Every finding on record at Westchester House, The

Based on interview and record review, the facility failed to ensure residents' personal possessions were kept safe from loss or theft and failed to maintain inventory sheets for four sampled residents (Residents #1, #8, #9 and #10). The census was 90. Review of the facility's Inventory of Personal Belongings policy, dated [DATE], showed: -The facility will reduce the potential for lost clothing and ensure that residents receive all of their personal clothing once it has been laundered; -The Laundry Department will be notified of each new resident admission, take the resident's clothing, mark it and account for each item on an inventory sheet, with description for each article of clothing; -The same procedure will be done each time new clothing is brought into the facility; -If any clothing is missing, the Laundry Department will make every possible attempt to find the clothing before the resident's discharge. Review of the facility's Closet Search-Lost and Unmarked Clothing policy, dated [DATE], showed: -Every attempt will be made to ensure lost clothing is found. All personal clothing will be handled in a manner to ensure that clothing is given back to the appropriate resident; -A concern and comment form should be completed, as appropriate, and turned into the Environmental Services Director or Social Services; -Using the descriptions given for the lost article of clothing, the Laundry Department will go to each room and search through every closet; -Once the article of clothing has been found, the resident/family will be notified; -If the article of clothing cannot be located, the Environmental Services Director and Social Services will work together to resolve the issue to the satisfaction of the resident. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -Impairment on both sides of lower body; -Dependent on staff for transfers; -Diagnoses included heart failure, kidney disease, respiratory disease and diabetes mellitus. Review of the resident's inventory sheet, undated, showed there was no documentation listing any belongings. Review of the resident's handwritten inventory sheet, undated, showed: -One brown faux fur blanket; -There was no documentation showing two makeup bags with products, three bottles of perfume, pants, or an electric toothbrush were listed. Review of the resident's progress notes, dated [DATE] through [DATE], showed no documentation the resident reported missing items or missing items were found or replaced by the facility. During an interview on [DATE] at 10:10 A.M., the resident said: -He/She was missing $700.00 worth of personal belongings, including an expensive faux fur blanket, three bottles of perfume, an electric toothbrush, pairs of pants and two bags full of makeup; -The resident spilled water on his/her faux fur blanket and instead of letting it dry on a chair, a staff member took it to the laundry to get washed; -The resident has asked for the faux fur blanket back and it was not returned; -He/She did not feel the facility was taking him/her seriously and had not updated him/her on the missing items. During an interview on [DATE] at 12:08 P.M., the Administrator said: -She was made aware sometime in February, the resident was missing two or three pairs of pants. At that time, she thought the pants were located in laundry and returned to the resident; -She could not find any documentation the resident's pants were ever returned and if they were still missing, the facility was responsible for reimbursing the resident for the missing items; -She saw an online review recently saying the resident was missing $700.00 worth of items; -She was not aware the resident was missing $700.00 worth of items and was currently investigating the matter with the resident. 2. Review of Resident #8's inventory sheet, dated [DATE], showed no documentation found listing a gold wedding band. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included dementia and Parkinson's Disease (a movement disorder of the nervous system). Review of the resident's progress notes, dated [DATE] through [DATE], showed: -On [DATE] at 9:53 A.M., the resident entered the building via stretcher, escorted by two Emergency Medical Technicians (EMT). The resident was alert but lethargic, was easily understood and denied pain. The resident was part of his/her own care plan decisions and a family member was there to confer with hospice nurse to sign paperwork and confirm care; -On [DATE] at 10:58 A.M., the resident was able to make needs known. The resident was newly admitted to hospice care; -On [DATE] at 11:37 A.M., the resident was observed moaning this morning, medication was administered for anxiety and pain; -On [DATE] at 4:11 P.M., resident deceased ; -On [DATE] at 4:38 P.M., during 3:00 P.M. rounds,. The resident was found with cessation of all vital signs. Confirmed by another nurse. Hospice, Primary Care Physician (PCP) and family notified. Director of Nursing (DON) and coroner made aware. Post mortem care provided. Family arrived at 4:10 P.M.; -On [DATE] at 5:39 P.M., the resident's remains were picked up by the mortuary; -There was no documentation the resident was wearing a gold wedding band or that the resident was missing a gold wedding band. During an interview on [DATE] at 12:15 P.M., Registered Nurse (RN) A said: -He/She worked with the resident on [DATE], [DATE], [DATE] and [DATE]; -He/She did not admit the resident when he/she returned from the hospital; -He/She remembers the resident was wearing his/her gold wedding band on [DATE] and on [DATE] after the resident returned from the hospital; -On [DATE], he/she cannot recall seeing the resident wearing his/her gold wedding band as the resident had his/her arms under the covers and was actively dying during his/her shift. RN A was more concerned about the resident's rapid decline of health at the time; -On [DATE], RN A checked on the resident after report, at approximately 3:00 P.M., and found the resident deceased . The resident was not wearing his/her gold wedding band; -On [DATE], the resident's son made RN A aware the resident's gold wedding band was missing after the resident's remains were picked up by the funeral home. He/She immediately searched the resident's room for the gold wedding band. It was not located. During an interview on [DATE] at 12:25 P.M., Certified Nurse Aide (CNA) B said: -He/She worked with the resident on [DATE], [DATE] and [DATE]; -He/She could not remember seeing the resident wearing a gold wedding band during his/her shifts; -He/She provided post mortem care for the resident on [DATE] and did not recall the resident wearing a gold wedding band; -On [DATE], the resident's son made him/her aware the resident was missing his/her gold wedding band while the resident's remains were still in his/her room; -CNA B searched the room, the bed, and the resident's clothes for the gold wedding ring and could not locate it. 3. Review of Resident #9's inventory, dated [DATE], showed: -$5.00 with change was listed; -There was no documentation found showing a wallet was listed. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive issues; -Diagnoses included Parkinson's disease, anxiety and depression. Review of the resident's progress notes, dated [DATE] through [DATE], showed no documentation regarding the resident's wallet or money was in his/her possession or was reported lost or missing. During an interview on [DATE] at 12:07 P.M., the Administrator said: -The resident called the police and reported she/he was missing his/her coin wallet with $60 in it; -The resident reported to a staff member he/she last saw it on [DATE] under his/her pillow; -The resident then changed his/her story and said it was in his/her wheelchair beside him/her when the resident last saw the wallet. During an interview on [DATE] at 12:05 P.M., CNA C said: -He/She last worked with the resident on [DATE], when the CNA helped the resident to the bathroom; -The resident had his/her wallet located on the side of his/her wheelchair when CNA C helped the resident to the bathroom; -CNA C worked with the resident consistently and the resident was very on his/her wallet making sure it was beside him/her while the resident was in his/her wheelchair or underneath his/her pillow when the resident went to lay down in the bed; -CNA C made sure the resident always had his/her wallet when working with the resident; -CNA C was not sure how much money was in the resident's wallet; -The resident was fully cognitive and was able to report when he/she was missing property. 4. Review of Resident #10's inventory sheet, dated [DATE], showed a pocketbook, a wallet and $13.00 with change was listed. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, anxiety and depression. Review of the resident's inventory sheet, dated [DATE], showed no documentation listing any denomination of money was listed as missing. Review of the resident's progress notes, dated [DATE] through [DATE], showed no documentation the resident had a wallet with cash money in his/her room or that the resident refused to keep the money in a resident trust account. There was not documentation the resident reported money missing from his/her wallet. During an interview on [DATE] at 12:07 P.M., the Administrator said: -The resident reported to the police today, that on [DATE], time unknown, $100 out of $200 was missing from his/her wallet; -The resident refused to keep the money in the resident trust account. 5. During an interview on [DATE] at 12:08 P.M., the Administrator said she expected residents to have inventory sheets in their electronic medical records and was not sure if each resident had inventory sheets or if they were complete. During an interview on [DATE] at 12:05 P.M., CNA C said: -CNA C made sure residents' personal property was kept safe from loss or theft by ensuring the residents who were cognitively aware had their personal property with them during his/her shift, following the residents' preferences and if a resident was not cognitively aware, CNA C would inform the nurse of any personal property so it would be secured; -Both nurses and CNAs were responsible for making sure inventory sheets were filled out upon resident admissions or when new items were brought in the facility. During an interview on [DATE] at 12:15 P.M., RN A said: -Nurses and/or family members filled out inventory sheets when residents were admitted and the form was kept in the residents' medical record; -Nurses would either lock up personal valuable items or send the valuables home with family to keep them safe from loss or theft. During an interview on [DATE] at 4:08 P.M., the DON said: -She expected nursing staff and the laundry department to fill out the inventory sheets with resident belongings upon admission; -She expected families to update nursing staff with any new items they bring in or remove from the residents' room so inventory sheets could be updated by staff; -The facility would look for any missing items once they were reported; -The facility would reimburse items if they were reported lost at the facility if they were not listed on the inventory sheet, providing a receipt was given by the resident or the residents' family; -They ensured residents' personal property was kept safe from lost and/or theft by maintaining inventory sheets; -The facility had the resident or the resident's family sign a clause in the Admissions Agreement showing they were responsible for any monies, jewelry, or other valuable items if they were kept in the resident's room; -She expected facility staff to have knowledge of and to follow facility policies. MO00253623 MO00254154 MO00254157 MO00254090

Based on observation, interview and record review, the facility failed to complete weekly skin assessments and to identify an open wound caused by cellulitis (a serious bacterial infection) for one resident (Resident #1) and failed to notify the resident's physician of the wound and obtain orders for the wound care. The facility also failed to discontinue wound care orders for the resident's right medial distal thigh and documented falsely in the resident's Treatment Administration Record (TAR). The sample size was four. The census was 90. Review of the facility's Skin Integrity and Pressure Ulcer/Prevention and Management Policy, dated 7/9/24, showed: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy (surgically created opening in the body to allow waste to exit the body) Continent Nurses Society); -A comprehensive skin inspection/assessment is completed on admission and re-admission to the center; -A skin assessment/inspection should be performed weekly by a licensed nurse. Skin observations also occur throughout points of care provided by Certified Nurse Assistants (CNA) during activities of daily living (ADL) care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. Review of Resident #1's Physician Order Sheets (POS), showed: -An order, dated 4/2/25, for wound care company to evaluate and treat; -There were no orders for weekly skin checks; -There were no orders for treatment to the resident's left thigh. Review of the resident's assessments, showed: -A weekly skin integrity data collection, dated 4/9/25, showed skin alterations included Moisture Associated Skin Damage (MASD) on the resident's perineal area (region between the anus and the genitals), open area/wound with a wound vacuum (wound vac, a medical device used to help heal wounds using negative pressure) present on the resident's right thigh and other was used to describe buttock. None of the areas were new; -There was no documentation of weekly skin integrity data collection assessments found after 4/9/25 through 5/12/25. Review of the resident's shower sheets, showed; -On 4/16/25, the body diagram with the right front thigh was circled with a handwritten note of wound vac and the back of the right and left buttocks circled with a handwritten note of redness, scabs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/25, showed: -Cognitively intact; -Impairment on both sides of lower body; -Dependent on staff for toileting, showers, lower body dressing, bed mobility and transfers; -Incontinent of bowel and bladder; -Surgical wounds present; -Diagnoses included heart failure, kidney disease, respiratory disease and diabetes mellitus. Review of the resident's care plan, undated, showed: -Problem: Resident was admitted with multiple wounds with worse one on his/her right thigh; -Interventions included: Treatment as ordered, weekly skin checks, and pressure reducing mattress. Review of the resident's progress notes, dated 5/1/25 at 10:05 P.M., showed the resident had areas to the left leg that were warm, red and painful to the touch. Notified the physician on call. Received new orders for antibiotics and a blood test. Continue to monitor the area. Review of the resident's shower sheets, showed: -On 5/3/25, a handwritten note said (he/she) didn't feel good. There was no other documentation found. Review of the resident's TAR, dated May 2025, showed: -An order, dated 4/4/25, for right inner thigh wounds, apply Santyl (an ointment used to debride ulcers) and Calcium Alginate (dressing used for exudating wounds) and cover with right dry dressing every Monday, Wednesday and Friday during day shift. Documentation showed the facility administered the treatment as ordered on 5/2, 5/5, 5/7 and 5/9; -An order, dated 4/28/25, for treatment to right medial (closest to center of body) distal (site furthest away from center) thigh. Cleanse wound with wound cleanser, apply Hydrofera Blue (dressing provides wound protection and addresses bacteria and yeast) to wound bed and dry dressing every Monday, Wednesday and Friday during day shift. Documentation showed the facility administered the treatment as ordered on 5/2, 5/5, 5/7, and 5/9. -An order, dated 5/5/25, for Collagen-Antimicrobial (dressing used to absorb exudate (drainage)) external sheet; cleanse right medial distal thigh with wound cleanser, apply collagen powder (powder used to absorb exudate) and Hydrofera Blue, cover with a dry dressing every shift Monday Wednesday and Friday. Documentation showed the facility administered the treatment as ordered on evening shift and resident sleeping during night shift for 5/9; administered on day shift, held for evening shift and other for 5/7; and administered on day, evening and night shifts for 5/9/25. Review of the resident's wound care company wound assessment, dated 5/5/25, showed: -Trauma (caused by mechanical force) wound located on right thigh, medial distal, measuring 8.1 centimeters (cm) by 11.3 cm by 0.3 cm deep, with 45% granulation tissue (red, new tissue), 25% slough (dead tissue separating from living tissue) and 30% eschar (dead tissue) in wound bed with a moderate amount of serosanguineous (composed of serum and blood) exudate present; -Wound orders and plan of care included: Cleanse wound with Hypochlorous acid (slightly acidic solution used to fight infections), apply collagen powder, 1 gram (gm) to base of clean wound bed, cover with Hydrofera Blue, then cover with a dry dressing every Monday, Wednesday and Friday. All orders will remain in effect until discontinued, revised, or replaced with additional orders. Ok to continue current treatment orders until able to obtain supplies/medications for updated orders; -Visit specific information: Rounded with the facility Wound Nurse, recommended change to plan of care to add collagen powder; -Medical Necessity for this encounter: After evaluating the wound/skin issues at this encounter, a change to the plan of care was required. Orders and instructions were left with the care facility and/or nursing staff. Bedside nurse was instructed on proper dressing changes or dressing change techniques to enhance wound healing; -There was no documentation of a wound assessment or plan of care for the resident's left thigh. Review of the resident's shower sheet, dated 5/7/25, showed no documentation found. The Certified Nurse Assistant (CNA) nor the nurse signed the document. Review of the resident's progress notes, showed no documentation a new wound was found on the resident's left posterior thigh with notification to the Primary Care Physician (PCP) for new orders. Observation on 5/9/25 at 10:10 A.M., showed: -The resident lay on a pressure reducing mattress, in a gown, wearing anti slip socks with a call light in reach; -There was a white dressing present on the resident's left posterior thigh, dated 5/7/25; -There was a white dressing present on the resident's right medial distal thigh, dated 5/7/25. Observation on 5/9/25 at 10:45 A.M., showed; -The Wound Nurse provided care to the resident; -The Wound Nurse removed a treatment, dated 5/7/25, from the resident's right medial distal thigh; -The Wound Nurse treated the wound on the resident's right medial thigh by cleansing the wound with sterile water and gauze, put Collagen-Antimicrobial sheet in the wound base, then Hydrofer Blue over it and covered the wound with a dry dressing, dated 5/9/25; -The Wound Nurse removed a treatment, dated 5/7/25, from the resident's left posterior thigh. The bandage had a moderate amount of purulent (thick, yellowish-green or yellowish fluid that is often associated with infection) drainage; -The Wound Nurse treated the wound on the resident's left posterior thigh by cleansing the wound with sterile water and gauze, put Xeroform gauze (dressing with petrolatum used to maintain moisture in wound) in the wound base and covered the wound with a dry dressing, dated 5/9/25; -The Wound Nurse explained she used sterile water to cleanse the wounds as the Hypochlorous acid stung and hurt the resident, making the resident resistant to wound care. It was the resident's preference. During an interview on 5/12/2, at 8:49 A.M., the wound care company Nurse Practitioner (NP) said: -She evaluated and treated wounds for the facility-identified residents; -She came once a week and did rounds with the facility's Wound Nurse; -She assessed residents' wounds, gave verbal recommendations to the Wound Nurse during rounds and then submitted a wound assessment report to the facility the day after her visit; -She expected the Wound Nurse to update the residents' POS in the electronic medical record (EMHR) with her new wound treatment orders after receiving the wound report; -She expected the Wound Nurse to discontinue any existing wound treatment orders when new wound treatment orders were received; -She expected the Wound Nurse to notify her if a product was unavailable so she could make new treatment orders; -She was aware the Wound Nurse was using Collagen-Antimicrobial dressing instead of collagen powder and sterile water instead of Hypochlorous acid during wound care; -She expected the facility to follow her wound treatment orders to facilitate wound healing. Observation on 5/12/25 at 9:03 A.M., showed: -The wound care company NP and the facility's Wound Nurse providing care to the resident; -The Wound Nurse removed the treatment, dated 5/9/25, from the resident's right medial distal thigh wound and cleaned it with sterile water, applied Collagen-Antimicrobial sheet to the wound base, placed Hydrofera Blue on top and then covered the wound with a dry dressing after the wound care company NP assessed and photographed the wound; -The Wound Nurse informed the wound care company NP the resident had a new skin issue located on his/her left posterior thigh; -The wound care company NP confirmed verbally the resident did not have a wound on his/her left posterior thigh during her last visit on 5/5/25 and she was not aware of the new wound; -The Wound Nurse removed the treatment, dated 5/9/25, from the resident's left posterior thigh. The bandage was soaked with dark brown drainage; -The wound care company NP assessed the wound on the resident's left posterior thigh, took photographs of the wound and gave the Wound Nurse verbal orders to apply Santyl to the wound bed, then Calcium Alginate over the Santyl, covered with a dry dressing; -The Wound Nurse cleaned the left posterior thigh wound with sterile water, applied Santyl to the wound bed, then Calcium Alginate over the Santyl and covered it with a dry dressing; -The wound care company NP explained to the resident the wound was caused by cellulitis combined with poor blood flow. Review of the resident's progress notes, on 5/12/25 at 10:23 A.M., showed: -There was no documentation the Wound Nurse notified the PCP of the new wounds found on the resident's left posterior thigh to obtain new orders; -There was no documentation the Wound Nurse notified the resident's responsible party (RRP) or the Director of Nursing (DON) of the new wounds found on the resident's left posterior thigh. Review of the resident's assessments, on 5/12/25 at 10:23 A.M., showed no documentation of a skin assessment or wound assessment completed on the resident from 5/9/25 though 5/12/25 During an interview on 5/12/25 at 10:25 A.M., CNA D said: -He/She was not assigned to the resident's care; -CNAs were expected to fill out shower sheets when providing bath or showers to residents; -CNAs were expected to document if a resident refused a bath or shower, any existing or new skin issues by marking on the body diagram the location and description of what was found; -CNAs were expected to notify the nurse immediately of any new skin issue so the nurse could immediately assess the residents' skin and provide treatment; -CNAs were expected sign the shower sheets, turn shower sheets into the nurse for their signature and then the nurse kept the shower sheets; -CNAs were expected to notify the nurse of any new skin issues so the nurse could evaluate and treat the resident. During an interview on 5/12/25 at 12:55 P.M., the Wound Nurse said: -She rounded with the wound care company NP once a week on residents who had orders for the NP to evaluate and treat their wounds; -The wound care company NP would tell him/her of any new wound treatment orders during rounds and the Wound Nurse would put the new wound treatment orders in residents' POS in the EMHR after the wound care during the NP's visit, on the same day; -She completed a weekly wound assessment in residents' EMHR after she received the wound care company NP submitted her wound report. The Wound Nurse received the NP's wound reports the day after service; -The weekly wound assessment included the wound description, measurements, whether or not the wound improved and the plan of care, including any new orders; -The Wound Nurse was responsible for discontinuing an existing wound treatment order when there was a new wound treatment order; -She was expected to assess any new wounds, document his/her findings in a wound assessment in the EMHR, notify the PCP for new orders, notify the DON the resident and the resident's responsible party; -The wound assessments generated a progress note automatically with a summary; -It was important to document the wound assessment when a wound was first found so there was a record of what was done, the date it was found and the condition of the wound for tracking purposes. It was also important to have the baseline wound assessment to see if the wound was improving or declining so changes in the plan of care could be made; -The residents were at risk of further breakdown of their skin, deterioration of the wound and/or infection if the PCP was not informed of the new wounds to get appropriate treatment orders; -She referred to the wound treatment orders found in the residents' EMHR when she administered their treatments; -She was responsible for completing weekly wound assessments for residents with existing wounds; -Nurses were responsible for completing weekly skin assessments for residents; -She was responsible for auditing residents' EMHR for completed weekly skin assessments once a week; -She was expected to notify the DON if a nurse did not complete a weekly skin assessment during their assignment; -She was not sure the last time she ran an audit for completed weekly skin assessments. She thought it might have been a week or two ago; -She expected the CNAs or nurses to notify him/her of any new skin issues immediately or during the next worked shift, so she could evaluate and get orders to treat the new wounds; -She was not made aware of any new skin issues on the resident prior to 5/9/25; -She did not have an order for the wounds on the resident's left posterior thigh on 5/9/25. When she saw the wound, she put a treatment on it; -She could not remember when she first the wound on the resident's left posterior thigh; -She should have discontinued the previous wound treatment orders for the right medial distal thigh when she put in the new treatment order on 5/5/25; -The Wound Nurse was not aware she had documented that she had administered the treatment orders dated 4/4/25, 4/28/25 and 5/5/28 for the resident's right medial distal thigh. It was inaccurate documentation and contradicting information. It did not accurately reflect that she was only administering the wound treatment order dated 5/5/25; -She should have notified the PCP of the new wounds found on 5/9/25 for new treatment orders, documented the wound assessment, notified the DON and resident responsible party before she left her shift on 5/9/25. She had every intention to do so but was taking care of other residents; -She was aware of the facility policies and had access to them. During an interview on 5/12/25 at 7:29 A.M. and at 1:48 P.M., the DON said: -The Wound Nurse was responsible for completing wound treatments for the residents; -Nurses were responsible for completing weekly skin checks, documenting the assessments in the residents' EMHR; -The Wound Nurse was responsible for overseeing the weekly skin assessments, ensuring they were completed by nurses; -She expected the Wound Nurse to tell the nurse to complete a skin assessment or the Wound Nurse to complete a skin assessment if the wound nurse found during her audit nurses did not complete residents' weekly skin assessment; -The Wound Nurse was expected to report to the DON the nurses who failed continually to complete resident weekly skin assessments; -The Wound Nurse was responsible for completing weekly wound assessments, documenting in the residents' EMHR; -The facility had a wound care company who came out once a week to evaluate and treat residents with open wounds, other than skin tears; -The Wound Nurse was responsible for rounding with the wound care company Nurse Practitioner every Monday, put in new orders, discontinue old orders and update the residents' EMHR with the new wound assessment; -The wound care NP sent in complete wound assessments every Tuesday and the Wound Nurse was expected to review them and make changes to the residents' orders as needed; -Failure to discontinue wound treatment orders when new wound treatment orders were received was confusing to any other nurse who tried to administer treatment to the wound as they would not sure which treatment order was accurate; -Documenting on three different orders was falsification of medical records and did not reflect what was actually administered to the residents; -She expected the Wound Nurse to complete a wound assessment, notify the PCP for new treatment orders, notify the resident and/or resident responsible party when a new skin issue was found. -Residents were at risk of further skin breakdown, deterioration of the new wound and/or infection if new orders were not received upon discovery of the new wounds -She expected nursing staff to have knowledge of and to follow facility policies. Review of the resident's wound care company wound assessment, dated 5/12/25 at 10:42 P.M., showed: -Visit specific Information: Rounded with facility Wound Nurse. Resident was diagnosed with cellulitis last week and was started on antibiotics with new wounds to left posterior thigh. Start Santyl and Calcium Alginate to posterior thigh wounds; -Trauma wound located on right thigh, medial distal, measuring 7.0 cm by 11.6 cm by 0.2 cm deep with 60% granulation tissue, 15% slough and 15% eschar tissue present in wound bed with a moderate amount of serosanguineous exudate present; No new treatment order listed; -Cellulitis wound on left thigh, posterior (back), first date wound recognized on 5/7/25, measuring 1.5 cm by 2.3 cm by 0.1 cm deep, 50% granulation, 30% skin and 20% eschar tissue present in wound bed with a moderate amount of Serosanguineous exudate present. Wound order: Cleanse wound with Hypochlorous acid, apply Santyl nickel thick to wound bed, edge to edge, apply calcium alginate inside wound base and cover with a super absorbent dressing. Change dressing daily and as needed. MO00253623

Based on observation, interview and record review, the facility failed to complete weekly skin assessments and to identify a 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) or eschar (non-viable, dark brown or black tissue). May also present as an intact or open/ruptured blister) pressure ulcer (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) for one resident (Resident #1) and failed to notify the resident's physician of the pressure ulcer and obtain orders for the wound care. In addition the facility failed to assess, document and obtain treatment orders for a pressure ulcer identified on admission (Resident #7). The sample size was four. The census was 90. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the facility's Skin Integrity and Pressure Ulcer/Prevention and Management Policy, dated 7/9/24, showed: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy (surgically created opening in the body to allow waste to exit the body) Continent Nurses Society); -Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. -A comprehensive skin inspection/ assessment is completed on admission and re-admission to the center; -A skin assessment/inspection should be performed weekly by a licensed nurse. Skin observations also occur throughout points of care provided by Certified Nurse Assistants (CNA) during activities of daily living (ADL) care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; -Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. 1. Review of Resident #1's Physician Order Sheets (POS), showed: -An order, dated 4/2/25, for wound care company to evaluate and treat; -There were no orders found for weekly skin checks; -There were no orders found for treatment to buttocks. Review of the resident's assessments, showed: -A weekly skin integrity data collection, dated 4/9/25, showed skin alterations included Moisture Associated Skin Damage (MASD) on the resident's perineal area (region between the anus and the genitals), open area/wound with a wound vacuum (wound vac, a medical device used to help heal wounds using negative pressure) present the resident's right thigh and other was used to describe buttock. None of the areas were new; -There was no documentation found showing there were weekly skin integrity data collection assessments found after 4/9/25 through 5/12/25. Review of the resident's shower sheets, showed; -On 4/16/25, the body diagram with the right front thigh circled with a handwritten note of wound vac and the back of the right and left buttocks circled with a handwritten note of redness, scabs. The nurse signed off. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/25, showed: -Cognitively intact; -Impairment on both sides of lower body; -Dependent on staff for toileting, showers, lower body dressing, bed mobility and transfers; -Incontinent of bowel and bladder; -At risk for pressure ulcers; -One Unstageable pressure ulcer (slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined) present; -Surgical wounds present; -Diagnoses included heart failure, kidney disease, respiratory disease and diabetes mellitus. Review of the resident's care plan, undated, showed: -Problem: At risk for unavoidable pressure injury development or decline of skin integrity; -Interventions included: Pressure redistribution mattress and weekly skin checks. Review of the resident's shower sheet, showed: -On 5/3/25, a handwritten note said (he/she) didn't feel good. There was no other documentation found. Review of the resident's Braden scale assessment (for predicting pressure ulcer risk) dated 5/4/25, showed staff documented a score of 13 (moderate risk). Review of the resident's shower sheet, showed: -On 5/7/25, there was no documentation found. Neither the CNA nor the nurse signed the document. Observation on 5/9/25 at 10:10 A.M., showed the resident lying on a pressure reducing mattress, in a gown, wearing anti slip socks with a call light in reach. During an interview on 5/9/25 at 10:12 A.M., the resident said: -His/Her buttocks were painful and he/she thought there might be an open area; -The nursing staff applied a cream to his/her buttocks after every incontinence episode. Observation on 5/9/25 at 10:45 A.M., showed; -The Wound Nurse assisted the resident to roll over to his/her right side; -The Wound Nurse removed the resident's dry brief, exposing his/her left buttock; -The resident's brief had a minimal amount of reddish, brown exudate (drainage) present where it was against the resident's left buttock; -There were three small open areas present on the resident's left buttock. The wound base on all three open areas appeared shiny and red; -The Wound Nurse cleansed the wounds with sterile water, placed Xeroform (dressing with petrolatum used to maintain moisture in wound) in the wound base and covered the wound with a dry dressing; -The Wound Nurse replaced the resident's brief and repositioned him/her on the bed. During an interview on 5/9/25 at 11:31 A.M., the Wound Nurse said: -The wounds on the resident's left buttock were new and she was not aware of them until the observation; -She was not sure what type of wounds were present on the resident's left buttock; -She was a new wound nurse, and started in the position a month ago. Review of the POS, showed no new orders dated 5/9/25. Review of the progress notes, showed no documentation staff notified the physician or resident's responsible party (RRP) of the wounds. During an interview on 5/12/25 at 8:49 A.M., the wound care company Nurse Practitioner (NP) said: -She evaluated and treated wounds for the facility-identified residents; -She came once a week and did rounds with the facility Wound Nurse; -She assessed residents' wounds, gave verbal recommendations to the Wound Nurse during rounds and then submitted a wound assessment report to the facility the day after her visit; -She expected the Wound Nurse to update the residents' POS in the residents' electronic medical health record (EMHR) with her new wound treatment orders after receiving the wound report; -She expected the facility to follow her wound treatment orders to facilitate wound healing. Observation on 5/12/25 at 9:03 A.M., showed: -The wound care company NP and the facility Wound Nurse providing care to the resident; -The Wound Nurse informed the wound care company NP the resident had a new skin issue located on his/her left buttock; -The resident was rolled over and the Wound Nurse removed a treatment, dated 5/9/25, from the resident's left buttock; -The wound care company NP said the open areas on the resident's left buttock were Stage II pressure ulcer, assessed the wound, took pictures and gave treatment instructions to the Wound Nurse. Review of the resident's progress notes, on 5/12/25 at 10:23 A.M., showed: -There was no documentation the Wound Nurse notified the Primary Care Physician (PCP) of the new wounds found on the resident's left buttock to obtain new orders; -There was no documentation the Wound Nurse notified the resident's responsible party (RRP) or the Director of Nurses (DON) of the new wounds found on the resident's left buttock. Review of the resident's assessments, on 5/12/25 at 10:23 A.M., showed: -There was no documentation found showing a skin assessment or wound assessment was completed on the resident from 5/9/25 through 5/12/25. During an interview on 5/12/25 at 10:25 A.M., CNA D said: -He/She was not assigned to the resident's care; -CNAs were expected to fill out shower sheets when providing bath or showers to residents; -CNAs were expected to document if a resident refused a bath or shower, any existing or new skin issues by marking on the body diagram the location and description of what was found; -CNAs were expected to notify the nurse immediately of any new skin issue so the nurse could immediately assess the residents' skin and provide treatment; -CNAs were expected sign the shower sheets, turn shower sheets into the nurse for their signature and then the nurse kept the shower sheets; -CNAs were expected to notify the nurse of any new skin issues so the nurse could evaluate and treat the resident. During an interview on 5/12/25 at 12:55 P.M., the Wound Nurse said: -She rounded with the wound care company NP once a week on residents who had orders for the NP to evaluate and treat their wounds; -The wound care company NP would tell her of any new wound treatment orders during rounds and the Wound Nurse would put the new wound treatment orders in residents' POS in the EMHR after the wound care NP's visit, on the same day; -She completed a weekly wound assessment in residents' EMHR after she received the wound care company NP submitted her wound report. The Wound Nurse received the NP's wound reports the day after service; -The weekly wound assessment included the wound description, measurements, whether or not the wound improved and the plan of care, including any new orders; -The Wound Nurse was responsible for discontinuing an existing wound treatment order when there was a new wound treatment order; -She was expected to assess any new wounds, document her findings in a wound assessment in the EMHR, notify the PCP for new orders, notify the DON, the resident and the resident's responsible party; -The wound assessments generated a progress note automatically with a summary; -It was important to document the wound assessment when a wound was first found so there was a record of what was done, the date it was found and the condition of the wound for tracking purposes. It was also important to have the baseline wound assessment to see if the wound was improving or declining so changes in the plan of care could be made; -The residents were at risk of further breakdown of their skin, deterioration of the wound and/or infection if the PCP was not informed of the new wounds to get appropriate treatment orders; -She referred to the wound treatment orders found in the residents' EMHR when she administered their treatments; -She was responsible for completing weekly wound assessments for residents with existing wounds; -Nurses were responsible for completing weekly skin assessments for residents; -She was responsible for auditing residents' EMHR for completed weekly skin assessments once a week; -She was expected to notify the DON if a nurse did not complete a weekly skin assessment during their assignment; -She was not sure the last time she ran an audit for completed weekly skin assessments. She thought it might have been a week or two ago; -She expected the CNAs or nurses to notify her of any new skin issues immediately or during the next worked shift, so she could evaluate and get orders to treat the new wounds; -She was not made aware of any new skin issues on the resident prior to 5/9/25; -She should have notified the PCP of the new wounds found on 5/9/25 for new treatment orders, documented the wound assessment, notified the DON and resident's responsible party before she left her shift on 5/9/25. She had every intention to do so but was taking care of other residents; -She was aware of the facility policies and had access to them. During an interview on 5/12/25 at 7:29 A.M. and at 1:48 P.M., the DON said: -The Wound Nurse was responsible for completing wound treatments for the residents; -Nurses were responsible for completing weekly skin checks, and documenting the assessments in the residents' EMHR; -The Wound Nurse was responsible for overseeing the weekly skin assessments, ensuring they were completed by nurses; -She expected the Wound Nurse to tell the nurse to complete a skin assessment or the Wound Nurse to complete a skin assessment if the wound nurse found during her audit nurses did not complete residents' weekly skin assessment; -The Wound Nurse was expected to report to the DON the nurses who failed continually to complete resident weekly skin assessments; -The Wound Nurse was responsible for completing weekly wound assessments, documenting in the residents' EMHR; -The facility had a wound care company who came out once a week to evaluate and treat residents with open wounds, other than skin tears; -The Wound Nurse was responsible for rounding with the wound care company Nurse Practitioner (NP) every Monday, put in new orders, discontinue old orders and update the residents' EMHR with the new wound assessment; -The wound care NP sent in complete wound assessments every Tuesday and the Wound Nurse was expected to review them and make changes to the residents' orders as needed; -She expected the Wound Nurse to complete a wound assessment, notify the PCP for new treatment orders, notify the resident and/or resident responsible party when a new skin issue was found. -Residents were at risk of further skin break down, deterioration of the new wound and/or infection if new orders were not received upon discovery of the new wounds -She expected nursing staff to have knowledge of and to follow facility policies. Review of the resident's wound care company wound assessment, dated 5/12/25 at 10:42 P.M., showed: -Visit specific Information included: Rounded with facility Wound Nurse. Resident had a new wound to left buttock, diagnosed as a Stage II Pressure Ulcer; -Stage II pressure ulcer, located on Left Buttock, first date wound recognized on 5/7/25, measuring 3.3 centimeters (cm) by 1.9 cm by 0.1 cm deep, with 70% epithelial (new skin, light pink) and 30% skin present in wound bed and a minimal amount of frank blood exudate (drainage) present; -Wound orders and plan of care included: Cleanse wound with Hyprochlorous acid (slightly acidic solution used to fight infections), cleanse wound with saline, protect peri-wound (area surrounding wound) with Skin Protectant, apply collagen powder (used to absorb exudate) one gram (gm) to clean wound bed, apply hydrogel gel (gel used to debride wound) and cover with silicone bordered foam dressing. Change dressing every Monday, Wednesday, Friday and as needed. 2. Review of Resident #7's entry MDS, showed an admission date of 4/7/25. Review of the resident's progress note, dated 4/7/25 at 5:30 P.M. showed the following: -admitted to facility from the hospital. Reddened at groin (area on each side of the body where the belly joins the legs); -Buttocks noted with a pressure ulcer to the sacrum (a large, triangular bone at the base of the spine) and gluteal (buttocks); -Protective ointment applied to all reddened areas; -Dressing was replaced to sacrum, clean and dry; -Feet noted with pressure ulcers to bilateral heels; -Orders verified; -No documentation of measurement of the pressure ulcers. Review of the resident's POS, dated 4/7/25, showed no orders for treatment to the buttocks, sacrum and bilateral heels. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 4/7/25, showed no treatment orders for reddened areas, sacrum and gluteal pressure ulcers. Review of the resident's progress note, dated 4/8/25 at 11:00 A.M., showed the resident was sent to the hospital. Review of the resident's hospital discharge record, dated 4/11/25, showed the following: -Diagnoses of urinary tract infection and changes in mental status; -Wound care discharge orders: Sacral/Coccyx: Unstageable pressure ulcer (wound not stageable due to wound bed covered with slough (soft dead tissue) and/or eschar (hard dry dead tissue)). Cleanse skin with soap and water, pat dry, apply Calmoseptine (topical medication used to treat and prevent minor skin irritations) to periwound (area surrounding wound), place Triad ointment (medication used to break down necrotic tissue) and cover with gauze; -Apply Aquacel dressing to callus on bilateral great toes, change every 3 to 5 days and as needed. Continue heels boots. Review of the resident's POS, dated 4/11/25, showed no orders for treatment to the buttocks, sacrum and bilateral heels. Review of the resident's progress notes, showed the following: -No documentation regarding the resident's pressure ulcer until 4/13/25; -4/13/25 at 11:51 P.M.: Skilled nursing note: showed a diagnosis of unstageable pressure ulcer of the sacral region. No further documentation regarding the unstageable pressure ulcer to the sacral region until 4/16/25; -4/16/25 at 3:33 A.M.: Skilled nursing note: showed a diagnosis of unstageable pressure ulcer of the sacral region. No further documentation regarding the unstageable pressure ulcer to the sacral region until 4/17/25. Review of the resident's admission MDS, dated [DATE], showed the following: -Diagnoses of high blood pressure, diabetes and stroke; -Short and long term memory loss; -Required total assist of staff for all activities of daily living; -Incontinent of bowel and bladder; -Skin: one unstageable pressure ulcer present upon admission. Review of the resident's progress note, dated 4/17/25 at 3:05 P.M., showed an unstageable pressure ulcer to the sacrum, covered in slough. Physician notified, new order for referral to outside wound company for treatment and potential debridement (removal of dead skin), dry dressing applied. Order to apply and monitor daily until seen by wound care company. Review of the resident's POS, dated 4/17/25, showed the following: -Wound Care Company to evaluate and treat sacrum wound; -Order dated 4/17/25: Apply bordered gauze dressing to sacrum daily until seen by wound company. Clean with wound cleaner, apply bordered gauze daily and as needed if soiled or damaged. Review of the progress note, dated 4/18/25 at 2:03 PM., showed the resident was sent to the hospital. During an interview on 5/12/25 at 10:22 A.M., CNA D said he/she had taken care of the resident., The resident required total care. He/she doesn't recall resident having a pressure ulcer on his/her buttocks. He/she would notify the charge nurse if he/she had seen a open area. During an interview on 5/13/25 at 12:25 P.M., RN E said he/she was the charge nurse on the resident's hall and took care of the resident. The pressure ulcer on the resident's buttocks was discovered during a skin assessment by the wound nurse. The skin assessment was initiated after management reviewed the resident's hospital paperwork. Staff had not reported any changes in the resident's skin. During an interview on 5/12/25 at 12:55 P.M., the Wound Nurse said 4/17/25 was the first time she was made aware of the resident's pressure ulcer. Staff should have made her aware of the pressure ulcer when the resident was admitted . During an interview on 5/12/25 at 10:10 A.M., the Director of Nurses said she expected the nurse to complete and document the assessment, notify the physician and complete the physician's order upon admission. In addition, staff are to notify the Wound Nurse of any wounds upon admission. MO00253623 MO00251251

Based on observation, interview and record review, the facility failed to ensure a resident with a significant weight loss was provided appropriate mealtime assistance resulting in a 9.43% weight loss within a 30 day time frame (Resident #36). In addition, the facility failed to notify the physician and Registered Dietician (RD) when a resident experienced a weight loss for one resident (Resident #31) and failed to ensure nutritional supplements and double portions were provided for one resident at risk for weight loss (Residents #22). The sample size was 18. The census was 78. Review of the facility's Hydration and Nutrition policy, revised 8/24/23, showed: -Each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status; -Federal Regulations; -Based on a resident's comprehensive assessment, the facility must ensure that a resident; -Maintains acceptable parameters of nutritional status; -Is offered sufficient fluid intake to maintain proper hygiene and health; -Is offered a therapeutic diet when there is nutritional problem and the health care provider orders a therapeutic diet; -Procedure; -A physician's order is obtained for all regular and therapeutic diets, including those with modified textures; -A minimum of three meals are provided each day. If a meal or particular food is refused, the resident is offered a substitute of a similar nutritive value; -The resident is positioned properly to consume meals and snacks. Assistance is provided as needed; -An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse; -Consultation with dietary and therapy personnel, is performed on admission and as needed; -The physician is notified of any concerns 1. Review of Resident #36's weight, dated 7/17/24 at 8:33 A.M., showed an admission weight of 176.0 pounds. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/24, showed: -Cognitively intact; -No rejection of care; -Required partial/moderate assistance with eating; -Dependent on staff for all personal hygiene; -Diagnoses included urinary tract infection (UTI), and diabetes; -Height: 74 inches; -Weight: 176 pounds. Review of the resident's Assessment/Nutritional Data Collection, dated 8/1/24, showed: -Regular diet with house supplements; -Height of 74.0 inches; -Weight: Body Mass Index (BMI) based on weight from hospital documents where resident was documented to weigh 180 pounds; -Meal intake: 0-50%; -Confused; -Feeding/Dining ability: Limited Assist; -Pressure Injury (injury to the skin and underlying tissue resulting from prolonged pressure on the skin); -At risk for malnutrition; -Monitoring/Evaluation of weight, intakes, chewing/swallowing, independence level and skin; -Resident admitted on [DATE]. Noted to be on hospice but is a full code. Resident is alert and oriented to person and place and not eating well on regular diet with regular texture. Has an order for house shakes (nutritional supplements) twice a day. Unsure of recent weight loss. No weight taken since admitted to facility. Has wounds and at risk for malnutrition due to inadequate by mouth intake and increased needs for wound healing. Please obtain weight. Review of the resident's weight, dated 8/2/24 at 3:25 P.M., showed the resident weighed 176.0 pounds. Review of the resident's current care plan, revised on 8/22/24, showed: -Diagnoses included Parkinson's disease, unspecified tremors and diabetes; -No information documented regarding the resident's nutritional status or activities of daily living. Review of the resident's Nutrition Assessment/Nutritional Data, dated 8/22/24, showed: -Regular diet; -Weight of 176 pounds on 8/2/24; -Comment related to meal intake: varied, mostly 26-75%; -Feeding/Dining ability: Limited assist; -No behaviors that would affect nutritional status; -At risk for malnutrition; -Resident readmitted on ,d+[DATE]. Noted to be on hospice but is a full code. Not eating very well on regular diet with regular texture. Intakes have been mostly 26-75%. Resident has wounds and at risk for malnutrition due to inadequate by mouth intakes and increased needs for wound healing. Recommend ordering weekly weights. During an observation and interview on 8/22/24 at approximately 2:44 P.M., the resident lay in bed on his/her back. The resident said he/she had cake earlier and was not cleaned up. He/She needed help with meals and staff never fed him/her. The only time he/she ate was when his/her spouse and adult child visited. Observation on 8/23/24 at 8:44 A.M., showed the resident lay in bed on his/her back. His/Her breakfast tray was on the bedside table, covered. No staff member assisted the resident. Observation on 8/23/24 at 9:02 A.M., showed the resident's spouse in the resident's room, feeding the resident. The spouse said when he/she arrived, the plate of food was covered and no one had set up the resident's tray. If he/she had not been there, the resident would not have received anything to eat. Staff never fed the resident. He/She had spoken to staff and asked them to feed the resident as he/she was unable to feed him/herself. The resident ate 100% of his/her meal with his/her spouse's assistance. Observation on 8/26/24 at 4:53 A.M., showed a handwritten sign saying please assist me with meals hung at the door and on the wall of the resident's room. Observation on 8/26/24 at 8:47 A.M., showed the resident lay in bed on his/her back. The resident's covered breakfast tray sat on the night stand. The resident opened his/her eyes and said he/she was hungry. The resident's breakfast meal consisted of biscuits and gravy, oatmeal, juice and water. He/She said he/she was hoping someone would feed him/her. The resident's hands shook as he/she tried to open the covered tray. He/she dropped the tray and was unable to feed him/herself. No staff assisted the resident. Observation on 8/26/24 at 9:01 A.M., showed the resident's tray of food was removed. He/She said staff came and took the tray and did not offer to feed him/her. He/She never received any assistance with breakfast and was still hungry. The resident said he/she did not eat and was still hungry. Observation and interview on 8/26/24 at 2:01 P.M., showed Certified Nursing Assistant (CNA) L stood over the resident and fed him/her lunch. When asked about the resident's breakfast tray, CNA L at first said he/she thought he/she fed the resident. The resident said, no, you came and took my food away. CNA L then said, Didn't your (son/daughter) feed you? The resident said no and they did not visit with him/her today. CNA L then said the resident had not had any breakfast. Observation and interview on 8/27/24 at 10:13 A.M., showed the resident lay in bed. His/Her spouse said when he/she arrived this morning, the resident's breakfast tray was untouched. The spouse placed signs throughout the resident's room to remind staff to feed the resident. Observation and interview on 8/27/24 at 10:34 A.M., showed CNA B and CNA K weighed the resident using a mechanical lift. The resident weighed 159.4 pounds, indicating a 9.43% weight loss since 8/2/24. CNA B said he/she was familiar with the resident and he/she needed total assistance with meals. The resident's hands shook and he/she would not be able to feed him/herself. During an interview on 8/28/24 at 9:08 A.M., CNA N said he/she was familiar with the resident and he/she definitely needed total assistance with meals due to his/her hand shaking. During an interview on 8/28/24 at 2:46 P.M., Licensed Practical Nurse (LPN) A said if residents were at risk for weight loss and required staff to assist with meals, the CNAs should feed the residents. During an interview on 8/27/24 at 12:16 P.M., the Registered Dietician (RD) said 9.43% within less than 30 days was considered a significant weight loss. The resident required assistance with meals and she expected staff to feed the resident as he/she was at risk for malnutrition. During an interview on 8/28/24 at 4:36 P.M., the Administrator and Director of Nursing (DON) said the resident was at risk for malnutrition and could not feed him/herself. The resident experienced a significant weight loss and staff should have fed the resident. 2. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure and diabetes. Review of the weight tab, showed: -Weight on 5/7/24 was 168.7 pounds; -Weight on 8/2/24 was 158 pounds, which showed a 6.34% weight loss for three months. Review of the progress notes, dated 8/8/24 through 8/27/24, showed: -On 8/8/24 at 12:34 P.M., the resident was discussed in a meeting on 8/7, monthly note for wounds and hemodialysis (HD, process for removal of waste and excess water from the blood due to kidney failure) has 30 mL of Prosource twice daily ordered, recommended to increase Prosource to three times daily to aid in wound healing and for increased needs for HD; -There was no documentation showing the physician was notified of the RD recommendations. Review of the physician summary sheet, dated 8/26/24, showed: -An order for Prosource (nutritional supplement) Give 30 milliliters (mL) by mouth two times a day for protein supplement for wound healing; -There was no physician order for Prosource three times a day. Review of the Medication Administration Record (MAR), dated August 1, 2024, through August 27, 2024, showed Prosource 30 mL was administered twice daily. During an interview on 8/28/24 at 12:53 P.M., Licensed Practical Nurse (LPN) D said if the dietician made a recommendation, the MDS nurse or the DON would enter the recommendation into the medical record. If LPN D saw a recommendation in the medical record, he/she would call the doctor and get an order, then enter it into the medical record. During an interview on 8/28/24 at 1:33 P.M., LPN A said if he/she received a dietary recommendation, he/she would call the doctor and verify the recommendation and if the order was okayed, it would be entered into the computer. During an interview on 8/24/24 at 4:36 P.M., the DON said she expected staff to notify the physician of weight loss and she expected dietary recommendations to be addressed within 48 hours. 3. Review of Resident #22's quarterly Nutrition Data Collection, dated 6/3/24, showed: -Double portions for all meals; -Fortified foods; -Height: 72 inches; -Weight on 5/6/24 of 137.2; -Resident eating fairly well on regular diet with regular texture and thin liquid, receiving double portions of food. Encourage intakes. Recommend ordering house shakes twice a day. Review of the resident's Weight Summary, showed: -6/10/24, a weight of 137.2 pounds. Review of the resident's care plan, revised 6/15/24, showed: -Focus: The resident has an activity of daily living self-care performance deficit related to weakness, impaired mobility and cognitive impairment; -Goal: The resident's activity of daily living will be met through the review date; -Interventions: The resident requires assistance by staff times one to eat; -Focus: The resident is at risk for weight fluctuation related to current health status and bilateral above the knee amputation, dysphagia and diabetes; -Goal: Resident wishes to maintain current weight through next review; -Intervention: Assist with meals as needed. Diet order as ordered. Supplements as ordered and does not like milk. Weekly weights, fortified foods, nutritional juice and double portions. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -No behaviors; -Required set up and clean up for meals; -Diagnoses included high blood pressure, diabetes, stroke and malnutrition. Review of the resident's undated POS, in use during the time of the investigation, showed no orders for health shakes or double portions. Review of the resident's Weight Summary, showed: -7/2/24, a weight of 136.8 pounds; -8/2/24, a weight of 134.1; -8/22/24, a weight of 132.3 pound, indicating 3.29% weight loss since 7/2/24. Review of the resident's breakfast meal ticket, dated 8/23/24, showed: -Allergies/dislikes: Dairy; -Regular texture/Double portions; -Fortified shakes. Observation and interview on 8/23/24 at 8:21 A.M., showed the resident received his/her plate of food. The meal consisted of one bagel, approximately two tablespoons of mixed fruit cocktail and approximately two tablespoons of cottage cheese. Milk and juice were on the tray. The resident said the food was disgusting and he/she would not eat it. No fortified shake was on the resident's tray. The resident said he/she did not recall ever receiving a fortified shake. The resident said he/she wanted oatmeal, but did not receive it. Observation on 8/23/24 at 8:25 A.M., showed the resident staring at his/her meal. The DON and another staff member walked in the resident's room and took the milk from his/her tray. Review of the resident's lunch meal ticket, dated 8/23/24, showed: -Regular texture/double portions; -Beef tip, butter pasta, sauerkraut, desert, dinner roll and juice. Observation on 8/23/24 at 12:47 P.M. , showed the resident received his/her lunch tray. The meal consisted of one roll, one serving of beef and noodles, one serving of vegetables, a cup of banana pudding, water and juice. The resident did not receive double portions. During an interview on 8/23/24 at 12:49 P.M., the resident said he/she did not receive sauerkraut. He/She did not like the beef pasta and would not eat it. He/She also did not receive a health shake today. Review of the resident's breakfast meal ticket, dated 8/26/24, showed regular texture/double portions. Observation on 8/26/24 at approximately 8:30 A.M., showed the resident in bed with his/her breakfast on the night stand. The breakfast consisted of one biscuit covered in gravy, one serving of scrambled eggs, a cup of oatmeal, water and juice. The resident said he/she planned to eat everything on the plate. Observation on 8/27/24 at 9:17 A.M., showed CNAs B and K weighed the resident using a mechanical lift. The resident weighed 132.6 pounds. Observation and interview on 8/27/24 at 12:00 P.M., showed frozen health shakes in the facility's main kitchen. The Dietary Manager (DM) said the health shakes were kept in the refrigerator and freezer, but they had not passed them out with meals. She was not sure when the shakes were last passed out with meals. During an interview on 8/27/24 at 12:16 P.M., the RD said the resident was recommended for house shakes and she expected staff to ensure it was on the physician's order and the resident was to receive it. The CNAs would place beverages, including milk, and shakes, on the carts to pass in between meals instead of with meals to ensure residents received health shakes. The resident should have received shakes if there was an order or recommendation. The resident was also supposed to receive double portions with each meal. During an interview on 8/28/24 at 4:36 P.M., the Administrator and DON said the resident had a diagnosis of malnutrition. The resident experienced a weight loss in the past and should have received fortified shakes and double portions. MO00240295 42247 45083

Based on observation, interview and record review, the facility failed to provide residents with food that was palatable and at a safe and appetizing temperature for 7 of 18 sampled residents (Residents #80, #38, #292, #81, #54, #36 and #79). The census was 87. Review of the facility Safe Food Handling Policy, dated 10/7/19, and revised on 4/16/23 and reviewed on 5/1/2024, showed: -All food purchased, stored and distributed is handled with accepted food-handling practices, and per federal, state and local requirements; -Danger Zone-means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause food borne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS). Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a food borne illness outbreak if consumed; -Food Distribution-means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. 1. Review of Resident #80's re-admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 8/5/24, showed: -Moderate cognitive impairment; -No behaviors; -Partial/moderate assistance in eating; -Diagnoses included heart failure, high blood pressure, thyroid disease, arthritis, malnutrition. During an interview on 8/26/24 at 1:43 P.M., the resident said lunch was terrible and tasted horrible. The resident only ate a few bites of mashed potato and chocolate pudding. He/She said foods were always served cold. 2. Review of Resident #38's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -No impairment of both upper and lower extremities; -Diagnoses included anemia (not having enough healthy red blood cells), high blood pressure, diabetes, high cholesterol, anxiety and depression. During an interview on 8/22/24 at 2:23 P.M., the resident said the food was not good and was always served cold, especially meals served in resident rooms. He/She said his/her family brings food when they visit. 3. Review of Resident #292's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -Independent on functional abilities; -Diagnoses included stroke, anemia, high cholesterol, seizure, malnutrition Schizophrenia (a serious mental health condition that affects how people think, feel and behave). During an interview 8/22/24 at 2:40 P.M., the resident said the facility's food was not good and cold when received. 4. Review of Resident #81's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: high blood pressure, end stage renal disease (ESRD, chronic irreversible kidney failure), dementia and Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). During an interview on 8/22/24 at 1:51 P.M. and on 8/26/24 at 1:17 P.M., the resident said the food was not too good and sometimes the food was cold. 5. Review of Resident #54's quarterly MDS, dated [DATE] showed: -Cognitively intact; -No swallowing disorders; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. During an interview on 8/22/24 at 5:11 P.M., the resident said the food is always cold. 6. Review of Resident #36's admission MDS, dated [DATE], showed: -Cognitively intact; -No rejection of care; -Diagnoses included urinary tract infection (UTI) and diabetes. During an interview on 8/22/24 at approximately 2:44 P.M., the resident said the food was not good. When it arrived to his/her room, it was always cold. The facility offered choices, but the choices were not good. He/She ate the food because that was all that was offered. 7. Review of Resident #79's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Diagnoses included anemia, UTI and malnutrition. During an interview on 8/22/24 at 11:30 A.M., the resident said the food sucks, and You get what you get. Staff would come around with a menu but it was not honored. The food was often delivered cold and staff were not able to warm it up. 8. During an observation on 8/28/24 at 8:50 A.M., during meal service, a sample tray was removed from the meal service cart on the 200 Hall. The food temperatures showed: -Sliced ham, 87 F; -Scrambled eggs, 88.7 F; -Hashbrown, 89 F; -Buttered bread, hard to the touch. 9. During an observation on 8/28/24 at 9:28 A.M., a test tray was removed from the hall cart on the 500 unit at 9:28 A.M. The food temperatures showed: -Scrambled eggs, 108.5 F; -Sliced ham, 93.0 F; -Oatmeal, 92.1 F; -Hashbrown, 101.1 F. 10. During an interview on 8/28/24 at 3:02 P.M., the Dietary Manager said staff should ensure food was served on time and not served cold. 11. During an interview on 8/28/24 at 4:37 p.m., the Administrator said hot foods were to be served hot and cold food should be cold. The food should be palatable and served in a timely manner. MO00232662 MO00226243 MO00225362 37681 42247 45083

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of three of 18 sampled residents. (Residents #36, #79, and #292) . The census was 78. Review of the facility's Comprehensive Care Plans and Revisions policy, reviewed 8/22/23, showed: -Policy: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; -Procedure; -The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; -When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery; -Definition: Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident; -Procedure; -Facility staff develops the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment; -The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. 1. Review of Resident #36's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/18/24, showed: -admitted [DATE]; -Cognitively intact; -No rejection of care; -Required substantial/maximal assistance for mobility; -Indwelling catheter (a medical device that drains urine from the bladder); -Diagnoses included urinary tract infection (UTI) and diabetes; -Bed rail not used. Review of the resident's physician orders, reviewed 8/5/24, showed: -Order dated 5/2/24. May insert midline catheter for five day IV (intravenous line, a flexible plastic tube that's inserted into a vein to deliver fluids, medicine, or blood products into the bloodstream) treatment; -Order dated 7/27/24. May use bedrails for assist with bed mobility Review of the resident's Evaluation for Use of Bed Rails, dated 8/6/24, showed: -Is resident being considered for bed rail or assistive device for the bed? Yes; -Recommended type: 1/4 partial rails. Review of the resident's care plan, revised 8/22/24, in use during the time of the investigation, showed no information regarding the use of an indwelling catheter or bed rails. Observations on 8/22/24 at approximately 2:44 P.M., 8/23/24 at 8:16 A.M. and 8/26/24 at 4:53 A.M., showed the resident lay in bed on his/her back. Quarter length side rails were raised on both sides. The resident's catheter bag hung on the right side of the bed, in a privacy bag. 2. Review of Resident #79's Evaluation for Use of Bed Rails, dated 6/7/24, showed: -Is the resident being considered for Bed Rail or assistive device for the bed? Yes; -Recommended type: 1/2 partial rails. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Required supervision or touching assistance with transfers; -Diagnoses included anemia, kidney disease, seizures and depression. Review of the resident's care plan, revised 8/6/24, in use during the time of the investigation, showed no information regarding the use of bed rails. Review of the resident's physician orders, last reviewed on 8/21/24, showed no order for the use of bed rails. Observations on 8/22/24 at approximately 11:30 A.M., 8/23/24 at 8:10 A.M. and 8/26/24 at 4:58 A.M., showed the resident lay in bed on his/her back. Half length bed rails were raised on both sides of the bed. 3. Review of Resident #292's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -Independent on functional abilities; -Diagnoses included stroke, anemia, high cholesterol, seizure, malnutrition, Schizophrenia (a serious mental health condition that affects how people think, feel and behave). Review of the resident's medical record showed the resident received a Level II Pre-Admission Screening Resident Review evaluation, (PASRR, this evaluation is required for all individuals suspected of mental illness ad/or intellectual disability or related condition seeking nursing home facility admission or wish to continue residing in a nursing facility). Review of the resident's care plan, in use at the time of the survey, showed it did not include the resident's PASRR II evaluation and the resident's mental health condition. During an interview on 8/22/24 at 2:40 P.M., the resident said he/she had not been to a care plan meeting nor had any staff invited him/her to attend a care plan meeting. 4. During an interview on 8/28/24 at 1:01 P.M., the Social Services Director said care plans were updated by the MDS Coordinator and herself. She was not sure how often they were supposed to be updated but thought they should be updated annually or quarterly. Care plans should be specific to each resident and should include information regarding catheters and bed rails. Level two screenings should also be included on the care plan. During an interview on 8/28/24 at 1:25 P.M., the MDS coordinator said everyone was responsible for updating care plans. Care plans should be resident specific and include care needs such as side rails, nutrition status, activities of daily living and catheters. Care plans were updated quarterly, annually and as needed. The Social Services Director was responsible for care plan meetings and sending out notices to residents and resident representatives. The care plan updates had not been consistent. During an interview on 8/28/24 at 4:36 P.M., the Administrator and Director of Nursing (DON) said care plans should be resident specific and include information regarding bed rails, catheters, weights, activities, activities of daily living and level two information. 45083

42247 Based on interview and record review, facility staff failed to notify, in a timely manner, the family/resident representative of three residents' change of room assignment after they tested positive of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) (Residents #62, #31, and #14). The facility census was 78. Review of the facility's COVID-19 Policy, reviewed on 7/12/24, showed: -Place a resident with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The resident should have a dedicated bathroom; -The facility could consider designating entire units within the facility, with dedicated healthcare provided, to care for residents with SARS-CoV-2 infection when the number of residents with SARS-CoV-2 infection is high; -Limit transport and movement of the resident outside of the room to medically essential purposes; -Communicate information about residents with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility and to other healthcare facilities; -Residents should only be placed in a COVID-19 care unit if they have confirmed SARSCoV-2 infection; -The facility's policy failed to mention that the residents' representative must be promptly notified if there were changes in room assignments. 1. Review of Resident #62's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/10/24, showed; -Cognitively intact; -Diagnoses included heart disease, kidney failure, anxiety and depression. Review of the resident's nurse's progress notes, showed: -On 8/12/24 at 3:56 P.M., called and spoke with family, and physician aware of resident COVID 19 diagnoses. Family expressed thankfulness for the call. Resident will be moving to Hall 500; -On 8/16/24 at 3:55 A.M., resident remains on isolation due to COVID positive. No cough, fever, shortness of breath or distress noted. Observation on 8/22/24 at 5:23 P.M., showed the resident in his/her room on the 500 Hall, laying in bed. Observation on 8/26/24 at 8:40 A.M., showed the resident in his/her room on 400 Hall, laying on his/her bed. Review of the resident's census showed the resident was moved off the isolation unit on 8/23/24. Review of the resident's medical record, showed no documentation the family was made aware the resident was moved. 2. Review of Resident #31's medical record, showed: -Cognitively intact; -Diagnoses included: COVID-19. Review of the progress notes, dated 8/15/24, showed at 3:45 P.M., the resident was tested for COVID-19, per facility policy-results were positive for COVID-19. Doctor and family made aware. Resident was transferred to another unit private room for isolation and respiratory precautions and observations. Observation on 8/22/24 at 2:47 P.M., showed the resident lay in bed in a private room on the isolation unit. Observation on 8/28/24 at 8:43 A.M., showed the resident was in his/her old room and lay in bed, with his/her oxygen on. The resident said he/she was glad to be back in his/her room. Review of the progress notes dated, 8/16/24 through 8/27/24, showed no documentation the family was made aware of the room change. 3. Review of Resident #14's medical record, showed: -Moderately impaired cognition; -Diagnoses included: Covid-19. Review of the progress notes, dated 8/16/24, showed at 9:19 A.M., resident was tested on [DATE] for COVID-19, per facility policy-results were positive for COVID-19. Doctor and family made aware. Resident was transferred to another unit-private room for isolation and respiratory precautions and observations. Observation on 8/22/24 at 2:16 P.M., showed the resident sat in a wheelchair next to the bed in his/her room on the isolation unit. Observation on 8/27/24 at 9:00 A.M., showed the resident sat in his/her wheelchair in a new room, on another unit. Review of the resident's census showed the resident was moved off the isolation unit on 8/26/24. Review of the progress notes dated 8/26/24 through 8/27/24 showed no documentation the family was made aware the resident was moved. 4. During an interview on 8/27/24 at 12:53 P.M., Licensed Practical Nurse (LPN) D said if a resident tested positive for Covid, they would be moved to isolation. The nurse who transferred the resident to the isolation unit was responsible for notifying the doctor and the family. When a resident was transferred off the isolation unit the nurse who received the resident was responsible for notifying the doctor and the family. 5. During an interview on 8/27/24 at 1:33 P.M. LPN A said if a resident tested positive for Covid, the resident would be moved to the isolation unit. He/She would notify the Director of Nursing, Administrator, Medical Records, the doctor, and the family. The process would be same when the resident moved off the isolation unit. 6. During an interview on 8/27/24 at 3:40 P.M., the Administrator said she would expect the family to be notified when a resident was moved. 45083

37681 Based on interview and record review, the facility failed to ensure residents or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care planning for six of 18 sampled residents (Residents #66, #80, #292, #50, #62 and #54). The census was 78. Review of the facility's Comprehensive Care Plans and Revisions policy, reviewed 8/22/23, showed: -Policy: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; -Procedure; -The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; -When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery; -Definition: Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident; -Procedure; -Facility staff develops the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment; -The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. 1. Review of Resident #66's medical record, showed: -admitted [DATE]; -RP was a family member; -Diagnoses included muscle weakness, need for assistance with personal care, chronic kidney disease, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and high blood pressure. During an interview on 8/22/24 at 4:28 P.M., the resident's RP said the resident was admitted to the facility back in January 2024. He/she was never contacted or invited to participate in a care plan meeting. He/she would like to attend care plan meetings. During an interview on 8/28/24 at 1:01 P.M., the Social Services Director (SSD) said she had not contacted the resident's RP for a care plan meeting. Review of the resident's medical record, showed no documentation indicating the RP was invited, or participated in the care plan meetings. 2. Review of Resident #80's re-admission Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/5/24, showed: -Moderate cognitive impairment; -No behaviors; -Partial/moderate assistance in eating; -Diagnoses included heart failure, high blood pressure, thyroid disease, arthritis, malnutrition. Review of the resident's medical record, showed he/she was his/her own responsible party. There were no care plan meeting documentation notes. During an interview on 8/22/24 at 11:25 A.M., the resident said he/she had not participated in a care plan meeting. He/She had no family and was able to make decisions for him/herself. The resident did not know the facility's plan for him/her and he/she had requested to be transferred to another facility. 3. Review of Resident #292's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors; -Independent on functional abilities; -Diagnoses included stroke, anemia, high cholesterol, seizure, malnutrition and Schizophrenia (a serious mental health condition that affects how people think, feel and behave). Review of the resident's medical record showed he/she was his/her own responsible party. There were no care plan meeting documentation notes. During an interview on 8/22/24 at 2:40 P.M., the resident said he/she had not been to a care plan meeting nor had any staff asked to the resident to attend a care plan meeting. 4. Review of Resident #50's annual MDS, dated [DATE] showed; -Cognitively moderately impaired; -Diagnoses included kidney failure, dementia, arthritis, malnutrition and depression. Review of the resident's social services notes, showed no documentation regarding care plan meetings. During an interview on 8/28/24 at 10:00 A.M., the resident said he/she could not recall his/her last care plan meeting. 5. Review of Resident #62's quarterly MDS, dated [DATE], showed; -Cognitively intact; -Diagnoses included heart disease, kidney failure, anxiety and depression. Review of the resident's social services notes, showed no documentation regarding care plan meetings and/or notification of family, and/or POA, regarding care plan meetings. During an interview on 8/26/24 at 8:43 A.M., the resident said he/she said he/she had not had a care plan meeting in a while. 6. Review of Resident #54's quarterly MDS, dated [DATE], showed; -Cognitively intact; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. Review of the resident's social services notes, showed no documentation regarding care plan meetings and/or notification of family, and/or POA, regarding care plan meetings. 7. During an interview on 8/28/24 at 1:01 P.M., the SSD said she was responsible for scheduling and documenting care plan meetings. She held care plan meetings for short term and skilled residents upon admission and discharge. She had not held care plan meetings for long-term residents. Residents #66, #80, #292, #50, #62 and #54 were long-term residents and she had not had care plan meetings with the resident or RP. During an interview on 8/28/24 at 1:25 P.M., the MDS coordinator said the SSD was responsible for updating care plan meetings and sending out notices to residents and RPs. Care plan meetings had not been consistent. During an interview on 8/28/24 at 4:36 A.M., the Administrator and Director of Nursing (DON) said they would expect care plan meetings to be held quarterly and as needed. Residents and RPs were expected to receive notification of care plan meetings. 45083

37681 Based on observation, interview and record review, the facility failed to ensure residents who received activities of daily living (ADL) received personal care in accordance with their personal needs for three of 18 sampled residents (Residents #36, #79 and #50). The census was 78. Review of the facility's Activities of Daily Living (ADLs), revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse; -Federal Regulations: F677 A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #36's medical record, showed diagnoses included Parkinsonism (a clinical syndrome characterized by tremor, rigidity and postural instability) unspecified tremors and high blood pressure. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/24, showed: -Cognitively intact; -No rejection of care; -Required partial/moderate assistance with eating; -Dependent on staff for all personal hygiene; -Diagnoses included urinary tract infection (UTI), and diabetes; -Height: 74 inches -Weight: 176 pounds. Review of the resident's care plan, in use during the time of the investigation, last revised on 8/22/24, showed: -Diagnoses included Parkinson's disease, unspecified tremors and diabetes; -No information regarding the resident's ADLs. Observation and interview on 8/22/24 at approximately 2:44 P.M., showed the resident lay in bed on his/her back with a hospital gown on. The resident's hospital gown, arms, hands and bed sheets had several red and pink spots. The resident said he/she had cake earlier that day and no one assisted him/her with eating or cleaning up afterwards. Staff never assisted the resident. The only time the resident received assistance with food or cleaning, his/her spouse and adult child would have to assist. Observation on 8/23/24 at 8:16 A.M., showed the resident lay in bed on his/her back. The resident had on the same hospital gown covered in what the resident described as cake. Red splotches remained on the bed sheets and the resident's arms. The resident's call light was on the floor next to the bed. Observation and interview on 8/23/24 at 9:02 A.M., showed the resident sat up in bed assisted and was assisted by his/her spouse who fed the resident. The resident had on the same hospital gown with the red and pink splotches. The resident's arm and bed sheets also showed pink and red splotches. The resident's spouse said he/she arrived and the resident was thirsty and hungry. His/Her bedding, gown and clothing was dirty and covered with red and pink splotches. The resident said his/her call light was out of reach and he/she kept yelling out for someone to change him/her during the late night and early morning. He/She yelled for an hour straight and no one came to check on him/her. The resident's spouse said he/she would feed the resident and clean him/her up. Observation on 8/26/24 at 4:53 A.M., showed the resident lay in bed on his/her back with his/her eyes closed. A handwritten sign said please assist me with meals hung at the door and on the wall of the resident's room. Observation on 8/26/24 at 8:47 A.M., showed the resident lay in bed on his/her back. The resident's covered breakfast tray was on the night stand. The resident opened his/her eyes and said he/she was hungry. The resident's breakfast meal consisted of biscuits and gravy, oatmeal, juice and water. He/She said he/she was hoping someone would feed him/her. The resident's hands were shaking. Observation on 8/26/24 at 9:01 P.M., showed the resident's tray of food was removed. He/she said staff came and took the tray and did not offer to feed him/her. He/She did not receive any assistance with breakfast and was still hungry. Observation and interview on 8/26/24 at 2:01 P.M., showed Certified Nursing Assistant (CNA) L stood over the resident and fed him/her lunch. When asked about the resident's breakfast tray, CNA L at first said he/she thought he/she fed the resident. The resident said, No, you came and took my food away. CNA L then said, Didn't your son/daughter feed you? The resident said No and they did not visit with him/her today. CNA L then said the resident had not had any breakfast. Observation and interview on 8/27/24 at 10:13 A.M., showed the resident lay in bed and smelled of feces. His/Her spouse was present and said they pushed the call light about 10 minutes ago and was waiting for someone to change the resident. When the spouse arrived that morning, the resident's breakfast tray was untouched. The spouse placed signs throughout the resident's room to remind staff to feed the resident. CNA B and CNA K, who were not assigned to the resident, said they would change the resident. During an interview on 8/27/24 at 10:34 A.M., CNA B said he/she was familiar with the resident and he/she needed total assistance with meals. The resident's hands shook and he/she would not be able to feed him/herself. During an interview on 8/28/24 at 9:08 A.M., CNA N said he/she was familiar with the resident and he/she definitely needed total assistance with meals due to his/her hand shaking. During an interview on 8/28/24 at 2:46 P.M., Licensed Practical Nurse (LPN) A said if residents needed assistance with ADLs, including meal assistance, staff was required to assist with meals. CNAs should feed the residents. If a resident was dirty and the bedding was dirty, staff were to ensure the resident was clean and had clean bedding. During an interview on 8/28/24 at 4:36 P.M., the Administrator and Director of Nursing (DON) said residents should be assisted with grooming and meals. It was unacceptable to leave the resident laying with cake on his/her hospital gown and bedding. The resident should have been assisted with his/her meal. 2. Review of Resident #79's care plan, in use during the time of the survey, revised 4/26/24, showed: -Focus: Activity's of daily living assistance needed to maintain or attain highest level of functioning; -Goal: Resident wishes to attain prior level of functioning; -Interventions: Assist with mobility and activity's of daily living as needed; -Focus: The resident is at risk for break in skin integrity related to ulcers and immobility; -Goal: Maintain intact skin with no skin breaks through the next review; -Interventions: Clean and dry skin after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Required supervision and/or touching assistance with toileting hygiene; -Diagnoses included anemia, neurogenic bladder, UTI, seizures and depression. During an interview on 8/26/24 at approximately 5:20 A.M., CNA I was not aware the resident was assigned to him/her. The resident was not checked during the night shift until after this interview. Observation on 8/26/24 at 5:24 A.M., CNAs F and I entered the resident's room to provide personal care. CNA I said they were going to do a complete bed-change because the resident was soaked. He/She said the resident usually used a urinal during the night but last night he/she did not. The pad under the resident was saturated with urine and the sheet under the pad had a ring on it and was wet down to the resident's knees. During an interview on 8/28/24 at 4:36 P.M., the Administrator and DON said residents were to be checked regularly and would expect ADLs to be carried out. 3. Review of Resident #50's annual MDS, dated [DATE] showed; -Cognitively moderately impaired; -Upper/lower extremities: No impairment; -Eating: Dependant-staff does all of the effort. Resident does none of the effort to complete the activity; -Diagnoses included kidney failure, dementia, arthritis, malnutrition and depression. Review of the resident's physician's orders, showed: -An order dated 7/31/24, for a 2 Calorie Med Pass Supplement (a fortified nutritional shake, adding calories and protein to the diet); -An order dated 7/13/24 for a Regular diet, Regular texture, Thin consistency. Review of the Registered Dietician's (RD) progress note, date 8/1/2024 at 1:21 P.M., showed RD was stopped by resident's roommate. Roommate let RD know the resident may need some assistance during meal times. RD spoke with resident who confirmed he/she needs help. Resident's hands are contracted and this makes it difficult for the resident to feed himself/herself. Resident hesitant on wanting help, but admits he/she needs it. RD empathized with resident and provided support. Also encouraged resident to eat in the dining room more often as well. Spoke with interim DON about issue. Recommend having staff assist resident during meal times to ensure he/she is able to eat and receive adequate nutrition. Resident has gained weight recently but body mass index (BMI, is a calculation that estimates body fat percentage, by comparing a person's weight to their height. A BMI under 18.5 is described as underweight. Between 18.5 and 24.9 defined as a healthy range. Between 25 and 29.9, is considered overweight, and between 30 and 39.9 , described as obesity), still only 20.1, Med pass, twice a day was ordered on 7/31/24. Observation on 8/27/24 at 9:15 A.M., and at 1:30 P.M., showed the resident in his/her room, seated on his/her bed with a meal tray on his/her bedside table. He/She slowly moved his/her utensil to his/her food, then to his/her mouth. The resident ate his/her meal without assistance. Observation and interview on 8/28/24 at 1:18 P.M., showed the resident in his/her room, seated on his/her bed. CNA P entered the resident's room with the resident's meal tray and placed the tray on the resident's bedside table. CNA P exited the room. The resident began attempting to eat his/her lunch. CNA P entered the room again, removed the tray from the resident's bedside table, and sat the tray on a chair at the foot of his/her bed. CNA P said he/she removed the tray because the resident ate slowly and he/she wanted to be able to help him/her eat, then exited the room. The resident's roommate walked over to the resident's tray, removed the pudding, and sat the pudding on the resident's bedside table. The resident said he/she was hungry and started eating his/her pudding, slowly moving the spoon to the pudding and then to his/her mouth, without assistance. Observation on 8/28/24 at 1:30 P.M., showed the resident in his/her room, seated on his/her bed. A meal tray was placed on his/her bedside table. The resident ate his/her meal without assistance. During an interview on 8/28/24 at 12:16 P.M., the RD said she expected staff to provide meal assistance when needed. A CNA should be assisting the resident with his/her meals. During an interview on 8/28/24 at 4:37 P.M., the Administrator said she expected staff to provide ADL care, including feeding assistance when needed. MO00240295

37681 42247 Based on observation, interview and record review, the facility failed to provide an on-going activity program based on resident preferences to support residents in their choice of activities and meet the needs of residents. The resident council meeting participants reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program for eight of 18 sampled residents (Residents #54, #26, #50, #62, #44, #55, #22 and #36). The census was 78. Review of the facility's Therapeutic Activities Program, dated reviewed 9/21/23, showed: -Activities -refers to any endeavor, other than routine activities of daily living (ADLs), in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence; -Program scheduling: -It is important for residents to have a choice about which activities they participate in, whether they are part of the formal activities program or self-directed. Additionally, a resident's needs and choices for how he or she spends time, both inside and outside the facility, should also be supported and accommodated, to the extent possible, including making transportation arrangements; -Individual or independent programming ensures that all residents who are unable or unwilling to participate in group programs have consistent, goal-oriented, and individualized recreation opportunities. All residents have a need for engagement in meaningful activities; -Residents who prefer not to participate in group programs and/or are independently involved in recreation pursuits will be identified through the assessment process: -Individual interventions will be developed based on each resident's assessed needs and the family will be notified for any special requests; -Each resident's individual program will include interventions that meet the resident's assessed social, emotional, physical, spiritual, and cognitive functioning needs. These approaches will reflect the resident's lifestyle and interests and will be incorporated into the interdisciplinary care plan; -Group programming ensures each resident the opportunity for active participation in group programming designed to accommodate his or her social and/or cognitive abilities and to promote quality of life. Review of the facility's August 2024 Activity's calendar, showed: -8/1/24 Coffee and Chat at 9:00 A.M. in the activity room, Price is Right in activity room at 10:00 A.M. and Pretty Nails in the activity room at 2:00 P.M. -8/2/24 Coffee and Chat at 9:00 A.M. in the activity room, Price is Right in activity room and movies in the activity room; -8/3/24 Coffee and Chat at 9:00 A.M. in the activity room, Price is Right in activity room at 10:00 A.M. and Pretty Nails in the activity room at 2:00 P.M.; -8/4/24, 8/11/24, 8/18/24 and 8/25/24 Jazz with breakfast at 7:30 A.M., Worship Services at 10:30 A.M. and puzzles and games all day; -8/5/24, 8/12/24, 8/19/24 and 8/26/24,Coffee and chat at 9:00 A.M., Price is Right at 10:00 P.M., Social hour from 2:00 P.M. to 5:00 P.M.; -8/6/24, 8/13/24, 8/20/24, and 8/27/24 Jazz with breakfast at 7:30 A.M., Catholic Services at 10:30 A.M. and social hour at 2:00 P.M.; -8/7/24, 8/14/24 and 8/21/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M. on 8/7 and 8/21, Movie at 2:00 P.M.; -8/8/24, 8/15/24 and 8/22/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M. and social hour at 2:00 P.M.; -8/9/24 and 8/24/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M. and Pretty nails on 2:00 P.M.; -8/10/24, 8/16/24, 8/30/24 and 8/31/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M., and Craft with [NAME] at 2:00 P.M.; -8/23/24, coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M. and Social hour at 2:00 P.M.; -8/28/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M., and Craft with [NAME] at 2:00 P.M.; -8/29/24 Coffee and chat at 9:00 A.M., Price is Right at 10:00 A.M. and Pretty nails on 2:00 P.M. Review of the facility's resident council minutes, dated 8/8/24, showed eight residents attended the Resident Council meeting. The residents requested more outings and entertainment. Residents would like to have activities outside of the facility. 1. Observations on all days of the survey on 8/22 and 8/23/24 and 8/26 through 8/28/24, showed no activities taking place. 2. During a group interview on 8/23/24 at 9:33 A.M., five residents, who the facility identified as alert and oriented, attended the group meeting. All five residents said no activities had taken place in about three weeks. They were also to stay in their rooms because of a COVID outbreak. Prior to the COVID outbreak, they were still limited in the activities and expressed this to facility staff. 3. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/24 showed; -Cognitively intact; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. Review of the resident's Activities Assessment, dated 11/7/23, showed: -Interest in life/activities: Very interested; -Type: Large group, small group, one on one: Very important. Review of the resident's care plan, in use during the survey, showed: -Focus: Participates in activities of choice through computer, word searches, reading and his/her favorite television programs; -Goals: Staff will assist with activities of choice through next review; -Interventions: Staff will assist with resident's preferred activities which include computer, watching television, word searches and favorite television programs. Observation and interview on 8/22/24 at 5:11 P.M., showed the resident sat on his/her bed in his/her room. The resident said there had not been any activities in a while. The only activities the resident did was watch television. 4. Review of Resident #26's quarterly MDS, dated [DATE], showed; -Cognitively intact; -Diagnoses included heart failure, high blood pressure, respiratory failure and diabetes. Review of the resident's care plan, in use during the survey, showed: -Focus: At risk for alteration in psychosocial well-being due to isolation/quarantine related to COVID-19; -Goal: The resident will have no indications of psychosocial well-being problem while in quarantine/isolation; -Interventions: Provide resident with in room activities. Observation and interview on 8/22/24 at 5:15 P.M., showed the resident sat on his/her bed in his/her room. The resident said there had not been any activities in a while. The only things the resident and his/her roommate had been doing was watching television and reading. 5. Review of Resident #50's MDS, dated [DATE], showed; -Cognitively moderately impaired; -Diagnoses included kidney failure, dementia, arthritis, malnutrition and depression. Review of the resident's Activities Evaluation, dated 7/25/24, showed: -Activities preferences: Bingo and Cards; -Type: One on one, small group: Somewhat important. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident participates in activities of choice through watching favorite television programs, religious services, current event programs, news programs, music, movies and friends and family visits; -Goal: Staff will assist resident with activities of choice through next review; -Interventions: Staff will assist with getting resident to preferred activities, including favorite television programs, religious services, current event programs, news programs, music, movies and friends and family visits; -Focus: The resident is dependent on staff for meeting physical and social needs due to cognitive deficits; -Goal: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date; -Interventions: Invite the resident to scheduled activities, thank resident for attendance at activity function. The resident needs assistance/escort with all activity functions; -Focus: Resident has COVID + alteration in psychosocial well-being due to isolation/quarantine related to COVID-19 visitation/restrictions; -Goal: The resident will have no indications of psychosocial well-being problems while in quarantine/isolation; -Interventions: Provide resident with in room activities. During an interview on 8/28/24 at 10:00 A.M., the resident said he/she could not remember when the last activities were provided by staff. 6. Review of Resident #62's quarterly MDS, dated [DATE] showed; -Cognitively intact; -Diagnoses included heart disease, kidney failure, anxiety and depression. Review of the resident's care plan, in use during the survey, showed: -Focus: At risk for alteration in psychosocial well-being due to isolation/quarantine related to COVID-19; -Goal: The resident will have no indications of psychosocial well-being problems while in quarantine/isolation; -Interventions: Provide resident with in room activities. Observation and interview on 8/26/24 8:43 A.M., showed the resident in his/her room, seated on his/her bed. He/she said he/she was unaware of any activities going on this month. 7. Review of Resident #44's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: heart failure, high blood pressure, diabetes, and thyroid disorder; -How important is it to you: -If you have books, newspapers, and magazines to read? Somewhat; -Listen to music you like? Somewhat; -Be around animals such as pets? Somewhat; -Keep up with the news? Somewhat; -To do things with group of people you like? Somewhat; -To do your favorite activities? Somewhat; -Go outside to get fresh air when the weather is good? Somewhat; -To participate in religious services or practices? Somewhat. Review of the Activity Evaluation dated 7/24/24, showed: Activity pursuit patterns and preferences: reading. Review of the care plan in use at the time of survey, showed: -Focus: resident was at risk for alteration in psychosocial well-being due to isolation/quarantine related to: COVID-19 restrictions or other reason for isolation/quarantine; -Goal: The resident will have no indications of psychosocial well-being problem while in quarantine/isolation; -Intervention included: provide resident within room activities. Observation and interview on 8/26/24 at 8:50 A.M., showed the resident lay in bed watching TV and said the facility had not had activities since Covid. No one had offered in room activities. He/She would like to do crossword puzzles or word search. Observation on 8/27/24 at 8:21 A.M., showed the resident lay in bed watching TV. During an interview on 8/28/24 at 12:53 A.M., Licensed Practical Nurse (LPN) D said the resident participated in activities. He/She participated in Resident Council and lots of stuff. During an interview on 8/28/24 at 2:00 P.M., Certified Nurse Aide (CNA) B said the resident did not participate in activities. The resident did what he/she wanted to do and he/she participated in activities. 8. Review of Resident #55's annual MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: high blood pressure, arthritis, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves); -How important is it to you: -If you have books, newspapers, and magazines to read? Very important; -Listen to music you like? Very important; -Be around animals such as pets? Very important; -Keep up with the news? Very important; -To do things with group of people you like. Very important; -To do your favorite activities? Very important; -Go outside to get fresh air when the weather is good? Very important; -To participate in religious services or practices? Very important. Review of the resident's care plan in use at the time of survey, showed: -Focus: resident participates in activities of choice through religious services/studies Resident Council music, TV programs, bingo, family, and friends visit, dominoes, cards, and board games; -Goal: Staff will assist resident with his/her activities of choice through next review; -Interventions: Staff will assist resident with activities of choice which include religious services/studies Resident Council, music, TV programs, bingo, family and friends visit, dominoes, cards, and board games. Review of the resident's Activity Evaluation, dated 5/30/24, showed; -Activity pursuit patterns and preferences: bingo, board games, cards, music, television; -Other preferences: frequency of activities, daily. Observation and interview on 8/22/24 at 1:34 P.M., showed the resident sat in his/her room watching TV. He/She said there were no activities because the residents on one unit had Covid. Observation on 8/23/24 at 7:44 A.M., showed the resident watched TV in his/her room. During an interview on 8/27/24 at 8:48 A.M., the resident said the staff told him/her to stay in his/her room because the facility had COVID on another unit. The facility did not offer in room activities. He/She would like a puzzle or to play cards. 9. Review of Resident #22's Activities Evaluation, dated 5/20/22, showed: Finds strength in faith, family/friend visits, music and religious services. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -No behaviors; -Diagnoses included diabetes, stroke, hemiplegic, dementia and malnutrition. Review of the resident's care plan, revised 5/10/24, in use during the time of the investigation, showed: -Focus: Resident will participate in activities of choice through family and friend visits, music, religious services and favorite television programs; -Goal: Staff will assist resident with activities of choice; -Interventions: Staff will assist resident with getting to his preferred activities such as family visits, music and religious services. During an interview on 8/22/24 at approximately 3:00 P.M., the resident said things were going okay at the facility. They didn't provide activities, but if they did, he/she would participate. 10. Review of Resident #36's admission MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Diagnoses included Urinary Tract Infection (UTI) and diabetes. Review of the resident's Activities Evaluation, dated 7/18/24, showed: -Likes activities. Pets, movies important; -One to one activities preferred. Review of the resident's care plan, last revised 8/22/24, in use during the time of the investigation, showed no information regarding the resident's activities of choice. During an interview on 8/22/24 at approximately 2:45 P.M., the resident said he/she had not participated in activities and staff had not offered activities or one on one visits. He/She would like to participate in activities if it was offered. 11. During an interview on 8/28/24 at 1:38 P.M., CNA B said the residents were not receiving activities. He/She was unsure why. The residents had complained because of a lack of activities. He/She had not seen any activities take place for at least a month. During an interview on 8/28/24 at 2:04 P.M., CNA S said residents were not receiving activities and had complained about it. 12. During an interview on 8/28/24 at 10:10 A.M., the Activity's Director (AD) said all activities were suspended after the COVID outbreak. She said it had been about three weeks. Prior to the outbreak, residents came to the activity room and watched Price is Right and drank coffee. She had an assistant who was supposed to conduct room visits and one on one activities, but the assistant was out with COVID. The AD said she completed some activities recently, but had no documentation. 13. During an interview on 8/28/24 at 4:36 P.M., the Administrator and Director of Nurses (DON) said they would expect residents to receive activities, even during a COVID outbreak. The activities should have been documented. The facility had a full-time AD and an assistant. The Administrator would expect the facility to provide activities and provide in room activities.

Based on observation, interview and record review, the facility failed to ensure physicians' orders for respiratory evaluation and treatments were followed for five residents out of 18 sampled residents (Residents #50, #62, #31, #14, and #44). The facility census was 78. Review of the facility policy binder, showed no policies regarding respiratory illness/infections. 1. Review of Resident #50's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/24 showed; -Cognitively moderately impaired; -Diagnoses included kidney failure, dementia, arthritis, malnutrition and depression. Review of the resident's nurse's progress notes, showed on 8/12/24 at 3:55 P.M., the resident was diagnosed positive for COVID-19, respiratory precautions in place. Review of the resident's physician's orders, showed: An order, dated 8/15/24, for Respiratory Evaluation and Treatment as indicated. Complete Respiratory assessment under assessment Tab. Contact Family, Primary Care Physician (PCP), Director of Nursing (DON), and document abnormal finding every shift for COVID, may discontinue (d/c) when facility is out of outbreak. Review of the resident's care plan, in use during the survey, showed: -Focus: At risk for respiratory illness due to exposure to COVID-19; -Goal: The resident will not experience complications requiring hospitalization while in quarantine; -Interventions: Educate the resident on the need and purpose of the quarantine period. Monitor for change in condition and notify practitioner of findings. Perform respiratory assessment on an ongoing basis while in quarantine. Place resident in an appropriate room to reduce exposure risk to self or others. Review of the resident's respiratory evaluations, dated 8/15/24 through 8/26/24, showed 15 out of 30 evaluation opportunities were not completed. 2. Review of Resident #62's quarterly MDS, dated [DATE] showed; -Cognitively intact; -Diagnoses included heart disease, kidney failure, anxiety and depression. Review of the resident's nurse's progress notes, showed on 8/12/24 at 3:56 P.M., the resident was diagnosed positive for COVID-19, respiratory precautions in place. Review of the resident's physician's orders, showed: An order, dated 8/15/24, for Respiratory Evaluation and Treatment as indicated. Respiratory Evaluation, and Treatment as indicated. Complete Respiratory assessment under assessment Tab. Contact Family, PCP, DON, and document abnormal finding every shift for COVID, may discontinue (d/c) when facility is out of outbreak. Review of the resident's care plan, in use during the survey, showed: -Focus: At risk for respiratory illness due to exposure to COVID-19; -Goal: The resident will not experience complications requiring hospitalization while in quarantine; -Interventions: Educate the resident on the need and purpose of the quarantine period. Monitor for change in condition and notify practitioner of findings. Perform respiratory assessment on an ongoing basis while in quarantine. Place resident in an appropriate room to reduce exposure risk to self or others. Review of the resident's respiratory evaluations, dated 8/15/24 through 8/26/24, showed 21 out of 30 evaluation opportunities were not completed. 3. Review of Resident #31's medical record, showed: -Cognitively intact; -Diagnoses included: COVID-19. Review of the care plan, in use at the time of survey, showed: -Focus: resident has a respiratory infection related to COVID positive; -Goal: the resident's symptoms will resolve without hospitalization ; -Interventions included: observe and notify the physician if the resident experiences increased respiratory distress such as shortness of breath or low oxygen saturation. Review of the physician order report, dated 8/27/24, showed: An order for: respiratory evaluation and treatment as indicated. Complete respiratory assessment under assessment Tab. Contact Family, PCP, DON, and document abnormal finding every shift for COVID, may discontinue (d/c) when facility is out of outbreak. The start date was 8/15/24. Review of the resident's respiratory evaluations, dated 8/15/24 through 8/26/24, showed 19 out of 30 evaluation opportunities were not completed. 4. Review of Resident #14's medical record, showed: -Moderately impaired cognition; -Diagnoses included: COVID-19. Review of the care plan, in use at the time of survey, showed: -Focus: resident is at risk for respiratory infection related to positive COVID test; -Goal: resident will experience no complications requiring hospitalization s; -Interventions: observe and notify physician if the resident experiences fever, cough, low oxygen saturation and shortness of breath. Review of the order summary sheet, dated 8/23/24, showed: An order for Respiratory Evaluation and Treatment as indicated. Complete respiratory assessment under assessment tab. Contact family, PCP, DON, and document abnormal finding, every shift for COVID, may discontinue when facility is out of outbreak. The start date was 8/15/24. Review of the resident's respiratory evaluations dated 8/15/24 through 8/26/24, showed 19 out of 30 evaluation opportunities were not completed. 5. Review of Resident #44's medical record, showed: -Moderately impaired cognition; -Diagnoses included: COVID-19. Review of the care plan, in use at the time of survey, showed: -Focus: At risk for respiratory exacerbation related to COVID 19. Symptoms sneezing, runny nose, watery eyes; -Goal: the resident will not experience complications requiring hospitalization s while in quarantine; -Interventions: monitor for change in condition and notify practitioner of finding. Review of the physician's order sheet, dated 8/26/24, showed: An order for Respiratory Evaluation, and Treatment as indicated. Complete respiratory assessment under assessment tab. Contact family, PCP, DON, and document abnormal finding, every shift for COVID, may discontinue when facility is out of outbreak. The start date was 8/15/24. Review of the resident's respiratory evaluations dated 8/15/24 through 8/24/24 showed 13 out of 27 evaluation opportunities were not completed. 6. During an interview on 8/28/24 at 12:53 P.M., Licensed Practical Nurse (LPN) D said all residents in the facility were currently getting a respiratory assessment completed every shift and documented under the respiratory assessments tab. The assessments consisted of assessing the residents for signs and symptoms of COVID, such as headaches, body aches and cold symptoms, and checking vital signs and oxygen saturation. 7. During an interview on 8/28/24 at 1:33 P.M. LPN A said the nurses were responsible for completing the respiratory assessments. The assessments were completed daily until the order ends and are documented on the Medication Administration Record. 8. During an interview on 8/28/24 at 4:36 P.M., the Administrator said she expected staff to follow the physician's orders and she would expect the respiratory assessments to be completed. 42247

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 33 opportunities, for errors, four errors occurred, resulting in a 12.12% medication error rate (Residents #242, #30, #23 and #29). The census was 78. Review of the facility's Administration of Medication Policy, dated 8/24/23, showed: -Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: -Right Drug: every drug administered must have an order from the provider. Compare the order with the Medication Administration Record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times: -Before removing the container from the drawer; -As the drug is removed from the container, and; -At the bedside before administering it to the resident; -Right Dose: check the MAR and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering; -A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication. Review of the information provided by the facility, titled Insulin Pen Use, undated, showed: -An insulin pen looks like a writing pen, contains an insulin reservoir, and has a dial or knob for setting the dose and a button at the back for injecting the dose. A disposable needle must be attached to the pen for each use; -Insulin preparation: -Remove the pen cap and attach the needle to the pen according to the manufacturer's instructions; -Prime the pen: hold the pen vertically with the needle pointing up, dial one or two units on the dosage knob, and presses the injection button several times until a drop of insulin appears at the tip of the needle. Unless otherwise directed by the manufacturer; -Dial the dosage knob to the correct dose. Review of the facility's Infusion Therapy-Intravenous (IV Fluids) Policy, dated revised 8/8/2023, showed: -Policy: The facility assures that each resident receives care and services for the provision of parenteral fluids consistent with professional standards of practice in order to provide safe administration of parenteral fluids by qualified, competent, and trained staff in accordance with state laws/practice acts; -The policy did not show how to or when to flush the line. 1. Review of Resident #242's medical record, showed: -Alert and able to make needs known; -Diagnosis of endocarditis (a life-threatening inflammation of the inner lining of the hearts chambers and valves). Review of the care plan, in use at the time of survey, showed: -Focus: Infection endocarditis; -Goal: Infection will resolve by review date; -Interventions included medications as ordered. Review of the physician's order summary, dated 8/23/24, showed: -An order for: IV: blood draw, flush with 10 milliliters (ml) normal saline (NS) before blood draw. Discard 5 ml blood, then draw for labs. Flush with 20 ml NS after blood draw *If non-valved catheter follow with Heparin (blood thinner) 10 units/ml as needed for blood draws; -There were no other orders to flush the peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein in the upper chest) line. Observation on 8/23/24 at 8:18 A.M., showed a staff member told Licensed Practical Nurse (LPN) J a resident needed to be stopped. LPN J said he/she needed to stop the residents IV, the night nurse hung it and he/she needed to disconnect it. LPN J entered the resident's room, the resident was resting on top of the bed, there was no IV infusing. LPN J asked the resident who stopped his/her IV. The resident said the other nurse stopped; the night nurse stopped it. LPN J flushed the PICC line with 10 ml of NS and 5 ml of heparin. LPN J said he/she would not know if the night nurse flushed the PICC line or not. LPN J went back to the staff member to verify which resident needed to be stopped. The staff member said it was another resident's feeding tube that needed to be stopped. During an interview on 8/23/24 at 8:46 A.M., the resident said the night nurse flushed his/her PICC line when they stopped the IV pump. 2. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 8/2/24, showed: -Cognitively intact; -Diagnosis of diabetes. Review of the physician order summary, dated 8/23/24, showed: -An order for: Lantus (long-acting insulin) 100 unit/mL, inject 30 unit subcutaneously (under the skin) in the morning for diabetic. Observation on 8/23/24 at 7:20 A.M., showed Licensed Practical Nurse (LPN) E removed the Lantus insulin pen from the top drawer of the cart, put a needle on the end of the insulin pen, turned the dial to 30 and administered the insulin; -The LPN did not prime the insulin pen. 3. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes. Review of the physician order summary, dated 8/23/24, showed: -An order for: Basaglar Kwik pen (long-acting insulin) 100 unit/mL, inject 30 unit subcutaneously in the morning related to diabetes; Observation on 8/23/24 at 7:35 A.M., showed LPN E removed the Basaglar insulin pen from the top drawer of the cart, put a needle on the end of the insulin pen, turned the dial to 30 and administered the insulin; -The LPN did not prime the insulin pen. 4. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: chronic obstructive pulmonary disease (COPD, lung disease), high blood pressure and coronary artery disease (CAD, plaque buildup in the wall of the arteries that supply blood to the heart). Review of the physician order summary, dated 8/23/24, showed: -An order for bumex (water pill) 2 milligrams (mg), give 2 mg one time a day related to COPD. Observation on 8/23/24 at 7:46 A.M., showed LPN J pulled the card of bumex 2 mg out of the drawer and punched two tablets of 2 mg (total of four mg) and administered to the resident. 5. During an interview on 8/23/24 at 1:54 P.M., LPN J said when he/she administered insulin he/she would put the needle on the insulin pen and turn the dial to the dose of insulin and administer it. IV lines are flushed before and after the antibiotic. He/She would flush with whatever was ordered. There should be a physician order to flush the IV. 6. During an interview on 8/23/24 at 2:05 P.M., LPN D said if the medication was 2 mg and the order said to administer 2 mg, he/she would give one tablet. Insulin should be primed with two units before turning the dial to the dose order. IV lines should have a physician order to flush them. The order will include how often to flush and what to flush with. 7. During an interview on 8/23/24 at 2:15 P.M., the Director of Nursing (DON) said she expected staff to follow the five rights when administering medications (right patient, right drug, right time, right dose, and right route) and she expected staff to follow the physician's orders. If a medication was 2 mg and the order said to administer 2 mg, staff should administer one pill. Insulin pens only need to be primed when they are first started. IV lines should have a physician's order for when to flush them. Heparin should never be given without a physician order. 8. During an interview on 8/28/24 at 4:36 P.M., the Administrator said she expected medications to be administered per physician orders and she expected staff to follow the facility's policy and procedures. MO00240295 MO00236848 MO00232662

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, medical device care or use, and wound care) with residents on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (an umbrella term for bacteria and other microorganisms that are resistant to antibiotics and other drugs designed to kill them) that employs targeted gown and glove use during high contact resident care activities) for five residents (Residents #79, #74, #19, #242 and #36). Furthermore, the facility failed to follow their incontinent care policy when staff provided perineal area care (cleansing between the legs and buttocks area) for three residents (Resident #79, 74, and #19). In addition, the facility failed to follow their Tuberculosis (TB, serious illness that mainly affects the lungs) policy for employees for six out of ten employees sampled. These failures had the potential to affect all residents in the facility. The sample was 18. The census was 78. Review of the facility's Enhanced Barrier Precautions Policy, reviewed on 6/3/24, showed: -EBP are indicated for residents with any of the following: -Wounds and/or indwelling (left inside the body) medical devices even if the resident is not known to be infected or colonized (germs on the body but do not make you sick) with a multidrug-resistant organism (MDRO, a bacterial infection that is resistant to multiple antibiotics, making it difficult to treat); -Wounds generally include chronic wounds; Examples of chronic wounds include, but are not limited to, pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers (ulcers caused by decrease in blood circulation); -Indwelling medical device examples include central lines (a long, flexible tube that's inserted into a vein near the heart); -Procedure: -The facility should develop a process to communicate which residents require the use of EBP for all high-contact resident care activities. The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on EBP; -Examples of high-contact resident care activities requiring gown and glove use include: -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter (drains urine from the bladder into a bag outside the body) and feeding tube (surgically inserted through the stomach wall and into the stomach to provide nutritional support); -Wound care: any skin opening requiring a dressing. Review of the EBP sign, undated, showed: -Everyone must clean their hands before entering and before leaving the room; -Providers and staff must also: wear gown and gloves for the following high contact resident care activities: -Bathing/showering; -Transfers; -Changing linens; -Providing hygiene; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter and feeding tube. Review of the facility's Hand Hygiene Policy, revised 6/30/24, showed: Associates perform hand hygiene (hand washing, antiseptic hand wash and alcohol-based rub) (even if gloves are used) in the following situations: -Before and after contact with the resident; -After contact with body fluids; -After removing PPE (e.g., gloves, gown, eye protection, facemask). Review of the facility's Perineal Care of the Female Patient Policy, undated, showed: -Introduction: Perineal care, which includes care of the external genitalia and the anal area, should occur during the daily bath and if the patient is incontinent of urine or stool. The procedure promotes cleanliness and prevents infection; -Implementation: perform hand hygiene; put on gloves and as needed, other personal protective equipment to comply with standard precautions. -Using a washcloth: -Wet a washcloth with warm water from a running spigot (or from a clean and disinfected bath basin) and apply mild soap; -Separate the patient's labia with one hand; -Using gentle downward strokes, clean the perineal area from the front to the back; -Wet a clean washcloth and rinse thoroughly from front to back; -Pat the area dry with a bath towel; -Turn the patient onto the side, to expose the anal area; -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back; -Using disposable cloth: -Open the package and remove a wet cloth; -Separate the patient's labia with one hand; -Using gentle downward strokes, clean from the front to the back of the perineum; -Turn the patient onto the side, to expose the anal area; -Using a new cloth, clean the anal area, starting at the posterior vaginal opening and wiping from front to back; -Completing the procedure; -After cleaning the perineum, perform hand hygiene, apply new gloves, apply a moisture-barrier skin protectant as needed; -Discard soiled articles in the appropriate receptacle; -Remove and discard your gloves and, if worn, other personal protective equipment; -Perform hand hygiene. Review of the Perineal Care of the Male Patient Policy, undated, showed: -Introduction: Perineal care, which includes care of the external genitalia and the anal area, should occur during the daily bath and after urination and bowel movements in cases of incontinence. The procedure promotes cleanliness and prevents infection; -Implementation: perform hand hygiene; put on gloves and as necessary, other personal protective equipment to comply with standard precautions; -Wet the washcloth with warm water from a running spigot (or from a clean, disinfected bath basin) and apply mild soap; -Hold the shaft of the penis with one hand; -Wash the penis with the washcloth, beginning at the tip and working in a circular motion from the center to the periphery (outer edge); -Wet a clean washcloth and rinse the area thoroughly, using the same circular motion; -Wash the rest of the penis, using downward strokes toward the scrotum. If appropriate, rinse well and pat dry with a towel; -Clean the top and sides of the scrotum; if appropriate, rinse thoroughly and pat dry; -Turn the patient onto the side, if possible, to expose the anal area; -Clean the bottom of the scrotum and the anal area. If appropriate, rinse well and pat dry; -Using disposable cleaning cloths: -Open the package and remove a wet cloth; -Hold the shaft of the penis with one hand, use the other hand to clean the urethral meatus with the cloth; -clean the penis with the cloth, beginning at the tip and working in a circular motion from the center to the periphery; -Using downward strokes toward the scrotum, clean the rest of the penis; -Clean the top and sides of the scrotum; -Turn the patient onto the side, if possible, to expose the anal area; -Clean the bottom of the scrotum and the anal area; -After cleaning the perineum, perform hand hygiene, apply new gloves, apply a moisture-barrier skin protectant, as necessary. Review of the facility's Tuberculosis- Testing and Screening (Associates, and Volunteers) Policy, dated revised: 6/28/2024, showed: -Missouri facilities should follow state regulation l9 CSR 20-20.100 that indicates that screening of residents on admission, and pre-employment and annual testing of associates and volunteers who work 10 hours or more per week; - All associates (and volunteers) are screened and tested for tuberculosis at the time of hire (baseline testing); - New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures: pre-placement risk assessment and symptom evaluation. The facility should use the Individual TB risk assessment and symptom screening tool for non-residents unless a state tool is mandated; -The facility should also perform skin test for Mycobacterium (M, causative agent of TB). Tuberculosis using the Mantoux skin test (TST, a skin test to determine if someone has latent TB). Skin testing will employ the two-step procedure. (If the reaction to the first test is less than 10 millimeters (mm) induration (bump), a second test will be given 1-3 weeks later); -Individuals with a documented history of a positive TST will not undergo skin testing. They will, however, be required to bring documentation from their private physician or the local health department of their work-up following conversion (i.e., chest x-ray report). Employment may begin only after documentation attesting to the non-infectious nature of the associate has been received; -Individuals with documented history of a negative TST performed within the last 12 months need to receive only 1 intradermal injection (between the layers of skin) of Purified Protein Derivative (PPD). (NOTE: In this instance, the prior skin test serves as the first step of a two-step procedure); -Individuals with no documented history of a TST skin test within the last 12 months will undergo the two-step procedure. 1. Review of Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 4/30/24, showed: -Cognitively intact; -Occasionally incontinent of urine. Review of the care plan in use at the time of survey, showed: -Focus: The resident has indwelling catheter related to diagnosis of neuropathic bladder (lacks bladder control due to brain, spinal cord, or nerve problem); -Goal: Will have no complications related to indwelling catheter use; -Interventions: EBP. Review of the physician's order summary, dated 8/28/24, showed, an order for EBP, diagnosis: Indwelling catheter, start date was 6/15/24. Observation on 8/26/24 at 5:24 A.M., showed a sign on the door for EBP. Certified Nurse aide (CNA) F and CNA I entered the resident's room wearing a face mask, performed hand hygiene and put gloves on. CNA I said the resident usually used a urinal during the night but last night he/she did not. The resident would need a complete bed change. CNA F used a washcloth and cleaned the resident's front peri area in a circular motion, then CNA F wrung the washcloth out over the resident's front perineal area. He/She then used disposable wet wipes to finish cleaning the area. CNA F used the same gloves and one washcloth to wash the resident's upper body and face. Neither CNA wore a gown while providing care to the resident and did not change gloves between dirty and clean. 2. Review of Resident #74's admission MDS, dated [DATE], showed: -Should brief interview for mental status be conducted? No; -Had short- and long-term memory problem; -Diagnoses included: gastrostomy tube (g-tube, feeding tube). Review of the care plan in use at the time of survey, showed: -Focus: The resident required tube feeding related to dysphagia (difficulty swallowing); -Goal: The resident will remain free of side effects or complications related to tube feeding through review date; -Interventions: EBP. Review of the physician order summary, dated 8/28/24, showed an order for EBP, diagnosis: G-tube. Observation on 8/26/24 at approximately 5:15 A.M., showed a sign on the door for EBP. CNA I and CNA F entered the resident's room, performed hand hygiene, and put gloves on. The resident was lying in bed with an abdominal binder (used to secure a G-tube, and provide support and stability during physical activity) on above the G-tube. Staff cleaned the front part of the perineal area, rolled the resident towards the window, then removed the brief and cleaned the back side. Staff put a clean sheet and pad on half the bed and tucked a clean brief under the resident, then rolled the resident towards the door and removed the soiled linens from the bed and placed in a bag. Staff then straightened out the linens and brief, rolled the resident onto his/her back and fastened the brief. With the same gloves on, staff reached inside the resident's drawers, then took a towel and wiped the resident's mouth; -Staff did not wear a gown while proving care and did not change their gloves when going from dirty to clean. 3. Review of Resident #19's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Current number of unhealed pressure ulcers; unstageable (unable to visualize wound bed): one. Review of the physician's order summary, dated 8/28/24, showed an order for EBP, diagnosis: wound. Observation on 8/26/24 at approximately 5:02 A.M. showed CNA I and CNA F entered the resident's room. There was a sign on the door for EBP. Both CNAs had a face mask on, performed hand hygiene and put gloves on. CNA F put peri-wash on a washcloth and started to wash the resident's suprapubic area (region of abdomen located below the umbilical region) in a circular motion. CNA I instructed CNA F to hand him/her a washcloth with peri-wash on it and CNA I provided instructions on how to provide perineal care as he/she provided the care to the resident. Neither CNA wore a gown while providing care to the resident. 4. Review of Resident #242's medical record, showed: -Alert and able to make needs known; -Diagnoses included: endocarditis (a life-threatening inflammation of the inner lining of the heart's chambers and valves). Review of the physician's order summary, dated 8/23/24, showed: -An order for: Observe peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein in the upper chest) line insertion site every shift for signs and symptoms of infection, notify Medical Doctor (MD) accordingly; -An order for: PICC gauge: 22; total length: 40; number of lumens (outside the body the PICC line splits into 1, 2 or 3 tubes): 3; type of infusion: continuous, intermittent, total parenteral nutrition (TPN, a special formula given through a vein provides most of the nutrients the body needs), Peripheral parenteral nutrition (PPN, a medical abbreviation for supplemental nutrition administered intravenously to patients who are unable to get enough nutrients from food), maintenance. Observation on 8/23/24 at 8:18 A.M., showed: -Licensed Practical Nurse (LPN) J entered the resident's room, wearing a face mask and flushed the PICC line; -There was no sign on the door indicating the resident was on EBP and staff did not wear a gown when he/she flushed the PICC line. 5. Review of Resident #36's admission MDS, dated [DATE], showed: -Cognitively intact; -Dependent with toileting and personal hygiene; -Indwelling catheter; -Has pressure ulcers ; -Diagnoses included: Progressive neurological disorder (conditions where there is a progressive deterioration in functioning), urinary tract infection, diabetes, high blood pressure. Review of the physician's order summary, dated 7/18/24, showed orders for EBP, diagnoses: Catheter, and wounds. Observation on 8/27/24 at 10:16 A.M., showed CNAs B and K entered the resident's room to weigh the resident using mechanical lift with scale. The resident had bowel incontinence and both CNAs provided perineal care. Neither CNA wore gowns while providing the care. 6. During an interview on 8/28/24 at 8:45 A.M., Certified Medication Technician (CMT) N said residents with wounds were on EBP. He/She would know which residents were on EBP because there would be a sign on the door. Staff were to wear face masks, gowns and gloves while providing direct care. 7. During an interview on 8/28/24 at 8:59 A.M., CMT O said he/she would know which residents were on EBP because there would be a sign on the door and a cart outside the door. Residents are on EBP because they have a catheter, wound or they are on antibiotics. PPE should be worn every time staff enter the resident's room. 8. During an interview on 8/28/24 at 12:53 P.M., LPN D said staff know if a resident was on isolation because there would be a sign on their door. Staff should wear a face mask, gown, and gloves while providing direct care to the residents who were on EBP. 9. During an interview on 8/28/24 LPN A said EBP was used for residents with feeding tubes, catheters, and wounds. Staff should wear face mask, gown and gloves while providing peri care, wound care, and g-tube feedings. He/She was not sure if staff needed to wear PPE while assisting residents with transfers. 10. Review of Employee AA's employee file, showed: -Date of hire: 8/7/24 -There was no documentation showing the employee received a 2 step TST. Review of Employee BB's employee file, showed: -Date of hire: 7/25/24; -There was no documentation showing the employee received a 2 step TST. Review of Employee CC's employee file, showed: -Date of hire: 7/10/24; -There was no documentation showing the employee received a 2 step TST. Review of Employee DD's employee file, showed: -Date of hire: 3/6/24; -There was no documentation showing the employee received a 2 step TST. Review of Employee EE's employee file, showed: -Date of hire: 1/17/24; -There was no documentation showing the employee received a 2 step TST. Review of resident FF's employee file, showed: -Date of hire: 1/10/24; -1st TST was documented as given on 1/10/24; -There was no documentation showing the results of the 1st TST and there was no documentation showing a second TST was completed. 11. During an interview on 8/28/24 at 4:36 P.M., the Administrator said she would expect for staff to change their gloves and perform hand hygiene when going from dirty to clean and follow the facility's policies and procedures on proper perineal care. She would expect for staff to wear PPE per the facility's policy. She would expect for staff to have their TB testing completed according to the policy. 45083

Based on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge, for two of three residents investigated for discharge (Residents #54 and #89). The census was 78. 1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/24 showed; -Cognitively intact; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. Review of the resident's progress notes, showed; -On 3/17/2024 at 9:29 A.M., Note Text: Resident requested that Social Services send referral for possible transfer, will follow up on referral; -On 3/29/2024 at 4:16 P.M., Note Text: Resident does not want to transfer to another facility anymore. Attempted to contact resident's family regarding Medicaid benefits. No answer, left a voicemail; waiting on a call back; -On 4/12/2024 at 5:21 P.M., Note Text: Per resident's family request, Social Services will send referral to another facility for possible transfer closer to family. Will follow up; -On 8/21/24 at 8:45 A.M., Note Text: Assessment complete. Resident ambulates in wheelchair. Resident is compliant with medication. Resident is compliant with Activities of Daily Living (ADLs). Resident prefers in room activities. Resident does have active discharge plans to transfer to a different facility; -On 8/28/2024 at 12:46 P.M., Note Text: Resident discharged from facility to new facility. Resident states he/she wants to be closer to his/her family. Resident vitals complete, complete assessment done before resident left, has all belongings. Review of the resident's medical record, showed no discharge summary, including a recapitulation of the resident's stay, was completed. 2. Review of Resident #89's medical record, showed: -admitted [DATE]; -Diagnoses included kidney failure, quadriplegia, muscle weakness, need for assistance with personal care and cognitive communication deficit; -discharged [DATE]. Review of the resident's progress notes, showed: -5/28/24 at 8:49 A.M., a Social Services note said home care did not accept referral due to capacity. Social Services Director (SSD) sent referral to another home health. Resident states plans to cancel discharge plans and medical transportation. Resident made aware of insurance noncoverage but refuses to fulfill financial obligations. Resident is aware of long-term option. Resident refuses to disclose personal banking information for Medicaid coverage at this time. SSD will follow up on future discharge plans; -5/28/24 at 9:59 A.M., SSD wrote medical transportation is still scheduled to pick resident up on 5/28/24 at 2:00 P.M Resident decided to keep discharge plans but still refuses to fulfill financial obligations post skilled services; -5/28/24 at 11:45 A.M., a nursing note. Patient given discharge paperwork. All questions answered. All medication given. Left at approximately 2:10 P.M. with medical transportation; -5/28/24 at 8:59 P.M., a nursing note. Resident has been discharged . Review of the resident's medical record, showed no discharge summary, including a recapitulation of the resident's stay, was completed. During an interview on 8/28/24 at 1:45 P.M., the Clinical Quality Coordinator provided the resident's progress notes and said nursing may have provided the resident with the discharge summary and they did not keep a copy of it. 3. During an interview on 8/28/24 at 1:01 P.M., the SSD said she did not recall completing a discharge summary, including the recapitulation of the residents' stay or when the residents discharged from the facility. During an interview on 8/28/24 at 4:36 P.M., the Administrator and Director of Nursing (DON) said they would have expected a discharge summary, including the recapitulation of the resident's stay, was completed when a resident discharged from the facility. 37681

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the wound treatment order, resulting in an untreated non-pressure wound, for one sampled resident (Resident #292). The sample was 18. The census was 78. Review of the facility's Wound Care Policy, revised on 7/12/24, showed: -Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the residents' choices; -The skin care program developed by the facility is interdisciplinary and implemented using a team approach; -The skin care program's interdisciplinary team functions as an action team; -Each discipline has a vital role in wound care. All disciplines focus on assessment, planning. implementing, and documenting care; -Communication is vital and should occur daily at the stand-up meeting, and in Grand Rounds, then weekly at the Resident at Risk (RAR) meeting, and monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting. Review of Resident #292's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 8/2/24, showed: -Moderate cognitive impairment; -No behaviors; -Independent on functional abilities; -Diagnoses included stroke, anemia, high cholesterol, seizure, malnutrition and schizophrenia (a serious mental health condition that affects how people think, feel and behave). Review of the resident's care plan in use at the time of survey, showed: -Focus: The resident has an arterial ischemic ulcer (wounds that occur when there is poor blood flow to the legs, causing tissue death and open wounds) of the left heel and ankle related to vascular insufficiency; -Goals: The resident will be free from infection or complications related to arterial ulcer through the review date; -Interventions: Assess wound: size, depth, margins, peri wound skin, sinuses (wounds that extend from the skin surface to various underlying tissues), undermining (wounds that appear small on the outside but grows larger underneath the skin). Exudates (fluid that leaks out of blood vessels into nearby tissues), edema, granulation (type of tissue formed on the surfaces of a wound during the healing process), infection, necrosis (death of body tissue, usually caused by a lack of blood flow to the tissue), eschar (dead tissue that forms over healthy skin), gangrene. Inspect feet daily, especially between the toes. Keep the feet clean and dry. Review of the resident's electronic medical record, showed: -A diagnosis of acquired absence of other left toes; -On 7/30/24, an order of Betadine External Solution (Povidone-Iodine, used to treat and prevent skin infections in minor burns, lacerations, cuts, and abrasions). Apply to left heel topically every day shift for wound. Paint heel with betadine, cover with gauze and Kerlix (bandage rolls and dressings used for wound care). During an interview and observation on 8/22/24 at 2:40 P.M., the resident's left foot dressing was coming loose and dirty. The dressing was not dated and initialed. The resident said sometimes, he/she had to ask the nurse to have the wounds cleaned and dressing changed. He/She did not remember the last time the dressing was changed. Observation on 8/26/24 at 5:00 A.M., showed the resident asleep in bed, facing the window with his/her feet uncovered. The left foot dressing was dirty, the bottom had black dirt and stained with wound drainage on the top part. The dressing was dated 8/24. During an interview on 8/26/24 at 1:14 P.M., the resident said the wound dressing was not changed for a couple of days. He/She was aware the wound dressing was stained and dirty, but no one would change the dressing over the weekend. During an interview on 8/26/24 at approximately 1:20 P.M., the Licensed Practical Nurse (LPN) C said the assigned nurse was responsible for providing wound care when the wound nurse was not available or not on the schedule. During an interview on 8/28/24 at 4:40 P.M., the Administrator said she would expect staff to follow the wound treatment as ordered. She would expect staff to follow their wound/skin care policy.

Based on observation, interview and record review, the facility failed to ensure one resident with wounds received necessary treatments. and services to promote healing (Resident #31). The sample size was 18. The census was 78. Review of the facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management Policy, dated revised: 7/9/2024, showed: -Skin observations also occur throughout points of care provided by Certified Nurse Aide's (CNA) during Activities of Daily Living (ADL) care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/11/24, showed: -Cognitively intact; -Diagnoses included: heart failure, stoke, calciphylaxis (a rare, serious disease that involves a buildup of calcium in small blood vessels of fat tissues and skin), end stage renal disease (ESRD, chronic irreversible kidney failure) and colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); -Number of unhealed pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction), Stage three (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling): one; -Open lesion other than ulcers, rashes, cuts (e.g. cancer lesion) was checked. Review of the care plan, in use at the time of survey, showed: -Focus: resident has a break in skin integrity to right lower extremity (RLE, leg) related to calciphylaxis wound, ESRD, date initiated 7/5/24; -Goal: Minimize risk for symptoms of infection through next review; -Interventions included: Observe dressing (every shift). -Focus: has breaks in skin integrity to RLE related to calciphylaxis. refer to wound observation tool; -Goal: Maintain intact skin with no skin breaks through next review; -Interventions: treatment as ordered; -Focus: has pressure ulcer noted refer to wound observation tool; -Goal: the resident's pressure ulcer will show signs of healing and remain free from infection by/through review date; -Interventions: administer treatments as ordered. During an interview on 8/22/24 at 4:55 P.M., the resident said he/she had wounds on his/her bottom and on the right leg and heel, staff are not changing the dressings like they should be. The wound nurse ordered the dressing to be changed twice day, but the staff were not doing that, so the treatment got changed to daily. The wound on the right heel has increased in size. It will heal and they will stop the dressing but when they do that, the wound comes back. Review of the Treatment Administration Record (TAR), dated 8/1/24 through 8/23/24, showed: -An order for: Cleanse sacral wound with Vashe (used for cleansing, irrigating, moistening, debridement, and removal of foreign material including microorganisms and debris from exudating and/or dirty wounds) solution, apply fibercol (a soft, absorbent dressing) to wound bed, cover with border gauze dressing every evening shift, every Tuesday, Thursday, Saturday for wound, start date 7/1/24. Discontinue date 8/23/24; -Documentation showed three out of 10 opportunities were blank; -An order for: Mupirocin ointment 2% (Bactroban, antibiotic) apply to right lower leg topical every shift for wound infection for seven days, cleanse right lower leg with Vashe wound cleanser, allow to soak for 15 minutes, apply Santyl (sterile enzymatic debriding ointment) with Bactroban to wound bed, cover with calcium alginate (highly absorbent dressing that promotes healing) cut to fit inside wound edges. cover with boarded gauze; change dressing three times a day (TID), start date was 8/2/24 and stop date was 8/9/24; -Documentation showed two out of 21 opportunities were blank; -An order for: Santyl ointment 250 unit/gm apply to right lower leg topically every shift for wound care, cleanse right lower leg with Vashe wound cleanser, allow to soak for 15 minutes, apply Santyl with Bactroban to wound bed, cover with calcium alginate cut to fit inside wound edges. cover with boarded gauze; change dressing TID, start date: 8/2/24. Discontinue date 8/17/24; -Documentation showed: two out of 44 opportunities were blank; -An order for: Santyl ointment 250 unit/gm, apply to right lower leg every shift for wound care. Cleanse right lower leg with Vashe wound cleanser, allow to soak for 15 minutes, apply Santyl cover with calcium alginate cut to fit inside the wound edges. Wrap with kerlix (gauze) daily, order date 8/17/24. Discontinue date 8/21/24; -Documentation showed: four out of 12 opportunities were blank; -An order for: skin prep (quick drying skin protectant) apply to right heel topically every shift, order date 7/23/24; -Documentation showed: six out of 59 opportunities were blank. Review of the progress notes, dated 8/1/23 through 8/23/24, showed: -On 8/7/24 at 2:00 P.M., resident leave of absence (LOA) this shift, treatment not completed; -On 8/11/24 at 11:08 P.M., Gentamicin Sulfate Cream 0.1%, apply to right lower leg rear topically every day and evening shift for wound care, UTC was documented; -On 8/11/24 at 11:09 P.M., Santyl ointment 250 unit/gm, apply to right lower leg every shift for wound care; unable to complete treatment ordered supplies are unavailable at this time; -On 8/17/24 at 6;48 A.M., Santyl, apply to right lower leg topically every shift for wound; resident did not want it changed now, relates should only be changed once per day; -On 8/19/24 at 6:27 A.M., Santyl, apply to right lower leg topically every shift for wound care; not available; -On 8/19/24 at 6:28 A.M., skin prep spray, apply to right heel topically every shift; not available. Review of the TAR, dated 8/1/24 through 8/23/24, showed: -On 8/7/24 the treatments were documented as a 10 (see progress notes); -On 8/11/24, the gentamicin and Santyl were documented as a 10; -On 8/17/24, the Santyl for evening shift was blank and night shift was documented as administered; -On 8/19/24, Santyl and skin prep were documented with a 10. Review of the TAR, dated 8/24/24 through 8/25/24, showed: -An order for: cleanse sacral wound with Vashe solution, apply collagen sheet with alginate to upper part of wound bed, cover with border gauze dressing every day shift every Monday, Wednesday, Friday, Sunday for wound. Resident had two medications for wound order, may place one dressing over entire wound area. Order Date was 8/23/2024; -Documentation showed: one out of one opportunity was blank; -An order for: Cleanse sacral wound with Vashe, apply Xeroform (a sterile non adherent dressing) to lower section of wound bed, cover with border gauze dressing every day shift every Monday, Wednesday, Friday, Sunday for wound Resident has two medications for wound order, may place one dressing over entire wound area. Order date was 8/23/2024; -Documentation showed: one out of one opportunity was blank; -An order for: Santyl ointment 250 unit/gm, apply to right lower leg every day shift every Monday, Wednesday, Friday, Sunday for wound care. Cleanse right lower leg with Vashe wound cleanser, allow to soak for 15 minutes, apply santyl cover with calcium alginate cut to fit inside wound edges, wrap with kerlix, order date was 8/22/24; -Documentation showed one out of two opportunities was blank. Review of the progress notes dated 8/24/24 through 8/26/24, showed: -On 8/26/24 at 4:10 P.M., soft area noted to right heel, with 2 open areas (o/a) noted, 1.75 centimeters (cm) x 1.5 cm o/a to the top, with a 2 cm x 1.5 cm o/a noted at the base of heel, doctor made aware. New order (n/o) given cleanse with Vashe, cover with foam dressing every day and as needed; -On 8/26/24 at 5:03 P.M., skin prep not applied. Cleaned and measured, notable o/a to center-to update doctor; -There was no documentation showing if the treatment was or was not completed on 8/25/24. Observation and interview on 8/26/24 at 11:16 A.M., showed the resident lay in bed. Licensed Practical Nurse (LPN) E entered the resident's room and removed the resident's blanket. The resident had a dressing on his/her right mid-calf area. The dressing had old drainage on it. The pillow under the resident's leg had a large amount of yellowish colored drainage on it. The nurse removed the dressing and soaked the wound with Vashe wound cleanser for 15 minutes, then cleaned the wound and applied a new dressing. The nurse positioned the resident on his/her side and removed the dressing form the sacrum (triangular bone located above the coccyx). The dressing was dated 8/24/24. There was large yellowish ring on the pad and sheet under the resident. The nurse said this was unacceptable. The nurse provided wound care and applied a new dressing. Then, the nurse went to get the Director of Nursing (DON). A few minutes later, the nurse and the DON entered the resident's room. The nurse showed the DON the discoloration on the bed and told the DON the resident did not urinate and he/she had a colostomy. The DON said the discoloration was 100% drainage. Observation of the right heel showed the skin was peeling off the heel and there were two open areas. The nurse described the open areas as a Stage two (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) and said the wounds were past skin prep. The DON asked the nurse if the resident was seen by the wound care team on Friday and the nurse said yes. The DON said the heel did not get that way in two days and skin prep was no longer an acceptable treatment. The DON said all the managers worked over the weekend and no one reported to her that the resident's treatments were not done. During an interview on 8/28/24 at 12:53 P.M., LPN D said usually the wound nurse did the treatments. If the wound nurse did not provide the wound care, the floor nurse would do it. A blank on the TAR meant someone forgot to chart or it was not done. If he/she saw a blank on the TAR, he/she would assess the resident to see if the bandage was changed or not. If the bandage had a wrong date on it, he/she would ask the resident because the nurses might have written the wrong date on it. If a resident's wound was draining, he/she expected staff to change the resident's sheets and clean the dressing. If a resident's sheets were soiled, he/she expected staff to change them. Resident #31's wound weeps a lot. He/She was seen by the wound team and they are aware of the drainage. All staff can do is follow the orders and change the dressing and sheets. During an interview on 8/28/24 at 1:33 P.M., LPN A said many times the nurse on the floor did the treatments. A blank on the MAR/TAR meant it was not done but he/she cannot be sure of it. If he/she saw a blank, he/she would tell the DON and check the progress of the bandage. During an interview on 8/26/24 at 11:16 A.M., the DON said if a staff member saw a wound, she expected them to clean the wound and report it to the doctor and the DON. Staff should measure wounds and document what they see. She expected staff to change soiled linens and turn and reposition the resident every couple of hours. The DON expected staff to follow physician orders. During an interview on 8/28/24 at 4:36 P.M., the Administrator said she expected wound care to be completed per physician orders. MO00240295 MO00226243 45083

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when the facility failed to administer medications as ordered for two of six sampled residents (Resident #1 and Resident #3). The census was 83. The administrator was notified on [DATE] of the past non-compliance. The facility had already began an investigation, counted the medication carts, added a corrected count to all controlled substance logs, interviewed staff and residents, notified the police, the resident's physician and family, in-serviced staff on abuse and misappropriation of resident property (including drug diversion) and terminated Licensed Practical Nurse (LPN) A. The deficiency was corrected on [DATE]. Review of the facility's Administration of Medications policy, reviewed [DATE], included: -Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the IO Rights of Medication Administration; -Right Drug: Every drug administered must have an order from the provider. --Compare the order with the medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times: a. Before removing the container from the drawer; b. As the drug is removed from the container and; c. At the bedside before administering it to the resident; --Do not prepare unmarked drug containers or illegible containers. Be sure to verify drugs at the patients' bedside with the MAR and two patient identifiers; -Right Resident: --Use two identifiers. --Ask the resident his or her full name and compare it to the name on the medication and/or treatment administration record (MAR/TAR) and compare the resident's photo to the resident. -Right Dose: --Check the MAR and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering; -Right Route: Check the order if it's oral (by mouth), IV (intravenous - in the vein), SQ (sub-cutaneous - under the skin), IM (intra-muscular - in the muscle), etc.; -Right Time and Frequency: Check the order for when it would be given and when was the last time it was given; -Right Documentation: Make sure to write the time and any remarks on the chart correctly. Medication administrations should be documented timely following the administration to the resident; --Controlled substances should be signed out from the descending count sheet and documented on the MAR for each routine and PRN dose of medication administered; --As needed administrations (PRN) medications should reflect the initial administration and the additional follow-up performed to determine the effectiveness of the medication administered; -Right Assessment: Note the resident's history and any parameters around drug administration; -Right to Refuse: Give the resident enough autonomy to refuse the medication after thoroughly explaining the effects. Medication refusals should be documented on the MAR with the reason for the refusal and the follow up from the licensed professional. Controlled substances that are refused after removal from the descending count record or wasted, should be destroyed by two licensed nurses and the waste documented on the MAR and on the descending count sheet; -Right Evaluation/Response: Ensure the medication is working the way it should. Ensure medications are reviewed regularly. Ongoing observations if required; -Right Education and Information: Provide enough knowledge to the resident of what drug he/she would be taking and what are the expected therapeutic and side effects. 1. Review of Resident #1's electronic medical record, showed: -admitted on [DATE]; -Diagnoses included peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, bladder function), multiple pressure ulcers, protein-calorie malnutrition, acute respiratory failure (inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), paraplegia (paralysis of the legs and lower body), and oropharyngeal dysphagia (difficulty swallowing). Review of the resident's electronic Physician Order Sheet (POS), showed: -An order dated [DATE], for Morphine Sulfate (narcotic pain medication) Oral Solution 20 MG (milligrams)/5 ML (milliliters), Give 0.25 ML by mouth every four hours as needed for pain; -An order dated [DATE], for Oxycodone - Acetaminophen (narcotic pain medication) 7.5-325 MG, give one tablet by mouth every 8 hours as needed for pain; -An order dated [DATE], Pain level every shift. Document pain scale 0-10. Review of the resident's progress notes, showed: -On [DATE] at 4:58 P.M.: Resident noted in a deep sleep since after breakfast. Resident taking slow breaths. Skin cool, color remains unchanged. Resident not awakening to take any medications. Call placed to durable power of attorney (DPOA). Informed to keep resident in the facility and not send him/her to the hospital. Call placed to physician to make aware. Received order to give the resident oxygen at 2 liters (2L) as needed (PRN) for comfort. Resident's DPOA on the way to the facility. Resident continues to be turned and made comfortable; -On [DATE] at 6:26 P.M.: New orders per physician for a Hospice consult. Resident's family made aware and ok with new orders; -On [DATE] 9:19 P.M.: Per DPOA, resident is not to be sent back out to the hospital. Resident will remain comfortable in the facility. Physician aware of family wishes; -On [DATE] at 3:55 P.M.: Resident resting in bed at this time. Resident unable to take medication at this time. Eyes closed not responding to nurse. Resident turned and repositioned, call light and personal items within reach. Safety measures in place; -On [DATE] at 10:16 A.M.: Resident with eyes closed, in supine position (lying face upwards) with turns every two hours. Resident did not take any medications or eat breakfast; -On [DATE] at 2:58 P.M.: Resident was deceased upon entering the room at 2:50 P.M. Verified by Registered Nurse (RN) and Licensed Practical Nurse (LPN). The physician was notified at 2:55 P.M. and gave the diagnosis of malnutrition. Family was at bedside. DPOA notified. Review of the resident's [DATE] MAR, showed: -Pain level every shift. Document pain scale 0-10. Order Date [DATE] at 7:56 A.M.; -On [DATE] evening check: Resident's pain level was recorded as 0, indicating the resident had no pain; -Oxycodone - Acetaminophen 7.5-325 MG, give one tablet by mouth every 8 hours as needed for pain; -On [DATE], Oxycodone-Acetaminophen 7.5-325 MG was not signed out as administered to the resident. Review of the resident's Controlled Substance Proof of Use log, showed: -Oxycodone - Acetaminophen 7.5-325 MG, give one tablet by mouth every 8 hours as needed for pain; -On [DATE] at 4:00 P.M., one tablet provided; -On [DATE] at 9:00 P.M., one tablet provided, which was only five hours after the previous dose and not the ordered 8 hours between doses. During an interview on [DATE] at 3:59 P.M., the Director of Nursing (DON) said the resident was end stage of passing away and was not swallowing and unable to take any oral medication for a couple days prior to LPN A stating he/she gave the medication to the resident. He/She could not prove LPN A took the pills, but it was very suspicious. 2. Review of Resident #3's electronic medical record, showed: -admitted on [DATE]; -Diagnoses included spinal stenosis (the spaces inside the bones of the spine get too small), pain in thoracic spine (the middle section of your spine), Stage II pressure ulcer (partial-thickness skin loss involving the epidermis (outer layer of skin) and dermis (the middle layer of skin in your body), and polyneuropathy (multiple peripheral nerves become damaged resulting in weakness, numbness, and burning pain). Review of the resident's electronic POS, showed: -An order dated [DATE], for Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen - narcotic pain medication), give one tablet by mouth every eight hours for spinal stenosis; -An order dated [DATE], for Percocet Oral Tablet 5-325 MG, give one tablet by mouth once daily (may give one tab daily) as needed for pain. Review of the resident's [DATE] MAR, showed: -Percocet Oral Tablet 5-325 MG, give one tablet by mouth every eight hours for spinal stenosis. Scheduled for 5:00 A.M., 1:00 P.M. and 9:00 P.M.; -On [DATE], documentation that one tablet was provided at the scheduled 5:00 A.M., 1:00 P.M. and 9:00 P.M. pass times; -Percocet Oral Tablet 5-325 MG, give one tablet by mouth once daily (may give one tab daily) as needed for pain; -On [DATE], no documentation that this medication was provided. Review of the resident's Controlled Substance Proof of Use log, showed: -Percocet 5-325 MG, give one tablet by mouth 3 times daily. Take one tablet by mouth once daily PRN: -On [DATE] at 5:00 A.M., One tablet provided; -On [DATE] at 1:00 P.M., One tablet provided; -On [DATE] at 4:00 P.M., One tablet provided; -On [DATE] at 8:00 P.M., One tablet provided; -On [DATE] at unknown time (documented with just a dash in the space provided to write the time), One tablet documented as wasted with only one nurse's signature. During an interview on [DATE] at 12:50 P.M., the resident said that he/she had only received one pain pill on the evening of [DATE] and that was around 9:00 P.M. The only reason he/she remembers this is because staff had previously questioned him/her about how many pills he/she got that night. During an interview on [DATE] at 3:59 P.M., the DON said staff are required to sign out the narcotic being wasted the same as if it was administered, including the time wasted. Staff are required to have another nurse witness and sign off on any narcotic that is being wasted. It is unacceptable for a nurse to waste a medication by themselves. He/she could not prove LPN A took the pill, but it was very suspicious. 3. During an interview on [DATE] at 1:50 P.M., the Administrator said medications should be given per the physician's order. MO00236673

Based on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when a staff member misappropriated $13,300 of resident's money from their personal account, without the resident's consent. This affected one of eight sampled residents (Resident #8). The census was 75. Review of the facility's Abuse, Neglect and Exploitation policy dated 7/18/23, showed the following: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart; -Exploitation, is defined as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion; -Misappropriation of resident property, is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent; -Willful, is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Misappropriation of Property and Exploitation: -Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent; -Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold intrinsic value to the resident. Residents are permitted to keep personal clothing and possessions for their use while in the facility, as long as it does not infringe upon the rights of other residents. Examples of resident property include jewelry, clothing, furniture, money, and electronic devices, the resident's personal information such as name and identifying information, credit cards, bank accounts, driver's licenses, and social security cards; -Examples of misappropriation of resident property include, but are not limited to: -Identity theft; -Theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items such as eyeglasses and hearing aids; -Unauthorized/coerced use by staff of resident's personal property; -Theft of money from bank accounts; -Unauthorized or coerced purchases on a resident's credit card; -Unauthorized or coerced purchases from resident's funds; -A resident who provides a gift to staff in order to receive ongoing care, based on staff's persuasion; and -Staff who accept money from a resident for any reason including when staff have made the resident believe that staff was in a financial crisis or the resident believes that he/she is in a relationship with the staff person; -Example of exploitation may include, but is not limited to: -When a resident, or resident representative, has given his/her money or belongings to staff as a result of coercion, or because the resident, or resident representative, believes that it was necessary (e.g., in order to receive good care). Review of the facility's Social Services Director (SSD) job description dated 12/6/16, showed the following: -The Social Services Director plans, organizes, develops, and directs the overall operation of the Social Services department to ensure all medically-related emotional and social needs of patients are met in accordance with all applicable laws, regulations, and corporate standards; -Specific Requirements: -Must possess the ability to make independent decisions when circumstances warrant such action; -Must be knowledgeable of social services practices and procedures as well as the laws, regulations, and guidelines governing social services functions in the post-acute care facility; -Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the social services department; -Maintains confidentiality of all proprietary and/or confidential information; -Must understand and follow company policies including harassment and compliance procedures; -Displays integrity and professionalism by adhering to the corporation's Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training; -Promotes a culture of integrity, maintains an open door policy, and does not participate in or allow retaliation against those who report good faith concerns; -Essential Functions: -Must be able to implement a social services program that meets the medically-related social and emotional needs of patients as well as State, Federal, corporate, and division guidelines; -Must be able to act as patient advocate and provide education to staff regarding patient rights; -Must be able to assist patient and family through education, financial planning assistance, liaison with community agencies, etc.; -Must exhibit excellent customer service and a positive attitude towards patients; -Must be able to concentrate and use reasoning skills and good judgment; -The SSD job description did not indicate the SSD in any way, could be personally responsible for management of resident's private funds. Review of Resident #8's face sheet on 2/22/24, showed the following: -admitted on [DATE]; -The resident's primary payment source listed as private pay; -The resident's adult child was listed as his/her responsible party. The document did not indicate if the resident's adult child was his/her financial Power of Attorney (POA) or if he/she was responsible for managing the resident's finances. Review of the resident's electronic admission packet dated 5/23/23, showed the following: -The information in the packet was reviewed with the resident. The sections titled legal representative and appointed representative were disabled and no representative for the resident was identified; -The packet included a Financial and Benefit Screening Form. The screening tool only included the resident's name and the name of the person completing the screening. All other sections were left blank and the document did not contain any information about the resident's assets or finances. Review of the resident's hospital record dated 10/25/23, showed the resident was listed as his/her own guarantor (person responsible to pay the bill). Review of the resident's care plan dated 12/14/23, showed no information documented regarding the resident's finances or how and by whom his/her money would be managed while admitted to the facility. Review of the Former SSD's employee file on 2/22/24 and 2/23/24, showed the following: -Hire date 5/2/23; -Several documents included the Former SSD's handwriting and/or signature; -Payroll direct deposit authorization form dated 5/11/23, included the Former SSD's bank account number and bank routing number, from his/her account with Bank A; -The name and routing number for Bank A, documented in several places in the employee file, indicating the Former SSD's paycheck or portion of each paycheck was deposited to the Former SSD's account at Bank A; -A document signed by the Former SSD on 5/25/23, indicated he/she acknowledged receipt and understanding of the facility's Abuse Policy. Review of a handwritten letter dated 10/20/23, showed the following: -The letter was written in the Former SSD's handwriting, consistent with the handwriting observed in the Former SSD's employee file; -The letter was signed by both the Former SSD and the resident and it was notarized; -The letter read, I (Resident #8), give (the Former SSD) permission to handle my finances, mail checks, pay bills, third party communication with my banks, credit card and any business matter. (The Former SSD) may also use monies when he/she needs to, in order to help me conduct business, to be sure I am okay and he/she is okay. (The Former SSD) can handle my money until I say he/she cannot and I will talk to anyone who would have an issue with my help. Review of the facility's undated self-report summary on 2/22/24 and 2/23/24, showed the following: -On 1/17/24 at approximately 4:30 P.M., the resident requested the Administrator come to his/her room, to speak with him/her. The resident said he/she wanted to know what the Administrator was going to do about the Former SSD, who took my money. The Interim Director of Nursing (DON) was present and reminded the resident that the Former SSD no longer worked at the facility. The resident acknowledged the Former SSD was terminated for assisting him/her with writing checks and taking care of his/her financial affairs. The resident voiced his/her understanding and stated that his/her adult child was now assisting him/her. The resident said his/her adult child came to visit and told him/her the Former SSD had written a check to him/herself from the resident's account. The resident asked the Administrator what she could do to punish the Former SSD. The Administrator asked the resident when the check was written, such as when the Former SSD was still employed at the facility or afterwards. The resident said, I think recently but I'm not sure. The resident said the Former SSD must have done it after he/she no longer worked at the facility. The resident said his/her adult child brought him/her a piece of paper to show him/her what the Former SSD had done. The resident said the Former SSD wrote him/herself a check for $500 and wrote bonus in the corner. The Administrator asked the resident if he/she could provide her with a copy of the check or a copy of the bank statement so she could research it. The resident said his/her adult child would be off work around 5:30 P.M., and he/she would call him/her and ask him/her to bring the document to the facility. The Administrator told the resident she would return in the in the morning to discuss the matter further and to review the document; -On 1/18/24, the Administrator returned to the resident's room with the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator, to speak with him/her. The resident said his/her adult child did not come to visit the evening of 1/17/24, but the resident did speak to him/her. The resident said his/her adult child was very upset with him/her for telling the Administrator about the missing money. The resident's adult child told him/her that he/she should leave it alone. The Administrator offered to call the resident's adult child, to make arrangements to obtain a copy of the proof that the Former SSD took money from the resident's account. The resident refused to allow the Administrator to call his/her adult child. When pressed about why he/she did not want the Administrator to call his/her adult child, the resident said his/her adult child was REALLY upset with him/her for telling the facility about the check. The Administrator asked the resident if they could call his/her bank together and make arrangements to get a copy of his/her bank statements or to inquire if any checks have cleared or been presented for $500, in the last three months. The resident agreed and they attempted to call the resident's bank, Bank B. The employee at Bank B was unable to assist the resident because a four digit code had to be sent to the phone number on file, before they could access his/her account and speak with him/her. The resident shared his/her cell phone number and it was not the phone number on file with the bank. The phone number on file was his/her adult child's cell phone number. The resident's adult child was unavailable to provide the verification code and the resident refused to allow the Administrator to call him/her. The Administrator was unable to obtain additional information to support the resident's claim against the Former SSD. The MDS Coordinator and the Administrator obtained permission from the resident to look through his/her belongings, as he/she may have bank statements among his/her things. They were unable to find any bank documents to substantiate or clarify the resident's claims against the Former SSD. The resident is unable to go to the bank in person due to his/her physical disabilities. The Administrator asked the resident if he/she allowed the Former SSD to access his/her accounts so that he/she would have the ability to write a check out to him/herself and the resident said he/she did not. The resident said the Former SSD would write a check out for him/her and then the resident would sign them. The resident has significant hand tremors and his/her signature would be very difficult to duplicate. The resident said the Former SSD never had blank checks belonging to the resident, in his/her possession. When asked why he/she thought the former SSD took money from him/her, after he/she left employment with the facility, he/she said, I don't know, I just know my (adult child) said it happened; -The Administrator returned to the resident's room on 1/18/24, later in the day, to ask him/her if he/she would allow the Administrator to speak to his/her adult child and the resident again told her No. The resident said, for one reason or another, his/her adult child was very upset with him/her for talking to the Administrator about the check and he/she needed his/her adult child to help him/her, so he/she should not call him/her about the issue. The Administrator asked the resident if it was possible that his/her adult child wrote the check and placed the blame on the Former SSD and the resident said I guess anything is possible. The resident and his/her adult child had been estranged from one another for several months or years, but his/her adult child had recently started visiting and talking with him/her on the phone. The Administrator offered to call the police for a police report to be made, but the resident didn't want to pursue a police report because his/her adult child was so upset with him/her; -On 1/19/24, the Administrator attempted to encourage the resident to allow him/her to talk to his/her adult child, but the resident continued to refuse. Based on the lack of evidence and cooperation, the Administrator was unable to verify the Former SSD ever misappropriated the resident's funds; -The Former SSD was terminated on 10/24/23 for his/her attitude towards his/her co-workers, inappropriate comments in the work place and violation of facility policy. Review of the facility's Follow-up Investigation Report dated 1/23/24, showed the following: -The Administrator researched the Former SSD's employee file and found statements regarding his/her involvement with the resident. The Administrator spoke multiple times with the resident and initially the resident said he/she requested the Former SSD help him/her because his/her adult child was estranged from him/her and he/she did not have anyone to assist him/her with his/her finances. The resident said he/she requested the Former SSD help him/her and was willing to sign a statement allowing him/her to access bank statements and fill out checks. At the time, the Former SSD denied during interviews with the Former Administrator, that he/she did anything but assist the resident. The former SSD was employed at the facility from 5/25/23 until 10/26/23. The Former SSD received counseling prior to the incident, for poor work relationships with his/her co-workers; -Approximately six days from the day the resident signed the request for the Former SSD to assist him/her with his/her finances, the Former SSD was terminated; -The resident has changed his/her narrative of the events multiple times over the course of the past week. The resident initially said he/she knew what he/she was signing, when the Former SSD asked him/her to sign the agreement, and he/she did not think Former SSD did anything wrong. The resident then said the Former SSD took $500 from him/her. The Administrator offered in front of witnesses more than once to call the police and the resident refused. The Administrator offered to call the resident's adult child, who now takes care of his/her finances, to obtain the information needed to evaluate if a crime had been committed. The resident refused to let the Administrator speak to his/her adult child. The resident was unable to provide the paper his/her adult child showed him/her implicating the Former SSD took $500 from his/her account. The resident said the Former SSD never had his/her checkbook or credit cards in his/her possession outside of the resident's room. The Administrator was unable to verify with Bank B if there were any checks written to the Former SSD, since October of 2023 for $500 because the resident's account was set-up with a passcode that required a pin to be sent to the cell number on file. The cell phone number on file for the resident's account at Bank B was his/her adult child's phone number; -On the evening of 1/19/24, the police arrived at the facility, regarding a complaint of fraud. The police officer interviewed the Administrator, then went to see the resident. The resident's adult child was present and was clearly unhappy the Administrator was present with police in the resident's room. The Administrator and the resident's adult child, stepped outside into the hall and the resident's adult child said the Former SSD had taken more than $500. When pressed for evidence to support the claims, he/she said he/she was still trying to get it. The resident's adult child said he/she told the resident not to speak to anyone regarding his/her personal finances. The resident's adult child was upset that the resident spoke to the MDS Coordinator and the Administrator, after he/she told the resident not to discuss it with anyone. The resident's adult child was resistive and hesitant to speak about the allegations. The Administrator informed him/her that the Former SSD no longer worked for the facility and it would be helpful if they knew when the money was allegedly taken. The resident's adult child was unable to provide a timeline. The police officer returned to the Administrator's office and said if and when they had proof of a crime, they should come to the police station and request to speak to him/her. The police officer did not take a complaint or file a report, due to lack of evidence of a crime having occurred so there was no complaint number at this time; -Based on the information available, conversations with the resident, his/her adult child and staff, the Administrator was unable to verify the Former SSD acted with ill will but rather simply made a poor choice of insisting the resident sign a document allowing the Former SSD to complete the task of handling the resident's personal funds. The choice of words in the document allows someone to assume the Former SSD was given full access to all of the resident's funds. The Former SSD's statements do not support that was his/her intention. The resident's adult child was unable to produce any evidence to support his/her allegations of misappropriation of the resident's funds. The local police found no merit in completing a report due to lack of evidence of a crime. The Former Administrator, at the time of the initial incident, investigated and spoke with the Former SSD, to obtain his/her statement and searched his/her office. The Former Administrator did not determine any wrong doing and likely would have allowed the Former SSD to return to work based on his findings, but he/she quit. The Former Administrator considered the investigation closed as the resident stated to him that he/she asked the Former SSD to assist him/her. The resident was upset because he/she thought the employee was fired for assisting him/her; -A copy of the handwritten letter dated 10/20/23, included in the investigation; -The Former SSD's handwritten statement dated 10/24/23, said the resident always asked the Former SSD to take his/her check payments to the front desk and to call his/her bank or credit card company. The Former SSD asked the resident why he/she didn't ask his/her family to help him/her with financial stuff. The resident said his/her adult child did not want to help him/her. The Former SSD told the resident he/she would help him/her if he/she covered him/herself, with a written agreement in case it backfires on him/her. The Former SSD agreed to help the resident and wrote up a document (the handwritten letter dated 10/20/23). He/She had only walked the resident's checks up to the front desk. He/She had also been present when the resident called the bank and ordered more checks. He/She was only (the resident's) social worker. The resident's cognitive score was 15 (reference to the resident's brief interview for mental status score and a score of 15 would indicate the resident was cognitively intact). The Former SSD did not force the resident into the agreement on 10/20/23 and if he/she thought it was going to get me fired, I would not have the note to my coworker as proof. The Former SSD went on to say, In this field with agency coming in and out and with new staff members working, (the resident) always leaves (his/her) checks sitting out and (his/her) cards. I always give (the resident) a speech on being responsible with his/her stuff and putting items up. Since I work closely with (the resident) if anything was to happen, the letter was to cover me, never to manipulate. The Former SSD said he/she never signed anything else or helped any other residents like he/she helped the resident. The resident begged the Former SSD to help him/her and it took some convincing and now this happens; -The MDS Coordinator's written statement dated 10/24/23, said he/she talked to the resident, as he/she was wanting to go to the hospital. The resident said something to the effect of the Former SSD being his/her power of attorney. The resident said the Former SSD had him/her sign a paper. The MDS Coordinator went to the Former SSD, to ask him/her about it. The Former SSD said the signed document was just so he/she could talk to the resident's bank for him/her. The MDS Coordinator asked the Former SSD where the paper he/she had the resident sign was. The Former SSD showed him/her a handwritten letter. The MDS Coordinator copied the letter and gave it to the Former Administrator. After the Former Administrator spoke to the Former SSD about it, the Former SSD came into the MDS Coordinator's office and confronted him/her as to why he/she did not tell (him/her) how big of a deal this was before (he/she) gave it to (the Former Administrator) and wanted to know who (he/she) could talk to now; -Receptionist C's handwritten statement dated 1/23/24, said he/she did recall the Former SSD brought checks up to mail for the resident, but he/she did not recall the Former SSD being in possession of the resident's checkbook in his/her presence. Review of the resident's bank records from Bank B on 2/22/24 and 2/23/24, showed the following: -A personal signature card dated 9/13/22, included images of the resident's signature; -A check from the resident's account, dated 10/20/23, in the amount of $3,300 and paid to the order of the Former SSD. Sales tax written on the memo line of the check. All of the information on the check, written out in the Former SSD's handwriting. The resident's name, signed on the signature line on the front of the check but the signature was not consistent with the resident's signature on his/her personal signature card. The Former SSD's signature, signed on the back of the check, endorsing it for deposit at Bank A. Information printed on the back of the check indicated the check was deposited at Bank A and credited to the account of within named payee; -A check, from the resident's account, dated 11/1/23, in the amount of $5,000 and paid to the order of the Former SSD. Loan and take LANHA $1,500 written on the memo line of the check. All of the information on the check, written out in the Former SSD's handwriting. The resident's name, signed on the signature line on the front of the check but the signature was not consistent with the resident's signature on his/her personal signature card. The Former SSD's signature, signed on the back of the check, endorsing it for deposit at Bank A. Information printed on the back of the check indicated the check was deposited at Bank A and credited to the account of within named payee; -A check, from the resident's account, dated 11/20/23, in the amount of $5,000 and paid to the order of the Former SSD. Christmas Bonus written on the memo line of the check. All of the information on the check, written out in the Former SSD's handwriting. The resident's name, signed on the signature line on the front of the check but the signature was not consistent with the resident's signature on his/her personal signature card. The Former SSD's signature, signed on the back of the check, endorsing it for deposit at Bank A. Information printed on the back of the check indicated the check was deposited at Bank A and credited to the account of within named payee. During interviews on 2/29/24 at 3:05 P.M. and on 3/1/24 at 1:15 P.M., the Former SSD said he/she started working at the facility in May of 2023. In his/her former role as SSD, it was his/her job primarily to advocate for residents and work with their families, participate in care planning and follow-up with residents or families regarding any concerns or grievances. His/Her employment at the facility ended in October of 2023. He/She had to cut ties with the facility because It was kind of a toxic environment. He/She ran into an issue with Resident #8 at the facility, with whom he/she had too much of a close, personal, trusting relationship with. The Former SSD would go in the resident's room and allow the resident to use his/her personal phone to make calls and handle his/her business. The calls would be on speaker phone and included such things as the resident paying bills or talking to his/her family. The Former SSD advised the resident he/she needed to get a power of attorney and perhaps get his/her adult child to help him/her more. The resident told the Former SSD that his/her adult child didn't want to help him/her. The Former SSD would help the resident with such things as making phone calls to handle his/her bills, mailing out things, he/she would call the resident's adult child and help with a lot of business stuff. The resident was always making some sort of payment, and the Former SSD would help him/her. He/She would call customer service for the resident's credit card when it would get locked out, and he/she would have the phone on speaker phone. The resident would have everything, his/her checks and credit cards, in his/her possession, up until he/she ordered a whole lot of checks. The resident asked the Former SSD if he/she could keep some of his/her checks in the social service office for him/her. The Former SSD put the resident's checks in his/her office, in a locked drawer. A lot of times, when he/she would go in the resident's room, he/she would have his/her checks, credit cards and everything out. The facility had agency staff come in, and so many people were in and out of the resident's room . The Former SSD said he/she Just worried about that and had conversations with the resident about what if something happened to those items. He/She would walk the resident's checks up to the front desk to mail them out for him/her. He/She wrote out some checks for the resident but the checks were for the resident's bills. He/She did not help any other residents with their money or financial affairs. The resident was the only resident in the facility with his/her own money and he/she was private pay. The Former SSD wrote a letter, saying he/she could help the resident with his/her money and had the resident sign it. The letter Kind of put a bad taste in everyone's mouth towards him/her because they thought the Former SSD was Going to take advantage of the resident. The Former SSD asked the resident to sign the letter because he/she was helping him/her do a lot of personal stuff. The letter was written in order for the Former SSD to be okay helping the resident, and he/she didn't want it to look like he/she taking advantage of the resident. The Former Administrator said it don't look good that he/she had the resident sign the letter. He/She understood what the Former Administrator was saying, but he/she told the Former Administrator he/she would not be coming back to work at the facility. He/She felt like the way everyone responded to the situation made his/her coworkers feel a certain way about him/her and he/she felt it was defamation of his/her character. He/She thought he/she was protecting him/herself with the letter. He/She considered the letter a legal document and contract to help the resident and to get permission to help him/her. The Former SSD didn't want People to think (he/she) was robbing the resident. The resident had approached the Former SSD about him/her helping his/her with finances. The Former SSD told the resident he/she didn't know if he/she should do it and he/she didn't think it was a good idea, but the resident would cry and continue to ask for help. A mobile notary came to the facility and was present when the resident signed the letter and it was notarized, in the resident's room with him/her present. The resident is cognitively intact and knew what he/she was doing and what was going on. The Former SSD said he/she would consider it part of his/her job description to help residents and advocate for them, such as with financial matters. The payroll office handled most financial manners, including giving out money to residents. He/She was not aware of any other staff in the facility who helped any other residents with finances or managing their private funds. The resident absolutely asked, many times, almost 50 times for the Former SSD to help with his/her finances, before he/she gave in to the resident's request. He/She told the resident he/she was here for work and needed to cover him/herself because the resident said his/her family was not willing to help, so the Former SSD said he/she would help the resident out when he/she had time. The resident said his/her adult child did not have his/her best interest and described many times not trusting his/her adult child to help with his/her with finances. He/She felt he/she was being punished for helping the resident out. When he/she left his/her employment at the facility, he/she gave the Former Administrator all of the resident's check books that he/she had locked up in his/her office. From there, he/she could not say what happened with them. The Former SSD let the resident know the Former Administrator had his/her check books and he/she may want to go talk to him/her. The resident said he/she hoped he/she hadn't gotten the Former SSD in trouble. The Former SSD told the resident not to worry about it and they did nothing wrong, it was fine. The resident did offer the Former SSD money but he/she didn't' take it because he/she knew that would be crossing the line and it wouldn't be right. The resident probably considered the Former SSD like a family member, but he/she didn't want to take advantage and only wanted to do the minimum to help him/her basically. He/She never saw any of the resident's bank statements but he/she was aware images of checks written from the resident's account would be included with his/her monthly bank statements. When this writer asked the Former SSD about checks written to him/her, in his/her handwriting, from the resident's account, the Former SSD asserted he/she did not know anything about the checks and said he/she was not aware checks were made out to him/her. He/She was not sure why there were checks written out to him/her from the resident's account. The Former SSD said if checks were written out to him/her, it meant after (he/she) turned the resident's checks over, someone had access to the checks and must have written his/her name on the checks. The Former SSD said he/she did not have the resident's checks in his/her possession, now or any time after he/she stopped working at th [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs by not providing baths/showers for three residents (Residents #1, #2 and #3). The sample size was four. The census was 75. Review of the facility's Activities of Daily Living (ADLs) policy, revised on 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse; -A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/23, showed: -Rarely/never understood by others; -Rarely/never understood others; -Short and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Always incontinent of bladder and bowel; -Total dependence on staff for bathing; -Diagnoses included Alzheimer's disease, stroke, aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia. Review of the resident's care plan, undated, showed: -Problem: ADL selfcare performance deficit related to dementia; -Interventions included: Bathing and showing: The resident was totally dependent on one staff to provide a shower two times per week and as necessary. Review of the resident's ADL documentation for bathing/showers, dated January 2024, showed: -The resident was scheduled for baths/showers on Wednesdays and Saturdays during the 3:00 P.M. to 11:00 P.M. shift; -The boxes were blank for the following days: 1/3/24, 1/27/24 and 1/31/24. Review of the resident's ADL documentation for bathing/showers, dated 2/1/24 through 2/23/24, showed: -The resident was scheduled for baths/showers on Wednesdays and Saturdays during the 3:00 P.M. to 11:00 P.M. shift; -The boxes were blank for the following days: 2/10/24, 2/14/24 and 2/21/24. Observation on 2/22/24 at 10:34 A.M., showed the resident lying in his/her bed, positioned to the left side with a pillow under his/her left shoulder and wearing pressure relieving boots on both feet. The resident's hair appeared unwashed and uncombed. The resident was covered with a blanket up to his/her chest. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Always incontinent of bladder; -Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) present for bowels; -Impairment on one side of lower body; -Required substantial/maximal assistance for shower/baths; -Diagnoses included heart failure, end stage renal disease and stroke. Review of the resident's care plan, undated, showed: -Problem: ADL assistance and therapy services needed to maintain or attain highest level of function; -Interventions included assist with mobility and ADLs as needed. Review of the resident's ADL documentation for bathing/showers, dated January 2024, showed: -The resident was scheduled for baths/showers on Mondays and Thursdays during the 7:00 A.M. to 3:00 P.M. shift; -The boxes were blank for the following days: 1/18/24, 1/22/24 and 1/29/24. Review of the resident's ADL documentation for bathing/showers, dated 2/1/24 through 2/23/24, showed: -The resident was scheduled for baths/showers on Mondays and Thursdays during the 7:00 A.M. to 3:00 P.M. shift; -The boxes were blank for the following days: 2/5/24, 2/12/24, 2/19/24 and 2/22/24. Observation on 2/23/24 at 8:52 A.M., showed the resident lying in his/her bed, positioned to his/her right side with a wedge behind the resident's right shoulder. The resident's hair appeared unbrushed. The resident was covered with a blanket up to his/her upper chest. During an interview on 2/23/24 at 9:16 A.M., the resident said: -He/She was not receiving bed baths or showers on his/her scheduled days, which were Wednesdays and Saturdays; -The last bed bath/shower he/she received was on Saturday, 2/17/24; -Staff only asked if the resident wanted a bed bath/shower on his/her scheduled days, even if he/she missed a bed bath/shower; -Staff fail to give the resident his/her scheduled bed bath/showers at least once every two weeks and since they will not offer one in between the scheduled times, the resident sometimes goes six days without bathing; -He/She feels dirty and sometimes ashamed of his/her appearance in front of others. 3. Review of Resident #3's admission MDS, dated [DATE], showed: -Rarely/never understood by others; -Rarely/never understood others; -Short and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Required an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for bladder; -Always incontinent of bowel; -Impairment on one side of both the upper and lower body; -Totally dependent on staff for bathing; -Diagnoses included stroke, hemiplegia (paralysis on one side of the body), kidney failure and aphasia. Review of the shower schedule for the resident's hall, showed the resident was scheduled for baths/showers every Wednesday and Saturday during the 7:00 A.M. to 3:00 P.M. shift. Review of the resident's shower sheets for January 2024, showed: -The resident refused a shower on 1/31/24; -There were no other shower sheets provided by the facility. Review of the resident's ADL documentation for bathing/showers, dated 1/23/24 through 2/5/24, showed: -The boxes were blank for every day. Review of the resident's shower sheets for February 2024, showed: -The resident received a bed bath on 2/9/24 and 2/21/24; -There were no other shower sheets provided by the facility. Review of the resident's ADL documentation for bathing/showers, dated 2/5/24 through 2/22/24, showed: -The boxes were blank for every day. Review of the resident's care plan, dated 2/22/24, showed: -Problem: ADL assistance and therapy services needed to maintain or attain highest level of function; -Interventions included assist with mobility and ADLs as needed. Observation on 2/22/24, at 9:23 A.M., showed the resident in his/her bed. The resident wore a hospital gown. The resident's face appeared unwashed with dried white substance around his/her mouth and dried substance accumulated around the resident's inner eyes. The resident's skin appeared dry and flaky. 4. During an interview on 2/23/24 at 9:28 A.M., Certified Nurses Aide (CNA) A said: -Residents received baths/showers two times a week; -Each hall had a shower book which included the residents' scheduled bath/shower days and times; -If staff were not able to give ADL dependent residents their baths/showers on their scheduled day and time, the residents would receive their next shower on their regularly scheduled day and time; -He/She would not know if a resident missed one of their bath/showers unless another CNA informed him/her during report when coming on shift. If he/she knew a resident missed a bath/shower, he/she would offer the resident one; -CNAs were required to fill out a shower sheet after every bath/shower they provided to residents; -Shower sheets were then turned into the nurse on duty for their signature; -CNAs were expected to reapproach a resident two or three times if a resident refused a bath/shower, note the refusal on the shower sheet and when documenting ADLs in the resident's electronic medical record (EMR), and notify the nurse of the refusal. During an interview on 2/23/24 at 9:36 A.M., Licensed Practical Nurse (LPN) B said: -Each resident received a bath/shower two times a week according to the schedule found in each hall's shower schedule binder; -CNAs were required to fill out a shower sheet after they provided baths/showers to residents and then turned it into the nurse on duty; -Shower sheets were filed in an accordion file at the nurses' station; -He/She expected nurses to write a progress note in a resident's EMR showing they missed their scheduled bath/shower during the day shift and then tell the on-coming nurse in report; -He/She expected the next shift, the evening shift, to offer and complete the resident's bath/shower; -He/She was not sure how staff would know if residents received their make-up bath/shower on the evening shift. During an interview on 2/23/24 at 11:11 A.M., the Administrator said: -She expected staff to have knowledge of and to follow the facility's policies and procedures; -She expected CNAs to provide ADL dependent residents baths/showers at least twice a week and more often if requested; -She expected staff to give a resident a bath/shower on the next shift or the next day if they had missed their scheduled bath/shower; -She expected CNAs to notify the nurse if they were not able to give residents their baths/showers; -She expected nurses to write a progress note in the residents' EMR showing the resident missed their scheduled bath/shower and to tell on-coming staff so they could follow-up; -She expected CNAs to tell the on-coming CNAs when a resident missed their bath/shower; -She expected CNAs to document on shower sheets if they provided a bath/shower to a resident, if a resident refused, as well as document any skin issues. Shower sheets were then turned into the nurse on duty; -CNAs were expected to document ADLs when they completed the bathing task for residents; -A blank in the ADL documentation showed a task was either not done or the CNA did not document the task; -She expected either the Director of Nursing (DON) or MDS Coordinator to check to see if residents were receiving their bath/showers at least weekly, if not daily. They could look at the shower sheets, ADL documentation and/or progress notes to see if baths/showers were completed; -Regular baths/showers were important to maintain skin health and integrity; -She expected nurses to document residents' refusal to take baths/showers in the EMR; -She expected nurses to write a progress note in the EMR, notify family and Primary Care Provider (PCP) if a resident continued to refuse a bath/shower; -She expected the DON or MDS Coordinator to address a resident's continued refusal of baths/showers, try to figure out the issue, make changes to the shower schedule if needed and update the care plan. MO00230414

Based on interview and record review, the facility failed to ensure a resident who admitted to the facility with a left ankle surgical wound on 6/26/23 received wound care orders timely. The facility obtained orders on 6/28/23 and failed to ensure dressing changes occurred after orders were received (Resident #1). The sample was 3. The census was 60. The administrator was notified on 8/3/23, of the past non-compliance. The facility has changed their admission order process to include if a resident is admitted with a wound that wound care orders will be verified. The deficiency was corrected on 7/15/23. Review of the Skin Integrity Prevention and Management policy, reviewed 3/31/23, showed: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent skin injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the National Pressure Injury Advisory Panel (NPIAP); -Procedure: -A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible damage already present. Signs may include dark areas surrounded by edema (swelling), profound redness and/or discoloration. A skin assessment/inspection occurs on admission/re-admission. Skin observations also occur throughout points of care provided by Certified Nurse Aides (CNA) during care, any changes or open area are reported to the nurse. The CNA will also report to the nurse if a topical dressing is identified as soiled, saturated or dislodged. The nurse will complete further inspection/assessment and provide treatment if needed; -A resident's risk may increase due to an acute illness or condition change and may require additional evaluation; -Certain risk factors have been identified that increase a resident's susceptibility to impair healing, include but not limited to: -Impaired/decreased mobility and decreased functional mobility; -Co-morbid conditions, such as diabetes; -Medications that may affect wound healing; -Impaired blood flow; -A skin assessment should be preformed weekly by a nurse. Review of Resident #1's hospital discharge summary, dated 6/26/23, showed: -Pertinent discharge diagnoses included: diabetes, atrial fibrillation (rapid irregular heart beat), and surgical repair of left open ankle fracture; -Surgical left ankle repair completed on 6/13/23; -Activity: Non-weight bearing lower left extremity, weight bearing as tolerated to right lower extremity; -Wound care: None needed; -Sutures/staples: Re-check in one week and follow up in clinic in one week; -Note: Orthopedics was requested to visit patient and take a look and remove sutures before discharge, Physician Assistant stated Orthopedics was busy and may not get to see the patient prior to discharge. If the patient goes to a skilled nursing facility (SNF) the sutures can be removed at follow up appointment. Review of the admission physician order sheet (POS), medication administration record (MAR) and the treatment administration record (TAR), dated 6/26/23, showed no admission wound care orders. Review of the medical record, showed: -admitted to facility: 6/26/23; -No admission skin assessment on 6/26/23. Review of the facility wound report, dated 6/25/23-7/1/23, showed: -Onset date: 6/26/23; -Location: Surgical wound; -Type: Surgical wound; -Stage/category: Well-approximated; -Measurements: Length: 0 centimeters (cm) x width 0 cm x depth 0 cm; -Drainage: Serosanguineous (blood tinged thin fluid); -Pain: No; -Treatment: Dry dressing every other day per resident; -Undated when measurements were obtained. Review of the progress notes, showed on 6/27/23 at 11:25 A.M.: Per the discharge orders, no wound care is needed for the surgical site. The resident to follow up with the surgeon in one week from 6/24/23. Review of the skin integrity assessment, dated 6/27/23 at 4:31 P.M., showed: -Skin intact: No; -Not intact: Surgical incision; -New finding: Yes; -If yes, list the date: Admission; -Site: Left inner ankle; -Note: Surgical incision/stitches on the inner and outer ankle/foot. Serosanguineous fluid coming from the exterior (outside) suture site. Per the discharge paperwork, no wound care is needed. The resident stated the Physician wanted the dressing changed every two days to keep the site clean and dry. Writer will follow up with Surgeon's office to clarify orders. The dressing had some fluid present and resident's follow up appointment is scheduled for 7/6/23; -No documentation if a treatment or dressing was applied to the surgical site; -No wound measurements. Review of the progress notes, showed: -On 6/27/23 at 4:34 P.M., the Surgeon's office was closed. Will follow up in the morning; -On 6/28/23 at 1:09 P.M., left a voice mail with Surgeon's office to obtain dressing change orders. The resident would prefer the dressings to be changed every other day to keep the wound dry and intact, waiting for a return call; -On 6/28/23 at 1:44 P.M., received a new order to change the left ankle wound with Xeroform (covers and protects low to non-draining wounds) and dry dressing change as needed (PRN) if soiled. Review of the June 2023 TAR, showed: -An order dated 6/28/23: Change dressing to left ankle wound with Xeroform and dry dressing PRN if the dressing is soiled. Change PRN; -Treatment noted as blank on 6/28/23, 6/29/23 and 6/30/23. Review of the admission skilled nursing documentation, dated 6/28/23 at 10:07 P.M., showed: -Principle reason for admission: Orthopedic; -Skilled nursing services: Fracture, boot to both right and left lower extremities; -Note: The resident continued with skilled therapy. He/She was alert to person, place, time and situation and able to make needs and wants known. Review of the July 2023 TAR, showed: -An order dated 6/28/23: Change dressing to left ankle wound with Xeroform and dry dressing as needed if the dressing is soiled. Change PRN; -Treatment noted as blank on 7/1/23, 7/2/23, and 7/3/23. Review of the facility wound report, dated 7/2/23-7/8/23, showed it did not list the resident on the report. Review of the progress notes, showed on 7/3/23 at 11:45 A.M., The resident and family requested the resident to be sent to the hospital for an infected wound. The nurse offered to assess the wound and spouse declined assessment and showed the nurse a picture of the surgical site. The resident's Physician notified and new order to send to the hospital for assessment. The resident's spouse packed belongings and home medications given to family. Review of the hospital emergency room notes, dated 7/3/23 at 12:08 P.M., showed: -Patient has a wound of the left medial (outer) ankle that has been gradually worsening since being discharged from the hospital. He/She was not discharged home with antibiotics. The patient reports headache, low-grade fever and throbbing pain to the affected area. Family stated they changed the dressing last night; -Review of skin: Ten incisions, one to the medial area of the left ankle with purulence (a sign of infection a white, yellow, or brown fluid and might be slightly thick in texture) over the incision and sutures in place; - Physician summary: Presented for drainage from the left ankle. Patient and family concerned for wound infection/drainage. He/She noted to have sutures present. Wound noted oozing/drainage to the surface. Seen by Orthopedics and will admit with intravenous (IV) antibiotics. Review of the hospital course, showed: -On 7/4/23 at 5:23 A.M.: Problems: -Open wound to the left foot with recent open reduction and internal fixation (ORIF, surgical procedure puts pieces of a broken bone into place using screws and plates); -Concern for soft tissue infection; -Concern for complicating cellulitis (skin infection); -Seen by orthopedics and placed on IV antibiotics; -Given risk factors, will broaden antibiotics to vancomycin (antibiotic), Cefepime (antibiotic) and Flagyl (antibiotic); -Check wound cultures; -Needs careful monitoring, at high risk for complication; -Was doing well at discharge from recent hospitalization but had worsening after about two days at facility. He/She noticed worsening drainage and surrounding redness. Review of the hospital operative report, dated 7/5/23, showed: -Preoperative diagnosis: Postoperative infection of the left medial ankle; -Proposed procedure: Open irrigation and debridement (surgical removal of dead or infected tissue) of the wound; -Procedure performed: Debridement of the wound. Skin, fat, fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place) and ligament were all removed as well as suture material. The debridement went down to the bone. The area of debridement was 10 cm in length and 2 cm in width; -Indications: The patient had sustained an open fracture dislocation to his/her ankle. He/She underwent an uncomplicated open reduction and internal fixation. He/She was sent to a skilled nursing facility where he/she received 1 dressing change. No one assessed until the family did and the family did dressing changes for 48 hours and brought him/her to the hospital where he/she was found to be draining purulent fluid. He/She was placed on IV antibiotics, when assessed this morning the wound was found to be draining, he/she was booked into the operating room urgently. Review of the hospital discharge surgical summary, dated 7/21/23, showed: -Assessment/plan: Left ankle surgical wound infection: Left ankle x-ray with diffuse (spread) soft tissue swelling, no hardware related complications noted. Blood cultures negative and wound cultures collected in the emergency room grew bacteria. The patient underwent surgery and wound vacuum placement on 7/5/23. The patient completed IV antibiotics 7/3/23-7/19/23. He/She will be discharged home with home health services. During an interview on 8/2/23 at 12:10 P.M., the resident's next of kin said the resident did not receive wound care at the facility during his/her stay. The staff did not obtain treatment orders for several days after his/her admission and then did not change the dressing when the dressing was dirty. The wound began to look infected and family and the resident wanted to go to the hospital for assessment. The family purchased the wound supplies and changed the dressing themselves as the facility did not change the dressing. The resident was admitted for an infection of the surgical wound, received surgery to clean the wound and received multiple antibiotics. He/She remained in the hospital for 17 days. During an interview on 8/3/23 at 8:45 A.M., the Administrator said the resident and the family had voiced concerns regarding his/her care on 7/13/23. The facility investigated the concerns and discovered the resident admitted to the facility following a surgical repair to the left ankle. The hospital discharge paperwork showed no wound care was needed. The admission nurse did not document the condition of the wound at admission and did not verify wound orders. The facility started in-servicing and training for the admission process, continuing wound/skin documentation and wound admission orders. All nursing staff had been in-serviced. During an interview on 8/3/23 at 12:45 P.M., the Wound Nurse said he/she just started the Wound Nurse position. If a resident is admitted to the facility with any kind of skin impairment, the nurse should verify wound care orders. Any wounds that show a change should be assessed and the Physician notified for a change in orders. Wounds should be documented on frequently to show the assessment and any potential wound changes. MO00221423

See Event ID UBXX12 Based on interview and record review, the facility failed to protect Resident #20's right to be free from abuse when Certified Nursing Assistant (CNA) Y grabbed the resident by the wrists, forcing the resident to get out of bed against his/her wishes, resulting in skin tears to both wrists. Additionally, the facility failed to protect Resident #35 from abuse when he/she was left overnight in the same room with Resident #36 who yelled at, repeatedly hit him/her, and tried to force Resident #35 from their shared room. The census was 65. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, dated 4/15/19, showed the following: -Position statement and guidelines: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to: Staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or other individuals. It is the policy and practice of the facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -Prevention: It is the policy of the facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation; -The facility must identify, correct and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur, to include trained and qualified registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms if any; -Identification: It is the policy of the facility to identify abuse, neglect and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators; -Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods, or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Training: It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: *Reporting abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -Procedure: *Following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent reoccurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation; *The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment , if needed; *When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator; *If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. 1. Review of Resident #20's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 12/17/22, showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands, clear comprehension; -Brief Interview for Mental Status/BIMS (a cognitive assessment) score of 15, indicating the resident is cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, personal hygiene and bathing; -Total dependence of one person required for transfers; -Mobility Devices: Wheelchair; -Always incontinent of bowel and bladder; -Diagnosis of anxiety. Review of the resident's care plan, located in the electronic health record (EHR), showed: Focus: -Resident has activity of daily living (ADL) self-care deficit performance, related to impaired balance due to syncope (dizziness); -Resident has pain/discomfort related to decreased mobility; -Resident has potential for skin tears related to fragile skin; Interventions: -Assist with mobility and ADLs as needed. Review of the MDS Nurse's progress note, dated 1/14/23 at 9:27 P.M., showed: -CNA (CNA Y) reported to nurse that resident had obtained a skin tear while transferring the resident into a chair. Resident has two skin tears to both wrists; top of the right wrist 4 centimeters (cm) by 2.5 cm, area steri-stripped (thin adhesive strips used to hold the skin together) and dry dressing applied. Top of left wrist 5 cm by 3 cm, area steri-stripped and dry dressing applied. Physician and family made aware. Review of the facility self-report to the State Survey Agency, dated 1/15/2023 at 9:08 A.M., showed: -It was reported to the Administrator this evening (1/14/23) that a resident (Resident #20) said he/she received skin tears during a transfer. Statements were obtained from Certified Nursing Assistant Y and Nurse Z. A telephone call was placed to Nurse AA, the outgoing nurse, to obtain a statement. Yesterday, at the change of shift (around 3:00 P.M.) the resident did not want to get out of bed. The resident has a history of refusing things and not wanting to get out of bed. The CNA said the resident was kicking at him/her and did not want to get up. The resident did say he/she was kicking at the CNA and did not want to get up. The CNA said as he/she was trying to calm the resident down, the resident was swinging and kicking, so he/she (the CNA) grabbed the resident's wrists so as not to get hit. The resident said the CNA grabbed him/her by the wrists to transfer him/her to the chair. The resident sustained skin tears on his/her wrists; -During walking rounds Nurse Z and Nurse AA discovered the resident's skin tears and Nurse Z (the on-coming nurse) dressed the resident's skin tears. It wasn't until later that another nurse (MDS Nurse) heard about the tussle, and the Administrator was notified about the incident. Review of an investigation statement, undated but documented by the Administrator, showed: -It was reported to Administrator, on 1/14/23 at approximately 7:30 P.M., that a resident (Resident #20) received skin tears during a transfer; -Statement was obtained from CNA Y and he/she was sent home; -Statement was obtained from Nurse Z and he/she was sent home; -Telephone call placed to Nurse AA and a statement was obtained. Nurse AA was placed on administrative leave; -CNA Y's statement identified himself/herself as engaging in a transfer with the resident. While transfer took place, skin tears were obtained; -Statement from the resident showed that a CNA was fighting with him/her. The resident did not want to get out of bed. The CNA gripped his/her wrists and caused the skin tears; -Further findings showed Nurse Z was aware of the situation. He/she dressed the resident's skin tears. However, he/she did not report the incident timely; -CNA Y and Nurse Z were placed on the do not return list from the agency. Review of the resident's statement for the facility investigation, recorded by the MDS Coordinator, showed: -Date of Statement: 1/14/23; -Time of Statement: 7:30 P.M.; -Resident said that CNA Y was fighting with me. I didn't want to get up. He/she grabbed my arms and caused skin tears. The resident was asked if he/she felt safe at the facility and the resident said not with that CNA. He/She did not want that CNA taking care of me. During an interview on 3/2/23 at 7:48 A.M., the resident said he/she told CNA Y he/she did not want to get up that day, but the CNA would not listen. The CNA grabbed him/her by the wrists causing the skin tears and made him/her get up and in a wheelchair anyway. He/She did kick and swing at the CNA during the transfer because he/she was angry the CNA would not listen to him/her. He/She felt as though his/her opinion did not matter. Review of the MDS Coordinator's statement for the facility investigation, dated 1/14/23 at 7:30 P.M., showed: -Date of Incident: Blank; -Time of Incident: Blank; -He/She got to work around 4:00 P.M. and went to get keys from Nurse Z. Nurse Z said he/she had to do a report on the resident's skin tears. Nurse Z did not mention how the resident got the skin tears; -The MDS coordinator went into the resident's room to obtain a blood pressure. She asked the resident what happened to his/her arms, as the resident had dressings on both wrists. The resident stated that a CNA was fighting with him/her. He/She did not want to get up and the CNA grabbed his/her wrists, causing the skin tears. During an interview on 2/23/23 at 12:30 P.M., the MDS Coordinator said the resident has resided at the facility for over a year. He/She is alert and does not have a history of accusing staff of abuse or handling him/her roughly. He/She does not like to get out of bed. She (MDS Coordinator) was on call on 1/14/23 and came to the facility on the evening shift because the Certified Medication Technician called off, so she came in to pass medications. Around 7:00 P.M. to 7:30 P.M., she went into the resident's room to get his/her blood pressure. She noticed the dressings on the resident's wrists and asked the resident what happened. The resident said CNA Y grabbed him/her earlier that day and made him/her get up causing the skin tears. He/She did not want to get up, but the CNA made him/her get up. The MDS Coordinator called the Administrator right after the resident told her. The Administrator told her to begin the investigation and she was on her way to the facility. CNA Z was working a double shift that day and was still working, but was assigned to a new group of residents and was no longer working with Resident #20. She got the CNA's statement and sent him/her home. She got Nurse Z's statement and sent him/her home. The Administrator arrived and they interviewed other staff and residents. Review of CNA Y's written statement to the facility, dated 1/14/23, showed: -Date of incident: 1/14/23; -Time of Incident: 2:40 P.M.; -Resident was refusing care and to get up out of bed. Advised resident charge nurse (Nurse AA) advised him/her (CNA) to get him/her up. Resident became combative kicking, yelling, punching while performing perineal care (cleaning the genitalia). Upon sitting the resident up in bed to perform a transfer, the resident kept swinging at him/her, and while trying to calm resident down, resident gained skin tears. Charge nurse was notified of the incident. Review of CNA Y's statement to the state agency, dated 1/16/23, showed he/she said he/she had worked at the facility through an agency for about five months. He/She was working a double shift on Saturday 1/14/23. He/She did not usually work day shift or with the resident. The resident had diarrhea that day. The nurse on the day shift asked CNA Y to get the resident up. He/She had not had any problems with the resident being combative that day prior to getting the resident up. As he/she went to get the resident out of bed and into the wheelchair, the resident kicked, screamed and yelled No. During the transfer, the resident sustained two scratches on the back of his/her wrists approximately one to two inches long. CNA Y immediately went out and told the day and evening shift nurses about the interaction. No one told him/her the resident could be combative until afterward. He/She worked that evening until almost 8:00 P.M., when the MDS Coordinator came to him/her and got his/her statement. He/She was then asked to clock out and go home. He/She wondered why they waited so long to send him/her home. During an interview on 3/6/23 at 9:05 A.M., CNA Y said he/she was scheduled to work a 16 hour shift that day and took care of the resident on the day shift, but not the evening shift. The resident was having diarrhea. The resident needed a complete bed change due to the diarrhea. Around 9:00 A.M., he/she wanted to get the resident up, but the resident did not want to get up, so he/she left the resident alone. Around 2:00 P.M., he/she provided the resident with perineal care and the resident was agitated, but did not want to get up. Nurse AA told him/her to get the resident up due to on-going diarrhea. The resident still did not want to get up and he/she told Nurse AA, who said to ask the resident again. When he/she asked the resident again, the resident consented, but became combative when he/she began to transfer the resident from the bed to the wheelchair. It was during the transfer, the resident sustained the skin tears, and he/she (CNA Y) told Nurse Z and Nurse AA about the skin tears right after it occurred at the end of the day shift, around 3:00 P.M. Review of Nurse Z's written statement to the facility, dated 1/14/23 at 7:38 P.M., showed: -Date of Incident: 1/14/23; -Time of Incident: 2:52 P.M.; -At 2:52 P.M., nurse (Nurse Z) was doing walking report with off-going nurse. CNA (CNA Y) approached and stated that Resident #20 had skin tears from tussling when he/she was getting the resident out of bed. Finished report with off-going nurse and went to resident's room to dress the skin tears. Resident stated he/she did not want to get out of bed, but they made him/her. During an interview on 3/3/23 at 2:55 P.M., Nurse Z said he/she and Nurse AA were making walking rounds at the shift change when CNA Y informed them about the resident's skin tears. He/she heard the CNA say he/she was getting the resident up, and the resident tussled with him/her causing the skin tears. He/She did not hear the CNA say the resident was hitting or kicking, just tussling. He/she did not ask the CNA what he/she meant by tussled. After finishing shift change report with Nurse AA, he/she went to the resident's room to dress the skin tears. The resident said the CNA made him/her get up causing the skin tears. He/She told the resident he/she was having diarrhea and the CNA got him/her up so he/she could change the resident's bed. The resident said he/she knew why the CNA got him/her out of bed, and he/she (the nurse) was right. He/She did not ask the resident any questions about what happened during the transfer. In hindsight, he/she should have asked the resident more questions. Had the CNA told him/her that resident did not want to get up, he/she would have went with the CNA and completed an occupied bed change (changing the bed with the resident in the bed). The resident has very thin and fragile skin. Review of Nurse AA's statement, sent to the facility via e-mail on 1/15/23 at 8:42 A.M., showed on Saturday (1/14/23) at approximately 3:15 P.M. he/she and Nurse Z were walking down the hall after counting the medication cart. They were walking from 400 hall to 300 hall when CNA Y said the resident had two skin tears, and he/she had to get the resident up to do a complete bed change. Nurse AA told Nurse Z to dress the skin tears and he/she would look at the skin tears on Monday. Nurse AA then left the hall. During an interview on 3/3/23 at 12:26 P.M., Nurse AA said on 1/14/23 after his/her shift was over, he/she and Nurse Z were walking down the hall when CNA Y told them the resident had sustained two skin tears after he/she got the resident up. He/She did not hear the CNA say anything about the resident tussling with him/her or that the resident was combative. The CNA should have told him/her the resident refused to get up. He/She would have told the CNA to leave the resident in bed as the resident has a right to refuse. Had he/she been aware of any abuse that occurred, he/she would have talked to the resident prior to leaving for the day. Review of CNA EE's written statement to the facility, dated 1/15/23, showed: -Date of Incident: 1/14/23; -Time of Incident: Blank; -He/she worked with the resident on the evening shift of 1/14/23. Around the beginning of the shift, the resident seemed upset. The resident said someone made him/her get out of bed and hurt his/her wrists. His/her wrists were bandaged at the time. He/She reported what the resident said to the nurse, who said he/she was aware of the incident. During an interview on 3/6/23 at 9:45 A.M., CNA EE said around 3:00 P.M. (on 1/14/23), the resident seemed upset, was kind of crying and seemed down. He/She asked the resident what happened and the resident said he/she did not want to get out of bed, but CNA Y made him/her. He/She told Nurse AA, who said he/she was aware of the incident. Around 4:00 P.M., the resident told him/her he/she did not want to get out of bed, but CNA Y forced him/her to get up. At some point during the conversation, the resident said CNA Y grabbed his/her wrists while getting him/her up causing the skin tears. CNA EE told Nurse Z who acted as though he/she did not know what was going on. CNA Y was still working at that time. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said she expects facility staff to follow their abuse and neglect policies, as well as the State and Federal regulations for reporting abuse/neglect issues. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expects staff to follow the facility abuse and neglect policy. Nurse Z should have asked CNA Y more questions when the CNA said the resident tussled with him/her, and should have asked the resident questions when the resident said the CNA made him/her get up causing the skin tears. Had those questions been asked, the facility policy would have been initiated at the time of the incident, and the CNA would have been sent home and not allowed to work after the incident occurred. 2. Review of Resident #35's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Independent with bed mobility, -Supervision needed with transfers, -Mobility Devices: Wheelchair. Review of Resident'#35's progress notes, showed the following: -On 1/19/23 at 9:33 P.M., the resident had a verbal altercation with his/her roommate about plugging items into an outlet. The nurse intervened and settled the argument; -On 1/20/23 at 8:00 A.M., the Director of Nursing assessed the resident. The resident stated his/her roommate hit him/her a few times with a closed fist. The area showed no bruising or swelling. The resident denied any pain. Review of Resident #35's care plan dated 1/24/23, located in the EHR showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Consult with resident on preferences regarding customary routine; -Focus: Resident has a psychosocial well-being problem related to altercation with another resident. Moved to another room; -Interventions/Tasks: Allow the resident time to answer questions and to verbalize feelings perceptions and fears. Increase communication between the resident/family/caregivers about care and living environment. When conflict arises, remove residents to a calm, safe environment and allow to vent/share feelings. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech -distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Moderately cognitively impaired; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Independent with bed mobility and transfers; -Mobility Devices: Walker; -Diagnosis of dementia. Review of Resident #36's progress notes, showed the following: -On 1/19/23 at 9:31 P.M., the resident had a verbal altercation with another resident (Resident #35). The nurse was able to break up the argument. The resident would not let his/her roommate plug items into an outlet. The nurse intervened and plugged the items in. The resident made the comment to the nurse, he/she is Crazy; -On 1/19/23 at 10:06 P.M., the resident stated his/her roommate (Resident #35) was not to be in his/her room. He/she hit his/her roommate several times. The staff removed the roommate for medications and an Accucheck (blood sugar monitoring) and then let the roommate back in the room after the resident calmed down. Approximately an hour later, the resident was up in the hallway stating the roommate had to go. The nurse went to check on the roommate and the roommate (Resident #35) said the resident (Resident #36) hit him/her again several times. The nurse drew the curtain between them. The CNA helped the resident calm down and get into bed. If there was a third instance with the resident hitting the roommate, they would relocate one of them to another room until the morning when the situation could be addressed by administration. Review of the facility's investigation dated 1/20/2023, no time noted, provided by the facility on 2/23/23 showed: -During review of the clinical notes, it was learned that Resident #36 struck roommate Resident #35; -MDS Coordinator assisted in moving Resident #35 to another room; -The social worker interviewed both residents, and Resident #36 did not recall striking the other resident; -The residents had not had any additional encounters and both were feeling safe. Resident #36 would not have a roommate. His/Her care plan would be updated to include this information. Review of Resident #36's care plan dated 1/24/23, located in the EHR, showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Medications as ordered. Psychiatric consult as ordered; -Focus: Resident has short term memory loss due related to diagnosis of dementia; -Interventions/tasks: Allow resident extra time for resident to respond to questions and instructions. Keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Provide resident with a homelike environment. -The care plan did not address the altercation with his/her roommate and interventions to prevent further occurrences. Review of a written witness statement form by Nurse DD dated 1/20/23 at 11:25 P.M., showed Resident #35 was yelling and the nurse went to get an accucheck on the resident. The resident stated he/she had been hit by Resident #36 and the resident was also hitting his/her wheelchair. The nurse checked on the resident and after an hour was doing okay. Later, Resident #36 came out into the hallway and told the nurse to get Resident #35 out of his/her room. During interviews on 2/23/23 at 1:30 P.M. and 4:30 P.M., Nurse DD said he/she was working short staffed the night of the incident. He/she was agency so did not know the residents well. He/She did not know if the residents had problems with each other. The first time he/she heard them yelling, he/she went into the room and Resident #35 told him/her Resident #36 had hit at him/her. Nurse DD immediately removed Resident #35 and brought him/her to the dining room area where he/she could observe him/her and administer his/her medication. He/she tried to find another room for the resident, but one side of the hall was being used for isolation, and there was only one room available on the other side, and the call light was not working in that room. Nurse DD did not feel comfortable putting the resident in the room without a working call light. Nurse DD talked to both residents and they seemed to be okay with each other, so he/she put the resident back in the room and left. A short time later, Resident #36 came out of the room yelling he/she wanted Resident #35 out of the room. When he/she got to the room, Resident #36 was banging on Resident #35's bedframe and yelling he/she wanted him/her out. The other staff member with him/her was able to get them calmed down and into bed. Staff pulled the curtain between the residents and turned off the light. He/She passed this information along to the other nurse in the building, who said he/she would notify the administrator. He/She probably should have done this him/herself, but he/she was working by him/herself and just was overwhelmed with getting everything done. During an interview on 3/2/23 at 10:00 A.M., Certified Medication Technician (CMT) O said he/she was working on the evening of 1/19/23. He/She heard Resident #35 screaming, he/she is Hitting me! CMT O went and got the nurse because the residents were not used to him/her. Resident #36 did not want Resident #35 in his/her room and kept yelling, he/she wanted him/her out of the room. When he/she and the nurse went in the room, Resident #35 said Resident #36 had hit him/her. Resident #36 was hitting at the other resident's bed and saying he/she wanted the other resident out of his/her room. The CMT kept telling Resident #36 not to hit the other resident, but he/she would not calm down. He/She just wanted the other resident out of the room. They were finally able to calm the residents down by pulling the curtain between them. CMT O thought they should have moved the resident out of room that night, but it was not his/her decision. CMT O did not think it was safe to keep them in the room together. During an interview on 2/23/23 at 12:30 P.M., Resident #35 said he/she tried and tried to get along with his/her roommate (Resident #36). Resident #36 was used to being by him/herself and did not want anyone in his/her room. Resident #36 would yell at Resident #35 if he/she was in the bathroom when he/she wanted to use it. It got to the point where Resident #35 would go down the hall to use the bathroom because he/she did not want to upset his/her roommate. One day, Resident #36 unplugged his/her television and electronic picture frame from the wall and told him/her, it was not his/hers to use. Resident #35 had talked to the social worker about changing rooms, but he/she did not want to cause problems. They told him/her there was a room with a bathroom which would be available in ten days and then this incident happened. Resident #36 would put on his/her pajamas at 6:00 P.M. and be ready to go to bed by 7:00 P.M. and would turn off the lights. On the night of the incident, Resident #35 did not want to go to bed at 7:00 P.M. because he/she had not gotten his/her medication yet, so he/she turned the light back on. Resident #36 started yelling at Resident #35 and told him/her to get out of the room and started to pull his/her covers off the bed. Resident #35 grabbed at the covers to keep them on the bed and Resident #36 began to hit Resident #35 with a closed fist. Resident #35 started yelling for help. The nurse came in and took him/her out of the room for a while but brought him/her back to the room. He/She did not really want to go back into the room with the other resident but agreed to stay in the room for the night. Resident #36 got upset again and started to push his/her wheelchair towards the door saying he/she wanted him/her out of the room. Resident #36 was swinging at Resident #35 trying to hit him/her. Finally Resident #36 went out into the hallway to yell at staff. Staff came into the room and got Resident #36 to calm down. They pulled the curtain between them and left the room. Resident #35 would have liked to go to another room, but the staff did not offer to take him/her to another room and he/she did not want to cause problems, so he/she figured it would be okay for the night. Review of a written witness statement form by the MDS Coordinator dated 1/20/23 at 8:00 A.M., showed she talked to Resident #35 regarding the incident from the prior evening. The resident said around 8:00 P.M., his/her roommate turned the light off. The resident told him/her to stop and leave the light on as he/she had not received his/her medication yet. It went downhill from there. Resident #36 told him/her he/she would not go to bed until Resident #35 left the room and grabbed his/her blanket. Resident #35 grabbed his/her blanket back and Resident #36 hit him/her on his/her left arm with his/her fist. There was no discoloration noted and the resident denied any pain. Resident #35 was moved to a different room. During an interview on 3/7/23 at 9:35 A.M., the MDS Coordinator said the Assistant Director of Nursing read about the incident during report the next morning. This was the first they knew about the incident. The report said Resident #36 hit Resident #35 twice. The former Director of Nursing did the investigation. Resident #35 does not like his/her light turned off until after he/she gets his/her medication. The other resident did not like him/her turning the light back on and hit him/her twice. The staff should have called the Administrator or the Director of Nursing the night of the incident for guidance. She would think the resident should have been moved out of the room that night because staff would wanted to make sure he/she was protected from the other resident. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said the residents should have been separated after the one hit the other for their safety. During an interview on 3/2/23 at 4:11 P.M., the Administrator said the staff should have moved the residents to separate rooms on the night of the incident to keep the residents safe. MO00212631 MO00212669 MO00212876 40865

36151 See Event ID UBXX12 Based on observation, interview and record review, the facility failed to follow their policies by failing to follow physician's orders, and/or Registered Dietician's (RD's) recommendations. The facility failed to make and provide any fortified foods (foods with additional calories/protein), provide double portions to residents with orders for double portions, provide accurate servings sizes per the recipe, and failed to consistently provide house shakes (nutritional drinks). The facility failed to ensure staff followed resident menu slips (used by dietary staff that shows each residents current diet orders/preferences) and/or failed to ensure menu slips, physician orders and care plans reflected residents' current diet order/preferences. In addition, the facility failed to ensure residents received assistance when needed. Nine residents were sampled. Of those nine, problems were found with four, three who had severe weight loss (a significant weight loss is considered 5% in one month, 7.5% in three months, and 10% in six months. A weight loss of more than 5% in one month, 7.5% in three months and 10% in six months is considered severe) (Residents #30, #25 and #26), and one who did not receive fortified foods, and did not consistently receive house shakes (Resident #28). The census was 65. Review of the facility's undated Resident at Risk (RAR) policy, dated 4/15/22, showed the following: -Policy: This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues; -Procedure: The facility establishes an organized interdisciplinary team to review the residents with identified nutritional issues or the potential for developing nutritional problems; -The team my consist of members representing a minimum of Food and Nutrition Services, RD, Nursing, Rehab and and Activities. Other departments such as Social Services, may also be involved; -The committee designates a team leader who is responsible for the following: -Developing a review list each week 24-48 hours before the meeting. The list includes residents who will be discussed in the meeting; -Ensuring the tasks are recorded on the Review List/Follow Up Form; -Distributing the form with the minutes after the meeting has been conducted; -The Review list includes but is not limited to the following: -Residents with significant weight change: -5% in 30 days; -7.5 % in 90 days; -10% in 180 days; -The designee for Food and Nutritional Services may do the following before the meeting: -Follows up on prior interventions to determine the effectiveness; -Updates food preferences; -Talks to the Certified Nursing Assistant (CNA) regarding the resident and dining; -Talks to the family if possible; -Reviews medical record, labs, nursing notes, etc; -The designee for nursing may do the following before the meeting: -Ensure that the admission weight and height have been obtained and in the medical record; -Review current labs; -Review snack/supplement intake; -When determining the cause, considers pain management, psychosocial needs and/or mood/depression; -Verify that the physician, resident and responsible party have been notified of any significant weight change; -Team members may make recommendations to the resident's physician and may include but not be limited to: -Frequency of monitoring weights; -Labs; -Initiation and/or changes regarding food portions and meal fortification; -Liberalization of the diet order; -Changes in the frequency and types of provided snacks/supplements; -Changes in seating in dining room related to level of assistance; -Therapy services; -If the committee identifies lack of progress towards the goal, the team will schedule a care conference with involved family members, physician and facility staff to review advanced care planning such as tube feeding, IVs, Hospice care, Comfort care, elimination of weight monitoring, etc; -Documentation occurs during the meeting using the Review List/Follow up Form: -Record any new interventions; -Record the follow up items along with the identified department; -All members that are present sign at the bottom of the Review List/Follow up Form; -The completed forms may be maintained in a binder for RAR minutes; -Documentation by designated committee member will be recorded on a progress note in medical record and will include: -Progression/digression of interventions; -Changes to interventions; -The care plan is updated during the meeting. Interventions should be specific and individualized and dated; -After the meeting the Review List is distributed; -Each team member is responsible for completing any assigned tasks before the next team meeting; -At the following meeting, the team leader reviews the minutes from the prior meeting to ensure each task was completed before going to new business. Review of the facility Fortified Foods Policy, Nutritional Care Diet Manual (NCM), undated, showed -Fortified foods have had nutrients added to them, typically energy and/or protein. For a patient who has inadequate intake, this can increase the amount of energy and protein without increasing volume of the meal or adding supplements. The benefits of fortified foods include; -Each portion contains more nutritional value than a non-fortified portion; -You can serve the same amount of food or number of food items offered; -Food waste is prevented because there is lower volume of food served; -Food items are usually sweeter with higher fat content and may taste better; -The likelihood the patient will feel overwhelmed by the amount of food offered is minimized; -The patient at nutritional risk is identified and the importance of consuming the special item is emphasized (may be labeled and may be part of diet order); -Routine monitoring of patient acceptance of the fortified food is essential to identify if additional interventions are required. Evaluate if residents with a decline in eating skills are receiving adequate eating assistance when the fortified food is provided. The patient may consume more of a fortified food between meals instead or in addition to meals. -Tips for a Successful Fortified Foods Program; -Diet Terminology: Use NCM Diet Order Terminology and Definition; -Worksheet to establish use of consistent terminology for fortified foods; -Develop sample meal plans for staff to follow until the RD nutritionist can individualize for patients; -Create a list of regular food and menu items available daily to offer; note energy and protein content (pudding, ice cream, yogurt and custard); -Establish a purchase list for fortified foods and include nutritional content; -Involve cooks, staff, and residents in the development of fortified food recipes; -Monitor taste and nutritional value of fortified foods and document any changes to recipes; -Evaluate consumption and acceptance of fortified foods by observing meal and snack time service; -Monitor patient eating skills and tolerance of food texture; -Dining: Ensure delivery of fortified foods at mealtimes; -Attractiveness/palatability, and timing of delivery of the fortified food is as patient requests (during or between meals); -Liberalize diet as much as possible to allow for wider selection and increased palatability of foods; -General tips to increase energy content of foods offered: Add butter, oil, cream, nut [NAME], and other fat sources. Butter and sour cream in mashed potatoes. Butter or oil on vegetables. Nut [NAME] mixed into hot cereal. Avocado on sandwiches; -Add extra moisture: gravies, condiments, and dipping sauces, Gravy on meats and potatoes, extra mayonnaise or ketchup, sauces for dipping; -Add extra sugar, maple syrup, honey, corn syrup: Hot cereal topped with any of above number of sugars preferred in hot beverage. Topping on desserts as feasible; -Use non-fat dry milk, nut [NAME], yogurt, pudding mix, non-fat dry milk in hot chocolate or hot beverage. Yogurt as substitute for eggs at breakfast; -Use full-fat dairy products, 2% or higher yogurt-no diet yogurt or regular yogurt sweetened with artificial sweetener. Full-fat yogurt may be difficult to find; in that case, serve the yogurt with the highest fat content available and without added artificial sweetener; -Whole milk instead of skim milk, regular cream cheese, sour cream. Add condensed or evaporated milk; -When only extra protein is needed: Patients who need to increase their protein intake may also benefit from supplementation with protein foods. You can help these patients meet their needs by: -Offering extra eggs in the morning; -Increasing the size of their milk offering and serving skim rather than higher-fat milk, if appropriate; -Adding yogurt, peanut/nut butter, or cottage cheese to a meal; -Offering a protein powder to be mixed into hot cereal; -Offering extra portions of the protein in an entree; -Providing extra scoop/slices of sandwich filling or strips of cheese/cold cuts; -Offering peanut butter, yogurt, cheese, or milk as snacks. Adding commercial protein powder or liquid to foods and beverages per facility protocol. Review of the facility's Nutritional Supplements Policy, Nutritional Care Diet Manual (NDC), undated, showed: -Patients may benefit from additional interventions in the form of supplementation to improve inadequate nutrient intake. Offering foods rich in nutrients to improve overall intake is beneficial, especially for older adults who have shown to demonstrate positive responses to these strategies. Oral nutritional supplements can promote increased energy intake when incorporated with feeding assistance from staff, which may result in greater energy intake and weight gain. The use of supplements to address malnutrition in health care settings has shown to be effective; -Commercial Supplements: Patients may prefer commercially available supplements because of their convenience. Commercial supplements may also be used as ingredients in homemade shakes. Various types of commercial supplements are available to increase overall nutritional intake, including: -Liquids (protein, total energy); -Powders (protein, energy); -Disease specific formulations (diabetes, renal, ketogenic); -Nutrient-dense formulations (2 kcal/ml formulas); -Thickened liquid (puddings, frozen cups, custard products); -Instead of commercially produced products, homemade supplements can be produced by using high-energy and high-protein foods that are often available in health care facilities or at home. Offering a variety of flavors of shakes, malts, and smoothies can meet varying patient preferences; -Dry milk powder, instant breakfast, a calorie enhancer, or protein powder can be added as well; -Think Outside the Blender. Each facility may have opportunities to offer variety and add nutrients to the homemade shakes or snacks. After ensuring food safety procedures for leftovers are met, consider offering unserved desserts on a snack cart or mixing them into homemade shakes to enhance flavor. Include snack and shake choices for residents on puree-consistency diets. Some examples of desserts that could be repurposed include; -Cooked/cooled pies (key lime, custard, Boston cream, fruit pie); -Baked goods-eclairs, donuts, brownies and cookies; -Fruit cobblers/crisps; -Pancakes, French toast and muffins. 1. Review of Resident #30's diagnoses, located in the electronic health record (EHR), showed cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia (difficulty swallowing), speech and language deficits, right and left above the knee amputations and abnormal weight loss. Review of the facility monthly weight report, showed: -8/2022: A weight of 149.0 pounds (lbs); -9/2022: A weight of 148.2 lbs; -10/2022: A weight of 151.5 lbs; -11/2022: A weight of 142.9 lbs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/22, showed: -Speech Clarity: Clear speech; -Makes Self Understood: Sometimes understands-responds adequately to simple, direct communication only; -Ability to Understand Others: Sometimes understands-responds adequately to simple, direct communication; -Severely impaired cognition; -Rejection of Care: Behavior not exhibited; -Eating-how the resident eats and drinks, regardless of skill: Supervision - oversight, encouragement or cueing. Setup help only; -Diagnoses of diabetes mellitus (low/high blood sugar), stroke, and hemiplegia (one sided paralysis) or hemiparesis (weakness on one side); -Height: 3'9; -Weight: 142. Review of the resident's current care plan, located in the EHR, showed: -Special Instructions: Resident is on mechanically altered diet (ground meats). Encourage resident to go to the dining room. If resident refuses, staff to remain with resident during meals; -Focus: -Date Initiated 6/24/22: At risk for weight fluctuation related to current health status; Goal: -Date Initiated 6/24/22: Resident wishes to maintain current weight through next review; Interventions: -Date Initiated 6/24/22: Assistance with meals as needed. Encourage resident to go to dining room for meals, if he/she refuses staff to remain with resident during meals. Supplements as ordered; -The care plan did not show the resident should receive double portions at all meals. Review of the resident's physician's order sheet (POS), showed: -No Date: Resident is on mechanically altered diet. Encourage to go to dining room. If resident refuses, staff to remain with resident during meals; -9/17/22: Give double portions with each meal due to weight loss; -9/21/22: Remeron (antidepressant, also used to increase the appetite) 15 milligrams (mg), one tablet by mouth at bedtime; -No order for fortified foods. Review of the resident's menu slips, provide by the facility on 2/24/23, showed: -Breakfast/Lunch/Dinner: Mechanical altered diet and fortified foods; -The menu slips did not show an order for double portions. Review of a Nutrition/Dietary Note, dated 11/3/22 at 12:07 P.M. documented by the RD, showed: -RD received referral from nursing per meeting related to weights. current body weight (CBW) on 10/31/22 is 143.5 lbs. with significant weight loss of 4.3% when compared to 10/21/22 weight of 149.9 lbs. usual body weight (UBW) is 145-150 lbs.; -Receives a regular mechanically altered, double portions, thin liquids with 62% average intake x 6 days per documentation which provides 1426 calories average daily. Independent with supervision at meals per documentation. Also receives house shakes TID which can provide an average of 420 calories and 12 grams (g) of protein, per documentation 70% intake per medication medical record (MAR); -No edema (swelling) noted; -Estimated nutritional needs (ENN): 1956 calories, 65 g of protein; -RD recommends consider a reweigh for weight loss confirmation and offer the house shakes TID between meals and hour of sleep (HS) instead of with meals to promote increased meal intakes and weight stability; -RD available as needed (PRN); -No recommendation for fortified foods. Review of the RD's Visitation Report, showed: -11/3/22: Obtain re-weight to confirm weight loss and offer house shakes TID between meals and HS instead of with meals to promote increased meal intakes and weight stability. Review of the resident's physician's order sheet (POS), showed: -11/4/22: House shakes TID a day for supplement. Give between meals and at bedtime; -No order for fortified foods. Review of the RD's Visitation Reports, showed: -11/25/22: Document % of intake of house supplements TID per MAR to monitor acceptance. Review of the facility monthly weight report, showed: -12/2022: A weight of 141.6 lbs; -1/2023: A weight of 141.6 lbs; Review of the resident's weight summary, located in the EHR, showed: -1/29/23: A weight of 165 lbs.; -2/5/23: A weight of 167.8 lbs.; -2/26/23: A weight of 167.8 lbs.; -No re-weights found. Review of the facility monthly weight report, showed: -2/2023: A weight of 167.8 lbs. This was a significant one month weight gain of 26.2 lbs. or 18.5%; -No re-weight was found in the resident's EHR. Review of the resident's last nutritional/dietary note, dated 2/22/23 and completed by the RD, showed: -Diet: Regular; -Texture: Mechanical soft; -Fortified Foods: No; -Supplements: Yes; -Ideal Body Weight/IBW: 143 lbs.; -Significant Weight Change: Yes; -Weight Gain: Yes; -Weight Gain: 5% or more in 30 days; -Weight Change Planned/Expected/Desired: No; -Food Preferences Updated: Yes; -Able to Make Food Preferences Known: Yes; -Summary: Current body weight is 167.8 lbs. with significant weight gain of 18.5% when compared to 1/1/2023 weight of 141.6 lbs. Receives tolerates a regular, mechanically altered, double entree portion with 55% average meal intake per documentation times six days which provides 1815 calories daily. Receives house shakes TID which provides an additional 600 calories and 18 grams of protein daily. No edema noted. Current intake does meet estimated nutritional needs. Will continue to monitor per protocol. RD is available PRN/as necessary; -Care Plan Reviewed: Yes; -There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the resident's MAR, dated 2/1/23 through 2/28/23 (a possible 84 intakes), showed the resident's intake of house shakes (administration times: 10:00 A.M., 2:00 P.M., and 8:00 P.M.) was: -100%: 63 times; -90%: 3 times; -75%: 6 times; -50%: 6 times; -30%: 1 time; -No intake recorded: 5 times. Review of the resident's MAR, 3/1/23 through 3/1/23, (a possible 3 intakes), showed the resident drank 100% 2 times and 50% one time. There was no documentation the resident refused the house shakes and/or did not like the house shakes. Observations of the facility medication carts in the hall where the resident resided, showed: -2/24/23 at 12:35 P.M.: No house supplements on the cart; -3/1/23 at 8:30 A.M.: Certified Medication Technician (CMT) L had a plastic bin containing ice and several house supplements on top of the med cart. Observation on 3/1/23 at 9:15 A.M., showed the resident sat in bed with no staff present. He/She received his/her breakfast on a Styrofoam plate with plastic utensils. He/She received regular portions of scrambled eggs, ground sausage, oatmeal, one small container of juice and one carton of whole milk. The milk had not been opened. The resident was not feeding himself/herself and did not have a house shake. At 9:27 A.M., the resident sat in his/her bed with the breakfast tray still in front of him/her. There were no staff in the room assisting the resident to eat, and the resident had eaten a couple of bites of his/her eggs. His/Her milk remained unopened and he/she did not have a house shake. The resident spoke softly and said he/she needs help to eat. Sometimes a staff member feeds him/her and sometime they don't. At 9:33 A.M., there was still no staff in the room assisting the resident. The resident still had not eaten but a couple of bites. The resident confirmed he/she needed assistance and said he/she was hungry. At 9:54 A.M., the resident remained in bed with his/her breakfast still in front of him/her. The resident was attempting to feed himself/herself with a plastic spoon. He/She did not have any staff assistance and his/her milk was still not opened. There was no house supplement observed. At 10:08 A.M., the resident still had no staff assisting him/her. He/She had eaten a couple of bites of scrambled eggs and oatmeal. He/She said he/she had been waiting for someone to feed him/her and he/she was still hungry. His/Her milk remained unopened. The resident said he/she did not like milk and would not want it even if it were open. He/She drank all of his/her juice. At 10:30 A.M., the resident's breakfast had been removed. The resident said he/she did not eat any more than at the observation at 10:08 A.M. before staff removed his/her breakfast. Review of the resident's meal consuption recorded by staff for 3/1/23 at 9:47 A.M., showed the resident ate 51%-75%. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 10:00 A.M. Observation on 3/1/23 at 1:35 P.M., showed the resident sat in bed. Staff served the resident regular portions of lasagna, and mixed vegetables on a Styrofoam plate and one bottle of root beer. The resident said staff assisted him/her to eat. The resident ate 100% of his/lasagna and 0% of the mixed vegetables. He/She was still drinking his/her root beer which he/she said he/she liked. He/She said he/she could have eaten more lasagna, but staff did not offer him/her more. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 2:00 P.M. Observation on 3/2/23 at 8:23 A.M., showed CMT O stood at the medication cart passing medications. There were no house shakes observed on the medication cart. Observation on 3/2/23 at 9:04 A.M., showed the resident lay in bed. He/She had not received his/her breakfast yet. At 9:21 A.M., the resident lay in bed with his/her breakfast served on a Styrofoam plate left on the bed table in front of him/her. No staff were in the room. The resident attempted to feed himself/herself with a plastic fork. The resident received regular portions of scrambled eggs, biscuit with gravy (uncut), one small bowl of watery grits (when the bowl was picked up the grits could be swirled around in the bowl), and one small container of juice. No condiments were served. The resident said he/she liked salt and pepper. but rarely receives the spices. The resident drank his/her juice and said he/she likes most types of juice. No house shake was noted. At 10:08 A.M., the resident's breakfast tray had been removed. He/She said a staff member assisted him/her to eat. He/She ate most of his/her breakfast because of the assistance and drank all of his/her juice. No house shake was noted in the room. During an interview on 3/2/23 at 11:40 A.M., the RD said he started serving the facility last October/November. He comes to the facility weekly. There had been a lot of dietary staff turnover since he has been coming to the facility. He reviews MARs to see if the residents are drinking house shakes. There have been some problems with the MARs being completed accurately. He recommends fortified foods, house shakes and double portions to add additional calories when there are concerns with weight loss. No one made him aware the resident did not like house shakes. He is always available if the facility has questions. During an interview on 3/2/23 at 12:00 P.M., the facility's Speech Therapist said the resident requires assistance with all meals. He/She needs someone to meal provide set-up and encouragement/cueing and physical assistance to eat. The resident also needs someone to remind him/her to eat at a slow rate because he/she is at risk to choke. Observation on 3/2/23 at 1:40 P.M., showed CMT O in the hall, passing medications. During an interview, CMT O said he/she works for an agency but has been to the facility several times. He/She did not have a plastic bin on his/her cart and there were no house shakes on his/her cart. CMT O said he/she went to the kitchen this morning and asked for a plastic bin but was told they did not have any. When he/she comes to an order for house shakes, he/she walks back to the medication room and gets it. Observation on 3/2/23 at 1:45 P.M., showed the resident was shown a carton of the facility house shake and asked if he/she had received a house shake today. The resident said no one had brought him/her one today. Staff do offer them sometimes, but not every day. He/She does not like them and doesn't want them. He/She does not like milk products, but does like juice. During an interview on 3/7/23 at 8:48 A.M., CMT L said he/she keeps a bin with house shakes and ice when he/she passes medications for convenience and to keep them cold. The resident does not like house shakes and will not drink them when offered. CMT L was not really sure why, but he/she had not told nursing management. The resident will drink juice, like apple juice and orange juice. CMT L was not aware there was a fortified juice. He/She did not know the resident needed feeding assistance or supervision. During an interview on 3/2/23 at 2:55 P.M., the Dietary Manager (DM) said he/she started at the facility on 9/22/22. The orders on the menu slips were in place when she started and she has not compared the menu slips to the POS for accuracy. She has not had time to check the diet orders on the menu slips against the RD recommendations or physician's orders for accuracy. She did not know the resident was supposed to receive double portion servings. Serving house shakes is the responsibility of the nursing department. Her department does not keep the plastic bins used for the supplements. She does not recall CMT O coming to the dietary department asking for a plastic bin today. Observation on 3/7/23 at 10:13 A.M., showed Nurse P and CNA Q obtained the resident's weight using a hoyer lift (a machine used to transfer a resident unable to bear weight). The resident weighed 128 lbs. This represents: -One month severe weight loss of 39.8 lbs. or 23.72% (a one month weight loss of 5% is considered significant, a weight loss greater than 5% is considered severe); -Three month severe weight loss of 13.6 lbs. or 9.60% (a three month weight loss of 7.5% is considered significant, a weight loss greater than 7.5% is considered severe); -Six month severe weight loss of 20.2 lbs. or 13.63% (a six month weight loss of 10% is considered significant, a weight loss greater that 10% is considered severe). During an interview on 3/7/23 at 12:35 P.M. agency Nurse CC said today is the first day he/she worked with the resident. He/She finds out about specific resident needs through shift change report and talking to residents directly. He/She did not know if the resident received staff assistance for meals or if the resident needed staff assistance during meals. He/She was not aware the resident was having weight loss. He/She looked at the resident's MAR and said the resident had an order today for fortified juice. During an interview on 3/7/23 at 2:12 P.M., agency CNA FF said today is about the fourth time he/she has worked at the facility. He/She has taken care of the resident before. He/She finds out what care a resident requires by listewning to shift report. As far as he/she is aware, the resident requires set-up assistance only for meals. He/She did not know the resident had dysphagia, weight loss, or required staff assistance at all meals. He/She did not know if the resident likes house shakes or not. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expected staff to follow what is on the menu slips when they are preparing the food. Every resident should have their meal consumption, as well as supplement consumption, recorded. She expected them to be recorded accurately. They use them during their weekly meetings and the RD uses them as well. Residents who need assistance or have an order for assistance should receive assistance. She expected resident with orders for double portions receive double portions, and she was not aware double portions were not being served. If a resident is not drinking their supplement, she expected staff to report that to the nursing manager. The RD sends recommendations to her, the Director of Nurses (DON), the DM and the MDS Coordinator, usually the day he is here. Nursing is responsible to obtain the orders from physicians. The care plans should be updated to reflect resident's current problems, goals and interventions. The medication carts should have plastic bins containing ice with house shakes. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Adequate hearing; -Adequate vision; -Usually understood; -Usually understands others; -No BIMS score recorded (a score of 0-07 indicates severely impaired cognition); -No rejection of care; -Required total dependence with two person assistance for bed mobility, transfers and dressing; -Required total dependence with one person assistance for eating, toilet use and personal hygiene; -Diagnoses of dementia, mild protein-calorie malnutrition, dysphagia and adult failure to thrive. Review of the resident's care plan, dated 7/6/22, located in the EHR, showed: -Focus: Resident has potential nutritional problem related to history of failure to thrive, decreased awareness for his/her needs. Receives a mechanically altered diet; -Interventions/Tasks: Administer medications as ordered; Assist resident to the dining room for meals; Observe for and report to MD as needed any signs of malnutrition: Emaciation, muscle wasting, significant weight loss: 3 lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months; Obtain weights as ordered; Provide and serve supplements as ordered: Med pass; Provide, serve diet as ordered. Monitor intake and record each meal; RD to evaluate and make diet change recommendations as needed; Resident is on regular mechanically altered diet texture; -The care plan did not show the use of built up utensils and ice cream at lunch and dinner. Review of the facility monthly weight report, showed: -September 2022: A weight of 120.3 lbs. Review of resident's progress notes, showed the following: -On 11/17/22 at 1:53 P.M., the resident's physician changed his/her diet to pureed due to his/her pocketing food; -On 11/30/22 at 2:46 P.M., the resident was reviewed in the resident at risk meeting. His/her weight stable for the past two weeks. He/She was on a puree diet, needed encouragement and assistance with eating and received house shakes; -On 12/7/22 at 2:00 P.M., the resident feeding self with encouragement. Staff to obtain weight; -On 12/8/22 at 8:47 P.M., the resident currently on a pureed diet, requires physical assistance with meals. Appetite fair with meals. He/She has house supplements ordered. He/She enjoys the supplements; -On 12/23/22 at 3:28 P.M., staff had a care plan meeting with the family to discuss hospice as his/her appetite had decreased significantly and he/she is losing weight. Review of the facility monthly weight report, showed: -December 2022: A weight of 110.6 lbs. Review of resident's progress notes, dated 1/3/23 at 11:23 A.M., showed the RD noted the resident had a weight of 105 lbs which was a significant weight loss of 5.1% when compared to 12/7/22 weight of 110.6 lbs. His/her body mass index (BMI, a measure of body fat based on height and weight) was 19.2 which was considered underweight. He/She received a regular, pureed diet with thin liquids. He/She consumed 50% of his/her meals six days a week per documentation which provided 1150 kcalories daily. He/She was supposed to be using built up utensils. He/She received assistance at meals per documentation and also received health shakes three times a day with meals which provided an additional 600 kcalories and 18 grams of protein per day. The RD recommended starting offering health shakes between meals and evenings to promote improved meal intakes with weight stability. Review of the resident's quarterly nutritional assessment, dated 1/18/23, showed the following: -Diet: Regular; -Fortified foods: No; -Supplements: Yes; -Supplement: House Shake; -Most recent height: 62.0 inches; -Most rec

Based on observation, interview and record review, the facility failed to follow their policies by failing to provide meals as required by physician's orders, and/or Registered Dietician's (RD's) recommendations. The facility failed to provide fortified foods (foods with additional calories/protein) and double portions of food. Additionally, the facility failed to provide accurate servings sizes per the recipe, and failed to consistently provide house shakes (supplemental nutritional drinks). The facility failed to ensure dietary staff followed resident menu slips (used to show resident's current diet orders/preferences), and failed to ensure the menu slips and care plans reflected current physician orders, dietary recommendations and preferences. In addition, the facility failed to ensure residents received assistance to eat as needed. Nine residents were sampled. Of those nine, three residents (Residents #30, #25 and #26) experienced severe weight loss (more than 5% in one month, 7.5% in three months and 10% in six months), and one resident (Resident #28) who did not receive fortified foods or consistently receive supplemental nutritional shakes. The census was 65. Review of the facility's undated Resident at Risk (RAR) policy, dated 4/15/22, showed the following: -Policy: This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues; -Procedure: The facility establishes an organized interdisciplinary team to review the residents with identified nutritional issues or the potential for developing nutritional problems; -The team my consist of members representing a minimum of Food and Nutrition Services, RD, Nursing, Rehab and and Activities. Other departments such as Social Services, may also be involved; -The committee designates a team leader who is responsible for the following: -Developing a review list each week 24-48 hours before the meeting. The list includes residents who will be discussed in the meeting; -Ensuring the tasks are recorded on the Review List/Follow Up Form; -Distributing the form with the minutes after the meeting has been conducted; -The Review list includes but is not limited to the following: -Residents with significant weight change: -5% in 30 days; -7.5 % in 90 days; -10% in 180 days; -The designee for Food and Nutritional Services may do the following before the meeting: -Follows up on prior interventions to determine the effectiveness; -Updates food preferences; -Talks to the Certified Nursing Assistant (CNA) regarding the resident and dining; -Talks to the family if possible; -Reviews medical record, labs, nursing notes, etc; -The designee for nursing may do the following before the meeting: -Ensure that the admission weight and height have been obtained and in the medical record; -Review current labs; -Review snack/supplement intake; -When determining the cause, considers pain management, psychosocial needs and/or mood/depression; -Verify that the physician, resident and responsible party have been notified of any significant weight change; -Team members may make recommendations to the resident's physician and may include but not be limited to: -Frequency of monitoring weights; -Labs; -Initiation and/or changes regarding food portions and meal fortification; -Liberalization of the diet order; -Changes in the frequency and types of provided snacks/supplements; -Changes in seating in dining room related to level of assistance; -Therapy services; -If the committee identifies lack of progress towards the goal, the team will schedule a care conference with involved family members, physician and facility staff to review advanced care planning such as tube feeding, IVs, Hospice care, Comfort care, elimination of weight monitoring, etc; -Documentation occurs during the meeting using the Review List/Follow up Form: -Record any new interventions; -Record the follow up items along with the identified department; -All members that are present sign at the bottom of the Review List/Follow up Form; -The completed forms may be maintained in a binder for RAR minutes; -Documentation by designated committee member will be recorded on a progress note in medical record and will include: -Progression/digression of interventions; -Changes to interventions; -The care plan is updated during the meeting. Interventions should be specific and individualized and dated; -After the meeting the Review List is distributed; -Each team member is responsible for completing any assigned tasks before the next team meeting; -At the following meeting, the team leader reviews the minutes from the prior meeting to ensure each task was completed before going to new business. Review of the facility Fortified Foods Policy, Nutritional Care Diet Manual (NCM), undated, showed -Fortified foods have had nutrients added to them, typically energy and/or protein. For a patient who has inadequate intake, this can increase the amount of energy and protein without increasing volume of the meal or adding supplements. The benefits of fortified foods include; -Each portion contains more nutritional value than a non-fortified portion; -You can serve the same amount of food or number of food items offered; -Food waste is prevented because there is lower volume of food served; -Food items are usually sweeter with higher fat content and may taste better; -The likelihood the patient will feel overwhelmed by the amount of food offered is minimized; -The patient at nutritional risk is identified and the importance of consuming the special item is emphasized (may be labeled and may be part of diet order); -Routine monitoring of patient acceptance of the fortified food is essential to identify if additional interventions are required. Evaluate if residents with a decline in eating skills are receiving adequate eating assistance when the fortified food is provided. The patient may consume more of a fortified food between meals instead or in addition to meals. -Tips for a Successful Fortified Foods Program; -Diet Terminology: Use NCM Diet Order Terminology and Definition; -Worksheet to establish use of consistent terminology for fortified foods; -Develop sample meal plans for staff to follow until the RD nutritionist can individualize for patients; -Create a list of regular food and menu items available daily to offer; note energy and protein content (pudding, ice cream, yogurt and custard); -Establish a purchase list for fortified foods and include nutritional content; -Involve cooks, staff, and residents in the development of fortified food recipes; -Monitor taste and nutritional value of fortified foods and document any changes to recipes; -Evaluate consumption and acceptance of fortified foods by observing meal and snack time service; -Monitor patient eating skills and tolerance of food texture; -Dining: Ensure delivery of fortified foods at mealtimes; -Attractiveness/palatability, and timing of delivery of the fortified food is as patient requests (during or between meals); -Liberalize diet as much as possible to allow for wider selection and increased palatability of foods; -General tips to increase energy content of foods offered: Add butter, oil, cream, nut butters, and other fat sources. Butter and sour cream in mashed potatoes. Butter or oil on vegetables. Nut butters mixed into hot cereal. Avocado on sandwiches; -Add extra moisture: gravies, condiments, and dipping sauces, Gravy on meats and potatoes, extra mayonnaise or ketchup, sauces for dipping; -Add extra sugar, maple syrup, honey, corn syrup: Hot cereal topped with any of above number of sugars preferred in hot beverage. Topping on desserts as feasible; -Use non-fat dry milk, nut butters, yogurt, pudding mix, non-fat dry milk in hot chocolate or hot beverage. Yogurt as substitute for eggs at breakfast; -Use full-fat dairy products, 2% or higher yogurt-no diet yogurt or regular yogurt sweetened with artificial sweetener. Full-fat yogurt may be difficult to find; in that case, serve the yogurt with the highest fat content available and without added artificial sweetener; -Whole milk instead of skim milk, regular cream cheese, sour cream. Add condensed or evaporated milk; -When only extra protein is needed: Patients who need to increase their protein intake may also benefit from supplementation with protein foods. You can help these patients meet their needs by: -Offering extra eggs in the morning; -Increasing the size of their milk offering and serving skim rather than higher-fat milk, if appropriate; -Adding yogurt, peanut/nut butter, or cottage cheese to a meal; -Offering a protein powder to be mixed into hot cereal; -Offering extra portions of the protein in an entrée; -Providing extra scoop/slices of sandwich filling or strips of cheese/cold cuts; -Offering peanut butter, yogurt, cheese, or milk as snacks. Adding commercial protein powder or liquid to foods and beverages per facility protocol. Review of the facility's Nutritional Supplements Policy, Nutritional Care Diet Manual (NDC), undated, showed: -Patients may benefit from additional interventions in the form of supplementation to improve inadequate nutrient intake. Offering foods rich in nutrients to improve overall intake is beneficial, especially for older adults who have shown to demonstrate positive responses to these strategies. Oral nutritional supplements can promote increased energy intake when incorporated with feeding assistance from staff, which may result in greater energy intake and weight gain. The use of supplements to address malnutrition in health care settings has shown to be effective; -Commercial Supplements: Patients may prefer commercially available supplements because of their convenience. Commercial supplements may also be used as ingredients in homemade shakes. Various types of commercial supplements are available to increase overall nutritional intake, including: -Liquids (protein, total energy); -Powders (protein, energy); -Disease specific formulations (diabetes, renal, ketogenic); -Nutrient-dense formulations (2 kcal/ml formulas); -Thickened liquid (puddings, frozen cups, custard products); -Instead of commercially produced products, homemade supplements can be produced by using high-energy and high-protein foods that are often available in health care facilities or at home. Offering a variety of flavors of shakes, malts, and smoothies can meet varying patient preferences; -Dry milk powder, instant breakfast, a calorie enhancer, or protein powder can be added as well; -Think Outside the Blender. Each facility may have opportunities to offer variety and add nutrients to the homemade shakes or snacks. After ensuring food safety procedures for leftovers are met, consider offering unserved desserts on a snack cart or mixing them into homemade shakes to enhance flavor. Include snack and shake choices for residents on puree-consistency diets. Some examples of desserts that could be repurposed include; -Cooked/cooled pies (key lime, custard, Boston cream, fruit pie); -Baked goods-eclairs, donuts, brownies and cookies; -Fruit cobblers/crisps; -Pancakes, French toast and muffins. 1. Review of Resident #30's diagnoses, located in the electronic health record (EHR), showed cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia (difficulty swallowing), and abnormal weight loss. Review of the facility monthly weight report, showed: -8/2022: A weight of 149.0 pounds (lbs); -9/2022: A weight of 148.2 lbs; -10/2022: A weight of 151.5 lbs; -11/2022: A weight of 142.9 lbs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/22, showed: -Speech Clarity: Clear speech; -Makes Self Understood: Sometimes understands-responds adequately to simple, direct communication only; -Ability to Understand Others: Sometimes understands-responds adequately to simple, direct communication; -Severely impaired cognition; -Rejection of Care: Behavior not exhibited; -Eating-how the resident eats and drinks, regardless of skill: Supervision - oversight, encouragement or cueing. Setup help only; -Diagnoses of diabetes mellitus (low/high blood sugar), stroke, and hemiplegia (one sided paralysis) or hemiparesis (weakness on one side); -Height: 3'9; -Weight: 142. Review of the resident's current care plan, located in the EHR, showed: -Special Instructions: Resident is on mechanically altered diet (ground meats). Encourage resident to go to the dining room. If resident refuses, staff to remain with resident during meals; -Focus: -Date Initiated 6/24/22: At risk for weight fluctuation related to current health status; Goal: -Date Initiated 6/24/22: Resident wishes to maintain current weight through next review; Interventions: -Date Initiated 6/24/22: Assistance with meals as needed. Encourage resident to go to dining room for meals, if he/she refuses staff to remain with resident during meals. Supplements as ordered; -The care plan did not show the resident should receive double portions at all meals. Review of the resident's physician's order sheet (POS), showed: -No Date: Resident is on mechanically altered diet. Encourage to go to dining room. If resident refuses, staff to remain with resident during meals; -9/17/22: Give double portions with each meal due to weight loss; -9/21/22: Remeron (antidepressant, also used to increase the appetite) 15 milligrams (mg), one tablet by mouth at bedtime; -No order for fortified foods. Review of the resident's menu slips, provide by the facility on 2/24/23, showed: -Breakfast/Lunch/Dinner: Mechanical altered diet and fortified foods; -The menu slip did not show an order for double portions. Review of a Nutrition/Dietary Note, dated 11/3/22 at 12:07 P.M. documented by the RD, showed: -RD received referral from nursing per meeting related to weights. Current body weight (CBW) on 10/31/22 is 143.5 lbs. with significant weight loss of 4.3% when compared to 10/21/22 weight of 149.9 lbs. usual body weight (UBW) is 145-150 lbs.; -Receives a regular mechanically altered, double portions, thin liquids with 62% average intake x 6 days per documentation which provides 1426 calories average daily. Independent with supervision at meals per documentation. Also receives house shakes three times a day (TID) which can provide an average of 420 calories and 12 grams (g) of protein, per documentation 70% intake per medication medical record (MAR); -No edema (swelling) noted; -Estimated nutritional needs (ENN): 1956 calories, 65 g of protein; -RD recommends consider a reweigh for weight loss confirmation and offer the house shakes TID between meals and hour of sleep (HS) instead of with meals to promote increased meal intakes and weight stability; -RD available as needed (PRN); -No recommendation for fortified foods. Review of the RD's Visitation Report, showed: -11/3/22: Obtain re-weight to confirm weight loss and offer house shakes TID between meals and HS instead of with meals to promote increased meal intakes and weight stability. Review of the resident's physician's order sheet (POS), showed: -11/4/22: House shakes TID a day for supplement. Give between meals and at bedtime; -No order for fortified foods. Review of the RD's Visitation Reports, showed: -11/25/22: Document % of intake of house supplements TID per MAR to monitor acceptance. Review of the facility monthly weight report, showed: -12/2022: A weight of 141.6 lbs; -1/2023: A weight of 141.6 lbs; Review of the resident's weight summary, located in the EHR, showed: -1/29/23: A weight of 165 lbs.; -2/5/23: A weight of 167.8 lbs.; -2/26/23: A weight of 167.8 lbs.; --There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the facility monthly weight report, showed: -2/2023: A weight of 167.8 lbs. This was a significant one month weight gain of 26.2 lbs. or 18.5%; --There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the resident's last nutritional/dietary note, dated 2/22/23 and completed by the RD, showed: -Diet: Regular; -Texture: Mechanical soft; -Fortified Foods: No; -Supplements: Yes; -Ideal Body Weight/IBW: 143 lbs.; -Significant Weight Change: Yes; -Weight Gain: Yes; -Weight Gain: 5% or more in 30 days; -Weight Change Planned/Expected/Desired: No; -Food Preferences Updated: Yes; -Able to Make Food Preferences Known: Yes; -Summary: Current body weight is 167.8 lbs. with significant weight gain of 18.5% when compared to 1/1/2023 weight of 141.6 lbs. Receives tolerates a regular, mechanically altered, double entree portion with 55% average meal intake per documentation times six days which provides 1815 calories daily. Receives house shakes TID which provides an additional 600 calories and 18 grams of protein daily. No edema noted. Current intake does meet estimated nutritional needs. Will continue to monitor per protocol. RD is available PRN/as necessary; -Care Plan Reviewed: Yes; -There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the resident's MAR, dated 2/1/23 through 2/28/23 (a possible 84 intakes), showed the resident's intake of house shakes (administration times: 10:00 A.M., 2:00 P.M., and 8:00 P.M.) was: -100%: 63 times; -90%: 3 times; -75%: 6 times; -50%: 6 times; -30%: 1 time; -No intake recorded: 5 times. Review of the resident's MAR, 3/1/23 through 3/1/23, (a possible 3 intakes), showed the resident drank 100% 2 times and 50% one time. There was no documentation the resident refused the house shakes and/or did not like the house shakes. Observations of the facility medication carts in the hall where the resident resided, showed: -2/24/23 at 12:35 P.M.: No house supplements on the cart; -3/1/23 at 8:30 A.M.: Certified Medication Technician (CMT) L had a plastic bin containing ice and several house supplements on top of the med cart. Observation on 3/1/23 at 9:15 A.M., showed the resident sat in bed with no staff present. He/She received his/her breakfast on a Styrofoam plate with plastic utensils. He/She received regular portions of scrambled eggs, ground sausage, oatmeal, one small container of juice and one carton of whole milk. The milk had not been opened. The resident was not feeding himself/herself and did not have a house shake. At 9:27 A.M., the resident sat in his/her bed with the breakfast tray still in front of him/her. There were no staff in the room assisting the resident to eat, and the resident had eaten a couple of bites of his/her eggs. His/Her milk remained unopened and he/she did not have a house shake. The resident spoke softly and said he/she needs help to eat. Sometimes a staff member feeds him/her and sometime they don't. At 9:33 A.M., there was still no staff in the room assisting the resident. The resident still had not eaten but a couple of bites. The resident confirmed he/she needed assistance and said he/she was hungry. At 9:54 A.M., the resident remained in bed with his/her breakfast still in front of him/her. The resident was attempting to feed himself/herself with a plastic spoon. He/She did not have any staff assistance and his/her milk was still not opened. There was no house supplement observed. At 10:08 A.M., the resident still had no staff assisting him/her. He/She had eaten a couple of bites of scrambled eggs and oatmeal. He/She said he/she had been waiting for someone to feed him/her and he/she was still hungry. His/Her milk remained unopened. The resident said he/she did not like milk and would not want it even if it were open. He/She drank all of his/her juice. At 10:30 A.M., the resident's breakfast had been removed. The resident said he/she did not eat any more than at the observation at 10:08 A.M. before staff removed his/her breakfast. Review of the resident's meal consumption recorded by staff for 3/1/23 at 9:47 A.M., showed the resident ate 51%-75%. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 10:00 A.M. Observation on 3/1/23 at 1:35 P.M., showed the resident sat in bed. Staff served the resident regular portions of lasagna, and mixed vegetables on a Styrofoam plate and one bottle of root beer. The resident said staff assisted him/her to eat. The resident ate 100% of his/lasagna and 0% of the mixed vegetables. He/She was still drinking his/her root beer which he/she said he/she liked. He/She said he/she could have eaten more lasagna, but staff did not offer him/her more. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 2:00 P.M. Observation on 3/2/23 at 8:23 A.M., showed CMT O stood at the medication cart passing medications. There were no house shakes observed on the medication cart. Observation on 3/2/23 at 9:04 A.M., showed the resident lay in bed. He/She had not received his/her breakfast yet. At 9:21 A.M., the resident lay in bed with his/her breakfast served on a Styrofoam plate left on the bed table in front of him/her. No staff were in the room. The resident attempted to feed himself/herself with a plastic fork. The resident received regular portions of scrambled eggs, biscuit with gravy (uncut), one small bowl of watery grits (when the bowl was picked up the grits could be swirled around in the bowl), and one small container of juice. No condiments were served. The resident said he/she liked salt and pepper. but rarely receives the spices. The resident drank his/her juice and said he/she likes most types of juice. No house shake was noted. At 10:08 A.M., the resident's breakfast tray had been removed. He/She said a staff member assisted him/her to eat. He/She ate most of his/her breakfast because of the assistance and drank all of his/her juice. No house shake was noted in the room. During an interview on 3/2/23 at 11:40 A.M., the RD said he started serving the facility last October/November. He comes to the facility weekly. There had been a lot of dietary staff turnover since he has been coming to the facility. He reviews MARs to see if the residents are drinking house shakes. There have been some problems with the MARs being completed accurately. He recommends fortified foods, house shakes and double portions to add additional calories when there are concerns with weight loss. No one made him aware the resident did not like house shakes. He is always available if the facility has questions. During an interview on 3/2/23 at 12:00 P.M., the facility's Speech Therapist said the resident requires assistance with all meals. He/She needs someone to provide meal set-up and encouragement/cueing and physical assistance to eat. The resident also needs someone to remind him/her to eat at a slow rate because he/she is at risk to choke. Observation on 3/2/23 at 1:40 P.M., showed CMT O in the hall, passing medications. During an interview, CMT O said he/she works for an agency but has been to the facility several times. He/She did not have a plastic bin on his/her cart and there were no house shakes on his/her cart. CMT O said he/she went to the kitchen this morning and asked for a plastic bin but was told they did not have any. When he/she comes to an order for house shakes, he/she walks back to the medication room and gets it. Observation on 3/2/23 at 1:45 P.M., showed the resident was shown a carton of the facility house shake and asked if he/she had received a house shake today. The resident said no one had brought him/her one today. Staff do offer them sometimes, but not every day. He/She does not like them and doesn't want them. He/She does not like milk products, but does like juice. During an interview on 3/7/23 at 8:48 A.M., CMT L said he/she keeps a bin with house shakes and ice when he/she passes medications for convenience and to keep them cold. The resident does not like house shakes and will not drink them when offered. CMT L was not really sure why, but he/she had not told nursing management. The resident will drink juice, like apple juice and orange juice. CMT L was not aware there was a fortified juice. He/She did not know the resident needed feeding assistance or supervision. During an interview on 3/2/23 at 2:55 P.M., the Dietary Manager (DM) said he/she started at the facility on 9/22/22. The orders on the menu slips were in place when she started and she has not compared the menu slips to the POS for accuracy. She has not had time to check the diet orders on the menu slips against the RD recommendations or physician's orders for accuracy. She did not know the resident was supposed to receive double portion servings. Serving house shakes is the responsibility of the nursing department. Her department does not keep the plastic bins used for the supplements. She does not recall CMT O coming to the dietary department asking for a plastic bin today. Observation on 3/7/23 at 10:13 A.M., showed Nurse P and CNA Q obtained the resident's weight using a hoyer lift (a machine used to transfer a resident unable to bear weight). The resident weighed 128 lbs. This represents: -One month severe weight loss of 39.8 lbs. or 23.72% (a one month weight loss of 5% is considered significant, a weight loss greater than 5% is considered severe); -Three month severe weight loss of 13.6 lbs. or 9.60% (a three month weight loss of 7.5% is considered significant, a weight loss greater than 7.5% is considered severe); -Six month severe weight loss of 20.2 lbs. or 13.63% (a six month weight loss of 10% is considered significant, a weight loss greater that 10% is considered severe). During an interview on 3/7/23 at 12:35 P.M. agency Nurse CC said today is the first day he/she worked with the resident. He/She finds out about specific resident needs through shift change report and talking to residents directly. He/She did not know if the resident received staff assistance for meals today or if the resident needed staff assistance during meals. He/She was not aware the resident was having weight loss. He/She looked at the resident's MAR and said the resident had an order today for fortified juice. During an interview on 3/7/23 at 2:12 P.M., agency CNA FF said today is about the fourth time he/she has worked at the facility. He/She has taken care of the resident before. He/She finds out what care a resident requires by listening to shift report. As far as he/she is aware, the resident requires set-up assistance only for meals. He/She did not know the resident had dysphagia, weight loss, or required staff assistance at all meals. He/She did not know if the resident likes house shakes or not. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expected staff to follow what is on the menu slips when they are preparing the food. Every resident should have their meal consumption, as well as supplement consumption, recorded. She expected them to be recorded accurately. They use them during their weekly meetings and the RD uses them as well. Residents who need assistance or have an order for assistance should receive assistance. She expected resident with orders for double portions receive double portions, and she was not aware double portions were not being served. If a resident is not drinking their supplement, she expected staff to report that to the nursing manager. The RD sends recommendations to her, the Director of Nurses (DON), the DM and the MDS Coordinator, usually the day he is here. Nursing is responsible to obtain the orders from physicians. The care plans should be updated to reflect resident's current problems, goals and interventions. The medication carts should have plastic bins containing ice with house shakes. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Adequate hearing; -Adequate vision; -Usually understood; -Usually understands others; -No BIMS score recorded (a score of 0-07 indicates severely impaired cognition); -No rejection of care; -Required total dependence with two person assistance for bed mobility, transfers and dressing; -Required total dependence with one person assistance for eating, toilet use and personal hygiene; -Diagnoses of dementia, mild protein-calorie malnutrition, dysphagia and adult failure to thrive. Review of the resident's care plan, dated 7/6/22, located in the EHR, showed: -Focus: Resident has potential nutritional problem related to history of failure to thrive, decreased awareness for his/her needs. Receives a mechanically altered diet; -Interventions/Tasks: Administer medications as ordered; Assist resident to the dining room for meals; Observe for and report to MD as needed any signs of malnutrition: Emaciation, muscle wasting, significant weight loss: 3 lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months; Obtain weights as ordered; Provide and serve supplements as ordered: Med pass; Provide, serve diet as ordered. Monitor intake and record each meal; RD to evaluate and make diet change recommendations as needed; Resident is on regular mechanically altered diet texture; -The care plan did not show the use of built up utensils and ice cream at lunch and dinner. Review of the facility monthly weight report, showed: -September 2022: A weight of 120.3 lbs. Review of resident's progress notes, showed the following: -On 11/17/22 at 1:53 P.M., the resident's physician changed his/her diet to pureed due to his/her pocketing food; -On 11/30/22 at 2:46 P.M., the resident was reviewed in the resident at risk meeting. His/her weight stable for the past two weeks. He/She was on a puree diet, needed encouragement and assistance with eating and received house shakes; -On 12/7/22 at 2:00 P.M., the resident feeding self with encouragement. Staff to obtain weight; -On 12/8/22 at 8:47 P.M., the resident currently on a pureed diet, requires physical assistance with meals. Appetite fair with meals. He/She has house supplements ordered. He/She enjoys the supplements; -On 12/23/22 at 3:28 P.M., staff had a care plan meeting with the family to discuss hospice as his/her appetite had decreased significantly and he/she is losing weight. Review of the facility monthly weight report, showed: -December 2022

Based on interview and record review, the facility failed to protect Resident #20's right to be free from abuse when Certified Nursing Assistant (CNA) Y grabbed the resident by the wrists, forcing the resident to get out of bed against his/her wishes, resulting in skin tears to both wrists. Additionally, the facility failed to protect Resident #35 from abuse when he/she was left overnight in the same room with Resident #36 who yelled at, repeatedly hit him/her, and tried to force Resident #35 from their shared room. The census was 65. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, dated 4/15/19, showed the following: -Position statement and guidelines: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to: Staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or other individuals. It is the policy and practice of the facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -Prevention: It is the policy of the facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation; -The facility must identify, correct and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur, to include trained and qualified registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms if any; -Identification: It is the policy of the facility to identify abuse, neglect and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators; -Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods, or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Training: It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: *Reporting abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -Procedure: *Following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent reoccurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation; *The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment , if needed; *When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator; *If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. 1. Review of Resident #20's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 12/17/22, showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands, clear comprehension; -Brief Interview for Mental Status/BIMS (a cognitive assessment) score of 15, indicating the resident is cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, personal hygiene and bathing; -Total dependence of one person required for transfers; -Mobility Devices: Wheelchair; -Always incontinent of bowel and bladder; -Diagnosis of anxiety. Review of the resident's care plan, located in the electronic health record (EHR), showed: Focus: -Resident has activity of daily living (ADL) self-care deficit performance, related to impaired balance due to syncope (dizziness); -Resident has pain/discomfort related to decreased mobility; -Resident has potential for skin tears related to fragile skin; Interventions: -Assist with mobility and ADLs as needed. Review of the MDS Nurse's progress note, dated 1/14/23 at 9:27 P.M., showed: -CNA (CNA Y) reported to nurse that resident had obtained a skin tear while transferring the resident into a chair. Resident has two skin tears to both wrists; top of the right wrist 4 centimeters (cm) by 2.5 cm, area steri-stripped (thin adhesive strips used to hold the skin together) and dry dressing applied. Top of left wrist 5 cm by 3 cm, area steri-stripped and dry dressing applied. Physician and family made aware. Review of the facility self-report to the State Survey Agency, dated 1/15/2023 at 9:08 A.M., showed: -It was reported to the Administrator this evening (1/14/23) that a resident (Resident #20) said he/she received skin tears during a transfer. Statements were obtained from Certified Nursing Assistant Y and Nurse Z. A telephone call was placed to Nurse AA, the outgoing nurse, to obtain a statement. Yesterday, at the change of shift (around 3:00 P.M.) the resident did not want to get out of bed. The resident has a history of refusing things and not wanting to get out of bed. The CNA said the resident was kicking at him/her and did not want to get up. The resident did say he/she was kicking at the CNA and did not want to get up. The CNA said as he/she was trying to calm the resident down, the resident was swinging and kicking, so he/she (the CNA) grabbed the resident's wrists so as not to get hit. The resident said the CNA grabbed him/her by the wrists to transfer him/her to the chair. The resident sustained skin tears on his/her wrists; -During walking rounds Nurse Z and Nurse AA discovered the resident's skin tears and Nurse Z (the on-coming nurse) dressed the resident's skin tears. It wasn't until later that another nurse (MDS Nurse) heard about the tussle, and the Administrator was notified about the incident. Review of an investigation statement, undated but documented by the Administrator, showed: -It was reported to Administrator, on 1/14/23 at approximately 7:30 P.M., that a resident (Resident #20) received skin tears during a transfer; -Statement was obtained from CNA Y and he/she was sent home; -Statement was obtained from Nurse Z and he/she was sent home; -Telephone call placed to Nurse AA and a statement was obtained. Nurse AA was placed on administrative leave; -CNA Y's statement identified himself/herself as engaging in a transfer with the resident. While transfer took place, skin tears were obtained; -Statement from the resident showed that a CNA was fighting with him/her. The resident did not want to get out of bed. The CNA gripped his/her wrists and caused the skin tears; -Further findings showed Nurse Z was aware of the situation. He/she dressed the resident's skin tears. However, he/she did not report the incident timely; -CNA Y and Nurse Z were placed on the do not return list from the agency. Review of the resident's statement for the facility investigation, recorded by the MDS Coordinator, showed: -Date of Statement: 1/14/23; -Time of Statement: 7:30 P.M.; -Resident said that CNA Y was fighting with me. I didn't want to get up. He/she grabbed my arms and caused skin tears. The resident was asked if he/she felt safe at the facility and the resident said not with that CNA. He/She did not want that CNA taking care of me. During an interview on 3/2/23 at 7:48 A.M., the resident said he/she told CNA Y he/she did not want to get up that day, but the CNA would not listen. The CNA grabbed him/her by the wrists causing the skin tears and made him/her get up and in a wheelchair anyway. He/She did kick and swing at the CNA during the transfer because he/she was angry the CNA would not listen to him/her. He/She felt as though his/her opinion did not matter. Review of the MDS Coordinator's statement for the facility investigation, dated 1/14/23 at 7:30 P.M., showed: -Date of Incident: Blank; -Time of Incident: Blank; -He/She got to work around 4:00 P.M. and went to get keys from Nurse Z. Nurse Z said he/she had to do a report on the resident's skin tears. Nurse Z did not mention how the resident got the skin tears; -The MDS coordinator went into the resident's room to obtain a blood pressure. She asked the resident what happened to his/her arms, as the resident had dressings on both wrists. The resident stated that a CNA was fighting with him/her. He/She did not want to get up and the CNA grabbed his/her wrists, causing the skin tears. During an interview on 2/23/23 at 12:30 P.M., the MDS Coordinator said the resident has resided at the facility for over a year. He/She is alert and does not have a history of accusing staff of abuse or handling him/her roughly. He/She does not like to get out of bed. She (MDS Coordinator) was on call on 1/14/23 and came to the facility on the evening shift because the Certified Medication Technician called off, so she came in to pass medications. Around 7:00 P.M. to 7:30 P.M., she went into the resident's room to get his/her blood pressure. She noticed the dressings on the resident's wrists and asked the resident what happened. The resident said CNA Y grabbed him/her earlier that day and made him/her get up causing the skin tears. He/She did not want to get up, but the CNA made him/her get up. The MDS Coordinator called the Administrator right after the resident told her. The Administrator told her to begin the investigation and she was on her way to the facility. CNA Z was working a double shift that day and was still working, but was assigned to a new group of residents and was no longer working with Resident #20. She got the CNA's statement and sent him/her home. She got Nurse Z's statement and sent him/her home. The Administrator arrived and they interviewed other staff and residents. Review of CNA Y's written statement to the facility, dated 1/14/23, showed: -Date of incident: 1/14/23; -Time of Incident: 2:40 P.M.; -Resident was refusing care and to get up out of bed. Advised resident charge nurse (Nurse AA) advised him/her (CNA) to get him/her up. Resident became combative kicking, yelling, punching while performing perineal care (cleaning the genitalia). Upon sitting the resident up in bed to perform a transfer, the resident kept swinging at him/her, and while trying to calm resident down, resident gained skin tears. Charge nurse was notified of the incident. Review of CNA Y's statement to the state agency, dated 1/16/23, showed he/she said he/she had worked at the facility through an agency for about five months. He/She was working a double shift on Saturday 1/14/23. He/She did not usually work day shift or with the resident. The resident had diarrhea that day. The nurse on the day shift asked CNA Y to get the resident up. He/She had not had any problems with the resident being combative that day prior to getting the resident up. As he/she went to get the resident out of bed and into the wheelchair, the resident kicked, screamed and yelled No. During the transfer, the resident sustained two scratches on the back of his/her wrists approximately one to two inches long. CNA Y immediately went out and told the day and evening shift nurses about the interaction. No one told him/her the resident could be combative until afterward. He/She worked that evening until almost 8:00 P.M., when the MDS Coordinator came to him/her and got his/her statement. He/She was then asked to clock out and go home. He/She wondered why they waited so long to send him/her home. During an interview on 3/6/23 at 9:05 A.M., CNA Y said he/she was scheduled to work a 16 hour shift that day and took care of the resident on the day shift, but not the evening shift. The resident was having diarrhea. The resident needed a complete bed change due to the diarrhea. Around 9:00 A.M., he/she wanted to get the resident up, but the resident did not want to get up, so he/she left the resident alone. Around 2:00 P.M., he/she provided the resident with perineal care and the resident was agitated, but did not want to get up. Nurse AA told him/her to get the resident up due to on-going diarrhea. The resident still did not want to get up and he/she told Nurse AA, who said to ask the resident again. When he/she asked the resident again, the resident consented, but became combative when he/she began to transfer the resident from the bed to the wheelchair. It was during the transfer, the resident sustained the skin tears, and he/she (CNA Y) told Nurse Z and Nurse AA about the skin tears right after it occurred at the end of the day shift, around 3:00 P.M. Review of Nurse Z's written statement to the facility, dated 1/14/23 at 7:38 P.M., showed: -Date of Incident: 1/14/23; -Time of Incident: 2:52 P.M.; -At 2:52 P.M., nurse (Nurse Z) was doing walking report with off-going nurse. CNA (CNA Y) approached and stated that Resident #20 had skin tears from tussling when he/she was getting the resident out of bed. Finished report with off-going nurse and went to resident's room to dress the skin tears. Resident stated he/she did not want to get out of bed, but they made him/her. During an interview on 3/3/23 at 2:55 P.M., Nurse Z said he/she and Nurse AA were making walking rounds at the shift change when CNA Y informed them about the resident's skin tears. He/she heard the CNA say he/she was getting the resident up, and the resident tussled with him/her causing the skin tears. He/She did not hear the CNA say the resident was hitting or kicking, just tussling. He/she did not ask the CNA what he/she meant by tussled. After finishing shift change report with Nurse AA, he/she went to the resident's room to dress the skin tears. The resident said the CNA made him/her get up causing the skin tears. He/She told the resident he/she was having diarrhea and the CNA got him/her up so he/she could change the resident's bed. The resident said he/she knew why the CNA got him/her out of bed, and he/she (the nurse) was right. He/She did not ask the resident any questions about what happened during the transfer. In hindsight, he/she should have asked the resident more questions. Had the CNA told him/her that resident did not want to get up, he/she would have went with the CNA and completed an occupied bed change (changing the bed with the resident in the bed). The resident has very thin and fragile skin. Review of Nurse AA's statement, sent to the facility via e-mail on 1/15/23 at 8:42 A.M., showed on Saturday (1/14/23) at approximately 3:15 P.M. he/she and Nurse Z were walking down the hall after counting the medication cart. They were walking from 400 hall to 300 hall when CNA Y said the resident had two skin tears, and he/she had to get the resident up to do a complete bed change. Nurse AA told Nurse Z to dress the skin tears and he/she would look at the skin tears on Monday. Nurse AA then left the hall. During an interview on 3/3/23 at 12:26 P.M., Nurse AA said on 1/14/23 after his/her shift was over, he/she and Nurse Z were walking down the hall when CNA Y told them the resident had sustained two skin tears after he/she got the resident up. He/She did not hear the CNA say anything about the resident tussling with him/her or that the resident was combative. The CNA should have told him/her the resident refused to get up. He/She would have told the CNA to leave the resident in bed as the resident has a right to refuse. Had he/she been aware of any abuse that occurred, he/she would have talked to the resident prior to leaving for the day. Review of CNA EE's written statement to the facility, dated 1/15/23, showed: -Date of Incident: 1/14/23; -Time of Incident: Blank; -He/she worked with the resident on the evening shift of 1/14/23. Around the beginning of the shift, the resident seemed upset. The resident said someone made him/her get out of bed and hurt his/her wrists. His/her wrists were bandaged at the time. He/She reported what the resident said to the nurse, who said he/she was aware of the incident. During an interview on 3/6/23 at 9:45 A.M., CNA EE said around 3:00 P.M. (on 1/14/23), the resident seemed upset, was kind of crying and seemed down. He/She asked the resident what happened and the resident said he/she did not want to get out of bed, but CNA Y made him/her. He/She told Nurse AA, who said he/she was aware of the incident. Around 4:00 P.M., the resident told him/her he/she did not want to get out of bed, but CNA Y forced him/her to get up. At some point during the conversation, the resident said CNA Y grabbed his/her wrists while getting him/her up causing the skin tears. CNA EE told Nurse Z who acted as though he/she did not know what was going on. CNA Y was still working at that time. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said she expects facility staff to follow their abuse and neglect policies, as well as the State and Federal regulations for reporting abuse/neglect issues. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expects staff to follow the facility abuse and neglect policy. Nurse Z should have asked CNA Y more questions when the CNA said the resident tussled with him/her, and should have asked the resident questions when the resident said the CNA made him/her get up causing the skin tears. Had those questions been asked, the facility policy would have been initiated at the time of the incident, and the CNA would have been sent home and not allowed to work after the incident occurred. 2. Review of Resident #35's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Independent with bed mobility, -Supervision needed with transfers, -Mobility Devices: Wheelchair. Review of Resident'#35's progress notes, showed the following: -On 1/19/23 at 9:33 P.M., the resident had a verbal altercation with his/her roommate about plugging items into an outlet. The nurse intervened and settled the argument; -On 1/20/23 at 8:00 A.M., the Director of Nursing assessed the resident. The resident stated his/her roommate hit him/her a few times with a closed fist. The area showed no bruising or swelling. The resident denied any pain. Review of Resident #35's care plan dated 1/24/23, located in the EHR showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Consult with resident on preferences regarding customary routine; -Focus: Resident has a psychosocial well-being problem related to altercation with another resident. Moved to another room; -Interventions/Tasks: Allow the resident time to answer questions and to verbalize feelings perceptions and fears. Increase communication between the resident/family/caregivers about care and living environment. When conflict arises, remove residents to a calm, safe environment and allow to vent/share feelings. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech -distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Moderately cognitively impaired; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Independent with bed mobility and transfers; -Mobility Devices: Walker; -Diagnosis of dementia. Review of Resident #36's progress notes, showed the following: -On 1/19/23 at 9:31 P.M., the resident had a verbal altercation with another resident (Resident #35). The nurse was able to break up the argument. The resident would not let his/her roommate plug items into an outlet. The nurse intervened and plugged the items in. The resident made the comment to the nurse, he/she is Crazy; -On 1/19/23 at 10:06 P.M., the resident stated his/her roommate (Resident #35) was not to be in his/her room. He/she hit his/her roommate several times. The staff removed the roommate for medications and an Accucheck (blood sugar monitoring) and then let the roommate back in the room after the resident calmed down. Approximately an hour later, the resident was up in the hallway stating the roommate had to go. The nurse went to check on the roommate and the roommate (Resident #35) said the resident (Resident #36) hit him/her again several times. The nurse drew the curtain between them. The CNA helped the resident calm down and get into bed. If there was a third instance with the resident hitting the roommate, they would relocate one of them to another room until the morning when the situation could be addressed by administration. Review of the facility's investigation dated 1/20/2023, no time noted, provided by the facility on 2/23/23 showed: -During review of the clinical notes, it was learned that Resident #36 struck roommate Resident #35; -MDS Coordinator assisted in moving Resident #35 to another room; -The social worker interviewed both residents, and Resident #36 did not recall striking the other resident; -The residents had not had any additional encounters and both were feeling safe. Resident #36 would not have a roommate. His/Her care plan would be updated to include this information. Review of Resident #36's care plan dated 1/24/23, located in the EHR, showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Medications as ordered. Psychiatric consult as ordered; -Focus: Resident has short term memory loss due related to diagnosis of dementia; -Interventions/tasks: Allow resident extra time for resident to respond to questions and instructions. Keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Provide resident with a homelike environment. -The care plan did not address the altercation with his/her roommate and interventions to prevent further occurrences. Review of a written witness statement form by Nurse DD dated 1/20/23 at 11:25 P.M., showed Resident #35 was yelling and the nurse went to get an accucheck on the resident. The resident stated he/she had been hit by Resident #36 and the resident was also hitting his/her wheelchair. The nurse checked on the resident and after an hour was doing okay. Later, Resident #36 came out into the hallway and told the nurse to get Resident #35 out of his/her room. During interviews on 2/23/23 at 1:30 P.M. and 4:30 P.M., Nurse DD said he/she was working short staffed the night of the incident. He/she was agency so did not know the residents well. He/She did not know if the residents had problems with each other. The first time he/she heard them yelling, he/she went into the room and Resident #35 told him/her Resident #36 had hit at him/her. Nurse DD immediately removed Resident #35 and brought him/her to the dining room area where he/she could observe him/her and administer his/her medication. He/she tried to find another room for the resident, but one side of the hall was being used for isolation, and there was only one room available on the other side, and the call light was not working in that room. Nurse DD did not feel comfortable putting the resident in the room without a working call light. Nurse DD talked to both residents and they seemed to be okay with each other, so he/she put the resident back in the room and left. A short time later, Resident #36 came out of the room yelling he/she wanted Resident #35 out of the room. When he/she got to the room, Resident #36 was banging on Resident #35's bedframe and yelling he/she wanted him/her out. The other staff member with him/her was able to get them calmed down and into bed. Staff pulled the curtain between the residents and turned off the light. He/She passed this information along to the other nurse in the building, who said he/she would notify the administrator. He/She probably should have done this him/herself, but he/she was working by him/herself and just was overwhelmed with getting everything done. During an interview on 3/2/23 at 10:00 A.M., Certified Medication Technician (CMT) O said he/she was working on the evening of 1/19/23. He/She heard Resident #35 screaming, he/she is Hitting me! CMT O went and got the nurse because the residents were not used to him/her. Resident #36 did not want Resident #35 in his/her room and kept yelling, he/she wanted him/her out of the room. When he/she and the nurse went in the room, Resident #35 said Resident #36 had hit him/her. Resident #36 was hitting at the other resident's bed and saying he/she wanted the other resident out of his/her room. The CMT kept telling Resident #36 not to hit the other resident, but he/she would not calm down. He/She just wanted the other resident out of the room. They were finally able to calm the residents down by pulling the curtain between them. CMT O thought they should have moved the resident out of room that night, but it was not his/her decision. CMT O did not think it was safe to keep them in the room together. During an interview on 2/23/23 at 12:30 P.M., Resident #35 said he/she tried and tried to get along with his/her roommate (Resident #36). Resident #36 was used to being by him/herself and did not want anyone in his/her room. Resident #36 would yell at Resident #35 if he/she was in the bathroom when he/she wanted to use it. It got to the point where Resident #35 would go down the hall to use the bathroom because he/she did not want to upset his/her roommate. One day, Resident #36 unplugged his/her television and electronic picture frame from the wall and told him/her, it was not his/hers to use. Resident #35 had talked to the social worker about changing rooms, but he/she did not want to cause problems. They told him/her there was a room with a bathroom which would be available in ten days and then this incident happened. Resident #36 would put on his/her pajamas at 6:00 P.M. and be ready to go to bed by 7:00 P.M. and would turn off the lights. On the night of the incident, Resident #35 did not want to go to bed at 7:00 P.M. because he/she had not gotten his/her medication yet, so he/she turned the light back on. Resident #36 started yelling at Resident #35 and told him/her to get out of the room and started to pull his/her covers off the bed. Resident #35 grabbed at the covers to keep them on the bed and Resident #36 began to hit Resident #35 with a closed fist. Resident #35 started yelling for help. The nurse came in and took him/her out of the room for a while but brought him/her back to the room. He/She did not really want to go back into the room with the other resident but agreed to stay in the room for the night. Resident #36 got upset again and started to push his/her wheelchair towards the door saying he/she wanted him/her out of the room. Resident #36 was swinging at Resident #35 trying to hit him/her. Finally Resident #36 went out into the hallway to yell at staff. Staff came into the room and got Resident #36 to calm down. They pulled the curtain between them and left the room. Resident #35 would have liked to go to another room, but the staff did not offer to take him/her to another room and he/she did not want to cause problems, so he/she figured it would be okay for the night. Review of a written witness statement form by the MDS Coordinator dated 1/20/23 at 8:00 A.M., showed she talked to Resident #35 regarding the incident from the prior evening. The resident said around 8:00 P.M., his/her roommate turned the light off. The resident told him/her to stop and leave the light on as he/she had not received his/her medication yet. It went downhill from there. Resident #36 told him/her he/she would not go to bed until Resident #35 left the room and grabbed his/her blanket. Resident #35 grabbed his/her blanket back and Resident #36 hit him/her on his/her left arm with his/her fist. There was no discoloration noted and the resident denied any pain. Resident #35 was moved to a different room. During an interview on 3/7/23 at 9:35 A.M., the MDS Coordinator said the Assistant Director of Nursing read about the incident during report the next morning. This was the first they knew about the incident. The report said Resident #36 hit Resident #35 twice. The former Director of Nursing did the investigation. Resident #35 does not like his/her light turned off until after he/she gets his/her medication. The other resident did not like him/her turning the light back on and hit him/her twice. The staff should have called the Administrator or the Director of Nursing the night of the incident for guidance. She would think the resident should have been moved out of the room that night because staff would wanted to make sure he/she was protected from the other resident. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said the residents should have been separated after the one hit the other for their safety. During an interview on 3/2/23 at 4:11 P.M., the Administrator said the staff should have moved the residents to separate rooms on the night of the incident to keep the residents safe. MO00212631 MO00212669 MO00212876

Based on interview and record review, the facility failed to protect Resident #20's right to be free from abuse when Certified Nursing Assistant (CNA) Y grabbed the resident by the wrists, forcing the resident to get out of bed against his/her wishes, resulting in skin tears to both wrists. Additionally, the facility failed to protect Resident #35 from abuse when he/she was left overnight in the same room with Resident #36 who yelled at, repeatedly hit him/her, and tried to force Resident #35 from their shared room. The census was 65. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, dated 4/15/19, showed the following: -Position statement and guidelines: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to: Staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or other individuals. It is the policy and practice of the facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -Prevention: It is the policy of the facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation; -The facility must identify, correct and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur, to include trained and qualified registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms if any; -Identification: It is the policy of the facility to identify abuse, neglect and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators; -Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods, or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Training: It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: *Reporting abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -Procedure: *Following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent reoccurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation; *The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment , if needed; *When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator; *If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. 1. Review of Resident #20's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 12/17/22, showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands, clear comprehension; -Brief Interview for Mental Status/BIMS (a cognitive assessment) score of 15, indicating the resident is cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, personal hygiene and bathing; -Total dependence of one person required for transfers; -Mobility Devices: Wheelchair; -Always incontinent of bowel and bladder; -Diagnosis of anxiety. Review of the resident's care plan, located in the electronic health record (EHR), showed: Focus: -Resident has activity of daily living (ADL) self-care deficit performance, related to impaired balance due to syncope (dizziness); -Resident has pain/discomfort related to decreased mobility; -Resident has potential for skin tears related to fragile skin; Interventions: -Assist with mobility and ADLs as needed. Review of the MDS Nurse's progress note, dated 1/14/23 at 9:27 P.M., showed: -CNA (CNA Y) reported to nurse that resident had obtained a skin tear while transferring the resident into a chair. Resident has two skin tears to both wrists; top of the right wrist 4 centimeters (cm) by 2.5 cm, area steri-stripped (thin adhesive strips used to hold the skin together) and dry dressing applied. Top of left wrist 5 cm by 3 cm, area steri-stripped and dry dressing applied. Physician and family made aware. Review of the facility self-report to the State Survey Agency, dated 1/15/2023 at 9:08 A.M., showed: -It was reported to the Administrator this evening (1/14/23) that a resident (Resident #20) said he/she received skin tears during a transfer. Statements were obtained from Certified Nursing Assistant Y and Nurse Z. A telephone call was placed to Nurse AA, the outgoing nurse, to obtain a statement. Yesterday, at the change of shift (around 3:00 P.M.) the resident did not want to get out of bed. The resident has a history of refusing things and not wanting to get out of bed. The CNA said the resident was kicking at him/her and did not want to get up. The resident did say he/she was kicking at the CNA and did not want to get up. The CNA said as he/she was trying to calm the resident down, the resident was swinging and kicking, so he/she (the CNA) grabbed the resident's wrists so as not to get hit. The resident said the CNA grabbed him/her by the wrists to transfer him/her to the chair. The resident sustained skin tears on his/her wrists; -During walking rounds Nurse Z and Nurse AA discovered the resident's skin tears and Nurse Z (the on-coming nurse) dressed the resident's skin tears. It wasn't until later that another nurse (MDS Nurse) heard about the tussle, and the Administrator was notified about the incident. Review of an investigation statement, undated but documented by the Administrator, showed: -It was reported to Administrator, on 1/14/23 at approximately 7:30 P.M., that a resident (Resident #20) received skin tears during a transfer; -Statement was obtained from CNA Y and he/she was sent home; -Statement was obtained from Nurse Z and he/she was sent home; -Telephone call placed to Nurse AA and a statement was obtained. Nurse AA was placed on administrative leave; -CNA Y's statement identified himself/herself as engaging in a transfer with the resident. While transfer took place, skin tears were obtained; -Statement from the resident showed that a CNA was fighting with him/her. The resident did not want to get out of bed. The CNA gripped his/her wrists and caused the skin tears; -Further findings showed Nurse Z was aware of the situation. He/she dressed the resident's skin tears. However, he/she did not report the incident timely; -CNA Y and Nurse Z were placed on the do not return list from the agency. Review of the resident's statement for the facility investigation, recorded by the MDS Coordinator, showed: -Date of Statement: 1/14/23; -Time of Statement: 7:30 P.M.; -Resident said that CNA Y was fighting with me. I didn't want to get up. He/she grabbed my arms and caused skin tears. The resident was asked if he/she felt safe at the facility and the resident said not with that CNA. He/She did not want that CNA taking care of me. During an interview on 3/2/23 at 7:48 A.M., the resident said he/she told CNA Y he/she did not want to get up that day, but the CNA would not listen. The CNA grabbed him/her by the wrists causing the skin tears and made him/her get up and in a wheelchair anyway. He/She did kick and swing at the CNA during the transfer because he/she was angry the CNA would not listen to him/her. He/She felt as though his/her opinion did not matter. Review of the MDS Coordinator's statement for the facility investigation, dated 1/14/23 at 7:30 P.M., showed: -Date of Incident: Blank; -Time of Incident: Blank; -He/She got to work around 4:00 P.M. and went to get keys from Nurse Z. Nurse Z said he/she had to do a report on the resident's skin tears. Nurse Z did not mention how the resident got the skin tears; -The MDS coordinator went into the resident's room to obtain a blood pressure. She asked the resident what happened to his/her arms, as the resident had dressings on both wrists. The resident stated that a CNA was fighting with him/her. He/She did not want to get up and the CNA grabbed his/her wrists, causing the skin tears. During an interview on 2/23/23 at 12:30 P.M., the MDS Coordinator said the resident has resided at the facility for over a year. He/She is alert and does not have a history of accusing staff of abuse or handling him/her roughly. He/She does not like to get out of bed. She (MDS Coordinator) was on call on 1/14/23 and came to the facility on the evening shift because the Certified Medication Technician called off, so she came in to pass medications. Around 7:00 P.M. to 7:30 P.M., she went into the resident's room to get his/her blood pressure. She noticed the dressings on the resident's wrists and asked the resident what happened. The resident said CNA Y grabbed him/her earlier that day and made him/her get up causing the skin tears. He/She did not want to get up, but the CNA made him/her get up. The MDS Coordinator called the Administrator right after the resident told her. The Administrator told her to begin the investigation and she was on her way to the facility. CNA Z was working a double shift that day and was still working, but was assigned to a new group of residents and was no longer working with Resident #20. She got the CNA's statement and sent him/her home. She got Nurse Z's statement and sent him/her home. The Administrator arrived and they interviewed other staff and residents. Review of CNA Y's written statement to the facility, dated 1/14/23, showed: -Date of incident: 1/14/23; -Time of Incident: 2:40 P.M.; -Resident was refusing care and to get up out of bed. Advised resident charge nurse (Nurse AA) advised him/her (CNA) to get him/her up. Resident became combative kicking, yelling, punching while performing perineal care (cleaning the genitalia). Upon sitting the resident up in bed to perform a transfer, the resident kept swinging at him/her, and while trying to calm resident down, resident gained skin tears. Charge nurse was notified of the incident. Review of CNA Y's statement to the state agency, dated 1/16/23, showed he/she said he/she had worked at the facility through an agency for about five months. He/She was working a double shift on Saturday 1/14/23. He/She did not usually work day shift or with the resident. The resident had diarrhea that day. The nurse on the day shift asked CNA Y to get the resident up. He/She had not had any problems with the resident being combative that day prior to getting the resident up. As he/she went to get the resident out of bed and into the wheelchair, the resident kicked, screamed and yelled No. During the transfer, the resident sustained two scratches on the back of his/her wrists approximately one to two inches long. CNA Y immediately went out and told the day and evening shift nurses about the interaction. No one told him/her the resident could be combative until afterward. He/She worked that evening until almost 8:00 P.M., when the MDS Coordinator came to him/her and got his/her statement. He/She was then asked to clock out and go home. He/She wondered why they waited so long to send him/her home. During an interview on 3/6/23 at 9:05 A.M., CNA Y said he/she was scheduled to work a 16 hour shift that day and took care of the resident on the day shift, but not the evening shift. The resident was having diarrhea. The resident needed a complete bed change due to the diarrhea. Around 9:00 A.M., he/she wanted to get the resident up, but the resident did not want to get up, so he/she left the resident alone. Around 2:00 P.M., he/she provided the resident with perineal care and the resident was agitated, but did not want to get up. Nurse AA told him/her to get the resident up due to on-going diarrhea. The resident still did not want to get up and he/she told Nurse AA, who said to ask the resident again. When he/she asked the resident again, the resident consented, but became combative when he/she began to transfer the resident from the bed to the wheelchair. It was during the transfer, the resident sustained the skin tears, and he/she (CNA Y) told Nurse Z and Nurse AA about the skin tears right after it occurred at the end of the day shift, around 3:00 P.M. Review of Nurse Z's written statement to the facility, dated 1/14/23 at 7:38 P.M., showed: -Date of Incident: 1/14/23; -Time of Incident: 2:52 P.M.; -At 2:52 P.M., nurse (Nurse Z) was doing walking report with off-going nurse. CNA (CNA Y) approached and stated that Resident #20 had skin tears from tussling when he/she was getting the resident out of bed. Finished report with off-going nurse and went to resident's room to dress the skin tears. Resident stated he/she did not want to get out of bed, but they made him/her. During an interview on 3/3/23 at 2:55 P.M., Nurse Z said he/she and Nurse AA were making walking rounds at the shift change when CNA Y informed them about the resident's skin tears. He/she heard the CNA say he/she was getting the resident up, and the resident tussled with him/her causing the skin tears. He/She did not hear the CNA say the resident was hitting or kicking, just tussling. He/she did not ask the CNA what he/she meant by tussled. After finishing shift change report with Nurse AA, he/she went to the resident's room to dress the skin tears. The resident said the CNA made him/her get up causing the skin tears. He/She told the resident he/she was having diarrhea and the CNA got him/her up so he/she could change the resident's bed. The resident said he/she knew why the CNA got him/her out of bed, and he/she (the nurse) was right. He/She did not ask the resident any questions about what happened during the transfer. In hindsight, he/she should have asked the resident more questions. Had the CNA told him/her that resident did not want to get up, he/she would have went with the CNA and completed an occupied bed change (changing the bed with the resident in the bed). The resident has very thin and fragile skin. Review of Nurse AA's statement, sent to the facility via e-mail on 1/15/23 at 8:42 A.M., showed on Saturday (1/14/23) at approximately 3:15 P.M. he/she and Nurse Z were walking down the hall after counting the medication cart. They were walking from 400 hall to 300 hall when CNA Y said the resident had two skin tears, and he/she had to get the resident up to do a complete bed change. Nurse AA told Nurse Z to dress the skin tears and he/she would look at the skin tears on Monday. Nurse AA then left the hall. During an interview on 3/3/23 at 12:26 P.M., Nurse AA said on 1/14/23 after his/her shift was over, he/she and Nurse Z were walking down the hall when CNA Y told them the resident had sustained two skin tears after he/she got the resident up. He/She did not hear the CNA say anything about the resident tussling with him/her or that the resident was combative. The CNA should have told him/her the resident refused to get up. He/She would have told the CNA to leave the resident in bed as the resident has a right to refuse. Had he/she been aware of any abuse that occurred, he/she would have talked to the resident prior to leaving for the day. Review of CNA EE's written statement to the facility, dated 1/15/23, showed: -Date of Incident: 1/14/23; -Time of Incident: Blank; -He/she worked with the resident on the evening shift of 1/14/23. Around the beginning of the shift, the resident seemed upset. The resident said someone made him/her get out of bed and hurt his/her wrists. His/her wrists were bandaged at the time. He/She reported what the resident said to the nurse, who said he/she was aware of the incident. During an interview on 3/6/23 at 9:45 A.M., CNA EE said around 3:00 P.M. (on 1/14/23), the resident seemed upset, was kind of crying and seemed down. He/She asked the resident what happened and the resident said he/she did not want to get out of bed, but CNA Y made him/her. He/She told Nurse AA, who said he/she was aware of the incident. Around 4:00 P.M., the resident told him/her he/she did not want to get out of bed, but CNA Y forced him/her to get up. At some point during the conversation, the resident said CNA Y grabbed his/her wrists while getting him/her up causing the skin tears. CNA EE told Nurse Z who acted as though he/she did not know what was going on. CNA Y was still working at that time. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said she expects facility staff to follow their abuse and neglect policies, as well as the State and Federal regulations for reporting abuse/neglect issues. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expects staff to follow the facility abuse and neglect policy. Nurse Z should have asked CNA Y more questions when the CNA said the resident tussled with him/her, and should have asked the resident questions when the resident said the CNA made him/her get up causing the skin tears. Had those questions been asked, the facility policy would have been initiated at the time of the incident, and the CNA would have been sent home and not allowed to work after the incident occurred. 2. Review of Resident #35's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech, distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Independent with bed mobility, -Supervision needed with transfers, -Mobility Devices: Wheelchair. Review of Resident'#35's progress notes, showed the following: -On 1/19/23 at 9:33 P.M., the resident had a verbal altercation with his/her roommate about plugging items into an outlet. The nurse intervened and settled the argument; -On 1/20/23 at 8:00 A.M., the Director of Nursing assessed the resident. The resident stated his/her roommate hit him/her a few times with a closed fist. The area showed no bruising or swelling. The resident denied any pain. Review of Resident #35's care plan dated 1/24/23, located in the EHR showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Consult with resident on preferences regarding customary routine; -Focus: Resident has a psychosocial well-being problem related to altercation with another resident. Moved to another room; -Interventions/Tasks: Allow the resident time to answer questions and to verbalize feelings perceptions and fears. Increase communication between the resident/family/caregivers about care and living environment. When conflict arises, remove residents to a calm, safe environment and allow to vent/share feelings. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech clarity: Clear speech -distinct intelligible words; -Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Understanding verbal content, however able: Understands - clear comprehension; -Moderately cognitively impaired; -Physical, verbal or other behaviors: Behaviors not exhibited; -Rejection of Care - Presence & Frequency: Behavior not exhibited; -Independent with bed mobility and transfers; -Mobility Devices: Walker; -Diagnosis of dementia. Review of Resident #36's progress notes, showed the following: -On 1/19/23 at 9:31 P.M., the resident had a verbal altercation with another resident (Resident #35). The nurse was able to break up the argument. The resident would not let his/her roommate plug items into an outlet. The nurse intervened and plugged the items in. The resident made the comment to the nurse, he/she is Crazy; -On 1/19/23 at 10:06 P.M., the resident stated his/her roommate (Resident #35) was not to be in his/her room. He/she hit his/her roommate several times. The staff removed the roommate for medications and an Accucheck (blood sugar monitoring) and then let the roommate back in the room after the resident calmed down. Approximately an hour later, the resident was up in the hallway stating the roommate had to go. The nurse went to check on the roommate and the roommate (Resident #35) said the resident (Resident #36) hit him/her again several times. The nurse drew the curtain between them. The CNA helped the resident calm down and get into bed. If there was a third instance with the resident hitting the roommate, they would relocate one of them to another room until the morning when the situation could be addressed by administration. Review of the facility's investigation dated 1/20/2023, no time noted, provided by the facility on 2/23/23 showed: -During review of the clinical notes, it was learned that Resident #36 struck roommate Resident #35; -MDS Coordinator assisted in moving Resident #35 to another room; -The social worker interviewed both residents, and Resident #36 did not recall striking the other resident; -The residents had not had any additional encounters and both were feeling safe. Resident #36 would not have a roommate. His/Her care plan would be updated to include this information. Review of Resident #36's care plan dated 1/24/23, located in the EHR, showed: -Focus: Resident at risk for change in mood or behavior due to medical condition; -Interventions: Medications as ordered. Psychiatric consult as ordered; -Focus: Resident has short term memory loss due related to diagnosis of dementia; -Interventions/tasks: Allow resident extra time for resident to respond to questions and instructions. Keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Provide resident with a homelike environment. -The care plan did not address the altercation with his/her roommate and interventions to prevent further occurrences. Review of a written witness statement form by Nurse DD dated 1/20/23 at 11:25 P.M., showed Resident #35 was yelling and the nurse went to get an accucheck on the resident. The resident stated he/she had been hit by Resident #36 and the resident was also hitting his/her wheelchair. The nurse checked on the resident and after an hour was doing okay. Later, Resident #36 came out into the hallway and told the nurse to get Resident #35 out of his/her room. During interviews on 2/23/23 at 1:30 P.M. and 4:30 P.M., Nurse DD said he/she was working short staffed the night of the incident. He/she was agency so did not know the residents well. He/She did not know if the residents had problems with each other. The first time he/she heard them yelling, he/she went into the room and Resident #35 told him/her Resident #36 had hit at him/her. Nurse DD immediately removed Resident #35 and brought him/her to the dining room area where he/she could observe him/her and administer his/her medication. He/she tried to find another room for the resident, but one side of the hall was being used for isolation, and there was only one room available on the other side, and the call light was not working in that room. Nurse DD did not feel comfortable putting the resident in the room without a working call light. Nurse DD talked to both residents and they seemed to be okay with each other, so he/she put the resident back in the room and left. A short time later, Resident #36 came out of the room yelling he/she wanted Resident #35 out of the room. When he/she got to the room, Resident #36 was banging on Resident #35's bedframe and yelling he/she wanted him/her out. The other staff member with him/her was able to get them calmed down and into bed. Staff pulled the curtain between the residents and turned off the light. He/She passed this information along to the other nurse in the building, who said he/she would notify the administrator. He/She probably should have done this him/herself, but he/she was working by him/herself and just was overwhelmed with getting everything done. During an interview on 3/2/23 at 10:00 A.M., Certified Medication Technician (CMT) O said he/she was working on the evening of 1/19/23. He/She heard Resident #35 screaming, he/she is Hitting me! CMT O went and got the nurse because the residents were not used to him/her. Resident #36 did not want Resident #35 in his/her room and kept yelling, he/she wanted him/her out of the room. When he/she and the nurse went in the room, Resident #35 said Resident #36 had hit him/her. Resident #36 was hitting at the other resident's bed and saying he/she wanted the other resident out of his/her room. The CMT kept telling Resident #36 not to hit the other resident, but he/she would not calm down. He/She just wanted the other resident out of the room. They were finally able to calm the residents down by pulling the curtain between them. CMT O thought they should have moved the resident out of room that night, but it was not his/her decision. CMT O did not think it was safe to keep them in the room together. During an interview on 2/23/23 at 12:30 P.M., Resident #35 said he/she tried and tried to get along with his/her roommate (Resident #36). Resident #36 was used to being by him/herself and did not want anyone in his/her room. Resident #36 would yell at Resident #35 if he/she was in the bathroom when he/she wanted to use it. It got to the point where Resident #35 would go down the hall to use the bathroom because he/she did not want to upset his/her roommate. One day, Resident #36 unplugged his/her television and electronic picture frame from the wall and told him/her, it was not his/hers to use. Resident #35 had talked to the social worker about changing rooms, but he/she did not want to cause problems. They told him/her there was a room with a bathroom which would be available in ten days and then this incident happened. Resident #36 would put on his/her pajamas at 6:00 P.M. and be ready to go to bed by 7:00 P.M. and would turn off the lights. On the night of the incident, Resident #35 did not want to go to bed at 7:00 P.M. because he/she had not gotten his/her medication yet, so he/she turned the light back on. Resident #36 started yelling at Resident #35 and told him/her to get out of the room and started to pull his/her covers off the bed. Resident #35 grabbed at the covers to keep them on the bed and Resident #36 began to hit Resident #35 with a closed fist. Resident #35 started yelling for help. The nurse came in and took him/her out of the room for a while but brought him/her back to the room. He/She did not really want to go back into the room with the other resident but agreed to stay in the room for the night. Resident #36 got upset again and started to push his/her wheelchair towards the door saying he/she wanted him/her out of the room. Resident #36 was swinging at Resident #35 trying to hit him/her. Finally Resident #36 went out into the hallway to yell at staff. Staff came into the room and got Resident #36 to calm down. They pulled the curtain between them and left the room. Resident #35 would have liked to go to another room, but the staff did not offer to take him/her to another room and he/she did not want to cause problems, so he/she figured it would be okay for the night. Review of a written witness statement form by the MDS Coordinator dated 1/20/23 at 8:00 A.M., showed she talked to Resident #35 regarding the incident from the prior evening. The resident said around 8:00 P.M., his/her roommate turned the light off. The resident told him/her to stop and leave the light on as he/she had not received his/her medication yet. It went downhill from there. Resident #36 told him/her he/she would not go to bed until Resident #35 left the room and grabbed his/her blanket. Resident #35 grabbed his/her blanket back and Resident #36 hit him/her on his/her left arm with his/her fist. There was no discoloration noted and the resident denied any pain. Resident #35 was moved to a different room. During an interview on 3/7/23 at 9:35 A.M., the MDS Coordinator said the Assistant Director of Nursing read about the incident during report the next morning. This was the first they knew about the incident. The report said Resident #36 hit Resident #35 twice. The former Director of Nursing did the investigation. Resident #35 does not like his/her light turned off until after he/she gets his/her medication. The other resident did not like him/her turning the light back on and hit him/her twice. The staff should have called the Administrator or the Director of Nursing the night of the incident for guidance. She would think the resident should have been moved out of the room that night because staff would wanted to make sure he/she was protected from the other resident. During an interview on 3/1/23 at 9:00 A.M., the facility Medical Director said the residents should have been separated after the one hit the other for their safety. During an interview on 3/2/23 at 4:11 P.M., the Administrator said the staff should have moved the residents to separate rooms on the night of the incident to keep the residents safe. MO00212631 MO00212669 MO00212876

Based on observation, interview and record review, the facility failed to follow their policies by failing to provide meals as required by physician's orders, and/or Registered Dietician's (RD's) recommendations. The facility failed to provide fortified foods (foods with additional calories/protein) and double portions of food. Additionally, the facility failed to provide accurate servings sizes per the recipe, and failed to consistently provide house shakes (supplemental nutritional drinks). The facility failed to ensure dietary staff followed resident menu slips (used to show resident's current diet orders/preferences), and failed to ensure the menu slips and care plans reflected current physician orders, dietary recommendations and preferences. In addition, the facility failed to ensure residents received assistance to eat as needed. Nine residents were sampled. Of those nine, three residents (Residents #30, #25 and #26) experienced severe weight loss (more than 5% in one month, 7.5% in three months and 10% in six months), and one resident (Resident #28) who did not receive fortified foods or consistently receive supplemental nutritional shakes. The census was 65. Review of the facility's undated Resident at Risk (RAR) policy, dated 4/15/22, showed the following: -Policy: This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues; -Procedure: The facility establishes an organized interdisciplinary team to review the residents with identified nutritional issues or the potential for developing nutritional problems; -The team my consist of members representing a minimum of Food and Nutrition Services, RD, Nursing, Rehab and and Activities. Other departments such as Social Services, may also be involved; -The committee designates a team leader who is responsible for the following: -Developing a review list each week 24-48 hours before the meeting. The list includes residents who will be discussed in the meeting; -Ensuring the tasks are recorded on the Review List/Follow Up Form; -Distributing the form with the minutes after the meeting has been conducted; -The Review list includes but is not limited to the following: -Residents with significant weight change: -5% in 30 days; -7.5 % in 90 days; -10% in 180 days; -The designee for Food and Nutritional Services may do the following before the meeting: -Follows up on prior interventions to determine the effectiveness; -Updates food preferences; -Talks to the Certified Nursing Assistant (CNA) regarding the resident and dining; -Talks to the family if possible; -Reviews medical record, labs, nursing notes, etc; -The designee for nursing may do the following before the meeting: -Ensure that the admission weight and height have been obtained and in the medical record; -Review current labs; -Review snack/supplement intake; -When determining the cause, considers pain management, psychosocial needs and/or mood/depression; -Verify that the physician, resident and responsible party have been notified of any significant weight change; -Team members may make recommendations to the resident's physician and may include but not be limited to: -Frequency of monitoring weights; -Labs; -Initiation and/or changes regarding food portions and meal fortification; -Liberalization of the diet order; -Changes in the frequency and types of provided snacks/supplements; -Changes in seating in dining room related to level of assistance; -Therapy services; -If the committee identifies lack of progress towards the goal, the team will schedule a care conference with involved family members, physician and facility staff to review advanced care planning such as tube feeding, IVs, Hospice care, Comfort care, elimination of weight monitoring, etc; -Documentation occurs during the meeting using the Review List/Follow up Form: -Record any new interventions; -Record the follow up items along with the identified department; -All members that are present sign at the bottom of the Review List/Follow up Form; -The completed forms may be maintained in a binder for RAR minutes; -Documentation by designated committee member will be recorded on a progress note in medical record and will include: -Progression/digression of interventions; -Changes to interventions; -The care plan is updated during the meeting. Interventions should be specific and individualized and dated; -After the meeting the Review List is distributed; -Each team member is responsible for completing any assigned tasks before the next team meeting; -At the following meeting, the team leader reviews the minutes from the prior meeting to ensure each task was completed before going to new business. Review of the facility Fortified Foods Policy, Nutritional Care Diet Manual (NCM), undated, showed -Fortified foods have had nutrients added to them, typically energy and/or protein. For a patient who has inadequate intake, this can increase the amount of energy and protein without increasing volume of the meal or adding supplements. The benefits of fortified foods include; -Each portion contains more nutritional value than a non-fortified portion; -You can serve the same amount of food or number of food items offered; -Food waste is prevented because there is lower volume of food served; -Food items are usually sweeter with higher fat content and may taste better; -The likelihood the patient will feel overwhelmed by the amount of food offered is minimized; -The patient at nutritional risk is identified and the importance of consuming the special item is emphasized (may be labeled and may be part of diet order); -Routine monitoring of patient acceptance of the fortified food is essential to identify if additional interventions are required. Evaluate if residents with a decline in eating skills are receiving adequate eating assistance when the fortified food is provided. The patient may consume more of a fortified food between meals instead or in addition to meals. -Tips for a Successful Fortified Foods Program; -Diet Terminology: Use NCM Diet Order Terminology and Definition; -Worksheet to establish use of consistent terminology for fortified foods; -Develop sample meal plans for staff to follow until the RD nutritionist can individualize for patients; -Create a list of regular food and menu items available daily to offer; note energy and protein content (pudding, ice cream, yogurt and custard); -Establish a purchase list for fortified foods and include nutritional content; -Involve cooks, staff, and residents in the development of fortified food recipes; -Monitor taste and nutritional value of fortified foods and document any changes to recipes; -Evaluate consumption and acceptance of fortified foods by observing meal and snack time service; -Monitor patient eating skills and tolerance of food texture; -Dining: Ensure delivery of fortified foods at mealtimes; -Attractiveness/palatability, and timing of delivery of the fortified food is as patient requests (during or between meals); -Liberalize diet as much as possible to allow for wider selection and increased palatability of foods; -General tips to increase energy content of foods offered: Add butter, oil, cream, nut [NAME], and other fat sources. Butter and sour cream in mashed potatoes. Butter or oil on vegetables. Nut [NAME] mixed into hot cereal. Avocado on sandwiches; -Add extra moisture: gravies, condiments, and dipping sauces, Gravy on meats and potatoes, extra mayonnaise or ketchup, sauces for dipping; -Add extra sugar, maple syrup, honey, corn syrup: Hot cereal topped with any of above number of sugars preferred in hot beverage. Topping on desserts as feasible; -Use non-fat dry milk, nut [NAME], yogurt, pudding mix, non-fat dry milk in hot chocolate or hot beverage. Yogurt as substitute for eggs at breakfast; -Use full-fat dairy products, 2% or higher yogurt-no diet yogurt or regular yogurt sweetened with artificial sweetener. Full-fat yogurt may be difficult to find; in that case, serve the yogurt with the highest fat content available and without added artificial sweetener; -Whole milk instead of skim milk, regular cream cheese, sour cream. Add condensed or evaporated milk; -When only extra protein is needed: Patients who need to increase their protein intake may also benefit from supplementation with protein foods. You can help these patients meet their needs by: -Offering extra eggs in the morning; -Increasing the size of their milk offering and serving skim rather than higher-fat milk, if appropriate; -Adding yogurt, peanut/nut butter, or cottage cheese to a meal; -Offering a protein powder to be mixed into hot cereal; -Offering extra portions of the protein in an entree; -Providing extra scoop/slices of sandwich filling or strips of cheese/cold cuts; -Offering peanut butter, yogurt, cheese, or milk as snacks. Adding commercial protein powder or liquid to foods and beverages per facility protocol. Review of the facility's Nutritional Supplements Policy, Nutritional Care Diet Manual (NDC), undated, showed: -Patients may benefit from additional interventions in the form of supplementation to improve inadequate nutrient intake. Offering foods rich in nutrients to improve overall intake is beneficial, especially for older adults who have shown to demonstrate positive responses to these strategies. Oral nutritional supplements can promote increased energy intake when incorporated with feeding assistance from staff, which may result in greater energy intake and weight gain. The use of supplements to address malnutrition in health care settings has shown to be effective; -Commercial Supplements: Patients may prefer commercially available supplements because of their convenience. Commercial supplements may also be used as ingredients in homemade shakes. Various types of commercial supplements are available to increase overall nutritional intake, including: -Liquids (protein, total energy); -Powders (protein, energy); -Disease specific formulations (diabetes, renal, ketogenic); -Nutrient-dense formulations (2 kcal/ml formulas); -Thickened liquid (puddings, frozen cups, custard products); -Instead of commercially produced products, homemade supplements can be produced by using high-energy and high-protein foods that are often available in health care facilities or at home. Offering a variety of flavors of shakes, malts, and smoothies can meet varying patient preferences; -Dry milk powder, instant breakfast, a calorie enhancer, or protein powder can be added as well; -Think Outside the Blender. Each facility may have opportunities to offer variety and add nutrients to the homemade shakes or snacks. After ensuring food safety procedures for leftovers are met, consider offering unserved desserts on a snack cart or mixing them into homemade shakes to enhance flavor. Include snack and shake choices for residents on puree-consistency diets. Some examples of desserts that could be repurposed include; -Cooked/cooled pies (key lime, custard, Boston cream, fruit pie); -Baked goods-eclairs, donuts, brownies and cookies; -Fruit cobblers/crisps; -Pancakes, French toast and muffins. 1. Review of Resident #30's diagnoses, located in the electronic health record (EHR), showed cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia (difficulty swallowing), and abnormal weight loss. Review of the facility monthly weight report, showed: -8/2022: A weight of 149.0 pounds (lbs); -9/2022: A weight of 148.2 lbs; -10/2022: A weight of 151.5 lbs; -11/2022: A weight of 142.9 lbs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/22, showed: -Speech Clarity: Clear speech; -Makes Self Understood: Sometimes understands-responds adequately to simple, direct communication only; -Ability to Understand Others: Sometimes understands-responds adequately to simple, direct communication; -Severely impaired cognition; -Rejection of Care: Behavior not exhibited; -Eating-how the resident eats and drinks, regardless of skill: Supervision - oversight, encouragement or cueing. Setup help only; -Diagnoses of diabetes mellitus (low/high blood sugar), stroke, and hemiplegia (one sided paralysis) or hemiparesis (weakness on one side); -Height: 3'9; -Weight: 142. Review of the resident's current care plan, located in the EHR, showed: -Special Instructions: Resident is on mechanically altered diet (ground meats). Encourage resident to go to the dining room. If resident refuses, staff to remain with resident during meals; -Focus: -Date Initiated 6/24/22: At risk for weight fluctuation related to current health status; Goal: -Date Initiated 6/24/22: Resident wishes to maintain current weight through next review; Interventions: -Date Initiated 6/24/22: Assistance with meals as needed. Encourage resident to go to dining room for meals, if he/she refuses staff to remain with resident during meals. Supplements as ordered; -The care plan did not show the resident should receive double portions at all meals. Review of the resident's physician's order sheet (POS), showed: -No Date: Resident is on mechanically altered diet. Encourage to go to dining room. If resident refuses, staff to remain with resident during meals; -9/17/22: Give double portions with each meal due to weight loss; -9/21/22: Remeron (antidepressant, also used to increase the appetite) 15 milligrams (mg), one tablet by mouth at bedtime; -No order for fortified foods. Review of the resident's menu slips, provide by the facility on 2/24/23, showed: -Breakfast/Lunch/Dinner: Mechanical altered diet and fortified foods; -The menu slip did not show an order for double portions. Review of a Nutrition/Dietary Note, dated 11/3/22 at 12:07 P.M. documented by the RD, showed: -RD received referral from nursing per meeting related to weights. Current body weight (CBW) on 10/31/22 is 143.5 lbs. with significant weight loss of 4.3% when compared to 10/21/22 weight of 149.9 lbs. usual body weight (UBW) is 145-150 lbs.; -Receives a regular mechanically altered, double portions, thin liquids with 62% average intake x 6 days per documentation which provides 1426 calories average daily. Independent with supervision at meals per documentation. Also receives house shakes three times a day (TID) which can provide an average of 420 calories and 12 grams (g) of protein, per documentation 70% intake per medication medical record (MAR); -No edema (swelling) noted; -Estimated nutritional needs (ENN): 1956 calories, 65 g of protein; -RD recommends consider a reweigh for weight loss confirmation and offer the house shakes TID between meals and hour of sleep (HS) instead of with meals to promote increased meal intakes and weight stability; -RD available as needed (PRN); -No recommendation for fortified foods. Review of the RD's Visitation Report, showed: -11/3/22: Obtain re-weight to confirm weight loss and offer house shakes TID between meals and HS instead of with meals to promote increased meal intakes and weight stability. Review of the resident's physician's order sheet (POS), showed: -11/4/22: House shakes TID a day for supplement. Give between meals and at bedtime; -No order for fortified foods. Review of the RD's Visitation Reports, showed: -11/25/22: Document % of intake of house supplements TID per MAR to monitor acceptance. Review of the facility monthly weight report, showed: -12/2022: A weight of 141.6 lbs; -1/2023: A weight of 141.6 lbs; Review of the resident's weight summary, located in the EHR, showed: -1/29/23: A weight of 165 lbs.; -2/5/23: A weight of 167.8 lbs.; -2/26/23: A weight of 167.8 lbs.; --There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the facility monthly weight report, showed: -2/2023: A weight of 167.8 lbs. This was a significant one month weight gain of 26.2 lbs. or 18.5%; --There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the resident's last nutritional/dietary note, dated 2/22/23 and completed by the RD, showed: -Diet: Regular; -Texture: Mechanical soft; -Fortified Foods: No; -Supplements: Yes; -Ideal Body Weight/IBW: 143 lbs.; -Significant Weight Change: Yes; -Weight Gain: Yes; -Weight Gain: 5% or more in 30 days; -Weight Change Planned/Expected/Desired: No; -Food Preferences Updated: Yes; -Able to Make Food Preferences Known: Yes; -Summary: Current body weight is 167.8 lbs. with significant weight gain of 18.5% when compared to 1/1/2023 weight of 141.6 lbs. Receives tolerates a regular, mechanically altered, double entree portion with 55% average meal intake per documentation times six days which provides 1815 calories daily. Receives house shakes TID which provides an additional 600 calories and 18 grams of protein daily. No edema noted. Current intake does meet estimated nutritional needs. Will continue to monitor per protocol. RD is available PRN/as necessary; -Care Plan Reviewed: Yes; -There was no documentation that showed a re-weight to determine if the weight of 167.8 lbs. was accurate when compared to the weight of 141.6 lbs. obtained on 1/1/23. Review of the resident's MAR, dated 2/1/23 through 2/28/23 (a possible 84 intakes), showed the resident's intake of house shakes (administration times: 10:00 A.M., 2:00 P.M., and 8:00 P.M.) was: -100%: 63 times; -90%: 3 times; -75%: 6 times; -50%: 6 times; -30%: 1 time; -No intake recorded: 5 times. Review of the resident's MAR, 3/1/23 through 3/1/23, (a possible 3 intakes), showed the resident drank 100% 2 times and 50% one time. There was no documentation the resident refused the house shakes and/or did not like the house shakes. Observations of the facility medication carts in the hall where the resident resided, showed: -2/24/23 at 12:35 P.M.: No house supplements on the cart; -3/1/23 at 8:30 A.M.: Certified Medication Technician (CMT) L had a plastic bin containing ice and several house supplements on top of the med cart. Observation on 3/1/23 at 9:15 A.M., showed the resident sat in bed with no staff present. He/She received his/her breakfast on a Styrofoam plate with plastic utensils. He/She received regular portions of scrambled eggs, ground sausage, oatmeal, one small container of juice and one carton of whole milk. The milk had not been opened. The resident was not feeding himself/herself and did not have a house shake. At 9:27 A.M., the resident sat in his/her bed with the breakfast tray still in front of him/her. There were no staff in the room assisting the resident to eat, and the resident had eaten a couple of bites of his/her eggs. His/Her milk remained unopened and he/she did not have a house shake. The resident spoke softly and said he/she needs help to eat. Sometimes a staff member feeds him/her and sometime they don't. At 9:33 A.M., there was still no staff in the room assisting the resident. The resident still had not eaten but a couple of bites. The resident confirmed he/she needed assistance and said he/she was hungry. At 9:54 A.M., the resident remained in bed with his/her breakfast still in front of him/her. The resident was attempting to feed himself/herself with a plastic spoon. He/She did not have any staff assistance and his/her milk was still not opened. There was no house supplement observed. At 10:08 A.M., the resident still had no staff assisting him/her. He/She had eaten a couple of bites of scrambled eggs and oatmeal. He/She said he/she had been waiting for someone to feed him/her and he/she was still hungry. His/Her milk remained unopened. The resident said he/she did not like milk and would not want it even if it were open. He/She drank all of his/her juice. At 10:30 A.M., the resident's breakfast had been removed. The resident said he/she did not eat any more than at the observation at 10:08 A.M. before staff removed his/her breakfast. Review of the resident's meal consumption recorded by staff for 3/1/23 at 9:47 A.M., showed the resident ate 51%-75%. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 10:00 A.M. Observation on 3/1/23 at 1:35 P.M., showed the resident sat in bed. Staff served the resident regular portions of lasagna, and mixed vegetables on a Styrofoam plate and one bottle of root beer. The resident said staff assisted him/her to eat. The resident ate 100% of his/lasagna and 0% of the mixed vegetables. He/She was still drinking his/her root beer which he/she said he/she liked. He/She said he/she could have eaten more lasagna, but staff did not offer him/her more. Review of the resident's MAR, showed staff recorded the resident drank 100% of his/her house shake on 3/1/23 at 2:00 P.M. Observation on 3/2/23 at 8:23 A.M., showed CMT O stood at the medication cart passing medications. There were no house shakes observed on the medication cart. Observation on 3/2/23 at 9:04 A.M., showed the resident lay in bed. He/She had not received his/her breakfast yet. At 9:21 A.M., the resident lay in bed with his/her breakfast served on a Styrofoam plate left on the bed table in front of him/her. No staff were in the room. The resident attempted to feed himself/herself with a plastic fork. The resident received regular portions of scrambled eggs, biscuit with gravy (uncut), one small bowl of watery grits (when the bowl was picked up the grits could be swirled around in the bowl), and one small container of juice. No condiments were served. The resident said he/she liked salt and pepper. but rarely receives the spices. The resident drank his/her juice and said he/she likes most types of juice. No house shake was noted. At 10:08 A.M., the resident's breakfast tray had been removed. He/She said a staff member assisted him/her to eat. He/She ate most of his/her breakfast because of the assistance and drank all of his/her juice. No house shake was noted in the room. During an interview on 3/2/23 at 11:40 A.M., the RD said he started serving the facility last October/November. He comes to the facility weekly. There had been a lot of dietary staff turnover since he has been coming to the facility. He reviews MARs to see if the residents are drinking house shakes. There have been some problems with the MARs being completed accurately. He recommends fortified foods, house shakes and double portions to add additional calories when there are concerns with weight loss. No one made him aware the resident did not like house shakes. He is always available if the facility has questions. During an interview on 3/2/23 at 12:00 P.M., the facility's Speech Therapist said the resident requires assistance with all meals. He/She needs someone to provide meal set-up and encouragement/cueing and physical assistance to eat. The resident also needs someone to remind him/her to eat at a slow rate because he/she is at risk to choke. Observation on 3/2/23 at 1:40 P.M., showed CMT O in the hall, passing medications. During an interview, CMT O said he/she works for an agency but has been to the facility several times. He/She did not have a plastic bin on his/her cart and there were no house shakes on his/her cart. CMT O said he/she went to the kitchen this morning and asked for a plastic bin but was told they did not have any. When he/she comes to an order for house shakes, he/she walks back to the medication room and gets it. Observation on 3/2/23 at 1:45 P.M., showed the resident was shown a carton of the facility house shake and asked if he/she had received a house shake today. The resident said no one had brought him/her one today. Staff do offer them sometimes, but not every day. He/She does not like them and doesn't want them. He/She does not like milk products, but does like juice. During an interview on 3/7/23 at 8:48 A.M., CMT L said he/she keeps a bin with house shakes and ice when he/she passes medications for convenience and to keep them cold. The resident does not like house shakes and will not drink them when offered. CMT L was not really sure why, but he/she had not told nursing management. The resident will drink juice, like apple juice and orange juice. CMT L was not aware there was a fortified juice. He/She did not know the resident needed feeding assistance or supervision. During an interview on 3/2/23 at 2:55 P.M., the Dietary Manager (DM) said he/she started at the facility on 9/22/22. The orders on the menu slips were in place when she started and she has not compared the menu slips to the POS for accuracy. She has not had time to check the diet orders on the menu slips against the RD recommendations or physician's orders for accuracy. She did not know the resident was supposed to receive double portion servings. Serving house shakes is the responsibility of the nursing department. Her department does not keep the plastic bins used for the supplements. She does not recall CMT O coming to the dietary department asking for a plastic bin today. Observation on 3/7/23 at 10:13 A.M., showed Nurse P and CNA Q obtained the resident's weight using a hoyer lift (a machine used to transfer a resident unable to bear weight). The resident weighed 128 lbs. This represents: -One month severe weight loss of 39.8 lbs. or 23.72% (a one month weight loss of 5% is considered significant, a weight loss greater than 5% is considered severe); -Three month severe weight loss of 13.6 lbs. or 9.60% (a three month weight loss of 7.5% is considered significant, a weight loss greater than 7.5% is considered severe); -Six month severe weight loss of 20.2 lbs. or 13.63% (a six month weight loss of 10% is considered significant, a weight loss greater that 10% is considered severe). During an interview on 3/7/23 at 12:35 P.M. agency Nurse CC said today is the first day he/she worked with the resident. He/She finds out about specific resident needs through shift change report and talking to residents directly. He/She did not know if the resident received staff assistance for meals today or if the resident needed staff assistance during meals. He/She was not aware the resident was having weight loss. He/She looked at the resident's MAR and said the resident had an order today for fortified juice. During an interview on 3/7/23 at 2:12 P.M., agency CNA FF said today is about the fourth time he/she has worked at the facility. He/She has taken care of the resident before. He/She finds out what care a resident requires by listening to shift report. As far as he/she is aware, the resident requires set-up assistance only for meals. He/She did not know the resident had dysphagia, weight loss, or required staff assistance at all meals. He/She did not know if the resident likes house shakes or not. During an interview on 3/2/23 at 4:11 P.M., the Administrator said she expected staff to follow what is on the menu slips when they are preparing the food. Every resident should have their meal consumption, as well as supplement consumption, recorded. She expected them to be recorded accurately. They use them during their weekly meetings and the RD uses them as well. Residents who need assistance or have an order for assistance should receive assistance. She expected resident with orders for double portions receive double portions, and she was not aware double portions were not being served. If a resident is not drinking their supplement, she expected staff to report that to the nursing manager. The RD sends recommendations to her, the Director of Nurses (DON), the DM and the MDS Coordinator, usually the day he is here. Nursing is responsible to obtain the orders from physicians. The care plans should be updated to reflect resident's current problems, goals and interventions. The medication carts should have plastic bins containing ice with house shakes. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Adequate hearing; -Adequate vision; -Usually understood; -Usually understands others; -No BIMS score recorded (a score of 0-07 indicates severely impaired cognition); -No rejection of care; -Required total dependence with two person assistance for bed mobility, transfers and dressing; -Required total dependence with one person assistance for eating, toilet use and personal hygiene; -Diagnoses of dementia, mild protein-calorie malnutrition, dysphagia and adult failure to thrive. Review of the resident's care plan, dated 7/6/22, located in the EHR, showed: -Focus: Resident has potential nutritional problem related to history of failure to thrive, decreased awareness for his/her needs. Receives a mechanically altered diet; -Interventions/Tasks: Administer medications as ordered; Assist resident to the dining room for meals; Observe for and report to MD as needed any signs of malnutrition: Emaciation, muscle wasting, significant weight loss: 3 lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months; Obtain weights as ordered; Provide and serve supplements as ordered: Med pass; Provide, serve diet as ordered. Monitor intake and record each meal; RD to evaluate and make diet change recommendations as needed; Resident is on regular mechanically altered diet texture; -The care plan did not show the use of built up utensils and ice cream at lunch and dinner. Review of the facility monthly weight report, showed: -September 2022: A weight of 120.3 lbs. Review of resident's progress notes, showed the following: -On 11/17/22 at 1:53 P.M., the resident's physician changed his/her diet to pureed due to his/her pocketing food; -On 11/30/22 at 2:46 P.M., the resident was reviewed in the resident at risk meeting. His/her weight stable for the past two weeks. He/She was on a puree diet, needed encouragement and assistance with eating and received house shakes; -On 12/7/22 at 2:00 P.M., the resident feeding self with encouragement. Staff to obtain weight; -On 12/8/22 at 8:47 P.M., the resident currently on a pureed diet, requires physical assistance with meals. Appetite fair with meals. He/She has house supplements ordered. He/She enjoys the supplements; -On 12/23/22 at 3:28 P.M., staff had a care plan meeting with the family to discuss hospice as his/her appetite had decreased significantly and he/she is losing weight. Review of the facility monthly weight report, showed: -December 2022: A weight of 110.6 lbs. Review of resident's progress notes, dated 1/3/23 at 11:23 A.M., showed the RD noted the resident had a weight of 105 lbs which was a significant weight loss of 5.1% when compared to 12/7/22 weight of 110.6 lbs. His/her body mass index (BMI, a measure of body fat based on height and weight) was 19.2 which was considered underweight. He/She received a regular, pureed diet with thin liquids. He/She consumed 50% of his/her meals six days a week per documentation which provided 1150 kcalories daily. He/She was supposed to be using built up utensils. He/She received assistance at meals per documentation and also received health shakes three times a day with meals which provided an additional 600 kcalories and 18 grams of protein per day. The RD recommended starting offering health shakes between meals and evenings to promote improved meal intakes with weight stability. Review of the resident's quarterly nutritional assessment, dated 1/18/23, showed the following: -Diet: Regular; -Fortified foods: No; -Supplements: Yes; -Supplement: House Shake

Based on interview and record review, the facility failed to promptly follow physician's orders by not immediately calling 911 when a resident had a change in condition (Resident #1) as evidenced by staff observing him/her to be slouched over in a chair, drooling with vomit and blood on the floor. Instead, staff called a non-urgent medical transportation service which took over two hours to arrive to transport the resident to the hospital. Staff failed to continually monitor and assess the resident's condition. The resident was placed in the intensive care unit (ICU) and placed on a ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently). The resident was admitted to the ICU with diagnoses that included encephalopathy (broad term for any brain disease that alters brain function)/seizures, prolonged postictal phase (period of time immediately following a seizure), altered mental status, acute hypoxemic respiratory failure (lung damage) with recent COVID-19 infection, acute blood loss anemia, and suspected gastrointestinal (GI) bleeding. The census was 87. The Director of Nursing (DON) was informed on 2/4/22 at 4:13 P.M. of an Immediate Jeopardy (IJ), which began on 1/18/22. The IJ was removed on 2/7/22 as confirmed by surveyor onsite verification. Review of the facility's Change in Resident's Condition or Status policy, effective date 11/26/18; reviewed 4/15/19, showed: -Purpose: To outline the actions required to address a change in resident's condition or status; -Policy: The facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by staff in accordance with state law. Review Resident #1's medical record, showed diagnoses included acute respiratory failure, personal history of COVID-19, other abnormalities of gait and mobility, weakness, personal history of a stroke and high blood pressure. Review of the resident's entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/14/22, showed the resident was admitted to the facility on [DATE] from an acute hospital. Review of the resident's Admission Tool, dated 1/14/22, showed: -admitted for COVID-19; -Cognitive impairment; -Able to make self understood; -Alert to person and situation; -No behaviors; -Required limited assistance for bed mobility, transfers, eating, toileting, personal hygiene, and dressing. Review of the resident's January 2022 nurse's notes, showed: -On 1/18/22 at 3:03 P.M., Called to resident room by staff. Resident appears to be seizing. Not easily aroused. Can be heard snoring with frothy discharge noted at mouth. Temperature 98.4, pulse 74, oxygen saturation 95 percent on room air and respirations 18. Call placed to MD. New orders given to send resident out to the ER for evaluation and treatment. Call placed to a non-emergency transportation service for transport. Estimated time of arrival (ETA) of one hour given; -On 1/18/22 at 4:41 P.M., Still waiting on transportation to arrive for transport. Resident aroused by sternal rub (applying painful stimulus by rubbing the knuckles of a closed fist firmly and vigorously on the sternum). Resident breathing without difficulty. Will continue to monitor; -On 1/18/22 at 5:15 P.M., Resident still awaiting transport to the emergency room (ER) for evaluation. Still aroused by stimuli. Resident had urinated on the floor and can be heard snoring like; -On 1/18/22 at 5:48 P.M., Emergency Medical Services (EMS) arrived to the facility to transport resident. While this nurse attempting to give report, EMS cut me off, asked for paperwork and stated that it should have been a 911 call instead. This writer and another nurse assisted three medics to place resident on the stretcher for transport. -Review showed no other vital signs documented while staff waited for EMS transport. Review of the resident's hospital records, dated 1/19/22 at 2:59 P.M., showed: -Acute care admission on 1/18/22; -Patient was brought to emergency department (ED) on 1/18/22 for possible seizure and prolonged postictal phase/altered mental status. Patient was intubated and placed on mechanical ventilation in ED. NG aspirate (process of feeding a nasogastric tube into the stomach of a patient and draining the stomach contents by suction) showed coffee-ground. He/she was admitted to the ICU; -Impression and Plan: Acute hypoxemic respiratory failure, altered mental status, recent COVID-19 infection, aspiration pneumonia, suspected upper GI bleed. Review of the resident's hospital records, dated 1/20/2, showed: -A esophagogastroduodenoscopy (EGD) (a edoscopic procedure that allows the doctor to examine the esophagus, stomach, and small intestine) which showed grade D (most severe) ulcerative esophagitis with no bleeding. -Impression and Plan: Suspected Upper GI bleed with grade D ulcerative esophagitis; encephalopathy: EEG does not show epileptiform activity, but does show signs of moderate to severe encephalopathy. Review of the facility's Witness Interview Form, dated 1/21/22 at 9:00 A.M., showed the following statement from Certified Nursing Assistant (CNA) B: I was told Resident #1 was moved using a Hoyer (mechanical) lift, but he/she didn't have the pad or anything under him/her. I tried to move him/her to the bed, but he/she wasn't able to stand/help me. I put his/her breakfast on the bedside table and he/she was eating it without any problems. A few hours later, I went to try and move him/her again, but he/she was sleeping with his/her eyes open, which I thought was weird. Around lunch time, I was helping a different resident across the hall and saw him/her walk out of the bathroom and sit back down in the chair. When I was doing my rounds around 2:00 P.M., he/she was still sleeping, but was making a snoring noise and drooling. I told the nurse about him/her and he/she went to check on him/her and thought he/she had a seizure and said he/she needed to sleep it off. Right after that, someone was doing their angel rounds and saw him/her and told the nurse. When I left at 3:00 P.M., he/she was still sitting in his/her chair. During an interview on 2/4/22 at 4:00 P.M., CNA B said he/she passed breakfast trays around 8:00 A.M. on 1/18/22. The resident ate breakfast with no issues and he/she collected the plate around 8:30 A.M. At that point, the resident was asleep in his/her wheelchair. Prior to breakfast, the resident was up, alert and talking. Throughout the morning, he/she kept checking on the resident and he/she was asleep. At one point, he/she checked the resident and saw he/she was asleep with his/her eyes open. CNA B did not notify the nurse at that time. Around 12:00 P.M., he/she saw the resident leaving the bathroom and returned to his/her chair. Before CNA B could assist, the resident was back in his/her chair. Lunch trays were delivered to resident rooms. Around 1:00 P.M., he/she returned to the resident's room to collect his/her lunch tray. The resident was still asleep and had not eaten lunch. Around 1:30 P.M., CNA B returned to the resident's room with CNA A. The resident's eyes were open, he/she was snoring and drooling at the same time. At that point, he/she went and got the nurse. The nurse said it sounded like the resident had a seizure. The nurse did a sternum rub and the resident did not wake up. The nurse said the resident had a seizure and would sleep it off. On the floor next to the resident was drool and what looked like red Kool-aid. CNA B could not say if the red substance on the floor was blood. The nurse said to leave the resident in his/her chair because he/she was too big to move and did not have a pad underneath him/her to safely transfer him/her back to the bed. They cleaned the resident's face and left him/her in the chair. He/she was not told to stay with the resident. CNA B continued his/her rounds. The resident was still asleep at 3:00 P.M. when CNA B checked on him/her before leaving for the day. He/she could not remember if the nurse assessed the resident, but he/she did see the nurse doing the sternum rub. During an interview on 1/31/22 at 2:00 P.M., CNA A said CNA B approached him/her before lunch and asked him/her to look at the resident. When CNA A arrived to the resident's room, the resident was in his/her wheelchair and was leaning to the right side of the chair drooling. Drool and blood were on the floor. The resident's eyes were open and he/she was making a snoring like sound. CNA A called the resident's name and he/she did not respond. They went to get Nurse C and told him/her what they saw. Nurse C said it sounded like it may have been a seizure and went to check on the resident. When Nurse C arrived to the room, he/she said the resident had a seizure, and he/she should sleep it off. CNA A said he/she told the nurse the resident's eyes were open and he/she was drooling. He/she did not appear to be asleep. The nurse said it was a seizure and to let the resident sleep it off. The nurse called the resident's name and he/she did not answer. CNA A did not see the nurse take vitals. The resident was new to the facility, but he/she never saw the resident in this condition. It was a very noticeable change in condition. During an interview on 1/31/22 at 2:12 P.M., Nurse C said the resident was able to make his/her needs known, but had some confusion and was admitted to the facility post COVID-19. Around 1:00 P.M., CNAs A and B approached him/her and described activity that sounded like a seizure. He/she entered the resident's room and the resident was asleep in his/her wheelchair. He/she did a sternum rub and the resident's eyes opened. He/she then obtained the resident's vitals, but was unable to get a blood pressure reading. 15 minutes after checking on the resident, Nurse C called the resident's physician. The physician did not answer so Nurse C sent the physician a text message. The physician responded and instructed the nurse to send the resident to the emergency room for an evaluation. Nurse C said the physician did not specify to call 911 or a non-emergency transportation service. He/she contacted a non-emergency transportation service and was given an estimated time of arrival of one hour. He/she kept checking on the resident and his/her condition remained the same. The resident was asleep and snoring, indicative of a seizure. Nurse C did not instruct any staff to stay with the resident the entire time. They went and checked on him/her frequently. The resident had frothy drool on his/her mouth, but Nurse C did not see any blood on the floor. He/she could not recall the exact time, but said the non-emergency transportation arrived after 4:00 P.M. The entire time, the resident slept and snored. During an interview on 1/31/22 at 3:10 P.M., the administrator and Director of Nursing (DON) said if there was a change in a resident's condition, the physician should be notified immediately and the resident should have been sent to the emergency room immediately. Based on the information that was provided to the physician by the nurse, the physician may not have deemed it necessary to instruct the nurse to call 911. The nurse should have also called 911. During an interview on 1/31/22 at 2:45 P.M., the resident's physician said the nurse texted her and said the resident had a seizure. She instructed the nurse to call 911 and send the resident out to the ER for an evaluation and treatment. Calling a non-emergency transportation was not acceptable. 911 should be called if residents exhibit symptoms of seizures, stroke, or GI bleed. The resident was admitted to the facility for complications associated with post COVID-19. He/she should have been sent to the emergency room immediately. During an interview on 2/4/22 at 1:00 P.M., the hospital nurse said when the resident was admitted , he/she was placed in ICU and was on a ventilator. The resident was diagnosed with a stroke and was septic (a widespread infection causing organ failure and dangerously low blood pressure). Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the 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 to be taken to address Class I violation(s). MO00196127

Based on observation, interview, and record review, the facility failed to routinely complete weekly skin assessments to identify any new occurrences of skin breakdown and/or new pressure areas. The facility also failed to ensure treatments were completed as ordered, accurately follow physicians orders for wound care and treatment for two of 10 sampled residents (Residents #2 and #3). The census was 76. Review of the facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management Policy and Procedure, dated revised 8/25/21, included: -Intent: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards; -Procedure: -A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas surrounded by edema (swelling); profound redness, or induration; bogginess; and/or discoloration. These signs possibly indicate an unavoidable 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)) or Stage IV (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling with slough, drainage, or even eschar) within a few days. A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout points of care provided by certified nurse aides (CNAs) during activities of daily living (ADL) care (bathing, dressing, incontinent care). Any changes or open areas are reported to the nurse; -A risk assessment tool, determines the patient's risk for pressure ulcer development. The score is documented on the tool and placed in the patient's medical record using the appropriate form; -A skin assessment should be performed weekly by a licensed nurse; -Measures to maintain and improve the patient's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure ulcer development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface in use with turning and repositioning as needed with ADL care/assistance; incontinent care, if needed, to include skin barriers application as needed; preventative wheelchair cushion, if indicated; skin inspections with particular attention to bony prominences; skin cleansing with appropriate cleanser at the time of soiling and at routine intervals; treat dry skin with moisturizers; minimize skin exposure to incontinence using devices (briefs) and skin barriers; minimize injury due to shear and friction through proper positioning, transfers, and turning schedules; encourage oral food and fluid intake; and improve patient's mobility and activity when potential exists; -Measures to protect the patient against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: reposition at least every 2-4 hours as consistent with overall patient goal and medical condition; utilize positioning devices to keep bony prominences from direct contact; ensure proper body alignment when side-lying; heel protection/suspension should be implemented while the patient is in bed; maintain head of the bed at the lowest degree of elevation consistent with medical conditions; use lift devices to move patients in the bed; a pressure redistribution mattress surface is placed under the patient; when positioned in a wheelchair, the patient is to be placed on a pressure reduction device and repositioned; when positioned in a wheelchair, consideration is given to postural alignment, distribution weight, balance, and stability; -When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient. 1. Review of Resident #2's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/21/21, showed the following: -No cognitive assessment completed and no behaviors identified; -Required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene; -No bladder and bowel assessment completed; -Diagnoses include debility, cardiorespiratory conditions, diabetes mellitus, cancer, coronary artery disease; hypertension, anxiety disorder, and depression; -At risk for pressure ulcer, no unhealed pressure ulcers; -Pressure reducing device for chair and bed; -No turn schedule implemented. Review of the weekly skin assessment records, from 1/5/22 through 2/28/22, showed the following: -1/5/22 - skin intact, no new findings; -1/12/22- skin intact; no new findings; -1/21/22-skin intact; no new findings; -2/21/22-skin intact, new findings: redness to coccyx (area located at the bottom portion of the spine), redness to elbow. Review of the resident's medical record, showed there was no shower sheets completed after 2/16/22. Shower sheets can alert staff to new or worsening skin conditions observed during showering/bathing. Review of the resident's electronic Treatment Administration Record (eTAR), showed: -An order dated 12/6/21, for Calmoseptine ointment 0.44-20.625% (Menthol-Zinc Oxide) Apply to coccyx topically every shift for redness; -From 1/1/22 through 2/28/22 staff failed to document administering the treatment for 61 out of out of 177 opportunities. Review of the weekly skin assessment records, dated March 2022, showed the following: -3/2/22, skin not intact (open area); new findings: Left elbow scabbed area, groin pink to right side of groin, Left trochanter (hip), deep tissue injury (DTI) purple and red discoloration, Right ankle (inner) unstageable (UNS) ulcer (an open sore on an external or internal surface of the body, caused by a break in the skin), Right heel UNS ulcer, granulation tissue noted, Left heel Stage II ulcer, granulation tissue noted, Left toe scab 5th toe, Sacrum UNS cluster wound, redness, Other heels soft; -3/9/22-Skin not intact open area/wound; no new findings: Left elbow scabbed area, groin pink to right side of groin, Left trochanter (hip) DTI, purple and red discoloration, Right ankle (inner) UNS ulcer, Right heel UNS ulcer, granulation tissue noted, Left heel stage 2 ulcer, granulation tissue noted, Left toe scab 5th toe, Sacrum unstageable cluster wound, redness, Other heels soft. Review of the facility's Wound Report, showed: -Staff failed to document identified reddened areas to the elbow and coccyx found on the resident's 2/21/22 skin assessment; -Staff failed to identify areas of concern for the resident until 3/2/22 and showed: -Acquired left heel. Pressure, Stage II, measuring 1.5 centimeter (cm) by 0.5 cm by 0.1 cm, first observation; -Acquired left hip. Pressure, DTI, measuring 13 cm by 8 cm by 0 cm, first observation; -Acquired right ankle-medial. Pressure, slough/eschar(dead tissue/skin) measuring 0.5 cm by 1.5 cm by 0 cm, first observation; -Acquired right heel. Pressure, (not staged), measuring 3 cm by 3.5 cm by 0 cm, first observation; -Acquired sacrum. Pressure, slough/eschar, measuring 5 cm by 5 cm by 0.1 cm, first observation. Review of the resident's care plan, last revised on 3/2/22, and in use during the survey, showed the following: -The resident has Stage II ulcer to left heel, unstageable ulcers to right heel, right medial ankle, sacrum, left hip related to immobility; -The resident required the bed as flat as possible to reduce shear. The resident prefers to be repositioned with (SPECIFY: 1-2 people); -Administer medications as ordered. Administer treatments as ordered. Assess 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 the physician. Avoid positioning the resident on (back). Educate the resident/family/caregivers as to causes of skin breakdown; including: Transfer/positioning requirements; importance of taking care during, ambulating/mobility, good nutrition and frequent repositioning. Review of the resident's electronic Treatment Administration Record (eTAR) showed: -An order dated 3/2/22, for Skin Prep Spray Miscellaneous apply to left hip topically every shift for DTI; -Staff failed to document the treatment administration on 3/3/22 day shift, 3/5/22 night shift, 3/6/22 night shift, 3/9/22 day shift; an order dated 3/10/22 to discontinue the treatment. -An order dated, dated 3/2/22 for Saline Wound Wash Solution (Sodium Chloride) Apply to left heel topically every day shift every 2 day(s) for wound apply honey gel, secure with dry dressing; change every 2 days. Further review of the wound report, dated 3/9/22, showed the following: -Acquired left heel. Pressure, Stage II, measuring 1.5 cm by 0.5 cm by 0.1 cm, unchanged; -Acquired left hip. Pressure, DTI, measuring 13 cm by 5 cm by 0 cm, improving; -Acquired right ankle-medial. Pressure, slough/eschar measuring 0.5 cm by 1.5 cm by 0 cm, unchanged; -Acquired right heel. Pressure, (not staged), measuring 3 cm by 3 cm by 0 cm, improving; -Acquired sacrum. Pressure, slough/eschar, measuring 4.5 cm by 5 cm by 0.1 cm, improving. Further review of the eTAR, showed: -An order dated 3/10/22, for Saline Wound Wash Solution (Sodium Chloride) Apply to left hip topically every day shift every 2 days for wound apply honey gel, secure with dry dressing. Change every 2 days. Observation of the resident on 3/16/22 at approximately 10:25 A.M., showed the resident lay on his/her right hip on a low air loss mattress (pressure reducing device) and a folded top sheet which was referred to as a draw sheet. The resident did not wear heel protecting boots. Nurse I cleansed the resident's left heel with Povodone- Iodine solution, and not the saline wound wash solution as ordered, followed by application of the apple-honey gel and securing with dry dressing. Staff failed to administer the correct treatment to the left heel. Further record review on 3/16/22, showed: -No skin assessments documented for March. Observation on 3/17/2022 at approximately 3:30 P.M., showed the resident lay in bed on his/her left side. A family member was present and they pulled back the resident's blankets to show the resident's pressure areas. The surveyor observed a deep red, round unopened area to resident's right hip. The resident's family turned the resident to view his/her left hip and pulled the sheet back for further assessment. The surveyor observed an uncovered dime sized open area to left distal hip. The resident did not have the ordered wound dressing in place. Nurse I entered the room and stated that the wound bed contained yellow slough and necrotic tissue. During an interview on 3/17/22 at approximately 4:30 P.M., the Director of Nursing (DON) said she was unaware the resident had areas of concern to his/her right hip and distal left hip. Review of the resident's wound assessment tool, dated 3/18/22, showed the area found on the resident's right left was classified as a pressure DTI with measurements of 10 cm by 5 cm by 0 cm and contained slough with measurements of 3.2 cm by 2.5 cm by 0.1 cm. The area identified to the right hip was classified as an unstageable DTI measuring, 2.54 cm by 2.22 cm by 0 cm. Further observation on 3/18/22 at approximately 11:00 A.M., showed Nurse I entered the resident's room and observed the resident laid on his/her left side on a low air loss mattress on top of white folded top sheet. The resident did not wear heel protecting boots. Nurse I completed all ordered treatments to the residents wounds. Nurse I said the resident should be wearing boots. Nurse I began to search the resident's room for the heel protecting boots and was unable to locate them. During an interview on 3/21/22 at approximately 2:30 P.M., the DON, Regional Director of Clinical Services (RCDS), and Executive Director (ED) said the expectation would be that wound care orders would be completed as ordered. If wound wash was ordered, the expectation would not be for Povidone-Iodine to be applied. During an interview on 3/21/22 at approximately 2:30 P.M., the resident's physician said she would expect skin assessments would be performed weekly on her patients. She believed they were completed weekly by the wound nurse. If skin assessments are not completed regularly the resident would be at risk for the development of more and more sores. She would expect a pressure ulcer would be found prior to reaching a stage IV or becoming unstageable and that staff would complete treatments as ordered. The physician said she would expect staff to complete treatments, as ordered. 2. Review of Resident #3's quarterly MDS, instrument completed by facility staff, dated 2/19/22, showed the following: -Required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene; and two person extensive physical assist for transfers; -Diagnoses include cancer, diabetes mellitus, renal insufficiency, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and fracture; -At risk for pressure ulcer, with several unhealed pressure ulcers; -Pressure reducing device for chair and bed; -No turn schedule implemented. Review of the facility wound report, showed the following: -Assessment Date 12/7/21, showed: resident was admitted with - left buttock pressure ulcer stage IV, right lateral leg pressure ulcer unstaged, sacrum pressure ulcer stage IV, right lateral shin pressure ulcer unstaged. Facility acquired wounds onset date 10/11/22 right heel pressure DTI, onset date 10/20/21 left heel; -No wound report for week of 12/13/21; -Assessment Date 12/21/21, showed: Left Buttock (pressure stage IV), right heel, pressure (unchanged), and sacrum (first observation, no reference) of wound reports; -Assessment Date 12/30/21, right lateral thigh -pressure Stage II (onset 12/29/21) and previously identified areas: sacrum, right lower buttock, and right heel, areas all identified as unchanged in condition. Review of the resident's weekly skin assessment records, showed the following: -1/4/22:, New findings- no; right buttock -UNS pressure ulcer with eschar and slough, Left buttock -stage IV pressure ulcer, wound bed beefy red, Right thigh rear- stage 2 pressure ulcer, pink wound bed, Right heel-DTI, intact skin, Left heel-soft, sacrum-stage IV pressure ulcer- wound bed beefy red; -1/11/22: New findings-yes; Right buttock -UNS pressure ulcer with eschar and slough, Left buttock -stage IV pressure ulcer, wound bed beefy red, new area left lateral buttock UNS ulcer, Right thigh rear- stage 2 pressure ulcer, pink wound bed, Right heel-DTI, intact skin, Left heel-soft, sacrum-stage IV pressure ulcer- wound bed beefy red; -1/19/22- New findings-no, Right buttock -UNS pressure ulcer with eschar and slough, Left buttock -Stage IV pressure ulcer, wound bed beefy red, new area left lateral buttock UNS ulcer, Right thigh rear- Stage II pressure ulcer, pink wound bed, Right heel-DTI, Left heel-soft, Sacrum-Stage IV pressure ulcer- wound bed beefy red, -No skin assessments from 1/23/22 until 2/21/22. Further review of the facility Wound Report showed the following: -Assessment Date 1/11/22, showed: the presence of all of the previously mentioned areas and 4 newly acquired pressure areas: right lateral thigh (stage II), right buttock (UNS), left lateral buttock (UNS), right shin (stage II); -Assessment Date 1/19/22, showed: The following areas were noted to be worsening: right heel. One newly acquired area was identified to the right posterior thigh (UNS). Additionally all previously mentioned areas remained on the report; -Assessment Date 2/11/22, showed: Two newly acquired areas- right mid buttock (pressure, UNS); -Assessment Date-2/17/22, showed: Two newly acquired areas- Right mid buttock pressure (Slough/Eschar). Right heel (worsening); -Assessment Date 2/22/22, showed: One newly acquired area-Right mid-buttock (pressure, UNS). Further review of the resident's weekly skin assessments, showed: -On 2/21/22-Skin intact-no (open/area/wound), New findings-no; coccyx (large wound/see wound assessment/treatment in progress.), Right lower leg (front)- pink open area of skin epithelial tissue/granulation tissue, sacrum (large wound/see wound assessment/treatment in progress); -On 3/1/22-Skin intact-no (open area/wound), New findings-no; Right buttock-stage IV ulcer, Right heel-unstageable ulcer, Sacrum-stage 4 ulcer. Review of the eTAR for resident's sacral wound, showed: -An order dated 3/2/22 for wound vac (vacuum assisted closure of a wound to promote wound healing) should be changed to his/her sacral area every Tuesday and Friday until 3/20 when it should be changed every Monday, Wednesday, and Friday; -An order dated 3/2/22 for lower buttock area to be cleansed with saline wound wash solution every Monday, Wednesday, and Friday for wound apply hydrocolloid, change with wound vac dressing change; -An order dated 3/2/22 for santyl applied to sacral wound topically every day shift, for wound care after cleaning with normal saline. Apply santyl to area of necrosis/slough, cover with calcium alginate, pack loosely with Dakins 1/4 strength moistened kerlix, cover with ABD and tape; change dressing daily. Further review of the TAR, on 3/18/21, showed that the wound vac change was to occur on Tuesdays and Fridays until 3/20/22. Currently the lower buttock treatment ordered to be completed with wound vac changes was scheduled for Mondays, Wednesdays and Fridays, not on actual wound vac change days ordered on Tuesdays and Fridays until 3/20/22. During an interview on 3/21/22 at approximately 11:30 A.M., Nurse J clarified the lower buttock wound was a separate wound from the sacral wound and should be dressed at the same time as the wound vac dressing was changed. Its location was in close proximity and it was covered by the wound vac dressing. When Nurse J was asked about the conflicting orders for left lower buttock treatments to be completed with wound vac treatments, but transcribed to perform on M,W,F, when the wound vac change was ordered only for T, F until 3/20/22, nurse J reviewed the order and said that he/she could understand how another nurse might be confused when reading the orders. 3. During an interview on 3/17/22 at 3:55 P.M., the DON said if there was no documentation, the treatment was not done. During an interview on 3/17/22 4:45 P.M., the DON said the charge nurses should do a weekly skin assessment and if clarification was needed, they should contact the treatment nurse for clarification, and if she was unavailable, they should clarify with a nurse manager and not the wound doctor because the wound company was outsourced and the facility has no way of contacting them. MO00198901

Based on observation, interview and record review, the facility staff failed to prevent an avoidable accident for one resident by using a shower bed, with two of four side rail pins missing, causing the resident to fall and sustain a fractured right arm. The facility failed to assess one resident's wheelchair after concerns had been raised about it's safety and the resident rolled across the outdoor pavement and flipped out of the wheelchair incurring injuries that required a hospital visit. In addition, the facility failed to ensure one resident's bed remained as close to the floor as possible and two other resident's had functional alarms in place. (Residents #2, #6, #13, #1 and #12) The sample size was 13. The census was 77. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/13/12, showed the following: -Adequate hearing/vision, clear speech; -Understood and understands; -No short/long term memory problems; -No behavioral problems; -Total dependence of two (+) persons for bed mobility, transfers, personal hygiene and bathing; -Walking in room/corridor did not occur; -Impairment of both upper and lower extremities; -[DIAGNOSES REDACTED]. -Height 5'11", weight 228 pounds, [AGE] years old. Review of a nurse's progress note, dated 7/12/12 at 6:47 A.M., showed the nurse found the resident laying on his/her back between the shower wall and shower bed (Gurney made from PVC pipe. The gurney has one side rail on each side. Each side rail has two metal pins, one at the top and one at the bottom. The pins are removed to lower the side rail and reinserted to keep the side rail in an upright position.) with Certified Nurse Aides (CNA) D and E at the resident's side. The resident had a compromised right arm and shoulder, was sent to a local hospital and admitted with a fractured right arm and dislocated right shoulder. Investigation done with corporate nurse, this writer and caregivers who showered resident. Resident had been offered bariatric shower bed which he/she refused. Resident requested regular size shower bed. CNAs turned resident onto his/her right side to wash his/her back. Weight of resident and unsteady gait of trunk against shower bed rail caused the rail to break allowing resident to roll onto the floor. Present shower bed discarded and a new and more secure one will be purchased. Review of a nurse's progress note, dated 7/14/12 at 10:18 P.M., showed the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. The resident is alert and oriented times three (person, place and time) and able to make needs known. During an interview on 8/20/12 at 12:40 P.M., the resident said the shower bed's side rails had been loose prior to his/her fall on 7/12/12. On the day of the fall, the CNA turned him/her onto his/her side to wash his/her back. The right side rail gave way and he fell and broke his/her arm. During an interview on 8/24/12 at 6:30 A.M., the Maintenance Director said on 7/12/12, he entered the shower room after the resident fell from the shower bed. The top of the right side rail had no metal pin in it. The side rail bar had separated from the base. During an interview on 8/24/12 at 7:35 A.M., the interim Director of Nurses (DON), said she was the Corporate Nurse and currently filling in as the DON until the new DON starts. On 7/12/12, the previous DON still worked at the facility. At the time of the resident's fall, the previous DON had not arrived at the facility yet, but she was present and staff summoned her to the shower room as soon as the resident fell . When she arrived in the shower room, the resident's head was pointed in the direction of the foot of the shower bed and his/her feet were pointed in the direction of the head of the shower bed. He/She must have flipped upside down during the fall to land in that position. The shower bed's right side rail had separated from the top to the middle. The top of the right side rail did not have a pin in it, but the bottom of the right side rail did. After the fall, a maintenance worker found two of the shower bed's four metal pins at the nurse's station. She did not know why or who put the metal pins at the nurse's station. She did not think CNA D and E knew the shower bed's side rails required metal pins. When the DON arrived, she told her to start investigating the resident's fall. She assumed the DON had done the investigation. She could not find the DON's investigation, so she was not sure if the DON investigated the fall or not. During a telephone interview on 8/24/12 at 8:55 A.M., CNA D said he/she had worked at the facility for six years. On 7/12/12, CNA E asked him/her to help with the resident's shower. He/She used the shower bed before and knew it should have metal pins at the top and bottom of each side rail. The right side rail did not have a metal pin at the top and the left side rail did not have a metal pin at the bottom. She did not feel comfortable using the shower bed because of the missing pins. It did not appear to be safe. She told the resident about the missing pins but the resident said to use it anyway, so they did. During the shower, they turned the resident onto his/her right side to wash his/her back. The top of the right side rail gave way and the resident fell from the shower bed to the floor. During an interview on 8/24/12 at 10:10 A.M., CNA E said he/she had worked at the facility for three years. He/She had taken care of the resident several times and had used the shower bed before. He/She and CNA D gave the resident a shower on 7/12/12. He/She stood on the left side of the resident and CNA D stood on the right side. He/She knew the shower bed had a metal pin missing before they put the resident onto the shower bed. He/She and CNA D told the resident about the missing metal pin and asked him/her to use the shower chair. The resident said he/she could not use the shower chair and told them to go ahead and use the shower bed. When they turned the resident onto his/her right side, the right side rail broke and the resident fell to the floor. During an interview on 8/24/12 at 10:20 A.M., the DON said she did not know CNA D and E knew about the missing metal pins. The shower bed should not have been used even if the resident told them to. CNA D and E should have told one of the nurses. During an interview on 8/24/12 at 11:30 A.M., the resident said he/she did not tell CNA D and E to use the shower bed. Why would he/she want to risk falling on the floor? He/She thought they had replaced the metal pins in the side rail before they took him/her to the shower room. During a telephone interview on 8/25/12 at 10:15 A.M., the facility's Medical Director said the CNAs should not have used the shower bed if they knew it had metal pins missing from the side rails. Even if the resident told them to use it, they should not have. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Severe cognitive impairment; -Total assistance of two or more staff for bed mobility, transfers, dressing, personal hygiene, toilet use and bathing; -Range of motion limitations for both upper and lower extremities; -No falls; -Mobility devices: wheelchair. Review of the resident's nurse's note, dated 7/21/12 at 12:00 P.M., showed the following: -The resident fell after his/her wheelchair rolled down the hill on the parking lot; -The assessment showed bleeding from the right side of the head and staff applied pressure to stop the bleeding; -The resident's family member said he/she locked the brakes, but they didn't work well and the wheelchair rolled down the hill; -The resident sent to the hospital for evaluation. Review of the resident's hospital admission note, dated 7/21/12, showed the following: -Fall after wheelchair rolled downhill, lost control and hit a curb; -Hit the right side of his/her head sustaining a laceration (cut); -He/She also sustained a small amount of bleeding in both lateral ventricles in the brain. Review of the resident's medical record, showed a readmitted [DATE], with a [DIAGNOSES REDACTED]. Observation on 8/21/12 at 5:35 A.M., showed the resident lay in bed with tracheotomy (a surgically created opening in the wind pipe to allow air to get into the lungs) connected to humidified air and a [DEVICE] (a tube surgically placed through the abdomen into the stomach used to administer fluids and nourishment). During an interview on 8/21/12 at 6:10 A.M., a family member said he/she spoke to a therapist regarding the wheelchair a few days prior to the fall. The therapist said he/she would ask the occupational therapist to take a look at the wheelchair, but he/she didn't look at the wheelchair that day. During an interview on 8/21/12 at 12:10 P.M., the therapy program manager said a family member did speak to him/her one day during the week regarding the resident's wheelchair. He/She said the family member said the wheelchair felt shaky but didn't describe anything specific about it. He/She didn't check the wheelchair at that time. During an interview on 8/22/12 at 2:30 P.M., a different family member said he/she has also spoken to the facility regarding the resident's wheelchair. He/She asked if he/she could repair the wheelchair because he/she had a sister that used a wheelchair and he/she has had to tighten the wheelchair at times. The facility told him/her not to work on the wheelchair because the therapy department would check the wheelchair. During an interview on 8/22/12 at 3:15 P.M., the occupational therapist said no one told him/her of the resident's wheelchair not working well or there was a problem with the brakes prior to the fall. He/She didn't know about it until 7/23/12, after the fall had occurred. If he/she had known there were concerns with the wheelchair he/she would have checked it. Since that time the wheelchair had been replaced with a specialized wheelchair used to help with positioning. During an interview on 8/23/12 at 1:15 P.M., the DON said a family member informed the therapy program manager that he/she had some problems with the wheelchair but he/she did not describe anything specific about the wheelchair. She said the program manager was a speech therapist and that is why he/she didn't check the wheelchair. 3. Review of Resident #13's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Walker mobility; -Limited assistance of one with transfers; -Setup and supervision with ambulation; -Extensive assistance with toileting; -Frequent incontinence of bladder; -Occasional incontinence of bowel; -No bowel or bladder toileting program; -Unsteady balance during transitions and walking but able to stabilize without human assistance; -No falls. Review of the resident's progress notes, showed the following: -The resident fell or was found on the floor, on multiple occasions from, 3/10/12 through 5/21/12. -On 5/23/12 at 6:00 P.M., the resident's physician instructed staff to keep the resident's bed in low position. The resident had no safety awareness; -The resident fell or was found on the floor on 5/25/12 at 8:25 A.M., and on 6/27/12 at 3:20 P.M. and 3:30 P.M. Review of the resident's annual MDS, dated [DATE], showed the following: -Falls, yes. Review of the resident's care plan, dated 7/4/12, showed the following: -History of multiple falls relating to disease process or conditions of DM, urinary tract infection (UTI), psychosis (loss of contact with reality), dementia and mental retardation; -Unsteady gait, lack of coordination and difficulty walking; -Falls also related to daily use of Geodon (an antipsychotic), Trileptal (an anticonvulsant) and Lamictal (an anticonvulsant); -Provide environmental adaptations: low or platform bed, call light within reach, adequate glare free lighting, area free of clutter. Review of the resident's progress notes, showed the resident fell four times between 7/5/12 and 8/16/12. Review of the resident's physician's orders [REDACTED]. -Ambulate with wheeled walker; -May have pressure sensitive alarm; -Bed in lowest position to floor. Review of the resident's fall risk assessment, dated 8/16/12, showed a total score of 28. According to the assessment, a resident who scored 10 or higher indicated fall risk. Observations of the resident on 8/22/12 at 10:41 A.M., 2:57 P.M., 5:16 P.M., 5:33 P.M. and 5:57 P.M., as well as on 8/23/12, at 7:00 A.M., 7:46 A.M., 9:44 A.M., and on 8/24/12 at 5:47 A.M., 7:10 A.M., 8:19 A.M. and 9:35 A.M., showed the resident in bed with the bed not in the lowest position to the floor. During an interview on 8/24/12 at 1:11 P.M., the DON said: -A resident's care plan should be updated to reflect any changes; -physician's orders [REDACTED]. -The resident's bed should be kept in the low position. 4. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -admission date of [DATE]; -Usually understood, understands; -Total dependence of one person for bed mobility, transfers, and locomotion on/off the unit; -Impairment of both upper and lower extremities; -[DIAGNOSES REDACTED]. -History of falls. Review of the resident's care plan, last reviewed on 6/21/12, showed the following: -Numerous falls at home prior to admission; -Bed and chair alarm. Review of the facility's "Incident/Accident" log, showed the resident fell on the following dates: -7/3/12 at 10:35 P.M.; -7/17/12 at 8:40 P.M. Observation on 8/20/12, from 8:00 A.M. until 1:30 P.M., during the survey process, showed the resident lay in bed with a pressure alarm pad on the floor, under the foot of the resident's bed, instead of on the bed. Observation on 8/21/12 at 5:30 A.M., showed the resident lay in bed with a pressure alarm pad on the floor underneath the foot of the resident's bed. From 5:55 A.M. until 2:00 P.M., the resident sat up in a broda chair (a reclining chair on wheels, used by residents that require support while sitting) with no chair alarm in use. Observation on 8/22/12 at 7:00 A.M., showed the resident lay in bed with a pressure alarm pad on the floor under the foot of the resident's bed. Observation on 8/24/12 at 5:45 A.M., showed the resident lay in bed with a pressure alarm pad on the floor underneath the foot of the bed. At 7:55 A.M., during morning care, CNA R said the pressure alarm pad should be on the resident's bed, he/she did not know why it was on the floor. During an interview on 8/24/12 at 9:00 A.M., the DON said the pressure alarm pad should not have been on the floor. Staff should have noticed and placed the pressure alarm pad on the bed. 5. Review of Resident #12's significant change MDS, dated [DATE], showed the following: -Rarely/Never understood; -Sometimes understands; -Short/Long term memory problem; -Moderately impaired decision making ability; -Total dependence of two (+) persons for bed mobility and transfers; -[DIAGNOSES REDACTED]. -No falls. Review of a "Post Fall Screening", dated 4/23/12, and competed by the therapy department, showed the following interventions were in place: chair alarm, bed alarm, lay down after meals and call light in reach. Review of the facility "Incident/Accident" tracking log, showed the resident fell on [DATE] at 4:00 P.M., requiring treatment outside of the facility. Review of the resident's "Fall Risk" assessment, completed on 5/27/12, showed a score of 24. A score of 10 or higher indicates the need for interventions to prevent falls. Review of the resident's care plan, last updated on 7/18/12, showed no bed alarm as an intervention to prevent falls. Review of the resident's POS, dated 8/1/12 through 8/31/12, showed an order for [REDACTED]. Observation on 8/21/12 at 6:00 A.M., showed the resident lay in bed, dressed. The pressure pads alarm box (thin vinyl pad with pressure sensors laid across the bed, the pad is attached to an alarm box, designed to alarm if the resident rises unassisted) lay on the resident's bed table, unplugged. Observation on 8/24/12 at 5:55 A.M., showed the resident lay in bed. The resident's pressure pad alarm box sat on top of the bed table, unplugged. CNA EE, provided personal care and transferred the resident into a wheelchair. The pressure pad did not alarm during personal care or the transfer. The CNA did not touch the alarm box during the care. 6. During an interview on 8/24/12 at 9:00 A.M., the DON said direct care staff are responsible for ensuring bed and chair alarms are in place and properly functioning. MO 791