19/13. Review of the resident's skin condition report, dated 2/19/13, showed the following: -Right anterior forearm, non-intact blister, 2.5 cm x 1 cm, scabbed over, dry; -Left lower abdomen, pressure ulcer, Stage II, serous drainage, pink wound bed; -The report contained no documentation regarding shearing on the coccyx and thigh, or previous drain site at mid-lower back. Review of the resident's night shift nurse's notes, dated 2/19/13, showed the resident was resting in bed with the head of the bed elevated watching television. Review of the resident's night shift nurse's notes, dated 2/20/13, showed the following: -Resident's perineal area was gaulded; -Resident most comfortable on his/her back with the head of the bed up 45 degrees. Review of the resident's February 2013 physician order [REDACTED]. -Left lower abdomen: Cleanse with normal saline (NS), apply [MEDICATION NAME] cream (a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. -Right posterior thigh: Cleanse with normal saline, apply triple antibiotic ointment with a dry dressing every day; -Coccyx: apply [MEDICATION NAME] (a dressing used for treatment of [REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/25/13, showed the following: -Cognitively intact; -Did not reject care; -Independent with bed mobility; -Dependent on staff for transfers, locomotion, dressing, and personal hygiene; -Ambulation did not occur; -Weight of 232 pounds; -On a therapeutic diet; -Had one Stage II pressure ulcer; -Had moisture associated skin damage; -Was not on a turning/repositioning program; Review of the resident's ADL flow sheet, completed by certified nursing assistants (CNA's), for February 2013 showed staff documented the following: -The resident required assist of two for bed mobility on all shifts; -Staff scored through, instead of initialing to indicate completed, that the resident was repositioned every two hours on the night shift on 2/22-2/23; -Staff scored through, instead of initialing to indicate completed, that the resident was repositioned every two hours on the day shift 2/23, 2/24, 2/26, and 2/27/13; -Staff scored through, instead of initialing to indicate completed, that the resident was repositioned every two hours on the evening shift 2/24 and 2/26/13; -Staff failed to complete any documentation indicating the resident was repositioned every two hours on the day shift, dated 2/19, and all three shifts for 2/28/13. Review of a fax, dated 2/25/13, sent to the resident's physician showed the following: -Noted 1.6 cm x 1 cm Stage II pressure ulcer on the resident's left outer ankle with a request for [MEDICATION NAME], change every three days; -Physician approved. Review of the resident's nurse's notes, dated 2/27/13 at 3:30 P.M., showed the following: -Fax sent for treatment orders to genital area and mid-lower spine (nine days after first documentation); -Staff failed to document condition of skin or why they were requesting treatment orders. Review of the resident's POS, undated, showed an order, dated 2/28/13, to cleanse genital area and mid-lower spine with NS (normal saline), apply triple antibiotic ointment and dry dressing until healed. Review of the resident's untimed nurse's notes, dated 2/28/13, shows wound care was provided to coccyx, lower back, and left lower abdomen with undefined causes of the wounds being pressure, surgical, and excoriation. Review of the resident's night shift nurse's notes, dated 2/28/13, showed the head of the resident's bed was up 50 degrees. Review of the resident's skin condition report, dated 3/3/13, showed the following: -LLQ abdomen: Stage II ulcer, 12.5 cm x 5 cm, small amount of serous (of a watery nature) drainage; -Coccyx: Stage II ulcer, 10.5 cm x 13.5 cm, wound bed pink and white; -Left outer ankle: unstageable ulcer (wound bed cannot be visualized because of presence of eschar or slough, hence cannot be staged), 1 cm x 1.1 cm, wound bed necrotic; -Right posterior thigh incontinent associated [MEDICAL CONDITION], 1.3 cm x 0.7 cm; -Lower mid-spine (old drain site), 6 cm x 0.5 cm x 0.5 cm, small amount of serous drainage. Review of the resident's medical record showed no evidence facility staff assessed the pressure ulcer on the resident's coccyx, and no evidence of documentation of pertinent characteristics of the ulcers, including location, size, depth, color of the ulcer and surrounding tissue, and description of any drainage, eschar, necrosis, odor tunneling, or undermining, from 2/19/12 (measured 4.0 cm x 2.4 cm) until 3/3/13 (measured 10.5 cm x 13.5 cm). During interview on 7/22/13 at a 11:45 A.M., the Director of Nursing (DON) said she could find no evidence the staff assessed the pressure ulcer on the resident's coccyx from 2/19/12 until 3/3/13. Review of the resident's March 2013 POS showed the following orders dated 3/4/13: -Discontinue [MEDICATION NAME] to the coccyx and change to [MEDICATION NAME] cream with dry dressing BID; -Lower mid-spine: cleanse with normal saline, apply [MEDICATION NAME] cream, and cover with a dry dressing daily. Review of the resident's nurse's notes, dated 3/6/13 at 1:30 A.M., showed the resident's bottom buttocks were discolored and genital area was enlarged. [MEDICATION NAME] powder was applied to genital area. Review of the resident's TAR (treatment administration record), dated 3/1/13-3/31/13, showed staff failed to document the [MEDICATION NAME] cream treatment to the resident's coccyx was completed on 3/6/13. Review of the resident's nurse's notes, dated 3/7/13, showed staff documented at 2:35 P.M., the resident had a new pressure ulcer on his/her right ankle, 3.5 cm x 2.5 cm with no drainage. Will continue to monitor. Review of the resident's March POS showed an order, dated 3/7/13, to cleanse right leg and ankle with normal saline, apply hydrogel (absorbent, moisturizing wound dressing), and dry dressing TID (three times a day). Review of the resident's activity of daily living (ADL) flow sheet for March 2013 showed the following staff documentation: -The resident required assistance of one for bed mobility on the night shift 3/1-3/25 and assistance of two 3/26-3/28; -The resident was independent with bed mobility on the day shift; -The resident was independent with bed mobility from 3/1/13 - 3/4/13 and required assistance of two from 3/5/13 - 3/28/13 on the evening shift; -Staff scored through, instead of initialing to indicate completed, that the resident was repositioned every two hours on the night shift 3/16/13. Review of the resident's undated TAR, showed the following: -On 3/8/13, the night shift staff initialed and scored through a treatment order for the resident's right leg/ankle, cleanse with NS, apply hydrogel and dry dressing. Change TID. -On 3/10/13, the evening staff scored through the right leg/ankle treatment. Review of the resident's nurse's notes, dated 3/10/13 at 4:20 A.M., showed the following: -Head of bed up 45 degrees; -Bed in highest position per resident's request. Review of the resident's POS for March 2013 showed the following orders dated 3/12/13: -No boots, avoid pressure to heels and lateral ankles; -Prevalon boots at all times; -Okay to do passive range of motion for dorsiflexion and weight bearing. Review of the resident's undated TAR showed the following: -No boots, avoid pressure to heels and lateral ankles, dated and initiated 3/15/13; -Prevalon boots at all times, dated and initiated 3/15/13 (three days after staff received the physician's orders [REDACTED]. Review of the resident's TAR, dated 3/1/13-3/31/13, showed staff failed to document the [MEDICATION NAME] cream treatment to the resident's coccyx was completed on the evening shift on 3/14/13 and 3/15/13. Review of the resident's undated TAR, showed the following: -On 3/13/13, the day shift staff failed to document the treatment for [REDACTED]. Review of the resident's nurse's notes, dated 3/15/13 at 3:30 A.M., staff documented the head of bed elevated 45 degrees; Review of the resident's undated TAR, showed the following: -On 3/15/13 the evening and night shift staff failed to document the treatment for [REDACTED]. -On 3/16/13 the night shift staff failed to document the treatment for [REDACTED]. Review of the resident's nutrition progress note written by the dietician, dated 3/16/13, showed the following: -Multiple wounds; -Obesity 234.5 pounds; -Total protein and [MEDICATION NAME] low; -Would check [MEDICATION NAME] and add multivitamin with minerals. Review of the resident's undated TAR, showed the following: -On 3/17/13 the night shift staff failed to document the treatment for [REDACTED]. -On 3/18/13 the evening shift staff failed to document the treatment for [REDACTED]. -Staff failed to document the [MEDICATION NAME] cream treatment to the resident's coccyx was completed on the evening shift on 3/18/13. Review of the resident's March 2013 POS showed an order, dated 3/19/13, for multivitamin with minerals and [MEDICATION NAME] level. Review of the resident's undated TAR, showed the following: -On 3/19/13 the night shift staff failed to document the treatment for [REDACTED]. -On 3/21/13 the evening shift staff failed to document the treatment for [REDACTED]. -On 3/22/13 the day and night shift staff failed to document the treatment for [REDACTED]. Review of the resident's care plan kept at a nurse's station that was not associated with the resident's hall, dated 3/22/13 (32 days after admission to the facility and 25 days after the admission comprehensive assessment), showed the following: -I am able to: Call for assistance when in pain, reposition self, ask for medication, and tell you what increases or alleviates pain; -Focus: I have an activities of daily living (ADL), self care performance deficit, related to limited mobility; -Intervention: Bed Mobility, I require one to two staff participation to reposition and turn in bed; -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -Two Stage II pressure ulcer (Left lower abdomen and coccyx) and an abrasion to lower mid spine, right lateral ankle, and right lateral foot related to immobility (did not address the ulcer on the resident's left ankle); -Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. -Report improvements and declines to my physician; -I require weekly skin assessment by a licensed nurse; -Pressure ulcers related to immobility; -If resident refuses treatment, confer with the resident, the Interdisciplinary team (IDT) and family to determine why and try alternative methods to gain compliance. Document alternative methods; -Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility; -The care plan did not address shearing to the right upper thigh or coccyx that was present on admission and how to prevent further shearing, the resident's support surfaces since admission, the resident's pressure reducing boots for his/her lower extremities, avoiding pressure to heels, or a turning/repositioning plan for the resident; -The care plan did not address the resident's request to use own wedges, cushions, and boots or refusal of care/medications. Review of the resident's untimed nurse's notes, dated 3/24/13, showed the following: -Pressure ulcer on coccyx 17 inches x 11 inches in total size, 10.5 inches x 8.5 inches was necrotic tissue. The rest was [MEDICATION NAME]; -Groin in left fold had 11 inch x 1 inch excoriated area; -Right heel had 9 inch x 7 inch necrotic tissue area; -Right outer ankle had 2 inch x 3 inch wound; -Right outer shin had 1 inch wound; -Will report wound to charge nurse. Review of the resident's nurse's notes, dated 3/25/13 at 11:15 P.M. showed the following: -Coccyx has an open area approximately the size of a softball on bilateral sides of buttocks with pink edges, white around inside, and area of black in the center approximately the size of a tennis ball; -Right ankle/leg (wound) is approximately the size of a nickel, white in color; -Right lower leg has an area approximately 3 cm x 1.5 cm, red/purple in color. Review of the resident's nurse's notes, dated 3/26/13 at 4:40 P.M. showed the following: -Coccyx is black/purple in the center with tissue that appears white with pink edges around black/purple area; -Right ankle is red/purple in color on top and bottom wound appears white in color. Review of facility fax, dated 3/26/13, showed an approved request for consultation orders at the hospital for wound care. Review of lab results, dated 3/26/13, showed a [MEDICATION NAME] level (drawn 3/23/13) of 9 milligrams per deciliter (mg/dL) (normal 21-43). Review of the resident's undated TAR, showed the following: -On 3/27/13 the day shift staff failed to document the treatment for [REDACTED]. Review of the resident's nurse's notes, dated 3/27/13 at 6:20 P.M. showed the following: -Right ankle approximately 3 cm x 1.5 cm, white/green-yellow center with black/purple edges, on side proximal to top of foot; -Right top ankle is approximately 1 cm x 2 cm, white/yellow-green; -Right heel approximately 8 cm x 9.5 cm, pink/red in color; -Coccyx approximately 16 cm x 7 cm, black in middle with white/pink edges with serosanguinous/white/yellow drainage. Review of the resident's undated TAR showed the following: -Staff circled initials, indicating that the Prevalon boots were not on the resident, on the day shift 3/27/13 and 3/28/13, the evening shift 3/25/13-3/28/13, and the night shift 3/26/13-3/28/13; -Treatment notes, on the back of the TAR on 3/26/13 on the night shift the resident states the staff threw out his/her boots; -On 3/27/13 on the evening shift the resident states boots were thrown away. Heels elevated off of bed. Review of the resident's skin condition report, dated 3/27/13, showed the following: -Right lower extremity with three Stage II pressure ulcers measuring 1 cm x 1.5 cm (proximal to ankle), 2.5 cm x 3 cm (distal to ankle), and 9 cm x 7 cm (heel), necrotic tissue in wound bed. All treated with hydrogel and dry dressing; -Coccyx: Stage II pressure ulcer, 8.5 cm x 8 cm, necrotic tissue in wound bed; -Left groin: wound type or stage not identified, 6.5 cm x 0.5 cm, cleansed with NS, [MEDICATION NAME] cream applied and dry dressing; -Right groin: wound type or stage not identified, 9 cm x 0.5 cm, cleansed with NS, [MEDICATION NAME] cream applied and dry dressing; -Scrotum: incontinence associated [MEDICAL CONDITION], superficial, 1 cm x 2 cm; -Genital area: incontinence associated [MEDICAL CONDITION], superficial, 1 cm x 0.5 cm. Review of the resident's medical record showed staff received an order to treat a pressure ulcer on the resident's right ankle on 3/7/13. The record showed no evidence staff assessed the ulcer from 3/7/13 to 3/27/13 and no evidence staff informed the physician of the necrotic tissue on the resident's right heel. Review of the resident's medical record also showed no evidence staff assessed the pressure ulcer on the resident's coccyx, and no evidence of documentation of pertinent characteristics of the ulcers, including location, size, depth, color of the ulcer and surrounding tissue, and description of any drainage, eschar, necrosis, odor tunneling, or undermining, from 3/3/13 (measured 10.5 cm x 13.5 cm) to 3/25/13 (measured 8.5 cm x 8 cm with necrotic tissue in wound bed). During interview on 7/22/13 at 11:45 A.M., the Director of Nurses (DON) said she could find no evidence staff assessed the resident's wounds from 3/3/13 and 3/27/13. Review of the resident's nurse's notes, dated 3/27/13 at 7:10 A.M., showed the resident in bed with head of bed up 45 degrees. Review of the resident's medical record showed he/she was admitted to the hospital for wound care on 3/28/13 and returned to the facility on [DATE]. Review of the resident's hospital history and physical examination [REDACTED] -Reason for transfer: wound care; -Numerous complications from his/her diabetes with [MEDICAL CONDITION] as well as several wound infections; -Incomplete quad, denies sensation below nipple line; -Sacral wound: Unstageable, 11.4 cm x 8.5 cm x 0.2 cm, wound appearance dry / necrotic, drainage serous / purulent / tan. And dry intact eschar covered the wound with slough on the surrounding edges; -Right lateral ankle wound: Unstageable, 3.1 cm x 2.4 cm x 0.1 cm, drainage serous / purulent / tan. Review of the resident's discharge orders/instructions from the hospital, printed 4/23/13, showed the following: -New disease management/teaching with associated lab work; -Wound care instructions; -Teaching/education: diabetic instruction, ostomy care, pain management, PICC line care; -Please leave PICC line in place for potential future use; -Please keep protective boots on feet to prevent foot drop; -Please turn every two hours; -[MEDICATION NAME] 10 mg tablet twice a day as needed (PRN) for muscle spasms. Review of the resident's Braden Scale, dated 4/23/13, showed a total score of 10, indicating high risk for pressure ulcers. Review of the resident's Weekly Wound Report, dated 4/24/13, showed the following: -Coccyx: Stage IV pressure ulcer, facility acquired, 13.5 cm x 10 cm x 3 cm, serosanguinous; -Scrotum: unstaged, wound type not indicated, red only; -Left groin: unstaged, wound type not indicated, 4 cm x 1 cm, serosanguinous drainage; -Right groin: unstaged, wound type not indicated, red only; -Left ankle: Stage II, facility acquired, 0.7 cm x 0.7 cm; -Midline abdominal incision: three areas with staples - one area had one staple and two areas had three staples, no measurements documented; -Right heel: Stage II, facility acquired, 0.5 cm x 0.5 cm; -Right axilla: red only; -Right proximal ankle: Stage II, facility acquired, 1 cm x 1.5 cm; -Right medial ankle: Stage II, facility acquired, 2 cm x 0.8 cm; -Right ankle at bone: Stage II, facility acquired, 3 cm x 2.5 cm, serosanguinous drainage; -Right distal ankle: Stage II, facility acquired, 1.5 cm x H5. Review of the resident's consultation report from the wound clinic, dated 4/30/13 at 10:00 A.M., showed the following: -Pack sacral wound twice a day with Dakin's soaked Kerlix, wring out well, and do not pack too tightly. Cover with ABD pad and tape; -Right ankle: discontinue [MEDICATION NAME], Meplex (an absorbent, atraumatic dressing made from [MEDICATION NAME] foam) to be changed every three days; -Please remove podus boots once a day for 30 minutes to let feet air dry a bit before reapplying; -Left ankle: [MEDICATION NAME] okay, change every three days; -Turn every two hours maximum; -Do not keep patient on back for more than two hours. Review of the resident's laboratory results, collected 5/3/13 and reported 5/4/13, showed the following: -RBC mil/cumm 2.82 (normal 3.8 - 5.8); -Hemoglobin gm/dL 8.3 (normal 12 - 18); -Hematocrit 25.6 percent (normal 37 - 53); -[MEDICATION NAME] 2.9 g/dL (normal 3 -5.5) Review of facility fax, dated 5/6/13, showed the following requests: -Vitamin C 500 mg for 30 days; -Zinc and Iron daily; -Med Pass or equivalent 60 cc TID between meals; -Lab results included with this fax; -Physician approved. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive assistance from two staff members for bed mobility; -Dependent for transfers, locomotion, and toilet use; -Required extensive assistance for dressing and personal hygiene; -Weight 195 pounds (16 percent weight loss in 90 days); -Three stage II pressure ulcers; -One stage III pressure ulcer; -One stage IV pressure ulcer; -On turning and repositioning program; -Ostomy. Review of the resident's undated POS showed an unsigned order, dated 5/7/13, for Arginade BID times 14 days. Review of the resident's consultation report from the wound clinic, dated 5/14/13 at 10:00 A.M., showed the following: -Since the resident is not being turned every two hours he/she has developed worsening pressure necrosis (localized tissue death that occurs in groups of cells in response to disease or injury); -Needs either a Dolphin or Clinitron bed if he/she is not going to be turned every two hours; -Please continue packing Dakins soaked Kerlix; -Right ankle [MEDICATION NAME] Ag, no Kerlix. Review of the resident's nurse's notes, dated 5/14/13 at 1:30 P.M. showed the following: -RN spoke with the resident regarding wound clinic appointment and condition of wound; -RN checks on resident frequently to make sure he/she is turned and repositioned; -Resident has always told RN staff repositions him/her; -Resident told RN he/she told the physician the condition of wounds is due to being up in the wheel chair two hours daily now and not due to staff not repositioning him. Review of the resident's care plan showed the following revisions: -Date of 5/1/13 under focus area followed by: Coccyx stage IV, right medial ankle Stage III, right heel Stage II, left ankle, right distal ankle, right proximal ankle; -Date of 5/6/13 under focus area followed by: Coccyx stage IV-Stage III (dated 5/23/13), right upper ankle stage II, right lower ankle stage III - Stage II (dated 5/15/13), right heel stage II - non-intact blister (dated 5/15/13); -I have a [MEDICAL CONDITION] - undated, handwritten intervention. Review of the resident's nutrition progress note written by the dietician, dated 5/22/13, showed the following: -Current weight 209 pounds; -Readmission weight 230 pounds; -Would recheck weight due to unusual weight; -Previous [MEDICATION NAME] and total protein low; -Would continue Vitamin C and discontinue Zinc Sulfate; -Would change Multivitamin to Multivitamin with minerals; -Would change Med Pass supplement to 90 cc TID. Review of the resident's lab, collected 5/29/13 and reported 5/29/13, showed the following: -RBC mil/cumm 2.81 (normal 3.8 - 5.8); -Hemoglobin gm/dL 8.2 (normal 12 - 18); -Hematocrit 25.4 percent (normal 37 - 53). Review of a facility fax, dated 5/30/13 (eight days after dietician recommendations), showed the following: -Dietician recommends to change Multivitamin to Multivitamin with minerals, change Med Pass to 90 cc TID, and discontinue Zinc; -No mention of dietician's request to continue Vitamin C; -Physician approved. Review of the resident's physician progress notes [REDACTED]. -No complaint from resident or staff today except follow up on [MEDICAL CONDITION]; -Resident admits to some fatigue; -[DIAGNOSES REDACTED]. -An order to obtain a reticulocyte count (lab test used to determine bone marrow activity) and guaiac stools (a test used to determine presence of blood in the stool) for three days. Review of the resident's treatment administration records (TAR) for 5/21/13 - 6/20/13 showed the following: -An entry for guaiac stools for three days; -No documentation indicating staff obtained stools for guaiac testing. Review of the resident's medical record also showed no evidence the staff obtained the reticulocyte count as the physician ordered. Review of a facility fax, dated 6/4/13, showed the resident's [MEDICATION NAME] and protein values were low with an order for [REDACTED]. Review of the resident's MAR, dated May, showed Vitamin C 500 mg daily was stopped on 6/7/13, as ordered on [DATE]. Review of the resident's MAR, dated 5/21/13 - 6/20/13, showed staff administered the Prosource 30 cc daily from 6/5/13 - 6/13/13. No documentation of refusal noted. Review of a facility fax to the physician, dated 6/13/13, showed staff documented the resident was refusing Prosource, and the physician ordered to discontinue Prosource. Review of the resident's consultation report from the wound clinic, dated 6/11/13 at 9:00 A.M., showed the following: -Remove dressing today when the resident returns to the facility and repack loosely with ? length of a full Kerlix soaked in ? strength Dakin's, cover with ABD pad and tape; -Please order [MEDICATION NAME] to apply to wound daily under Dakin's Kerlix to help with debridement; -He/she bleeds each time wound is debrided but necrotic tissue is so foul smelling that it has to be debrided. Review of the resident's nutrition progress note written by the dietician, dated 6/30/13, s

Based on interview and record review, facility staff failed to identify multiple risk factors of dehydration and failed to implement interventions to ensure sufficient fluid intake to prevent dehydration in one discharged resident (Resident #7), a resident with open draining wounds, infection and elevated temperature, of two sampled discharged residents and two sampled residents (total sample of four residents) at risk for dehydration. Facility census was 85. 1. Review of an undated facility policy for physician notification for decreased nutritional intake showed it was the facility's policy to monitor the nutritional intake of all residents and to notify the physician when necessary. The procedure by which the facility would implement the policy directed staff to record the residents' food and fluid intake at each meal. If a resident consumed less than 50% food or 200 cc's (cubic centimeters) fluid, the respective charge nurse would be notified in writing per "Decreased Nutritional Intake Report". The charge nurse would record the inadequate nutritional intake on the treatment sheet. The physician would be notified when fluid intake was less than 600 cc's in 24 hours and/or a resident refused food intake three consecutive times and/or a resident consumed less than 50% at six consecutive meals. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 09/13/10 showed the following: -He/she had memory problems; -Was moderately impaired with cognitive skills for decision-making; -He/she required extensive assistance of one person for eating; -Had limited range of motion on both sides with partial loss of voluntary movement of the arm, hand, leg and foot; -His/her function for activities of daily living had deteriorated; -He/she had chewing problems; -He/she left 25% or more of food uneaten at most meals; -He/she had open [MEDICAL CONDITION] other than ulcers, rashes or cuts; -Facility staff monitored an acute medical condition; -He/she had deteriorated (received more support). Review of the resident's care plan dated 09/20/10, showed direction for staff to complete the following interventions: -Problem: Mobility impaired related to contractures of the left hand and [MEDICAL CONDITION] scapula (the large, flat, triangular bone which forms the posterior part of the shoulder). Interventions included: Observe resident's function ability every day, staff report any significant change to physician and document, segment tasks as needed, provide resident with sufficient time to complete tasks; -Problem: Injury risk, trauma potential related to weakness, confusion. Interventions included: Place water, call light and belongings of choice within reach, encourage resident to utilize staff for assistance; -Problem: Feeding deficit related to bilateral upper extremity limitations. Interventions included: Record food eaten on tray monitor flow sheet, must feed totally, provide small bites; -Problem: Skin integrity impaired related to history [MEDICAL CONDITION] to [MEDICAL CONDITION] and disease process. Interventions included: Give extra fluids between meals, use universal precautions, report dry, red, weeping or non-intact skin prn (as needed); right hand treatment per physician's orders [REDACTED]. -Problem: Pressure ulcer left buttock. Interventions included: Monitor for signs and symptoms of infection at site (redness, drainage, pain at site, foul odor), nurses aides report to charge nurse, charge nurse reports to physician, complete treatments as prescribed, monitor nutritional status, encourage food/fluid intake and record. Review of the resident's physician's orders [REDACTED]. Review of the resident's Body System Assessment sheets showed: -On 12/17/10 on the 3:00 P.M. to 11:00 P.M. shift, resident had a temperature of 100.6? Fahrenheit (F) (normal body temperature 98.6?F) and had poor skin turgor (elasticity of the skin, a sign commonly used by health care workers to assess the degree of fluid loss or dehydration), hands contracted. Nurses notes showed facility staff contacted the physician and received orders to obtain a urinalysis; -On 12/18/10 on the 11:00 P.M. to 7:00 A.M. shift, resident had a temperature of 99.6?F, fair skin turgor, contractures in the right and left hand, unable to assess hand grips; -On 12/19/10 on the 11:00 P.M. to 7:00 A.M. shift, resident had a temperature of 99.3?F, fair skin turgor, contractures in the right and left hand, unable to assess hand grips; -On 12/20/10 on the 11:00 P.M. to 7:00 A.M. shift, resident had a temperature of 99.3?F, fair skin turgor, contractures in the right and left hand, unable to assess hand grips. Review of a microbiology report for a urine culture (a routine test done when a urinary tract infection is identified through urinalysis) for urine collected 12/18/10, received 12/18/10 and completed 12/20/10, showed escherichia coli (the cultured organism) and the physician wrote an order for [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 12/22/10 at 8:00 P.M., facility staff administered the resident's first dose of [MEDICATION NAME] and continued to administer [MEDICATION NAME] 100 mg twice a day until last dose noted at 8:00 A.M. on 12/27/10 (the day facility discharged the resident to the hospital); -On 12/23/10 at 11:00 A.M., resident received Tylenol 650 mg by mouth for wound treatment and at 1:30 P.M., resident "still hurting"; -On 12/23/10 at 1:30 P.M., resident received [MEDICATION NAME] N-100 (a combination of Tylenol and an opioid [MEDICATION NAME]), one tablet P.O. (by mouth) for complaint of hand pain and at 2:30 P.M., facility staff did not note further complaints; -On 12/24/10 at 1:20 P.M., resident received Tylenol 650 mg P.O. for complaint of hand pain and at 2:30 P.M., the resident rested; -On 12/24/10 at 7:00 P.M., resident received Tylenol 650 mg P.O. due to wound care and at 9:00 P.M., facility staff noted medication " effective at this time; " -On 12/25/10 at 9:55 A.M., received Tylenol 650 mg P.O. for increased temperature of 100.6?F and at 12:00 Noon, facility staff noted temperature down to 99.4?F; -On 12/26/10 at 10:00 A.M., resident received Tylenol 650 mg P.O. for complaint of hand pain and at 12:30 P.M., facility staff noted no complaints. Review of the resident's Treatment Record dated 12/01/10-12/31/10 showed: -On 12/21/10 resident ate less than 50% of meals at breakfast, lunch and supper and resident drank less than 200 cc's at breakfast; -On 12/22/10 resident ate less than 50% of meals at lunch and supper and drank less than 200 cc's at lunch and refused to drink fluids at supper; -On 12/23/10 resident ate less than 50% of meals at breakfast, lunch and supper and drank less than 200 cc's at breakfast; -On 12/24/10 resident ate less than 50% at lunch and supper and drank less than 200 cc's at lunch and supper; -On 12/25/10 resident ate less than 50% at breakfast, refused his/her lunch and supper meals, and refused to drink fluids at breakfast, lunch and supper; -On 12/26/10 resident refused to drink fluids at breakfast (his/her fourth mealtime where he/she refused fluids). Review of the resident's nurses notes showed the following: -On 12/21/10, no notes; -On 12/22/10 at 10:46 A.M., resident received new orders via fax, see physician's orders [REDACTED].M., received fax for clarification as to why facility requested x-ray of right shoulder, sent clarification fax at 1:45 P.M., (fax communication and orders did not pertain to the resident's fluid status); -On 12/23/10 at 10:04 A.M., faxed physician regarding therapist's request for comparison x-ray to determine need for lap restraint. 10:48 A.M., received faxed order from physician for x-ray of right scapula (shoulder blade). 10:55 A.M., contacted mobile x-ray service for x-ray. 11:00 A.M., resident received Tylenol (a pain reliever) 650 milligrams (mg) for wound treatment. 11:15 A.M., mobile x-ray service presented to complete the ordered x-ray. 12:15 P.M., resident said he/she felt better. 1:30 P.M., resident received [MEDICATION NAME] N-100 one tablet for hand pain. At 2:15 P.M., resident said he/she felt better; -On 12/24/10 at 1:20 P.M., resident received Tylenol 650 mg for complaint of hand pain. 2:10 P.M., no further complaint reported. 7:00 P.M., administered Tylenol 650 mg for wound care per PRN orders per certified medication technician. At 8:00 P.M., treatment to bilateral (both sides) hands done. 7:00 A.M. to 3:00 P.M. shift did not complete the treatment on this date. 10:00 P.M., no signs or symptoms of discomfort or pain noted (no notes regarding the resident's decreased intake of food or fluids); -On 12/25/10 at 9:55 A.M., resident received Tylenol 650 mg for temperature, (no notation regarding the resident's refusal to eat meals or take fluids at meals); -On 12/26/10 at 10:00 A.M., resident received Tylenol 650 mg for complaint of hand pain, (no notes regarding the resident's refusals to take fluids). Review of a skin condition report completed by Licensed Practical Nurse (LPN) N, dated 12/26/10 showed the resident had a stage III pressure sore (a full thickness of skin is lost, exposing the subcutaneous tissues that presents as a deep crater with or without undermining adjacent tissue). The wound exhibited a moderate amount of serosanguinous (composed of serum and blood, both body fluids) drainage. LPN N noted a foul drainage odor and noted measurements as length 2 centimeters (cm), width 1.5 cm and depth 3.3 cm and current treatment order from the wound clinic to pack with Dakin's (a diluted sodium hypochlorite solution, which has been used as a topical anti-infective for skin and wounds) with wet to moist dressing three times per day. Review of the Merck Manual of Geriatrics (1990) showed clinical signs and symptoms of infection included elevated temperature, inflamed wound margins, and malodorous exudates (foul odor drainage), p. 142. During an interview on 01/04/11 at 3:25 P.M., Registered Nurse (RN) K said he/she worked at the facility since June and had recently changed to the 7:00 A.M. to 3:00 P.M. shift; he/she had worked with the resident a couple of times. He/she worked the day shift 12/23/10. He/she did not remember anything from shift report that day. He/she said the facility policy related to nutrition and hydration was to notify the physician if a resident refused meals for three shifts or consumed less than 25% for six shifts, or if fluid intake was less than 600 cc's in 24 hours. He/she said for a resident with a urinary tract infection [MEDICAL CONDITION], a typical intervention he/she would put in place would be to encourage fluids and with a resident who had a UTI and open and draining wounds, he/she would " Push fluids; push more since (the resident) had an open wound. " RN K said he/she was not aware of the resident's UTI and did not know if the nurse aides knew about it or not. Nurse aides learned about resident ' conditions through the charge nurses. RN K said he/she did not know how much fluid was on a normal meal tray. The resident was quiet on 12/23/10. RN K said the resident did not have use of his/her hands; he/she would try, but could not do anything. He/she was unable to feed his/herself or drink independently. He/she said the resident's hands had scabs all over them and had to be dried well before he/she applied the dressings because the hands would " bleed and bleed. " He/she said where the hands did not bleed, they drained a light yellow to yellow pus that exhibited an odor. He/she described the wound on the resident's thigh/buttock to be "long, huge" and with a little bit of odor and some yellow pus drainage. He/she did not remember if he/she reported anything significant regarding the resident to the 3:00 P.M. to 11:00 P.M. shift. He/she said if nurse aides did not give notification for decreased food and fluid intake, he/she assumed the resident took in 100%. During an interview on 01/05/11 at 2:15 P.M., LPN N said he/she worked as charge nurse on 12/25/10 and 12/26/10. He/she did not know the resident had a UTI, but typical nursing interventions for residents with UTI's included administering antibiotics, maintaining sterility when working with wounds and ensuring proper nutrition. He/she did not normally observe meals and depended on what the nurse aides reported to him/her. He/she did not direct the nurse aides to do any additional monitoring or encouraging of fluids on 12/25/10 or 12/26/10. He/she did not know the facility policy related to physician notification. Review of the resident's nurses notes showed the following: -On 12/27/10 at 1:15 P.M. resident noted with increased lethargy (fatigue/listlessness) did not want to eat or drink, respirations even and non-labored, resident not verbally responsive, no signs and symptoms of pain noted. DON updated due to in office; she said to call physician. Temperature 99.8?F, at 1:18 P.M., paged physician, at 1:20 P.M., resident's family member called and updated with change in condition. Family member en route to facility. 1:32 P.M., paged physician. 1:35 P.M., physician called back. Received orders to send resident to the hospital. 1:38 P.M., ambulance called and en route. 1:40 P.M., gave report to hospital emergency room . 1:45 P.M., ambulance presented and transported resident to hospital. Review of an admission note to the hospital dated 12/27/10, showed the resident presented with a chief complaint of altered mental status and: -Had been worsening over the past three days; -His/her symptoms began one week ago when it was presumed he/she had a urinary tract infection; -He/she gradually became weaker and weaker; -Past medical/surgical history included a history of admission for dehydration; -Physical exam of the resident showed he/she was poorly responsive, oral mucosa was very dry and covered with oral thrush; -Laboratory data showed sodium of 169 millequivalents per liter (mEq/L), normal range for adults and elderly 136-145 mEq/L and chloride of 129 mEq/L, normal range for adults and elderly 98-106 mEq/L; -Assessment and plan showed the resident had altered mental status likely secondary to his/her " profound [MEDICAL CONDITION] " (high sodium level); -To correct the [MEDICAL CONDITION] and altered mental status, the resident received two [MEDICATION NAME] () of normal saline in the emergency room . After those two liters, his/her sodium dropped from 169 mEq/L to 166 mEq/L. The medical staff planned to attempt to correct the sodium level slowly as to avoid cerebral [MEDICAL CONDITION] (swelling of the brain). With the resident's degree of dehydration it was likely the [MEDICAL CONDITION] had been relatively chronic in nature. During an interview on 01/05/11 at 10:30 A.M., the resident's member said the facility did not notify him/her of the resident's decreased oral intake at any time between 12/22/10 and 12/27/10. He/she visited the resident on 12/24/10 and found the resident had been napping, woke up for the visit, but did not speak to him/her. The resident told his/her family member he/she was thirsty in the hospital emergency department on 12/27/10 and drank freely and easily through a straw at that time. During an interview on 01/05/11 at 2:33 P.M., the DON said the resident's physician was aware of the resident's wounds on his/her hands, pressure sore and urinary tract infection [MEDICAL CONDITION] and all issues were addressed through treatment and medication orders. She said she would have expected the resident's physician to be notified if the resident refused fluids at four consecutive meals. She said nursing should be aware of all residents with infections and that information should be passed along in report. She said shift report was where the off-going nurse reported to the on-coming nurse issues including any new orders, changes in condition, any falls, headaches and temperatures. During an interview on 01/04/11 at 9:20 A.M., the resident's physician said he/she would expect nursing to note decreased food/fluid intake and encourage the resident with meal consumption and fluid intake. He/she would also expect facility staff to notify the family of the situation and to monitor the resident. He/she would expect nursing to identify a resident at risk of dehydration secondary to a stage III pressure sore and bleeding, serous wounds on both hands. Review of Mosby's Diagnostic and Laboratory Test Reference, Sixth Edition (2003) showed if free body water were to decrease, the serum sodium concentration would rise; the kidney would then respond by conserving free water. Symptoms of [MEDICAL CONDITION] included dry mucous membranes, thirst and agitation. Chloride was the major extracellular anion. It's main purpose was to maintain electrical neutrality, mostly as a salt with sodium. It followed sodium losses and accompanied sodium excesses to maintain electrical neutrality. Signs and symptoms of hyperchloremia (increased chloride) included lethargy, weakness and deep breathing. Increased levels of chloride could suggest dehydration. Review of the Nurse Assistant in a Long-Term Care Facility Manual (Certified Nurses Aide Manual), (Rev. 2001) showed: -Average oral intake for an adult is 2000 to 3000 cubic centimeters (cc) of fluid per day and total body output should be about the same; -Fluids are eliminated through perspiration (sweating), breathing, feces (stool) and urine; -The physician or charge nurse may restrict or encourage fluid intake. It is the charge nurse's responsibility to know what has been ordered and to communicate this information to the nurse assistant; -When " intake and output " (I&O) is ordered, accuracy is very important and the resident and his/her family should be informed of the procedure; -The nurse assistant generally checks and records the resident's liquid intake at mealtime and between meals; -At mealtime, check resident's tray before serving and after the resident has eaten to determine intake of fluids. Remember to include any foods that turn to liquid if allowed to stand at room temperature; -Observe resident for signs of dehydration or [MEDICAL CONDITION]; -Warning signs of dehydration that a resident may be at risk for or suffer from dehydration include: Drinks less than six cups of liquids per day; has one or more of the following: Dry mouth, cracked lips, sunken eyes, dark urine; needs help drinking from a cup or glass; frequent vomiting, diarrhea or fever; is easily confused/tired; -Measure and record urinary output accurately and any other body discharges such as vomitus and diarrhea; mention diaphoresis (sweating) if resident perspires profusely; -Action steps for residents at risk of dehydration include: Report observations and warning signs to nurse and dietician; encourage resident to drink every time you see the resident; offer two to four ounces of water or liquids frequently; be sure to record fluid intake and output; offer ice chips frequently (unless the resident has a swallowing problem); offer sips of liquid between bites of food at meals and snacks; make sure pitcher and cup are near enough and light enough for the resident to lift; offer appropriate assistance as needed if resident cannot drink without help; and -For residents with pressure sores, follow action steps for residents at risk of dehydration so resident gets more to drink. Review of the State Operations Manual (SOM) at Interpretive Guidelines for hydration showed risk factors for the resident becoming dehydrated included fluid loss and increased fluid needs, for example diarrhea, fever, uncontrolled diabetes. (Resident #7 had a draining pressure ulcer on his/her left thigh and macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) hands secondary to a history of [MEDICAL CONDITIONS] a urinary tract infection). Additional factors listed included: functional impairments that make it difficult to drink, reach fluids or communicate fluid needs and refusal of fluids. (The resident had a [DIAGNOSES REDACTED]. MO 551