Every finding on record at Willowcreek Wellness & Rehabilitation

Based on observation, interview and record review the facility failed to provide a clean and homelike environment for two residents (Residents #82 and #15) whose bathrooms were not kept in good repair. The facility also failed to maintain a common-use shower room in good repair when several areas of wall tile were missing. The sample size was 23. The census was 106. Review of the facility's Resident Rooms and Environment policy, dated 08/20, showed:-Purpose: To provide residents with a safe, clean, comfortable and homelike environment;-Policy: The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This should include ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. To this end, the facility encourages residents to use their personal belongings to the extent possible;-The facility will ensure that corridors have handrails that are firmly secured and affixed to thecorridor walls. Review of the facility's Privacy and Dignity Policy, dated 01/26, showed:-Purpose: To ensure that the care and services provided by the facility promote and/or enhance privacy, dignity and overall quality of life;-Policy: The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. 1.Review of Resident #82's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/22/26, showed:-admission date: 04/14/26;-Cognition intact; -Independent with Activities of Daily Living (ADLs); resident completes the activity by him/herself with no assistance from a helper.-Diagnoses included: Elevated blood pressure, Charcot's Joint (progressive destruction of bone and soft tissues) of right ankle/foot and absence of the left leg below the knee (BKA). Review of the resident's care plan, last updated 07/30/26, showed-Focus: The resident has amputation of the left BKA;--Desired outcome: Mobility will be restored by use of prosthesis, use of adaptive equipment such as crutches, cane, walker or wheelchair;--Interventions: Monitor/document emotional status of resident. Observe resident's acceptance of body image changes, ability to cope with physical changes. Be supportive. Encourage resident to vent fears, concerns and any other relevant feelings;-Focus: On Pain medication ; therapy related to (r/t) Charcot's Joint of right ankle/foot;--Desired outcome: Will be free of any discomfort or adverse side effects from pain medication;--Interventions: Monitor for increased risk for falls. During an interview on 08/10/26 10:55 A.M., the resident said he/she was moved into this room about a month ago. The resident said the toilet overflows. He/She informed maintenance frequently. The maintenance staff will come down and plunge the toilet, and it will overflow again. This is a real concern especially when the resident attempts to wipe his/her own buttocks, and his/her hand touches the water with fecal material in it. The resident said this is a huge problem in their room and others. Observation on 08/12/26 at 09:04 A.M., showed in the bathroom adjacent to the resident's room, the grab bar on the wall was loose. There was water all over the floor in the bathroom. Water leaked around the base of the toilet and reached into the resident's room. During an interview on 08/12/26 at 9:04 A.M., the Maintenance Director said a handle rail would become loose is if someone pulled on it. They would never have moved the resident into a room that needed repairs. The facility changed the wax ring (building material used for toilet seals) approximately one week ago from today. The issue was resolved at that time. The Maintenance Director said he trialed the toilet with a flush, and at that time, the toilet did not overflow or back-up like prior. Now the water leaked from around the base of the toilet and did reach into the resident's room. During an interview on 08/12/26 at 9:56 A.M., Housekeeper T said he/she was cleaning the resident's room today. When he/she went to the adjacent bathroom, he/she saw toilet paper in the toilet, along with water filled to the rim of the bowl. Housekeeper T noticed there was water coming from the base of the toilet. Housekeeper T informed the Maintenance Director who went to get the wet vac (a specialized vacuum to clean up water). Observation on 08/14/26 at 11:08 A.M., showed several wipes pulled from the pipes below the toilet. The grab bar was secured to the wall. During an interview on 08/14/26 at 11:08 A.M., the Maintenance Director said the handrail in the resident's bathroom was tightened this morning. The facility hired plumbers to snake the toilet, and they pulled out several wipes that had clogged the toilet. The plumbers removed all the debris. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed:-Cognition intact;-Diagnoses included: Cellulitis (bacterial skin infection that causes painful, red, swollen, and warm skin) of left lower limb, open wound to left lower leg, dialysis (filters the blood), and kidney disease. Observation on 08/11/26 at 7:00 A.M., of the resident's bathroom, showed there was a hole in the drywall under the sink, that exposed the pipes that led to the resident's toilet. Observation on 08/12/26 at 8:59 A.M., of the resident's bathroom showed the pipes under the sink remained exposed, and there were no baseboards throughout the room. During an interview on 08/11/26 at 7:00 A.M., the resident said a pipe burst (unknown date). During an interview on 08/13/26 at 8:24 A.M., certified nurse's aide (CNA) H said the pipes under the sink leaked, but he/she was not sure why the facility tore out the dry wall. During an interview on 08/14/26 11:08 A.M., the Maintenance Director said he/she was hired a month ago, and renovation were in progress. The residents' rooms without baseboards do not look like a homelike environment, but the baseboards cannot be put on until the new floors are laid down. The hole under the sink was caused from a burst pipe. This will be fixed/patched up when the floors are completed in 1 1/2 weeks. 3. Observation during all days of survey on 08/11/26 at 9:58 A.M., 08/12/26 at 9:45 A.M., 08/13/26 at 1:59 P.M. and 08/14/26 at 12:45 P.M., of the shower room across from room [ROOM NUMBER] showed:-Three yellow tiles missing from the top row of tiles, on the wall adjacent to the toilet;-Five medium-size yellow tiles missing from the wall under the toilet paper holder; -A piece of unfinished drywall, approximately 3 feet by 4 feet, at the bottom of the wall, directly underneath the area with the five missing yellow tiles.-A damaged toilet paper holder, with no toilet paper. During an interview on 08/14/26 at 12:00 P.M., CNA I said he/she did not know what caused the wall damage in the shower room across from room [ROOM NUMBER] or how long the shower room had been in disarray. During an interview on 08/14/26 11:08 A.M., the Maintenance Director said the shower room across from room [ROOM NUMBER] was brought to his attention as of yesterday. The contractors are going to fix this bathroom as well. 4. During an interview on 08/14/26 at 3:18 P.M., the Director of Nursing (DON) said she would expect a homelike environment, with baseboards in the rooms, holes in drywall to be repaired, toilet paper in the shower rooms and no missing tiles on the walls. 3133613

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity when the Director of Maintenance engaged in an argument with one resident (Resident #82). The sample was 23. The census was 106.Review of the facility's Privacy and Dignity policy, dated January 2026, showed:-Purpose: To ensure that the care and services provided by the facility promote and/or enhance privacy, dignity and overall quality of life;-Policy: The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality;-Privacy Considerations:--The Facility respects each resident's private space and personal property;--Staff interact with residents in a respectful manner, including;--Speaking respectfully;--Listening attentively;--Recognizing social status and personal choices;-Staff address residents as individuals, focusing on their unique needs and preferences. Review of Resident #82's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/22/26, showed:-admission date 04/14/26;-Cognition intact;-Independent with activities of daily living (ADLs). Resident completes the activity by themself with no assistance from a helper;-Diagnoses included elevated blood pressure and absence of the left leg below the knee. Review of the resident's care plan, last updated 07/30/26, showed:-Focus: Has a history of trauma;--Desired outcome: Create an emotionally and physically safe environment;--Interventions: Encourage resident to verbalize feelings of distress, establish therapeutic nonjudgement relationships, respond with empathy and respect;-Focus: Has a psychosocial well-being problem actual or potential related to ineffective coping skills;--Desired outcome: Will identify appropriate diversional activities by the review date, will identify coping mechanisms (new and old);--Interventions: To answer questions and verbalize feelings perceptions, and fears as needed (PRN). Assist/encourage support to set realistic goals. Needs assistance/encouragement/support to identify problems that cannot be controlled. Observation on 08/12/26 at 9:04 A.M., showed the resident's bathroom with a loose handrail that was almost detached from the wall. While the Director of Maintenance attempted to respond to a question, the resident talked over the Director of Maintenance. The conversation between them became loud, with both using raised voices. The resident told the Director of Maintenance the handrail was loose for some time. The Director of Maintenance said no, because they would never have moved the resident into a room that needed repairs. The resident called the Director of Maintenance, [NAME], while waving his/her hands. The Director of Maintenance said I am not your [NAME] and get your hands out of my face. The Supervisor of Housekeeping told the Director of Maintenance to remove him/herself from the room. During an interview on 08/12/26 at 9:04 A.M., the Director of Maintenance said the handrail was loose. The only way that could occur is if the resident pulled on it. On 08/13/2026 at 10:38 A.M., the Director of Maintenance said he/she was educated on how to leave an intense situation. During an interview on 08/12/26 at 9:34 A.M., Licensed Practical Nurse (LPN) K said he/she saw the Director of Maintenance and the resident were in a discussion about the bathroom. The resident became loud and the Director of Maintenance did not like that. The Director of Maintenance told the resident not to put his/her hand in his/her face, he/she was a grown man/women. At that time, Housekeeping Supervisor told the Director of Maintenance to exit the room. The resident had behaviors and this behavior was normal for him/her. Staff are not taught deescalation techniques at this facility. LPN K was taught deescalation techniques from other facilities but denied any education here. During an interview on 08/14/26 at 10:12 A.M., the resident said the interaction with the Director of Maintenance made him/her feel like a child. During an interview on 08/14/26 at 3:18 P.M., the Director of Nursing (DON) said she expected residents to be spoken to with kindness and respect at all times. All employees are taught how to appropriately deescalate residents. 304369531336133055821

Based on interview and record review, the facility failed to ensure staff immediately reported an allegation of abuse in accordance with the facility's policy, resulting in a delayed response and investigation, and the facility's failure to report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe for one resident (Resident #1). The sample was 4. The census was 110.The Administrator was notified on 05/27/26 of the past non-compliance, which occurred on 05/15/26. The facility in-serviced staff regarding Abuse and Neglect reporting protocols and staff demonstrated understanding. The deficiency was corrected on 05/20/26. Review of the facility's Abuse Prevention and Prohibition policy, revised 01/26, showed:-Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements;-Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property;-Training:--Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics:---Who is a covered individual responsible for reporting;-Prevention:--Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring;-Reporting/Response:--Facility staff are mandatory reporters:---Facility owners, operators, employees, managers, agents, and contractors are obligated to report known or suspected instances of abuse of elder or dependent adults;---Facility staff will report known or suspected instances of abuse to the Administrator, or his/her designee;--The facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime;---Immediately, but no later than two hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation). Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/28/26, showed:-Moderate cognitive impairment;-No hallucinations or delusions;-No rejection of care behavior;-Impairment of both upper and lower extremities;-Dependent on assistance with activities of daily living (ADLs);-Diagnoses included central cord syndrome (CCS, an injury to the central part of the spinal cord in the neck), cognitive communication deficit, need for assistance with personal care, weakness, and muscle spasms. During an interview on 05/27/26 at 1:08 P.M., the resident said a Certified Nurse Aide (CNA) was changing him/her and the CNA stuck his/her finger into the resident's rectum. The resident said, Fuck, what are you doing? The CNA said he/she rubbed something off his/her buttocks. The resident told the CNA that he/she stuck his finger up the resident's buttocks and the CNA said, Oh, sorry my bad. The resident felt like he/she was sexually abused because nobody else had ever put their finger into his/her rectum. He/She told the nurse he/she did not want the CNA to come in and take care of him/her anymore. He/She did not know the CNA's name. Review of the facility's investigation, dated 05/22/26, showed:-On 05/16/26, the resident reported an allegation of abuse to Housekeeper (HK) A;-On 05/16/26, HK A reported the allegation of abuse to the Housekeeping Supervisor (HKS);-On 05/18/26, HK A was asked to identify the resident;-When questioned regarding the delay in further reporting, HK A stated he/she was unable to recall the resident's name or room number at that time;-Once the resident was identified, the Regional Director of Operations (RDO) and the Director of Social Services conducted an interview to obtain the resident's statement. During an interview on 05/27/26 at 10:17 A.M., HK A said on 05/15/26, between 10:00 A.M. and 11:00 A.M., the resident reported a couple weeks ago, one of the CNAs touched him/her inappropriately by putting their finger into the resident's rectum. The resident identified the CNA to HK A as CNA B when he/she walked by his/her room. HK A attempted to report it before he/she left for the day at 2:00 P.M., but nobody was in the office. He/She called the HKS that night or the night after and reported the allegation. HKS said she would report it to the appropriate person. During an interview on 05/27/26 at 12:19 P.M., HKS said HK A called her on the evening of 05/16/26 and reported the resident alleged he/she was abused by CNA B when the CNA put his/her finger into the resident's rectum. On 05/18/26, HKS asked HK A to show her who the resident was, and she then reported the allegation to the RDO. Nobody was at the facility over the weekend and she did not know that she should have come up to the facility on [DATE] when the allegation was initially reported to her. She has since received training on the facility's abuse reporting policy. During an interview on 05/27/26 at 3:30 P.M., RDO said the HKS reported the allegation of abuse on 05/18/26. RDO asked the HKS when the allegation happened and when the resident reported it to HK A. HKS said the resident reported the allegation to HK A on 05/15/26, and it was reported to HKS on 5/16/26. HKS said HK A did not know the resident's name or room number and was off work for two days, so HKS waited until 05/18/26 when HK A returned to work to identify the resident. During an interview on 05/27/26 at 3:42 P.M., the Administrator said he expected any allegation of abuse to be reported immediately, up through the chain of command and to the Administrator. He expected the allegation to be reported to DHSS within the required two-hour timeframe. He expected the facility staff to ensure the resident's safety, to suspend the staff named in the allegation, and to complete an investigation related to the allegation. He expected HK A to have reported the allegation immediately to the Administrator or his/her supervisor. The Administrator expected the HKS to report the allegation immediately, even if she did not know the resident's name or room number. The Administrator expected staff to be knowledgeable of and to follow facility policies and procedures. 3017546

Based on observation, interview and record review, the facility failed to accurately document physician ordered treatments on the Treatment Administration Record (TAR) for three residents (Residents #77, #112 and #92). The sample was five. The census was 112.Review of the facility's Documentation - Nursing Policy, dated 6/20, showed:-Purpose: To provide documentation of resident status and care given by nursing staff;-Policy:--Nursing documentation will be concise, clear, accurate and evidence based. Narrative charting, as outlined in specific policies and procedure, will be used for initial treatments or procedure. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts and other documentation tools will be used as appropriate.--Nursing staff will not falsify or improperly correct nursing documentation.-Procedure:-Alert Charting describes what is going on;--Describe the resident's condition, include what you see, hear, smell, feel, etc. Review of the facility's Wound Management policy, dated 6/2020, showed:-Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure;-A resident who has a wound will receive necessary treatment and service to promote healing, prevent infection and prevent new pressure injuries from developing;-III. Documentation:--Licensed Practical Nurse (LPN), Registered Nurse (RN) will document effectiveness of the current treatment in the resident's medical record on a weekly basis. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/26 showed:-admission date: 8/22/25;-Diagnoses included: Anemia (lack of healthy red blood cells), diabetes, lung disease. Review of the resident's physician's order summary report, showed:-Order dated 2/23/26, right posterior buttocks, cleanse with normal saline, pat dry and apply Calcium Alginate (Ca+ Ag, a highly absorbent, biodegradable, and biocompatible wound dressing), cover with silicone foam dressing daily and as needed (PRN);-Order dated 2/27/26, right foot, paint with Betadine (powerful, amber-colored antiseptic solution used to kill bacteria), cover with dry dressing daily and as needed. Review of the resident's Treatment Administration Record dated 3/2026, showed:-Right posterior buttocks, cleanse with normal saline, pat dry and apply Ca+ Ag, cover with silicone foam dressing daily and PRN;--On 3/17/26, documentation blank;- Right foot paint with Betadine, cover with dry dressing daily and as needed;--On 3/17/26, documentation blank. Observation on 3/18/26 at 9:01 A.M., showed, the resident's bandage to the right leg and foot dressing was dated for 3/16/26. Observation on 3/18/26 at 9:26 A.M., showed the resident had a dressing on his/her coccyx dated 3/17/26. During an interview on 3/18/26 at 9:26 A.M., Wound Nurse 1 said, he/she works Monday through Friday as the wound nurse. He/She expected the nurses to review the resident's Treatment Administration Record and change the dressing if it's soiled or outdated. During an interview on 3/18/26 at 8:59 A.M., Wound Nurse 2 said, he/she worked the floor last night (3/17/26). At 9:26 A.M., Wound Nurse 2 said he/she changed the dressing on the right foot on 3/16/26. 2. Review of Resident #112's quarterly MDS, dated [DATE], showed:-admission date: 1/30/24;-Diagnoses included: Anemia, hyponatremia (low sodium), hip fracture, malnutrition, lung disease. Review of the resident's order summary report, showed:-A physician order, dated 4/8/25, sacrum (tailbone) cleanse with normal saline (NS sterile water) Vashe (wound cleanser) pat dry pack with calcium alginate, change daily or as needed. Observation on 3/18/26 at 11:52 A.M., showed the resident's bandage on the sacrum was dated for 3/17/26. During an interview on 3/18/26 at 11:52 A.M., Wound Nurse 2 said the current bandage date was 3/17/26. Review of the resident's TAR, dated 3/2026, showed:-Sacrum wound, blank entries, for four of 11 opportunities;- On 3/17/26 sacrum wound showed a blank entry, no documentation regarding the wound dressing change on 3/17/26. 3. Review of Resident #92's admission MDS, dated [DATE], showed:-admission date: 2/23/26;-Diagnoses included: Anemia, renal disease, stroke, malnutrition, lung disease. Review of Resident #92's TAR, dated 3/2026, showed:-A physician order, dated 3/12/26, left inner thigh and left stump, cleanse with NS or wound cleaner, Ca+ Ag, cover with dry dressing daily and PRN;-One out of three opportunities left blank. 4. During an interview on 3/18/26 at 8:39 A.M., Wound Nurse 1 said there are no residents that are missing their treatments. The vibe was clock out after eight hours even if wounds aren't finished. 5. During an interview on 3/18/26 at 1:39 P.M., the Director of Nursing (DON) said she expected all treatments to be documented at the time they are completed. 6. During an interview on 3/18/26 at 1:39 P.M., the Regional Nurse said nurses have a computer on their carts specifically to chart in real time after a treatment is completed. 7. During an interview on 3/18/26 at 2:11 P.M., the Administrator said she expected the nursing department to chart on the treatments being completed. She would expect precise charting to be done. 28059852805846

Based on interview and record review, the facility failed to respond to Resident #99's change in condition when the resident, who had a tracheostomy (surgical opening in the trachea to create an airway), experienced a change in breathing, becoming abnormally fast. Facility staff failed to complete a thorough, documented assessment and failed to contact the resident's physician in a timely manner. The resident expired at the facility. This deficient practice affected one out of three residents sampled. The census was 119.The Administrator was notified on [DATE] of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. Upon notification, the facility administration immediately conducted an investigation into the incident, in-serviced nursing staff regarding changes in residents' condition, arranged for a contracted respiratory therapist to come in and evaluate all residents who have tracheostomies, developed a plan and included it in their Quality Assurance and Performance Improvement (QAPI) program. The IJ was corrected on [DATE]. Review of the facility's changed of condition policy, dated 6/20, showed:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner;-Policy: Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death;-I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs andsymptoms that might represent an ACOC;-II. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:--B. A significant change in the resident's physical, cognitive, behavioral or functional status;--D. A decision to transfer or discharge the resident from the Facility;-Procedure: I. The Licensed Nurse will notify the resident's Attending Physician when there is:--C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications;--D. A need to alter treatment significantly;--E. A decision to transfer or discharge the resident from the Facility;-II. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms;-III. Notifying the Attending Physician:--A. The Attending Physician will be notified timely with a resident's change in condition;--B. Notification to the Attending Physician will include a summary of the condition changeand an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required;--C. The Licensed Nurse will review the resident's advanced directives and ensure that theAttending Physician is aware of the resident's wishes. Interventions should be in accordance with the resident's instructions;-IV. Reporting Information to the Attending Physician:--A. Emergency Situations;---i. In emergency situations, (e.g., a resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray), the Licensed Nurse will;----a. Immediately call the Attending Physician;----(i) NOTE: If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director;----(ii) If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital;---b. Notify the Nursing Supervisor of emergency situation;-VI. Documentation:--A. A Licensed Nurse will document the following;--i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes;--ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received;--v. The incident and brief details in the 24-Hour Report;--vii. Complete an incident report per Facility policy;-B. A Licensed Nurse will communicate any changes in required interventions to the IDTmembers involved in the resident's care;-C. A Licensed Nurse will document each shift for at least seventy-two (72) hours;-D. Documentation pertaining to a change in the resident's condition will be maintained inthe resident's medical record and on the 24-Hour Report. Review of Resident #99's face sheet, showed the following diagnoses:-acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body),-tracheostomy,-shortness of breath-pulmonary edema (a serious, often life-threatening condition defined by excess fluid accumulation in the lung air sacs, making breathing difficult and impairing oxygen intake),-stroke, and-diabetes. Review of the resident's admission Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the assessment incomplete at the time of survey. Review of the baseline care plan dated [DATE], showed;-Health conditions: Oxygen therapy, suctioning, and tracheostomy (trach) care;-Level of Consciousness/cognition: Coma (a state of deep unconsciousness) and cognitively impaired. Review of the physician's electronic physician's orders sheet, dated [DATE], showed:-An order dated [DATE], for tracheostomy: Suction resident as needed (PRN), hyperoxygenation (increase oxygen(O2) rate/flow) the resident by increasing oxygen flow to 8 Liters (L) before procedure and between suctioning;-An order dated [DATE]: Oxygen saturation every (Q) shift and PRN. Notify Medical doctor (MD), if O2 saturation is less than 90%;-An order dated [DATE]: Always elevate the head of bed (HOB) 35-45 degree;- An order dated [DATE]: Full code (use all necessary life saving measures);- An order dated [DATE]: Replace inner cannula during trach care every day and as needed;-An order dated [DATE]: Resident has a chronic lung disorder and shortness of breath (SOB) while laying flat, raise HOB or provide extra pillow in bed for comfortable breathing;- An order dated [DATE]: Tracheostomy, humidified oxygen at 28% 2 L via trach;-An order dated [DATE]: High flow 28% via trach collar (HFT) (heated/humidified and blend of air/O2) PRN (as needed) with FIO2 (Fraction of Inspired Oxygen) titrate (increase) in 2L. Review of the nurse's progress notes, showed:-On [DATE] at 8:03 P.M., the resident's family member was concerned about the resident having increased, rapid respirations noted at 26-28 (normal 12-18 breaths per minute) with a combination of slow decreased shallow breathing. The nurse obtained vital signs: Blood pressure (BP) 114/65 (normal 120/80), heart rate (HR) 64 (normal 60-100), temperature (T) 97.6 (normal 98.6), oxygen saturation (Sp02) 90% (normal 95-100%). The nurse noticed the concentrator was on 3L instead of 5L. The resident required high humidify 02 at 28%. The nurse bumped up the 02 to 5L. FI02 titrated in a 2L removed due to the concentrator being unable to be bumped up 5L. The resident was placed on adaptor to adjust up to 5L. The resident's family member requested the resident be sent out to the hospital.-On [DATE] at 8:43 P.M., the nurse placed a call to the physician to report the respiratory concerns. Resident's 02 88-90% at 5L, noted accessory muscles used when breathing (indicates respiratory distress). Nurse received new orders to send resident out to hospital.-On [DATE] at 1:30 A.M., the resident returned to the facility, and paramedics said the resident's trach was suctioned and changed. Review of the resident's progress notes, dated [DATE] showed only medication administration notes. During an interview on [DATE] at 10:53 A.M., Licensed Practical Nurse (LPN) J said he/she worked from 7:00 A.M.-7:00 P.M. on [DATE]. LPN J was not aware the resident had a recent hospitalization in the prior week. He/She was unaware of any changes in condition related to the resident being hospitalized . LPN J made rounds on the resident every two hours, and the resident was fine. No Certified Nurse Aide (CNA) reported anything being abnormal with the resident that shift. LPN J said if there was not a progress note in the electronic medical record (EMR), then he/she did not chart a progress note. During an interview on [DATE] 1:06 P.M., CNA K said, he/she worked evening shift on Sunday [DATE] with the resident. The resident had no signs of distress or anything wrong during his/her shift. During an interview on [DATE] at 4:33 P.M, CNA H said he/she did not obtain a hand off report from the prior CNA on evening shift when arriving at 11:00 P.M. on [DATE]. It was not normal for an oncoming shift to not obtain a verbal report from the leaving CNA. When CNA H worked the previous night, the resident was not breathing funny. CNA H first noticed the resident's abnormal breathing at approximately 11:05-11:07 P.M. during rounds. CNA H reported to LPN G that the resident was not breathing right. CNA H described it as a normal person who ran and was out of breath. CNA H said LPN G went into the room, did not do an assessment and said the resident was fine. CNA H told LPN G that the resident's hands appeared discolored, bluish to gray in color. LPN G said again the resident was fine, and that LPN G was going on break at approximately at 11:20-11:40 P.M. CNA H grabbed a chair to sit outside the door. When he/she peeked at the resident, he/she was not breathing. CNA H said he/she palpated (felt) the neck for a pulse, then the wrist. CNA H had an unsteady hand and obtained the needed assistance from CNA L. CNA L grabbed the vital machine (machine to check blood pressure), while CNA M ran to Hall B to search for a nurse. The Hall B nurse initiated cardiopulmonary resuscitation (CPR). On [DATE] at 12:17 A.M., CNA H notified the ADON of Hall A of the crisis. During an interview on [DATE] at 1:13 P.M., LPN G said on [DATE], he/she saw the resident between 7:00 P.M.-8:00 P.M., when medication was administered. At that time, he/she did not perform any vitals. LPN G could not recall the resident's respiration rate during the night shift on [DATE], but the resident was breathing fast, similar to Kussmauls (a deep, rapid, and labored breathing pattern), and the resident's breathing never changed. LPN G did not think the resident's condition had changed because the previous shift nurse passed on in report that the resident always breathes abnormally, and that was how the resident was breathing at the shift change (at 7 P.M.). At approximately 11:20-11:40 P.M., when the CNA brought the resident's breathing to his/her attention, LPN G put the personal pulse ox (mobile device placed on the fingernail to check resident's oxygen level), and the resident's oxygen level was 93-96%. LPN G was exhausted and needed a break. LPN G said he/she informed the Hall B nurse that he/she was going to lunch. LPN G said if the resident's condition was not his/her normal, then he/she should have been sent to the hospital. During an interview on [DATE] at 2:08 P.M., CNA L said, he/she was working a different hall (during the night shift on [DATE]) when he/she was pulled to assist with a crisis on Hall A. CNA H said a resident might be dead. CNA L asked where was the Hall A nurse. CNA L checked for pulse; the vital machine was unable to register any sign of life. CNA L said she/she started CPR. Staff went to search for a nurse. CNA L said he/she was running the code due to there not being a nurse on that side of the building. The Assistant Director of Nursing (ADON) provided the staff members directions by phone on dispatching 911, and to keep compressions active. During an interview on [DATE] at 2:30 P.M., LPN N said a CNA told him/her a resident had passed away. When LPN N saw the resident, he/she knew the resident was deceased . LPN did not feel a pulse and there was no breathing because the chest cavity not raised with inhaling/exhaling. LPN N initiated chest compressions (CPR) after the code status was known. LPN N said he/she was unaware who was ran the code, which meant no one was assigning roles to staff members. LPN N said the original nurse (LPN G) did not inform other staff members he/she stepped outside to leave for lunch. LPN N said, when LPN G returned to the facility, emergency medical services (EMS) took over the scene. Review of the LPN's nurse progress note at [DATE] at 3:22 A.M., showed resident expired due to hypoxia, last seen around 11:30 P.M., aide notified me that resident's breathing looked a little funny, upon assessment noted that resident's condition was the same as 7:00 P.M., on my arrival. Received in report that resident has been breathing strange all shift and that it was nothing to be alerted about, residents 02 was 93. After assessment I took a break and did not return into the facility until 12:20 A.M., after assisting another nurse with another situation in the building. Resident had already coded and Emergency Medical Technicians (EMTs) were in doing chest compression until time of death (TOD) called at [DATE] at 12:52 A.M. Review of the Fire Department's report dated [DATE] at 2:29 A.M., showed:-Fire Department dispatched to facility for a cardiac arrest (heart stopped) on a patient. Staff reported this arrest was unwitnessed. Staff had begun hands only CPR. Patient was assessed and found to be pulseless and apneic (temporary cessation of breathing). CPR resumed. Attempted to use Ambu bag (provide manual breaths) to the patient, no air flow. Inner trach cannula (easily removed to be cleaned or replaced, preventing mucus buildup) was removed and found to be completely occluded (clogged) with mucus plug (a thick, solid, or semi-solid accumulation of secretions that partially or completely blocks the trach tube, hindering airflow). Patient was suctioned, with copious (a large) amount of thick mucus removed. A new inner trach cannula was placed. The patient had continued Ambu bagging without difficulty. The patient was placed on the cardiac monitor (medical device that continuously or intermittently records the heart's electrical activity), which showed asystole (no rhythm/pulseless) time of death (TOD) was declared at 12:52 A.M. During an interview on [DATE] at 9:39 AM., the ADON for Hall A said she was notified by CNA H on [DATE] at 12:17 AM. the resident was not breathing. The ADON said to call a code, grab a nurse and a crash cart. The ADON gave the CNA orders how to proceed with the CPR of the resident. Another CNA called 911. EMS was already in the building for another situation and responded. LPN G should have called sooner, should have completed a thorough assessment, obtained a set of vital signs and addressed the concerns of the CNA, since the CNA had more experience with the patient. LPN G failed to do basic nursing of (ABC) airway, breathing and circulation. The ADON expected LPN G to have assessed the patient, notified the ADON of a change, and followed up with the physician, or called the ADON if there was something different occurring. The ADON said LPN G should have told another nurse he/she was going on break to have another nurse to cover him/her. Serenity hall is a high acuity floor. The ADON could not find a report sheet from the day/eve nurse from [DATE]. The day/evening shift nurse said the resident was good and had no problems. During interviews on [DATE] at 4:24 P.M. and 5:03 P.M., the Physician said if the resident experienced a change of condition, the staff should have called him. If the resident had secretions, they should have suctioned the resident. The resident was very sick and not in good shape, and he did not think anything could have been done to change the resident's outcome. During an interview on [DATE] at 10:31 A.M., Director of Nursing (DON) said she expected an assessment to be completed and then notify the provider of a change in a resident's condition. LPN G should have taken CNA H's word and did more. The nurse did not do his/her diligence with his/her nursing skills and did not follow protocol. The DON expected the nurse to inform the other nurse when going on break. All staff should have coverage to monitor their hall if/when they leave. The staff started CPR per protocol. During an interview on [DATE] at 10:31 A.M., the Regional Nurse said staff should have contacted the physician when they became aware the resident's breathing was different. During an interview on [DATE] at 12:54 P.M., the Administrator said she expected the nurses to chart on each trach patient. She wants the next nurse to know what the condition of the patient was for the last eight to twelve hours, by looking in the nurse's progress notes. The resident should have been monitored for 72-hours after a hospitalization. The Administrator expected staff and agency staff to do a full head to toe assessment with a quick suction. Nurses should never dismiss the claims of a CNA, especially when CNA H had more experience with the resident. The Administrator expected the nurse to follow ABC guidelines; just because they are on a trach you cannot just say this is their new baseline. The Administrator expected the nurse to reach out to the ADON, DON or MD if he/she had any doubt of the breathing being abnormal. The Administrator said, You cannot take another nurse's hand off report that the resident has a new baseline. Had the nurses wrote a progress note after the hospitalization, they could have referred back and saw what the actual baseline was, normal, or abnormal. CNA H's claims of the discoloration of the resident's hands should have triggered LPN G to conduct a head to toe assessment. The Administrator would not expect LPN G to delegate CNA H to watch over a resident that may/may not have been in distress. LPN G should have provided a handoff report to one of the nurses still in the facility before leaving on break.28027812799835

Based on interview and record review, the facility failed to ensure one resident (Resident #55) was free from significant medication errors when he/she did not receive his/her required Biktarvy (an antiviral medication) on a scheduled basis, per the physician's order, to control the resident's human immunodeficiency virus (HIV, a virus attacking the immune system). The sample was 15 and census was 119. Review of the facility's Physician Order Policy, dated 6/2020, showed:-Purpose: This will ensure that all physicians' orders are completed and accurate;-Policy: The Medical Records Department will verify the physicians' orders are complete, accurate and clarified as necessary;-Whenever possible, the licensed nurse: Registered Nurse (RN) or Licensed Practical Nurse (LPN) receiving the order will be responsible for documenting and implementing the order;-Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline;-Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the medication administration record (MAR) and treatment administration record (TAR).Review of the facility's Medication Administration Policy, undated, showed:-Purpose: To provide practice standards for safe administration of medications for residents in the facility;-Policy: Medication will be administered by a licensed nurse (RN or LPN) per the order of an Attending Physician or licensed independent Nurse Practitioner (NP) or as consistent with state law;-V. Medications may be administered one hour before or after the scheduled medication administration time;-XVII: Holding Medications: Whenever a medication is held for any reason, the licensed nurse will initial the appropriate area on the MAR and circle his/her initials. The licensed nurse will document the reason the medication was held on the back of the MAR;-The policy did not address next steps for Certified Medication Technicians (CMTs), LPNs or RNs, if a medication is not available;-The policy did not state when to notify the Medical Doctor (MD) about an unavailable medication;-The policy did not address pulling the unavailable medication from the Emergency kit (Ekit) if not available on the medication cart. Review of the Biktarvy.com manufacturer's website, showed:-How to take Biktarvy: Take Biktarvy exactly as your healthcare provider tells you to take it. Do not miss a dose;-Can be taken any time of day;-When your Biktarvy supply starts to run low, get more form your healthcare provider or pharmacy. This is very important because the amount of virus in your blood may increase if the medicine is stopped even for a short time. The virus may develop resistance to Biktarvy and become harder to treat;-Do not miss a dose of Biktarvy. It is important to take Biktarvy on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance;-Resistance: Sometimes HIV can change or mutate. This change might make a medicine not work as well. This is called a resistance mutation or treatment resistance. When HIV becomes resistant, it is tougher to treat. Resistance is permanent and not reversible, which means future treatment options could be limited. That is why it is important to understand ways to reduce the risk of resistance. Taking your medication as prescribed and takin g a treatment that has a high barrier to resistance, like Biktarvy, can help prevent drug resistance. Review of Resident #55's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/12/26, showed:-admission date 02/05/26;-Cognitively intact;-Diagnoses included HIV, mood disorder, and nutritional anemia (insufficient intake or absorption);-Activities of Daily Living (ADLs) moderate to supervision assistance required. Review of the resident's care plan, located in the electronic medical record, showed the following problem and interventions:-Focus: Impaired immunity related to HIV;-Goal: Will not display complications related to HIV;-Interventions: Encouraged fluid intake and adequate rest to bolster the immune system; Monitor/Document/Report to MD as needed (PRN) signs and symptoms of infection. The resident is at risk for contracting infections due to impaired immune status; use universal precaution to prevent infection. Review of the electronic physician order sheet (ePOS), showed: -Order date 02/05/26 with a start date 02/06/26, Biktarvy oral tablet 50-200-25 milligram (mg), give one tablet by mouth one time a day for HIV scheduled dose at 9:00 A.M. Review of the resident's February 2026 MAR showed:-Order date 02/05/26 with start date 02/06/26 for Biktarvy oral tablet 50-200-25 mg, give one tablet by mouth one time a day for HIV, scheduled dose at 9:00 A.M.;-First dose missed dated 02/06/26: reason left blank;-Doses missed 02/07/26: reason #7 (see progress note),-Dose missed 02/08/26: reason left blank,-Dose missed 02/09/26: reason #7 (see progress note),-Dose missed 02/10/26: reason left blank,-Dose missed 02/16/26: reason left blank-Dose missed 02/26/26 : reason #7 (see progress note); and-Dose missed 02/28/26: reason left blank.-For the month of February, five out of 23 opportunities missed without a documented reason; -Three out of 23 opportunities missed with documentation of #7, meaning see progress note. Review of the MAR showed no progress note related to Biktarvy on 02/06/26. Review of the MAR progress note dated 02/07/26 at 11:29 A.M., showed Biktarvy oral intake (PO) tablet 50-200-25 mg one tablet daily for HIV, requires an approval from the Director of Nursing (DON). Review of the MAR progress note dated 02/07/26 at 1:00 P.M., showed Biktarvy PO tablet 50-200-25 mg one tablet daily for HIV, patient in hospital, returned later that day. Review of the MAR showed no progress note related to Biktarvy on 02/09/26, 02/10/26, or 02/16/26. Review of the MAR progress note dated 02/26/26 at 12:38 A.M., showed Biktarvy PO tablet 50-200-25 mg one tablet daily for HIV, patient in hospital, returned later that day. Review of the MAR showed no progress note related to Biktarvy on 02/28/26. Review of the resident's March 2026 MAR showed:- Order date 02/05/26 for Biktarvy oral tablet 50-200-25 mg, give one tablet by mouth one time a day for HIV, scheduled dose at 9:00 A.M. Review of the MAR progress note dated 03/04/26 at 11:00 A.M., showed Waiting on pharmacy. During an interview on 03/04/26 at 2:13 P.M., Assistant Director of Nursing 1 (ADON 1) said he/she expected the CMTs to inform the nurse assigned to the resident if a resident refused their medication and the reason(s) why the resident refused their medication(s). Then the nurse can document the response in the nurse's progress notes. ADON 1 would need to contact the CMT on the hall to find out the purpose of the documentation of #9 on the resident's MAR. At 2:18 P.M., ADON 1 called CMT A on the phone. ADON 1 said CMT A said the resident's Biktarvy was not in the medication cart, and he/she didn't recall administering it. CMT A said there was no card for Biktarvy. ADON 1 asked CMT A if he/she notified his/her direct nurse. CMT A said he/she was training a newer CMT and did not follow up with the nurse or pharmacy. ADON 1 said #9 means not administering missed medication. Observation on 03/04/26 at 3:17 P.M., showed ADON 1 brought the Biktarvy bottle, last filled on 02/10/26, and there were 13 pills in the container. The quantity of the bottle was 30 tablets. During an interview on 03/04/26 at 3:17 P.M., ADON 1, said there should be less than 13 pills remaining in the bottle. During an interview on 03/05/26 at 10:25 A.M., the DON said all medications are equally important, even the over-the-counter (OTC), and MD should be notified if a medication is not administered. For example, if the medication is not there, CMTs and nurses should check the E-kit, and call the pharmacy to see why the medication is not in the facility. The DON said for medications that are not in the E-kit, staff need to call the pharmacy and see what the delay is. The DON said staff should notify the MD and see if there is an interchangeable medication. The DON said staff were required to use #7 or #9 on the MAR/TAR with a follow-up note on why that medication was not there or not administered. The DON said the CMTs were expected to call the pharmacy, tell the nurse, unit manager or DON. The DON expected staff to follow with upper management with some form of notification when medications were missed or unavailable. During an interview on 03/05/26 at 10:25 A.M., the Regional Nurse said she did medication audits and identified areas for improvement. The audits showed a breakdown within the facility and had re-education in progress. The Regional Nurse said the resident who received Biktarvy saw operational failure, because the pharmacy did not send the Biktarvy in a bubble pack card. The pharmacy sent it in a bottle, which CMTs are used to seeing with OTC medications, not prescription medications. The Regional Nurse said, part of the correction plan is for Biktarvy to be in the E-kit. The Regional Nurse was aware the resident had missed five doses of Biktarvy during the month of February. A resident who did not obtain the prescriber's recommended dosage runs the risk of drug resistance. 2791187

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin as a result of pressure or friction) receives treatments as ordered when staff failed to apply wound care as ordered by the physician for one resident (Resident #8). The sample was 7. The census was 107.Review of the facility's Wound Management policy, dated 6/2020, showed:-Purpose: To provide a system for the treatment and management of residents with wounds, including pressure and non-pressure injury;-Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing. Review of the resident's medical record, showed:-Diagnoses included muscle weakness and need for assistance with personal care;-An order dated 1/8/26, to cleanse coccyx (tailbone area) with normal saline/Vashe (wound cleanser), pat dry, apply Santyl (wound debridement ointment), apply calcium alginate ag (absorbent dressing) and cover with dry dressing daily and as needed. Review of the facility's wound report, dated 1/26/26 through 2/2/26, showed the resident with a coccyx pressure ulcer stage 3 (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). Observation on 2/5/26 at 7:23 A.M., showed Licensed Practical Nurse (LPN) D completed wound care for the resident after the treatment became soiled. LPN D assisted the resident to his/her left side and cleansed the wound with wound cleanser. He/She then packed the wound with calcium alginate and covered with boarder gauze. No Santyl applied to the wound. During an interview on 2/5/26 at 4:03 P.M., the Nurse Consultant/Interim Director of Nursing said if a dressing is soiled and required to be changed at a non-routine time, staff should still apply the treatment as ordered. 2719750

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for one resident (Resident #8). The resident called staff to the room and requested to be cleaned of incontinence and was told to wait for the next shift. The sample was 7. The census was 107.Review of the facility's Perineal Care policy, dated 6/2020, showed:-Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown;-Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident needs. Review of Resident #8's medical record, showed:-Diagnoses included muscle weakness and need for assistance with personal care;-A Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/13/25, showed the resident cognitively intact. Dependent on staff for personal hygiene. Frequently incontinent of urine. Always incontinent of bowel;-A care plan, in use at the time of the investigation:--Focus: Activity of daily living (ADL) self-care performance deficit/requires assistancewith all ADLs;---Goal: Will be properly dressed and groomed daily;--Staff to assist as needed with care. Observation on 2/5/26 at 6:34 A.M., showed the resident in his/her room and appeared to be asleep. An odor of bowel movement in the room. Observation on 2/5/26 at 6:51 A.M, showed the resident's call light lit up above the resident's door and beeped at the nurse's station. At 6:52 A.M., a staff member walked down the hall and entered the resident's room. The resident spoke to the staff member and staff member said they are waiting for day staff to come in. The staff member had turned off the call light and exited the room. At 6:53 A.M., the resident said he/she told the staff person he/she needed to be cleaned up and was told he/she had to wait. This happens all the time. Everyone says they are not his/her aide and will not help him/her. His/Her bottom burns when he/she is not cleaned up. Review of the staffing sheet for the resident's hall, showed on the 11:00 P.M. to 7:00 A.M. shift, Certified Nursing Assistant (CNA) A assigned to the resident. Observation on 2/5/26 at 7:06 A.M., showed the resident's call light turned back on. At 7:07 A.M., a staff member walked down the hall and entered the room. The indicator light above the door turned off. The staff member said I do not know who the aide will be today. The staff member exited the room. A second staff member entered the room. He/She introduced him/herself as the nurse and asked if the resident needed anything from him/her. The resident's response could not be heard. The staff person exited the rom. The first staff member talked to the nurse as they walked down the hall, away from the resident's room, and said he/she did not have the resident on his/her assignment, he/she was just answering the light. The nurse said okay. Both staff left the hall. At 7:18 A.M., CNA B arrived to the room and said the nurse is about to do wound care. At 7:20 A.M., Licensed Practical Nurse (LPN) D arrived at the room. CNA C arrived to the room. At 7:23 A.M., the three staff assisted the resident on his/her back, uncovered the resident and unsecured the resident's brief. A large amount of soft bowel movement was on the resident's buttocks and pushed up into the resident's wound dressing. The CNAs provided personal hygiene and LPN D completed wound care. The resident said his/her bottom is getting sore. During an interview on 2/5/26 at 4:03 P.M., the Nurse Consultant/Interim Director of Nursing said residents should be provided care as soon as they request it and staff get the assistance they need. It is not acceptable to ask a resident to wait for the next shift to come in. 2719750

Based on interview and record review, the facility failed to follow their policy regarding notifying the resident's responsible party when one resident (Resident #81) had a fall and was subsequently sent to the hospital. Staff did not notify the resident's representative until the day after the fall, when the family member, who was listed as an emergency contact, arrived at the resident's room for a visit with the resident and found the room empty. The sample was 15 and the census was 119. Review of the facility's Response to Falls Policy, undated, showed:-Purpose: To ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention;-Policy:--I. Residents experiencing a fall will be promptly assessed and treated for injuries;--II. The resident's physician and responsible party will be notified;-Procedure: The licensed nurse will notify the responsible party of the fall and any resulting interventions and/or treatments;-Documentation:--II Document notification of the physician and responsible party. Review of Resident #81's medical record showed:-admission date of 02/26/26;-Diagnoses: General edema (overall swelling), high blood pressure) and chronic obstructive pulmonary disease (ineffective breathing (COPD);-The resident's adult children listed as emergency contacts on the facesheet;-No other family relatives listed as emergency contacts on the facesheet.-The resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, was incomplete at the time of survey. Review of the resident's care plan, in use at the time of the survey, showed the following problem and interventions:-Focus: The resident is at risk for falls related to mobility deficits;-Goal: The resident will be free of minor injury through the review date;-Interventions: Anticipate the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (PRN), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers as to causes. Review of the electronic physician's order sheet (ePOS), showed:-Order date of 02/26/26, family/responsible party is aware of medical condition. Review of the nurse's progress notes showed:-On 03/01/26 at 4:16 P.M., the resident was on close observation from a fall this afternoon. Two certified nurses' assistants (CNAs) attempted to transfer the resident to a Hoyer (mechanical lift) and when the resident was lowered to a wheelchair, after removing holder straps from Hoyer, the resident slid to the floor. This nurse (Licensed Practical Nurse (LPN) B) assessed the resident while on the floor. The resident was able to move both arms; both lower extremities were swollen. The resident's chief complaint was left knee pain. The resident was lifted off the floor with Hoyer and back to bed. The physician was made aware of the resident's complaint of left knee pain and ordered an x-ray (high quality image(s) of the structures in the body);-No documentation that staff contacted the resident's responsible party about the 03/01/26 fall incident;-On 03/02/26 at 5:40 A.M., this morning, the resident requested to go to the hospital to be further evaluated for fall incident on 03/01/26; complaints of back pain and leg pain. Resident continues on neuro (neurological) checks with vital signs. At 6:40 A.M., paramedics arrived. At 9:40 A.M., the physician was notified;-On 03/02/26 at 9:53 A.M., a late entry, the resident's adult child here at the facility, made aware of resident calling 911 to go to the hospital. Nurse informed the resident's adult child which hospital the resident was sent to. Review of the facility's injury report dated 03/01/26 at 1:00 P.M., showed LPN B called the niece (unknown name) at 1:40 P.M. and informed her of the resident's fall. During an interview on 03/04/26 at 3:32 P.M., LPN B said he/she did not speak to the emergency contact; the resident notified his/her family by cell phone. LPN B said the policy does say to notify the next of kin. LPN B then corrected his/her statement and said he/she told the family the facility would obtain an x-ray. During an interview on 03/04/26 at 1:02 P.M., Adult Child 1 said Adult Child 2 arrived at the facility (03/02/26) and found out the resident was not there and had been sent out to the hospital. Adult Child 2 learned about the fall during the visit to the facility. Adult Child 1 said the family was unaware why the resident was sent to the hospital. Adult Child 1 called the facility to find out specifics, but the facility did not call back. During an interview on 03/05/26 at 10:25 A.M., the Director of Nursing (DON) said she expected the nurse to follow protocol and notify the next of kin about any incident. 2792996

Based on observation, interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when staff failed to change a Peripherally Inserted Central Catheter line (PICC, central line placed in the upper arm into a large vein near the heart for long term intravenous (IV) medications) dressing as ordered and ensure the dressing was secured to prevent the risk of infection to the insertion site, for one resident (Resident #10). The sample was 7. The census was 107. Review of Resident #10's medical record, showed:-Diagnoses included osteomyelitis (bone infection) of the vertebra (spine);-An order dated 1/15/26, for central line dressing change every 7 days and as needed for PICC line left upper extremity;-A treatment administration record, dated January 2026, showed the PICC Line dressing change not documented as completed;-A treatment administration record, dated February 2026, showed the PICC line dressing change not documented as completed. The next scheduled treatment, that prompts staff to change the PICC line dressing, not scheduled to trigger on the treatment administration record until 2/11/26. Observation and interview on 2/5/26 at 3:00 P.M., showed the resident in his/her room in bed. His/her parent was on the phone. The resident said he was admitted on [DATE]th and was admitted with his/her PICC line for antibiotics. He/She has an infection in his spine. The resident's parent said the infection control doctor said the dressing to the PICC line needed to be changed at least weekly and staff do not change it. The resident said the dressing on his/her PICC line site was changed on 1/29/26 and that is the first time staff changed it at the facility. They changed it because it was coming off, and now it is coming off again. Observation showed antibiotics infused into the left arm PICC line. The outer aspect of the PICC line dressing hung off loosely. The resident lifted the edge up and showed that it could be pulled up almost to the insertion site. During an interview on 2/5/26 at 4:03 P.M., the Nurse Consultant/Interim Director of Nursing said if a dressing is changed as needed, it does not change the due date for the next treatment. If the treatment is loose or is falling off, staff need to clean the site and replace the dressing. If the PICC line looks like there are integrity issues, staff need to contact the physician. 2736346

Based on observation, interview and record review, the facility failed to provide services based on acceptable standards of practice by not clarifying a physician order for one resident who was not being monitored throughout the day for his/her diabetes (Resident #2) and for failing to complete a follow up accucheck (blood sugar test) per physician order for one resident who had elevated blood sugar (Resident #5). The sample was 5. The census was 104.Review of the facility's Physician Orders Policy, revised dated June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The medical records department will verify that physician orders are complete, accurate and clarified as necessary;--A licensed Nurse will transcribe telephone orders with date, time, and signature of the person receiving the order;-Orders will include a description complete enough to ensure clarity of the physician's plan of care;-Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order;-Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the communication system for that discipline;-Documentation pertaining to the physician order will be maintained in the resident's medical record. Current month's administration record will be maintained in the medication administration record (MAR)/treatment administration record (TAR). Review of the facility's Diabetic Care Policy, revised dated June 2020, showed:-Purpose: To improve the quality of care delivered to the residents with diabetes;-Policy: Blood glucose levels will be monitored at specific intervals as ordered by the attending physician;-The resident will be monitored for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar);-Procedure: The License Nurse will monitor the resident blood glucose per the Attending Physician's order and will administer the medication as indicated;-Notify the Attending Physician if blood sugar is outside of the ordered parameters;--Of treatment and results;--For any possible changes in insulin and oral diabetes medication;-Document the episode in the resident's medical record including;--Resident's symptoms;--Interventions;--Resident's response to treatment;--Physician notification. 1.Review of Resident #2's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/25, showed:-Cognitive intact;-Needs moderate assistance with activities of daily living (ADLs). Review of the resident's electronic medical record (EMR), showed diagnoses included diabetes and kidney failure. Review of the resident's hospital after-visit summary, dated 5/2/25, showed continued medications included insulin aspart (a short-acting insulin) 100 unit (U)/milliliter (ml) vial for injection, inject (administer) 6U under the skin every eight hours as needed (PRN). Review of the resident's physician order sheet (POS), showed:-An order, dated 5/2/25, for insulin aspart, inject 6U under the skin every eight hours PRN;-No physician order to check the resident's blood sugar. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Is at risk for abnormal blood sugars related to diabetes;-Goal: Will be free from any signs and symptoms of hypoglycemia and hyperglycemia through the review date;-Interventions included diabetes medication as ordered by doctor;-No documentation related to the resident's refusals of accuchecks and/or insulin administration. Review of the resident's MARs, showed insulin aspart not documented as administered from May 2025 through January 2026. During an interview on 1/7/26 at 10:13 A.M., the Medical Director said he expected staff to follow physician orders. He was unaware if there is an order for completion of accuchecks in the resident's POS. He did not know if the hospital ordered accuchecks. He expected facility staff to check the resident's blood sugars two times daily and to administer the insulin aspart as ordered if the resident had elevated blood sugar levels. During an interview on 1/7/26 at 10:30 A.M., Assistant Director of Nurses (ADON) B said facility staff should have clarified the orders from the resident's hospital after visit-summary, since it said to administer insulin aspart every eight hours PRN. During an interview on 1/7/26 at 10:59 A.M., the Medical Director said due to the resident's refusals, it was hard to obtain the resident's accuchecks and administer his/her insulin. He did not believe the resident's refusals were care planned. 2. Review of Resident #3's admission MDS, dated [DATE], showed:-Cognitively intact;-Wheelchair;-Hoyer (mechanical) lift;-Dependent (resident needs assistance from two or more people) with ADLs. Review of the resident's EMR, showed:-admission date 7/1/20;-Diagnoses included diabetes, hepatitis C (infection of the blood), obstructive sleep apnea (ineffective breathing while sleeping), morbid obesity (overweight), and altered mental status (disorder that affects brain function). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Has diabetes without complications;-Goal: Will be free from any signs and symptoms of hyperglycemia through the review date. Review of the resident's POS, showed:-An order, dated 7/2/25, for insulin lispro (Humalog, a short-acting insulin), inject per sliding scale, under the skin every eight hours PRN;-An order, dated 7/2/25, for insulin glargine (Lantus, a long acting insulin) 100 unit/ml, inject 20U subcutaneously (fatty part of the body) at bedtime. Review of the resident's progress notes, showed:-On 1/5/26 at 5:09 P.M., the resident's blood glucose was 484. Nurse contacted the Medical Director, who ordered 24U of Lantus and 12U of Lispro with an accucheck within two hours;-The next blood sugar check was confirmed at 1/6/26 at 7:05 A.M., blood glucose level was 113;-No documentation of blood sugar checked between 1/5/26 at 5:09 P.M. and 1/6/26 at 7:05 A.M. During an interview on 1/7/26 at 1:28 A.M., ADON B said she expected staff to follow the facility's policy and procedures. She expected Certified Medical Technicians (CMTs) to assist with accuchecks and insulin administration if the LPNs or Registered Nurses (RNs) are running behind or needing help. This is a task that can be delegated to the CMTs. During an interview on 1/7/26 at 2:00 P.M., the Administrator said the Director of Nursing (DON) and ADONs should follow up on all orders written from the Medical Director.

Based on interview and record review, the facility failed to follow their Behavior Management and Resident Drug and Alcohol Abuse policies by failing to provide local services and resources for two sampled residents (Resident #1 and Resident #2) who were admitted with a history of substance abuse and continued to use and abuse illegal substances in the community. The residents left the faciity on leave of absences (LOAs), sometimes for days. Resident #1 overdosed several times in the facility with illegal substances. Staff used Narcan several times to revive the resident. Resident #2 overdosed once in the facility and once in the community and was hospitalized twice with a diagnosis of drug overdose and severe intoxication. Both residents were allowed to continue to go out on LOA and return to the facility intoxicated. Additionally, Resident #2 made threats to shoot up the facility and made inappropriate sexual comments and gestures towards female staff. The census was 108. Review of the facility's Behavior Management policy, revised [DATE], showed:-Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services which create an environment to promote emotional and psychosocial well-being, meet each resident's needs and include individualized approaches to care;-Upon observing the adverse behavioral symptom, staff will do the following as indicated: -Ensure the safety of the resident as well as all other residents;-Document the incident on the 24-hour report;-The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed;-Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility;-Nursing Staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated:-Date and time of behavior;-Location of resident when the behavior occurred;-Description of the behavior (e.g., what the resident said or did and if the behavior intensified);-Non-verbal cues;-What seemed to cause the behavior; and -Any interventions used and their effect.-In assessing the resident for potential causal factors, licensed nursing staff will consider the following factors and document their findings in the medical record:-Physical conditions (e.g., pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence);-Environmental conditions;-Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition);-Medical conditions that require treatment; -Mental health conditions, which may contribute to resident's behavior;-It is also important for the facility to use an interdisciplinary team (IDT) approach which includes the resident, their family, or resident representative. Review of the facility's Resident Drug and alcohol abuse policy, revised [DATE], showed:-Purpose: To provide a safe and drug-free environment for residents while at the facility;-The facility will admit a resident who has a history of drug and alcohol abuse if their primary diagnosis is suitable for skilled care;-The facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana (a psychoactive drug that contains a chemical compound called tetrahydrocannabinol (THC), which is responsible for the intoxicating effects of marijuana.) or any type of drug paraphernalia in the facility or on the grounds of the facility;-All illegal drugs and/or drug paraphernalia will be confiscated from the resident and/or their room;-For the purpose of this policy alcohol is not considered to be an illegal drug;-The only drugs permissible at the facility and/or on facility grounds are those for which there is an attending physician order;-The facility has a zero-tolerance policy for the abuse of alcohol in the facility or on the grounds of the facility;-Any resident found in violation of this policy will be discharged to a more appropriate setting for care;-Social Services may provide residents with this policy in the following circumstances: -In the facility specific information provided to residents upon admission; -If the resident has a history of substance abuse:-a. alcohol;-b. narcotics; or-c. other substances; -If the resident is at risk for post-acute withdrawal symptoms; -If the resident is at risk for behavior disturbance;-If the resident has a substance abuse care plan;-If the resident has brought illegal drugs or alcohol into the facility; -If IDT feels it is appropriate to provide the resident with the policy;-After the Social Worker provides the resident with the policy, the resident will be asked to sign the Resident Drug and Alcohol Abuse Policy Acknowledgement Form, stating they are aware of the facility's zero tolerance policy on the use or possession of illegal drugs and its policy on alcohol abuse;-The facility will use its best efforts to obtain the resident's medical records if the resident has a history of drug or alcohol abuse, or use of illegal drugs;-Residents whose medical record provides a history of drug or alcohol abuse may be seen by a psychologist who will address current behavioral management issues for the resident as part of their care plan;-The care plan will be communicated to the attending physician and facility staff to specifically address the resident's behavioral problems;-The IDT will review the care plan after it is developed, and as needed thereafter;-The facility will provide residents who have a history of drug and alcohol abuse with information on local services and resources that can assist with treating drug or alcohol abuse;-Residents who wish to attend meetings such as Alcoholics Anonymous or Narcotics Anonymous, the facility will provide transport assistance to and from the meetings;-The IDT will determine whether the resident needs to be accompanied by a staff member;-Any drugs, drug paraphernalia, or alcohol will be destroyed or handed over to the authorities as required;-If a resident violates this policy, the resident will also be subject to drug screening to test for the presence of any illegal substances in their body;-If the drug screening is positive, the resident will be discharged according to facility discharge procedures;-If the resident refuses the drug screening, they could be discharged according to the facility discharge procedures. 1. Review of Resident #1's admission history and physical report, dated [DATE], showed:-History of marijuana use;-The resident consumed two alcoholic drinks, two to three times per week. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:-admitted [DATE];-Cognitively intact;-No behaviors exhibited;-Independent with all activities of daily living (ADLs); -Diagnoses included compression fractures, opioid abuse, cannabis use, alcoholic cirrhosis of liver (a chronic liver disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells), congestive heart failure and chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems). Review of the resident's social history assessment, dated [DATE], showed:-Habits: Marijuana, crack cocaine (free base form of the stimulant cocaine that can be smoked) and heroin (an illegal, highly addictive opioid drug processed from morphine) use. Review of the resident's progress notes, showed:-On [DATE] at 7:19 A.M., the resident was on Leave Of Absence (LOA) with family since 11:45 A.M. on [DATE]. At 11:33 A.M., the resident's family member called concerned about the resident being on LOA and not having his/her medications. The resident was supposed to return to the facility on [DATE];-On [DATE] at 11:12 P.M., the resident was found on floor, in his/her room with vomit and blood next to him/her. The nurse assessed him/her. He/She had a hematoma to left side of his/her head. He/She was lethargic and unresponsive. The nurse and two Certified Nurse Aides (CNAs) transferred the resident to his/her bed. The physician was notified. He/She gave order to send the resident to emergency room. Review of the resident's hospital drug screen, dated [DATE], showed it was positive for cocaine (a powerfully addictive stimulant drug, primarily distributed and used as an illegal street drug) and Fentanyl (a powerful synthetic opioid. The substance is up to 50 times more potent than heroin and 100 times stronger than morphine). Review of the resident's progress notes, dated [DATE] at 1:09 P.M., showed the resident was educated on drug abuse prevention. Social services were contacted for possible inpatient drug treatment program to address resident's extensive drug abuse history. Review of the resident's social history assessment, dated [DATE], showed his/her habits included cocaine use. Review of the resident's progress notes, showed:-On [DATE], the resident's care plan meeting was held on [DATE]. The resident, social worker and Assistant Director of Nursing (ADON) attended. The resident was his/her own responsible party. The resident was concerned about not receiving milk with his/her breakfast tray. He/She was excited about his/her weight gain. No documented discussion about drug use; -On [DATE] at 2:20 P.M., the resident was on LOA with his/her parent;-On [DATE] at 9:30 A.M., resident on LOA with family. Review of the resident's social history assessment, dated [DATE], showed his/her habits included drinking and drugs. Review of the resident's care plan, in use during the survey, showed:-Problem: History of alcohol, opioids and cannabis abuse (date initiated [DATE]);-Interventions: Encouraged resident to attend counseling services. Ensured resident/Responsible Party (RP) was familiar with facility's policy for Drug/Alcohol use. Educated resident on dangers of using drugs/alcohol with prescribed medications. Monitored for any changes and notified MD/RP/Administrator/Director of Nursing (DON) immediately. Review of the resident's progress notes, showed:-On [DATE] at 9:06 A.M., the resident was on LOA with sibling. At 10:22 P.M., the resident remained on LOA;-On [DATE] at 12:30 A.M., the resident returned to the building;-On [DATE] at 8:12 P.M., the resident was LOA;-On [DATE] at 3:03 P.M., the resident remained on LOA with sibling;-On [DATE] at 9:00 A.M., the resident was on LOA. Physician was notified. The plan of care was ongoing;-On [DATE] at 12:02 A.M., the resident continued to be on LOA. The oncoming nurse was notified. At 6:15 A.M., the resident called the facility and said he/she would return later. At 11:01 P.M., the resident returned to the facility. He/She was reinstated into system. He/She was exhausted and wanted to rest;-On [DATE] at 7:10 P.M., the nurse noted a CNA informed him/her the resident was detained by police at a nearby store. He/She was suspected to be under the influence. The police returned the resident to the facility. The resident's medication was held per physician order. The resident could not walk and needed assistance of two staff to get into bed;-On [DATE] at 1:13 A.M., the nurse assessed the resident. He/She was in bed, snoring loudly. Staff monitored for change in condition. Review of the resident's social services note, dated [DATE] at 3:03 P.M., showed the previous Administrator and the Social Services Director (SSD) met with resident and put him/her on a behavior contract for drug use. Review of the resident's care plan, in use during survey, showed it was updated on [DATE] with the following intervention: The resident was on a behavior contract regarding behaviors involving altered mental status with prior history of substance abuse and police department. Review of the resident's behavior contract, dated [DATE], showed:-Problem: The resident has as history of alcohol and drug use;-Goal: The resident understood if he/she violated the facility's policy by using illegal substances, he/she would be subject to immediate discharge;-Date to be achieved: [DATE];-Care plan/copy given to resident: Blank;-The contract failed to show how the IDT would work with the resident and to revise the care plan and contract related to his/her non-adherence to the contract. Review of the resident's progress notes, showed:-On [DATE] at 1:46 P.M., resident signed out of facility. He/She would return later;-On [DATE] at 3:54 P.M., the resident was noted to have unstable balance, assisted to a wheelchair and brought to nurses' station where he/she became unresponsive. A sternal rub was performed with no results. Oxygen was applied using non-rebreather (a device for delivering high concentrations of supplemental oxygen to patients who are breathing on their own but have severe respiratory distress or hypoxia). Narcan (medicine that can save someone from a heroin, Fentanyl, or prescription opioid medicine overdose) was administered twice and 911 called. Review of the resident's hospital drug screen, dated [DATE], showed it was positive for Fentanyl and cannabis. Review of the resident's progress notes, showed:-On [DATE] at 6:48 P.M., new order received from physician for urine drug screen. The results were requested and not provided. Review of the resident's social services notes, dated [DATE] at 11:42 P.M., showed the SSD spoke to the resident about the incident on [DATE]. The resident said he/she took his/her medications. He/She ate a brownie, and it must have been laced with something. The SSD asked the resident to meet with a counselor. The resident said he/she would think about it. Review of the resident's progress notes, showed:-On [DATE] at 3:08 P.M., the resident signed out LOA;-On [DATE] at 11:03 A.M., resident on LOA;-On [DATE] at 9:52 A.M., signed out LOA with parent;-On [DATE] at 1:46 P.M., the resident signed out LOA with parent;-On [DATE] at 12:48 P.M., resident's family member called and was concerned about the resident being allowed to sign him/herself out of the facility. The family member said the resident's sibling lived in another state. At 12:52 P.M., the resident remained on LOA. His/Her number was not working. At 1:21 P.M., the nurse was made aware of resident's absence and family member concerns. At 10:17 P.M., the resident remained on LOA. Review of the resident's counseling clinical note, dated [DATE] at 12:00 P.M., showed the resident checked him/herself out of facility for a few days. Counselor would check back next week. Review of the resident's progress notes, showed:-On [DATE] at 1:59 A.M., the resident remained on LOA;-On [DATE] at 6:20 P.M., resident was found in his/her room, on the floor in a crouched position between the bed and bedside table. He/She was unresponsive to verbal stimuli. He/She was repositioned to supine position on floor and noted to have a laceration to the right side of his/her forehead, with a moderate amount of dark red blood present and resident continued to be unresponsive. 911 was called. Review of the resident's hospital discharge paperwork, dated [DATE], showed a diagnosis of accidental overdose of opiates and forehead laceration. The resident received three stitches to his/her forehead. No documentation of drug screen. Review of the resident's progress notes, dated [DATE] at 12:55 A.M., showed the resident returned to facility, upset about room search. He/She received three stitches to forehead. Diagnoses were low oxygen and a fall. Review of the resident's medical record, on [DATE], showed no documented social services notes. Review of the resident's care plan, in use during the survey, showed:-Intervention: The resident had a fall and was found to have altered mental status. Cannabis edible wrappers were found in his/her room as well as cannabis paraphernalia and a half-smoked cannabis cigar (date initiated, [DATE]);-Problem: Noncompliant with facility's drug policy (date initiated, [DATE]);-Goal: Resident will comply with drug policy through next review-Interventions: Encouraged resident to attend drug counseling. Re-educated resident on facility's drug policy. Continued to monitor for any changes. Made physician and psych aware of behavior. Review of the resident's behavioral health diagnostic assessment, dated [DATE], showed:-Reason for referral: Opioid abuse, uncomplicated;-History of presenting illness: No history of mental illness, and some mild anxiety. Resident reported he/she abused opioids for ten years. He/She used daily prior to admission to the facility. The resident went to rehab for substance abuse a few years ago;-Risk factors: Current and history of alcohol/substance abuse;-Treatment plan: Adjustment, sleep disturbance, substance abuse;-Short term goals: Resident would verbalize at least two reasons for substance use and adaptive alternatives; Resident would verbalize at least two alternatives to substance abuse during session (blank) of three sessions. Resident would list four triggers (persons, places, and things) that may precipitate relapse during session (blank) of four sessions;-Assessment discussed with SSD. Review of the resident's medical record, showed no documented social services notes on [DATE]. Review of the resident's medical record, showed his/her family member was designated as his/her Power of Attorney (POA) on [DATE]. Review of the resident's progress notes, showed:-On [DATE] at 2:49 P.M., resident went out on LOA and did not sign out at nurse's station;-On [DATE] at 10:04 P.M., the resident was away from the facility;-On [DATE] at 1:14 A.M., the resident remained on LOA. At 3:43 P.M., the resident returned from LOA at 11:30 A.M. No distress noted. Review of the resident's medical record, showed no documentation of psychiatric visits for [DATE]. Review of the resident's progress notes, showed:-On [DATE] at 12:25 P.M., resident was on LOA;-On [DATE] at 7:41 A.M., resident was on LOA. At 3:31 P.M., resident remained on LOA;-On [DATE] at 3:51 P.M., resident went on LOA with a female before lunch. At 4:58 P.M., the resident remained on LOA;-On [DATE] at 1:56 P.M., resident on LOA. Review of the resident's psychological services progress note, dated [DATE] at 11:47 A.M. to 12:12 P.M., showed:-Substance Abuse: History;-Long term therapy goals: The resident would understand the severity of the substance use and decide upon a recovery plan;-Intervention: Assessed current mood and anxiety symptoms to ascertain current emotional functioning. Provided support to the resident. Requested the resident describe a thought or feeling in more details. Asked clarifying questions. Validated and accepted all aspects of the resident's current and past experiences;-Resident's Response: The resident was calm and engaging. He/She was receptive to feedback and interventions. The resident said he/she was doing, ok. Review of the resident's psychological services progress note, dated [DATE] at 9:31 A.M. to 9:59 A.M., showed:-Substance Abuse: History;-Long term therapy goals: The resident would understand the severity of the substance use and decide upon a recovery plan;-Intervention: Assessed current mood and anxiety symptoms to ascertain current emotional functioning. Provided support to the resident. Requested the resident describe a thought or feeling in more details. Asked clarifying questions. Validated and accepted all aspects of the resident's current and past experiences. Facilitated discussion on substance abuse ;-Resident's Response: The resident was calm and engaging. He/She was receptive to feedback and interventions. The resident said he/she was doing, ok. Review of the resident's progress notes, showed:-On [DATE] at 12:29 A.M., resident on LOA, called and said he/she would not return tonight. At 3:15 P.M., the resident returned from LOA;-On [DATE] at 12:46 P.M., resident on LOA;-On [DATE] at 1:45 P.M., resident on LOA;-On [DATE] at 6:01 A.M., the nurse entered resident's room to give morning medications, pulled his/her curtain back and he/she was not in bed. The nurse called the resident's name. He/She did not respond. The nurse knocked on the bathroom door and the resident did not respond. The nurse checked behind the curtain again and saw the resident slumped on the side of the bed in a seated position. The nurse called his/her name again, no response. The nurse performed vigorous rub to chest, with no response. The nurse called other staff for assistance. A second nurse instructed him/her to administer Narcan. Narcan was administered and the resident did not respond. A third nurse called 911. The resident was transported to the hospital. At 2:49 P.M., the resident returned to facility;-On [DATE] at 11:10 P.M., the resident was found in his/her bedroom unresponsive at 10:45 P.M. The nurse gave the resident a dose of Narcan 4 mg per nasal, waited 3 minutes and gave a second dose. Emergency Medical Services (EMS) was called and arrived for transport. The resident was awake and talking to staff when EMS arrived. The resident was transported to the hospital;-On [DATE] at 6:51 A.M., the resident returned from the hospital. Review of the resident's social services notes, dated [DATE] at 11:20 A.M., showed the SSD had an emergency meeting with the resident and his/her POA. They discussed his/her behavior over the weekend. They discussed the resident not leaving the facility, and his/her room being searched. The resident and his/her POA agreed to interventions. The resident agreed to go to inpatient drug treatment. At 4:54 P.M., the SSD met with the resident again and contacted several facilities. Review of the resident's medical record on [DATE], showed not documented drug screenings for [DATE] and [DATE]. Review of a Behavior Contract, dated [DATE], showed:-Problem: Resident was suspected of using drugs over the weekend;-Goal: Resident has agreed to a drug program. Resident understood if he/she went against the company policy by using illegal substance, he/she would be subject to immediate (end of sentence);-The contract failed to show how the IDT would work with the resident and resident representative to revise the care plan and contract related to his/her non-adherence to the contract. Review of the resident's psychological services progress note, dated [DATE] at 8:50 A.M. to 9:19 A.M., showed:-Substance Abuse: History;-Long term therapy goals: The resident would understand the severity of the substance use and decide upon a recovery plan;-Intervention: Assessed current mood and anxiety symptoms to ascertain current emotional functioning. Provided support to the resident. Requested the resident describe a thought or feeling in more details. Asked clarifying questions. Validated and accepted all aspects of the resident's current and past experiences. Facilitated discussion on substance abuse;-Resident's Response: The resident was calm and engaging. He/She was receptive to feedback and interventions. The resident said he/she was doing, ok. He/She denied using illegal substances. Review of the social services notes, dated [DATE] at 12:12 P.M., showed the SSD met with the resident and discussed the drug and alcohol policy, the new behavior contract and the behavior management policy. He/She received a copy of his/her care plan. The resident and his/her POA agreed to him/her being transferred to a hospital for medical drug detox. During an interview on [DATE] at 1:28 P.M. and [DATE] at 11:26 A.M., the resident said he/she had been at the facility since [DATE]. He/She was admitted from the hospital for rehab. He/She left the facility by him/herself and with family. He/She usually left in the morning. Sometimes, he/she would not return to the facility. He/She used Fentanyl, cannabis and sometimes cocaine. He/She bought drugs when he/she left the facility. He/She used the drugs before he/she returned to the facility. He/She was told he/she overdosed on Saturday. He/She does not remember what happened. He/She snorted Fentanyl on Saturday. He/She thinks he/she has overdosed three or four times in the facility. He/She used drugs due to back pain. He/She was clean for three months, then the back pain returned. He/She had an order for oxycodone, but it was not strong enough. He/She thinks he/she told the doctor about the pain medication. He/She cannot remember when he/she saw the physician. He/She abused drugs for nine years and was actively using when admitted to the facility. He/She completed substance abuse treatment years ago. A lady came to the facility to talk to him/her. The facility mentioned inpatient treatment a few months ago, but it never happened. Staff searched his/her room, but not his/her person. He/She signed a behavior contract in June and today. He/She and his/her POA met with the SSD yesterday. The facility is sending him/her to a hospital for medical detox. He/She was waiting for the van to transport him/her to the hospital. During an interview on [DATE] at 11:54 A.M., Licensed Practical Nurse (LPN) A said on [DATE], one of the aides went on break and saw the resident detained by the police, at a nearby store. The aide notified LPN A. LPN A drove to the store. The police said the resident was under the influence of drugs or alcohol and could not walk. The police transported the resident back to the facility. LPN A reported the incident to the previous DON. The resident was independent with ADLs. LPN A was not sure why the resident was admitted to the facility. The resident had a history of substance abuse. He/She had several overdoses in the facility. He/She was his/her own responsible party and sometimes he/she left for days. He/She would tell staff he/she was leaving with his/her parent or sibling. His/Her POA informed staff the resident does not have a son, and his/her parent is deceased . When staff suspect a resident is under the influence, they notified the DON and social worker. LPN A thinks residents are put on a behavior contracts. Staff also notify the physician. The physician ordered them to hold the resident's narcotics. If the resident was his/her own RP, the family was not notified. The resident never told LPN A he/she was having severe back pain. He/She had an order for pain pills. During an interview on [DATE] at 12:22 P.M., LPN B said he/she worked at the facility for two months. On [DATE], he/she was near the resident's hall and heard someone yell nurse! When he/she entered the resident's room, the nurse was doing chest compressions. LPN B retrieved the Narcan, and another nurse administered the dose to the resident. He/She woke up. EMS arrived and transported the resident to the hospital. LPN B quit because of the overdoses in the facility. The overdoses happened a lot on weekends. Staff complained about the residents being allowed to sign themselves out. The Administrator said if they pass a test, they can leave the facility. When staff suspected a resident was under the influence, they were supposed to notify the Administrator and physician. Staff never received clear direction on what they should do when a resident overdosed. During an interview on [DATE] at 1:20 P.M., LPN C said he/she worked at the facility for a few weeks. On [DATE], he/she attempted to give the resident his/her morning medication. The resident's curtain was pulled. He/She called the resident's name, and he/she did not respond. He/She pulled the curtain back and the resident was not in bed. LPN C checked the resident's bathroom, and he/she was not in there. He/She pulled the resident's curtain back again and saw the resident on the floor. The resident was breathing. LPN C asked the aide for the resident's history. The aide said the resident was known to overdose. LPN C asked another nurse for assistance. The nurse told LPN C to administer Narcan to the resident. The resident did not initially respond to the Narcan. EMS arrived and told him/her he/she needed to go to the hospital. The resident could not stand up. LPN C contacted the ADON, physician and resident's POA. The resident's POA was upset. The POA said the resident was not safe at the facility. The POA was afraid every time he/she received a call from the facility, it was to say the resident was deceased . LPN A was not aware of any other overdoses in the facility. LPN C has not received training on residents with substance abuse issues. During an interview on [DATE] at 12:45 P.M., the SSD said she has worked at the facility for 14 years. The resident was admitted for short-term rehab. He/She completed rehab and was not able to return to his/her apartment. She was not aware of the incident in February. She found out the resident had substance abuse issues in June or July. The resident was found unresponsive. He/She said his/her nephew made brownies laced with drugs. The resident signed a behavior contract on [DATE]. She contacted a few substance abuse treatment facilities. She did not receive any return calls. She contacted a treatment facility on [DATE] and the resident refused to do treatment. He/She also refused to see a counselor. The resident was not doing drugs on the premises. She believes that is why the resident stayed out late. He/She was his own responsible party and was allowed to leave the building. The resident told staff he/she was on LOA with his/her parent, son or sibling. Staff found out recently he/she did not have a son, his/her father is deceased and his/her sibling lives in another state. His/Her POA was enacted on [DATE]. When the first incident occurred, the resident's POA begged the facility not to discharge him/her. The resident should have been discharged . She sent referrals to other facilities. They did not accept him/her. The resident left for medical detox on [DATE]. He/She will be at the hospital for 14-21 days. 2. Review of Resident #2's progress notes, showed:-On [DATE] at 3:30 P.M., the previous DON noted the resident signed out around 9:00 A.M., to go to the store. He/She did not return by lunch time. A CNA went to the store to check on the resident. The resident was still at the store. The resident did not return later. The DON directed the nurse to contact law enforcement to obtain his/her location via his/her ankle monitor. At 11:17 P.M., the nurse called and spoke with resident's family member. The family member said the resident was ok and he/she was unsure if the resident would return to the facility tonight. The nurse informed the family member the resident needed to return before midnight;-On [DATE] at 10:18 A.M., the resident remained on LOA;-On [DATE] at 9:00 P.M., the resident returned to the facility via EMS from the hospital, with a diagnosis of vomiting/nausea and dehydration. The physician was notified. The resident was readmitted to the facility. Review of the Social Services notes, dated [DATE] at 6:35 P.M., showed the SSD noted the resident was admitted to the facility from the hospital, he/she was shot in the back by someone he/she knew. He/She was released on bond and had an ankle monitor. He/She agreed to meet with a behavioral health counselor. The resident rights, and drug and alcohol policy were reviewed with the resident. He/She scored a 15 (cognitively intact)on the brief interview for mental status (BIMS, a standardized assessment tool to screen cognitive functioning) assessment. Review of the resident's admission MDS, dated [DATE], showed: -admitted [DATE];-Cognitively intact;-No behaviors exhibited;-Diagnoses included paraplegia (spinal cord injury) and psychoactive substance abuse (the harmful or excessive use of substances that alter brain function and produce psychological effects). Review of the resident's care plan, in use during the survey, showed:-Problem: The resident had a psychosocial well-being problem due to pain, recent admission, mood, and psychoactive substance abuse (Date Initiated: [DATE])-Goal: He/She will demonstrate adjustm[TRUNCATED]

Based on interview and record review, the facility failed to ensure medication was ordered timely and administered as ordered for one resident (Resident #1) who suffered from chronic pain. This caused the resident to experience severe pain and call emergency medical services to transport him/her to the hospital to receive his/her medication. The sample size was nine. The census was 118.Review of the facility's Pain Management policy, revised 6/20, showed:-Purpose: To ensure accurate assessment and management of the resident's pain;-Policy: A licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain;-Procedure: --Pain assessment: --A licensed nurse will assess each resident for pain upon admission; --The licensed nurse will develop a care plan for pain management, including non-pharmacological interventions; --Pain management: --The licensed nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR); --The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale; --Nursing staff will implement timely interventions to reduce the increase in severity of pain. Review of Resident #1's medical record, showed:-Diagnoses included discitis of the unspecified thoracic region (a serious condition characterized by inflammation of the intervertebral discs, which are the soft, cushion-like structures located between the vertebrae of the spine), other chronic pain, post-polio syndrome (a condition that causes gradual muscle weakness and muscle atrophy (loss) that can affect people who have had polio.), unspecified abdominal pain, chest pain, unspecified, low back pain, unspecified and muscle weakness. Review of the resident's electronic Physician's Order Sheet (ePOS), showed an order dated 2/26/25, for oxycodone HCL (an opioid used to treat pain) 20 milligrams (mg), give one tablet by mouth four times a day. Review of the resident's pain clinic after visit summary, dated 5/20/25, showed:-Goals discussed: Chronic care plan;-Return in one month for pain management;-Analgesics: No changes. Cannot take over the counter supplements while in the facility. Review of the resident's pain clinic after visit summary, dated 6/20/25, showed:-Goals discussed: Chronic pain care plan;-Return in about three months. Review of the resident's July 2025 electronic Medication Administration Record (eMAR), showed:-An order with a start date of 2/26/25 to obtain pain level via numeric pain scale every shift (pain is rated on a scale of 1-10, with 10 being the highest);-An order for oxycodone HCL 20 mg, give one tablet by mouth, four times a day;-On 7/11/25, a 0 documented for pain level at midnight. Medication documented as administered at 12:00 A.M. Review of the resident's progress notes, showed on 7/11/25 at 12:57 A.M., a medication administration note for oxycodone HCL oral tablet, 20 mg. No medication to give. At 7:50 A.M., Medication was just delivered. Review of the resident's July 2025 eMAR, showed:-On 7/19/25, a 0 documented for pain level at 12:00 A.M. Nothing documented for pain level at 6:00 A.M. 0 documented for pain level at 12:00 P.M. A 7 documented at 12:00 A.M. for administration. Nothing documented at 6:00 A.M. for administration. A 9 documented at 6:00 P.M. for administration;-Chart code: 7 = Not administered/See progress note;-Chart code: 9 = Other/See progress notes. Review of the resident's progress notes, showed on 7/19/25 at 6:34 A.M., a medication administration note for oxycodone HCL oral tablet, 20 mg. Medication will arrive on next schedule run and made physician aware and no new order obtained. Review of the resident's July 2025 eMAR showed on 7/20/25, a 0 documented for pain level at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Medication documented as administered at 12:00 P.M. A 9 documented at 6:00 P.M. for administration. Review of the resident's progress notes, showed on 7/20/25 at 10:30 A.M., a medication administration note for oxycodone HCL oral tablet, 20 mg. Drug unavailable. At 1:57 P.M., Unavailable. Called physician. He stated could give whatever dosage of oxycodone staff had in stat kit which would equal ordered dosage. There was none in the stat kit. Review of the resident's July 2025 eMAR showed on 7/27/25, an X documented for pain level at 6:00 P.M. A 9 documented at 6:00 P.M. for administration. Review of the resident's progress notes, showed on 7/27/25 at 8:48 P.M., a medication administration note for oxycodone HCL oral tablet, 20 mg. On order. Pharmacy stated it will be here on the night run. Review of the resident's July 2025 eMAR showed on 7/28/25: -An X documented for pain level at 12:00 P.M. A 9 documented for pain level at 6:00 A.M.; -A 9 documented at 12:00 A.M. and 6:00 A.M. for administration. Review of the resident's progress notes, showed on 7/28/25 at 5:11 A.M., ordered from pharmacy. At 5:50 A.M., to be delivered on pharmacy run. Review of the resident's August 2025 eMAR, showed:-An order for oxycodone HCL 20 mg, give one tablet by mouth, four times a day;-On 8/3/25, a 0 documented for pain level at 12:00 A.M. A 7 documented at 12:00 A.M. for administration. Review of the resident's progress notes, showed on 8/5/25 at 11:35 A.M., a medication administration note for oxycodone HCL oral tablet, 20 mg, ordered. At 5:14 P.M., the pharmacy called. The resident's medication pending today's arrival. Delivery tentative for this evening. Review of the resident's August 2025 eMAR, showed:-On 8/5/25, a 6 documented for pain level at 12:00 P.M. A 9 documented at 12:00 P.M. for administration;-On 8/13/25, nothing documented for pain level at 6:00 P.M. Nothing documented for 6:00 P.M. administration. Review of the resident's progress notes, showed on 8/14/25 at 6:35 A.M., a medication note for oxycodone HCL oral tablet, 20 mg. Awaiting delivery from pharmacy. Review of the resident's August 2025 eMAR, showed:-On 8/14/25, an X documented for pain level at 12:00 A.M. and 6:00 A.M. Nothing recorded for pain level at 6:00 P.M. A 7 documented at 12:00 A.M. and 12:00 P.M. for administration. Nothing documented at 6:00 P.M. for administration. Review of the resident's progress notes, showed on 8/15/25 at 2:11 A.M., reordered medication. At 5:21 A.M., reordered medication. At 3:22 P.M., medication to be received on next pharmacy run. Review of the resident's August 2025 eMAR, showed on 8/15/25, an X documented for pain level at 12:00 A.M. and 6:00 A.M. and 6:00 P.M. A 7 documented at 12:00 A.M., 12:00 P.M. and 6:00 P.M. for administration. Review of the resident's progress notes, showed on 8/31/25 at 7:24 P.M., a medication note for oxycodone HCL oral tablet, 20 mg. On order from the pharmacy. At 11:17 P.M., ordered from the pharmacy, awaiting delivery. Review of the resident's August 2025 eMAR, showed on 8/31/25, a 0 documented for pain level at 12:00 A.M. A 7 documented at 12:00 A.M. for administration. Nothing documented for pain level at 12:00 P.M. Nothing documented at 12:00 P.M. for administration. An X documented for pain level at 6:00 P.M. A 9 documented at 6:00 P.M. for administration. Review of the resident's September 2025 eMAR, showed:-An order for oxycodone HCL 20 mg, give one tablet by mouth, four times a day;-On 9/1/25, an X documented for 12:00 A.M, an X documented for 6:00 A.M, a 5 documented for 12:00 P.M. and a 0 documented for 6:00 P.M. A 9 documented for 12:00 A.M. and 6:00 A.M. administration;-Chart codes showed 5 = Hold/See nurse's note. Review of the resident's progress notes, showed:-On 9/1/25 at 12:27 A.M., the resident called 911 to be sent to the hospital. When staff asked the resident why he/she wanted to go to the hospital, he/she stated he/she had been in bed all day without a pain pill. The nurse explained the order was in the system and they were just awaiting the delivery from the pharmacy. The nurse offered Tylenol and ibuprofen as a substitute until the medication comes in, but the resident refused those options. Emergency Medical Technicians (EMTs) arrived at midnight to transport the resident to the hospital. At 4:23 A.M., the resident returned from the hospital. He/She was diagnosed with a urinary tract infection. The resident denied pain and had been given oxycodone 15 mg in the emergency room (ER). At 5:22 A.M., a medication note for oxycodone HCL oral tablet, 20 mg. Awaiting delivery from the pharmacy;-On 9/18/25 at 6:21 P.M., the resident in bed requesting to go to the hospital. The staff asked the resident what was going on, and he/she stated he/she was in excruciating pain but did not specify where and was given routine pain meds 30 minutes prior. Resident would not let staff obtain his/her vitals;-On 9/19/25 at 1:11 A.M., the resident returned from the hospital with narcotics. They were held due to cognitive state. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/20/25, showed:-Cognitively intact;-Adequate hearing and vision;-Makes self understood: Understood;-Ability to understand others: Understands;-No behaviors or rejection of care;-Pain Management: --At any time in the last five days, has the resident: --Received scheduled pain medication regimen? Yes; --Received non-medication intervention for pain? No;-Should a pain assessment be completed? Yes. Review of the resident's care plan, revised on 9/22/25, showed:-Focus: Resident requires pain management. Chronic pain;-Interventions/Tasks: -Monitor/document for probable cause of each pain episode. Remove/limit causes where possible; -Monitor/record/report to nurse resident complaints of pain or requests for pain treatment; -Notify physician if interventions are unsuccessful;-Focus: Resident is receiving palliative care from hospice provider;-Interventions/Tasks: -Assess resident coping strategies and respect resident wishes; -Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain;-Focus: Resident has impaired cognitive function/dementia or impaired thought processes related to pain;-Interventions/Tasks: Administer medications as ordered. Review of the resident's progress notes, showed:-On 9/24/25 at 5:53 P.M., a medication note for oxycodone HCL oral tablet, 20 mg. Awaiting delivery from the pharmacy;-On 9/25/25 at 6:38 A.M., awaiting delivery from the pharmacy. Review of the resident's September 2025 eMAR, showed:-On 9/24/25, an X documented for pain level for 6:00 P.M. A 9 documented for 6:00 P.M. administration;-On 9/25/25, an X documented for pain level for 12:00 A.M. and 6:00 A.M. A 0 documented for 12:00 P.M. A 9 documented for 6:00 P.M. A 9 documented for the 12:00 A.M. and 6:00 A.M. administration. Review of the resident's progress notes, showed on 10/17/25 at 7:53 A.M., the resident went to the hospital. At 10:26 A.M., the resident was upset scheduled pain pill was not given at the exact time as prescribed but was given inside the allotted time frame allowed. Resident called 911 stating he/she was complaining of chest pain. The resident did not complain of chest pain with staff or the nurse. At 2:10 P.M., the resident returned from the hospital. Review of the resident's October 2025 eMAR showed on 10/19/25, an X documented for pain level for 6:00 A.M., an N/A documented for 12:00 P.M. and a X documented for 6:00 P.M. A 9 documented for the 6:00 A.M., 12:00 P.M. and 6:00 P.M. administration. Review of the resident's progress notes, showed:-On 10/19/25 at 5:39 A.M., a medication note for oxycodone HCL oral tablet, 20 mg. Needs to be ordered from pharmacy. At 9:45 P.M., certified nurse's aide informed nurse resident wanted a pain pill. The nurse informed the resident, he/she was out of pain medication and will reorder it. Resident then asked if he/she could have his/her muscle relaxer. The nurse said OK. The resident then said he/she would call 911 to go to the ER but he/she wanted his/her muscle relaxer before he/she called. The resident stated he/she had not had a pain pill since midnight 10/19/25. The resident is currently lying in bed, no signs and symptoms of distress noted but reports pain 8 out of 10 on a scale of 1-10. At 10:41 P.M., the resident called 911 to be taken to the hospital because he/she is out of pain medication. Emergency Medical Services (EMS) here to take resident to the hospital for evaluation. At 10:44 P.M., the nurse reordered the pain medication and the medication will be processed for scheduled delivery tomorrow evening. Review of the resident's October 2025 eMar, showed:-An order dated 10/20/25 for Hydrocodone HCL oral solution 5 mg. Take four tablets by mouth one time. Ok for pull from e-kit until card comes (one time order for one day);-On 10/20/25, a 10 documented for pain level for 6:00 P.M. A 9 documented for the 6:00 P.M. administration.-On 10/20/25 at 8:45 P.M., four 5 mg tablets administered. Review of the resident's progress notes, showed:-On 10/20/25 at 2:00 PM., the resident returned from the hospital with a diagnosis of chronic pain. The resident was administered pain medication prior to discharge. At 7:15 P.M., staff placed a call to the pharmacy regarding the resident's ordered pain medication which had not arrived as promised. A new order was obtained from the physician to pull four tablets of 5 mg oxycodone from the emergency kit and to have the medications sent stat (immediately). Review of the resident's October 2025 eMAR, showed on 10/21/25, an X documented for pain level for 6:00 P.M. A 9 documented for the 12:00 A.M. administration. Review of the resident's progress notes, showed on 10/27/25 at 2:33 P.M., a medication note for oxycodone HCL 20 mg. Not available. Will be on next delivery. At 5:33 P.M. an order change note to give four tablets of oxycodone HCL 5 mg by mouth one time only for pain until 10/28/25. At 5:57 P.M. the resident complained of chronic pain and called an ambulance. The resident's medication was given as ordered. The EMT took a copy of the resident's face sheet and exited the facility without the resident. Review of the resident's October 2025 eMAR, showed on 10/29/25, a 7 documented for pain level for 6:00 A.M. A 7 documented for the 6:00 A.M. administration. Review of the resident's progress notes, showed on 10/29/25 at 5:34 A.M., a medication note for oxycodone HCL 20 mg. On order from the pharmacy. During interviews on 10/29/25 at 9:15 A.M. and at 12:40 P.M., the resident said they run out of his/her pain medication a lot. The hard part is the staff cannot tell him/her when he/she will be getting it. He/She has had to go for hours without the medication and has been in horrible pain. This is why he/she has been calling 911 and going to the hospital. They offer him/her Tylenol or ibuprofen but it has never worked in the past and then the pain gets so bad he/she can hardly stand it. The staff tell EMS he/she is only trying to get more medication, but he/she only wants the pain medication the physician has ordered for him/her. Staff tell him/her it will be there soon, and it is hours or the next day before it arrives. The staff do not tell him/her they are out of his/her medication until it is due, then he/she has no idea when he/she will get it and how much pain he/she will be in by the time it arrives. He/She did not get his/her morning pain medication again this morning until almost lunch time. It is very frustrating to have to worry about how long he/she is going to have to be in pain before he/she can get the medications, which the physician has ordered for him/her. He/She had not seen a pain specialist for several months. They had not scheduled another appointment for him/her. The last appointment was cancelled because transportation did not show up. During an interview on 10/29/25 at 1:15 P.M., Licensed Practical Nurse (LPN) A said when a resident's medication runs low, they are supposed to call the pharmacy to reorder more. If the order calls for a script, then they should call the resident's physician and have them send over the script and then follow up and make sure they got it. They should offer Tylenol if there is an order for it if there is a wait. There is a problem with the pharmacy when you call a few days before the prescription runs out, then they say it is too early for a refill. By the time they will refill it, then they must start the whole process of contacting the physician again to get the script over or the pharmacy does not immediately send the medication over. The resident gets upset and immediately calls 911. He/She does not want any other interventions. During an interview on 10/29/25 at 12:15 P.M., the Assistant Director of Nursing said staff should order the medication a few days before it runs out. The resident takes so much medication, a card of 30 runs out very quickly. The pharmacy wants a new script when they get a new order. The medication they carry in the e-kit is not the same dosage the resident is prescribed, so they have to contact the physician and get an order for the different dosage before the pharmacy will okay it from the e-kit. All of this takes time, and sometimes the resident runs out of the medication before they can get it filled. The staff have offered the resident other non-pharmacological interventions, but he/she will not accept them. He/She is not receptive to taking non-opioid pain relievers. During an interview on 10/29/25 at 11:30 A.M., the Director of Nursing said staff should call the pharmacy and order the medication several days before it runs out so the resident does not go without it. The staff can also check the e-kit and pull the medication from there if they have it, to hold the resident over until the medication arrives from the pharmacy. The resident calls 911 because he/she believes he/she will get a higher dosage of the medication at the hospital. There have been times when he/she called 911 even after receiving his/her medication. The EMS personnel are familiar with him/her. He/She refuses all non-pharmacological interventions like position changing, heat and non-opioid medications. Review of an email sent from the DON on 11/3/25 at 11:30 A.M., showed the resident attended his/her pain clinic appointments in May and June for imaging and injections but refused later appointments, preferring to adhere to his/her current oxycodone pain management as he/she liked this regimen the best. They spoke to the resident and he/she agreed to go and they scheduled an appointment for 12/1/25. During an interview on 10/29/25 at 1:30 P.M., the Administrator said the resident should get his/her medication as ordered. He/She should not be in pain for hours because the medication was unavailable. She expected staff to order it before it ran out or pull it from the e-kit if it did not arrive on time. During an interview on 10/31/25 at 9:30 A.M., the resident's physician said the resident should not go without his/her pain medication, but there is an issue with the facility staff and the pharmacy. The facility staff should order the medication on time. The pharmacy should fill it on time. They want a script every time and this takes time to call the physician and get one sent over. He thinks the resident is drug seeking and should see a pain specialist, but the resident has refused to see one in the past. He did not know if anyone approached the resident recently to suggest this again, but they should try to get him/her to go see one. 2646728

Based on interview and record review, the facility failed to follow their policy when a resident experienced a change in condition. Resident #1 fell out of an elevated bed onto the floor and was transported to the emergency room on 5/26/25. The resident sustained a fracture to his/her right femur (thighbone), and a contusion to his/her shoulder, The resident was readmitted to the facility on [DATE], with discharge instructions identifying symptoms to monitor for that may require the resident to return to the hospital. Facility staff documented a change in condition consistent with the hospital discharge instructions, including vomiting and lethargy, beginning on 5/29/25. On 5/30/25, the resident's oxygen saturation and respiratory rate were low and the physician was notified with orders obtained for oxygen. The facility did not document notifying the physician of the resident's vomiting, lethargy, sweating, increased blood pressure, and elevated blood sugar. The resident continued to decline, eating less, increased lethargy and sleeping, pocketing food, unable to open eyes and inability to take oral pain medications. When the resident became unresponsive on 6/2/25, staff contacted emergency services and sent the resident to the hospital. The resident expired shortly after arriving to the hospital. In addition, the facility failed to ensure physician orders for wound care were followed for one out of three sampled residents (Resident #5). Resident #5's wound treatment was not completed for two days. The census 108. The Administrator was notified on 6/18/25 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 5/29/25. The IJ was removed on 6/18/25 as confirmed by surveyor onsite verification. 1. Review of the facility's Change of Condition Notification policy, revised 6/2020, showed: -Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner; -Definition: -An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains; -Clinically important means a deviation that, without intervention, may result in complications or death; -Members of the interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent and ACOC; -The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: -An injury/accident; -A significant change in the resident's physical, cognitive, behavioral or functional status; -A significant change in treatment; and/or -A decision to transfer or discharge the resident from the facility; -The licensed nurse will notify the resident's attending physician when there is an: -Incident/accident involving the resident; -An accident involving the resident which results injury and has the potential for requiring physician intervention; -A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications; -A need to alter treatment significantly -A decision to transfer or discharge the resident from the facility; -The licensed nurse will assess the resident's change of condition and document the observations and symptoms; -Notifying the Attending Physician: -The attending physician will be notified timely with a resident's change in condition; -Notification to the attending physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required; -Emergency Situations: -If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital; -Notify the nursing supervisor of emergency situation; -A licensed nurse will document the following: -Date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes; -The time the attending physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received; -Update the care plan to reflect the resident's current status; -The incident and brief details in the 24-hour report; -Complete an incident report per facility policy; -A licensed nurse will communicate any changes in required interventions to the IDT members involved in the resident's care; -A licensed nurse will document each shift for at least seventy-two (72) hours; -Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-hour report. Review of the facility's Neurological Assessment policy, revised 2/2019, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Nursing staff will perform a neurological assessment in the following circumstances: -Upon attending physician order; -Following a fall or other accident/injury involving head trauma; or -When indicated by resident's condition; -The following information will be documented in the resident's medical record: -The date and time the procedure was performed; -All the assessment data obtained during the procedure, including: -Eye opening; -Verbal response; -Motor response; -Pupillary response; -Limb response; -If the resident refused the procedure, the reason(s) why and the intervention taken; -The signature and title of the person recording the data; -Notify the attending physician of any change in a resident's neurological status. Early signs of neurologic compromise include changes it the resident's level of consciousness and pupillary activity; -Report other information in accordance with facility policy and professional standards of practice. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/25, showed: -Cognitively intact; -Used a wheelchair; -Roll left to right - substantial/maximal assistance; -Impairment on one side -upper extremity; -Impairment on both sides - lower extremity; -Toileting hygiene/shower/bathe - dependent; -Diagnoses included depression, heart failure, diabetes, and non-Alzheimer's dementia. Review of the resident's medical record, showed diagnoses included muscle wasting and atrophy (the thinning or loss of muscle tissue) to the right and left shoulders, hemiplegia (inability to move on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominate side, disorder of bone density and structure, muscle weakness, dementia, and Alzheimer's disease. Review of the resident's care plan, showed: -Focus: The resident has a history of stroke with right sided hemiplegia: -Goal: Be free from further complication from stroke through review; -Interventions included: Monitor level of consciousness, visual function changes, inability to communicate, aphasia (difficulty communicating), dizziness, weakness, and restlessness; -Focus: Impaired cognitive function related to unspecified dementia: -Goal: Maintain current level of cognitive function; -Interventions included: Monitor/document/report to the physician any changes in cognitive function, specifically changes in: Decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of the resident's progress notes, showed: -5/26/25 at 8:53 A.M., at 6:15 A.M., the certified nursing assistant (CNA) reported the resident rolled off bed. Staff entered the room, noted the resident lying on the floor on the right side of the bed. Resident positioned halfway on his/her left side and back. Resident stated he/she slid off the bed and landed on the left shoulder, and hit his/her head. Resident complained of pain moving his/her upper arms, left leg, and right thigh. Pain is causing limited range of motion to all extremities. Obtained vital signs: Blood pressure 168/96 (normal 90/60 through 120/80), temperature 97.8 (normal 97.8 through 99.1), heart rate 88 (normal 60 through 100), respirations 16 (normal 12 through 18). Notified 911, resident sent to the hospital. Notified the physician. New orders for x-ray and keep bed in low position. Review of the resident's emergency room paperwork, dated 5/26/25 at 9:34 A.M., showed: -Chief Complaint: Patient presents with a fall; -At 9:34 A.M., patient with a history of high blood pressure, diabetes, stroke, congestive heart failure (CHF), dementia, and right above-the-knee amputation, presenting to the emergency department (ED) via emergency medical services (EMS) complaining of pain all over after apparently falling out of bed at the nursing home earlier this morning. Apparently, nursing home staff found him/her on the floor just after 6:00 A.M. this morning. They assisted him/her back into bed without event, but he/she apparently began to complain of pain all over. He/She recalls rolling out of bed. He/She states he/she landed on his/her left shoulder. When asked to describe these specific areas where he/she hurts the most, he/she states it is his/her left shoulder and right thigh. He/She notes that he/she has phantom limb pain (pain occurring in extremities that have been amputated) in the right lower extremity. He/She relates a mild headache and neck stiffness; -Review of systems: Neurological: Positive for headaches; -Comment: Patient who rolled out of bed at the nursing home, complaining of headache, neck pain, left shoulder pain, and right thigh pain. Review of the resident's hospital After Visit Summary, dated 5/26/25 printed 12:59 P.M., showed: -Call 911 if any of these happen: -Confused or difficulty arousing; -Fainting or loss of consciousness; -Rapid or very slow heart rate; -Difficulty with speech or vision, weakness of an arm or leg; -When to seek medical advice: Call your healthcare provider right away if any of these happen: -Another unexplained fall; -Severe headache; -Nausea and vomiting. Review of the resident's progress notes, showed: -5/26/25 at 3:53 P.M., the resident returned from hospital at 2:00 P.M. Resident diagnosed with closed fracture of neck of the right femur and contusion to left shoulder. Physician notified, new orders received. No new concerns noted. Resident is resting in bed, morphine (narcotic pain medication) intramuscular (injected into the muscle) 4 milligram (mg) given at the hospital prior to return. Pain is rating of 7 on a scale of 0 to 10 (0 indicates no pain, 10 indicates the worse pain imaginable), stated he/she wants to sleep. Vitals blood pressure 117/71, heart rate 108, temperature 98.4, respirations 18, oxygen saturation (percentage of oxygen in the blood) 96% (normal 95% through 100%). Review of the resident's physician orders showed: -An order dated 5/26/25, low bed at all times; -An order dated 5/27/25, chart status post fall with injury every shift in progress notes; -An order dated 5/30/25, oxygen 2 liters as needed. Review of the resident's progress notes, showed: -5/27/25 at 11:28 A.M., Social Worker met with the resident to do a trauma screen. Resident explained that he/she has not had any trauma before in life, but because of his/her fall, is scared because this had never happened before; -5/27/25 at 2:14 P.M., incentive spirometry (device used for deep breathing exercises) daily/as needed (PRN) for 5 breaths. Resident will place the mouthpiece in mouth, sealing lips around it. Instruct the resident to breathe in slowly and deeply as possible, holding breath for 3-5 seconds. Exhale and rest between breaths, cough as necessary. Nurse to evaluate lungs sounds before and after use of the Incentive Spirometer, document achieved volume, heart rate, respirations, oxygen saturations and treatment time. Rinse the mouthpiece after each use. Every dayshift for shortness of breath related to chronic obstructive pulmonary disease (COPD, lung disease): Resident did not feel up to it; -5/29/25 at 2:21 P.M., nurse called to the resident's room. Resident had emesis (vomited) twice. Resident is alert, but is also lethargic (a state of extreme tiredness, sluggishness, and lack of energy), unable to swallow anti-emetic (medication or treatment that prevents or relieves nausea and vomiting) at this time. Denies any pain or discomfort at this time. Pain meds being held due to lethargy. Swelling to right hip and left shoulder. Is currently resting in bed, call light in reach. Will continue to monitor vital signs: blood pressure 110/75, heart rate 77, respirations 17, temperature 97.5, oxygen saturation 92%; -5/29/25 at 11:11 P.M., no nausea or vomiting this shift. Resident ate less than 25 percent for dinner, drank half a nepro shake (health shake for individuals with kidney failure). Denies any pain or discomfort at this time. Resident slept majority of this shift, currently resting in bed with call light in reach. Vital signs: blood pressure 103/76, heart rate 97, temperature 98.4, respirations 17, oxygen saturation 92%; -5/30/25 at 6:30 A.M., resident sensitive to touch, unable to tolerate vital signs check, yelling don't touch me, stop. Resident noted sweaty this morning, gown damp. Blood pressure 156/77 in left leg compared to reading in upper left arm/wrist blood pressure of 89/56, pulse 81, respiration 14, temperature 98.3, oxygen saturation 88%, blood sugar 214 (normal less than 140). Notified physician. Gave orders for oxygen 2 liters as needed and to monitor; -5/31/25 at 1:05 P.M., no nausea or vomiting this shift. Resident ate less than 25 percent for both meals. Denies any pain or discomfort at this time. Resident slept majority of this shift. Currently resting. No concerns noted at this time, will continue to monitor for any acute change in condition; -6/1/25 at 3:19 P.M., resident slept most of day shift. Noted to be pocketing food (holding food in the mouth and not swallowing). Given puree for lunch. Ate less than 25 percent. Resident is resting in bed at this time, call light in reach. Will continue to monitor; -6/2/25 at 5:51 A.M., resident continues on observation related to fall with injuries to neck of the right femur and contusion to left shoulder. Resident moaned like he/she was in pain when being repositioned and changed. This nurse attempted to give resident as needed pain medication, but resident would not open his/her eyes. Resident is sleeping deeply but does respond to pain stimulus when being moved. Resident in bed with bed in low position and call light within reach; -6/2/25 at 8:20 A.M., during medication administration, notified by Certified Medication Technician (CMT) that resident blood pressure was low, and pulse elevated. Upon assessment, resident noted to have labored breathing. Eyes glossy and non-reactant to light. Unable to obtain oxygen saturation. Head of bed elevated, and oxygen therapy applied. Resident had become non-responsive to verbal commands. But responded to physical touch. Call place to 911. Resident transferred to the hospital via EMS. Management and medical doctor made aware. Message left for responsible party and first emergency contact. Awaiting call back at this time; -6/2/25 at 9:09 A.M., responsible party states he/she received call from hospital stating resident had expired. Management and medical doctor made aware. Review of the resident's vital sign log in the medical record, showed: -6/2/25 at 2:10 A.M., blood pressure 141/63, lying/left arm; -6/2/25 at 8 A.M., blood pressure 95/41, lying/left arm; -No documentation related to history of low blood pressure found. During an interview on 6/17/25 at 3:34 P.M., CNA C said he/she saw the decline in the resident in just a couple of days. The resident could not sit in his/her wheelchair. Over the days after the accident, the resident would not eat. He/She tried to feed the resident, but the resident said he/she could not eat. The resident was barely eating after the fall. After the fall, the resident would not hardly open his/her eyes. He/She noticed the resident would not stay awake. During an interview on 6/18/25 at 2:23 P.M., Licensed Practical Nurse (LPN) B said he/she called the doctor to get medication and intramuscular (IM) injection because the resident vomited. He/She was not able to get the IM injection from the medication dispensing machine. He/She was alerted about the vomiting and decline on 5/29/25. He/She had contacted the doctor that day and should have documented in the resident's chart. They doctor did not order to send the resident out. LPN B said he/she was not aware of the information on the resident's after visit fall hospital discharge paperwork indicating reasons for sending the resident back to the hospital. Nursing was supposed to look at that paperwork. If he/she had seen the after visit summary paperwork, he/she would have made a note in the resident's record. Looking back now, he/she would have sent the resident out. During an interview on 6/20/25 at 9:20 A.M., LPN F said he/she did not see the resident's after visit hospital summary. He/She got updated reports from each shift when he/she came in. The resident told him/her that he/she bumped his/her head. The resident told LPN F he/she hit the floor hard. When he/she came back to work, the resident was put on pain management. The medication was strong and the resident was not used to all that medication. He/She would have sent the resident out when he/she vomited. During an interview on 6/20/25 at 9:48 A.M., LPN A said he/she did not know there had been a change in the resident. The resident was sleeping a lot, but he/she did not know if this was a change in his/her behavior. The resident's vital signs were fine, so he/she did not think there was a change. LPN A said the resident would not wake up to take his/her medicine. The resident would wake up a little before, but now the resident would not open his/her mouth up all the way. He/She did not feel safe giving the resident his/her medication, so it was held. LPN A said he/she got updates at shift change, but did not know anything about the resident vomiting or being lethargic. He/She looked over the resident's progress notes and said the facility should have sent the resident out because, looking back, moaning and not opening his/her eyes was a change in the resident's condition. During an interview on 6/20/25 at 10:47 A.M., LPN J said he/she was one of the nurses who reviewed hospital discharge paperwork for the facility. Nursing staff are to review the 24-hour report. All nurses have access to the 24-hour report. The 24-hour nursing report would have given indication of the resident's decline over time. During an interview on 6/20/25 at 10:51 A.M., LPN M said they are to report to the supervisor any change in condition. During an interview on 6/20/25 at 11:40 A.M., the Assistant Director of Nursing (ADON) said the resident should have been sent to the hospital after the change of condition. The ADON said the medical doctor was adamant about not sending the resident out, so the nurse did not send him/her out. The resident should have been sent out when he/she had emesis and was lethargic, but the medical doctor said not to. She expected all nurses to review the 24-hour nursing report and compare with the observations made. During an interview on 6/20/25 at 11:41 A.M., the Director of Nursing (DON) said if staff were concerned about a resident's change in condition and wanted to send him/her out, she would expect staff to send them out even if the physician refused, and then notify her. If they feel strongly about the resident's need for further care, she would want them to send the resident out and she would talk with the physician. She would rather them do that than do nothing and then something happens. She does not feel like the medical director got the full picture with the resident. She feels like the medical director would have sent the resident out if he had the full picture of what was going on with the resident. During an interview on 6/18/25 at 11:25 A.M., the Medical Director said he knew the resident, but could not remember what he was told about what happened to the resident. The resident's health was compromised. He/She was an amputee, on dialysis, had poor circulation, and was a very sick patient. He is not sure if staff called him, but he knew about the fall. He could not say what the cause of death was. He definitely expected staff to follow the level of care the resident had been assessed for. Staff should have called about the resident's blood pressure dropping because they cannot treat/maintain blood pressure at the facility. The resident had to be sent out for that. During an interview on 6/18/25 at 12:09 P.M., the Interim DON said she expected the doctor to be notified for any of the symptoms listed on the resident's hospital discharge paperwork. She expected the resident to have been sent out before he/she was. She did not know why the resident was not sent out. If the nurse thought it was an emergency, she expected the nurse to prioritize and send the resident out. The nurse that had the resident the morning he/she was sent out did not tell her right away about the resident's condition. There were two days she did not get to review the 24-hour notes. Maybe she would have caught the resident's decline. She expected the nurse managers to do that and report the information to her. She was not told about the resident's decline. She expected the nurse managers to review the 24-hour notes and report to her. At 12:50 P.M., the Interim DON said LPN A should have notified the doctor on 6/2/25 when he/she tried to give pain medication, but the resident would not open his/her eyes. Nurses have nursing judgement, and she was not sure why LPN A did not send the resident out at that time. That is what usually happens. The nurse use nursing judgement and notify the physician afterwards if they think a resident should be sent out and do not have time to call or cannot reach the doctor. 2. Review of the facility's Physician Order Policy, revised 6/2020, showed: -Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified is necessary; -Telephone Orders: -A Licensed Nurse will transcribe telephone orders with date, time and signature of the person receiving the order; -Orders will include a description complete enough to ensure clarity of the physician's plan of care; -Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline; -Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the medication administration record (MAR)/treatment administration record (TAR). Review of the facility's Wound Management policy, revised 6/2020, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Arterial Ulcer- an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (tissue death). Arterial/ischemic ulcers may be present in individuals with moderate-to-severe peripheral vascular disease, generalized arteriosclerosis, inflammatory autoimmune disorders, or significant vascular disease elsewhere. The arterial ulcer is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot; -Venous Insufficiency Ulcer- an open lesion of the skin and tissue of the lower leg, usually occurring in the area of the lower leg or above the ankle. Venous insufficiency ulcers may be caused by one (or a combination of) factor(s) including: loss of (or compromised) value function in the vein, partial or complete obstruction of the vein, and/or failure of the calf muscle to pump the blood; -Wound Management Principles Wound bed: -Remove devitalized tissue and foreign debris; -Maintain moisture; -Minimize tension/pressure on the wound; -Pack dead space lightly; -Control bacterial bioburden and infection; -Documentation: -New pressure injuries or wounds will be documented on the 24 Hour Log. Wound documentation will occur at a minimum of weekly until the wound is healed. Documentation will include: Location of wound; length, width, and depth measurements recorded in centimeters (cm); direction and length of tunneling and undermining (if applicable); appearance of the wound base; drainage amount and characteristics including color, consistency, and odor; appearance of wound edges; description of the peri-wound (skin surrounding the wound) condition or evaluation of the skin adjacent to the wound; presence of pain. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No upper body impairment; -Lower body impairment: 1 side; -Dependent (Helper does all effort. Resident does none of the effort to complete activity): Toileting, lower body dressing, and personal hygiene; -Total number venous and arterial ulcers: 1; -Treatments: Pressure reducing device bed, application nonsurgical dressing; -Diagnoses included heart failure, peripheral vascular disease (PVD, poor circulation), end stage renal disease (ESRD), malnutrition, and quadriplegia (paralysis of all four limbs). Review of the resident's care plan, revised 9/10/24, showed: -Focus: Resident has a venous ulcer of the right lower calf related to congestive heart failure, PVD; -Goal: Resident's ulcer will be healed by the review date. Resident will have no signs/symptoms of infection through the review date; -Interventions: Document location of wound, amount of drainage, peri-wound area, pain, edema (swelling), and circumference measurements per facility protocol. Evaluate wound. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Minimize exposure of skin to moisture from incontinence, wound drainage, or perspiration. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 1/27/25-5/30/25, cleanse right lateral (side) lower leg with hypochlorous (wound cleanser that increases oxygenation of the wound site to improve healing). Apply calcium alginate (highly absorbent dressing) with silver, xeroform (non-adherent dressing) to wound bed. Cover with super absorbent dressing, kerlix (gauze wrap) and with ACE wrap. Daily and as needed (PRN) every dayshift for wound care; -An order, dated 5/30/25-6/4/25, cleanse right lateral lower leg with hypochlorous. Apply calcium alginate with silver, Gentamicin Ointment to wound bed. Cover with super absorbent dressing, kerlix and with ACE wrap. Daily and PRN every dayshift for wound care; -An order, dated 6/4/25, cleanse right lateral lower leg with hypochlorous. Apply calcium alginate with silver to wound bed. Cover with super absorbent dressing, kerlix and with ACE wrap. Daily and PRN every dayshift for wound care. Review of the resident's May 2025 TAR, showed the ordered treatment not marked as completed on 5/4/25, 5/8/25, 5/11/25, 5/16/25, 5/18/25, 5/21/25, 5/24/25, 5/25/25, and 5/26/25; Review of the resident's June 2025 TAR, reviewed on 6/18/25, showed the ordered treatment not marked as completed on 6/13/25, 6/15/25, and 6/16/25. Review of the facility's wound report, showed the following for the resident: -4/30/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7 cm, 2.5 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily. Clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/7/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7 cm, 2.5 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily. Clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/14/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 6.8 cm, 3 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/21/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7.3 cm,3.5 width, depth 0.3 cm; -Wound status: subsequent-Worsening; -Dressing change: Daily clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/28/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 8 cm,3.5 width, depth 0.3 cm; -Wound status: subsequent-Worsening; -Dressing change: Daily clean with normal saline, calcium alginate. Gentamicin (antibiotic) ointment. Absorptive dressing, dry dressing; -6/4/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7.5 cm, 4 width, depth 0.3 cm; -Wound status: subsequent-stable; -Dressing change: Daily clean with normal saline, calcium alginate. Absorptive dressing, dry dressing; -6/11/25 Wound location: Right Post

Based on interview and record review, the facility failed to ensure residents were free from neglect when staff failed to provide necessary services to avoid physical harm. On 5/26/25, Certified Nursing Assistant (CNA) D provided care to Resident #1, who had limited mobility after a stroke affecting his/her dominant side and an above the knee amputation. The resident had been assessed as needing total dependence on staff for personal hygiene and required substantial/maximal assistance to roll left to right. Resident #1 was left unattended in a raised bed when CNA D walked away to change his/her gloves. The resident fell out of the elevated bed onto the floor and was transported to the emergency room. The resident sustained a fracture to his/her right femur, a contusion to his/her shoulder, and the resident expressed feelings of being scared due to the traumatic event. The sample size was 12. The census was 108. The Administrator was notified on 6/18/25 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 5/26/25. The IJ was removed on 6/18/25 as confirmed by surveyor onsite verification. Review of the facility's Abuse Prevention and Prohibition Program Operational Manual, Abuse and Neglect policy, revised 8/2020, showed: -Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -Each resident has the right to be free from mistreatment, neglect, and abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors; -The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: -Training: All employees, contractors and volunteers will be trained through orientation and ongoing training sessions, no less than annually, on the following topics: -Who is a covered individual responsible for reporting; -Abuse prevention; -Identification and recognition of signs and symptoms of abuse/neglect; -Protection of residents during an abuse investigation; -Investigation; ` -Reporting and documentation of abuse and neglect; -Reporting requirements of staff related to allegations of abuse/neglect without fear of reprisal; -Follow-up from the facility; -Prevention: -Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring; -The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; -Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict; -Identification: -The facility provides facility staff with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect: -Physical Neglect: -Inadequate provision of care; -Caregiver indifference to resident's personal care and needs; -Leaving someone unattended who needs supervision. Review of the facility's Care and Services policy, revised 6/2020, showed: -Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process; -Policy: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem ad self-worth; -Procedure: -The facility will have sufficient staff to provide services to residents with the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by individualized resident assessments and plans of care. Review of the facility's Care Planning policy, revised 6/2020, showed: -Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individualized assessed needs; -Each resident's comprehensive care plan will describe the following: -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; -Resident Rights-Care planning: -The resident has the right to receive the services and/or items included in the plan of care; -The interdisciplinary team will revise the Comprehensive Care Plan as need at the following intervals: -As dictated by changes in the resident's condition; -To address changes in behavior and care; and -Other times as appropriate or necessary. Review of the facility's undated Fall Management Program, showed: -Purpose: To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program; -Policy: The facility will provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation; -Procedure: -Assessment: -The licensed nurse will assess each resident for their risk of falling upon admission, quarterly, and with a significant change in condition; -Based on the information gathered from the history and assessment of the resident, the nursing staff and interdisciplinary team, with input from the attending physician, will identify and implement interventions to reduce the risk of falls; -Care Planning: -The nursing staff will develop a plan of care specific to the resident's care needs with interventions to reduce the risk of falls; -The interdisciplinary team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response; -Functional Mobility: -Reassess patient's mobility status daily; -Determine the safest use of side rails; -Post-Fall: -Following a resident's fall, the licensed nurse will complete an incident report and a post-fall assessment and investigation within 24 hours or as soon as practicable; -The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated; -The Interdisciplinary Team Committee will meet within 72 hours of a fall. The IDT Committee will review and document: -Summary of events following a fall; -Root cause analysis; -Referrals, as necessary; and -Interventions to prevent future falls; -Documentation: -The Interdisciplinary Team Committee will document findings and recommendations in the resident's medical record; -Nursing staff will document the resident's response to interventions being utilized in the resident's medical record; -The resident's care plan will be updated as necessary; -Education: -Staff are in-serviced to the Fall Management Program at a minimum annually as well as immediately after any changes/up-dates to this program; -Interim in-services is provided, as needed, based on frequency and severity of falls; -In-service records are maintained to document that all staff attends in-service on all aspects of the fall program at least annually. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/25, showed: -Cognitively intact; -Used a wheelchair; -Roll left to right - substantial/maximal assistance; -Impairment on one side -upper extremity; -Impairment on both sides - lower extremity; -Toileting hygiene/Shower/bathe - dependent; -Diagnoses included depression, heart failure, diabetes, and non-Alzheimer's dementia. Review of the resident's medical record, showed diagnoses included muscle wasting and atrophy (the thinning or loss of muscle tissue) to the right and left shoulders, hemiplegia (inability to move on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominate side, disorder of bone density and structure, muscle weakness, dementia, and Alzheimer's disease. Review of the resident's care plan, showed: -Focus initiated 8/22/24: The resident has an activity of daily living (ADL) self-care performance deficit related to right side hemiplegia; -Goal: Maintain current level of ADL function; -Interventions/Tasks: -Initiated on 8/22/24, personal hygiene/oral care: The resident is totally dependent on staff for personal hygiene and oral care; -Initiated on 5/2/25, roll left to right: Substantial/maximal assistance. Review of the resident's progress notes, showed: -5/26/25 at 8:53 A.M.: at 6:15 A.M., CNA reported resident rolled off bed. Staff entered the room and noted the resident lying on the floor on the right side of the bed. Resident positioned halfway on the left side and back. Resident stated he/she slid off the bed and landed on the left shoulder and hit his/her head. Resident complained of pain moving his/her upper arms, left leg, and right thigh. Pain is causing limited range of motion to all extremities. Obtain vital signs: Blood pressure 168/96 (normal 90/60 through 120/80), temperature 97.8 (normal 97.8 through 99.1), heart rate 88 (normal 60 through 100), respirations 16 (normal 12 through 18). Notified 911, resident sent to the hospital. Notified the physician. New orders for x-ray and keep bed in low position; -5/26/25 at 3:53 P.M., resident returned from the hospital at 2:00 P.M., resident diagnosed with closed fracture of the neck of the right femur and contusion to the left shoulder. Physician notified; new orders received. Review of the resident's hospital records, for date of service 5/26/25, showed: -Chief complaint: Patient presents with fall: 9:34 A.M., patient with a history of right above the knee amputation, presenting to the emergency department via emergency medical services (EMS) complaining of pain all over after apparently falling out of bed at the nursing home earlier this morning. Apparently, nursing home staff found him/her on the floor just after 6:00 A.M. this morning. They assisted him/her back to bed without event, but he/she apparently began to complain of pain all over. He/She recalls rolling out of bed. He/She states he/she landed on his/her left shoulder and right thigh. He/She notes that he/she has phantom limb pain (pain felt in extremities that have been amputated) in the right lower extremity. He/She relates a mild headache and neck stiffness. He/She denies any chest pain, rib pain, abdominal pain, or back pain. He/She denies any nausea, vomiting, visual changes, or acute neurologic changes. He/She states he/she is never ambulatory and does not use a prosthetic right leg; -Musculoskeletal: Positive for arthralgias (pain in one or more joints), myalgias (muscle pain), and neck stiffness; -Neurological: Positive for headaches; -Closed fracture of neck of right femur; -Contusion of left shoulder. Review of the resident's Trauma Screen, effective 5/27/25 at 11:13 A.M., showed: -Has the event caused you to feel very scared, helpless, or horrified - Yes; -Has the event caused you to be constantly on guard, watchful, or easily startled - Yes; -Have you tried hard not to think about the event or went out of your way to avoid situations that remind you of it - Yes; -Summary of care provided: He/She has not had any past trauma in his/her life, but this fall has scared him/her, and he/she tries not to think about it, and he/she hopes it does not ever happen again. Review of the resident's progress notes, showed on 5/27/25 at 11:28 A.M., social worker met with the resident to do a trauma screen with him/her. The resident explained that he/she had not had any trauma before in his/her life, but because of his/her fall, he/she was scared because this had never happened before. Review of the facility's Initial Reporting form, dated 5/26/25, showed: -Alleged Victim - Resident #1; -Steps taken to protect resident: Assessment was conducted and was noted to have pain on exam that limited mobility in the affected left (L) shoulder and right (R) leg. Vitals obtained and resident was placed in bed in low position until the ambulance could arrive; -Witness - Blank; -Report Submission: Interim Director of Nursing (DON) on 5/26/25 at 1:15 P.M.; -No facility investigation, summary, witness statements, and/or findings provided at the time of the investigation. Review of CNA D's Correction Action Memo, showed: -Dated 5/26/25; -Type of violation: -Violation of policy or procedure; -Carelessness; -Employer Statement: -You were doing rounds and providing cares when it was reported that a resident fell out of the bed. Also, during this shift there has been an allegation of drug and alcohol abuse while working. Spoke with CNA D at 1:40 P.M. and he/she was suspended, pending investigation; -Action Being Taken: Suspension; -Employee Statement: He/She stated that he/she was providing cares and he/she got bowel movement on his/her gloves. He/She then went to change them and that is when the resident rolled out the bed; -Employee signature - Verbal by phone on 5/26/25 at 1:40 P.M.; -Supervisor signature - dated 5/26/25; -Witness signature - blank; -Dated 5/29/25; -Type of violation: -Violation of safety rules; -Unsatisfactory performance; -Carelessness; -Employer Statement: You were assisting a resident with cares, alone, and when you turned and changed gloves, the resident fell out of bed onto the floor and a fracture was indicated on his/her scans; -Action Being Taken: Termination; -Objective/Solution: This resident needed 2-person assist for transfers/bed mobility/and ADLs. There was no assist bar to help with rolling and due to stepping away, CNA D left the bed up and the resident rolled out and an injury occurred. This would have been prevented if CNA D were using 2 staff; -Supervisor signature dated 5/29/25. During an interview on 6/17/25 at 12:11 P.M., Licensed Practical Nurse (LPN) I said he/she knew the resident. The resident had passed away. The resident had a femur (upper leg bone) fracture. The fall happened on the night shift. The resident was being changed and somehow rolled out of bed. He/She did not know the name of the staff who had provided the care but knew him/her by face. The staff was a night shift aide. LPN I said he/she was just coming into work. In shift report, he/she was told the resident had been assessed and sent to the hospital. The resident was total care. The resident needed help in bed sometimes, but could move himself/herself around in bed. The resident's bedrails were to be up all the time, except when he/she was receiving care. The bedrails were for reposition assistance. The resident was an amputee. He/She was not sure if the resident could stop a fall. He/She expected staff to use two people if the resident was supposed to have that and it was never ok to turn their back to or walk away from a resident when the bed was in a high position. During an interview on 6/17/25 at 1:19 P.M., Certified Medication Technician G said it took two people to assist the resident. During an interview on 6/17/25 at 1:23 P.M., CNA H said he/she knew the resident. He/She found out the resident had fallen out of bed on Memorial Day. He/She did not talk with the resident about the fall and didn't know how the resident had fallen out of bed. When he/she came back to work, the resident was gone. CNA H said it took two people to transfer the resident. It took one person to provide care and to reposition him/her. During an interview on 6/17/25 at 1:27 P.M., LPN I said the number of staff to provide care for the resident depended upon whether or not he/she had just come from dialysis. Sometimes the resident was weak. It would take two people then but regularly, only one or two staff. He/She expected the staff to follow the resident's care plan. During an interview on 6/17/25 at 3:48 P.M., CNA C said he/she was familiar with the resident. He/She worked the night the resident fell out of bed. CNA D was assigned to the resident. He/She went to the resident's room to ask for CNA D's assistance with his/her resident and walked away back to his/her resident's room. A few minutes later, CNA D came to the door and said the resident is on the floor. The resident's bed was not against the wall, it was positioned in the room, so the floor was on both sides of the bed. The resident was a 1-person assist and fairly easy to roll. CNA C said when he/she got to the room, the resident was on his/her right side on the floor. The rails were not up on the bed on either side. The resident fell away from the side CNA D was on. He/She said CNA D said he/she went to change his/her gloves and that is how the resident fell. The bed was high when he/she went to ask CNA D for help. The resident just wanted them to get him/her up off the floor. The day the resident fell, he/she smelled alcohol on CNA D's breath when they were face to face, rolling a different resident in bed. CNA C reported this to the ADON (Assistant Director of Nursing). CNA D had come back from break smelling like weed and alcohol. He/She reported it to his/her supervisor (ADON). He/She called the ADON in the A.M. and told her CNA D couldn't work that hall. He/She said CNA D was lit and couldn't do anything. During an interview on 6/17/25 at 4:32 P.M., the Regional Nurse Consultant (RNC) said CNA D was no longer an employee after the resident's fall. Based on the investigation, CNA D did not have a 2nd person to assist with the resident's care. CNA D did not follow the resident's care plan. CNA D had been educated before. The resident was in bed and was non-weight bearing which is why he/she needed 2-people for care. The RNC said no one ever reported to her that CNA D smelled like alcohol or marijuana. She expected staff to follow the resident's care plan. During an interview on 6/18/25 at 6:46 P.M., the Interim DON said by the time the fall had been reported to her, CNA D was gone. She said it was reported to her in the past that CNA D had used alcohol/drugs while at work, but she did not have enough information to substantiate the allegations. She saw CNA D a few times, but did not smell drugs or alcohol on him/her. During an interview on 6/20/25 at 9:20 A.M., LPN F said Resident #1 told him/her the he/she bumped his/her head and he/she hit the floor hard. When he/she (LPN F) came back to work, after the fall, the resident was put on a pain management program because of the fall. LPN F said CNA D would be off the floor for long periods of time and take extended breaks. He/She said CNA D would not come back sometimes until it was time to provide care to the residents at the end of the shift. During an interview on 6/20/25 at 9:48 A.M., LPN A said he/she had worked with the resident before. He/She changed the resident alone on 6/1/25, after the resident had the fall, because they were short staffed with only one CNA and himself/herself. He/She knew the resident was 2-person assist. During an interview on 6/20/25 at 11:40 A.M., the ADON said she did not expect CNA D to turn his/her back or walk away from the resident to change gloves while the bed was still in high position. The resident required 2-person assist for transfers but that was because he/she used a mechanical lift. She was aware of the facility's in-service requiring the resident have 2-person assist for care. Based on the in-service, CNA D should have had an extra staff helping provide care to the resident. She expected CNA D to have gotten another staff member. The resident's fall could have been prevented. He/She asked the Interim DON to get a drug/alcohol test on CNA D but the Interim DON said she did not smell any alcohol on CNA D and could not tell if CNA D was impaired. During an interview on 6/18/25 at 12:09 P.M., the Interim DON said she did not know about the situation until about 10 or 10:30 A.M. the day of the fall. The nurse who had the resident had quite a few things going on, so that nurse did not tell her right away. She was originally told the resident fell out of bed. She talked with CNA D. She said CNA D told her the resident's bed was up about hip high. The resident had a large loose stool. He/she went to change his/her gloves, turned away from the bed, and changed gloves. Either way, no rail guards were up. She expected there to be 2-people providing care to the resident. The resident fell out of bed. CNA D was caring for the resident but was not following the care plan. The Interim DON said it was neglect because CNA D walked away without there being a 2nd person to assist with providing care. CNA D had already left the shift (worked nights) before she knew of the incident. She did not request an alcohol test because CNA D had already been gone a while and she did not know how long alcohol stayed in a person's system. She called CNA D a couple of times, because she needed to know what happened. She told CNA D he/she was suspended pending investigation, but he/she did not come back. He/She expected CNA D and all nursing staff to follow the resident's care plan. She expected all staff to follow the facility's policies. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions 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 deficiency was lowered to the D level. This statement does not denote 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). MO00255229

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for three of three residents observed during wound care. Staff failed to change their gloves or sanitize their hands prior to entering the room, prior to exiting the room, and in-between removing soiled dressings, cleaning the wound, and applying new wound dressings. The staff also failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatment, for three residents (Residents #5, #8, and #9). The sample size was 12. The census was 108. Review of the facility's Hand Hygiene Policy, revised 6/2020, showed: -Purpose: To ensure all individuals use appropriate hand hygiene while at the facility; -Policy: The facility considers hand hygiene the primary means to prevent the spread of infection; -Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy; -Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to: -Wash hands with soap and water: -When soiled with visible dirt or debris; -After removing personal protective equipment (PPE) and before moving to another resident in the same room or exiting the room; -Alcohol-based hand hygiene products can and should be used to decontaminate hands: -Immediately upon entering a resident occupied area regardless of glove use; -Immediately upon exiting a resident occupied area regardless of glove use; -Before moving from one resident to another in a multiple-bed room or procedure area regardless of glove use; -Hand hygiene is always the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand hygiene procedures. Review of the facility's Standard and Enhanced Precautions policy, implemented April 2024, showed: -Policy: The Facility will utilize current guidance from the CDC and the CMS to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection; -Standard Precautions: -Hand Hygiene: Hand hygiene refers to hand washing with soap (anti-microbial or non- antimicrobial) OR using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water. -Gloves: Gloves (clean, non-sterile) are worn when direct contact with blood, body fluids mucous membranes, non-intact skin, and other potentially infected material is anticipated; -Gowns: A gown is worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood body fluids, secretions, or excretions or cause soiling of clothing; -Enhanced Barrier Precautions: -For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care; -EBP are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high-risk. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/25, showed: -Cognitively intact; -Diagnoses included heart failure, malnutrition, and quadriplegia (paralysis of all four limbs). Review of the resident's care plan, dated 5/20/25, showed: -Focus: EBP related to wound; -Goal: Reduce transmission of pathogens; -Interventions: Staff members will wear clean gown and gloves while performing high contact resident care activities to include dressing, bathing/showering, providing hygiene, changing linens, changing briefs or toileting assistance. Review of the resident's electronic Physician Order Sheet (ePOS) showed an order, dated 6/4/25, cleanse right lateral (outer) lower leg with hypochlorous (wound cleansing solution). Apply calcium alginate (absorbent dressing) with silver to wound bed. Cover with super absorbent dressing, kerlix (gauze wrap) and with ACE wrap. Daily and as needed (PRN) every dayshift for wound care. Observation on 6/17/25 at 930 A.M., showed Licensed Practical Nurse (LPN) L stood at the nursing cart in front of the resident's room. He/She prepared the wound care supplies at the cart, applied gloves, and entered the resident's room. LPN L did not perform hand hygiene prior to applying gloves and did not put on a gown. LPN L pulled down the resident's right sock. The resident's leg was swollen around the wrap. LPN L removed the soiled dressing. While removing the dressing, a large piece of the resident's skin tissue came off with the dressing. The resident said Ouch. LPN L cleansed the area and applied a new dressing without changing his/her gloves or performing hand hygiene. LPN L secured the area with kerlix wrap. He/She cleaned up the supplies, removed gloves, and exited the resident's room without performing hand hygiene. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -No upper or lower body impairment; -Dependent (Helper does all effort. Resident does none of the effort to complete activity) for toileting, upper and lower body dressing, and personal hygiene; -Diagnoses included cancer, high blood pressure, stroke, and malnutrition. Review of the resident's care plan, revised 6/2/25, showed: -Focus: EBP related to wound; -Goal: Reduce transmission of pathogens; -Interventions: Staff members will wear clean gown and gloves while performing high contact resident care activities to include dressing, bathing/showering, providing hygiene, changing linens, changing briefs or toileting assistance. Review of the resident's, ePOS, showed an order, dated 5/14/25, cleanse left side of foot. Dry and apply xeroform (non-adherent dressing) and dry dressing. Every day shift every 3 days for wound management. Review of the facility's wound report, dated 6/11/25, showed the following for the resident: -Wound location: Left Lateral Foot; Arterial Ulcer; -Length: 1 centimeter (cm), 0.8 width, depth 0.1 cm; -Wound status: subsequent-Improving; -Dressing change: Every three days. Clean with normal saline. Xeroform, dry dressing. Observation on 6/17/25 at 9:35 A.M., showed LPN L stood at the nursing cart in front of the resident's room. He/She prepared the wound care supplies at the cart, applied gloves, and entered the resident's room. LPN L did not perform hand hygiene prior to applying gloves and did not put on a gown. LPN L removed the resident's left sock. The resident had a dressing to his/her left ankle. LPN L removed the soiled dressing, cleaned the area with the same gloved hands, cut the xeroform with scissors, and applied the xeroform to the wound. LPN L secured the area with a foam bandage. He/She did not change gloves or perform hand hygiene. LPN L cleaned up the trash, removed gloves, and left the resident's room. He/She did not perform hand hygiene after removing gloves and before exiting the room. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No upper body impairment; -Lower body impairment on both sides; -Dependent (Helper does all effort. Resident does none of the effort to complete activity) for toileting, upper and lower body dressing, and personal hygiene; -Surgical wound; -Diagnoses included diabetes, anxiety, and malnutrition. Review of the resident's care plan, revised on 6/5/25, showed: -Focus: Resident requires EBP related to indwelling urinary catheter and wound; -Goal: Resident will not verbalize or demonstrate symptoms of isolation related to enhanced barrier precautions placement while reducing risk of infection transmission; -Interventions: Appropriate PPE will be utilized during high contact care by care givers (dressing, bathing/showering, transferring in room or therapy gym, providing hygiene, changing linens, changing briefs, or assisting with toileting). Provide education to resident and resident representative as appropriate. Resident is not isolated to their room-they can move around freely. Review of the resident's ePOS, showed an order, dated 6/4/25, cleanse abdomen and dry. Apply collagen pad and soft silicone foam dressing every day shift every other day for wound management. Review of the facility's wound report dated 6/11/25, showed the following for the resident: -Wound location: Midline Abdomen; -Length: 20 cm, 5 cm width, depth 0.1 cm; -Wound status: subsequent-Improving; -Dressing change: Every other day. Clean with normal saline. Xeroform, Collagen Sheet, dry dressing. Observation on 6/17/25 at 9:40 A.M., showed the resident in his/her room. LPN L applied gloves at the treatment cart and used scissors to cut/prep the dressing. LPN L did not put on a gown prior to entering the resident's room. LPN L entered the resident's room and removed the old dressing from the resident's abdomen. He/She cleaned the wound bottom to top with the same gloved hands. LPN L wiped the edges of the wound with a gloved finger and then picked at the top of the resident's wound with the same gloved hand. LPN L applied the xeroform that was cut into 5 small pieces down the resident's abdomen. He/She then secured the wound with two large bandages. One at the top of the wound and one at the bottom. He/She did not change his/her gloves or perform hand hygiene. LPN L cleaned up the trash, removed gloves, and left the resident's room without performing hand hygiene. 4. During an interview on 6/18/25 at 1:20 P.M., LPN L said EBP precautions are to be used for every dressing change. Staff are supposed to place on gown and gloves before providing care if a resident is on EBP precautions. Hand hygiene should be performed before and after each treatment. During an interview on 6/18/25 at 2:30 P.M., LPN B said if a resident is on EBP for wound care, staff are expected to wear gloves, a gown maybe. Nursing staff should wash hands/perform hand hygiene when entering room and before putting on gloves, after removing gloves, and before putting on new gloves. Nursing staff should wash hands in between glove changes when gloves are soiled. During an interview on 6/18/25 at 1:25 P.M., the Director of Nursing said when indicated, EBP is supposed to be used with any type of care like dressing changes. They are to be used to protect the resident from infections. She would expect hand hygiene to be competed on entry into room, when changing gloves, when gloves are soiled and after removing the gloves. Hand hygiene or washing hands should be completed every time staff change gloves. Gloves should be changed between dirty and clean areas. Hand hygiene or hand washing should be performed in-between glove changes.

Based on interview and record review, the facility failed to follow their grievance policy to maintain an effective grievance process for residents to voice grievances and promptly resolve them for one resident who voiced a grievance over staff treatment (Resident #1). The facility failed to take immediate action to prevent further potential violations of any resident rights while the grievance was being investigated. The facility failed to provide a summary of the pertinent findings including whether the grievance was confirmed and failed to follow up with the resident to inform him/her of the findings of the investigation and any corrective actions recommended in a timely manner. The facility also failed to ask the resident if he/she was satisfied with the outcome of the results of the investigation. The failures had the potential to affect all residents. The sample size was 4. The facility census was 115. Review of the facility's Grievance/Missing Property policy, revised 8/2020, showed: -Purpose: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints; -Policy: The facility advises residents and their representatives (including family, legal representatives and advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. The facility ensures that there is no retaliation for filing a grievance or complaint and ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints. The disposition of all resident grievances and/or complaints is recorded in the facility's resident grievance/compliant log; -Duties and obligations of staff: All alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator immediately; -Designation of Grievance Official: The facility will identify a Grievance Official who is responsible for: -Overseeing the grievance process; -Receiving and tracking grievances through to their conclusion; -Leading any necessary investigations by the facility; -Issuing written grievance decisions to the resident; and -Coordinating with state and federal agencies as necessary for specific allegations; -Grievance investigation: Upon receiving a resident grievance/complaint form, the Grievance Official or designee begins an investigation into the allegations. The Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The department director of an involved employee is notified of the nature of the complaint and that an investigation is underway; -The investigation and report include, as applicable: -The date and time the grievance was received; -The date and time of the alleged incident; -The circumstances surrounding the alleged incident; -The location of the alleged incident; -Steps taken to investigate the grievance; -The resident's account of the alleged incident; -The employee's account of the alleged incident; -Accounts of any other individuals involved (i.e., employee's supervisor, etc.); -Summary of the pertinent findings including whether the grievance was confirmed or not confirmed: -Recommendations for corrective action; and -Date the written grievance was issued; -The Administrator will be provided with a completed resident grievance/complaint investigation report within five (5) working days of the incident utilizing facility specific forms; -If follow-up is required, the Administrator is responsible for ensuring that the follow-up action is taken in a timely manner; -The Administrator/designee will maintain copies of resident grievance investigation reports for no less than 3 years from the issuance of the grievance decision; -The facility will inform the resident or his or her representative or concerned party of the findings of the investigation and any corrective actions recommended in a timely manner; -If the resident is not satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint to the local Long-Term Care Ombudsman's office or to the state department. Review of the facility's March 2025 grievance concern log, showed no grievance concern documented for Resident #1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: -Cognitively intact; -Upper extremity impairment on one side; -Wheelchair; -Diagnoses included, anemia (lower than normal red blood cells or hemoglobin) and renal insufficiency (a condition where the kidneys don't function as well as they should). Review of the resident's grievance/complaint report, dated 3/5/25, showed: -Describe the nature of the grievance/complaint (be specific): -The resident said that a Certified Nurses Aide (CNA) slammed him/her into the restroom. CNA A wanted him/her to stand up. He/She told CNA A he/she needed the lift. CNA A slammed his/her leg against the resident's foot to get him/her off the toilet; -Signed 3/5/25 by Social Service Director (SSD); -For office use only: -Date: blank; -Received by: blank; -Title: blank. Review of the facility's grievance investigation, showed: -CNA A's statement, signed, and no date; -To whom this may concern, please accept this statement regarding the incident that happened on 3/1/25, night shift. In brief, Certified Nurse Assistant (CNA) A helped the resident to the bathroom with the sit to stand (mechanical lift). The resident had a bowel movement. CNA A cleaned the resident up and put him/her back into his/her chair with the sit to stand. Staff met at the resident's room and CNA A put him/her back in bed using the sit to stand; -Review of the facility's corrective action memo, dated 3/5/25, showed; -Employee: CNA A; -Acting Director of Nursing (ADON): Supervisor; -Type of violation: Altercation/Customer Service; -Employer statement: Suspension pending investigation; -No start date of suspension documented; -Action being taken: Suspension; -No employee signature or date documented; -No supervisor signature or date documented; -Employee refused to sign box unchecked/left blank/unmarked; -No resident written account of the alleged incident noted; -No documentation related to steps and/or actions taken documented; -No summary of the pertinent findings including whether the grievance was confirmed or not confirmed; -No documentation of the resident's satisfaction or non-satisfaction of the outcome of the investigation; -No resident information related to the right to appeal the results of the investigation via written compliant. Review of the facility's re-education in-service, showed: -3/5/25, Customer Service training; -No documented training provided to CNA A; -3/6/25, Customer Service training; -No documented training provided to CNA A; -3/7/25, Customer Service training; -No documented training provided to CNA A; -3/12/25, Transfer training; -No documented training provided to CNA A. Review of the resident's progress notes, showed: -Late Entry-Social Service note, dated 3/5/25 at 5:23 A.M., the Social Worker, Executive Director and the Assistant Director of Nursing (ADON) met with the resident to see what happened to him/her, and he/she was upset with the way he/she was being transferred. It was explained to him/her that the facility will start an investigation, and the facility wanted him/her to be safe and be comfortable; -Social Services note, dated 3/6/25 at 7:29 P.M., Social Worker spoke with the resident to see how he/she was doing and he/she stated he/she was fine. The resident told what the nurse did yesterday and that some x-rays were ordered. He/She was asked if he/she felt safe at the facility. He/She felt safe; -No nursing documentation of the alleged incident prior to or after the Social Service note. Review of the resident's progress notes, showed: -Social Service note, dated 3/7/25 at 12:39 P.M., Social Worker spoke with the resident to see how he/she was doing today. The resident said hi ms/her shoulder was bothering him/her from the incident the other day. He/She would like to get it checked out. The Charge Nurse and ADON were was notified; -General progress note, dated 3/7/25 at 4:21 P.M., the resident reported to the Social Worker that right upper extremity (RUE) was painful due to incident days prior. Medical Director (MD) made aware. New x-ray orders received. During an interview on 5/12/25 at 10:25 A.M., the resident said he/she wanted to use the restroom and asked for help getting to the bathroom. CNA A brought the lift to his/her room. He/She said the aide told him/her to stand up. He/She told CNA A he/she was tired, but CNA A insisted. The resident stood up because he/she did not want to argue. The resident got weak while standing. CNA A stomped on both the resident's feet, trying to hurry him/her up to sit on the toilet. The resident was getting weaker. CNA A pushed him/her down on the toilet. The resident tried to brace himself/herself for the fall. He/She fell back hard and hurt his/her back. The resident demonstrated to the surveyor how he/she tried to brace himself/herself. The resident stretched out his/her arms slightly behind him/her with open hands. The resident told CNA A that was abuse. The resident asked the CNA if he/she knew that was abuse. The aide just smirked and kind of laughed. The resident told the CNA he/she was going to report what happened. He/She used the bathroom and then went to bed. When the resident got up the next day, he/she reported the incident to the nurse assigned to him/her. The resident didn't hear anything back from the nurse about what he/she reported. The resident went to the nurse in charge of that nurse. The resident told the Administrator and finally the doctor. He/She said the doctor told the Administrator. They finally gave him/her an x-ray, but he/she didn't know what the results were. He/She said there was a meeting with the ADON and Administrator. They all told him/he what CNA A did was unintentional. He/She knew when someone was doing something intentional to him/her. All CNA A had to do was apologize. It was intentional. The resident talked with staff a few weeks later and someone told him/her, You don't see CNA A around here, do you? He/She thought the CNA A was no longer working at the facility. The resident was shocked and flabbergasted when he/she saw CNA A working. No one does nothing and that makes the resident upset about it. It's like the facility doesn't care. They don't care but the resident cares. His/Her back was hurting today. His/Her pain level right then was about an 8. The pain medication just took the edge off. The pain was affecting his/her ability to put 100% into his/her therapy. He/She couldn't do his/her best because to the pain and couldn't make good progress. He/She wanted to start walking and get out of here. During an interview on 5/12/25 at 2:55 P.M., the ADON said the resident felt like CNA A was being rough. The resident was a bigger person. They told the resident the rough treatment was unintentional. She thought the resident may have fallen down hard, but knowing CNA A, they thought it was unintentional. CNA A used the sit to stand and said the resident didn't say anything. They educated CNA A and removed him/her from the resident's floor. CNA A received customer service and lift training. The resident wasn't a sit to stand at the time. He/She was moderate assist times one. He/She had come back from dialysis (a treatment to clean the blood when the kidneys are not able to) and was probably a little weak. She didn't know if the resident was assessed. It was decided the resident would use the sit to stand after dialysis because he/she was weaker when he/she came back to the facility. She wasn't sure if CNA A was suspended but he/she was taken off the schedule until they found out what happened with the alleged incident. No one talked to the CNA A about apologizing to the resident. The resident said he/she just wanted CNA A to apologize. CNA A was moved to a different floor and shift. They thought the resident would not see CNA A because he/she would be asleep. During an interview on 5/12/25 at 4:07 P.M., the Social Service Director (SSD) said the incident happened over the weekend. She wasn't there, so didn't get the initial information from the resident. When she spoke with the resident, he/she tried to fill her in on what happened. She couldn't remember off hand what the resident told her about the incident. She asked if the resident felt safe. He/She did. During a telephone interview on 5/12/25 at 7:39 P.M., CNA A said he/she guessed the resident had to go to the bathroom and was upset that he/she didn't get there right away. The resident rang his/her call light. He/She went to the resident's room and used the sit to stand to help him/her with the bathroom. He/She didn't push, stomp, or kick the resident. There were no words exchanged. As far as he/she knew, the resident was not upset. He/She was not given any corrective and/or disciplinary paperwork to sign. He/She gave his/her statement to the Executive Director/Administrator. He/She said the Executive Director called him/her to ask what happened. The Executive Director said the resident said CNA A was loud and irate. It was nighttime so he/she would never have been loud. Residents were asleep. He/She was taken off the schedule for seven days. He/She had in-service education on patient safety, transfers, and abuse. He/She worked at the facility, but was no longer assigned on the resident's unit. During an interview on 5/13/25 at 11:29 A.M., the Regional Nurse Coordinator (RNC) and Administrator were unaware of the resident wanting an apology from CNA A. They expected the Acting DON and nursing to follow up with the resident to address unresolved issues. Both the RNC and the Administrator expected the findings of the grievance process to be documented. They expected the resident to receive the outcome of the findings and said the resident should have been asked if he/she was alright with the things the facility did to resolve his/her issue with CNA A. They expected all facility staff to follow the grievance process policy.

Based on observation, interview and record review, the facility failed to complete a thorough investigation of alleged abuse for one resident per facility policy (Resident #1). Review of the facility soft investigation, provided during the onsite investigation, showed no written statement from the resident, actions taken, summary, and/or conclusion of the investigation or findings. The sample size was 4. The census was 115. Review of the Abuse Prevention policy, revised 8/2020, showed: -Investigation: -The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts; -If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the facility's management team (the investigator) to investigate the alleged incident; -If the investigation is delegated, the Administrator provides the investigator with any supporting documents related to the alleged incident; -The facility ensures protection of residents during abuse investigations; -The investigator may take some or all of the following steps: -Reviews all relevant documentation; -Reviews the resident's medical record to determine events preceding the alleged incident; -Interviews the person(s) making the alleged incident; -Interviews the resident's attending physician as need to determine the resident's current level of cognitive function and medical condition; -Interview facility staff members who have had contact with the resident during the period of the alleged incident; -Reviews all events leading up to the alleged incident; -Communicate with the Administrator daily regarding the progress of the investigation; and -Prepares an investigation report documenting findings of the investigation; -The investigator notifies the Ombudsman when an abuse investigation is being carried out; -Facility staff who have been accused of abuse may be reassigned duties that do not involve resident care or suspended from duty until the Administrator has reviewed the investigation results; -The investigator records the investigation results on the Abuse Investigation Reporting Form; -The investigator provides a copy of the completed investigation report to the Administrator within 5 working days of the initial report of abuse, mistreatment, neglect, or unexplained injury; -The Administrator will provide a written report of the results of all abuse investigations and consequent actions to the appropriate agencies; -If the investigation substantiated the allegation, corrective action will be documented as part of the investigation and implemented to prevent recurrence; -If the investigation reveals that the initial report was unsubstantiated, the investigation ceases immediately; -The facility shall retain documentation relating to a facility staff member's involvement with the incident in the facility staff member's personnel record, according to regulation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: -Cognitively intact; -Upper extremity impairment on one side; -Wheelchair; -Diagnoses included, anemia (lower than normal red blood cells or hemoglobin) and renal insufficiency (a condition where the kidneys don't function as well as they should). Review of the resident's progress notes, showed: -Late Entry-Social Service note, dated 3/5/25 at 5:23 A.M., the Social Worker, Executive Director and the acting Director of Nursing (DON) met with the resident to see what happened to him/her, and he/she was upset with the way he/she was being transferred. It was explained to him/her that the facility will start an investigation, and the facility wanted him/her to be safe and be comfortable; -Social Services note, dated 3/6/25 at 7:29 P.M., Social Worker spoke with the resident to see how he/she was doing and he/she stated he/she was fine. The resident told what the nurse did yesterday and that some x-rays were ordered. He/She was asked if he/she felt safe at the facility. He/She felt safe; -No other documentation related to the resident's allegation. Review of the resident's grievance/complaint report, dated 3/5/25, showed: -Describe the nature of the grievance/complaint (be specific): The resident said that a certified nurse assistant (CNA A) slammed him/her into the restroom. CNA A wanted him/her to stand up. He/She told CNA A he/she needed the lift. CNA A slammed his/her leg against the resident's foot to get him/her off the toilet; -Signed 3/5/25 by Social Service Director; -For office use only: -Date: blank; -Received by: blank; -Title: blank. Review of the facility's investigation, showed: -3/5/25 CNA A's corrective action memo; -Employee written statement alleging incident date 3/1/25; -In-Service training dated 3/5, 3/6, 3/7, and 3/12/25; -Resident safety questionnaires; -No written resident statement of alleged incident; -No summary of action steps taken and/or recommendations; -No investigation report of the findings and/or conclusion of the investigation; -No documentation of notification of Ombudsman related to the soft investigation of allegation; -No Abuse Investigation Reporting Form; -No notification of investigation results to appropriate agencies; -No date(s) of the suspension and no documentation of in-service education related to the allegation. Review of the facility's re-education in-service, showed: -3/5/25, Customer Service training; -No documented training provided to CNA A; -3/6/25, Customer Service training; -No documented training provided to CNA A; -3/7/25, Customer Service training; -No documented training provided to CNA A; -3/12/25, Transfer training; -No documented training provided to CNA A. During an interview on 5/13/25 at 10:53 A.M., the Human Resource Manager said the Administrator and nursing were responsible for the investigation. She did not assist or participate in the investigation process. During an interview on 5/13/25 at 11:29 A.M., the Executive Director said this issue came up in March when the resident filed a grievance. He and the Acting Director of Nursing (Acting DON) spoke with the resident about what happened with CNA A. The allegation was discussed with the team. The team decided the allegation was a customer service issue when care was provided to the resident. The team didn't think it was abuse. The allegation wasn't investigated as abuse because the team decided it was a customer service issue with providing care. They in-serviced staff but can't explain why CNA A's signature wasn't on any of the in-service sheets. He/She was the reason the in-service training was being provided. The Executive Director and the Regional Nurse Consultant (RNC) both expected all allegations of known or suspected abuse to investigated completely. They expected staff to have documented the details of the allegation in the resident's record. They expected the facility's abuse policy to be followed.

Based on observation, interview, and record review, the facility failed ensure residents were free from abuse by Resident #3, who yelled, cursed and threatened them. Resident #3 was described as bullying residents and used racial slurs towards his/her roommate. Residents refused to go to activities or eat in the dining room to avoid being around the resident. The census was 120. The Administrator was notified on 3/3/25 at 11:15 A.M., of an immediate jeopardy (IJ) which began on 1/29/25. The IJ was removed on 1/30/25 as confirmed by surveyor on-site verification. Review of the facility Abuse Prevention and Prohibition Program policy, revised on 10/24/2022, showed: -Purpose: To ensure the Facility establishes, operationalizes, and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, and other residents; -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: -Training: Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics: Who is a covered individual responsible for reporting. Abuse prevention. Identification and recognition of signs and symptoms of abuse/neglect. Protection of residents during an abuse investigation. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Prevention: -Staff, residents and families will be able to report concerns, incidents and grievances without of retribution or retaliation; -Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect is at risk for occurring; -Residents identified by staff as exhibiting abusive behavior that requires professional services not provided in the Facility will be reviewed by the IDT (interdisciplinary team) and/or physician. Appropriate referrals will be made, and treatment plans will be modified; -The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; -The Facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse; -Resident Assessments and Care Planning are performed to monitor resident needs and address behaviors that may lead to conflict; -Identification: -The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect; -Possible Signs and Symptoms of Psychological Abuse or Neglect, includes depression, withdrawal, and anger; -Investigation: -The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of unknown source, or criminal acts; -The Facility has protocols for investigations; -If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, the Administrator or designee, may appoint a member of the Facility's management team to investigate the alleged incident; -Protection: The Facility protects residents from any harm that could result from abuse investigations. Review of the facility's Violence Between Residents policy, dated 8/2020, showed: -Purpose: To protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the facility; -Policy: The Facility acts promptly and conscientiously to prevent and address altercations between residents; -Prevention: Facility Staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or Facility Staff. Any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing (DON), and the Administrator; -Response to an Altercation: Separate the residents, and institute measures to calm the situation. Determine what happened, including what might have led to aggressive conduct on the part of one or more residents involved in the altercation. Notify each resident's representative and Attending Physician of the incident. Review the events with the Charge Nurse and DON, including interventions staff can take to prevent additional incidents. Consult with Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. Make any necessary changes in the Care Plan for any or all of the involved residents as necessary. Document in the resident's interventions and their effectiveness in the resident's medical record. Consult with psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a Care Plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Team. Complete the Incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the Facility, transfer the resident. Report incidents, findings, and corrective measures to appropriate agencies. Review of Resident #3's admission face sheet showed: -Admission 6/6/24; -The resident was listed as his/her own responsible party. Review of the resident's progress notes, located in the electronic health record (EHR), dated 6/6/24 at 12:52 P.M., showed the resident arrived at 12:00 noon, alert and oriented x 4 (person, place, time and situation). Got off ambulance stretcher and walked to room with a steady gait. Review of the Guidelines for Resident Behavior, signed by the resident and co-signed by the Social Service Director (SSD) on 6/6/24, showed: -General Conduct: residents are expected to treat staff, other residents with respect, dignity and privacy. Conduct must be consistent with accepted community standards, local, federal and state laws. Unacceptable conduct includes but is not limited to physical abuse, verbal abuse. This conduct is not permitted on or about the facility; -Non-Compliance: if we determine that residents' behavior is contrary to these rules and is compromising their health care or that of other residents, these residents will be subject to administrative actions. Review of the resident's care plan, located in the EHR, showed: -Problem, 6/6/24: Resident has a mood problem, depression; -Goal: Resident will not experience any increase in signs and symptoms of mood disturbance. Interventions: Administer medications as ordered. Behavioral health consult as needed. Communicate with resident regarding mood state and treatment. Encourage resident to express feelings. Encourage resident to participate in activities of choice. Encourage to maintain as much independence and control/decision making as possible. Notify medical provider of increased episodes of mood disturbance; -Problem, 6/13/24: Resident has a behavior problem. Resident was noted to speak rudely to roommate, eating off other residents' plates, verbally aggressive with staff, disrespectful to staff; -Goal: resident will have fewer episodes of behaviors through review date. Interventions/Tasks (6/13/24); -Interventions: speak in calm manner. Behavioral health consults as needed. Communicate with resident regarding behaviors and treatment. Consult with Pastoral care, Psych services, and/or support groups. Minimize potential for behaviors by offering tasks that divert attention. Monitor behavioral episodes and attempt to determine underlying causes. Intervene as necessary to protect the rights and safety of others. Encourage not to curse or speak disrespectfully and/or aggressive to staff. Notify medical provider of increased episodes of behaviors. -6/14/24: Encouraged to speak to roommate respectfully and encouraged not to eat off of other resident's plates. Review of the resident's record showed there was no behavior management program or ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs documented. Review of the resident's progress note, dated 6/12/24 at 2:26 P.M., showed the resident's physician saw the resident at the facility. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/24, showed: -Speech Clarity: clear speech, distinct intelligible words; -Makes Self Understood: ability to express ideas and wants: understood; -Ability To Understand Others: understood; -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): behavior not exhibited; -Mobility Devices: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of high blood pressure, diabetes mellitus (high blood sugar) and depression. Review of the resident's medication administration record (MAR, a form where nurse documents medication administration and behavioral episodes) dated 6/6/24 through 6/30/24, located in the EHR, showed: -6/6/24: Duloxetine HCI (antidepressant) 30 milligrams (mg) daily; -Behaviors: Verbally aggressive with staff: occurred 1 time on the evening shift (6/13/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the evening shift (6/13/24); Review of the resident's progress notes, dated 6/13/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behavior on the evening shift of 6/13/24. Review of the resident's progress note, on 6/14/24 at 12:07 P.M., showed the SSD documented the resident said he/she was there short term and was just waiting on his/her apartment to be approved. Resident rights were reviewed including the facility guidelines for behavior, drugs, and smoking. Review of the resident's MAR, dated 7/1/24 through 7/31/24, showed no behaviors documented. Review of the resident's progress note, dated 7/3/24 at 6:59 P.M., showed: -Resident had verbal disagreement with another resident, nursing staff present at the time, no contact made. Resident separated from the other resident. Resident was calm sitting outside in the smoking area listening to music; -No SSD or IDT follow-up documented. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 7/10/24, showed: -Diagnoses: post-traumatic stress disorder (a mental health disorder that can develop after witnessing a traumatic event), nicotine dependence, cocaine use (in remission), other specific personality disorders, and persistent mood disorder; -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up, says he/she was still trying to make the best of his/her situation. Decides he/she does not want medication to help him/her stop flipping out. Discussed trying to stay calm and walking away from conflict, which I am not sure he/she was completely on board with. Denies symptoms of depression or anxiety. Just mood swings he/she says; -Objective: resident was engaged with examiner in a cooperative and polite manner. Mobility was within normal limits. Stream of mental activity was logical, relevant, coherent, and goal directed; -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's progress notes showed: -7/11/24 at 6:22 A.M.: the resident had a verbal altercation with roommate. Resident was loud, disturbing, and using profane language. The resident slammed the door behind roommate; -7/11/24 at 10:29 A.M., IDT note (Administrator, former Director of Nursing (DON), SSD and Nursing Manager): verbal disagreement with roommate. The resident called roommate a racial slur. Roommate did not like this and told the resident so. The resident became upset when staff intervened. The resident left the room shutting the door loudly. The resident educated to be considerate of others' feelings and preferences. The resident verbalized understanding; -7/11/24 at 3:04 P.M., completed by the SSD: spoke with the resident about his/her disagreement with roommate this morning. He/She said he/she closed the door but did not mean to slam it. Explained to him/her if he/she has a problem with his/her roommate just come and speak to them. Also spoke about changing rooms. He/She said he/she was happy with that; -7/13/24 at 11:17 A.M., documented by the Administrator: met with resident for psychosocial follow-up. Said he/she likes his/her new room and new roommates. Reinforced with resident that he/she must remain respectful with facility staff. Said he/she understands and was working on it. He/She feels that due to his/her size, he/she may come across as more upset than he/she actually was. Reeducated that he/she can bring any concerns to facility management, social service, this author, and will communicate any future needs of concerns to the appropriate parties; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP. Review of the resident's progress note dated 7/16/24 at 2:06 P.M., and completed by the SSD, showed a care plan meeting was held with the resident to discuss verbal outbursts toward staff and other residents, and explain this is not a good fit for him/her. He/She continues to ask facility to give him/her another chance and he/she continues the same behavior. SSD has been asked to start looking for another facility. He/She gave SSD a few facilities to send his/her referral to. Review of the resident's care plan showed: -On 7/11/24, Observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs. Encourage to maintain as much independence and control/decision making as possible. Praise and indication of progress in behaviors; -On 7/29/24, Encourage to take all medications and notify physician of all refusals. Review of the resident's MAR, dated 8/1/24 through 8/31/24, showed: -Behaviors: Verbally aggressive with staff occurred 5 times on the day shift (8/3, 8/4, 8/7, 8/14, and 8/27), and cursing staff occurred 1 time on the evening shift of 8/23; -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (8/3, 8/4, 8/7, 8/24, and 8/27), and educated on reasons not to curse at staff on the evening shift of 8/23. Review of the resident's progress notes, dated 8/1/24 through 8/31/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behaviors on 8/3, 8/4, 8/7, 8/14, 8/23, or 8/27/24. Review of the resident's progress note, dated 8/7/24 at 12:00 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the resident's progress note, dated 8/10/24 at 1:20 P.M., completed by the SSD, showed the resident was informed during care plan meeting that was held that the facility was still trying to find him/her another facility, however no one has accepted him/her as of yet. They are still sending referrals out and once a facility had accepted him/her he/she will be informed. Review of the resident's progress note, dated 8/14/24 at 4:03 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the facility Resident Council meeting minutes, dated 8/15/24 at 2:00 P.M., showed: -Staff members present: the former DON, Activity Director (AD) and Activity Aide (AA) F; -18 residents attended, including: Resident #3, Resident #2, and Resident #14; -New Business: discussed Resident #3 was a bully. Always arguing with staff and peers; -There was no facility response to the Resident Council concerns regarding Resident #3's behaviors. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 8/27/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. He/She was still trying to make the best of his/her situation. Decides he/she does not want any further medication to help him/her from stop flipping out. Denies any symptoms of depression or anxiety at this time; -Objective: engaged with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's MAR, dated 9/1/24 through 9/30/24, showed; -Behaviors: -Verbally aggressive with staff: occurred eight times on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and four times on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Disrespectful to staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Cursing staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Educated on reasons not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24); -Encouraged not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24). Review of the resident's medical record, from 9/4/24 through 9/30/24, showed: -No documentation the resident's physician, psychiatrist and/or psychiatric NP were notified of the resident's behaviors after they occurred; -No documentation of SSD or IDT follow-up; -The care plan showed no new interventions/tasks implemented from 9/1/24 through 9/30/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others: behavior not exhibited; -Mobility Device: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: Supervision or touching assistance, independent. Review of the facility Resident Council meeting minutes, dated 9/20/24 at 10:00 A.M., showed: -Staff members present AD and AA F; -14 residents attended, including: Resident #3, Resident #2, Resident #4, and Resident #14; -Discussed: Activities spoke to Resident #3. He/She promised to stop bothering and cursing out staff and residents; -Resident Council Follow-Up completed by the former DON and signed on 9/24/24: Spoke to Resident #3 and he/she agreed to do better. Staff will keep watch. Review of the resident's behavior tracking located on the MAR, dated 10/1/24 through 10/31/24, showed; -Behaviors: -Verbally aggressive with staff: occurred 16 times on the day shift (10/8, 10/9, 10/10, 10/12, 10/13, 10/15, 10/16, 10/17, 10/22, 10/23, 10/24 and 10/26/24), and three times on the evening shift (10/23, 10/24 and 10/27/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff for all day and evening shift documented behaviors; -No behaviors identified on the evening shift on 10/22/24. Review of the resident's progress notes, from 10/1/24 through 10/31/24, showed: -On 10/22/24 at 7:48 P.M.: the resident noted yelling and cursing in the hallway walking from the front door, stating that they gone have to call the MF police because imma bust that MF down if they don't let me out this MF. They can't hold me no MF in here. They are treating us like we in jail and I've done my time. The resident educated on smoking times and policy. The resident acknowledged teaching, but stated he/she can sign out to smoke. The resident made aware that smoking on the front was prohibited. The resident stated we can't hold him/her hostage and stated his/her sister would be here to pick him/her up. The resident educated on signing out of the facility upon leaving. This nurse also spoke with the resident asking him/her to calm down and stop yelling and using profanity in such an aggressive tone in the hallway around all the other residents. The resident walked away and continued cursing, yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/22/24 at 8:27 P.M.: police called related to resident's behaviors. Police arrived and the resident appeared to be calm at this time. The resident continued to have other residents to come to his/her room and after one of the residents asked to leave, Resident #3 followed the other resident to that resident's room after being told it was after hours and resident's roommate are in bed and resting now and visiting was not allowed at this time. The resident stated, MOVE ME. Police called at this time, and arrived and resident calm stating I'm ok, y'all just want me to go off, and he/she walked away. Police stated the resident needs to be sent to the hospital for mental health behaviors and if needed call them back to assist with removing the resident from the facility. Physician called and new orders received to send resident out for behaviors and to follow up with psych immediately; -10/22/24 at 8:38 P.M.: the resident refusing to go to the hospital. Sitting up front at this time stating his/her sister in on his/her way; -No documentation the resident's physician was notified the resident refused to go to the hospital for his/her behaviors. No documentation the facility notified the physician the resident refused to go to the hospital as ordered; -10/23/24 at 5:39 P.M.: showed the resident continued to yell out in dining room cursing at staff and using profanity loud and in an intimidating tone to staff. Resident unhappy with meal and states They are feeding me like an animal so I'm going to act like an animal. Resident redirected on using inappropriate language in common areas and around all other residents. This nurse explained to resident this is disrespectful and unacceptable behavior. The resident continued to walk off yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/24/24 at 3:00 P.M.: the resident continued to yell, curse and be intimidating to staff and other residents. The resident educated on bullying and reminded that this is inappropriate behavior. The resident redirected and went on down the hall mumbling; -No documentation the resident's physician or psychiatrist/psychiatrist NP was notified; -Review of the resident's progress notes showed no SSD or IDT follow up regarding the resident's 10/22, 10/23, and 10/24/24. -No documentation regarding the resident's behaviors, except on 10/22, 10/23, and 10/24/24. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 10/19/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. Appears to be very particular, also has a big voice, tall. Asked him/her to not be as intimidating which he/she says he/she is just being him/her; -Objective: met with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's psychiatric NP notes, dated 10/1/24 through 10/31/24, showed: -10/22/24, late evening: Resident having disruptive behavior. Just recently saw the resident and will see on next visit. The resident repeatedly refuses to add additional medications. The resident constantly demanding and disruptive. Is supposed to be going to hospital; -10/23/24, evening: Another call, the resident was cussing and being disruptive. The resident refused to go to the hospital the night before. This time it was in the dining room. The resident was cussing at staff and yelling about food he/she doesn't like. Cussed and was loud walking back to room. Resident is very antisocial - hard to redirect. Will see at next visit, but the resident continually denies anything he/she has done and refuses medication changes; -10/24/24, afternoon: Disruptive and inappropriate to staff. Refuses to speak calmly. Will see at next visit, but resident refuses any wrongdoing to me. Further review of the resident's care plan showed no new interventions/tasks regarding the resident's behaviors implemented from 10/1/24 through 10/31/24. Review of the resident's behavior tracking located on the MAR, dated 11/1/24 through 11/30/24, showed; -Behaviors: Verbally aggressive with staff: occurred three times on the day shift (11/5, 11/7, and 11/9/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff. Review of the resident's medical record from 11/5 through 11/9/24, showed: -No documentation the resident's physician, psychiatrist, and/or psychiatric NP were notified on 11/5, 11/7, or 11/9/24; -No documentation the SSD or IDT followed up regarding the resident's behavior on 11/5, 11/7, or 11/9/24; -The care plan showed the resident was put on a behavior contract on 11/18/24, for being aggressive with a peer. Review of the resident's psychiatric notes, completed by the NP, dated 11/16/24, showed: -Medications: duloxetine HCI 30 mg daily; -Subjective: seen for regular follow-up. Still talking about moving but says no one has found him/her a place. He/She had not been very proactive however in working with the facility, and places they have worked hard to find for him/her, he/she has declined. Denies symptoms of depression or anxiety. Again, tried to discuss medications for his/her mood, but he/she says that he/she did not feel the need, and says he/she was fine. It's everyone else that was messing with him/her. He/She had a large stature with a deep intimidating tone. Again, reminded him/her to try and be mindful towards others. He/She continued to say he/she isn't doing anything wrong; -Plan: will follow monthly. Discussed signs of depression, anxiety, changes in cognition, when to notify staff of symptoms. Discussed symptom management. Practice stress management. Review of the resident's progress notes showed: -11/16/24 (Saturday) at 8:32 A.M., completed by the Administrator, nurse responded to room after hearing the resident arguing with his/her roommate (Resident #4). Staff immediately separated both residents. The resident's roommate said that Resident #3 pushed his/her chest. Resident #3 denies this. Staff witnessed only arguing, no physical contact. Skin assessment completed. No marks, redness, swelling, or bruising noted. Physician made aware. New order to consult with psychiatrist and send Resident #3 out for psychiatric evaluation. Ambulance and police called to send resident out to psychiatrist evaluation; -11/16/24 at 2:46 P.M.: resident returned from hospital by ambulance. Resident very irate and cursing in the halls. This nurse asked resident to calm down and resident began to curse more. Resident is currently outside in the courtyard threatening to leave against medical advice. Oncoming nurse made aware. Will continue to monitor behavior. Review of the hospital after visit summary from the hospital, dated 11/16/24, showed no new orders. Review of the MAR, showed no documentation of behavior by staff on the day shift of 11/16/24. Review of the resident's progress note's showed: -11/18/24 at 6:48 P.M., documented by the SSD: SSD spoke with resident to see how he/she was feeling since Saturday. He/She stated he/she feels a lot better. He/She was watching TV with his/her friend and seems happy; -11/19/24 at 4:30 P.M., documented by the SSD: SSD spoke with the resident today. He/She was in a pleasant mood. He/She said he/she likes his/her new room and likes that he/she has more space. He/She was feeling much calmer since the incident with the other resident. Review of a Behavior Contract, dated 11/18/24, showed: -Behavior: the resident had a verbal altercation with his/her roommate; -Goals: Resident had agreed to come and speak to staff when there was a concern with another resident and refrain from raising his/her voice to residents and staff; -Date To Be Achieved: 2/18/25; -Resident refused to sign the Behavior Contract; -SSD signed the Behavior Contract 11/18/24. Review of the resident's care plan showed on 11/18/24 the resident was put on a behavior contract for being aggressive with a peer. Review of the facility Resident Council meeting minutes, dated 12/19/24 at 1:30 P.M., showed: -Staff members present: AD and AA F; -26 residents attended, including: Resident #2, Resident #4, Resident #7, and Resident #14; -Other Concerns: Residents are complaining about the Resident #3 bullying, cursing all the time, taking their cigarettes and nothing is being done; -No facility response to the Resident Council concerns. Review of the resident's behavior tracking located on the MAR, dated 12/1/24 through 12/31/24, showed no behaviors documented. Review of the resident's psychiatric notes, completed by the NP, dated 12/6/24, showed: -Medications: duloxetine HCI 30 mg daily; -Subjective: he/she denies any actions that are intimidating and always says other people just be messing with him/her; -Discussed medication, as he/she had wanted over the summer, but says he/she was doing fine and just wants to move. The resident was however not helping with this, and he/she was completely able to find placement on his/her own. Appears to want everyone else to do these things, and complains when things aren't done his/her way; -Resident was always calm, polite, pleasant to me, but it always seems like he/she was just telling me what I want to hear and says he/she was always polite to everyone else. This however was not the case as several residents and staff say he/she was at times using foul and loud language; -Objective: The resident's thought content revealed no evidence of delusional ideation, obsessions, or any other preoccupations. The resident was alert and oriented x 3; -Plan: will follow monthly. Discussed signs of depression, anxiety, changes in cognition, when to notify staff of symptoms. Discussed symptom management. Practice stress management. Review of the resident's behavior tracking located on the MAR, dated 1/1/25 through 1/31/25, showed no behaviors documented. Review of the resident's progress note, dated on 1/3/25 at 7:37 P.M., showed the resident causing a disruption on hall. The resident yelling and cursing at staff d

Based on observation, interview, and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened both residents and staff members. Staff failed to develop and/or implement a care strategy that focused on behavior prevention through on-going Social Service counseling sessions when other options failed. After a behavior occurred, staff failed to closely monitor the resident to ensure the safety of other residents, failed to consistently report behaviors to the physician, and/or psychiatrist/psychiatric Nurse Practitioner (NP) as per policy. The facility failed to ensure Social Services and/or the interdisciplinary team (IDT) consistently followed up on the resident's behaviors in a timely manner. The resident's behaviors triggered one resident's PTSD (post-traumatic stress disorder, a mental health condition that can develop after experiencing or witnessing a traumatic event) and resulted in other residents feeling bullied and intimidated. Residents refused to go to activities or eat in the dining room to avoid being around the resident. The census was 120. The Administrator was notified on 3/3/25 at 11:53 A.M., of an immediate jeopardy (IJ) which began on 1/29/25. The IJ was removed on 1/30/25 as confirmed by surveyor on-site verification. Review of the facility's Behavior-Management policy, undated, showed: -Purpose: -To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the resident's quality of life; -To ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and service that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care; -Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: -a) Identifying residents whose behaviors may pose a risk to self and others; -b) Developing individual and practical care strategies based on assessed needs; -c) Implementing the behavior management program; -d) Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs; -The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program; -It is important to understand that behavior management is not behavior modification. Behavior management means the IDT seeks to accommodate the resident with behavioral problems as much as is practical in the facility; -When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.) Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s); -The facility must provide necessary behavioral health care and services which include: -a) Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; -b) Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being; -c) Providing meaningful activities which promote engagement and positive meaningful relationship between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being; -d) Providing an environment and the atmosphere that is conducive to mental and psychosocial well-being; -Procedure: -I. Assess Causal Factors: A. When a resident exhibits adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.), Licensed Nursing Staff will document the behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible casual factors and interventions attempted; B. Upon observing the adverse behavioral symptom, staff will do the following as indicated: i. Ensure the safety of the resident as well as all other residents; ii. Document notification of the Attending Physician; iii. Document notification of the resident's family and/or responsible party about the change in behaviors and the Attending Physician's response; iv. Document the incident on the 24-hour report; C. The Charge Nurse will assign a staff members(s) to monitor/shadow the resident as needed; i. Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility; D. Nursing Staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated: i. Date and time of behavior; ii. Location of resident when the behavior occurred; iii. Description of the behavior (e.g., what the resident said or did and if the behavior intensified); iv. Non-verbal cues (e.g., darting eyes may indicate anxiety or fear, crossed arms may signal withdrawal or fear, and tears may indicate sadness, frustration or fear); v. What seemed to cause the behavior; vi. Any interventions used and their effect; E. In assessing the resident for potential causal factors, Licensed Nursing Staff will consider the following factors and document their findings in the medical record; i. Physical conditions (e.g., pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence); ii. Environmental condition (e.g., inappropriate room temperature, noise, overcrowding); iii. Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition, financial concerns); iv. Medical conditions that require treatment; v. Mental health conditions, which may contribute to resident's behavior; F. It is also important for the facility to use an IDT approach that includes the resident, their family, or resident representative; -II. Implementation of Interventions to Alleviate Possible Causal Factors; A. Possible non-psychotherapeutic drug interventions to consider, include, but are not limited to: i. Physical comfort; ii. Environmental conditions; iii. Psychosocial stressors; iv. Medical conditions; B. In trying to manage the behavioral problem; i. Work to build a positive, trusting relationship with the resident; ii. Use effective verbal and non-verbal communication techniques; iii. Encourage independence in the resident; iv. Avoid arguing, having yes/no battles, or [NAME] with the resident; v. Redirect or divert the resident's attention to a positive topic, activity, or object; -III. Evaluation of Outcome of Non-Drug Interventions; A. In the evaluation of outcomes, Licensed Nursing Staff will do the following: i. Document observations, interventions and outcome; ii. Document the resident's progress or lack of progress on the shift/weekly nursing notes and interdisciplinary notes; iii. A Licensed Nurse will summarize the results of the medications and the behaviors on the monthly Behavioral Summary Form; B. Consider psychiatric consultation if appropriate. Review of the facility's Resident Council policy, revised on 6/2020, showed: -Purpose: To promote the exercise of a resident's right to organize and participate in resident groups at the Facility; -Policy: The facility encourages residents' involvement and input in the operation of the Facility through the Resident Council; -Responsibilities of the Resident Council: -Making recommendations for the improvement of resident services provided by the Facility; -Reviewing reports submitted to the Council and making recommendations and/or taking appropriate action; -Studying problem areas and making recommendations for their solution; -Maintaining minutes of all meetings and submitting a copy to the Administrator for review; -A Resident Council response form is utilized to track issues and their resolution; -If the Council raises an issue of concern, the Department responsible for the issue or service is responsible for addressing the item(s) of concern promptly; -The facility will respond in writing to written request or concerns of the resident council in a prompt and timely manner; -The Facility will respond to issues discussed by the Resident Council and may use Resident Council Department Response Form; -The Facility's Quality Assessment & Assurance Committee reviews the Resident Council minutes from the Resident Council as part of its quality review. Review of the facility's Resident Council Follow-Up form, showed: All complaints/concerns identified during resident council will be documented as a grievance on the grievance form. This will include a detailed description of the complaint. It will then be delegated to the appropriate department for resolution. This resolution will be documented on the grievance form as well. A designee will then meet with the resident to discuss the resolution and ensure all parties are satisfied. The completed grievance will then be forwarded to the Administrator for review and approval. These concerns will then be reviewed at the next resident council as Old Business to ensure that concerns have not persisted. Review of the Social Service Director (SSD) job description, undated, showed: -Position Description included: Responsible for identifying psychosocial, mental, and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs; -Principle Responsibilities: -Plans, organizes, implements, evaluates, and directs a comprehensive Social Services program; -Works with Social Services staff, IDT, and administration to promote and protect resident rights and the psychological well-being of all residents. Prevents and addresses resident/resident abuse; -Maintains accurate and timely documentation; -Participates in the development of a written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to be accomplished for those needs/issues, and the appropriate social worker interventions; -Works with the IDT and administration to promote and protect resident rights and the psychological well-being of each resident. Prevent and address resident abuse; -Document progress in meeting the psychosocial needs of residents; -Educate nursing personnel regarding the role of the social worker in the facility and the psychosocial needs of the residents; -Provide clinical interventions to address catastrophic events that occur during a resident's stay in the facility. Review of Resident #3's admission face sheet showed: -admitted [DATE]; -The resident was listed as his/her own responsible party. Review of the resident's progress notes, located in the electronic health record (EHR), dated 6/6/24 at 12:52 P.M., showed the resident arrived at 12:00 noon, alert and oriented x 4 (person, place, time and situation). Got off ambulance stretcher and walked to room with a steady gait. Review of the Guidelines for Resident Behavior, signed by the resident and co-signed by the SSD on 6/6/24, showed: -Any resident may exhibit problem behaviors, but the intent of the Guidelines is to address the volitional (done intentionally, not by accident) of those individuals who have the capacity to understand the consequences of their behaviors; -Resident Compliance: admission to a facility is based on a resident's need for care. A resident's compliance with his/her plan of care and cooperation with staff during the stay in the facility is encouraged; -General Conduct: residents are expected to treat staff, other residents with respect, dignity and privacy. Conduct must be consistent with accepted community standards, local, federal and state laws. Unacceptable conduct includes but is not limited to: physical abuse, verbal abuse. This conduct is not permitted on or about the facility; -Non-Compliance: if we determine that residents' behavior is contrary to these rules and is compromising their health care or that of other residents, these residents will be subject to administrative actions. Failure to comply with these rules may result in the initiation of the following administrative actions: A. The initiation of a Behavioral Management Plan between the resident and the facility. A Behavioral Management Plan should be developed under the guidance of trained professionals; B. Referral to local law enforcement agency; C. Discharge from the facility when the violations meet the thresholds of state and federal regulations (for example, if the violations are a danger to the resident or others). Review of the resident's care plan, located in the EHR, showed: -Problem, 6/6/24: Resident has a mood problem, depression. Goal: Resident will not experience any increase in signs and symptoms of mood disturbance. Interventions/Tasks: Administer medications as ordered. Behavioral health consult as needed. Communicate with resident regarding mood state and treatment. Encourage resident to express feelings. Encourage resident to participate in activities of choice. Encourage to maintain as much independence and control/decision making as possible. Notify medical provider of increased episodes of mood disturbance; -Problem, 6/13/24: Resident has a behavior problem. Resident was noted to speak rudely to roommate, eating off other residents' plates, verbally aggressive with staff, disrespectful to staff; -Goal: resident will have fewer episodes of behaviors through review date. Interventions/Tasks (6/13/24); -Approach, speak in calm manner. Behavioral health consults as needed. Communicate with resident regarding behaviors and treatment. Consult with Pastoral care, Psych services, and/or support groups. Minimize potential for behaviors by offering tasks that divert attention. Monitor behavioral episodes and attempt to determine underlying causes. Intervene as necessary to protect the rights and safety of others. Encourage not to curse or speak disrespectfully and/or aggressive to staff. Notify medical provider of increased episodes of behaviors. 6/14/24: Encouraged to speak to roommate respectfully and encouraged not to eat off of other resident's plates. Review of the resident's record showed there was no behavior management program or ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs documented. Review of the resident's progress note, dated 6/12/24 at 2:26 P.M., showed the resident's physician saw the resident at the facility. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/24, showed: -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: ability to express ideas and wants: understood; -Ability To Understand Others: understood; -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): behavior not exhibited; -Mobility Devices: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of high blood pressure, diabetes mellitus (high blood sugar) and depression. Review of the resident's medication administration record (MAR, a form where nurse documents medication administration and behavioral episodes) dated 6/6/24 through 6/30/24, located in the EHR, showed: -6/6/24: Duloxetine HCI (antidepressant) 30 milligrams (mg) daily; -Behaviors: Verbally aggressive with staff: occurred 1 time on the evening shift (6/13/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the evening shift (6/13/24); Review of the resident's progress notes, dated 6/13/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behavior on the evening shift of 6/13/24. Review of the resident's progress note, on 6/14/24 at 12:07 P.M., showed the SSD wrote the resident said he/she was here short term and was just waiting on his/her apartment to be approved. Resident rights were reviewed including the facility guidelines for behavior, drugs, and smoking. Review of the resident's MAR, dated 7/1/24 through 7/31/24, showed no behaviors documented. Review of the resident's progress note, dated 7/3/24 at 6:59 P.M., showed: -Resident had verbal disagreement with another resident, nursing staff present at the time, no contact made. Resident separated from the other resident. Resident was calm sitting outside in the smoking area listening to music; -No SSD or IDT follow-up documented. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 7/10/24, showed: -Diagnoses: post-traumatic stress disorder (a mental health disorder that can develop after witnessing a traumatic event), nicotine dependence, cocaine use (in remission), other specific personality disorders, and persistent mood disorder; -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up, says he/she was still trying to make the best of his/her situation. Decides he/she does not want medication to help him/her stop flipping out. Discussed trying to stay calm and walking away from conflict, which I am not sure he/she was completely on board with. Denies symptoms of depression or anxiety. Just mood swings he/she says; -Objective: resident was engaged with examiner in a cooperative and polite manner. Mobility was within normal limits. Stream of mental activity was logical, relevant, coherent, and goal directed; -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's progress notes showed: -7/11/24 at 6:22 A.M.: the resident had a verbal altercation with roommate. Resident was loud, disturbing, and using profane language. The resident slammed the door behind roommate; -7/11/24 at 10:29 A.M., IDT note (Administrator, former Director of Nursing (DON), SSD and Nursing Manager): verbal disagreement with roommate. The resident called roommate a racial slur. Roommate did not like this and told the resident so. The resident became upset when staff intervened. The resident left the room shutting the door loudly. The resident educated to be considerate of others feelings and preferences. The resident verbalized understanding; -7/11/24 at 3:04 P.M., completed by the SSD: spoke with the resident about his/her disagreement with roommate this morning. He/She said he/she closed the door but did not mean to slam it. Explained to him/her if he/she has a problem with his/her roommate just come and speak to them. Also spoke about changing rooms. He/She said he/she was happy with that; -7/13/24 at 11:17 A.M., documented by the Administrator: met with resident for psychosocial follow-up. Said he/she likes his/her new room and new roommates. Reinforced with resident that he/she must remain respectful with facility staff. Said he/she understands and was working on it. He/She feels that due to his/her size, he/she may come across as more upset than he/she actually was. Reeducated that he/she can bring any concerns to facility management, social service, this author, and will communicate any future needs of concerns to the appropriate parties; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP. Review of a Behavior Contract, dated 7/16/24, showed: -Behavior: resident has had several verbal outbursts with staff; -Goal (must be measurable): resident will learn to stop with the verbal outburst and speak in a calm manner. If this behavior continues, resident can be at risk for discharge from facility; -Date To Be Achieved: 10/16/24; -SSD signed the Behavior Contract on 7/16/24; -Resident refused to sign the contract. Review of the resident's progress note dated 7/16/24 at 2:06 P.M., and completed by the SSD, showed a care plan meeting was held with the resident to discuss verbal outbursts toward staff and other residents, and explain this is not a good fit for him/her. He/She continues to ask facility to give him/her another chance and he/she continues the same behavior. SSD has been asked to start looking for another facility. He/She gave SSD a few facilities to send his/her referral to. Review of the resident's care plan showed: -On 7/11/24, Observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs. Encourage to maintain as much independence and control/decision making as possible. Praise and indication of progress in behaviors; -On 7/29/24, Encourage to take all medications and notify physician of all refusals. Review of the resident's MAR, dated 8/1/24 through 8/31/24, showed: -Behaviors: Verbally aggressive with staff occurred 5 times on the day shift (8/3, 8/4, 8/7, 8/14, and 8/27), and cursing staff occurred 1 time on the evening shift of 8/23; -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (8/3, 8/4, 8/7, 8/24, and 8/27), and educated on reasons not to curse at staff on the evening sift of 8/23. Review of the resident's progress notes, dated 8/1/24 - 8/31/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behaviors on 8/3, 8/4, 8/7, 8/14, 8/23, or 8/27/24. Review of the resident's progress note, dated 8/7/24 at 12:00 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the resident's progress note, dated 8/10/24 at 1:20 P.M., completed by the SSD, showed the resident was informed during care plan meeting that was held that the facility was still trying to find him/her another facility, however no one has accepted him/her as of yet. They are still sending referrals out and once a facility had accepted him/her he/she will be informed. Review of the resident's progress note, dated 8/14/24 at 4:03 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the facility Resident Council meeting minutes, dated 8/15/24 at 2:00 P.M., showed: -Staff members present: the former DON, Activity Director (AD) and Activity Aide (AA) F; -18 residents attended, including: Resident #3, Resident #2, and Resident #14; -New Business: discussed Resident #3 was a bully. Always arguing with staff and peers; -There was no facility response to the Resident Council concerns regarding Resident #3's behaviors. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 8/27/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. He/She was still trying to make the best of his/her situation. Decides he/she does not want any further medication to help him/her from stop flipping out. Denies any symptoms of depression or anxiety at this time; -Objective: engaged with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's MAR, dated 9/1/24 through 9/30/24, showed; -Behaviors: -Verbally aggressive with staff: occurred eight times on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and four times on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Disrespectful to staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Cursing staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Educated on reasons not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24); -Encouraged not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24). Review of the resident's medical record, from 9/4/24 through 9/30/24, showed: -No documentation the resident's physician, psychiatrist and/or psychiatric NP were notified of the resident's behaviors after they occurred; -No documentation of SSD or IDT follow-up; -The care plan showed no new interventions/tasks implemented from 9/1/24 through 9/30/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others: behavior not exhibited; -Mobility Device: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: Supervision or touching assistance, independent. Review of the facility Resident Council meeting minutes, dated 9/20/24 at 10:00 A.M., showed: -Staff members present AD and AA F; -14 residents attended, including: Resident #3, Resident #2, Resident #4, and Resident #14; -Discussed: Activities spoke to Resident #3. He/She promised to stop bothering and cursing out staff and residents; -Resident Council Follow-Up completed by the former DON and signed on 9/24/24: Spoke to Resident #3 and he/she agreed to do better. Staff will keep watch. Review of the resident's behavior tracking located on the MAR, dated 10/1/24 through 10/31/24, showed; -Behaviors: -Verbally aggressive with staff: occurred 16 times on the day shift (10/8, 10/9, 10/10, 10/12, 10/13, 10/15, 10/16, 10/17, 10/22, 10/23, 10/24 and 10/26/24), and three times on the evening shift (10/23, 10/24 and 10/27/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff for all day and evening shift documented behaviors; -No behaviors identified on the evening shift on 10/22/24. Review of the resident's progress notes, from 10/1/24 through 10/31/24, showed: -On 10/22/24 at 7:48 P.M.: the resident noted yelling and cursing in the hallway walking from the front door, stating that they gone have to call the MF police because imma bust that MF down if they don't let me out this MF. They can't hold me no MF in here. They are treating us like we in jail and I've done my time. The resident educated on smoking times and policy. The resident acknowledged teaching, but stated he/she can sign out to smoke. The resident made aware that smoking on the front was prohibited. The resident stated we can't hold him/her hostage and stated his/her sister would be here to pick him/her up. The resident educated on signing out of the facility upon leaving. This nurse also spoke with the resident asking him/her to calm down and stop yelling and using profanity in such an aggressive tone in the hallway around all the other residents. The resident walked away and continued cursing, yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/22/24 at 8:27 P.M.: police called related to resident's behaviors. Police arrived and the resident appeared to be calm at this time. The resident continued to have other residents to come to his/her room and after one of the residents asked to leave, Resident #3 followed the other resident to that resident's room after being told it was after hours and resident's roommate are in bed and resting now and visiting was not allowed at this time. The resident stated, MOVE ME. Police called at this time, and arrived and resident calm stating I'm ok, y'all just want me to go off, and he/she walked away. Police stated the resident needs to be sent to the hospital for mental health behaviors and if needed call them back to assist with removing the resident from the facility. Physician called and new orders received to send resident out for behaviors and to follow up with psych immediately; -10/22/24 at 8:38 P.M.: the resident refusing to go to the hospital. Sitting up front at this time stating his/her sister in on his/her way; -No documentation the resident's physician was notified the resident refused to go to the hospital for his/her behaviors. No documentation the facility notified the physician the resident refused to go to the hospital as ordered; -10/23/24 at 5:39 P.M.: showed the resident continued to yell out in dining room cursing at staff and using profanity loud and in an intimidating tone to staff. Resident unhappy with meal and states They are feeding me like an animal so I'm going to act like an animal. Resident redirected on using inappropriate language in common areas and around all other residents. This nurse explained to resident this is disrespectful and unacceptable behavior. The resident continued to walk off yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/24/24 at 3:00 P.M.: the resident continued to yell, curse and be intimidating to staff and other residents. The resident educated on bullying and reminded that this is inappropriate behavior. The resident redirected and went on down the hall mumbling; -No documentation the resident's physician or psychiatrist/psychiatrist NP was notified; -Review of the resident's progress notes showed no SSD or IDT follow up regarding the resident's 10/22, 10/23, and 10/24/24. -No documentation regarding the resident's behaviors, except on 10/22, 10/23, and 10/24/24. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 10/19/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. Appears to be very particular, also has a big voice, tall. Asked him/her to not be as intimidating which he/she says he/she is just being him/her; -Objective: met with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's psychiatric NP notes, dated 10/1/24 through 10/31/24, showed: -10/22/24, late evening: Resident having disruptive behavior. Just recently saw the resident and will see on next visit. The resident repeatedly refuses to add additional medications. The resident constantly demanding and disruptive

Based on interview and record review, the facility failed to ensure one resident (Resident #102) received care consistent with professional standards to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). This resulted in the resident developing a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) prior to receiving treatment orders. In addition, facility staff failed to follow the wound care nurse practitioner's orders, resulting in the wound condition declining. The sample was eight. The census was 121. The Administer was notified of past non-compliance on 2/3/23. The facility has re/educated the nursing staff on skin observation, pressure relieving devices and off-loading; descriptively completing weekly skin assessments to include adding location of areas, and the wound care management policy to include entering orders, completing assessments within timely manner, and obtaining Wound Care Team orders immediately. The deficiency was corrected on 1/13/23. Review of the facility's Skin Care and Wound Management Overview Policy, undated, showed: -Policy: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment; -Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition. Resident/patient skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital; -Treatment: select the appropriate form: (A) Pressure ulcer documentation. Complete for pressure ulcers; (B) Skin impairment documentation. Complete for all skin impairment issues that require measurements to indicate if healing is occurring; obtain a physician's order; document treatment on the Treatment Administration Record (TAR). Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/23, showed: -Required extensive assistance of one staff for bed mobility and eating; -Required total assistance of one staff for toilet use, personal hygiene and bathing; -Had limited range of motion in one upper extremity and both lower extremities; -Diagnoses included: medically complex condition, dementia and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue); -At risk for developing pressure ulcer? Yes; -Number of Stage III pressure ulcers: One; -Number of Stage III pressure ulcers that were present on admission/reentry? One. Review of the resident's care plan, initiated 7/26/22 and revised on 10/25/22, showed: -Focus: Resident had impaired skin integrity, or was at risk for altered skin integrity due to impaired mobility, incontinence. admitted with sacral (coccyx, tailbone area) wound Stage II (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). Wound has healed -Goal: Resident will not exhibit complications from altered skin integrity (i.e., infection) through next review; -Interventions: administer treatments as ordered by medical provider; -Wound Care Team to treat and eval, undated. During an interview on 1/23/23 at 11:10 A.M. and 1/26/22 at 5:00 P.M., Wound Nurse A said the nurses on the floor do weekly skin assessments on all residents. If a nurse discovered a new wound, the nurse should assess the area. The nurse may measure the wound, but they do not stage the wound. The nurse should call the physican for treatment orders and notify the responsible party. The nurse should document their assessment and give a description of the wound including measurements if completed, document if the physican was notified and if any orders were received. The Wound Care Nurse Practitioner (NP) comes to the facility weekly and measures and stages the wounds. She also does the weekly documentation of the wounds. The facility's management team has access to the Wound Care NP notes, but the floor nurses do not have access. The floor nurse would not know if a wound was getting better or worse because they only have access to the treatment orders. Review of the resident's progress notes, dated 11/8/22 through 11/29/22, showed no documentation of a wound on the sacrum. Review of the resident's Wound Care NP notes, showed: -On 11/8/22, no wound on sacrum/coccyx; -On 11/29/22, showed: History of Present Illness (HPI): staff states the patient is no longer going to the wound clinic. Requesting the Wound Care NP to follow patient; -Assessment: Location: sacrum; -Type: pressure ulcer/injury: Stage III; -Wound bed description: 100% granulation tissue (new connective tissue); -Peri-wound (wound edges): normal; -Exudate (drainage): moderate; -Color: serosanguinous (yellowish drainage will small amounts of blood); -No measurements documented; -Plan: cleanse with wound cleanser, apply collagen powder (dissolves in the wound to form a protective gel), calcium alginate (helps absorb fluid in the wound), and cover with dry dressing, change daily and as needed. Review of the resident's TAR, dated November 2022, showed: -An order to apply sacrum Mepilex every other day for wound prevention, dated 10/21/2022, was discontinued on 11/2/22; -An order started on 11/5/22 and discontinued 11/29/22, to apply Mepilex every three days for wound prevention; -An order started on 11/30/22, for a wound on the sacrum, directed staff to cleanse with normal saline, apply collagen powder, calcium alginate, cover with dry dressing, change daily and as needed; -No treatment for any open wound to the sacrum/coccyx area prior to 11/30/22. Review of the resident's Wound Care Team notes, dated 12/21/22, showed: -Assessment: Location: sacrum; -Type: pressure/injury: Stage III; -Wound bed description: 70% granulation tissue, 10% necrotic (dead tissue) tissue and 20% slough (moist dead tissue) tissue; -Measurements: length 6.0 centimeters (cm) X width 3.5 cm X 0.2 cm; -Peri-wound: normal; -Exudate: moderate; -Color: serosanguinous; -Plan: cleanse with wound cleanser, apply silver alginate (antimicrobial, used in treatment of at risk or infected chronic wounds), cover with foam dressing, change daily and as needed; -Additional notes: stable. Review of the resident's Wound Care Team notes, dated 12/28/22, showed: -Assessment: Location: sacrum; -Type: pressure ulcer/injury: Stage III; -Wound bed description: 70% granulation tissue, 10% necrotic tissue and 20% slough tissue; -Measurements: 7.0 cm X 6.8 cm X 0.2 cm; -Peri-wound: normal; -Exudate: moderate; -Color: serosanguinous; -Plan: cleanse with wound cleanser, apply silver alginate, and cover with foam dressing change daily and as needed; -Additional notes: declined. Review of the Wound Care Team notes, dated 12/31/22, showed: -Assessment: Location: sacrum; -Type: pressure ulcer/injury: Stage III; -Wound bed description: 70% granulation tissue, 10% necrotic tissue and 20% slough tissue; -Measurements: 7.0 cm X 6.8 cm X 0.2 cm; -Peri-wound: normal; -Exudate: moderate; -Color: serosanguinous; -Plan: cleanse with wound cleanser, apply silver alginate, and cover with a foam dressing, change daily and as needed; -Additional notes: declined. Review of the resident's TAR, dated December 2022, showed: -An order for the sacrum, cleanse with normal saline, apply collagen powder, calcium alginate, cover with dry dressing, change daily and as needed: Documented as completed daily from 12/1 through 12/31/22; -The treatment order to cleanse with wound cleanser, apply silver alginate and cover with a foam dressing, change daily and as needed as ordered by the wound care team on 12/21, 12/28, and 12/31/22 was not transcribed to the TAR. Review of the resident's Wound Care Team notes, dated 1/2/23, showed: -Assessment: Location: sacrum; -Type: pressure ulcer/injury: Stage III; -Wound bed description: 60% necrotic tissue post debridement (manual removal of dead tissue): 50% necrotic, 40% slough, and 10% granulation; -Measurements: 6.7 X 6.8 X U (unable to determine); -Peri-wound: normal; -Exudate: large; -Color: serosanguinous and yellow; -Plan: cleanse with wound cleanser, apply Santyl (medicine that removes dead tissue from wounds so they can start to heal) and silver alginate, cover with a foam dressing, change daily and as needed; -Additional notes: declined, wound debridement. Review of the TAR, dated 1/1/23 through 1/10/23, showed: -An order for the sacrum, cleanse with normal saline, apply collagen powder, calcium alginate, cover with dry dressing, change daily and as needed: Documented as completed on 1/1 and 1/2/23, discontinued on 1/2/23; -An order started on 1/3/23, for sacrum: cleanse with normal saline, apply Santyl and calcium alginate to wound bed, cover with dry dressing change daily and as needed in the morning for wound care. The treatment order did not include the silver alginate or foam dressing as ordered by the wound NP. Review of the resident's progress notes, on 1/10/23 at 11:09 A.M., showed the resident was sent out to the hospital on referral from wound management NP with concerns of the residents sacral wound. During an interview on 1/26/23 at 1:32 P.M., Wound Nurse B said treatment orders are entered into the computer by the Wound Care Teams NP, unless the NP calls the facility and asks them to enter an order. Wound Nurse B had not seen the Wound Care NP notes and did not have a password to access the Wound Care NP notes until today. During an interview on 1/26/23 at 2:33 P.M., the Wound Care Team NP said she comes to the facility weekly to assess the resident's wounds. She was recently out for three weeks and another NP was filling in for her while she was out. The NP is made aware of any new wounds by facility staff. The facility had a problem in the past with the nurses failing to enter treatment orders into the computer. About three to six months ago she started entering the treatment orders, if she has access to the resident's medical record. If she does not have access to the resident's medical record, she will ask the staff to do it. After the orders are entered, the facility's staff should go into the computer and confirm the orders. The treatment listed under Plan should be the same treatment listed on the TAR. Calcium alginate and silver alginate are not the same medication. If the facility did not have a medication available, the nurse should call the NP for further orders. During an interview on 1/26/23 at 5:00 P.M., Wound Nurse A said the NP enters the treatment orders into the computer. The NP bases treatments on what supplies are available. After the orders are entered, the nurse needs to confirm the orders. If the orders entered into the system did not match what was on the Wound Care NP notes, the wound nurse should call the NP back to verify the orders and document it in the progress notes. During an interview on 1/26/22 at approximately 5:30 P.M., the Director of Nursing (DON) said the facility had a good wound care program. Wound Nurse B has been in this position about a month. The facility had identified concerns with wounds and documentation and began re/educating the staff on January 11 through January 13, 2023. The DON would expect for staff to follow the facility's policy and procedures. MO00212403

Based on observation, interview and record review, facility staff failed to follow the resident's diet orders for a resident on a puree diet. The resident had an order for a dysphagia puree diet and required supervision with eating. The activity assistant brought a whole donut into the resident's room, left the donut and did not verify the resident's diet order or ensure the resident had supervision while eating. This resulted in a choking incident for this resident (Resident #76). The census was 105. The administrator was notified on 1/27/22 at 3:15 P.M. of an Immediate Jeopardy (IJ), which began on 1/27/22. The IJ was removed on 1/28/22, as confirmed by surveyor onsite verification. During an interview on 1/28/22 at 10:32 A.M., the Dietary Manager said food provided by staff outside the dietary department, even if not on the written menu, is considered an alternate menu item. Activity staff provide their own snacks not obtained from the facility kitchen. These are alternates. Residents should always be provided food that is the proper texture and consistency. Review of the facility's diet Consistency Census Report, dated 1/27/22, showed four residents listed as receiving a dysphagia puree diet, to include Resident #76. Review of the facility's Activity Leader Position Description, dated June 2019, showed: -The position of activities leader provides individualized activity care and services for residents. This position functions as both a team member within the activities department and an interdisciplinary team member for an assigned unit(s) fostering team success. While focusing on delivery of quality care, the position must also manage assigned resources; -Job duties and responsibilities: -Leads a variety of activities: One on one and group activities on/off assigned unit(s), outside and/or in the community for a diversified population as assigned; -Provides supplies and equipment for residents to participate in individual activities as assigned; -Communicates and coordinates all plans for assigned actives with activity coordinator/activity director and other departments (schedules, food, room arrangements, escort assistance and transportation); -May assist residents with activities of daily living needs, i.e., transfer, toileting, feeding, etc.; -Qualification knowledge/skills and abilities: Must have the ability to make independent decision when circumstance warrant such action. Review of Resident #76's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/12/21, showed: -Cognitively intact; -Extensive assistance required for bed mobility, transfers, dressing and personal hygiene; -Total dependence on staff for locomotion on and off the unit and toilet use; -Supervision-oversight, encouragement or cuing required for eating; -Primary medical condition category stroke; -Diagnoses included diabetes and [CONDITION(S)]/[CONDITION(S)] (paralysis on one side of the body). Review of the resident's care plan, in use at the time of the survey, showed: -Focus initiated 12/5/20: Risk for stroke complications: -Goal: Will remain free of secondary complications; -Interventions: Monitor for signs/symptoms of aspiration. Monitor for signs/symptoms of dysphagia (difficulty swallowing); -Focus initiated 12/10/20: Resident has nutritional problems related to stroke, [CONDITION(S)], dysphagia, chronic kidney disease, vitamin D deficiency, acute kidney failure and high cholesterol: -Goal: Resident will maintain adequate nutritional status; -Interventions: Monitor meal intake, offer substitutions if provided meal is declined, position resident properly for eating/swallowing; Provide meals per diet order, regular dysphagia puree, thin liquids diet; -Focus initiated 12/18/20: The resident has impaired cognitive function: -Goal: Be able to communicate basic needs on a daily basis. Will maintain current level of cognitive function; -Interventions: Observe/document/report to medical provider any change in cognitive function, specifically change in decision making ability, memory, recall or general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; Provide a program of activities that accommodates abilities; -Focus initiated 2/20/21: Activities of daily living (ADL) self-care performance deficit, requires assistance with ADL, cognitive deficit, functional deficit. The resident is alert and able to communicate with staff: -Goal: Will maintain current level of function; -Interventions: Observe and anticipate resident's needs: Thirst, food, body positioning, pain and toileting needs. Requires physical assistance for oral intake. Has left side [CONDITION(S)]. Requires dysphagia puree diet; -Focus initiated 2/20/21: At risk for impaired communication related to stroke: -Goal: Resident is able to understand and verbalize basic communication with staff; -Interventions: Anticipate and meet needs. Observe for declines in communication. Observe/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed; -Focus initiated 5/13/21: The resident is dependent on nursing staff for activity engagement. Has forgetful and limited mobility: -Goal: Will show engagement in activity engagement. Forgetful and limited mobility; -Interventions: Assist with transport to activities as needed. Encourage attendance to entertainment programs, large and small groups, activities, volunteer demonstration and religious activities. Review of the resident's medical diagnoses list, showed diagnoses included stroke, [CONDITION(S)], dysphagia and dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) following stroke. Review of the resident's electronic physician order sheet (ePOS), for January 2022, showed: -An order dated 1/18/21, for regular diet, dysphagia puree texture. Thin consistency, super cereal (high calorie porridge) at breakfast for diet type; -An order dated 2/9/21, may allow moist mechanical soft solids as requested with CLOSE one on one supervisor, due to fast rate of intake; -An order dated 11/3/21, continue skilled speech therapy three times a day for four weeks to treat cognitive-linguistic deficits following recent change in status; -An order dated 11/26/21, discontinue skilled speech therapy due to plateau in progress. Review of the resident's speech therapy evaluation and plan of treatment, dated 7/14/21, showed: -Diagnoses: Stroke, dysphagia and cognitive communication deficit; -Short term goals: Resident will increase ability to safely swallow mechanical soft/chopped texture to within functional limits 10% verbal cues, 0% verbal cues and 0% tactile cues for implementation of compensatory strategies in order to safely consume least restrictive diet; -Long-term goal: Resident will improve swallow abilities to distant supervision as evidenced by ability to safely and efficiently swallow less restrictive diet with minimal signs and symptoms of oral dysphagia, coughing and/or wet vocal qualities post swallows in order to safely consume least restrictive diet; -Treatment approach may include: Treatment of swallowing dysfunction and/or oral function for feeding; evaluation of oral and pharyngeal (the part of the throat behind the mouth) swallow function; -Resident's goal: To eat better; -Current referral: Reason for referral: Resident referred to speech therapy due to exacerbation of decreased oral/pharyngeal function and cognitive impairment indicating the need for speech therapy to assess/evaluate least restrictive oral intake, enhance cognitive skills; -Intake/diet level: Puree consistencies, thin liquids, successive swallows; -Clinical bedside assessment of swallowing: Diet texture analysis: Soft diet-chopped = moderate; clinical signs and symptoms of dysphagia; anterior (front) spillage, biting cheek, excessive mastication (chewing) time, residue on palate (oral cavity) and/or tongue with clearance attempts and poor attention to task; -Behaviors impacting safety: Reduced attention to task, decreased safety awareness and poor self-monitoring skills; -Recommendations: Diet: puree consistency; liquids: thin liquids; supervision: distant supervision. Review of the resident's speech therapy notes, showed: -Date of service 7/15/21: Resident seen in room sitting upright in the wheelchair. Speech therapy presented trial tray of mechanical soft solids for lunch meal. Noted several impulsive rates of intake during meal and large bite sizes, requiring continuous verbal prompts for safe oral intake. The resident reported meat item chopped was too tough and attempted to expel food from the oral cavity following verbal request from speech therapy but was unable to expel food and ended up swallowing food times, indicating decreased safety awareness and increased risk for aspiration or choking. Resident presented with coughing towards end of session and attempted to place additional bites of solids in oral cavity while coughing, indicating poor safety awareness. Speech therapy requested the resident to perform additional swallows but required maximal verbal and tactile cues to refrain from continued oral intake; -Date of service 7/21/21: Resident in room sitting upright in wheelchair. The resident presented with severe impulsivity during meal, requiring constant verbal cues for slower rate of intake, setting down utensils between bites, clearance of oral cavity following each bite and liquid washes. Resident presented with adequate mastication, bolus manipulation and clearance of solids with mechanical soft solids, but due to severe impulsivity, the resident is unsafe with soft solids; -Date of service 8/13/21: Resident seen in room with trail of mechanical soft solids during session. Resident reported meat items being too difficult to masticate and expelled meat from oral cavity. Speech therapy removed meat items from tray and continued trail with side items. The resident consumed 75% of the side items served with meal, with moderate to maximal verbal cues for smaller bites/sips and slower rate of intake. Noted attempts to place additional bites of solids before clearance of previous bites, requiring verbal cues for clearance of each bite and use of liquids washes consistently. No noted signs or symptoms of airway penetration during meal but noted continued concerns for safety due to severe impulsive behaviors during intake without supervision. Noted poor carryover supervision from staff consistently, requiring continued diet downgrade due to need for maximal supervision with upgraded diets for safe oral intake. Staff reported not enough staff to monitor resident during all meals at this time; -Date of service 11/26/21: Resident seen in room sitting upright in wheelchair. Speech therapy updated resident on discharge plan and recommended for the resident to participate in activities in the facility following discharge of services for increased stimulation and continued use of visual aides and environmental aides for orientation and recall abilities. The resident verbalized agreement with recommendations. Speech therapy presented assessments to determine the resident's current cognitive status. The resident repeatedly reported having trouble focusing throughout assessment, likely impacting the resident's performance during assessment. The resident completed the brief interview for mental status and scored 11 out of 15, indicating moderate cognitive deficits. The resident also completed the St. Louis University Mental Status Examination and scored 14 out of 30, indicating severe cognitive deficits. The resident presented with difficulty processing information, as evidenced by need for self-talk and repetition of instructions. Review of the resident's Dietary Nutritional Assessment, dated 12/8/21, showed: -Diet: Dysphagia puree, thin liquids; -Swallowing disorders: No; -Dining skills: Limited assistance; -Potential for altered nutrition related to dysphagia as evidenced by need for mechanically altered diet. Observation on 1/27/22 at 10: 45 A.M., showed Activity Assistant DD propelled a cart down the hall and offered donuts to residents. At 10:53 A.M., a wet and gargled cough was audible in the hall. Observation down the hall, showed the resident sat in his/her room, up in a wheelchair and faced the door. There were no staff in the room at this time or in view of the resident. The bedside table was at his/her side. The resident coughed, held his/her neck, and appeared to choke. A donut and a cup of beverage sat on the bedside table, in reach of the resident. Certified Nursing Assistant (CNA) F immediately came down the hall and entered the resident's room, leaned the resident forward and patted his/her back as he/she told the resident, you're not supposed to have that. The resident was conscious and able to verbalize some, but with garbled speech. The resident swallowed the food item in his/her mouth and stopped coughing. At this time Registered Nurse (RN) I entered the room and asked the resident if he/she was ok and to open his/her mouth, then left the room. CNA F disposed of the donut and left the resident's room. During an interview on 1/27/22 at 10:56 A.M., the resident said that he/she just swallowed a big chunk of donut, but was ok. At 11:39 A.M., the resident remained up in a wheelchair in the room and was unable to say what type of diet he/she is on, but said they crush my pills. Review of the resident's progress notes, showed: -On 1/27/22 at 1:45 P.M., writer heard someone coughing and what sounded like choking. Writer walked into the resident's room and saw the CNA patting his/her back trying to get him/her to cough up the donut he/she had eaten. Resident eventually swallowed the donut. He/she remained conscience and was able to talk the entire time. Upon assessment, lungs are clear and oxygen levels within normal limits. No signs of distress noted; -Follow up note: At 2:36 P.M., physician called and made aware of event, new orders for speech therapy evaluation and treat, and STAT (immediate) chest x-ray two view. Resident's family called and message left. Awaiting call back; -On 1/27/22 at 6:32 P.M., family return call, made aware of event, no concern noted. Physician called and made aware of results of chest x-ray. No new orders noted. Review of the resident's Respiratory Data Gathering Tool, dated 1/27/21 at 2:21 P.M., showed: -Reason for review: Choking event; -Observed breathing pattern, normal; -Breath sounds, clear; -Description of cough, dry. Review of the resident's ePOS, showed: -An order dated 1/27/22, clarification order: Skilled speech therapy three times a week for four weeks for dysphagia; advance diet through modifications, instruct in use of strategies for safety with deglutition (the action or process of swallowing). Resident to remain on pureed diet/thin liquids; -An order dated 1/27/22, for chest x-ray, anteroposterior (AP, front to back view) and lateral (view from the side), STAT. Review of the resident's radiology results report, dated 1/27/22, showed: -Procedure: Chest, 2 views; -Date of service: 1/27/22; -Clinical information: Choked at lunch, shortness of break, lethargic (sluggish); -Results: The lungs are clear. During an interview on 1/27/22 at 11:46 A.M., the activity director said there are only two activity staff. Activity Assistant DD is the only one at the facility today. During an interview on 1/27/22 at 12:09 P.M., CNA F said the resident is on a puree diet. During an interview on 1/27/22 at 12:14 P.M., Activity Assistant DD said he/she had only been employed since December 2021. He/she provides activities, such as passing food three to four times a week. He/she does not know which residents are on diet restrictions. There is a list of residents, from dietary, that activity staff use to know diets. He/she does not have one today and he/she is still getting familiar with the residents. He/she was not told today who can and cannot have a donut. He/she just asks the resident and if they say they want one, he/she will go ahead and give it if he/she is familiar with the resident, otherwise, he/she will ask staff. If a choking incident were to occur, he/she would call the nurse and ask for assistance immediately. If a resident was on a puree diet, he/she could not provide them with a donut. During an interview on 1/27/22 at 12:40 P.M., the activity director said the activity department gets a list from dietary, maybe every six weeks, to show residents with diet restrictions. The list is usually on his/her desk and accessible to the activity staff. He/she does not have a list today, but will get it and will give Activity Assistant DD the list before he/she passes popcorn today. During an interview 1/27/22 at 1:15 P.M., RN I said he/she is the nurse assigned to the resident and responded to the choking incident. He/she assessed the resident after the incident and the resident was okay and stable at this time. He/she was not aware of the resident's diet prior to the incident. He/she is an agency nurse and it is his/her first day at the facility today. He/she saw the activity staff passing donuts. The activity staff did not ask about the resident's diet restrictions. During an interview on 1/27/22 at 1:39 P.M., the Medical Director said he/she would expect staff to follow diet orders including diets with specialized textures, including a dysphagia-pureed diet. Residents who had a stroke or dementia may be put on a pureed diet. If a resident was not eating well, the facility would have speech therapy evaluate them. The Medical Director did not recall if the resident had any problems with swallowing. One of the risks of giving a resident a whole donut, who is on a pureed diet, is the resident could aspirate (when something enters the lung or airway by accident). During an interview on 1/27/22 at 1:51 P.M., the Director of Nursing (DON) said she is not sure what training activity staff receive. The resident's diet is listed in the electronic medical record. Anytime activity staff do anything with food, they should meet with the nurse manager or herself. Lists of diets are bad because they may be old. No activity staff approached her today regarding donuts, to learn the resident's diets. If activity staff are passing food and do not know a resident's diet, they should meet with the unit manage or herself. Residents on a pureed diet cannot have a donut. The risk could include choking. She was not made aware of any choking incident today and that is something she would expect staff to inform her of. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation.

Based on observation, interview and record review, the facility failed to follow their skin care and wound management policy by failing to assess, document and follow the nurse practitioner's (NP) orders to treat one resident's right ischium pressure ulcer. In addition, the facility failed to assess and update one resident's physician and/or NP when there was deterioration noted to the resident's pressure ulcer. The facility identified three residents with pressure ulcers. All three residents were sampled and problems were found with two. (Residents #2 and #3). The census was 103. Review of the facility Skin Care and Wound Management Overview policy, dated 7/1/2016, showed: Definition: -A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction; Policy: -The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment; -Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition. Resident/patient skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital; -Skin care and wound management program includes, but is not limited to: a) Analysis of facility pressure ulcer data for quality improvement opportunities; b) Application of treatment protocols based on clinical best practices standards for promoting wound healing; c) Daily monitoring of existing wounds; d) Identification of residents/patients at risk for development of pressure ulcers; e) Implementation of prevention strategies to decrease the potential for developing pressure ulcers and/or wounds; Procedure/Prevention: -Complete the Braden Scale (an assessment used to determine a resident's risk for developing pressure ulcers) on admission, weekly for three weeks, quarterly and with change of clinical condition to identify risk indicators; -Complete an Admission Observation Tool. Identify areas of shin impairment and pre-existing signs; -Identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Risk factors may include: Friction and shear, healed pressure ulcer, decreased activity, decreased sensory perception, increased moisture on skin, impaired blood flow, infection; -Develop a care plan with individualized interventions to address risk factors; -Communicate risk factors and interventions to the care giving team; -Evaluate for consistent implementation of interventions and effectiveness at clinical meeting; -Modify and document goals and interventions as indicated; -Communicate changes to the care plan; Treatment: -Select and complete the appropriate form: a) Pressure Ulcer Documentation. Complete for all pressure ulcers; b) Skin Impairment Documentation. Complete for all skin impairment issues that require measurement to indicate if healing is occurring; -Review and select the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -Obtain a physician order; -Communicate interventions to caregiver team; -Document treatment on the Treatment Administration Record (TAR); -Monitor and document progress; -Evaluate effectiveness of interventions during the clinical meeting; -Modify goals and interventions as indicated; -Communicate changes to the care giving team. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/22/21, showed: -admitted [DATE]; -Adequate hearing; -Moderately impaired vision; -Ability to express ideas and wants: Understood; -Understanding verbal content: Understands; -Clear speech - distinct intelligible words; -Brief Interview of Mental Status (BIMS, a cognitive assessment) score of 15, a score of 13-15 indicates cognitively intact; -Rejection of care: Not exhibited; -Total dependence of two (+) persons required bed mobility, dressing, and toilet use; -Transfers: Activity did not occur; -Total dependence of one person required for personally hygiene and bathing; -Functional limitation in range of motion of both upper and lower extremities; -Mobility device: Wheelchair; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Risk of pressure ulcers?: Yes; -Unhealed pressure ulcers?: Yes; -Number of Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). May also present as an intact or open/ruptured blister): 1; -Number of Stage III pressure ulcers (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 and tunneling): 1; -Number of unstageable pressure ulcers (Unstageable pressure ulcer: Slough and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin): 1. Review of the resident's care plan, dated 7/12/21, showed: -Daily assistance from nursing staff for activities of daily living care. Has limited mobility due to [CONDITION(S)] and is incontinent; -Alert and able to communicate needs; -Requires two staff assistance for bed mobility, bathing, dressing and two staff assistance with a hoyer lift (mechanical device that transfers a resident unable to bear weight); -Skin inspection per facility protocol. Observe for redness and open areas and report to the charge nurse; -Limited mobility to upper and lower extremities. Needs to be in alignment at all times while in wheelchair and in bed. Provide skin care with each incontinent episode and with daily care; -At a higher risk for impairment to skin integrity/pressure ulcers related to spinal cord injuries with limited mobility; -History of pressure ulcer to the right heel, two small superficial open areas to top of right foot and deep tissue injury (DTI: Unstageable pressure ulcer, suspected deep tissue injury in evolution) to left heel; -Daily skin inspection during care; -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Treatments per physician orders; -Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Weekly Skin Check form, completed by a facility nurse, dated 8/10/21 at 1:46 A.M., showed right toes and a DTI to the left heel. Review of the resident's Skin Grid Pressure form, completed by a facility nurse, dated 8/11/21, showed a DTI to the left heel, but no pressure ulcer on the right ischium. Review of the resident's Weekly Skin Check form, dated 8/17/21 at 1:46 A.M., showed: -Are there any skin conditions or changes, ulcers, or injuries?: Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented skin check?: No; -No other documentation noted on the form. Review of the resident's wound care company's notes, completed by the NP and dated 8/17/21, showed: -New wound on the right ischium (the lower right buttock) with orders requested; Wound/Ulcer #2: -Location: Right ischium; -Wound bed description: 70% granulation (pink or red tissue with shiny, moist, granular appearance) and 30% slough; -Measurements: Length - 2.5 centimeters (cm) by 5.0 cm depth - unable to determine (utd); -Peri-wound (tissue surrounding the pressure ulcer): Normal; -Exudate (drainage): Small; -Color: Serosanguineous (thin like water with a red or pink tinge); -Plan: Treatment is cleanse with wound cleanser, apply collagen (a protein used to stimulate wound healing), apply Medi-Honey (a treatment used for [CONDITION(S)] and and wounds, has antibacterial properties and supports the removal of necrotic tissue), cover with foam dressing, change daily and PRN (as necessary); -Goals: Promote healing and comfort. Review of the facility Weekly Wound Log, dated 8/18/21, showed: -Right ischium: Unstageable, 2.5 cm by 5.0 cm by utd. Treatment: Collagen/Medi-Honey/Foam dressing. Review of the resident's TAR (where nurse initial a treatment has been completed as ordered), dated 8/1/21 through 8/31/21, showed: -8/17/21: An order to clean the right buttocks (right ischium) with wound cleanser and cover with foam dressing daily. The order did not include collagen and Medi-Honey. The order was discontinued (dc'd) on 8/24/21; -Staff initialed the treatment (without collagen and Medi-Honey) as completed from 8/17/21 through 8/24/21; -8/25/21: Clean right ischium with wound cleanser, apply Medi-Honey and collagen powder, cover with a foam dressing daily; -Staff initiated the treatment as completed on 8/25/21. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Braden Observation Tool (an assessment used to determine a resident's risk of developing pressure ulcers), dated 8/23/21, showed a score of 12 or high risk to develop pressure ulcers. Review of the resident's wound care company notes, completed by the NP and dated 8/24/21, showed: Wound/ulcer #2: -Location: Right ischium; -Wound bed description: 30% granulation and 70% slough; -Measurements: Length 3.5 cm by width 4.5 cm by depth utd; -Peri-wound: Normal; -Exudate: Small; -Color: Sero-sanguineous; -Plan: Cleanse with sound cleanser, apply collagen, apply Medi-Honey, cover with foam dressing daily and PRN; -Additional notes: Stable. Review of the facility Weekly Wound Log, dated 8/25/21, showed: -Right ischium: Unstageable, 3.5 cm by 4.5 cm by utd. Treatment: Collagen/Medi-Honey/Foam dressing. Review of the resident's progress notes, showed: -8/25/21 at 12:45 P.M., the resident was found unresponsive and sent to a local hospital for evaluation and treatment; -8/29/21 at 12:30 P.M., the resident returned with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge orders, dated 8/29/21, showed and order for Santyl (an ointment that removes dead tissue from a wound or pressure ulcer), apply to affected area once daily. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Undated: Santyl to the buttock every morning as directed for wound healing; -No start or discontinue date noted on order. Review of the resident's Skilled Documentation form, completed by a facility nurse, dated 8/30/21 at 12:30 P.M., showed: Wound Care Information: -Does the resident have a wound?: Yes; -Location of resident's wounds: Feet and buttock; -No descriptions documented (size, drainage, color, etc was documented); -Wounds followed by wound care company. Review of the resident's Skilled Documentation form, dated 8/31/21 at 12:30 P.M., showed: Wound Care Information: -Does the resident have a wound?: Yes; -Location of resident's wounds: Bilateral feet and buttock; -No descriptions documented; -Wounds followed by wound care company. Review of the resident's wound care company notes, completed by the NP and dated 8/31/21, showed: CC: Follow-up of multiple wounds; Wound/ulcer #2: -Location: Right ischium; -Type: Pressure ulcer/injury: Unstageable (depth obscured); -Wound bed description: 30% granulation and 70% slough; -Measurements: Length 2.5 cm by width 5.5 cm by utd; -Peri-wound: Normal; -Exudate: Small; -Color: Sero-sanguineous; -Plan: Cleanse wound with wound cleanser, apply collagen, apply Medi-Honey, cover with foam dressing to change daily and PRN; -Additional notes: Stable. Review of the resident's TAR, dated 8/1/21 through 8/31/21, showed: -8/29/21: Santyl ointment to the right buttock (right ischium) every night shift; -8/29/21: No initial the treatment had been completed; -8/30/21: A dc date of 8/30/21 for the Santyl; -No other treatment documented for the right ischium for August. Review of the resident's POS, dated 8/30/21 through 8/31/21, showed no treatment order for the right ischium. Review of the resident's TAR, dated 9/1/21 through 9/9/21, showed: -No treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility Weekly Wound Log, dated 9/1/21, showed: -Right ischium: Unstageable, 2.5 cm by 5.5 cm by 0.3 cm. Treatment: Collagen/Medi-Honey/Foam Dressing. Review of the resident's Skilled Documentation form, dated 9/5/21 at 8:30 A.M., showed: Wound Care Information: -Does the resident have a wound?: Yes; -Location of resident's wounds: Multiple areas. Review of the resident's Braden Observation Tool, dated 9/5/21 at 12:30 P.M., showed a score of 14 or moderate risk to develop pressure ulcers. Review of the resident's progress notes, showed: -9/5/21 at 12:30 P.M.: Re-admission from hospital. readmitted with toxic [CONDITION(S)] and wounds. Wounds: Left/right heel and right buttocks; -9/6/21 at 1:56 P.M.: Resident's physician made aware of buttock wound 2.0 cm by 0.5 cm. New order: Wound physician to evaluate and treat. Triple antibiotic ointment ([MEDICATION(S)]) applied and dry dressing. Review of the resident's wound care company's notes, completed by the NP and dated 9/7/21, showed: Wound/ulcer #2: -Location: Right ischium; -Wound bed description: 30% granulation and 70% slough; -Measurements: Length 3.0 cm by width 4.2 cm by depth utd; -Peri-wound: Normal; -Exudate: Small; -Color: Sero-sanguineous; -Plan: Cleanse wound with wound cleanser, apply collagen, apply Medi-Honey, cover with foam dressing daily and PRN; -Additional notes: Improving. During an interview on 9/9/21 at 8:20 A.M., Nurse B said the facility currently had no treatment or wound nurse. Each nurse on duty is responsible to complete resident treatments. The NP from the wound company comes to the facility every Tuesday. Observation and interview on 9/9/21, showed: -At 8:30 A.M., Resident #2 lay in bed on a low air loss mattress (special mattress used for wound/pressure ulcer prevention or healing). The resident had dressings on both feet and he/she said the nurse put the dressings on yesterday. The resident said he/she also had a pressure ulcer on his/her buttock, but the nurse did not put a dressing on that one. Sometimes a nurse will change the dressing and sometimes they won't. Sometimes it's every two days, sometimes longer. It depends on the nurse that is working; -At 8:42 A.M., the resident lay in bed for a skin assessment. Certified Nursing Assistant (CNA) C positioned the resident onto his/her left side showing a pressure ulcer on his/her buttock covered by yellow slough and black necrotic tissue, The pressure ulcer had no dressing. The CNA said this was the first time this morning he/she saw the resident. He/she had the resident yesterday and the resident did not have a dressing on his/her buttock. Yesterday around 10:00 A.M., he/she gave the resident a shower, then laid the resident down. He/she told Nurse A, who was on duty yesterday as well as today, the resident had a shower and was ready for his/her treatments. When he/she came in yesterday at 1:00 P.M., to get the resident up in his/her wheelchair, the resident still did not have a dressing on the right ischium, but had dressings on his/her feet. He/she did not tell the nurse again and got the resident up. He/she thought since the nurse had done the dressings to the feet there must have been a reason the nurse chose not to do the dressing on the right ischium. During an interview on 9/9/21 at 8:50 A.M., Nurse A said although he/she completed the treatments to the resident's feet on 9/8/21, he/she probably forgot to complete the treatment on the resident's right ischium. Although there was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she had not put the order on the TAR because he/she is usually too busy. He/she did not know how other nurse's would know the resident had a treatment on the right ischium if the order was not on the TAR. He/she was not certain whether other nurses were doing the treatment or not. Review of the resident's progress note, dated 9/9/21 at 11:06 A.M., and completed by Nurse A, showed he/she applied Santyl ointment and a dry dressing to the resident's buttock. The pressure ulcer measured 5.0 cm by 5.0 cm, with necrotic tissue in the center. Review of the resident's POS, showed an order dated 9/9/21, for Santyl to the buttock check daily and PRN. On 9/10/21, the Santyl order was dc'd and the treatment order for the right ischium was changed on the POS and TAR to: Cleanse the pressure ulcer with wound cleanser, apply collagen and Medi-Honey and a foam dressing daily and PRN. During a telephone interview on 9/14/21 at 11:30 A.M., the NP said Nurse D, who normally makes rounds with her but has not been there for the past few weeks, first brought the resident's right ischium pressure ulcer to her attention on 8/17/21. She gave Nurse D an order to cleanse with wound cleanser, collagen, Medi-Honey and cover with a foam dressing daily and PRN. He/she was not aware the order on the TAR, from 8/17/21 through 8/24/21, did not include the collagen and Medi-Honey, which could explain why he/she was not seeing improvement. She expected her treatment orders to be followed. On 9/1/21 and 9/7/21 there was a dressing covering the pressure ulcer. On 9/17/21, Nurse A told her there was currently no order for the right ischium. She told Nurse A the order should be to cleanse the pressure ulcer with wound cleanser, apply collagen and Medi-Honey and cover with a foam dressing daily and PRN which was the same order she gave to Nurse A on 9/1/21. She was not aware the treatment did not show up on the TAR until 9/10/21. She was not aware the resident had stated the treatment was not being completed daily. During a telephone interview on 9/15/21 at 10:50 A.M., the Director of Nurses (DON) said the TARs are in the electronic medical system. The TAR prompts a nurse as to what treatment should be completed during what shift. If a treatment is not on the TAR, a nurse may not know a treatment is ordered. She reviewed the resident's August and September 2021 TARs. Nurse D took the order from the NP on 8/17/21 and was responsible to add it to the orders, including the TAR accurately. She could not be certain if the nurses had been completing the order as the NP intended, or if they were just cleansing the pressure ulcer and applying a foam dressing from 8/17/21 through 8/24/21. When the resident returned on 8/29/21, Nurse E added the order for Santyl per the hospital discharge orders. Nurse F discontinued the Santyl order as the facility substitutes collagen and Medi-Honey for Santyl. Nurse F failed to contact the physician to discontinue the Santyl and begin the Medi-Honey and collagen and failed to add the order on the POS or TAR. She spoke to Nurse A who made rounds with the NP on 9/1/21 and 9/7/21. Nurse A should have added the NP orders to the TAR. Because there were no orders in place from 8/30/21 through 9/10/21, she cannot be certain the treatment was being done or being done as ordered. When a nurse completes the readmission skin assessment, she expects there to be a complete description of any wound or pressure ulcer with the exception of the stage of the pressure ulcer. The NP from the wound care company stages the pressure ulcers. During a telephone interview on 9/15/21 at 11:05 A.M., Nurse A said he/she had been doing the resident's treatment daily using Medi-Honey and collagen although he/she had no proof since the order was not on the TAR. CNA C should have told him/her he/she forgot to do the treatment on 9/8/21, prior to getting the resident up. He/she failed to put the NP's orders on the TARs because he/she gets busy and forgets. He/she said he/she works every Tuesday, Wednesday and Thursday and every other weekend. She said a nurse working on his/her days off would probably not know the resident had a treatment because it is not on the TAR. 2. Review of Resident #3's admission MDS, dated [DATE], showed: -admitted [DATE]; -BIMS score of 10, a score of 08-12 indicates moderate impairment; -Total dependence of two (+) persons required for bed mobility, transfers, dressing and toilet use; -Total dependence of one person required for personal hygiene and bathing; -Always incontinent of bladder; -[CONDITION(S)] (an opening into the colon or large intestine through the abdomen); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Risk of pressure ulcers?: Yes; -Unhealed pressure ulcers?: Yes; -Number of Stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling): 1. Review of the resident's Braden Observation Tool, dated 7/2/21, showed a score of 16 or low risk to develop pressure ulcers. Review of the resident's care plan, completed on 7/8/21, showed: -Impaired cognition function, short and long term memory loss; -The care plan did not address wounds or pressure ulcers. Review of the facility Weekly Wound Log, dated 9/1/21, showed the resident had one pressure ulcer on the coccyx (area in the center and at the top of the buttocks directly below the small of the back). Review of the resident's progress note, dated 9/6/21 at 3:10 P.M., showed the resident has a moisture rash located on his scrotum. Physician notified. [MEDICATION(S)] powder (an antifungal medication) was applied as ordered. Review of the resident's POS, showed an order dated 9/7/21, for [MEDICATION(S)] powder apply to scrotum in the evening. Review of the resident's Skin Grid Non-Pressure, and Skin Grid Pressure forms, dated 9/8/21, showed no documentation regarding the resident's scrotum. Review of the resident's Braden Observation Tool, dated 9/8/21, showed a score of 14, or moderate risk to develop pressure ulcers. Review of the resident's TAR, dated 9/1/21 through 9/30/21, showed: -[MEDICATION(S)] powder to the scrotum every evening shift. The treatment had been initialed as completed on 9/7, 9/8 and 9/9. Observation on 9/10/21, showed: -At 6:26 A.M., the resident lay in bed. CNA G assisted to reposition the resident for a skin assessment that showed three open areas on the resident's scrotum with approximately 50% brown necrotic tissue. The CNA said the areas were like that yesterday, Thursday, as well. The nurse's know about the areas. He/she (the CNA) had had been putting Triad cream (a moisture barrier) on the resident's scrotum. Observation on 9/10/21 at 8:05 A.M., showed the resident lay in bed. Nurse E said he/she was aware of the open areas. There seemed to be more drainage today. She had been putting [MEDICATION(S)] powder on the open areas. He/she had not called the physician or NP to inform them the area on the scrotum had opened up with necrotic tissue. The nurse measured the entire area that contained the three open areas and it measured 4.6 cm by 7.5 cm. During an interview on 9/10/21 at 8:30 A.M., CNA H said he/she took care of the resident two days ago on Wednesday. The resident's scrotum had a blister on it, but there were no open areas. He/she told the nurse who came in and put an ointment on it. He/she could not recall what nurse though. During an interview on 9/10/21 at 10:55 A.M., the DON said she looked at the open areas. They measured 4.0 cm by 4.0 cm, 2.0 cm by 2.0 cm and 2.0 cm by 2.0 cm. She identified the open areas as excoriation. Review of the resident's progress notes, from 9/7/21 through 9/10/21, showed no documentation of when the moisture related tissue damage on the resident's scrotum opened, forming the three open areas with necrotic tissue. During a telephone interview on 9/14/21 at 11:30 A.M., the NP said she had only seen the area on the resident's scrotum on 9/7/21, and it appeared to be a moisture related wound, not pressure ulcer related. She gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not know where the order for [MEDICATION(S)] powder came from, but that would work as well. Today, the resident had been sent to [CONDITION(S)] so she was unable to see the resident's scrotum. The DON showed her a picture. She noticed the open areas with necrotic tissue and she would no longer consider that to be moisture related and would now classify the areas as pressure ulcers. During a telephone interview on 9/15/21 at 10:50 A.M. the DON said she expects staff to notify the physician or the wound company NP when a wound or pressure ulcer shows deterioration. Only nurses should be applying treatments to a wound or pressure ulcer, not the CNAs. 3. During a telephone interview on 9/14/21 at 11:06 A.M., the NP said she does not access facility electronic medical records including the TARs, when she is in the facility. She does not complete a body assessment of the residents she sees. She relies on facility staff to let her know if there is a new wound or pressure ulcer. The facility can and should contact her anytime there is a new wound or pressure ulcer or a change in a wound or pressure ulcer. 4. During a telephone interview on 9/15/21 at 2:00 P.M., the Medical Director said when a resident is admitted or readmitted he expects nurses to document a description of the wound or pressure ulcer and for a treatment order to be obtained. If an order is discontinued, he would expect staff to contact the physician or wound company NP for a new order. Orders should be placed on the POS and TAR as ordered by the physician or wound company NP. This information should be documented per current standards. If a pressure ulcer or wound is deteriorating, the facility should contact the physician or wound company NP to determine if a new treatment should be started.

Based on interview and record review, the facility failed to provide necessary behavioral health care services for three residents, with known substance abuse problems, to address their drug use problems. On [DATE], Resident #1 was sent to the hospital for [CONDITION(S)] (slow heart rate) and a change in cognition/orientation. At the hospital, he/she tested positive for [MEDICATION(S)] (a powerful synthetic opioid) and opioids. On [DATE], Resident #3, had a change in condition and a drug screen was ordered, due to recent behavior and mental status change. On [DATE], he/she was suspected of a possible drug overdose, [MEDICATION(S)] (used to treat an overdose in an emergency) was administered and he/she was transferred to the emergency room (ER) for evaluation. He/she returned that same day with a positive drug screen for [MEDICATION(S)], opioids and [MEDICATION(S)] (a controlled substance used to treat anxiety and panic disorder). On [DATE] Resident #2 went out on leave of absence (LOA). On [DATE], he/she was suspected of distributing illicit drugs to other residents and admitted to illicit drug abuse of xanny ([MEDICATION(S)]) bars and heroin. Resident #1 consumed some of the drugs, overdosed and had to be revived with [MEDICATION(S)]. Resident #4 was admitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice has the potential to affect the 12 residents the facility identified as currently having a substance abuse related diagnosis. The sample was four and problems were found with all four (Residents #1, #3, #2 and #4). The census was 114. The administrator was informed on [DATE] at 12:05 P.M. of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Resident Substance Abuse in Facility policies and standard procedures, revised on [DATE], showed: -Scope: This policy is applicable to all adult living centers; -Definitions: -Abused substances: for the purpose of this policy, is meant to imply drugs consumed by any route that have no medical use or drugs that are prescribed by a physician for other persons, or route or schedule; Abused substances may also include alcohol; -FDA: Food and Drug Administration: a federal agency of the United States that resides under the Department of Health and Human Services and is responsible for protecting and promoting public health. The FDA is the branch that assigns drugs/medications/substances to their level of use (Schedule I-IV) including uses, contraindications and safety information; -Illicit drug: For the purpose of this policy, a drug that is potentially dangerous, has a high potential for abuse and has no currently accepted medical use; medication/drugs/substances in any form that is considered within the FDA's Scheduled I drugs; -Schedule I classification of drugs: substances assigned by the FDA to this level have no current accepted use in medical practice and are considered to be highly addictive in nature (examples include but not limited to heroin and other illegal or illicit substances); -Possession: having, owning or controlling an item of property in room, on the person or within the vicinity of the resident; -Substance Abuse: for the purpose of this policy, is meant to imply a condition or state in which a person is consuming drugs by any route that have no medical use (including schedule I drugs) or consuming prescription drugs that are prescribed by a physician that is intended for another person, or consumed in a different route or schedule; -Under-the-influence or an altered state of consciousness (ASC): for the purpose of this policy, is understood to mean residents whose actions differ from their normal waking state at baseline which may include those who are behaving erratically or who are unusually drowsy or unresponsive as a result of consuming drugs or alcohol. Supportive evidence may include the smell of alcohol on the resident's breath or body, white powder substances near the nose and mouth and/or drug paraphernalia on or near the resident; -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to staff when substance abuse is confirmed or suspected in a resident and not intended to be a step by step procedure. Each resident will be provided care based on their individual medical and emotional needs and on their physical ability to self-perform or have assistance to perform the operations. A facility may admit a resident who has a history or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Being under the influence of illicit or illegal drugs or alcohol places the resident at risk for overdose, falls, and respiratory depression and places other residents at risk for injury by a resident under the influence of illicit or illegal drugs or alcohol. The facility will safeguard the resident under the influence of illicit or illegal drugs to the extent possible, as well as provide a safe environment for other residents, staff and visitors. This may include up to discharge of the substance abusing resident; -Procedure: -I. Information: -Inform residents and/or their responsible party of this substance abuse policy upon admission. For suspected or known substance abusers consider obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -II. Management of Acute Episodes: -In the event a resident is found to be under the influence of abused substances, administer [MEDICATION(S)] per instructions on the label; -III. Providing for Other Resident's Safety: -A: Provide an observation for other residents for their well-being and safety as substance abusers do not always abuse alone; -B: Include residents in the safety observation, but not limited to those that: -May have similar substance abuse issues or history of substance abuse; -May be a roommate, currently or formerly of the resident abusing substances; -Residents who may have been seen together recently, in the last few hours; IV. Follow up care for a resident abusing substances: -A: When feasible and when the resident is medically and mentally stable, the nurse will provide education to the resident/responsible party including but not limited to: -Safety of self and others during abuse episodes; -That possession of drugs and/or drug paraphernalia is not permitted while a resident in the facility; -Resident may be given a 30 day discharge notice upon first offense; -B: Care Plan and Education; -Provide options for treatment available to resident/representative including but not limited to psychological evaluation and/or counseling and medical evaluation and/or counseling. Care plan resident specific triggers for abusing drugs, if known; V. Repeated substance abuse episodes, if applicable: -Residents found to be under the influence of drugs/substances or in possession of drug paraphernalia after repeated episodes will be subject to a 30 day notice of discharge provided to the resident/responsible party; VI. Documentation; -Education to the resident and responsible party regarding substance abuse policy; -Provide information regarding potential 30 day discharge for repeat episodes; -Provide education and document regarding safety of self and others including staff. 1. Review of Resident #1's medical record, reviewed on [DATE], showed: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed on [DATE], discharged to an acute hospital. Review of the resident's nurse's notes, showed: -Note dated [DATE] at 11:37 P.M., At approximately 9:00 P.M., the Nurse came into patient room. Resident was in his/her chair unresponsive. Couldn't obtain blood pressure. Resident showed labored breathing. 911 called. Performed jaw thrust and sternum rub until paramedic arrived; -Note dated [DATE] at 10:47 P.M., Called the hospital at approximately 4:00 P.M. Requested resident update. Resident is now oriented. Toxic screening is positive for [MEDICATION(S)] and opioids. Resident is now lethargic and sleeping. Family member informed; -Note dated [DATE] at 10:05 P.M., charge nurse notified Director of Nursing (DON) via phone for resident alleging he/she was provided an illegal substance from a certified nursing assistant (CNA) DON reported to facility and reviewed hospital labs and immediately notified law enforcement. Resident transferred to the emergency roiagnom on [DATE], for [CONDITION(S)] and change in condition/orientation. Upon return to the facility on [DATE], resident confided in Charge Nurse that he/she received a powdery substance from the CNA which he/she believed caused his/her change in condition. CNA was immediately suspended pending investigation. Resident denies any drug usage since hospitalization . State agency notified. Emergency contact and MD notified. Social Services to follow up in the A.M. Education provided on illicit drug use and possible adverse reactions. Resident verbalized understanding. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Did not exhibit any behaviors; -Independent, no help or staff oversight at any time for locomotion on and off the unit; -No psychological therapy received. Review of the resident's progress notes, showed: -SSW B note, dated [DATE] at 2:34 P.M., resident came into the office to talk about the incident that happened over the weekend which lead to him/her being sent to the hospital. Resident stated he/she was hurt because he/she felt that he/she and the CNA were better than that. He/she asked why did he/she do that to hurt me. I asked the resident how is he/she feeling today and he/she said he/she is taking it one day at a time. I explained to him/her I have to do three day IFU (Follow up); -SSW B note, dated [DATE] at 8:21 A.M., resident is alert and oriented to person, place and time and is able to make his/her needs known. He/she remains in the facility for long-term. His/her family is support system while he/she is in here and talks to them on a daily basis. The resident remains a full-code which means if he/she goes into [CONDITION(S)], he she wants CPR. His/her assessment was done and he/she is cognitively intact; -No further social services or nurses notes regarding the incident on [DATE]. Review of the resident's Care Plan, revised on [DATE], showed: -Focus: Resident tested positive for substance ([MEDICATION(S)]) causing overdose; -Goal: Will continue to maintain expectations as determined through assessment for compliance with treatment plan through next review; -Interventions: Law enforcement notified, social services to follow-up with rehab services. During an interview on [DATE] at 9:23 A.M., Social Services Worker (SSW) A and SSW B said no services were offered to Resident #1 after the incident occurred on [DATE]. Review of the facility's investigation, dated [DATE], showed: Resident #1 was found unresponsive in his/her room on Friday, [DATE] at 9:00 P.M. 911 was called and resident was transferred to the hospital. Resident was admitted with the initial diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On Monday, [DATE], resident readmitted to the facility during the evening. Upon readmission, resident confided to charge nurse charge nurse that prior to discharge on ,d+[DATE], he/she had ingested what he/she believed to be heroin. He/she told the charge nurse that he/she obtained the heroin from a staff member. The charge nurse immediately called the DON, who completed a self-report through the DHSS portal. The DON also called the police and made a report. An Officer responded but was unable to give a case number. The staff gave a hand written statement and left the building suspended pending investigation. Further review of the resident's progress notes, showed a social services note, dated [DATE] at 3:15 P.M. SSW A spoke with the resident about celebrating New Year and that we don't want you taking any drugs or medication that is not prescribed, because your medication and drugs do not mix. He/she stated he/she learned a lesson from what happened the last time and he/she will not be doing any drugs period. Review of the resident's psychiatric assessment, dated [DATE], showed he/she was an everyday smoker, denies use of alcohol and other substances, has a history of cannabis use. Further review of the resident's nurse's notes, dated on [DATE] at 1:13 P.M., the resident suspected of illicit drug use evidenced by lethargy, sweating, and flight of ideas. Resident required [MEDICATION(S)] and admitted to consuming heroin and [MEDICATION(S)]. Resident refused transport to the ER and showed no signs and symptoms of distress. Law enforcement dispatched with interviews performed by a detective and officer. Physician notified with orders to discontinue as needed narcotics. Family notified and reported to facility to speak with resident. Provided illicit drug use and facility policies. Resident verbalized understanding. Further review of the resident's care plan, updated on [DATE], showed: -Focus: Staff has found it difficult to assist the resident with abstaining from recreational drug use. The resident has had several episodes of drug use with one episode resulting in an overdose. Drug screen positive for marijuana. Drug screen positive for [MEDICATION(S)] and opiates. The resident admitted to heroin use and ingesting [MEDICATION(S)] not provided by a physician. The resident has refused inpatient drug treatment; -Goal: The resident will understand the need to abstain from mind altering substances through the next review date; Interventions: Resident educated related to drug abuse policy/behavior contract issued and monitored at smoking time. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Using Illicit Drugs in the Facility. Resident admits to using heroin; -Goal: Resident agrees not to use any controlled substances, illicit drugs or alcohol on our premises. Should you violate this contract, you will be at risk for immediate discharge; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. During an interview on [DATE] at 12:00 P.M., Resident #1 said on [DATE], his/her roommate (Resident #4) entered into their room and told the resident he/she needed to check on his/her girl/boyfriend (Resident #2). When the resident arrived to Resident #2's room, he/she saw Resident #2 sitting in his/her wheelchair nodding. Resident #1 saw five buttons in his/her mouth. Resident #1 told Resident #2 to lay some down. According to Resident #1, Resident #2 had a bag with crack cocaine, heroin and doorman (Resident #1 described doorman as an agent used to dilute the heroin). Resident #1 ingested some of the heroin and placed the bag filled with the illegal substances into his/her pocket. He/she could not recall what happened next. The facility staff issued [MEDICATION(S)]. On the day of the incident, Resident #1, Resident #2 and Resident #4 broke down the heroin Resident #2 brought into the facility. Resident #2 obtained the heroin from a family member when he/she went on a leave of absence. Resident #1 said it was a large amount of heroin, and it was supposed to be for personal use. He/she did not know if Resident #2 planned to sell the heroin or crack. Resident #1 said he/she had used heroin for years and had not planned on stopping. He/she used on occasion with Resident #2 and Resident #3 and Resident #4. About a week ago, he/she witnessed Resident #3 in his/her room with staff, being revived. He/she approached Resident #3 the following day and asked what happened. Resident #3 told him/her that he/she used heroin. Resident #1 told Resident #3 to share the next time. Resident #1 said this was not the first time he/she used in the facility but could not recall the other incidents. Other residents were able to bring drugs into the facility and sell them to other residents. He/she refused to name the other residents. During an interview on [DATE] at 9:35 A.M., Nurse E said he/she had only been at the facility for two days when the incident occurred on [DATE], during the early morning hours. He/she was not familiar with the residents at all. At approximately 4:00 A.M., Nurse E did rounds and discovered Resident #1 in Resident #2's room asleep. He/she woke the resident up and explained he/she could not be in the resident's room. At the time, Nurse E did not suspect any suspicious activity. He/she returned to the room and saw Resident #1 rinsing out a bowl at Resident #2's sink. He/she looked down and saw what looked like a bag of candy. Upon further inspection, Nurse E saw one bag with green pills and two additional bags with white pills. He/she obtained a glove and picked up the items and saw the bags contained illegal substances and secured the items in the nurse's medication room. Nurse E contacted the DON for further instructions. While he/she waited for the DON, Nurse E continued to check on Resident #1 and Resident #2. Nurse E was not familiar with the residents and did not know if they had known issues with drugs. During an interview on [DATE] at 9:00 A.M., Nurse C said the drugs were discovered by Nurse E when he/she arrived on the scene. He/she was asked to assist by the DON. Resident #1 was administered [MEDICATION(S)] and was aroused. Resident #1 was known to abuse drugs while at the facility. During an interview on [DATE] at 9:15 A.M., Nurse D said he/she observed Resident #1 after he/she was issued [MEDICATION(S)]. The resident refused to go to the hospital. The resident was known to abuse drugs. This was not the resident's first time requiring [MEDICATION(S)]. 2. Review of Resident #3's medical record, showed: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 12:30 P.M., the medical director said upon admission, he orders a psychiatric evaluation be completed when a resident has known substance abuse issues. The evaluation would determine what care is needed. Further review of the resident's medical record, showed no psychiatric evaluation completed in the facility. Review of the resident's admission MDS, dated [DATE], showed: -admitted on [DATE], from an acute hospital; -Cognitively intact; -Exhibited no behaviors; -Independent with locomotion on the unit; -Used a wheelchair. Review of the resident's psychiatric evaluation, provided by the facility and completed by a hospital, dated [DATE], showed the resident denied the use of alcohol or drugs. Review of the resident's nurse's notes, showed: -On [DATE] at 8:15 A.M., the resident was found in a fetal position on the floor of his/her room. The roommate said the resident laid him/herself on the floor. Staff attempted to help the resident up on his/her feet and into the bed. The resident was very unstable on his/her feet and was being combative. The physician was called and ordered to hold all narcotic medication. The resident is to be monitored and if condition gets worse, the resident is to be sent to the hospital; -On [DATE] at 1:00 P.M., an order was received from the physician to have a drug screening done due to patient's recent behaviors and mental status changes. Patient agreed to allow labs to be drawn when he/she sat and spoke with the social worker. Review of the resident's social service note, showed on [DATE] at 4:28 P.M., the SSW B spoke to the resident about using illegal drugs on company ground. The resident was still in denial about using the drugs. SSW B went over the substance abuse and behavior contract with the resident and he/she agreed and signed the agreement. SSW B informed the resident they would have to find him/her somewhere to go. The resident said he/she would call a family member to pick him/her up. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Substance Abuse -Goal: Agree not to use controlled substances and will not bring any drugs or alcohol in the facility or accept any drugs or alcohol from outside sources; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. Further review of the resident's nurse's notes, showed on [DATE] at 5:48 P.M., the resident was suspected of illicit drug use and possible overdose requiring the use of [MEDICATION(S)] and transfer to the hospital for an evaluation. The resident returned with a positive drug screen for [MEDICATION(S)], opioids and [MEDICATION(S)]. Education provided on illicit drug use and facility policies. Resident has chosen to leave the facility against medical advice. Review of the resident's care plan, updated on [DATE], showed: -Focus: Suspected drug abuse. The resident displayed behaviors of those associated with possible drug abuse; -Goal: The resident will have fewer episodes of behaviors through the review date; -Interventions: Behavior health consultation, as needed, monitor behavior episodes and attempt to determine underlying causes and notify medical provider of increased episodes of behaviors; -Focus: The resident is at risk for demise related to substance use disorder. The resident's drug screen was positive for [MEDICATION(S)]; -Goal: The resident will abstain from mind altering substances while a resident at the facility through the review date; -Interventions: Educate resident on following the prescribed treatment regimen and leave of absence policy. Encourage the resident to express feelings regarding addiction. Encourage support system of family and friends and evaluate the resident for the following symptoms; stumbling, nodding off even when standing or in mid conversation, incoherent speech, erratic behavior, slurred speech, rambling, nervous, jerky movements and eating candy. Offer drug abuse treatment program and refer to psych services/counseling/support services as needed. During an interview on [DATE] at 12:00 P.M., Resident #1 said he/she used heroin, along with Resident #3. Resident #1 could not recall the exact date, but said about a week ago, Resident #3 told him/her he/she ingested heroin and staff had to assist. Resident #3 used heroin provided by Resident #2 on [DATE]. During an interview on [DATE] at 9:00 A.M., Nurse C said he/she arrived on the scene on [DATE], during the early morning and was instructed to assist. Resident #3 was administered [MEDICATION(S)] but was difficult to arouse. She then did a sternum rub and the resident was still difficult to arouse. Emergency medical services (EMS) arrived and the resident was transported to the hospital. The resident was admitted to the facility with known issues with substance abuse. During interviews on [DATE] at 9:00 A.M. and [DATE] at 2:23 P.M. and [DATE] at 11:00 A.M., the administrator said Resident #3 admitted he/she obtained the drugs from Resident #2. When Nurse E reported the incident, he/she mistakenly said Resident #1 was in Resident #3's room. However, it was discovered while investigating that Resident #1 was actually in Resident #2's room and Resident #3 was given drugs by Resident #2. After Resident #1 was aroused, he/she told staff Resident #3 was involved. Resident #1 was near Resident #3's room during the investigation. Staff entered into the room and administered [MEDICATION(S)]. The resident was sent to the hospital for further evaluation and treatment. He/she returned the same day and left the facility against medical advice. 3. Review of Resident #2's admission MDS, dated [DATE], showed: -admitted on [DATE], from an acute hospital; -Cognitively intact; -Exhibited no behaviors; -Locomotion on and off the unit occurred only once or twice. Set up from staff required; -Used a wheelchair. Review of the resident's nurse's note, dated [DATE] at 8:17 P.M., showed the resident was observed receiving items through the front door from a visitor. Screener performed inventory of items, finding suspected illicit drugs. Law enforcement notified and confirmed capsules contained heroin. Law enforcement packaged capsules as evidence. Social Services reviewed policy with resident. Education provided on drug policy and adverse risks related to recreational drug use. Medical doctor and emergency contact made aware. Resident placed on one on one observation for 48 hours. Psychiatric consult ordered. Resident refused urine sample and denies actual drug use. The resident refused to identify visitor. Review of the resident's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated [DATE], for a psychiatric evaluation. Further review of the resident's medical record, showed no psychiatric evaluation completed. During an interview on [DATE] at 1:36 P.M., the DON said the resident refused a psychiatric evaluation. Review of the resident's Concern Form, dated [DATE], showed: -Description of Concern: Resident had a visitor bring him/her something. The screener at the door did an inventory on the items and found illegal drugs (heroin). Resident refused to name the family member; -Notify DON, social services and administrator; -Actions to Resolve the Concern: Resident was educated on the company policy in drugs and safety. Resident stated that he/she didn't need help because that wasn't drugs. During an interview on [DATE] at 9:23 A.M., SSW A and SSW B said no services were offered to Resident #2 after the incident on [DATE]. Further review of the resident's nurse's notes, showed: -On [DATE] at 4:25 P.M., leave of absence with family; -On [DATE] at 1:59 P.M., the resident was suspected of distributing illicit drugs to other residents and verbally admitted to illicit drug abuse. Resident states he/she no longer has any drugs because he/she passed them out to pay off debt he/she had with other residents. Resident states he/she consumed xanny bars and heroine. Resident consented to room and person check which did not reveal any substances. Resident refused hospital transfer for evaluation. No signs and symptoms of distress. Resident refuses skin and vital assessment. Resident placed on one on one observation to rule out acute reaction to drug use. Physician notified with orders to discontinue prescription narcotics. Social services currently providing psychosocial follow-up; -On [DATE] at 4:15 P.M., SSW B spoke to the resident about using illegal drugs on facility grounds and he/she did admit to using the drugs. Social worker read and went over the substance abuse contract and behavior contract with him/her and he/she agreed to sign them. The social worker explained to the resident that staff needed to find somewhere for him/her to go immediately and to call someone to come get him/her. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Substance Abuse; -Goal: Agree not to use any controlled substance and will not bring any drugs or alcohol in the facility or accept any drugs from outside sources; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. During an interview on [DATE] at 11:25 A.M., Resident #4 said Resident #2 left the facility the day before the incident ([DATE]) and obtained the drugs. He/she observed the drugs and saw [MEDICATION(S)], crack cocaine, heroin and doorman. On [DATE], he/she told Resident #1 to check on his/her boy/girlfriend (Resident #2). Resident #1 used the drugs with Resident #2 and tried to hide the drugs in his/her pocket, but they fell out. Resident #4 denied using substances that morning but said he/she had used opioids while a resident at the facility and regularly smokes marijuana. He/she received marijuana from another resident in the facility, but refused to name the resident and would not confirm if the resident was still at the facility. During an interview on [DATE] at 12:00 P.M., Resident #1 said on [DATE], his/her roommate (Resident #4) came in to their room and told Resident #1 he/she needed to check on his/her girl/boyfriend (Resident #2). When the resident got to the Resident #2's room, he/she saw Resident #2 sitting in his/her wheelchair nodding. Resident #1 saw five buttons in his/her mouth. Resident #1 told Resident #2 to lay some down. According to Resident #1, Resident #2 had a bag with crack cocaine, heroin and doorman. He/she ingested some of the heroin and placed the bag filled with the illegal substances into his/her pocket. He/she could not recall what happened next. The facility staff issued [MEDICATION(S)]. On the day of the incident, Resident #1, Resident #2 and Resident #4 broke down the heroin Resident #2 brought into the facility. Resident #2 obtained the heroin from a family member when he/she went on a leave of absence. Resident #1 said it was a large amount of heroin, and it was supposed to be for personal use. He/she did not know if Resident #2 planned to sell the heroin or crack. He/she said other residents were able to bring drugs into the facility and sell them to other residents. He/she refused to name the other residents. During an interview on [DATE] at 9:35 A.M., Nurse E said he/she had only been at the facility for two days when the incident occurred on [DATE], during the early morning hours. He/she was not familiar with the residents at all. At approximately 4:00 A.M., Nurse E did rounds and discovered Resident #1 in Resident #2's room asleep. He/she woke the resident up and explained he/she could not be in the resident's room. At the time, Nurse E did not suspect any suspicious activity. He/she returned to the room and saw Resident #1 rinsing out a bowl at Resident #2's sink. He/she looked down and saw what looked like a bag of candy. Upon further inspection, Nurse E saw one bag with green pills and two additional bags with white pills. He/she obtained a glove and picked up the items and saw the bags contained illegal substances and secured the items in the nurse's medication room. Nurse E contacted the DON for further instructions. While he/she waited for the DON, Nurse E continued to check on Resident #1 and Resident #3. Nurse E was not familiar with the residents and did not know if they had known issues with drugs. During an interview on [DATE] at 3:45 A.M., CNA J said he/she was present when the drugs were found in Resident #2's room. Nurse E confiscated the drugs and secured them in the nurse's cart. He/she was familiar with all three residents involved. Resident #1 was the only one who required assistance from nursing. The others were independent. CNA J witnessed all three residents, during the night shift, ambulating throughout the facility behaving strangely. During an interview on [DATE] at 9:15 A.M., Nurse D said the incident occurred on [DATE], during the night shift, but earlier during the morning. When he/she arrived, the DON told him/her to assist with the residents. Resident #2 was in his/her room. He/she was alert and refused [MEDICATION(S)]. During an interview on [DATE] at 11:00 A.M., the administrator confirmed the drugs were discovered in Resident #2's room, next to Resident #1's wheelchair. Resident #2 refused [MEDICATION(S)]. He/she admitted to obtaining the drugs from a family member on [DATE], and distribut

Based on interview and record review, the facility failed to provide protective oversight for three residents (#1, #3, and #2) out of a sample of 4 residents, with known substance abuse issues, by not ensuring the residents were safe from illegal drugs brought into the facility and used by residents. On [DATE], Resident #1 was sent to the hospital for [CONDITION(S)] (slow heart rate) and a change in cognition/orientation. At the hospital he/she tested positive for [MEDICATION(S)] (a powerful synthetic opioid) and opioids. On [DATE], Resident #3, had a change in condition and a drug screen was ordered, due to recent behavior and mental status change. On [DATE], he/she was suspected of a possible drug overdose, [MEDICATION(S)] (used to treat a drug overdose in an emergency situation) was administered and he/she was transferred to the emergency room (ER) for evaluation. He/she returned the same day with a positive drug screen for [MEDICATION(S)], opioids and [MEDICATION(S)] (a controlled substance used to treat anxiety and panic disorder). On [DATE], Resident #2 went out on leave of absence (LOA). On [DATE], he/she was suspected of distributing illicit drugs to other residents and admitted to illicit drug abuse of xanny ([MEDICATION(S)]) bars and heroin. Resident #1 consumed some of the drugs, overdosed and had to be revived with [MEDICATION(S)]. This deficient practice has the potential to affect the 12 residents the facility identified as currently having a substance abuse related diagnosis. The census was 114. The administrator was informed on [DATE] at 12:05 P.M. of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Resident Substance Abuse in Facility policies and standard procedures, revised on [DATE], showed: -Scope: This policy is applicable to all adult living centers; -Definitions: -Abused substances: for the purpose of this policy, is meant to imply drugs consumed by any route that have no medical use or drugs that are prescribed by a physician for other persons, or route or schedule; Abused substances may also include alcohol; -FDA: Food and Drug Administration: a federal agency of the United States that resides under the Department of Health and Human Services and is responsible for protecting and promoting public health. The FDA is the branch that assigns drugs/medications/substances to their level of use (Schedule I-IV) including uses, contraindications and safety information; -Illicit drug: For the purpose of this policy, a drug that is potentially dangerous, has a high potential for abuse and has no currently accepted medical use; medication/drugs/substances in any form that is considered within the FDA's Scheduled I drugs; -Schedule I classification of drugs: substances assigned by the FDA to this level have no current accepted use in medical practice and are considered to be highly addictive in nature (examples include but not limited to heroin and other illegal or illicit substances); -Possession: having, owning or controlling an item of property in room, on the person or within the vicinity of the resident; -Substance Abuse: for the purpose of this policy, is meant to imply a condition or state in which a person is consuming drugs by any route that have no medical use (including schedule I drugs) or consuming prescription drugs that are prescribed by a physician that is intended for another person, or consumed in a different route or schedule; -Under-the-influence or an altered state of consciousness (ASC): for the purpose of this policy, is understood to mean residents whose actions differ from their normal waking state at baseline which may include those who are behaving erratically or who are unusually drowsy or unresponsive as a result of consuming drugs or alcohol. Supportive evidence may include the smell of alcohol on the resident's breath or body, white powder substances near the nose and mouth and/or drug paraphernalia on or near the resident; -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to staff when substance abuse is confirmed or suspected in a resident and not intended to be a step by step procedure. Each resident will be provided care based on their individual medical and emotional needs and on their physical ability to self-perform or have assistance to perform the operations. A facility may admit a resident who has a history or diagnosis of substance abuse. However, residents may not possess, use or provide any illicit drugs or abuse drugs in any manner, and may not have drug related paraphernalia in their possession while a resident in the facility. Being under the influence of illicit or illegal drugs or alcohol places the resident at risk for overdose, falls, and respiratory depression and places other residents at risk for injury by a resident under the influence of illicit or illegal drugs or alcohol. The facility will safeguard the resident under the influence of illicit or illegal drugs to the extent possible, as well as provide a safe environment for other residents, staff and visitors. This may include up to discharge of the substance abusing resident; -Procedure: -I. Information: -Inform residents and/or their responsible party of this substance abuse policy upon admission. For suspected or known substance abusers consider obtaining a physician's order to provide [MEDICATION(S)] (brand name [MEDICATION(S)] - used to treat narcotic overdose in an emergency situation) in the event of an emergency -II. Management of Acute Episodes: -In the event a resident is found to be under the influence of abused substances, administer [MEDICATION(S)] per instructions on the label; -III. Providing for Other Resident's Safety: -A: Provide an observation for other residents for their well-being and safety as substance abusers do not always abuse alone; -B: Include residents in the safety observation, but not limited to those that: -May have similar substance abuse issues or history of substance abuse; -May be a roommate, currently or formerly of the resident abusing substances; -Residents who may have been seen together recently, in the last few hours; IV. Follow up care for a resident abusing substances: -A: When feasible and when the resident is medically and mentally stable, the nurse will provide education to the resident/responsible party including but not limited to: -Safety of self and others during abuse episodes; -That possession of drugs and/or drug paraphernalia is not permitted while a resident in the facility; -Resident may be given a 30 day discharge notice upon first offense; -B: Care Plan and Education; -Provide options for treatment available to resident/representative including but not limited to psychological evaluation and/or counseling and medical evaluation and/or counseling. Care plan resident specific triggers for abusing drugs, if known; V. Repeated substance abuse episodes, if applicable: -Residents found to be under the influence of drugs/substances or in possession of drug paraphernalia after repeated episodes will be subject to a 30 day notice of discharge provided to the resident/responsible party; VI. Documentation; -Education to the resident and responsible party regarding substance abuse policy; -Provide information regarding potential 30 day discharge for repeat episodes; -Provide education and document regarding safety of self and others including staff. 1. Review of Resident #1's medical record, reviewed on [DATE], showed: -The resident was admitted on [DATE]; -Diagnoses included seizures, poisoning by other opioids-accidental, major depression and anxiety. Review of the resident's Discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed a [DATE] discharge to an acute hospital. Review of the resident's nurse's notes, showed: -A note dated [DATE] at 11:37 P.M., showed at approximately 9:00 P.M., the nurse came into resident's room. Resident was in his/her chair and was observed to be unresponsive. The nurse couldn't obtain a blood pressure. The resident showed labored breathing. 911 was called. The nurse performed jaw thrust and sternum rub until the paramedic arrived. -A note dated [DATE] at 10:47 P.M., called the hospital at approximately 4:00 P.M. Requested resident update. Resident is now oriented. Toxic screening is positive for [MEDICATION(S)] and opioids. Resident is now lethargic and sleeping. A family member had been informed. -A note dated [DATE] at 10:05 P.M., showed the charge nurse notified Director of Nursing (DON) via phone, for resident alleging he/she was provided an illegal substance from a certified nursing assistant (CNA). DON reported to facility and reviewed hospital labs and immediately notified law enforcement. Upon return to the facility on [DATE], resident confided in Charge Nurse that he/she received a powder substance from the CNA which he/she believed caused his/her change in condition. CNA was immediately suspended pending investigation. The resident denied any drug usage since hospitalization . State agency notified.(DHSS) Resident's emergency contact and medical doctor (MD) were notified. Social Services to follow up in the A.M.(morning). Education provided on illicit drug use and possible adverse reactions. Verbalized understanding. Review of the quarterly MDS, dated [DATE], showed the resident to be: -Cognitively intact; -Did not exhibit any behaviors; -Independent, no help or staff oversight at any time for locomotion on and off the unit; -No psychological therapy received. Review of the resident's progress notes, showed: -Social service worker B's (SSW) note, dated [DATE] at 2:34 P.M., showed the resident came into the office to talk about the incident that happened over the weekend which lead to him/her being sent to the hospital. The resident stated that he/she was hurt because he/she felt that he/she and the CNA were better than that. He/she asked why did he/she do that to hurt me. I asked the resident how is he/she feeling today and he/she said he/she is taking it one day at a time. I explained to him/her I have to do a three day IFU (Follow up); -A SSW B note, dated [DATE] at 8:21 A.M., showed the resident is alert and oriented to person, place and time and is able to make his/her needs known. He/she remains in the facility for long-term. His/her family is support system while he/she is here and talks to them on a daily basis. The resident remains a full-code, which means if he/she goes into [CONDITION(S)], he/she she wants Cardio Pulmonary Resuscitation (CPR). His/her assessment was done and he/she is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15; -No further social services or nurse's notes regarding the incident on [DATE]. Review of the resident's Care Plan, revised on [DATE], showed: -Focus: The resident tested positive for substance ([MEDICATION(S)]) causing overdose; -Goal: He/She will continue to maintain expectations as determined through assessment for compliance with treatment plan through next review; -Interventions: Law enforcement will be notified, social services will follow-up with rehab services. Review of the facility's investigation, dated [DATE], showed: Resident #1 was found unresponsive in his/her room on Friday, [DATE] at 9:00 P.M. 911 was called and resident was transferred to the hospital. Resident was admitted with the initial diagnosis of [CONDITION(S)]. On Monday, [DATE], resident readmitted to the facility during the evening. Upon readmission, resident confided to charge nurse that prior to discharge on [DATE], he/she had ingested what he/she believed to be heroin. He/she told the charge nurse that he/she obtained the heroin from a staff member. The charge nurse immediately called the DON, who completed a self-report through the DHSS portal. The DON also called the police and made a report. An officer responded, but was unable to give a case number. The staff, CNA O, gave a hand written statement and was suspended pending investigation. He/She left the facility Review of CNA O's hand written statement, dated [DATE], showed: I haven't gave nobody nothing in this nursing home. During an interview on [DATE] at 10:28 A.M., the administrator and DON said after CNA O gave a hand written statement, he/she was suspended pending an investigation. They had repeatedly attempted to reach out to the staff member to obtain a more in-depth interview, but he/she never responded and was terminated. Review of the resident's psychiatric assessment, dated [DATE], showed he/she was an everyday smoker, denies use of alcohol and other substances, has a history of cannabis use. Further review of the resident's nurse's notes, dated [DATE] at 1:13 P.M., showed he/she was suspected of illicit drug use evidenced by lethargy, sweating, and flight of ideas. Resident required [MEDICATION(S)] and admitted to consuming heroin and [MEDICATION(S)]. Resident refused transport to the emergency room and showed no signs and symptoms of distress. Law enforcement dispatched with interviews performed by a detective and officer. The physician ordered the facility to discontinue as needed (prn) narcotics. The family was notified and they reported to the facility to speak with the resident. Provided illicit drug use and facility policies. Resident verbalized understanding. Further review of the resident's care plan, updated on [DATE], showed: -Focus: Staff has found it difficult to assist the resident with abstaining from recreational drug use. The resident has had several episodes of drug use with one episode resulting in an overdose. The drug screen was positive for marijuana, drug screen positive for [MEDICATION(S)], and opiates. The resident admitted to heroin use and ingesting [MEDICATION(S)], not provided by a physician. The resident has refused inpatient drug treatment; -Goal: The resident will understand the need to abstain from mind altering substances through the next review date; -Interventions: Resident educated related to drug abuse policy/behavior contract issued and monitored at smoking time. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Using Illicit Drugs in the Facility. Resident admits to using heroin; -Goal: Resident agrees not to use any controlled substances, illicit drugs or alcohol on our premises. Should you violate this contract, you will be at risk for immediate discharge; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. During an interview on [DATE] at 12:00 P.M., Resident #1 said on [DATE], his/her roommate (Resident #4) came in to their room and told Resident #1 he/she needed to check on his/her girl/boyfriend (Resident #2). When Resident #1 got to Resident #2's room, he/she saw Resident #2 sitting in his/her wheelchair nodding. Resident #1 saw five buttons in his/her mouth. Resident #1 told Resident #2 to lay some down. According to Resident #1, Resident #2 had a bag with crack cocaine, heroin and doorman (Resident #1 described doorman as an agent used to dilute the heroin). Resident #1 ingested some of the heroin and placed the bag filled with the illegal substances into his/her pocket. He/she could not recall what happened next. The facility staff issued [MEDICATION(S)]. On the day of the incident, Resident #1, Resident #2 and Resident #4 broke down the heroin Resident #2 brought into the facility. Resident #2 obtained the heroin from a family member when he/she went on a leave of absence. Resident #1 said it was a large amount of heroin, and it was supposed to be for personal use. He/she did not know if Resident #2 planned to sell the heroin or crack. Resident #1 said he/she had used heroin for years and had not planned on stopping. He/she used on occasion with Resident #2, Resident #3 and Resident #4. About a week ago, he/she witnessed Resident #3 in his/her room, with staff, being revived. He/she approached Resident #3 the following day and asked what happened. Resident #3 told him/her he/she used heroin. Resident #1 told Resident #3 to share the next time. Resident #1 said this was not the first time he/she used in the facility, but could not recall the other incidents. Other residents were able to bring drugs into the facility and sell them to other residents. He/she refused to name the other residents. During an interview on [DATE] at 9:35 A.M., Nurse E said he/she had only been at the facility for two days when the incident occurred on [DATE], during the early morning hours. At approximately 4:00 A.M., Nurse E did rounds and discovered Resident #1 in Resident #2's room asleep. He/she woke the resident up and explained he/she could not be in the resident's room. At the time, Nurse E did not suspect any suspicious activity. He/she returned to the room and saw Resident #1 rinsing out a bowl at Resident #2's sink. He/she looked down and saw what looked like a bag of candy. Upon further inspection, Nurse E saw one bag with green pills and two additional bags with white pills. He/she obtained a glove and picked up the items and saw the bags contained illegal substances and secured the items in the nurse's medication room. Nurse E contacted the DON for further instructions. While he/she waited for the DON, Nurse E continued to check on Resident #1 and Resident #2. Nurse E was not familiar with the residents and did not know if they had known issues with drugs. During an interview on [DATE] at 9:00 A.M., Nurse C said the drugs were discovered by Nurse E when he/she arrived on the scene. He/she was asked to assist by the DON. Resident #1 was administered [MEDICATION(S)] and was aroused. Resident #1 was known to abuse drugs while at the facility. During an interview on [DATE] at 9:15 A.M., Nurse D said he/she observed Resident #1 after he/she was issued [MEDICATION(S)]. The resident refused to go to the hospital. The resident was known to abuse drugs. This was not the resident's first time requiring [MEDICATION(S)]. 2. Review of Resident #3's medical record, showed: -admitted on [DATE]; -Diagnoses included arthritis, opioid abuse, uncomplicated, chronic [CONDITION(S)] C, and other psychoactive substance abuse, uncomplicated. Review of the resident's physician's orders, showed an order, dated [DATE], for a psych consult, as needed. Review of the resident's admission MDS, dated [DATE], showed: -admitted on [DATE], from an acute hospital; -Cognitively intact; -Exhibited no behaviors; -Independent with locomotion on the unit; -Used a wheelchair. Review of the resident's psychiatric evaluation, dated [DATE], showed he/she denied the use of alcohol or drugs. Review of the resident's nurse's notes, showed: -On [DATE] at 8:15 A.M., the resident was found in a fetal position on the floor of his/her room. The roommate said the resident laid him/herself on the floor. Staff attempted to help the resident up on his/her feet and into the bed. The resident was very unstable on his/her feet and was being combative. The physician was called and ordered to hold all narcotic medication. The resident is to be monitored and if condition gets worse, the resident is to be sent to the hospital; -On [DATE] at 1:00 P.M., an order was received from the physician to have a drug screening done due to patient's recent behaviors and mental status changes. Patient agreed to allow labs to be drawn when he/she sat and spoke with the social worker (The results were not back prior to his/her being sent to the hospital on [DATE]). Review of the resident's social service note, dated [DATE] at 4:28 P.M., showed SSW A spoke to the resident about using illegal drugs on company grounds. The resident was still in denial about using the drugs. SSW A went over the substance abuse and behavior contract with the resident and he/she agreed and signed the agreement. SSW A informed the resident they would have to find him/her somewhere to go. The resident said he/she would call a family member to pick him/her up. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Substance Abuse -Goal: Agree not to use controlled substances and will not bring any drugs or alcohol in the facility or accept any drugs or alcohol from outside sources; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. Further review of the resident's nurse's notes, dated [DATE] at 5:48 P.M., showed the resident was suspected of illicit drug use and possible overdose requiring the use of [MEDICATION(S)] and transfer to the hospital for an evaluation. The resident returned with a positive drug screen for [MEDICATION(S)], opioids and [MEDICATION(S)]. Education provided on illicit drug use and facility policies. Resident has chosen to leave the facility against medical advice. Review of the resident's care plan, updated on [DATE], showed: -Focus: Suspected drug abuse. The resident displayed behaviors of those associated with possible drug abuse; -Goal: The resident will have fewer episodes of behaviors through the review date; -Interventions: Behavior health consultation, as needed, monitor behavior episodes and attempt to determine underlying causes and notify medical provider of increased episodes of behaviors; -Focus: The resident is at risk for demise related to substance use disorder. The resident's drug screen was positive for [MEDICATION(S)]; -Goal: The resident will abstain from mind altering substances while a resident at the facility through the review date; -Interventions: Educate resident on following the prescribed treatment regimen and leave of absence policy. Encourage the resident to express feelings regarding addiction. Encourage support system of family and friends and evaluate the resident for the following symptoms; stumbling, nodding off even when standing or in mid conversation, incoherent speech, erratic behavior, slurred speech, rambling, nervous, jerky movements and eating candy. Offer drug abuse treatment program and refer to psychiatric services/counseling/support services as needed. During an interview on [DATE] at 12:00 P.M., Resident #1 said he/she used heroin, along with Resident #3. Resident #1 could not recall the exact date, but said about a week ago, Resident #3 told him/her that he/she ingested heroin and almost passed out. Resident #1 told Resident #3 to share with him/her the next time. Resident #3 used heroin provided by Resident #2 on [DATE]. During an interview on [DATE] at 9:00 A.M., Nurse C said he/she arrived on the scene on [DATE], during the early morning and was instructed to assist. Resident #3 was administered [MEDICATION(S)], but was difficult to arouse. He/she then did a sternum rub and the resident was still difficult to arouse. Emergency medical services (EMS) arrived and the resident was transported to the hospital. The resident was admitted to the facility with known issues with substance abuse. During interviews on [DATE] at 9:00 A.M. and [DATE] at 2:23 P.M. and [DATE] at 11:00 A.M., the administrator said Resident #3 admitted he/she obtained the drugs from Resident #2. When Nurse E reported the incident, he/she mistakenly said Resident #1 was in Resident #3's room. However, it was discovered while investigating that Resident #1 was actually in Resident #2's room and Resident #3 was given drugs by Resident #2. After Resident #1 was aroused, he/she told staff Resident #3 was involved. Resident #1 was near Resident #3's room during the investigation. Staff entered into the room and administered [MEDICATION(S)] to Resident #3. Resident #3 was sent to the hospital for further evaluation and treatment. He/she returned the same day and left the facility against medical advice. 3. Review of Resident #2's admission MDS, dated [DATE], showed: -admitted on [DATE], from an acute hospital; -Cognitively intact; -Exhibited no behaviors; -Locomotion on and off the unit occurred only once or twice. Set up from staff required; -Used a wheelchair. Review of the resident's nurse's note, dated [DATE] at 8:17 P.M., showed he/she was observed receiving items through the front door from a visitor. Screener performed inventory of items, finding suspected illicit drugs. Law enforcement notified and confirmed capsules contained heroin. Law enforcement packaged capsules as evidence. Social Services reviewed policy with the resident. Education provided on drug policy and adverse risks related to recreational drug use. MD and emergency contact made aware. Resident placed on one on one observation for 48 hours. A psychiatric consultation was ordered. Resident refused urine sample and denies actual drug use. The resident refused to identify visitor. Review of the resident's medical record, showed: -Diagnoses included [CONDITION(S)], pressure ulcers, major depression and psychoactive substance abuse, uncomplicated; -An order, dated [DATE] for a psychiatric evaluation. Further review of the resident's medical record, showed no psychiatric evaluation completed. During an interview on [DATE] at 1:36 P.M., the DON said the resident refused a psychiatric evaluation. Review of the resident's Concern Form, dated [DATE], showed: -Description of Concern: Resident had a visitor bring him/her something. The screener at the door did an inventory on the items and found illegal drugs (heroin). The resident refused to name the family member; -Notify DON, social services and administrator; -Actions to Resolve the Concern: Resident was educated on the company policy on drugs and safety. Resident stated that he/she didn't need help because that wasn't drugs. Further review of the resident's nurse's notes, showed: -On [DATE] at 4:25 P.M., resident went on a leave of absence with family; -On [DATE] at 1:59 P.M., the resident was suspected of distributing illicit drugs to other residents and verbally admitted to illicit drug abuse. Resident states he/she no longer has any drugs, because he/she passed them out to pay off debt he/she had with other residents. Resident states he/she consumed xanny bars and heroin. Resident consented to a room and person check, which did not reveal any substances. Resident refused a hospital transfer for evaluation. No signs and symptoms of distress. Resident refused skin and vital assessment. Resident was placed on one on one observation to rule out acute reaction to drug use. MD notified with orders to discontinue prescription narcotics. Social services currently providing psychosocial follow-up; -On [DATE] at 4:15 P.M., the SSW B spoke to the resident about using illegal drugs on facility grounds and he/she did admit to using the drugs. SSW B read and went over the substance abuse contract and behavior contract with him/her and he/she agreed to sign them. SSW B explained to the resident that staff needed to find somewhere for him/her to go immediately and to call someone to come get him/her. Review of the resident's signed Behavioral Contract, dated [DATE], showed: -Behavior: Substance Abuse; -Goal: Agree not to use any controlled substance and will not bring any drugs or alcohol in the facility or accept any drugs from outside sources; -Date to be achieved: [DATE]. This was the resident's only Behavioral Contract. During an interview on [DATE] at 12:00 P.M., Resident #1 said on [DATE], his/her roommate (Resident #4) came in to their room and told Resident #1 he/she needed to check on his/her girl/boyfriend (Resident #2). When Resident #1 got to Resident #2's room, he/she saw Resident #2 sitting in his/her wheelchair nodding. Resident #1 saw five buttons in his/her mouth. Resident #1 told Resident #2 to lay some down. According to Resident #1, Resident #2 had the day of the incident, Resident #1, Resident #2 and Resident #4 broke down the heroin Resident #2 brought into the facility. Resident #2 obtained the heroin from a family member when he/she went on a leave of absence. Resident #1 said it was a large amount of heroin, and it was supposed to be for personal use. He/she did not know if Resident #2 planned to sell the heroin or crack. He/she used on occasion with Resident #2. Other residents were able to bring drugs into the facility and sell them to other residents. He/she refused to name the other residents. During an interview on [DATE] at 9:35 A.M., Nurse E said he/she had only been at the facility for two days when the incident occurred on [DATE], during the early morning hours. He/she was not familiar with the residents at all. At approximately 4:00 A.M., Nurse E did rounds and discovered Resident #1 in Resident #2's room asleep. He/she woke the resident up and explained he/she could not be in the resident's room. At the time, Nurse E did not suspect any suspicious activity. He/she returned to the room and saw Resident #1 rinsing out a bowl at Resident #2's sink. He/she looked down and saw what looked like a bag of candy. Upon further inspection, Nurse E saw one bag with green pills and two additional bags with white pills. He/she obtained a glove and picked up the items and saw the bags contained illegal substances and secured the items in the nurse's medication room. Nurse E contacted the DON for further instructions. While he/she waited for the DON, Nurse E continued to check on Resident #1 and Resident #3. Nurse E was not familiar with the residents and did not know if they had known issues with drugs. During an interview on [DATE] at 9:15 A.M., Nurse D said the incident occurred on [DATE], during the night shift, but earlier during the morning. When he/she arrived, the DON told him/her to assist with the residents. Resident #2 was in his/her room. He/she was alert and refused [MEDICATION(S)]. During an interview on [DATE] at 11:00 A.M., the administrator confirmed the drugs were discovered in Resident #2's room, next to Resident #1's wheelchair. Resident #2 refused [MEDICATION(S)]. He/she admitted to obtaining the drugs from a family member on [DATE], and distributed the drugs to Resident #1 and Resident #3. During an interview on [DATE] at 11:25 A.M., Resident #4 (Resident #1's roommate) said Resident #2 left the facility the day before the incident ([DATE]) and obtained the drugs. He/she observed the drugs and saw [MEDICATION(S)], crack cocaine, heroin and doorman. On [DATE], he/she told Resident #1 to check on his/her boy/girlfriend. Resident #1 used the drugs with Resident #2 and tried to hide the drugs in his/her pocket, but they fell out. Resident #4 denied using substances that morning, but said he/she had used opioids while a resident at the facility and regularly smokes marijuana. He/she received marijuana from another resident in the facility, but refused to name the resident and would not confirm if the resident was still at the facility. 4. Review of the facility's investigation, dated [DATE], showed: -Summary of Occurrence; -Resident #2 is suspected of distributing illicit drugs to other residents (Residents #1, #3 and #4). Resident #1 verbally admitted to giving out illicit drugs to pay off his/her debt to other residents and also his/her own use. Charge nurse observed three bags of drugs, later identified as heroin and [MEDICATION(S)] on the floor in front of Resident #2's bed and next to Resident #1's wheelchair as they both sat with change in normal orientation. Resident #3 and Resident #4 were also identified as utilizing. [MEDICATION(S)] administered to Resident #1 and #3, with Resident #3 transferred to the ER and returned with positive drug screen ([MEDICATION(S)]/opiates). Law enforcement dispatched. During interviews conducted by law enforcement, Residents #2 and #1 implied that although this supply of drugs was received from Resident #2's family during his/her recent LOA, they also received drugs from staff members in the

Based on interview and record review, the facility failed to provide needed care and services in accordance with the resident's preferences, goals for care and professional standards of practice to meet the resident's needs for one resident (Resident #1). The resident had a [DIAGNOSES REDACTED]. It came back with a critical glucose (blood sugar) of 658. The lab attempted to call the facility six times over the next twelve hours before they could get a nurse to come to the phone. They then reported the critical lab to the nurse. The nurse did not document this or report the results to the physician. No follow-up care was provided to the resident regarding the critical lab. On [DATE] at 11:02 A.M., staff noted the resident with cool clammy skin, sweating and unlike normal self, blood sugar HI (result above 500 that cannot be measured on the machine/glucometer) and was sent to the hospital via ambulance where he/she expired. The resident sample was seven. The census was 110. The administrator was notified on [DATE] at 1:55 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Laboratory and Radiological Services and Results Reporting policy, dated [DATE], showed: -Laboratory services is any examination of materials derived from the human body for purposes of providing information for the diagnosis, prevention or treatment of [REDACTED]. -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The safety of residents, staff and visitors is the primary importance. The purpose of this policy is to provide guidance for reporting of results from laboratory and other diagnostic services to the ordering practitioner. The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. There are clinical and physiological risks when laboratory or other diagnostic services are not performed in a timely manner or the results of these services are not reported and acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment, assessment and interventions. Nurses will have a sense of urgency for reporting critical labs and radiological findings to the ordering prescriber and document reporting of such items in the progress notes; -The facility assumes the responsibility for the timeliness and quality of the laboratory and radiological services chosen and will make changes as needed to secure services; -The facility will have an on-going written agreement with a qualified laboratory to provide services to meet the needs of the resident population; -Reporting: -Reports are provided to a licensed nurse by telephone for critical values or values out of the therapeutic range of normal followed by a hard or digital copy for medical record keeping; -The facility will review the results in a timely manner and notify the ordering physician/provider of the results and document reporting and follow-up care in the progress notes; -Nurse responsibility of reporting to practitioner: -Unit nurses will contact the supervisor for any concern of results that may be cause for concern or that additional investigation may be required prior to placing the results on/in the medical record; -Urgency of reporting: -A sense of urgency is required for critical, alert or panic values that are telephoned to the facility for laboratory or other diagnostic services by outside vendors; -The nurse will document the information and provide a read-back for accuracy; -The nurse will relay the information to the supervisor and/or provide follow up for action. Review of Resident #1's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE] from an acute care hospital; -Resident is rarely/never understood; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -[DIAGNOSES REDACTED]., stroke, [MEDICAL CONDITION], and osteo[DIAGNOSES REDACTED] (bone infection) of left foot/ankle. Review of the resident's care plan, showed: -Focus: Date initiated [DATE]: Resident has [MEDICAL CONDITION] related to diabetes, [MEDICAL CONDITION]: -Goal: Be free of signs/symptoms of [MEDICAL CONDITION] through the review date; -Interventions/tasks: Monitor/document/report to physician as needed any signs/symptoms or problems related to [MEDICAL CONDITION]; -Focus: Date initiated [DATE]: Resident has diabetes: -Goal: Be free from any signs/symptoms of [MEDICAL CONDITION] (high blood sugar) and [DIAGNOSES REDACTED] (low blood sugar) through review date; -Interventions/tasks: Diabetes medication as ordered by the physician. Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered. Monitor/document/report to the physician as needed any signs/symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Review of the resident's medical record, showed: -The resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED].>-An order dated [DATE], to monitor for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] (i.e., sweating, tremor, pallor, [MEDICAL CONDITION] palpations, nervousness, headache, confusion, light headedness, slurred speech, lack of concentration, irritability, staggering gate, etc.) every shift; -Order discontinued, no date discontinued specified; -The resident hospitalized on [DATE]; -The resident re-admitted on [DATE]; -An order dated [DATE], for insulin [MEDICATION NAME] (rapid acting insulin) solution pen-injector, 200 unit/milliliter (ml). Inject 8 units subcutaneously (under the skin) at bedtime; -An order dated [DATE], for [MEDICATION NAME] (anti-diabetic medication) 5 milligram (mg) by mouth in the morning for diabetes. During an interview on [DATE] at 9:16 A.M., Licensed Practical Nurse (LPN) E said he/she is not familiar with the facility policies and procedures and he/she is not able to access the resident census report. He/she is agency nurse/staff. The surveyor would have to ask a regular staff person any questions about protocols. During an interview on [DATE] at 2:28 P.M., with the Director of Nursing (DON) and Staff Development Coordinator (SDC) nurse, the DON said the [DATE] order to monitor signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] was discontinued when the resident was sent out to the hospital in [DATE] and was not reordered upon readmission. The resident was diabetic and on insulin and the order should have been reinstated upon readmission. There is no order to have the resident's blood sugar level routinely checked, but since there is an order for [REDACTED]. Further review of the resident's medical record, showed: -An order dated [DATE] for a complete blood count (CBC, a blood test used to evaluate overall health and detects a wide range of disorders) and comprehensive metabolic panel (CMP, a blood test that measures blood glucose, electrolytes and fluid balance), to be drawn on [DATE]; -No CBC and CMP drawn on [DATE]; -No documentation on [DATE] to identify why the resident's CBC and CMP was not drawn as ordered; -A CBC and CMP drawn on [DATE]. During an interview on [DATE] at 2:28 P.M., with the DON and SDC, the DON said she was not sure why the CBC and CMP laboratory values were not drawn on [DATE] as ordered. She would have expected it be drawn as ordered. Review of the resident's CBC and CMP laboratory results report, collected on [DATE] at 3:02 A.M. and reported [DATE] at 11:01 A.M., showed: -Order provider: Physician H; -Report flag: Report contains critical results; -Glucose 658 (normal 100 through 140), critically high; -White blood cells (WBC) 14.1 (normal 4XXX,[DATE].8, a result higher than 10.8 can indicate infection), Flagged high; -[DIAGNOSES REDACTED] absolute count (tests for infection) 9.70 (normal 1XXX,[DATE].60, a result higher than 7.60 can indicate infection), Flagged high; -A note hand written on the laboratory report, on [DATE] notified physician, sent to emergency room for further evaluation. Review of the resident's progress notes, showed: -No documentation on [DATE] to show the physician was notified of the critical glucose or flagged high WBC and [DIAGNOSES REDACTED] absolute count; -A nurse's note dated [DATE] at 11:02 A.M., resident noted to have cool clammy skin, sweating and unlike normal self. Resident unable to swallow and pocketing food. Vital signs: Blood pressure ,[DATE], respirations 24, oxygen saturation (percent of oxygen in the blood) 99% on room air, pulse 78, temperature 97.1, blood sugar HI. Resident is alert, but unable to verbalize needs, wheezing noted upon transfer to the hospital via ambulance. At 12:25 P.M., emergency room nurse provided update, resident has expired. During an interview on [DATE] at 2:28 P.M., with the DON and SDC, the DON said a blood sugar result of HI indicates a blood sugar level above 500. Review of the resident's hospital emergency room records, showed: -Arrived to the emergency roiagnom on [DATE] at 9:34 A.M., -Chief complaint: Weakness x3 days at least, patient is non-verbal, blood sugar problem greater than 600 per nursing home; -Patient with past medical history of [REDACTED]. The patient was found in this state by the nursing providers today, per report from the facility nurse practitioner. He/she states that laboratory work from a few days ago showed an elevated potassium, as well as elevated blood sugar level. The resident is found minimally responsive, tachypneic (elevated respiratory rate), with blood sugar greater than 600 on finger stick assessment; -Physical exam: In acute distress, mottled (a purple discoloration of skin that occurs close to death), ill appearing; -Skin: Mottled diffusely. Grossly infected appearing, necrotic pressure ulcers to right hip, as well as coccyx. Purulent (puss filled, indication of infection) drainage from both areas noted; -Glucose point of care test: Collected [DATE] at 9:49 A.M., showed a blood sugar level greater than 500; -High probability septic shock (a life-threatening condition caused by a severe localized or system-wide infection); -an order for [REDACTED]. -Critical care addendum: Septic shock; -Emergency Department notes: Patient arrived via ambulance from the nursing home. Nursing home staff report the resident's laboratory values were abnormal since last Thursday with a blood sugar over 600. Pressure ulcers noted on both left and right hips; -Patient appears critically ill on arrival. He/she is mottled diffusely and tachypneic. Respiratory effort has changed. He/she now exhibits agonal (abnormal breathing pattern characterized by gasping, labored breathing) respirations, with approximately 5 breaths per minute (normal is ,[DATE]); -Time of death was declared at 11:37 A.M. During an interview on [DATE] at 11:04 A.M., Physician H said he/she was not informed of the critical laboratory results until the day the resident was sent to the hospital. If he/she would have been made aware of the high WBC and [DIAGNOSES REDACTED]s, he/she may have ordered antibiotics, it depends on other clinical signs. On [DATE] at 12:05 P.M., Physician H said the resident was a diabetic and received insulin. He/she would have expected to be notified of the critical blood glucose laboratory value immediately. Infection may have caused the blood glucose to increase. If he/she would have been made aware of the critical result, he/she would have sent the resident to the hospital for treatment. During an interview on [DATE] at 11:35 A.M., a representative for the laboratory said six attempts were made to contact the facility. They were not able to get a nurse to come to the phone the first five attempts. The first attempt to contact the facility was on [DATE] at 12:01 P.M. A representative of the laboratory was not able to reach staff at the facility to report the critical laboratory results until 12:51 A.M. on [DATE]. The laboratory results were reported to LPN I at the facility with read back confirmation. During an interview on [DATE] at 2:28 P.M., with the DON and SDC, the DON said the critical laboratory results should have been called into the physician prior to [DATE]. The facility relies on the electronic health record to show when a laboratory report is ready. Staff should not have to dig beyond that. The facility did not get communication from the laboratory company. The facility has reached out to the laboratory corporation regarding this concern. Now, once the laboratory is not able to reach a nurse, they can call the DON or administrator. This process is something that the facility is working out now, and is not written in facility policy and not in a written agreement with the laboratory company. During an interview on [DATE] at 9:10 A.M., a representative for the laboratory company said he/she was not aware of any changes made in the way critical laboratory values are reported to the facility. During an interview on [DATE] at 11:37 A.M., the Vice President of Client Operations for the laboratory company said the facility has not contacted her directly regarding concerns with critical laboratory values, but she is aware of communication between the facility and the local account representative. On [DATE], the facility communicated concerns with laboratory values not being called or faxed. Currently, the process for communicating critical laboratory values is, the laboratory calls the facility. If the facility does not answer, the report is put on a list of facilities that need to be contacted and representatives of the laboratory call and recall until they can get a hold of someone. This is the process for all facilities. During an interview on [DATE] at 12:50 P.M., the local account representative for the laboratory said the facility has not been in contact with him/her regarding changing the notification process. He/she did have communication with the facility around [DATE], regarding concerns of laboratory results not being reported timely, but an investigation into the concern showed no issues on the laboratory end regarding timely notification. There was no discussion about changing notification processes. During an interview on [DATE] at 2:28 P.M., with the DON and SDC, the DON said staff should immediately report critical laboratory values to the physician. LPN I is agency staff. Agency staff are provided with an orientation manual that they can review for facility processes. This is the same information provided to facility staff. There is also one of these manuals at each nurse's station that they can reference. She would expect agency staff to be competent in facility protocols required for the job as well as acceptable standards of practice. During an interview on [DATE] at 3:44 P.M., the administrator said facility staff were in-serviced on [DATE] about reporting critical laboratory values, this was after the concern was identified. This information was added to the agency binder. No direct in-servicing has been provided to agency staff regarding this expectation. 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 onsite 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 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). MO 055

Based on interview and record review, the facility failed to ensure that 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, for one resident (Resident #1). The resident admitted on [DATE], per facility records, with intact skin and a suspected deep tissue injury to the sacrum (tail bone area). On 6/19/20, the facility documented a wound to the sacrum and left ankle as opened. They were both documented as stage III ulcers (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). The wound nurse practitioner was consulted and ordered daily dressing changes to both areas. When staff transcribed the orders into the system, they transcribed the orders incorrectly, resulting in the treatments only being scheduled for every other day. On 7/16/20, the resident was sent out to the hospital and required a left leg amputation due to the condition of the wound. The resident returned on 7/27/20. The readmission assessment identified the presence of the coccyx (tail bone area) ulcer. There was no mention of a hip wound. The facility failed to obtain treatment orders for the coccyx wound until 8/3/20. At that time, an order was also obtained for a stage III right hip wound that had not yet been documented as present in the medical record. Three residents with wounds were sampled, problems were identified with one. The resident sample was seven. The census was 110. Review of the facility's Skin Care and Wound Management Overview policy, reviewed 5/30/19, showed: -A pressure ulcer is defined as a localized injury to skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction; -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment; -Each resident is evaluated upon admission and weekly thereafter for changes in skin condition. Resident skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital; -Skin care and wound management program includes, but is not limited to: Application of treatment protocols based on clinical best practices standards for promoting wound healing, daily monitoring of existing wounds, identification of residents at risk for development of pressure ulcers, implementation of prevention strategies to decrease the potential for developing pressure ulcers; -Procedure: Prevention: -Complete the Braden Scale (pressure ulcer risk assessment) on admission, weekly times 3, quarterly and with change of clinical condition to identify risk indicators; -Complete an Admission Observation Tool. Identify areas of skin impairment and pre-existing signs; -Develop a care plan with individualized interventions to address risk factors; -Evaluate for consistent implementation of interventions and effectiveness at clinical meeting; -Treatment: -Select and complete the appropriate form: Pressure Ulcer Documentation, complete for all pressure ulcers; -Obtain a physician's orders [REDACTED].> -Document treatment on the treatment administration record (TAR); -Monitor and document progress. Review of the facility's Measuring a Wound, Skin Care and Wound Management policy, dated 7/1/16, showed: -Wounds will be measured weekly; -Place resident in a consistent position which allows for accurate wound measurement, remove soiled dressing, cleanse wound as ordered; -Measure length, width, depth, undermining (wound open underneath the border of the wound) and tunneling (a channel that tunnels from the wound into/through the muscle or subcutaneous tissue) in centimeters (cm). Review of Resident #1's medical record for May 2020, showed: -The resident admitted to the facility on [DATE]; -An order dated 5/30/20 and start date 6/1/20, weekly skin evaluation by licensed nurse; -No treatment orders for May 2020. Review of the resident's admission skilled nursing and wound assessment, dated 5/29/20 at 6:45 P.M., showed: -Wound care; -Multiple [DIAGNOSES REDACTED]. Scabbing and dark areas to both lower extremities and both feet described below. Areas are dry, no opening or exudate (drainage). Sacrum red/purple suspected deep-tissue injury (SDTI). All skin is continued open to air per hospital documentation. Will monitor weekly with routine skin assessments. Review of the resident's formal pressure ulcer risk assessment instrument, provided by the facility as for all admissions/readmissions from March 2020 through September 2020, requested on 9/8/20 at 3:05 P.M., showed the following: -No formal pressure ulcer risk assessment instrument for the resident's 5/29/20 admission; -No formal pressure ulcer risk assessment instrument for the resident's 7/27/20 readmission; -A Braden Observation Tool, dated 8/10/20, showed a score of 12. A score of 10-12 indicated high risk. Review of the resident's care plan, showed: -Focus: Initiated 6/16/20 and updated 7/8/20: Potential for skin/tissue integrity moderate risk related to [DIAGNOSES REDACTED]. Left lateral (outer side) ankle, sacrum, left heel, right heel, left great toe, right fist metatarsal, left first metatarsal, left lateral foot, right lateral foot (the type of wounds in these areas not specified); -Goal: Have skin intact; -Interventions/tasks included: Assess skin weekly and as needed; use positioning and pressure relieving mattress on bed and cushion on wheelchair; when out of bed, change positions by toileting, uploading, shifting weight, ambulating or return to bed for rest; -Focus: Initiated 7/8/20 and revised 7/8/20: At risk for decline related to pressure ulcers. Has impaired mobility and is incontinent. Left lateral ankle, sacrum, left heel, right heel, left great toe, right first metatarsal, left first metatarsal, left lateral foot, right lateral foot; -Goal: Pressure ulcers will exhibit signs of healing evidenced by decreased in size, improved appearance and be free from signs and symptoms of infection. Resident will not develop any new areas of skin breakdown through next review; -Interventions/tasks included: Administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing with care. Measure length, width and depth where possible. Assess and document status of wound edges, wound bed and healing progress. Report improvements and declines to the physician; educate caregivers as the cause of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; follow facility policies/protocols for the prevention and treatment of [REDACTED]. Report lose dressing to treatment nurse; Resident requires assistance from staff for turning and repositioning. Turn and reposition every two hours and as needed; wound care consult per physician order. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/4/20, showed: -admitted [DATE] from an acute care hospital; -Resident is rarely/never understood; -Extensive assistance required for bed mobility, transfer, dressing, toilet use and personal hygiene; -[DIAGNOSES REDACTED]., stroke, malnutrition or at risk for malnutrition, [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED] (bone infection) of left foot/ankle; -Determination of pressure ulcer risk: Formal assessment instrument and clinical assessment; -At risk for pressure ulcers; -No unhealed pressure ulcer(s); -No venous and arterial ulcers; -Use of pressure reducing device for bed. Review of the resident's weekly skin checks for June 2020, showed: -No skin check completed prior to 6/5/20; -On 6/5/20 at 6:29 P.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -Sacrum reddened area; -Other, scabbed area to both lower extremities; -On 6/12/20 at 10:29 A.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -Sacrum red purple in color, soft; -On 6/19/20 at 10:29 A.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: Yes; -If yes, document the change: Using the body diagram, record any finding. Use the description field to describe the change, explain the change and identify location of additional relevant documentation: Sacrum open area, wound nurse made aware (no measurement or description provided); -On 6/26/20 at 6:29 A.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -Sacrum open area. Review of the resident's nurse's notes for June 2020, showed no documentation regarding wounds. Review of the resident's skin grid pressure assessments, showed: -Dated 6/17/20: -Left ankle (outer), pressure: 3.0x2.5x0.3 stage III. Granulation tissue (new tissue growth) and eschar (dry dead tissue) present. Wound bed pink and necrotic; -Sacrum, pressure: 4.5x3.5x0.3 stage III. Granulation tissue present. Wound bed pink; -Dated 6/22/20: -Left ankle (outer), pressure: 2.3x1.8x0.1 stage III. Granulation tissue and slough (moist dead tissue) present. Wound bed pink; -Sacrum, pressure: 3.0x3.2x0.2 stage III. Granulation tissue and slough present. Wound bed pink; -Dated 6/30/20: -Left ankle (outer), pressure: 2.5x3.2x0.2 stage III. Slough present. Wound bed yellow; -Sacrum, pressure: 6.5x6.0x0.1 stage III. Granulation tissue and slough present. Wound bed pink. Review of the medical record for June 2020, showed: -An order dated 6/18/20, wound consult; -An order start date 6/18/20, daily wound assessment, document abnormalities in progress notes; -Nurses notes for June 2020, showed no wound assessment abnormalities documented; -An order start date 6/18/20, cleanse area to left outer ankle with wound cleanser, allow to dry and cover with foam dressing and wrap secure in place daily, every other day; -A TAR for June 2020, with a treatment start date of 6/18/20 and discontinued 6/25/20, cleanse area to left outer ankle with wound cleanser, allow to dry and cover with foam dressing and wrap secure in place daily, every other day: Scheduled to be changed every other day, not documented as completed one of four scheduled opportunities; -An order start date of 6/18/20, cleanse area to sacrum with wound cleanser, allow to dry and cover with foam dressing daily and as needed daily, every other day; -A TAR for June 2020, with a treatment start date of 6/18/20, cleanse area to sacrum with wound cleanser, allow to dry and cover with foam dressing daily and as needed daily, every other day: Scheduled to be changed every other day, not documented as completed one of seven scheduled opportunities; -An order start date of 6/26/20, cleanse area to left outer ankle with wound cleanser, allow to dry, apply Santyl (ointment that removes dead tissue from wounds) to wound bed and cover with foam dressing, wrap and secure in place daily, every other day; -A TAR for June 2020, with a treatment start date of 6/26/20, cleanse area to left outer ankle with wound cleanser, allow to dry, apply Santyl to wound bed and cover with foam dressing, wrap and secure in place daily, every other day: Documented as applied every other day. During an interview on 9/17/20 at 8:44 A.M., the Wound Nurse Practitioner (NP) said he/she was initially consulted to see the resident on 6/18/20. Orders were given to cleanse the wounds, apply Santyl and dry dressing daily. Both the order for the sacrum and left outer ankle should have included the application of Santyl and should have been completed daily. Not every other day. The facility staff is responsible to accurately transcribe the orders into the electronic medical record system. He/she provides the orders to staff when he/she is onsite at the facility. Santyl is a daily dressing change. He/she is not sure if facility staff know how to access all of his/her records in the electronic medical record system, if not they should. He/she assessed and documented all wounds, to include what treatment orders were given to the facility. He/she is looking at the notes now and it indicates daily treatments with Santyl ordered on [DATE] for both the ankle and sacrum. Staff could look at his/her notes to verify orders. Santyl is a daily treatment, he/she would never order Santyl every other day. It is required to be changed every 24 hours. He/she saw the resident for multiple wounds, to include the sacrum and left outer ankle. Review of Wound NP's wound assessment detail documentation, requested from the facility on 9/14/20 at 11:30 A.M., and provided by the facility as all the Wound NP notes/assessments for all wounds, showed: -Date of service 6/18/20: -Sacrum pressure ulcer, wound open. Measurement: (in length x width x depth measured in cm) 3x3.2x0.2. Unstageable (wound depth unable to be determined due to coverage of the wound bed by dead tissue). Medium amount of serosanguineous (blood tinged) drainage red, brown. Necrotic amount: Large 67%-100%, eschar, adherent slough; -The facility provided no documentation for the left outer ankle wound; -Date of service 6/25/20: -Sacrum pressure ulcer, wound open. Measurement: 6.5x6x0.1. Unstageable, medium serosanguineous drainage, red, brown. Necrotic amount: Large 67%-100%, eschar, adherent slough. Wound progress: Worsening; -The facility provided no documentation for the left outer ankle wound; -The documentation provided by the facility did not include treatment orders. During an interview on 9/17/20 at 2:28 P.M., with the Director of Nursing (DON) and Staff Development Coordinator, the DON said treatment orders provided by the Wound NP should be administered as ordered. The Wound NP came in today and in-serviced her on how to access his/her notes. No one in the facility knew how to access the Wound NP notes prior to today. Further review of the resident's progress notes, showed: -Weight change note dated 7/2/20 at 3:32 P.M., weight loss not desired. Receives a puree diet. Staff report that he/she requires assistance at meals and is fed by staff at times to promote increased intake. Has stage III wound to left ankle; -Nurses note dated 7/16/20 at 1:02 P.M., per wound nurse, nurse practitioner, and physician send to hospital for left ankle wound evaluation. Review of the resident's weekly skin checks for July 2020, showed: -On 7/3/20 at 9:35 A.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -No documentation of any wound sites or description; -On 7/10/20 at 3:35 P.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -No documentation of any wound sites or description; -(Resident at the hospital from 7/16/20 through 7/27/20); -No skin check completed from 7/27/20 through 8/2/20; -No skin grid reports provided for the left ankle (outer) or sacrum for July 2020. Review of the facility's pressure reports, used as facility tracking and not part of the resident's medical record, showed the following for the resident: -Report dated 7/6/20: -Left lateral ankle, stage III, 4.0x4.5x0.3. Progress: Declined, 25% slough; -Sacrum/coccyx, stage III, 8.0x7.0x0.1. Progress: Declined, cluster of 2; -Report dated 7/13/20: -Left lateral ankle, stage III, 7.5x4.5x1.5. Progress: Declined, 75% slough; -Sacrum/Coccyx, stage III, 6.0x6.5x0.1. Progress: Improved, cluster of 2. Review of Wound NP's wound assessment detail documentation, requested from the facility on 9/14/20 at 11:30 A.M., and provided by the facility as all the Wound NP notes/assessments for all wounds, showed: -Date of service 7/1/20: -Sacrum pressure ulcer, wound open. Measurement: 8x7x0.1. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening; -The facility provided no documentation for the left outer ankle wound; -Date of service 7/9/20: -Sacrum pressure ulcer, wound open. Measurement: 6x6.5x0.1. Unstageable, medium amount serosanguineous drainage red, brown. Granulation tissue: Medium 34%-66%. Necrotic amount: Medium 34%-66%, adherent slough. Wound progress: Improving; -The facility provided no documentation for the left outer ankle wound; -Date of service 7/16/20: -Sacrum pressure ulcer, wound open. Measurement: 3x7.5x0.1. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening; -The facility provided no documentation for the left outer ankle wound; -Date of Service 7/30/20: -Sacrum pressure ulcer, wound open. Measurement: 8.5x5.5x0.1. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening; -The documentation provided by the facility did not include treatment orders. Review of the resident's medical record for July 2020, showed: -A TAR for July 2020, with a treatment start date of 6/18/20 and discontinued 7/27/20, cleanse area to sacrum with wound cleanser, allow to dry and cover with foam dressing daily and as needed, every other day: Documented as applied every other day; -A TAR for July 2020, with a treatment start date of 6/26/20 and discontinued 7/27/20, cleanse area to left outer ankle with wound cleanser, allow to dry, apply Santyl to wound bed and cover with foam dressing, wrap and secure in place daily, every other day: Documented as applied every other day; -No documentation staff clarified the treatment orders to be completed daily; -The resident hospitalized [DATE]; -The resident re-admitted on [DATE] with a left above the knee amputation (AKA). Review of the resident's admission observation tool, dated 7/27/20 at 5:01 P.M., showed: -Wound care; -Are there any skin areas noted: Yes. Document any and all skin areas of concern: -Coccyx pressure ulcer, no measurements or description; -Left knee surgical incision; -No documentation of a right hip wound. Further review of the resident's progress notes, showed a nurse's note dated 7/27/20 at 6:43 P.M., resident readmitted from the hospital status [REDACTED]. Resident skin clean and dry and intact with noted open areas to left extremity with AKA, 37 stables intact and no noted drainage; coccyx, right inner ankle, right outer great toe and heel noted open areas. All with treatment in place as ordered. Further review of the resident's medical record for July 2020, showed: -No treatment ordered for the sacral wound after readmission; -No documentation any wound treatments provided 7/27/20 through 8/2/20; -No documentation of a right hip wound 7/27/20 through 8/2/20. Review of the resident's weekly skin checks for August 2020, showed: -On 8/3/20 at 5:01 P.M.: -Are there any skin conditions or changes, ulcers or injuries? No; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -Right toe(s), right second toe (no further description); -On 8/10/20 at 5:01 P.M.: -Are there any skin conditions or changes, ulcers or injuries? No; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: (blank); -No documentation of any wound sites or description; -On 8/17/20 at 5:01 P.M.: -Are there any skin conditions or changes, ulcers or injuries? No; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: (blank); -No documentation of any wound sites or descriptions; -On 8/24/20 at 5:01 P.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -No documentation of any wound sites or descriptions; -On 8/31/20 at 5:01 P.M.: -Are there any skin conditions or changes, ulcers or injuries? Yes; -If yes, review prior weekly skin check and/or most recent nursing evaluation to determine is this new since the last documented check: No; -No documentation of any wound sites or descriptions. Further review of the facility's pressure reports, used as facility tracking and not part of the resident's medical record, showed the following for the resident: -Report dated 8/3/20: -Sacrum/coccyx, stage III, 8.5x5.5x0. Progress: Remained same, cluster of 2; -Right hip, stage III, 3.5x2.0x0.1; -Report dated 8/10/20: -Sacrum/coccyx, stage III, 8.5x5.5x0. Progress: remained the same, cluster of 2, 75% slough; -Right hip, stage III, 3.5x2.0x0.1. Progress: Remained the same, cluster of 2, 100% slough; -Report dated 8/17/20: -Sacrum/coccyx, stage III, 10.5x8.5x2. Progress Declined, cluster of 2 merged into 1, 100% slough; -Right hip, stage III, 3.6x6 (no depth measured). Progress: Remained same, cluster of 2, 100% slough; -Report dated 8/27/20: -Sacrum/coccyx, stage III, 10x8x2. Progress: Remained same, cluster of 2 merged into 1, 100% slough; -Right hip, stage III, 3x6.1 (no depth measured). Progress: Remained same, cluster of 2, 100% slough. Review of Wound NP's wound assessment detail documentation, requested from the facility on 9/14/20 at 11:30 A.M., and provided by the facility as all the Wound NP notes/assessments for all wounds, showed: -Date of Service 8/20/20: -Sacrum pressure ulcer, wound opened. Measurements: 10.5x8.5x2. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening. Foul odor after cleansing; -Date of service 8/25/20: -Sacrum pressure ulcer, wound opened. Measurements: 10x8x2. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening. Foul odor after cleansing; -Date of service 9/2/20: -Sacrum pressure ulcer, wound opened. Measurements: 11x8x1.5. Unstageable, medium amount serosanguineous drainage red, brown. Necrotic amount: Large 67%-100%, adherent slough. Wound progress: Worsening. Foul odor after cleansing; -The documentation provided by the facility did not include treatment orders. Review of the resident's medical record for August 2020, showed: -No treatments ordered or documented as provided through 8/3/20; -No wound cultures or antibiotics orders for the foul smelling wounds; -An order start date 8/4/20, daily wound assessment. Document abnormalities in progress notes; -No documentation of wound assessments daily in the progress notes; -An order start date 8/4/20, cleanse area to right hip, allow to dry, apply Santyl to wound bed and cover with dry dressing daily and as needed; -A TAR for August 2020, with a treatment start date of 8/4/20, cleanse area to right hip, allow to dry, apply Santyl to wound bed and cover with dry dressing daily and as needed: -Documented as not completed nine of 28 opportunities and coded as either other, see nurses notes or resident sleeping; -Nurses notes for August 2020, showed no documentation why treatments were not completed as ordered or reattempts to apply the treatment when the resident was not sleeping; -An order start date of 8/4/20, cleanse area to sacrum, allow to dry, apply Santyl to wound bed and cover with dry dressing daily and as needed; -A TAR for August 2020, with a treatment start date 8/4/20 and discontinued 8/20/20, cleanse area to sacrum, allow to dry, apply Santyl to wound bed and cover with dry dressing daily and as needed: -Documented as not completed eight of 17 opportunities and coded as either other, see nurses notes or resident sleeping; -Nurses notes for August 2020, showed no documentation why treatments were not completed as ordered or reattempts to apply the treatment when the resident was not sleeping; -An order start date of 8/21/20, cleanse area to sacrum with Dakin's solution (a hypochlorite solution made from diluted bleach and is used as an antiseptic in wounds), apply Santyl to wound bed, lightly pack with Dakin's moistened gauze and cover with dry dressing daily and as needed; -A TAR for August 2020, with a treatment start date of 8/21/20, cleanse area to sacrum with Dakin's solution, apply Santyl to wound bed, lightly pack with Dakin's moistened gauze and cover with dry dressing daily and as needed: -Documented as not completed one of 11 opportunities and coded as other, see nurses notes; -Nurses notes for August 2020, showed no documentation why the treatment was not completed as ordered. Review of the resident's skin grid pressure assessments, for August 2020, showed: -Dated 8/27/20: -Sacral: Progression: No change. Site details: Length 10, width 8, depth 2, Stage III (appearance of wound bed and wound edges or presence of drainage and odors not documented); -Right trochanter (hip): Progression: No change. Site details: Length 3, width 6.1, no depth documented, Stage III (appearance of wound bed and wound edges or presence of drainage and odors not documented). Further review of the resident's August 2020 progress notes, showed: -Nurses note dated 8/20/20 at 7:19 P.M., resident assessed by wound specialist, new orders noted; -Nurses note dated 8/26/20 at 3:32 P.M., resident assessed by wound specialist on 8/25/20 with concerns on non-healing of sacrum ulcer. Nurse practitioner requested the DON to consult with family on their wishes for possible aggressive surgical interventions vs hospice care. Family responds today and requested for NP to assess resident and make decision to transfer out to hospital or treat in place. NP notified and will assess resident on 8/27/20; -NP progress note dated 8/28/20 at 2:48 P.M., late entry: Resident seen on 8/27/20 and pressure ulcer to the sacrum assessed. Recommendation is to treat resident in place. Daily dressing changes as ordered, turn resident every two hours. Keep clean and dry. Indwelling urinary catheter for incontinence and to keep wound dry. Laboratory values to be drawn on 8/31/20 to assess white blood cell (WBC) count. Resident remains afebrile (without fever) and there is no signs of an active infection at this time. Review of the resident's laboratory report, showed: -Collection date 9/2/20 at 3:02 A.M.; -Report date 9/2/20 at 11:01 A.M.; -White blood cells (WBC) flagged high at 14.1 (indicate possible infection), reference range 4.5 - 10.8; -[DIAGNOSES REDACTED]s Absolute flagged high at 9.7 (indicate possible infection), reference range 1.5 - 7.6); -Physician not notified of the flagged results until 9/5/20; -A hand written note on the laboratory report: 9/5/20, notified physician, sent to emergency room for further evaluation. During an interview on 9/14/20 at 11:04 A.M., Physician H said he/she was not notified of the laboratory report until the day the resident went to the hospital. He/she may have ordered antibiotics depending on if there were clinical signs of infection. Further review of the facility's pressure reports, used as facility tracking and not part of the resident's medical record, dated 9/2/20, showed the following for the resident: -Sacrum/coccyx, stage III, 11x8x1.5, undermining 1.3 and 2.5. Progress: Improved, cluster of 2 merged into 1, 75% slough; -Right hip, stage III, 3x6 (no depth measured). Progression: Remained same, cluster of 2, 100% slough. Review of the resident's skin grid pressure assessments, dated 9/3/20, showed: -Sacral: Progression: Improved. Site details: Length 11, width 8, depth 1.5, Stage III (appearance of wound bed and wound edges or presence of drainage and odors not documented); -Right trochanter: Progression: No change. Site details: length 3, width 6, no depth documented, Stage III (appearance of wound bed and wound edges or presence of drainage and odors not documented). Further review of the resident's medical record, showed: -An order dated 9/3/20 and start date 9/3/20, pressure reduction mattress to bed at all times, low air loss mattress for pressure reduction; -Nurses note dated 9/3/20 at 4:36 P.M., NP in to assess the resident. New orders given for low air loss mattress due to wounds. Mattress ordered, awaiting arrival; -Nurses note dated 9/5/20 at 11:02 A.M., resident noted to have cool clammy skin, sweating and unlike normal self. Resident unable to swallow and pocketing food. Vital signs: Blood pressure 104/54, respirations 24, oxygen saturation 99% on room air, pulse 78, temperature 97.1, blood sugar HI. Resident is alert, but unable to verbalize needs, wheezing noted upon transfer to the hospital via ambulance. -No further daily wound assessments, measurement or description documented; -No pressure reduction mattress ordered prior to 9/3/20. Review of the resident's hospital emergency room records, showed: -Arrived to the emergency roiagnom on [DATE] at 9:34 A.M., -Chief complaint: Weakness x 3 days at least, patient is non-verbal, blood sugar problem greater than 600 per nursing home; -Patient with past medical history of [REDACTED]. The patient was found in this state by the nursing providers today, per report from the facility nurse practitioner. He/she states that laboratory work from a few days ago showed an elevated potassium, as well as elevated blood sugar level. The resident is found minimally responsive, tachypneic (elevated respiratory rate), with blood sugar greater than 600 on finger stick assessment; -Physical exam: In acute distress, mottled (a purple discoloration of skin that occurs close to death), ill appearing; -Skin: Mottled diffusely. Grossly infected appearing, necrotic pressure ulcers to right hip, as well as coccyx. Purulent (puss filled, indication of infection) drainage fr

Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #[AGE]) received treatment and care in accordance with professional standards of practice by not investigating a dressing that had been in place for an extended period of time, not conducting routine skin assessments and not pursuing orders for care. The resident developed two additional wounds in three months time. The sample size was 24. The census was 124. Review of Resident #[AGE]'s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/26/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Unable to ambulate; -Dependent on staff for transfers; -Limited assistance required for bed mobility and hygiene; -[DIAGNOSES REDACTED]. The lymphatic system is a part of the immune system and vital for immune function); -Number of venous/arterial ulcers (ulcers/wounds caused by lack of blood flow): None. Review of the care plan, dated [DATE] and last revised on 2/1/20, showed the following: -Problem: Resident has increased nutrient needs for protein related to increased demands for nutrients due to wound healing; -Goal: Resident will consume an average of [AGE]% of food and oral supplement; -Interventions: Provide meals per physician diet orders and resident preferences, provide medical food supplement of Med Pass 2.0, [AGE] cubic centimeters (cc) four times a day, administer vitamin/mineral supplement, [MED], vitamin D and [MEDICATION NAME] [MED] (iron) per physician's orders [REDACTED]. Review of the only available skin assessment, dated 10/24/19, showed the following: -Any skin conditions or changes, ulcers or injuries? No; -Resident's skin is clean, dry and intact. Review of the wound care clinic's after visit summary, dated 10/31/19 at 12:12 P.M., showed the following: -Dressing change at the clinic on 11/4/19 at 8:00 A.M.; -Dressing change at the clinic on 11/7/19 at 2:00 P.M.; -Dressing change at the clinic on [DATE] at 8:00 A.M.; -Follow up with wound physician at the clinic on 11/14/19 at 10:00 A.M.; -Wound care: Apply aqua cel ag (a moisture-retention dressing which forms a gel on contact with wound fluid and has antimicrobial properties of ionic silver) to the open wound on left leg, cover with dry gauze, apply compression dressing and change twice weekly; -Apply medi grip stocking (provides light compression) to right lower leg. Review of the electronic order sheet (e-POS), showed no orders for wound care. Review of the treatment administration record (TAR) for November and December 2019 and January 2020, showed no entry regarding wound care. Review of the facility's weekly wound/pressure ulcer report, showed the resident's name not listed. Observation on 1/30/20 at 7:05 A.M., showed a strong, foul odor at the resident's bed. Certified Nurse Aide (CNA) A, present in the room, assisted with a skin assessment of the resident. The CNA removed the covers, and the odor intensified. There was a tight wrap on the resident's left lower leg and a compression stocking on the right lower leg. CNA A turned the resident to his/her right side, and the skin observed was intact. The surveyor requested a nurse to assist with the unwrapping of the resident's legs for a further skin assessment. During an interview on 1/30/20 at approximately 7:15 A.M., the resident said the dressing on his/her left leg had not been changed since the end of October. He/she had been going to the wound care clinic, and no one at the facility had removed the dressing since October. During an interview on 1/30/20 at 7:15 A.M., Licensed Practical Nurse (LPN) B said he/she would change the dressing after he/she finished morning tasks. During a follow up interview on 1/30/20 at approximately 7:25 A.M., LPN B said the wound nurse would arrive at the facility in approximately 15 minutes and would change the dressing. During a follow up interview on 1/30/20 at approximately 7:35 A.M., LPN B said LPN C/unit manager would be the one to change the resident's dressing, because the wound nurse would not be in. During an interview on 1/30/20 at 8:30 A.M., LPN C said he/she would change the resident's dressing at 9:30 A.M., and a further skin assessment could be done at that time. Observation on 1/30/20 at approximately 9:20 A.M., showed the Director of Nursing (DON) completing the dressing change on the resident's left lower leg, preventing a skin assessment at that time. The odor from the resident's leg had dissipated. When asked, the DON offered no explanation why she changed the dressing. The resident gave permission for the dressing to be changed a second time, to allow a skin assessment to be done. The DON and LPN C left the room. Observation on 1/30/20 at approximately 9:30 A.M., showed LPN C returned to the room with dressing supplies and removed the dressing from the resident's left lower leg. The skin of the left lower leg had the appearance of a prune, approximately 1/4 to 1/3 cup of dead skin lay at his/her foot, and three open areas were observed. LPN C said the open areas were vascular wounds. Measurement of the areas showed the wound on the left shin measured 2.4 centimeters (cm) long (head to toe) by 1.1 cm wide (side to side), the lateral (to the side) calf wound measured 1.7 cm long by 1.4 cm wide and lateral to that wound showed another area that measured 0.5 cm by 0.5 cm. All three open areas appeared clean and deep pink in color. After cleansing the open areas, LPN C applied calcium alginate (dressing for moderate to strong draining wounds that are partial to full thickness, including vascular/venous ulcers) to each open area and covered with gauze dressing, wrapped the leg from foot to knee with what he/she referred to as a padding layer, followed by a compression layer. Further review of the ePOS, showed an order, dated 1/30/20 at 8:57 A.M., to cleanse the leg wound with wound care (wound cleanser) then apply DermaGinate AG (same as aqua cel) to open wound on left leg, secure with dry gauze, apply [MEDICATION NAME] compression dressing (compression bandage designed for vascular ulcers) twice weekly on Monday and Thursday. During an interview on 2/3/20 at 10:40 A.M., a representative from the wound clinic said the resident had not been to the wound clinic since 10/31/19. He/she was scheduled to return on 11/4/19, 11/7/19, [DATE], 11/14/19 and 12/5/19. He/she said the clinic was told once or twice that the appointment was canceled by the facility due to transportation issues, and the other times the resident refused to go. He/she could not provide details of the wound but would have the wound care clinic nurse call. He/she said someone from the facility called the clinic on Thursday 1/30/20 and scheduled an appointment for [DATE]. During a follow up interview on 2/3/20 at 10:50 A.M., the resident lay in bed and said when he/she returned from the wound clinic on 10/31/19, a staff member took the paperwork, and the resident could not remember when he/she was supposed to go back for a follow up appointment. He/she said I would never refuse to go for an appointment. I don't want to lose my leg. Staff never mentioned anything about a visit to the wound care clinic. He/she added that his/her leg felt much better since the dressing was changed. Review of the medical record on 2/3/20 at approximately 11:00 A.M., showed no order for a visit at the wound care clinic on [DATE] and no documentation in the progress notes regarding a wound care appointment. During an interview on 2/3/20 at 12:13 P.M., a Registered Nurse (RN) at the wound care clinic reiterated the resident had not been to the wound clinic since 10/31/19, and he/she missed the last five appointments due to resident's refusal or transportation issues, as reported by the facility. At the time of the last visit, the resident had one wound located on his/her left shin. During an interview on 2/4/20 at 7:22 A.M., the administrator said the nurse should follow the physician's orders [REDACTED]. If a resident had a wrap on the leg, the nurse should take the initiative to remove it to see is what is there and get an order for [REDACTED]. During an interview on 2/4/20 at 9:03 A.M., the corporate nurse said the nurse should have noticed the dressing on the resident's leg and investigated by removing the wrap, calling the physician to obtain orders for the wounds, conducting follow up wound/skin assessments and monitoring the leg on the facility wound report. During an interview on 2/4/20 at 11:00 A.M., the DON said that on Thursday (1/30/20) morning she was in the MDS office when the MDS coordinator asked her if she knew anything about the resident having a wound. The DON said this resident was not even on her radar and she had no knowledge of any wounds. No one had brought that to her attention previously. She went to the resident's chart and did not see any wound care orders. She went to the resident and removed the wrap from the resident's left leg. She said LPN C obtained an order for [REDACTED]. When asked why she pursued the dressing/wound on Thursday (1/30/20), she said she believed that since a member of the survey team started asking questions, the staff started chattering and word got back to her. She added that the staff were supposed to perform weekly skin assessments on all residents, and the CNAs should check residents' skin during baths/showers. Review of the shower sheets for the month of January 2020, showed no available information for this resident, thus no skin assessment. During an interview on 2/5/20 at 12:20 P.M., the resident's physician said the resident has lymphadema and a history of [MEDICAL CONDITION], and he believed the resident was being seen at the wound care clinic for a venous ulcer. The nurse should have noticed the dressing, investigated the reason for the dressing and obtained orders for care. During an interview on 2/6/20 at 11:15 A.M., the wound care physician, who had been treating the resident, said, That's terrible that the dressing has not been removed in three months. The resident was supposed to return to the wound clinic a few days after the last visit in October, but they had not seen him/her since then. It was very possible that the lack of attention to the resident's leg could have contributed to additional wounds. The resident's leg could have developed some swelling, and the continued pressure on his/her skin, with no relief, would not have been good.

Based upon the information gathered during the investigative process a regulatory violation was substantiated. The facility received a citation at F686. For additional information see the SOD at event ID #8XRR12.

Based on observation, interview and record review, the facility failed to ensure staff provided consistent monitoring, assessments, documentation and physician updates for two full code residents that experienced changes in their conditions. One was found lifeless and unable to be revived and the other was found unresponsive and transferred to the hospital (Residents #278 and #104). The census was 130. Review of the facility's policy regarding Skilled Documentation Guidelines, updated [DATE], showed: -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Daily clinical notes are written by a licensed clinician to provide documentation/evidence that care services meet and have been provided above the criteria for more than routine care. Residents receiving skilled services should be assessed/evaluated overall but documentation should reflect specific charting assessments/evaluations based on diagnosis, physician requirements and resident needs that require a skilled clinician; -Procedure: 1. Completed and thorough notes must be written for each resident receiving skilled care. Each resident will have specific care needs with resident specific documentation of care provided that will be reflected in the progress note; -A. Clinical notes for Respiratory Conditions (pneumonia, [MEDICAL CONDITIONS] ([MEDICAL CONDITION])) may include: Lung sounds (each shift), abnormal sounds and location, nature of respirations, depth and rate, use of accessory muscles, sounds audible without stethoscope, dyspnea (difficult or labored breathing) on exertion and/or at rest, cough, productive or non productive, moist or dry, depth (deep or shallow), frequency, describe any sputum produced (color, consistency and amount), temperature: take every four hours while febrile (with an elevated temperature), monitor in the morning and in the evening, hydration, resident newly ill with a respiratory disease should be on intake and output (I & O). Note the adequacy of fluid intake and how much encouragement resident needs to take fluids. 1. Review of Resident #278's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -Limited staff assistance for personal hygiene; -Extensive staff assistance for bed mobility and dressing; -Total staff assistance for transfers and toileting; -Incontinent of bowel and bladder. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. to an infection) and acute [MEDICAL CONDITION] with hypercapnia (too much carbon [MEDICATION NAME] in the blood); -Cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]); -Vital signs every shift; -Levalbuteral Nebulzation solution (a [MEDICATION NAME] used to prevent and treat wheezing and shortness of breath caused by breathing problems) one vial every four hours as needed for shortness of breath/wheezing; -Order dated [DATE], oxygen at two L per nasal cannula every shift. Review of the resident's care plan, updated [DATE], showed: -Problem: At risk for ineffective tissue perfusion (decreased in oxygen to the tissues) related to [MEDICAL CONDITION], with a history of [MEDICAL CONDITION]; -Approach: Assist the resident/family/caregiver of signs/symptoms of respiratory compromise. Maintain a clear airway by encouraging the resident to clear his/her own secretions with effective coughing. Suction as needed to clear airway. Monitor/document changes in orientation, increased restlessness, anxiety and air hunger. Monitor breathing patterns. Report abnormalities to the physician: nasal flaring, respiratory depth changes, altered chest excursion, use of accessory muscles, pursed lip breathing (is an act of inhaling through the nose and exhaling slowly against pursed lips), oxygen as ordered and oxygen saturations (O2 sat, amount of oxygen in the blood). Review of the resident's progress notes, showed: -[DATE] 10:19 A.M.: Resident noted to have weakness. Skin warm and dry to the touch. Head of bed (HOB) evaluated. Answers to name and responds to staff when name called. Resident did not eat or drink this am. Encouraged to eat and assist given, updated the physician and new orders noted; [DATE] at 11:00 A.M.: Urine obtained and placed in refrigerator. 1:35 P.M.: Labs not drawn yet. Updated responsible party on change in status and noted behaviors. Responsible party wants resident to go to the ER, DON (Director of Nurses) aware. 2:41 P.M.: Gateway called for transport. 2:55 P.M.: Ambulance here, given report, updated on residents condition. 5:16 P.M.: Resident admitted to hospital for altered vital signs and mental status; -[DATE] at 10:10 P.M.: Skilled Documentation: Readmit. hospitalized with left lower lobe pneumonia. Blood pressure: ,[DATE] (normal ,[DATE]), Temperature: 98.2 (normal 98.6), Pulse 80 (normal 60 - 100), Respirations 20 (normal ,[DATE]). Lung sounds: Abnormal breath sounds noted, wheezing (a high-pitched [MEDICATION NAME] sound made while breathing. It's often associated with difficulty breathing). Antibiotic therapy: pneumonia; -[DATE] 10:26 P.M.: Resident returned from hospital. Alert, stable, denies pain. Transferred to bed with assist of two without difficulty. Lungs with some wheezing on the left side. Right lung clear to auscultation. Oxygen at 3 liters (L) per minute. O2 sat at 98% (normal ,[DATE]). Call to the physician to verify discharge orders. Review of the resident's Medication Administration Record [REDACTED] -Levalbuteral HCL nebulization solution one vial orally via nebulizer every four hours as needed for shortness of breath/wheezing. No documentation staff administered the medication; -Oxygen at two liters every shift. Staff documented as administered: [DATE] night shift O2 Sat of 94%; [DATE] on day shift O2 Sat of 94%, evening shift O2 Sat of 94%, nights: blank; [DATE] on day shift O2 Sat of 95%, evening shift O2 Sat of 94% and night shift 96%. Review of the resident's POS, showed an order dated [DATE], to send the resident to the hospital emergency room for evaluation. Review of the resident's progress notes, showed: -[DATE] at 6:01 A.M. through 5:29 P.M., and [DATE] at 2:10 P.M., showed no documentation regarding the order dated [DATE], to send the resident to the emergency room . No documentation regarding the resident's lung sounds or vital signs documented; -No further documentation regarding the resident's condition until [DATE] at 5:00 A.M.; -[DATE] at 5:00 A.M.: Resident found in bed unresponsive with no pulse. Resident is a full code. CPR initiated and 911 called. CPR in progress when paramedics entered the room. Monitor placed on resident to determine heart activity, none noted. CPR stopped at 5:14 A.M. Physician notified, cause of death [MEDICAL CONDITIONS]. Resident's family member notified. During an interview on [DATE] at 1:25 P.M., Certified Nurse Aid (CNA) EE said the resident was in and out of the hospital. He/she didn't recall who his/her aide was that day. During an interview on [DATE] at 1:30 P.M., CNA FF said he/she remembered talking with resident when he/she returned from the hospital. He/she and other staff were surprised by the resident's death. During an interview on [DATE] at 1:47 P.M., Nurse W said when a resident is admitted to the facility, the nurse should document the resident's condition for 72 hours unless there is problem. The nurse should continue to document until the resident is stable. The documentation should include a full assessment including lung sounds and vital signs. During an interview on [DATE] at 6:57 A.M., Certified Medication Technician (CMT) X said the resident's respirations were bad a few days before he/she passed away. During an interview on [DATE] at 3:02 P.M., the Medical Director said she would expect the staff to monitor and document the resident's vitals signs, O2 sats every shift for 7 days and if the resident wasn't receiving skilled services at least 72 hours. During an interview on [DATE] at 4:05 P.M., the administrator said the resident was receiving skilled nursing services for pneumonia. She would have expected staff to document any abnormal findings in the nurse's notes and notify the physician. During an interview on [DATE] at 9:45 A.M., the administrator said if the resident is in a skilled bed for therapy or for skilled nursing, staff should document daily, every shift until the resident comes off skilled services. During an interview on [DATE] at 2:33 P.M., the resident's physician said after admission, he would expect staff to assess and document. It is the facility's responsibility to train agency staff. They should document assessments after the resident was readmitted from the hospital. Staff should document any change and notify the physician. During an interview on [DATE] at 5:48 P.M. the facility's regional nurse director of clinical operations said she would expect a skilled note at least once per day. The facility charts by exception, but if there are abnormal findings she would expect the staff to document and call the physician. 2. Review of Resident #104's significant change in status MDS, dated [DATE], showed: -Adequate hearing; -Clear speech, distinct intelligible words; -Ability to express ideas and wants: Sometimes understands, responds to simple, direct communication only; -Ability to understand others: Usually understands, misses some/part of message but comprehends most of conversation; -Extensive assistance of two (+) persons required for transfers; -Total dependence of one person required for dressing, eating and personal hygiene; -[DIAGNOSES REDACTED]. -Pain in the past five days: Yes; -Feeding tube (gastrostomy tube ([DEVICE]), a tube inserted into the the stomach through the abdomen to infuse nutrition, water and medications). Review of the resident's current care plan, showed: -Impaired cognitive functions/dementia or impaired thought processes related to short term memory loss, long term memory loss: Discuss concerns about confusion, disease process with resident/family. Engage resident in simple, structured activities; -Alteration in comfort related to chronic pain, depression and limited mobility. Resident is able to call for assist when in pain, ask for medication and say how much pain he/she is in; -Monitor/record/report any signs symptoms of non-verbal pain (noisy, deep/shallow or labored breathing), vocalizations (grunting, moans, yelling out, silence), face (sad, crying, worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled up, thrashing); -[MEDICAL CONDITION] or an acute (sudden) confusional episode related to acute disease process dementia: Identify yourself at each interaction, face resident when speaking and make eye contact. Resident understands consistent, simple, direct questions; -Full code status. Observation on [DATE] at 9:35 A.M., showed the resident lay in bed, with the head of the bed up. The resident said he/she was fine, but would like to be repositioned. Observation on [DATE] at 5:56 A.M., showed the resident lay in bed awake, with the head of the bed up. He/she did not engage in conversation during the observation. Review of the resident's nurse's progress notes and medical record, showed: -[DATE] at 5:03 P.M.: The resident was in a wheelchair and noted to have a small emesis (vomit). The resident's tube feeding was disconnected and he/she was transferred back to bed. Noted cough, no wheezes. Blood pressure ,[DATE], heart rate 100, temperature 100.1 degrees, axillary (underneath the arm, an axillary temperature is usually 0.5 to 1 degree lower than an oral temperature, the average oral temperature is 98.6 degrees), oxygen saturation rate of 94% room air. physician's orders [REDACTED]. -[DATE] at 6:03 P.M.: Mobile x-ray here for x-ray; -[DATE] at 9:45 P.M.: Still awaiting chest x-ray results. Resident resting in bed with the head of the bed elevated, no other emesis noted. [DEVICE] residual 20 cubic centimeters (cc) (residual is checked to determine volume of fluid remaining in the stomach during feeding, a residual of 200 to 250 cc or less is considered normal). Tube feeding held. No signs or symptoms of pain or discomfort; -A radiology (chest x-ray) report, showed the following: Date of service [DATE], lungs clear, normal cardiac size. Conclusion: No acute cardiopulmonary findings; -No follow-up monitoring, assessment or physician notification (regarding the change of condition as documented on [DATE] at 5:03 P.M.) was documented on the 11:00 P.M. to 7:00 A.M. shift (11:00 P.M. beginning on [DATE] and ending on [DATE] at 7:00 A.M.), the 7:00 A.M. to 3:00 P.M. shift for [DATE], or the 3:00 P.M. to 11:00 P.M. shift on [DATE]). Observation on [DATE] at 6:42 A.M. and 7:34 A.M., showed the resident lay in bed with the head of the bed up. His/her eyes were closed. Review of the resident's nurse's progress notes, showed: -[DATE] at 1:32 A.M.: At midnight rounds, the resident was found unresponsive. 911 was called at 12:42 A.M., they arrived at 12:50 A.M. Physician and DON were notified at 1:06 A.M. Resident is on the way to the hospital; -[DATE] at 6:26 A.M.: Call placed to hospital. The resident was admitted with a [DIAGNOSES REDACTED]. Observation and interview on [DATE] at 6:09 A.M., showed the resident was not in his/her room and his/her bed had been stripped. CMT X said he/she worked the midnight shift and sent the resident to the hospital. Last night during shift report, the evening shift nurse said the resident had been having emesis during the evening and they turned off the resident's tube feeding pump. They did not call the resident's physician. He/she went in the resident's room around midnight. The resident had an emesis and was unresponsive. He/she called 911. The resident was sent to the hospital and diagnosed with [REDACTED]. During an interview on [DATE] at 9:00 A.M., Nurse Y said he/she took care of the resident on the day shift on [DATE]. He/she was in the resident's room several times during his/her shift. At around 10:00 A.M., CNA BB told him/her there was something on a towel that was laying on the resident. He/she went in to the resident's room and there was brown liquid resembling tube feeding. He/she turned off the tube feeding pump and cleaned the resident's mouth. He/she did not see leaks in the tube feeding line and did not see any brown liquid in the resident's mouth. At around 12:00 P.M. or 1:00 P.M., he/she turned the tube feeding pump back on. Nurse Y checked on the resident one more time before his/her shift ended. He/she did not obtain the resident's vital signs, assign anyone to obtain the resident's vital signs, or document any of his/her observations or assessments He/she did not contact the physician regarding the resident's emesis or turning off the tube feeding pump. He/she informed Nurse AA (evening shift nurse) about the resident at the shift change. During an interview on [DATE] at 9:35 A.M., CNA Z said he/she was not the resident's CNA on the day shift of [DATE], but he/she did assist CNA BB in taking care of the resident. The resident had a towel laying over him/her when they went in the room around noon. The towel had brown spots on it. He/she helped CNA BB reposition the resident. The resident said it hurt when they turned him/her, but that was normal for the resident. The tube feeding was on. He/she did not see tube feeding leaking anywhere. That was the only time he/she went into the resident's room. During a telephone interview on [DATE] at 11:41 A.M., CNA BB said he/she worked the day shift on [DATE]. The resident was not feeling well, he/she was kind of throwing up a bit. Just a little bit of throwing up. He/she asked Nurse Y to come in the room. Nurse Y placed the tube feeding on hold. CNA BB cleaned the resident then left. Nurse Y did not ask him/he to obtain vitals, and he/she did not see Nurse Y assess the resident or obtain vitals. CNA BB went back to the resident's room later, but he/she could not recall if the tube feeding was on or off that time. Someone else, maybe a hospice person, he/she was not sure, but it was someone that comes in every couple of days or so to see the resident, told him/her they had to change the resident's gown again because of an emesis. CNA BB did not remember if he/she told Nurse Y about that or not. During a telephone interview on [DATE] at 11:39 A.M., Nurse AA, said he/she was assigned to the resident on the evening shift on [DATE]. He/she is new at the facility and [DATE] was the second time he/she worked alone. He/she did not know the residents very well. He/she arrived for work around 2:45 P.M. and received report from Nurse Y. He/she and Nurse Y did a walking round about 3:30 P.M. Nurse Y said the resident had emesis on the day shift. The resident did have what appeared to be emesis on a towel that laid on top of him/her. The tube feeding had been turned off. At around 4:00 P.M., he/she went into the resident's room alone. The resident had another emesis. He/she asked CNA CC to clean the resident. At around 5:30 P.M., the resident had not had another emesis, so he/she turned the tube feeding back on. The resident moaned, kind of grimaced as if he/she wanted to be left alone when he/she touched him/her. He/she did assess the resident's skin, which was warm and his/her color was good. The resident was not speaking to him/her, but since he/she was new, he/she did not know if that was different for the resident. The last time he/she checked the resident was around 7:00 P.M. or 7:15 P.M., and the resident appeared to be fine. He/she did not obtain a set of vitals, document an assessment of the resident or notify the resident's physician regarding the emesis on the day shift or evening shift. He/she got overwhelmed during the shift and forgot to do those things but should have. CNA CC did not tell him/her the resident was gagging or mumbling. Had he/she been informed the resident was gagging, he/she would have obtained a set of vitals and probably sent the resident to the hospital. During a telephone interview on [DATE] at 1:19 P.M., CNA CC said he/she had worked with the resident several times. He/she made rounds around 3:00 P.M. on [DATE]. The resident was dry at that time and seemed alright. After dinner, Nurse AA said the resident had vomited and asked him/her to clean the resident up. He/she went into the resident's room. The resident had vomited a medium amount of brown colored fluid, his/her tube feeding was still infusing. The resident was not like his/her normal self, he/she was not speaking like he/she normally did, just grumbling and mumbling. He/she asked Nurse DD to come into the resident's room, because Nurse AA was passing medications. Nurse DD turned the resident's tube feeding pump off. CNA CC cleaned the resident, there was some brown fluid in the resident's mouth. He/she checked on the resident a couple more times before leaving that evening. The last time was around 9:15 P.M. The resident was not vomiting any longer, but he/she was gagging, like heaving. The resident was still not speaking to him/her those last two times. The resident's tube feeding was still off. He/she told Nurse AA about the resident heaving and gagging. During an interview on [DATE] at 4:46 P.M., Nurse DD said he/she worked the evening shift on [DATE], but was not the resident's nurse. He/she was familiar with the resident and had cared for the resident before. The resident has been a bit more sleepy over the past week. He/she was the nurse that wrote the nurse's note on [DATE] at 5:03 P.M. and received the order for the chest x-ray. He/she reported the emesis and pending chest x-ray results to the midnight nurse at shift change on [DATE]. He/she had not worked with the resident since that time. On the evening shift of [DATE], CNA CC asked him/her to see the resident because the resident had an emesis. He/she went to the resident's room and turned the tube feeding pump off. He/she asked CNA CC if Nurse AA was aware of the emesis and the resident's condition. CNA CC said Nurse AA was aware, so he/she assumed Nurse AA had assessed the resident at that point. He/she went back to his/her own side after CNA CC told him/her Nurse AA was aware. If he/she had been the resident's nurse that evening, he/she would have obtained vitals, completed an assessment and called the physician. During an interview on [DATE] at 10:21 A.M., the DON reviewed the resident's nurse's notes and said staff should have documented every shift and as necessary after the first emesis. They should have continued to assess and document until the resident was stable. The physician should have been updated if the symptoms did not stop. She was not notified of this, but should have been. During an interview on [DATE] at 3:00 PM, the resident's physician, also the facility Medical Director, reviewed the resident's nurse's progress notes. She would have expected facility staff to monitor, assess and document every shift after the first emesis was identified on [DATE] at 5:03 P.M. She would have expected the assessments and documentation to continue until the resident was no longer symptomatic and stable. If the resident continued to have symptoms, she would have expected staff to contact her.

Based on observation, interview and record review, the facility failed to follow physician's orders for weight loss prevention and nutritional needs and ensure acceptable parameters for nutritional status were maintained to prevent severe weight loss for one resident, who experienced a 12.01% weight loss within a three month period and another sampled resident who experienced weight loss. The facility identified 10 residents who received tube feedings. Of those 10, four were chosen for the sample of 26 and problems were found with two (Residents #5 and #102). The census was 130. 1. Review of Resident #5's Admission Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/18, showed: -Entry date of 11/26/18; -Severely impaired cognitive skills for daily decision making; -Altered level of consciousness; -Required total assistance of one staff for eating; -[DIAGNOSES REDACTED]. -Required a feeding tube (gastrostomy tube ([DEVICE]) a tube inserted through the abdomen that delivers nutrition directly to the stomach); -Proportion of calories received while tube feeding was 26 to 50%; -Height and weight: Blank. Review of the resident's weight summary sheet, showed the resident weighed 143.2 pounds (lbs) on 12/10/18. Review of the resident's undated care plan, showed: -Focus: Initiated on 12/4/18, the resident had a nutritional problem and required eternal nutrition and hydration via feeding tube to meet his/her needs; -Goal: Maintain adequate nutritional and hydration status as evidenced by maintaining weight within 5% for one month and 10% within six months, no signs and symptoms of malnutrition (lack of proper nutrition caused by not having enough to eat) or dehydration to meet estimated needs through the next review date; -Focus: Initiated on 12/28/18, the resident had impaired mobility and no means of verbal communication. He/she required total assistance with all activities of daily living care; -Interventions: The resident received nothing by mouth (NPO). He/she required total assistance for tube feeding; -Interventions: Initiated on 1/2/19, the resident was NPO. Administer [MEDICATION NAME] 1.5 (therapeutic nutrition that provides complete, balanced nutrition for patients who are tube fed, with increased calorie and protein needs, or those with limited volume tolerance), at 55 cubic centimeter (cc) per hour for 20 hours, allowing four hours for the resident to be detached for care. Continue to monitor weight. Review of the resident's electronic physician's order sheet (POS), dated 1/1/19 through 3/31/19, showed: -[DIAGNOSES REDACTED]. -NPO diet due to a stroke, beginning 11/27/18; -On 2/27/19, an internal feed order every shift until 3/1/19. Increase [MEDICATION NAME] 1.5 to 35 cc per hour continuously. The order was completed; -On 2/27/19, an internal feed order every shift until 3/1/19. Increase [MEDICATION NAME] 1.5 to 45 cc per hour continuously. The order was completed; -On 2/27/19, an internal feed order every shift for [MEDICATION NAME] 1.5 at 55 cc per hour continuously from 4:00 A.M. to 12:00 A.M. Start date was 3/3/19. Review of the resident's nurse's note, dated 1/31/19 at 11:40 A.M., showed a weight warning. The resident weighed 139.6 lbs. Recommended tube feeding change to [MEDICATION NAME] 1.5 at 55 cc per hour, allowing four hours for the resident to be detached for care. Further review of the resident's nurse's note, dated 2/20/19 at 2:31 P.M., showed a weight warning. The resident weighed 131.3 lbs. The resident was reviewed for significant weight loss. He/she remained NPO and required internal nutrition to meet 100% of nutritional and hydration needs. The resident was placed on tube feeding of Ensure (a nutritional supplement) 30 ml per hour from 6:00 A.M. to 12:00 A.M. This would provide a total of 501 kcals (kilo calorie, a unit of energy of 1000 calories) (30% of estimated needs) and 20.5 grams of protein (37 percent of estimated protein needs). Weight loss related to inadequate internal nutrition. Recommended tube feeding change to [MEDICATION NAME] 1.5 at 55 cc per hour, allowing four hours for the resident to be detached for care. Start tube feeding at 25 ml per hour and increase by 10 cc per hour every day until final rate of 55 cc per hour is met in three days. Continue to monitor weights. Further review of the resident's weight summary sheet, showed the resident weighed 131.0 lbs on 3/11/19. Review of the resident's paper POS, showed an order dated 3/14/19, for a tube feeding change. Ensure Plus, 30 milliliters (ml) per hour from 6:00 A.M. until midnight (12:00 A.M.). Further review of the resident's electronic POS, showed an order, dated 3/14/19, for Ensure Plus Liquid. Give 30 ml per hour via feeding tube every 18 hours for tube feeding, starting at 6:00 A.M. and off at 12:00 A.M. The order was discontinued. Review of the resident's Medication Administration Record [REDACTED] -Internal Feed Order every shift for [MEDICATION NAME] 1.5 at 55 cc per hour continuously from 4:00 A.M. until 12:00 A.M., signed it was given from 3/3/19 through 3/19/19; -Ensure Plus Liquid. Give 30 ml per hour via feeding tube every 18 hours for tube feeding starting at 6:00 A.M. and off at 12:00 A.M., signed it was given on 3/15/19, 3/16/19, 3/17/19 and 3/18/19. Further review of the MAR, showed the Ensure was discontinued on 3/18/19. During an interview on 3/18/19 at 1:20 P.M., the registered dietician (RD) said the resident was supposed to receive [MEDICATION NAME] 1.5 at 55 ml cc per hour for 20 hours. The order began on 2/27/19. The [MEDICATION NAME] started at 35 cc per hour and progressed within a three day period, until it reached 55 ml. She never recommended Ensure. It would not have met the resident's nutritional needs. The resident was on hospice and the hospice company could change the resident's orders. However, the resident was doing well and had shown progress. They were thinking about taking him/her off hospice to place him/her in speech therapy because he/she could now respond to verbal prompts. The resident had a significant weight loss due to his/her tube feeding not meeting his/her nutritional needs. The resident never received Ensure while in the facility. She was not sure why it was listed on the POS. The RD would make the recommendations and provide the information to the unit nurse. The unit nurse was responsible for ensuring her recommendations were communicated with the physician and placed on the resident's POS. The orders should have been clear and easy to comprehend. During an interview on 3/19/19, at 7:06 A.M., Social Worker II said he/she was not aware of a discussion regarding taking the resident off hospice. The hospice company was at the facility frequently. The resident made tremendous progress and was able to respond verbally to prompts. Observation on 3/14/19 at 8:47 A.M., showed the resident lay in bed and received his/her tube feeding. [MEDICATION NAME] 1.5 at 55 cc, dated 3/14/19 at 4:00 A.M. to 12:00 A.M., with 500 ml left to count. The pump was infusing at 35 ml per hour with 100 ml flush per hour. Observation on 3/14/19 at 11:15 A.M., showed the resident lay in bed and received his/her tube feeding. [MEDICATION NAME] 1.5 at 55 cc, dated 3/14/19 at 4:00 A.M. to 12:00 A.M., with 350 ml left to count. The pump was infusing at 35 ml per hour with 100 ml flush per hour. Observations on 3/18/19 at 7:06 A.M., 9:30 A.M., and 1:42 P.M., showed the resident lay in bed and received his/her tube feeding. [MEDICATION NAME] 1.5, dated 3/18/19 at 6:00 A.M. The running feed rate was 30 ml per hour. Observation on 3/18/19 at 12:40 P.M., showed Restorative Therapy Aide (RTA) U and Certified Nurse Aide (CNA) EE weighed the resident. His/her weight was 126 lbs. This was a total weight loss of 12.01%, since his/her beginning weight of 143.2 lbs on 12/10/18. (Centers for Medicare & Medicaid Services (CMS), guidelines define severe weight loss as a loss of greater than 5% in one month, greater than 7.5% in three months and greater than 10% in six months). During an interview on 3/18/19 at 2:20 P.M., Nurse N said the resident was supposed to receive 30 ml per cc of [MEDICATION NAME] 1.5. The last time he/she checked the resident's orders, he/she received 30 ml and was off for four hours. During an observation and interview on 3/18/19 at 2:21 P.M., Nurse N checked the resident's electronic POS and said the resident was supposed to receive [MEDICATION NAME] 1.5, infusing at 55 cc per hour. He/she thought it was for 30 cc per hour. Due to the resident not receiving the proper amount, it could have caused a significant weight loss. During an interview on 3/19/19 at 7:22 A.M., the Director of Nurses (DON) said hospice changed the resident's order to Ensure back in January. When she was shown the order for Ensure dated 3/14/19, she said she was not aware of the order. If the order was for [MEDICATION NAME] at 55 cc per hour, the resident should have received the [MEDICATION NAME] at 55 cc per hour. If he/she received 30 cc per hour, he/she would not have his/her nutritional needs met and would have lost weight. 143 lbs to 126 lbs within a three month period was a significant weight loss. The orders should have been clear. She said she could not explain the 3/14/19 order for Ensure. During an interview on 3/19/19 at 2:10 P.M., the DON and regional director of clinical operations said Nurse N signed off that he/she gave the resident Ensure and [MEDICATION NAME], but the resident never received Ensure. This was verified by the RD. Observation on 3/19/19 at 2:17 P.M., showed the resident lay and bed and received [MEDICATION NAME] 1.5 at 30 cc per hour. During an interview on 3/19/19 at 2:15 P.M., Nurse N said there was a paper physician's order for Ensure at 30 cc per hour. He/she never gave the resident Ensure because he/she was on [MEDICATION NAME] 1.5 at 55 cc per hour. He/she was confused about the order. Today (3/19/19) the resident was placed back on Ensure at 30 cc per hour due to not being able to tolerate 55 cc per hour. Hospice gave the order because they would not pay for [MEDICATION NAME]. He/she infused the [MEDICATION NAME] at 30 cc since the Ensure was to be infused at 30 cc per hour. During an interview on 3/19/19 at 2:20 P.M., Physician E said hospice could recommend an order, but it had to be approved by her. It was possible the resident received an order for [REDACTED]. This would cause a significant weight loss because the resident would not have received the adequate protein intake. The resident experienced a significant weight loss within a three month period because he/she received the [MEDICATION NAME] at 30 cc per hour. The resident never received Ensure and the nurse should not have signed the MAR indicated [REDACTED]. During an interview on 3/20/19 at 9:49 A.M., the administrator said they did not have a policy on the prevention of weight loss. They have a facility meeting every Wednesday for a risk review and weight loss is discussed. They follow the parameters of Center for Medicare Services (CMS) regarding weight loss. During an interview on 3/20/19 at 4:45 P.M., the administrator, and the regional director of clinical operations said staff was expected to follow the physician's orders. The resident experienced a significant weight loss within the three month time frame. The orders should have been clear to read so staff could determine what the resident was supposed to receive. 2. Review of Resident #102's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -No behaviors; -Total dependence with activities of daily living; -[DIAGNOSES REDACTED]. -Weight: 224 lbs; -Weigh loss of 5% or more in the last month or loss of 10% or more in the last six months: Yes; -Feeding tube; -51% or more of total calories through the tube feeding. Review of the resident weight change note, dated 1/21/19, showed he/she was reviewed for significant weight loss times three months. The resident remains NPO and requires 100% of nutrition and hydration via [DEVICE] Review of the resident's POS, showed an order dated 2/12/19, for a tube feed order every fours, Formula: Glucerna 1.5 (Specialized high-calorie nutrition with a unique carbohydrate blend for enhanced glycemic control), give one can (237 cc) via feeding tube. Review of the resident's care plan, updated on 2/14/19, showed: -Focus: Requires tube feeding with regards to a stroke; -Goal: Will maintain adequate nutritional and hydration status and a stable weight with no sign or symptoms of malnutrition or dehydration through the next review date; -Intervention: Dependent with the tube feeding and water flushes. See the resident's physician's orders for current feeding orders. Review of the resident's MAR, dated (MONTH) 2019, showed blank spots for Glucerna on the following days: -2/14, 2/15, 2/16, 2/17 at 1:00 A.M. and 5:00 A.M.; -2/21 at 1:00 A.M.; -2/27 at 5:00 A.M. Review of the resident's MAR, dated (MONTH) 2019, showed blank spots for Glucerna on the following days: -3/1 and 3/2 at 5:00 A.M.; -3/3 and 3/4 at 1:00 A.M. and 5:00 A.M.; -3/7, 3/9, 3/14 and 3/15 at 1:00 A.M. and 5:00 A.M.; -3/18 at 5:00 A.M. Review of the resident's medical record, showed the following weights for (MONTH) 2019 and (MONTH) 2019: -February (unknown date): 223.6 lbs; -3/13: 203 lbs; -3/14 (reweigh): 214 lbs; -3/20: 213 lbs. (This represents a 10.6 lb or 4.75% weight loss in one month). Observation on 3/18/19 at 12:30 P.M., of central supply room [ROOM NUMBER], showed cans of Glucerna available for use. During an interview on 3/20/19 at 2:45 P.M., the Registered Dietitian (RD) said the resident's Glucerna order is a carbohydrate steady nutritional drink which meets 100% of the resident's nutritional needs. It is very important for the resident to receive the nutritional drink as ordered. She reviewed the resident's MAR, and was aware the resident was not receiving the nutritional drink as ordered. She reported the concern to the DON and the regional director of clinical operations during the stand up meetings, but did not know if the concern was addressed. The resident has lost 50 pounds since being admitted to the facility in (MONTH) of (YEAR). During an interview on 3/20/19 at 2:55 P.M., the regional director of clinical operations said the RD brought the concern to her attention. They did do a can count of the nutritional drink but did not knows the exact count. If the MAR indicated [REDACTED]. She would expect the nutritional drink to be administered as ordered.

Based on observation, interview and record review, the facility failed to prevent one of three sampled residents (Resident #1) from acquiring pressure ulcers, failed to obtain necessary treatment orders to treat the pressure ulcers, and failed to prevent the pressure ulcers from worsening. A total of eight residents had pressure ulcers. The census was 112. Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's nurse's admission assessment, dated 6/28/18, showed the resident's left hip wound bed was red, with edges intact, and a small amount of drainage. Review of the resident's nurse's progress note, dated 6/28/18 at 7:37 P.M., showed the resident had a reddened area on his/her left hip. Review of the resident's nurse's progress note, dated 6/29/18 at 12:30 P.M., showed the resident had a left trochanter (hip) wound. Review of the physician's history and physical, dated 6/29/18, showed the resident's skin had no open areas. Review of the resident's nurse's assessment, dated 7/2/18, showed the resident had a left hip (buttock) stage II (partial thickness skin loss involving the epidermis and/or dermis. Superficial and presents clinically as an abrasion, blister or shallow crater) pressure ulcer, which measured 2 centimeters (cm) in length, by 3 cm in width. Review of the resident's (MONTH) (YEAR), nurse's progress notes, showed no notification of the physician and no treatment order obtained regarding the resident's left buttock stage II pressure ulcer. Review of the resident's (MONTH) (YEAR), treatment administration record (TAR), showed no treatments documented as completed to the left hip stage II pressure ulcer. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/18, showed the following: -No memory problem; -Verbal behavioral symptoms directed toward others; -Required extensive assistance with care and transfers; -Able to propel him/herself in the wheelchair; -Required intermittent catheterization; -Stage II pressure ulcer present upon admission. Review of the resident's care plan, dated 7/7/18, showed the following: -Resident is resistive to care, refused to allow nurse to complete scheduled treatment; --Interventions/Tasks: ---Allow resident to make decisions about treatment regime, to provide sense of control; ---Educate resident/family/caregivers of the possible outcome of not complying with treatment or care; ---Give clear explanation of all care activities prior to and as they occur during each contact; ---If possible, negotiate a time for activities of daily living (ADLs), so the resident participates in the decision making process. Return at the agreed upon time; ---Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. -Resident has potential to demonstrate verbally abusive behaviors, related to poor impulse control. Resident has used profanity/verbally abusive with staff; --Interventions/Tasks: ---Psychiatric consult as indicated; ---Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; ---When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later; ---Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. -Resident has actual impairment to skin integrity, surgical wound to mid back (sutures); --Interventions/Tasks: ---Has pressure relieving/reducing mattress while in bed and pressure reducing cushion while in chair to protect the skin; ---Educate resident/family/caregivers of causative factors and measures to prevent skin injury; ---Encourage good nutrition and hydration in order to promote healthier skin; ---Identify/document potential causative factors and eliminate/resolve where possible; ---Keep skin clean and dry. Use lotion on dry skin; ---Monitor/document location, size and treatment of [REDACTED]. ---Order blood work and cultures of any open wounds, as ordered by the physician; ---Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the resident's nurse's progress note, dated 7/24/18 at 7:05 P.M., showed staff documented the resident asked the nurse to look at his/her bottom. Upon assessment, resident noted to have open area to both buttocks. Left buttock 4 by 4, with black necrotic (dead tissue) tissue in center. Right buttock 3 by 3, with black necrotic tissue in center and yellow slough (dead tissue) around edges. Areas cleansed and Santyl ([MEDICATION NAME] ointment) applied with dry dressing. Review of the resident's nurse's assessment, dated 7/24/18, showed staff documented the resident's left buttock pressure ulcer was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed), and measured 4 cm in length, by 4 cm in width, with eschar. The resident also had a right buttock unstageable pressure ulcer, which measured 3 cm in length, by 3 cm in width, with eschar and slough present. Review of the resident's physician's orders [REDACTED]. Review of the resident's (MONTH) (YEAR), Treatment Administration Record (TAR) showed no pressure ulcer treatment documented as completed until 7/25/18, on the resident's left and right buttock pressure ulcers. The treatment was also not documented as completed on 7/27/18. Review of the resident's nurse's progress note, dated 7/31/18, showed the following: -At 2:06 P.M., the resident was seen during wound rounds that morning. Resident had expressed toward the end of last week, that he/she had a wound on each side of his/her bottom. Resident agreed to allow nurse to bring wound doctor in to see the areas when he/she came in for rounds. Resident stated the wounds just happened. During wound rounds the resident was observed to have two unstageable wounds. The right buttock measured 4 cm by 4 cm, covered with soft eschar, and the left buttock measured 4.3 cm by 3 cm, covered with soft eschar: -At 2:20 P.M., the resident stated that he/she only had the wounds on his/her bottom for less than a week. After leaving the resident's room, this writer was able to clarify that the resident's wounds had in fact been there for much longer than one week, at the minimum three weeks, but likely longer than that. Review of the resident's POS, showed the following: -An ordered dated 7/31/18, to cover the right and left buttock pressure ulcer with [MEDICATION NAME] (antiseptic solution), cover with silver alginate (antimicrobial dressing), cut to fit anterior area of wound, cover with gauze or ABD (Army Battle Dressing. Abdominal pad dressing used for large wounds requiring high absorbency), and cover with foam dressing daily, every day shift, til healed, for skin integrity; -An order dated 8/3/18, for [MEDICATION NAME] (antibacterial) tablet 875-125 milligram, give one tablet by mouth two times a day for 7 days, for infection. Review of the resident's TAR, dated (MONTH) (YEAR), showed no treatment documented as completed on 8/4/18, to the resident's left and right buttock pressure ulcer. Review of the resident's urinalysis with culture and sensitivity, dated 8/3/18, showed the resident had a urinary tract infection. Review of the resident's nurse's progress notes showed staff documented the following: -On 8/3/18 at 4:06 P.M., resident currently at nurse's station and noted to have chills with temperature of 100.5 (normal 97 to 99) degrees Fahrenheit (F). Call placed to physician and new orders noted to give [MEDICATION NAME] (antibiotic) one gram intramuscular (IM), one time only, and then start [MEDICATION NAME] (antibacterial) twice a day for 7 days; ---At 5:56 P.M., [MEDICATION NAME] and [MEDICATION NAME] administered. Resident continues to have chills. Alert and able to propel self throughout the facility. Fluids encouraged. As needed (PRN) Tylenol administered for pain and fever. Resident refusing to be sent out for treatment and evaluation, stated he/she wanted to stay in the facility; ---At 10:27 P.M., resident continues to run a fever between 101 and 103.1 degrees F. This nurse gave PRN Tylenol with little effect. Resident refusing to go to the hospital. This nurse educated resident on wounds and infection and risks of having a fever for extended periods of time. Resident continues to refuse and propelled him/herself outside in front of the building. Alert and able to make all needs known. Fluids encouraged, but refused; ---At 10:48 P.M., call placed to physician's exchange to make him/her aware of resident refusal to go out to the hospital and increasing temperature. Awaiting return call; ---At 10:58 P.M., physician returned call and wanted resident to be sent to emergency room (ER) for treatment and evaluation. Physician aware resident is refusing, antibiotic already being administered and continues to run a fever. Resident went to his/her room and resting in bed; -On 8/4/18 at 3:37 P.M., Resident remains on antibiotic for urinary tract infection without any adverse reactions noted. Afebrile, temperature 98.9 degrees F. [MEDICATION NAME] administered as ordered. No complaint of pain; ---At 10:45 P.M., resident temp 103.2, gave Tylenol. Rechecked 15 minutes later, temperature still 103.2, BP 110/68 (pressure of circulating blood on the walls of blood vessels. Normal 120/80), pulse 127 (measure of heart rate. Normal between 60 to 100). Advised resident that this nurse will call doctor to report vital signs (temperature, pulse, respirations, blood pressure). Resident stated, I don't care about you all calling the doctor, I'm not going out, just like I didn't go out the other night when he tried to send me. Educated resident risks. Called physician and waiting on call back. Will continue to monitor. -On 8/5/18 at 6:46 [NAME]M., resident in room sleeping throughout night without interruption. Tylenol given as ordered. Temperature noted to decrease to 101.2 degrees F. Resident continues to verbalize refusal to be transferred to ER. -On 8/6/18 at 1:09 P.M., resident continues with antibiotics for urinary tract infection with no adverse reaction noted. Resident encouraged to stay off of bottom related to wounds on both buttocks with daily dressing changes. Resident temperature 97.9 degrees F. ---At 5:05 P.M., resident shivering, fever 103.6 degrees F. Tylenol given, will continue to monitor; ---At 7:08 P.M., temperature 102.3 degrees F. Physician notified, new order for blood culture, continue on antibiotic. At 7:43 P.M., Resident stated he/she was not feeling well; ---At 10:09 P.M., resident continues on antibiotic for urinary tract infection. Resident febrile, physician notified. -On 8/7/18 at 4:58 [NAME]M., Resident's temperature 104.2 degrees F. Gave Tylenol, rechecked temperature, 101.4 degrees F. Contacted physician to get order to send resident out to hospital. Physician gave verbal consent. Resident also agreed to go to hospital and transported by ambulance. Review of the resident's hospital record, dated 8/7/18, showed the resident admitted with [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth varies by anatomical location) pressure ulcers on right and left buttock. Review of the resident's hospital wound assessment, dated 8/7/18, showed the following: -Left buttock (ischial area) unstageable pressure ulcer, which measured 6 cm in length, by 5 cm in width; -Right lower buttock unstageable pressure ulcer, which measured 5 cm in length, by 4.2 cm in width, by 2 cm in depth. Review of the resident's physician's hospital consult note, dated 8/7/18, showed the following: -Bilateral gluteal (buttock)/ischial (lower part of the hip bone) ulcers, with necrotic eschar and underlying purulence with foul odor; -Plan to place a bilateral wound vac in the operating room. Review of the resident's hospital infectious disease consultation note, dated 8/9/18, showed the following: -Recently developed pressure ulcers on the buttocks which had been getting worse; -Underwent debridement of bilateral gluteal ulcers, down to bone; -Wound cultures showed an infection; -On treatment with antibiotics. During an interview on 8/9/18 at 3:30 P.M., the administrator said the following: -The resident was very uncooperative with care, sat in his/her wheelchair for long periods of time and would not go to bed; -The resident developed pressure ulcers; -The nursing staff knew to check on the resident and pass information along to the next shift. Review of the resident's (MONTH) (YEAR), POS, showed the following: -Resident re-admitted to the facility on [DATE]; -Place moist hydrogel dressing to right gluteal and left ischial pressure ulcers. Apply calmoseptime around peri wound skin to prevent moisture associated skin damage until seen by plastics. Review of the resident's care plan, dated 8/10/18, showed the following: -Resident has pressure ulcer to bilateral buttocks; --Interventions/Tasks; ---Assess/record/monitor wound healing per facility protocol. Measure length, width and depth. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; ---Assist resident with turning; ---Educate 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; ---Follow facility policies/protocols for the prevention/treatment of [REDACTED].>---If resident refuses treatment, confer with resident and family to determine why and try alternative methods to gain compliance; ---Monitor, document and report to physician changes in skin status, appearance, color, wound healing and size, and signs/symptoms of infection. Review of the resident's (MONTH) (YEAR), nurse's progress notes, showed the following: -On 8/10/18 at 7:55 P.M., the resident returned to the facility; --Left ischial pressure ulcer measured 6.5 cm in length, by 4.5 cm in width, with bloody drainage, yellow slough and no odor; --Right lower gluteal pressure ulcer measured 5 cm in length, by 4 cm in width, with bloody drainage; --At 11:01 P.M., the resident came to desk yelling related to wanting a [DEVICE] (vac) (negative pressure wound therapy. Therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds); --The evening nurse (3:00 P.M. to 11:00 P.M.) made resident aware that no order was in place for wound vac; --Resident began to curse and yell, stating he/she had been in his/her wheelchair too long and that was the reason for his/her wounds; --The night staff agreed to lay resident down, then resident refused stating he/she was going to smoke and wheeled him/herself out the front door; --When resident returned inside, he/she stated he/she wasn't ready to lay down and wanted to unpack his/her room; -On 8/11/18 at 12:37 P.M., resident voicing concerns related to wound and wound care to be done as ordered; --Resident encouraged to stay off bottom as much as possible; --Wounds on left and right gluteal fold. Review of the resident's pressure ulcer assessment, dated 8/11/18, documented done by the Assistant Director of Nurses (ADON), showed the following: -Left buttock pressure ulcer measured 9.2 cm in length, by 9.8 cm in width, by 6.1 cm in depth, with 0.7 cm undermining at 3 o'clock, and 1.4 cm undermining at 7 o'clock; -Right buttock pressure ulcer measured 6.8 cm in length, by 6.1 cm in width, by 6.4 cm in depth, with 0.8 cm undermining at 4:30 o'clock, 1.2 cm undermining at 6 o'clock, 2.5 cm undermining at 7 o'clock, and 6.2 cm tunneling at 7:30 o'clock. Review of the resident's POS, dated 8/11/18, showed an order for [REDACTED]. Review of the resident's (MONTH) (YEAR), TAR, showed the [MEDICATION NAME] documented given as ordered. Review of the resident's nurse's progress notes, dated 8/12/18 at 12:00 P.M., showed the following: -Resident voiced concerns related to wound and wound care to be done as ordered; -Resident encouraged to stay off bottom as much as possible; -Wounds on left and right gluteal fold, with moderate amount of drainage. Review of the resident's (MONTH) (YEAR), POS, dated 8/12/18, showed the pressure ulcer treatment order changed. Cover right and left buttock with [MEDICATION NAME], cover with silver alginate, cut to fit anterior area of wound, cover with gauze or ABD and cover with foam dressing, daily til healed every day shift, for skin integrity. Review of the resident's nurse's progress notes, dated 8/13/18 at 8:55 P.M., showed the following: -Resident was due to have wound vac applied; -It was reported by unit coordinator that resident needed a Y connector (to connect two or more dressings), but it was not available; -The unit coordinator said he/she would return at approximately 7:30 P.M., to apply the wound vac using another technique; -The unit coordinator was unable to return, so the wound vac was not placed; -This nurse placed a dressing over the wound so that it would not be exposed; -The unit coordinator stated he/she would apply the wound vac on 8/14/18. Review of the resident's nurse's progress notes, dated 8/14/18 at 2:47 P.M., showed the following: -Resident seen by wound physician today; -Resident had two unstageable pressure ulcers to left and right ischial areas; -Resident was recently discharged from the hospital with surgical debridements to both sites and an order for [REDACTED].>-Left ischial pressure ulcer measured 8.3 cm in length, by 8.9 cm in width, by 3.7 cm in width, with 25% slough. Moderate amount of serosanguineous drainage noted, with no odor; -Right ischial pressure ulcer measured 6.4 cm in length, by 5.1 cm in width, by 4.0 cm in depth, with 25% slough. Moderate amount of serosanguineous drainage noted, with no odor Review of the resident's (MONTH) (YEAR), POS, dated 8/14/18, showed the pressure ulcer treatment order changed. Wound vac to right and left ischial pressure ulcer. Change dressing on Tuesday, Thursday and Saturday (setting 125 mmHg continuously), every day shift. Apply Santyl to wound bed, then place wound vac foam soaked in Dakins Solution (antiseptic) in place with dressing and attach wound vac with setting of 125 mmHg on Tuesday, Thursday and Saturday. Review of the resident's (MONTH) (YEAR), TAR, showed the following: -The treatment order to the right and left buttock pressure ulcer, obtained on 8/10/18, was documented as completed from 8/11/18 through 8/15/18; -On 8/16/18, the treatment order from 8/14/18, was documented as completed, except for the wound vac; -Wound vac not started by 8/17/18. Observation on 8/16/18, from 2:40 P.M. to 6:10 P.M., showed the resident lying on his/her right side in bed, without being turned/repositioned. During an interview on 8/16/18 at 6:10 P.M., the resident said he/she had been on his/her right side and not turned/repositioned since 12:30 P.M. on that day. During an interview on 8/16/18 at 8:38 [NAME]M., Nurse A said the following: -When the resident was admitted on [DATE], he/she had little reddened areas, stage I pressure ulcers on his/her right and left buttock; -Nurse A did not know the resident developed a stage II pressure ulcer on his/her left buttock; -On 7/24/18, Nurse A noted the resident had unstageable pressure ulcers on his/her right and left buttock, with slough and necrotic tissue. The wound doctor was notified and ordered treatments. Dressing changes were done daily; -Nurse A did the resident's treatments every day before he/she got out of bed to the wheelchair; -The resident was non-compliant, stayed up all day in his/her wheelchair and refused to go back to bed until late at night; -Weekly skin assessments should be done every week; -If the certified nurse assistants observe any pressure ulcers, it should be reported to the nurse right away; -The nurse should notify the physician immediately and obtain a treatment order; -Treatments should be done as ordered by the physician. Review of the resident's nurse's progress notes, dated 8/16/18, showed the resident's left and right buttock pressure ulcer treatment was documented as completed without the wound vac. Observation of the resident' pressure ulcers on 8/17/18 at 10:30 [NAME]M., showed the following: -Left buttock/ischial stage IV pressure ulcer, which measured 8.0 cm in length, by 9.8 cm in width, by 3.3 cm in depth, with 0.6 cm tunneling at 3 o'clock, and 1.8 cm tunneling at 7 o'clock; -Right buttock/ischial stage IV pressure ulcer, which measured 5.7 cm in length, by 5.8 cm in width, by 3.6 cm in depth, with 0.6 cm undermining at 4:30 o'clock, 0.9 cm undermining at 6 o'clock, 2.4 cm undermining at 7:30 o'clock, and 4.7 cm tunneling between 7:30 and 8 o'clock. During an interview on 8/13/18 at 3:20 P.M., Nurse B said the following: -He/She worked the weekend, night shift on 8/4 and 8/5/18; -The resident had pressure ulcers, but refused treatments on that weekend; -The resident was agitated when he/she came past the nursing station at 11:30 P.M. on 8/4/18; -The resident received a suppository routinely at night; -The resident is alert and said could tell if he/she had a bowel movement; -The physician should have been notified right away of the resident's pressure ulcers and treatments done as ordered. During an interview on 8/16/18 at 1:30 P.M., the Director of Nurses said the following; -Staff should have notified the physician on 7/2/18, of the resident's left hip stage II pressure ulcer and done treatments as ordered; -Staff should have done weekly skin and wound assessments on the resident; -The nurse should have assessed the resident's skin daily when the resident's suppository was given; -When the resident returned from the hospital on [DATE], staff did not have all of the pieces for the wound vac to do the treatment as ordered; -The resident was uncooperative at times and would not lay down for care and treatments to be done. During an interview on 8/16/18 at 2:35 P.M., the ADON said the following: -Staff should have notified the nurse of the resident's left hip stage II pressure ulcer on 7/2/18; -The physician should have been notified and treatments done as ordered; -When the resident was re-admitted on [DATE], he/she attempted to put the Y connector on the wound vac, but it was not correct; -On 8/11/18, the ADON called the staff who does the ordering of the parts, but they didn't work on the weekend; -The ADON called the administrator, who called the central supply staff, who told the ADON where to go in the building to get the part, but it wasn't the correct part; -The wound doctor ordered another treatment on 8/14/18, until the part for the wound vac came in. During an interview on 8/17/18 at 9:40 [NAME]M., the resident's physician said the following: -The resident was non-compliant and resisted care; -The facility was having trouble getting staff to provide the proper care for the resident; -Staff should have notified the physician, and treated the resident's stage II pressure ulcer, prior to 7/24/18, when the right and left buttock pressure ulcers were found to be unstageable and necrotic; -Staff should have provided treatment as ordered, including the wound vac, to the resident's right and left buttock pressure ulcer, after the resident returned to the facility on [DATE]. During an interview on 8/17/18 at 10:15 [NAME]M., the resident's wound physician said the following: -Staff should have notified the physician, and treated the resident's left hip stage II pressure ulcer, prior to 7/24/18, when the right and left buttock pressure ulcers were found to be unstageable and necrotic; -Staff should have notified the physician if they were unable to do the resident's wound vac treatments; -It should not have taken a week to get parts for the wound vac. Review of the facility's Policies and Standard Procedures regarding skin care and wound management, dated 7/10/16, showed the following: -A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear and/or friction; -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds; -The interdisciplinary team works with the resident and family to identify and implement interventions to prevent and treat potential skin integrity issues; -The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions contributing to it and description of impairment to determine appropriate treatment. MO 747 MO 046

Based on interview and record review, the facility failed to track residents' bowel patterns, assess and monitor residents for signs and symptoms of a fecal impaction, document assessments, communicate residents' BMs, implement interventions to prevent constipation and fecal impaction. Out of five sampled residents, one was sent to the hospital due to a fecal impaction. (Resident #30) The census was 104. Review of Resident #30's face sheet, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 8/16/17, showed the following: -Problem: At risk for constipation related to decreased mobility and diminished appetite; -Goal: Will have normal bowel movement at least every third day; -Approaches included: Encourage to sit on toilet to evacuate bowels if possible, follow facility bowel protocol for bowel management, IMPACTION: break up stool with lubricated finger and remove gently with each episode, follow with enema as ordered to clear bowel, monitor medications for side effects of constipation, keep the physician informed of any problems and monitor/document/report to physician any signs and symptoms of complications related to constipation. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/17, showed the following: -Understood/understands; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 15 of 15 (cognitively intact); -Dependent on two staff members for transfers; -Extensive assistance for toilet use; -Always incontinent of bowel; -No bowel toileting program; -No constipation present; -No complaint of pain; -Non-ambulatory; Review of the resident's physician's orders [REDACTED]. -An order dated 8/8/17, for [MEDICATION NAME] (pain medication for moderate to severe pain) 25 milligrams (mg) every six hours as needed (PRN) for pain; -An order dated 8/8/17, for [MEDICATION NAME] sodium ([MEDICATION NAME], stool softener) 100 mg twice daily (BID); -An order dated 8/8/17, for Senna (laxative) [MEDICATION NAME] sodium 8.6-50 mg, one tablet at bedtime; -No PRN (as needed) enema or laxative orders; -An order dated 10/16/17, to send the resident to the hospital for evaluation and treatment of [REDACTED]. Review of the resident's Medication Administration Record, [REDACTED]. Review of the resident's BM record, dated 10/1/17 through 10/16/17, showed the following: -No documentation for 10/4 or 10/5/17; -Staff documented no BM on 10/6/17; -No documentation for 10/7, 10/8 or 10/9/17; -Staff documented no BM on 10/10 and 10/11/17; -No documentation for 10/12 or 10/13/17; -Staff documented no BM on 10/14/17; -No documentation for 10/15 or 10/16/17. Review of the resident's progress notes, dated 10/1/17 through 10/16/17, showed the following: -No documentation regarding the resident's BM pattern; -10/15/17 at 10:28 P.M., the resident complained of pain 10/10 (severe) while sitting and 2/10 (mild) when lying down. Physician's exchange notified, still awaiting return phone call. No further assessment documented. No follow up documentation noted including if the resident's physician was notified of the resident's complaints of pain; -10/16/17 at 1:40 P.M., the resident complained of pain to his/her groin area. He/she refused pain medications. No further assessment documented; -10/16/17 at 3:29 P.M., resident having loose dark colored stool with red blood mixed in with it. Nurse practitioner notified and orders received to send resident to the hospital for evaluation. Family was notified. No further assessment documented; -No further documentation including when and how the resident was transported to the hospital for evaluation. Review of the resident's POS showed, an order dated, 10/16/17, to send the resident to the hospital for evaluation and treatment for [REDACTED]. Review of the resident's hospital discharge record, dated 10/20/17, showed the following: -Hospital admitted : 10/16/17; -Admission Diagnosis: [REDACTED]. -Discharge Diagnoses: [REDACTED]. Review of the resident's POS, for October 2017, showed the following; -Order dated 10/20/17, for [MEDICATION NAME] powder (laxative) 17 grams (GM) by mouth once daily; -Order dated 10/20/17, for Senna-[MEDICATION NAME] sodium 8.6-50 mg BID. Review of the resident's progress notes, dated from 10/20/17 through 10/24/17, showed the following: -10/20/17 at 6:16 P.M., readmitted from hospital via ambulance. Hospital [DIAGNOSES REDACTED]. -No documentation regarding the resident's BM patterns and/or abdomen assessments. Review of the resident's BM record, dated 10/21/17 through 10/24/17, showed the following: -Medium BM on 10/21/17; -No documentation for 10/22 or 10/23/17. During interviews on 10/24/17 at 11:03 A.M., and 10/30/17 at 12:20 P.M., the resident said he/she was sent to the hospital for a fecal impaction. He/she was dependent on staff to assist with transfers to and from the toilet, did not have a history of constipation and/or fecal impaction and could not remember his/her last bowel movement, but since staff have to take him/her to the toilet or clean him/her up after an incontinent episode, the staff should know the last time he/she had a bowel movement. During an interview on 10//24/17 at 10:28 A.M., the MDS coordinator provided a copy of a clinical alert-listing report, showing which residents in the facility had not had a documented BM in three days. The MDS coordinator said the report was generated by the facility's computer program. She did not know how or if the facility utilized the report. He/she knew how to access the program because the previous facility he/she worked in had the same computer program and he/she knew how to run the reports, but he/she was not responsible for running the reports at this facility. Review of the clinical alert report dated 10/24/17, showed the resident listed on the report on 10/10, 10/11 and 10/14/17. During an interview on 10/24/17 at 10:45 A.M., the interim Director of Nursing (DON) said, the certified nurse aides (CNAs) were responsible for documenting residents' BMs each shift in the computer. It would be the responsibility of the charge nurse to monitor residents for constipation and fecal impaction. She did not know if the computer could track residents' BM patterns and/or how information regarding residents' BMs were communicated from the CNAs to the charge nurses. She was unaware the computer could generate a clinical alert report to identify residents who had not had a BM and/or staff failed to document on the BM tracking report. She had never seen a clinical alert report prior to the surveyor asking to see one. She is unaware if any of the nurses know the report is available and/or how to access the report. The facility does not have a policy regarding bowel patterns for residents. During an interview on 10/24/17 at 11:00 A.M., the facility's nurse educator said the CNAs were responsible for documenting in the computer when a resident has a BM and the charge nurses were responsible for monitoring residents' BMs. He/she was not aware of any policy or procedure to follow if a resident didn't have a BM and did not know who was responsible for making sure the CNAs were documenting on each shift. The facility educator did not know how information regarding residents' BMs was communicated from the CNAs to the nurses and he/she did not know where to find or how to access the clinical alert reports. During an interview, on 10/24/17 at 12:15 P.M., CNA A said the CNAs were responsible for documenting in the computer every shift if their residents had a BM or not. He/she did not know who was responsible for making sure the CNAs document in the computer. The CNA had never seen a clinical alert report and had never been instructed to notify the nurse if a resident had not had a BM in three or more days. During an interview on 10/24/17 at 1:27 P.M., Nurse B said he/she had worked at the facility for several months. CNAs were responsible for documenting resident's BMs in the computer every shift. He/she didn't know who was responsible for assuring the CNAs did shift to shift charting, had never seen a clinical alert report and would not have any idea how to access one on the computer. The nurse did not know if the facility had a policy regarding resident BM patterns. During an interview on 10/24/17 at 4:09 P.M., the administrator and DON both said the facility did not have a policy for tracking and monitoring residents' BM patterns. They had both only been at the facility for about three weeks as interims. The former DON was from a staffing agency. Neither were aware the facility's computer program could generate a clinical alert report for residents who had not had a BM in three or more days. Neither one of them knew how to generate a report from the computer. Both agreed there should be a policy and the clinical alert reports should be generated daily and provided to the charge nurses for review. During an interview on 10/24/17 at 4:13 P.M., the facility medical director's nurse practitioner said it would be the expectation that the facility monitor residents' BM patterns. If a resident did not have a documented BM in 3 days, staff should provide a PRN laxative. If the laxative did not work, the expectation would be for staff notify the resident's primary care physician. The facility should have a policy and procedure for monitoring residents' BM patterns and if there was a program that monitored the residents' BM pattern, the facility should utilize it daily. During an interview on 11/1/17 at 7:57 A.M., the resident's primary care physician's representative said there was no record the facility attempted to contact the physician about the resident not having a documented bowel movement for 13 days. If the resident did not have a bowel movement in that period of time, he/she most likely developed a fecal impaction. The facility should have a policy and/or procedure to monitor residents' BM patterns. MO 444

Based on observation, interview and record review, the facility failed to provide assistance during meals for a resident who had impaired use of the upper and lower extremities of his/her body and experienced unplanned severe weight loss. This affected one of five sampled residents. (Resident #36) The census was 104. Review of Resident #36's hospital discharge progress notes, dated 9/28/17, showed the following: -Acute inpatient rehabilitation for spinal cord injury; -Height 6 foot (ft) 5 inches (in); -Weight 175 pounds (lbs); -Set up for meals with built up utensils and hinged fork; -Discharge to long term care facility. Review of the resident's facility face sheet, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED].>-No orders for built up utensils, speech therapy or interventions to promote weight gain. Review of the resident's admission progress notes, dated 9/28/17, showed a weight of 175 lbs. Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED].>-No orders for speech therapy or built up utensils. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/9/17, showed the following: -Brief interview for mental status (BIMS), a brief screen for cognitive impairment score: 15 of 15 (cognitively intact); -Required extensive assistance from staff for eating; -Upper/lower extremity impairment on both sides; -Height, 77 in; -Weight, 175 lbs; -Weight loss, no/unknown; -Not on a physician prescribed weight loss regimen; -Therapeutic diet; -[DIAGNOSES REDACTED]. Review of the resident's monthly weight tracking log, showed the following: -9/28/17, the resident's weight, obtained while standing,175.0 lbs with a line through the text and an entry dated, 10/5/17, showed the entry was incorrect; -9/29/17, weight 162.4 lbs; -10/5/17 weight 162.4 lbs. Review of the resident's admission nutritional assessment dated [DATE], showed the following: -CCD, regular texture and thin liquids; -Extensive assistance with dining skills; -No adaptive eating equipment; -[DIAGNOSES REDACTED]. -Height 65 inches; -162.4 lbs; -Ideal body weight (IBW), 113-137 lbs; -Nutritional interventions included, continue CCD diet and maintain weight within plus/minus 5% X 1 month and 10% X 6 months. Further review of the resident's monthly weight tracking log, showed the following: -10/10/17, weight 164.0 lbs; -10/18/17, weight 163.7 lbs. Review of the resident's care plan, dated 10/23/17, showed the following: Problem: Overweight, related to excess energy and intake. Low activity resulting in decreased needs; Goal: Maintain weight within plus/minus 5% X one month or plus/minus in six months; Interventions: Notify registered dietician (RD), family and physician of significant weight changes; Problem: Activities of Daily Living (ADL); Goal: Will improve overall function in ADL abilities through the review date; Interventions: Required one staff physical participation to eat. Limited mobility and Range of Motion (ROM) to upper extremities; -The care plan did not address, the need for built up utensils while eating and/or weight loss. Further review of the resident's monthly weight tracking log, dated 10/25/17, showed a weight of 162.4 lbs. Review of the resident's POS, dated 11/1/17 through 11/30/17, showed the following: -CCD, regular texture and thin liquids; -No orders for built up utensils, speech therapy or interventions to promote weight gain. Observation and interview on 11/3/17 at 10:33 A.M., showed the resident sat on the edge of the bed and Certified Nurse Aide (CNA) A transferred him/her from his/her bed to a wheelchair. The resident's untouched breakfast tray sat on the over bed table next to the bed. The resident said he/she did not want the breakfast tray because it had sat on the table for two and a half hours. CNA A offered to heat the plate of food, but the resident refused and said again, the tray had been sitting on the table for over two and a half hours and he/she would just wait for lunch. When asked who was responsible for assisting residents with eating their food, CNA A said who ever brought the tray in the room was responsible for feeding the resident. CNA A admitted he/she brought the breakfast tray to the room, but said the resident was sleeping and did not want to eat. After CNA A left the room, the resident said CNA A did not try and wake him/her up to eat. None of the staff will assist him/her with eating, staff drop off the tray and walk out. It has been an ongoing problem since his/her admission to the facility. The resident left the room without eating or drinking anything from the breakfast tray in his/her room. No built up utensils were visible. Observation on 11/3/17 at 12:42 P.M., showed the resident lay in bed, fully clothed. A tray with a chef salad, wrapped with plastic wrap and a plate of turkey, potatoes and vegetable, covered with a plate warmer sat on the over bed table. At 12:59 P. M., the resident sat in a wheelchair in his/her room, facing the over bed table. CNA A stood beside the resident talking on a cell phone (on speaker). The CNA had the phone in one hand and a fork in the other. After several seconds the CNA disconnected the call and continued to stand over the resident and offer him/her a bite of food. The chef salad remained on the table covered with plastic wrap. No built up utensils were visible. At 1:08 P.M., the resident's room was empty, his/her lunch tray was gone, but the chef salad remained on the over bed table. Observation and interview on 11/3/17 at 1:23 P.M., showed the resident sat in a wheelchair in front of the over bed table. The resident was leaning over the table eating the chef salad in a lapping motion with his/her tongue. When asked what was going on, the resident said he/she had gone outside to smoke and when he/she came back to his/her room, no staff were available to feed him/her. He/she always ate his/her meals by leaning over the plate. He/she did not have the use of his/her hands. He/she used to weigh 175 pounds, but since admission to the facility, he/she had lost a lot of weight. The resident did not know his/her current weight. He/she did not want to eat in the assist dining room because he/she did not want to be seen being fed by another person. He/she preferred to eat in the privacy of his/her own room. During an interview and observation on 11/3/17 at 1:50 P.M., the resident said, he/she hurt all over. He/she can feel every bone in his/her body sticking out. Nurse C performed a head to toe skin assessment on the resident. The resident's skin was intact, but he/she appeared to be very thin with no excess fatty tissue and his/her shoulder and hip bones were very prominent. When the resident stood up to be transferred from bed to a wheelchair, he/she stood well over 6 foot tall. When asked who was responsible for feeding dependent residents, Nurse C said the CNA that passed the meal tray should set up and feed the resident. The facility did not assign staff to feed residents in their rooms. The person who delivered the tray was expected to feed the resident. The nurse said he/she was not aware if the resident had any weight loss since admission. Observation on 11/3/17 at 2:19 P.M., showed the resident weighed 156.6 lbs., which reflected a severe weight loss of 18.4 lbs (10.5% of his/her body weight), since admission on 9/28/17. (Centers for Medicare and Medicaid Services (CMS) defines severe weight loss is defined as greater than 5% in one month, greater than 7.5% in three months or greater than 10% in six months). Further review of the resident's medical record, showed no documentation regarding weight loss or that staff identified the resident was not overweight as identified in the care plan or and not 65 inches as noted in the nutritional assessment. During an interview on 11/3/17 at 2:45 P.M., the administrator and Director of Nursing, said they had only been at the facility for 5 days, they did not know about the resident's weight loss. Neither were aware if the facility had a policy for monitoring residents' weight loss. During an interview on 11/6/17 at 12:30 P.M. the speech therapist said at the request of the facility, he/she was treating the resident to see if he/she could be more independent with eating. The resident already had built up utensils he/she brought from the hospital and seemed to be receptive to therapy. During a interview on 11/8/17 at 1:00 P.M., the facility's RD said, she was the person who crossed out the weight of 175 lbs on 10/5/17. He/she was told by the restorative aide the resident's correct weight was 162.4. He/she entered the wrong height for the resident in the computer. He/she realized now, the resident's height was miscalculated. When the initial information was entered into the computer, the computer generated a report showing the resident was overweight. During an interview on 11/8/17, the resident's primary care physician's nurse practitioner, said they had no documentation from the facility that the resident was losing weight. Residents that required assistance from staff should be monitored for weight loss. Review of the facility's resident weight policy, dated 5/19/16, showed the following: -A resident's weight will be accurately obtained within 24 hours of admission, if the resident is able; -The admission weight will be obtained at the facility and not recorded from previous hospital paperwork or by asking the resident and/or family; -Obtain weekly weights once weekly for 4 weeks for baseline; -Stable residents will be weighed monthly thereafter, unless physician or [DIAGNOSES REDACTED].>-Document weights in the electronic health record (EHR); -If a resident has a plus/minus of 5 pounds in one week, staff will reweigh the resident within 24 hours; -Validate the weight with a nurse; -Notify the interdisciplinary team, doctor and family if indicated. MO 039

Based on interview and record review, the facility failed to ensure staff initiated Cardiopulmonary Resuscitation (CPR, life sustaining measures in the event that the heart stops beating) for a resident with a full code order. Resident #20 was found unresponsive by a Certified Nurse Aide (CNA) who reported it to the nurse. The CNA then proceeded to another resident's room. The nurse did not initiate CPR or call 911, but reported it to another nurse who also did not initiate CPR or call 911. No staff called a code in order for other facility staff to respond to the resident. The resident expired. This affected one of three sampled residents. The census was 110. Review of the facility's Initiate CPR policy, dated [DATE], showed the following: -Definitions: -Code status: The recorded, expressed wishes of the resident indicating procedures performed or not performed in the event of cardiac or respiratory activities cease. Every resident has a code status-if not indicated otherwise, a full code will be performed in the event of respiratory/cardiac cessation; -CPR-includes external heart massage using chest compressions and clearing of the airway including oxygen delivery in an effort to restore or maintain cardiopulmonary function until a higher level of care is accessed; -Policy: -It is the policy of this facility to promote resident centered care by respecting resident's right to formulate an advance directive including to initiate CPR by trained staff if requested and indicated following The American Heart Guidelines (AHA); -Procedure: -Upon admission, discuss code status with the resident and/or family/guardian and document; -The facility will maintain and train staff on a communication method that will quickly alert staff as to the code status of a resident in the event heart or respirations cease; -Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the code status and communicate this to the team; -If CPR is indicated, staff will begin CPR and call 911 with these exceptions: -There is a valid DNR order in place; -There is obvious signs of clinical death (e.g. rigor mortis, dependent lividity (settling of the blood in the lower portion of the body post mortem, causing a purplish-red discoloration of the skin), decapitation, transection, or decomposition) are present; -The resident is decapitated or the resident's body has been transected; -Initiating CPR could cause injury or peril to the rescuer. 1. Review of Resident #20's admission record, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. When [MEDICAL CONDITION] affects the arteries of the heart, it's called [MEDICAL CONDITION] (CAD)), mild cognitive impairment, muscle weakness, [MEDICAL CONDITION] (irregular heartbeat), [MEDICAL CONDITION] (joint pain and stiffness) [MEDICAL CONDITION] (benign enlargement of the prostate), hypertension (high blood pressure), chronic ischemic [MEDICAL CONDITION], (also known as CAD, is a condition that affects the supply of blood to the heart), [MEDICAL CONDITION], (any disease or disorder of the circulatory system outside of the brain and heart) and [MEDICAL CONDITION] (inadequate blood flow to the veins); -Advance directive, full code. Review of the resident's care plan initiated on [DATE], showed the following: -Focus: Full code status, resident has end of life choices related to code status, living will; -Wishes regarding living will, advanced directives will be honored; -Resident is a full code if [MEDICAL CONDITION] occurs CPR will be initiated and 911 will be called. Review of the resident's medication review report/physician's orders [REDACTED]. Review of the resident's code status form originally dated [DATE] and updated on [DATE], showed the resident wanted to be a full code, which showed all measures of resuscitation would be taken including CPR, calling 911 and emergency IV's and medications. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated [DATE], showed the following: -A brief interview for mental status (BIMS) score 15 out of 15, cognitively intact; -Required extensive assistance by staff for bed mobility, transfers, dressing, toilet use and hygiene; -Moderate pain frequently; -No shortness of breath. Review of the resident's progress notes, showed the following: -On [DATE] at 7:31 A.M., the resident complained of not being able to void. Catheter changed at 2:00 A.M. Resident tolerated the procedure without any difficulty. Urine dark reddish brown; -On [DATE] at 8:39 A.M., (the only nurses note since [DATE]), showed the nurse was called to room by the CNA at approximately 5:50 A.M. The resident was unresponsive, noted to be without pulse, respirations or blood pressure, and lack of pupil response. Call placed to physician, physician gave order to pronounce death as CAD. Pronounced at 5:55 A.M. Director of Nursing (DON) and family made aware (no vitals documented). During an interview on [DATE] at 6:50 A.M., CNA P said he/she checked on the resident around 12:30 A.M. to 1:00 A.M. on [DATE]. He/she was sleeping and snoring. Around 2:00 A.M., the resident called him/her into the room to turn on the air conditioning. CNA P did his/her rounds at approximately 4:00 A.M. The resident was fine and the CNA asked him/her if he/she needed to go to the bathroom. The resident said no. At 5:50 A.M., CNA P found the resident unresponsive. He/she did not touch the resident at that time but saw his/her chest was not rising, and the resident was not snoring. CNA P went to get Nurse Q. Nurse Q went to the resident's room and took his/her pulse and said he/she was not responding. Nurse Q then went up the hall. CNA P went into another resident's room. When CNA P came out of that room, Nurse Q was standing at the nurses' desk. CNA P asked Nurse Q what he/she (CNA P) should be doing and Nurse Q said he/she spoke to the Director of Nursing (DON). CNA P asked Nurse Q again what he/she should be doing and Nurse Q said to clean the resident up. CNA P went into the resident's room to provide post mortem care. The resident was cool on the front but when he/she rolled the resident over, his/her back was still a little warm and his/her feet were warm. He/she had been a CNA for a long time and no rigor mortis (muscles and joints become very stiff) had set in. The resident was heavy, but not stiff. He/she believed the resident had not been dead for a long time. CNA P knew the resident was a full code, because Nurse Q told him/her. No staff initiated CPR. Review of a written statement completed by Nurse Q (an agency nurse), showed on [DATE] around 5:30 A.M., when he/she was passing medications, CNA P told him/her that the resident was unresponsive. Upon entering the room, the resident was not responding to the sternal rub. He/she went to get the medical equipment from the nurses' station. The resident did not have a pulse or blood pressure, his/her eyes were fixed and his/her skin was cold. CNA P said he/she last saw the resident around 3:40 A.M., and he/she was breathing. Nurse Q then called the doctor and the DON. The physician called back around 6:40 A.M., with a cause of death. Review of an written added entry completed by Nurse Q, showed at approximately 6:05 A.M. (on [DATE]), he/she asked another nurse (Nurse R) to come here, because he/she needed him/her. Nurse Q explained that the resident was a full code, but his/her body was cold and asked what he/she should do. Nurse R said to call the doctor and let him/her know the situation. Nurse R returned to his/her work. Nurse Q went to get the DON's number and returned to his/her unit. During an interview on [DATE] at 2:10 P.M., Nurse Q said he/she worked a double shift, evening and nights on ,[DATE] into [DATE]. He/she went into the resident's room around midnight to give the resident his/her pain medication and the resident was sleeping. He/she knew the resident was alive as his/her chest was moving. Around 5:45 A.M., CNA P came and got him/her and said the resident was not responsive. Nurse Q went into the resident's room and knew he/she was dead, because he/she was yellow. Nurse Q said the resident was usually pale but was yellow and cold. He/she went to the nurses' station, saw the resident was a full code and obtained the stethoscope (medical instrument used to listen to the action of the heart or breathing) and pulse oximeter (measures the amount of oxygen levels of the blood). He/she then took the resident's vitals. Nurse Q thought he/she documented this. Nurse Q then went to Nurse R, because Nurse R was a regular facility nurse. Nurse R told him/her to just call the doctor. Nurse Q called the DON who asked him/her if he/she did CPR and Nurse Q told her he/she did not. The DON told Nurse Q he/she should have done CPR. Nurse Q said he/she worked in the facility pretty consistently for the last two weeks. He/she did not receive any training. Nurse Q would just go by report he/she received when coming on duty. He/she did not know to call a code or where the crash cart was located. The resident used his/her call light often. Nothing unusual occurred with the resident that night prior to his/her death. During an interview on [DATE] at 11:57 A.M., Nurse R said he/she worked the night shift on ,[DATE] into [DATE]. Around 5:45 A.M., Nurse R was in a resident's room. Nurse Q came into the room and said there was something he/she needed to ask. Nurse R asked Nurse Q to wait a moment as he/she was in the middle of hanging an IV (intravenous-used to administer a fluid). Nurse Q waited outside of the room until Nurse R was finished. Nurse R said this was approximately five minutes later. Nurse Q said the resident expired and he/she needed the doctor's number. Nurse R said, You're kidding me? and asked Nurse Q how he/she knew the resident was dead. Nurse Q said because the resident was yellow. Nurse R asked what he/she meant, and Nurse Q said yellow and cold. Nurse R asked if the resident was a full code and Nurse Q told him/her he/she thought so. Nurse Q did not report any vital signs to Nurse R. No code was called nor was 911 called. Nurse R said no nurse went into the room, because no code was called. Nurse R said the resident would let them know if something was wrong. Nothing had been unusual with the resident that night. Review of a written statement completed by the former DON and dated [DATE], showed she received a call at 6:06 A.M. on [DATE] from Nurse Q. Nurse Q stated the resident expired and the time of death was unknown. Nurse Q stated he/she thought the resident had been dead for three hours. Nurse Q stated staff found the resident at 5:50 A.M. with no pulse, no respirations and cold. The former DON asked the nurse if the resident was a DNR (do not resuscitate) and he/she said the resident was a full code. The nurse responded no when asked if CPR was started or 911 was called. The former DON asked why this was not done and Nurse Q said she spoke to Nurse R who told him/her to call the DON and notify the family. The former DON said he/she needed to call the physician and the coroner due to unexpected death. During an interview on [DATE] at 12:08 P.M., the resident's physician said the resident's major issue was [MEDICAL CONDITION], ambulation, pain and cardiac issues. Recently they had gotten his/her pain under control and the resident was doing okay. She received a voicemail on the morning of [DATE], from one of the nurses that the resident had expired and they needed a diagnosis. She said staff should have done CPR on the resident and any resident who was a full code. She also said the nurses cannot call a death. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility inserviced facility and agency staff on calling a code, conducting CPR and calling 911. In addition, the facility implemented an agency orientation book to include CPR procedures. The facility is conducting mock CPR drills to ensure appropriate action is taken. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation. MO 639

Based on observation, interview and record review, the facility failed to provide appropriate care to one of four sampled residents with pressure ulcers. Staff failed to carry forward treatment orders to the current physician order [REDACTED]. The facility identified eight residents with pressure ulcers. The total sample was 21. (Resident #5) The census was 120. Review of Resident #5's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 8/17/11, and quarterly review MDS dated [DATE], showed the following: -Short and long term memory problems; -Severe cognitive impairment; -Dependent on staff for bed mobility, transfers, dressing and personal hygiene; -Incontinent of bowel and bladder; -No behaviors; -Limitations of range of motion of both hands, legs and feet; -Not at risk for developing pressure ulcers; -[DIAGNOSES REDACTED]. -On 8/17/11, weighed 119 pounds with no or unknown weight loss in past 6 months. On 11/10/11, weighed 102 pounds with no or unknown weight loss in past 6 months. Review of an occupational therapy progress notes, showed the following: -10/19/11, the resident had bilateral hand contractures. Palm protectors provided and staff educated; -10/26/11, palm protectors applied and passive range of motion provided. Review of the resident's care plan, updated 11/5/11, showed the resident at risk for skin breakdown. On 11/22/11, a pressure ulcer on the resident's coccyx (tailbone) measured 1 centimeter (cm) and on 1/24/11, staff added palm protectors to bilateral hands. Approaches included to provide treatment per physician orders, pressure reduction cushion in wheelchair and pressure reducing mattress, turn and reposition every two hours and observe for signs and symptoms of infection. Review of the resident's laboratory test results dated 11/4/11, showed the resident's [MEDICATION NAME] level (indicator of nutritional status) registered 14.7 (normal range 20 to 40). Review of the resident's Braden scale (pressure ulcer risk assessment) dated 11/7/11, showed the resident at risk for developing pressure ulcers. Further review of occupational therapy progress notes, showed the following: -11/16/11, bilateral hand range of motion to decrease likelihood of additional falls, pressure areas, skin breakdown, promote proper joint alignment and allow for hand hygiene. Caregiver education for positioning and safety of contractures; -12/16/11, bilateral hand hygiene completed. Certified nurses aide (CNA) educated on need for daily hand hygiene, palm protector application and safety precautions with good understanding. Resident tolerated palm protectors for several hours with no irritation noted. Review of the facility's pressure ulcer log, dated 11/22/11, showed the resident acquired a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous). May also present as an intact or open/ruptured blister.) pressure ulcer on the coccyx. Review of the November and December 2011 and January 2012 physician order [REDACTED]. -An order dated 11/22/11, to apply [MEDICATION NAME] (an opaque dressing that provides a moist healing environment) to coccyx pressure ulcer every three days and as needed until healed; -An order dated 12/23/11, to apply bilateral palm protectors as tolerated with regular safety checks and daily hand hygiene. Further review of the weekly pressure ulcer log, dated 12/9/11 through 12/28/11, showed the resident continued to have a 1.0 cm by 1.0, Stage II pressure ulcer on the coccyx. On 1/5/12 and 1/25/11, staff documented the pressure ulcer measured 1.0 cm by .5 cm. Review of the January 2012 treatment administration record (TAR), showed nursing staff documented the application of bilateral palm protectors every shift and [MEDICATION NAME] applied to the coccyx pressure ulcer every three days. Review of the facility weight reports for 2/11 through 1/12, showed the following weights recorded for the resident: -12/11, 100 pounds; -1/12, 121 pounds, with a note written to the side of the form ? current weight. Review of the February 2012 POS, showed the following: -No order to apply [MEDICATION NAME] to coccyx pressure ulcer every three days and as needed until healed; -An order dated 12/23/11, to apply bilateral palm protectors as tolerated with regular safety checks and daily hand hygiene. Review of the February 2012 TAR on 2/7/12, showed the following: -No order transcribed or documentation that staff provided treatment of [REDACTED]. -Weekly skin assessments highlighted to be completed on 2/2 and 2/9/12. No documentation the assessments were completed; -Bilateral palm protectors applied and documented on each shift from 2/1/12 through 2/7/12. Observation on 2/6/12 at 9:15 A.M., showed the resident sat in a wheelchair at the side of his/her bed with his/her hands fisted and palm protectors in place. Observations until 3:02 P.M., showed no palm protectors in the resident's hands. During an interview during the initial tour on 2/6/12 at approximately 10:00 A.M., Nurse J said the resident was incontinent of bowel and bladder, dependent on staff for all activities of daily living, exhibited no behaviors, had a Stage II pressure ulcer on the coccyx and no contractures. Observation on 2/7/12 at 7:47 A.M., showed the resident sat in a wheelchair with no palm protectors in place and his/her hands fisted. At 10:50 A.M., the resident lay in bed, wearing a urine saturated incontinence brief and no palm protectors in his/her hands. Certified Nurses Aide (CNA) U applied gloves, wet the end of a towel with water and applied soap from the soap dispenser to the wet portion of the towel. He/she carried the wet towel to the resident's bedside, removed the soiled incontinence brief and while the resident lay on his/her side, the CNA stood behind the resident and wiped the resident's peri-area to buttocks once down the center front to back, readjusted the towel and wiped a second time. The CNA then dried the resident with the dry portion of the towel. The CNA did not cleanse the front of the resident's peri-area, hips or other areas of skin which had been in contact with urine or rinse the soap from the resident's skin. Observation at that time, showed the resident had a [MEDICATION NAME] dressing on the coccyx dated 2/1/12, 3-11 and initials and an uncovered Stage II pressure ulcer which measured approximately 2 cm by 2 cm on the right buttock. Observation on 2/7/12 at 2:55 P.M., showed the resident lay in bed with no palm protectors in his/her hands. Nurse J performed a skin assessment and treatment at the request of the surveyor. The resident continued to have the [MEDICATION NAME] dressing on his/her coccyx which was dated 2/1/12. The nurse removed the dressing and a strong foul odor permeated the room. The nurse measured the unstageable (slough and/or eschar (necrotic tissue, black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin): Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission.) black necrotic pressure ulcer on the coccyx as 7.2 cm long by 6 cm wide with a depth of 2 cm. and surrounded by reddened area which measured approximately 1 cm around the necrotic tissue. During an interview at 3:20 P.M., Nurse J said he/she last saw the pressure ulcer around the 2/1/12, when another nurse performed the treatment. He/she said the treatment order must have been dropped when the orders were changed over at the beginning of the month. At 3:20 P.M., the resident continued to have his/her hands fisted with no palm protectors in place. Review of the POS [REDACTED]. Obtain a low air loss mattress. Cleanse the wound with wound cleanser. Apply [MEDICATION NAME] around the wound edges. Apply Santyl (a [MEDICATION NAME] agent) to the wound bed and cover with a dry dressing daily until healed. Observation on 2/8/12 between 5:00 A.M. and 1:30 P.M., the resident had no palm protectors in place and both hands fisted. Review of the resident's nurses notes dated 2/8/12, showed the following: -At 7:30 A.M., staff called the resident's physician regarding pressure ulcer and odor from wound. Antibiotic and specialized wound management consultation ordered. -At 11:00 A.M., staff notified a family member regarding the pressure ulcer and new orders. Explained options for tube feeding or hospice care. Family member would contact other family members and call back; -At 2:00 P.M., Appetite good at breakfast and drank 360 cubic centimeters (cc) of fluid. Nurse practitioner in to assess pressure ulcer; -At 7:00 P.M., spoke with doctor related to resident's condition. Added [DIAGNOSES REDACTED]. Review of the resident's laboratory test results dated 2/9/12, showed the resident's [MEDICATION NAME] level registered 4.7. Observation on 2/9/12 between 8:25 A.M. and 10:05 A.M., showed the resident had no palm protectors in place and both hands fisted. At 10:05 A.M., the surveyor asked Nurse T to assess the resident's hands. Nurse T opened the resident's right hand with difficulty. A foul odor was present. The fingernails were long, jagged and soft. There was an open area that measured 1 centimeter (cm) by 1.5 cm pressure ulcer on the inner thumb. The first finger at the first joint had a .5 cm by .5 cm open area. During an interview at that time, Nurse T, who had returned to work on 2/6/12, said he/she had not seen the resident's coccyx or hands since returning to work. He/she said the resident should receive range of motion and have the palm protectors applied daily. He/she looked in the resident's bedside table, found one palm protector but was unable to locate the other palm protector. He/she cleansed the resident's right hand and applied the palm protector. Review of the resident's nurse's notes dated 2/9/12, showed an order to cleanse the pressure ulcer on right hand inner thumb and first finger with wound cleanser, apply [MEDICATION NAME] (used to increase blood flow to the area and fights bacteria growth) and leave open to air two times per day, until healed. During an interview on 2/9/12 at 3:45 P.M., the administrator and corporate nurse said weekly skin assessments should be documented on the TAR. The charge nurse for the unit is responsible for performing treatments. The treatment orders should be carried over to the next month's POS and treatments should be completed and documented as ordered. During an interview on 2/10/12 at 10:30 A.M., the Director of Nursing said the skin assessments were recently changed from the night shift to shower days. Palm protectors should be applied by the CNA's. The nurses' are responsible for ensuring all orders on the TAR are provided and documented. During an interview on 2/22/12 at 10:15 A.M., the resident's primary care physician said facility staff did not inform him that when the unstageable pressure ulcer was discovered (on 2/7/12), the resident's dressing had not been changed in six days. He said this could have made a difference in the development of the ulcer, but the resident's nutritional status was very compromised. Review of the facility's undated wound care protocols, showed the following: -Wound prevention: -Low to moderate risk (score 5 to 14) or if the resident is extensive assist to totally dependent with bed mobility and/or has a Stage I (An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: -- Skin temperature (warmth or coolness); -- Tissue consistency (firm or boggy); -- Sensation (pain, itching); and/or -- A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) and Stage II pressure ulcers without complications. Provide standard textile mattress with heel care cushion in bed and /or care seat cushion for chair.