Every finding on record at Windsor Rehabilitation & Health Care Center

Based on interview and record review, facility staff failed to ensure three residents (Resident #6, #21, and #90) had access to their trust fund account which included evenings and weekends. The facility census was 37. 1. Review of the policies provided showed staff did not provide a policy for the availability of funds. Review of the facility's admission Packet, undated, showed in the personal property of resident section, upon execution of this agreement the facility shall provide the resident or his/her authorized representative with a copy of a policy discussing the resident's rights regarding his or her own personal funds, which may be kept on deposit in the facility's resident trust account. Review of the facility's policy titled, Resident Rights, showed the resident rights include but are not limited to if resident wishes, have community manage personal funds. 2. Review of Resident #6's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/09/25, showed staff assessed the resident as cognitively intact. During an interview on 6/24/25 at 3:43 P.M., the resident said the facility manages his/her funds. He/She said he/she is unable to get money on the weekends and he/she has to request it prior to the weekend if he/she needed funds. 3. Review of Resident #21's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/24/25, showed staff assessed the resident as cognitively intact. During an interview on 6/24/25 at 11:32 A.M., the resident said the facility kept his/her money in the office. He/She said he/she is not able to get money on the weekends and would need to request funds prior to the weekend. 4. Review of Resident #90's Discharge Summary MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 6/24/25 at 2:31 P.M., the resident said staff held his/her money for him/her. He/She said he/she is not able to request funds during the weekend. 5. During an interview on 06/25/25 at 9:00 A.M., the administrator said they do not have staff to distribute funds on the weekends. During an interview on 06/25/25 at 9:15 A.M., the Business Office Manager (BOM) said she is not in the facility on the weekends to disperse funds. The BOM said the residents know he/she is here late on Fridays and he/she makes sure they have the money they need for the weekend.

Based on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment when staff failed to maintain resident rooms and common areas in good repair. The facility census was 37. 1. Review of the policies provided showed staff did not provide a policy for environmental concerns. 2. Observation on 06/23/25 at 10:55 A.M., showed resident occupied room [ROOM NUMBER], bed two, with a white stain to the top of the nightstand and the fall mat next to the bed with build up of brown debris. 3. Observation on 06/23/25 at 11:05 A.M., showed resident occupied room [ROOM NUMBER] floor sticky. Observation on 06/23/25 at 2:00 P.M., showed the resident room floor sticky. 4. Observation on 06/23/25 at 1:45 P.M., showed resident occupied room [ROOM NUMBER] with linens and trash on the floor, a strong odor and multiple flies. During an interview on 06/23/25 at 1:45 P.M., the resident said the flies bother him/her. 5. Observation on 06/23/25 at 1:58 P.M., showed resident occupied room [ROOM NUMBER] with a dirty and stained floor. The mirror above the sink with missing reflective material. During an interview on 6/24/25 at 2:06 P.M., the resident said the condition of the floor bothered him/her. He/She said he/she liked a clean floor. 6. Observation on 6/24/25 at 11:36 A.M., showed resident occupied room [ROOM NUMBER] with missing and chipped paint and black marks on the wall by the bed. The floor is dirty with debris, and the tiles are cracked and stained. The entrance door had black marks across the bottom and missing and chipped paint. The bathroom door had missing and chipped paint. The mirror above the sink had missing reflective material. 7. Observation on 6/24/25 at 8:38 A.M., showed the 300 hall with brown stains on the floor and the crevices between the floor and the baseboard have a buildup of debris. The outside of the resident occupied room doors #301, #302, #304, #305, #306, #307 and #308 had black marks across the bottom and missing and chipped paint on the trim of the doors. The handrails on both sides of the hall had missing and chipped paint. 8. Observation on 06/24/25 at 3:57 P.M., showed resident occupied room [ROOM NUMBER] with a sticky and stained floor. The air conditioning unit had a yellow and pink substance on it. The walls had sections of a brown and black substance, missing paint and holes. The bathroom wall had a large section of missing paint. During an interview on 06/24/25 at 3:57 P.M., the resident said he/she did not feel the room was homelike and he/she wore shoes because he/she did not want to walk barefoot on the floor. 9. Observation on 6/24/25 at 11:32 AM, showed the resident occupied room [ROOM NUMBER] floor had a large black stain and dirty with a buildup of debris in between the tiles. The mirror above the sink is missing reflective material. The walls had exposed nails and holes. The entry and bathroom door had missing and chipped paint and black marks. During an interview on 06/24/25 at 3:36 P.M., the resident said he/she did not feel like the room was homelike. 10. During an interview on 07/02/25 at 1:13 P.M., Licensed Practical Nurse (LPN) L said if staff notice a housekeeping concern, such as a spill on the floor, then they should clean it up and report it to housekeeping. He/She said if staff notice an environmental concern, they should report it to maintenance and fill out a eminence report. He/She has reported environmental issues in the past, but nothing recently. During an interview on 07/02/25 at 1:16 P.M., Certified Nurse Aide (CNA) K said staff should report a stain on the floor to housekeeping. He/She said if a resident room had issues in need of repair, staff would report the issues to the Director of Nursing (DON) and complete a maintenance form. He/She said he/she had noticed prior environmental issues and reported the issues to maintenance, which the maintenance worker was addressing. During an interview on 0702/25 at 1:19 P.M.,, Housekeeper M said the housekeeping staff cleans the floors, mirrors and hard surfaces in the resident rooms on a daily basis. He/She said staff use a special cleaner for floor stains, but if staff are unable to get the stains out, then they should report the stains to maintenance. He/She said he/she had noticed stains on the floors in the resident rooms, which he/she had reported to his/her supervisor. During an interview on 07/02/25 at 1:24 P.M., the administrator said the housekeeping staff clean the resident rooms daily, including the floors and hard surfaces. He/She said they deep clean the resident rooms weekly, and the housekeeping supervisor audits the cleanliness of the rooms. He/She said if the floor is stained, staff should submit a maintenance request to strip and wax the floor. He/She said if staff notice an environmental concern, staff should complete a maintenance form. He/She said the maintenance worker checks the maintenance log daily and the maintenance supervisor audits the resident rooms monthly for any environmental concerns. He/She said he/she had not seen any environmental concerns, except missing and chipped paint down the hallways, which maintenance is working on. During an interview on 07/02/25 at 1:25 P.M., the Director of Nursing (DON) said the resident rooms are cleaned daily, including floors and hard surfaces and deep cleaned weekly. He/She said the housekeeping supervisor audits resident rooms weekly. He/She said if the floors are stained, staff are directed to log the concern in the maintenance book, which is checked daily. He/She said the maintenance worker should strip and wax the floor if heavily stained. He/She said if there are environmental concerns, staff are directed to log the concern for the maintenance worker to address. He/She said the maintenance supervisor checks the rooms monthly for concerns. He/She said he/she had not seen any environmental concerns, except missing and chipped paint down the hallways, which maintenance is working on.

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the medical, nursing, mental and psychosocial needs for four residents (Resident #9, #18, #21 and #27) out of sixteen sampled residents. The facility census was 37. 1. Review of the facility's policy titled Care Planning, dated December 2014, showed every resident will be assessed using the Minimum Data Set (MDS), a federally mandated assessment tool, according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Staff are directed to use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning and well being as possible. 2. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of Post Traumatic Stress Syndrome (PTSD) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's care plan, dated, 06/21/25, showed the care plan did not contain direction for staff in regard to resident's diagnosis of PTSD. During an interview on 6/23/25 at 11:12 A.M., the resident said he/she has a diagnosis of PTSD. He/She said loud noises and yelling triggered his/her PTSD symptoms. He/She said he/she had care plan meetings, but did not know if PTSD is addressed in his/her care plan. 3. Review of Resident #18's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of PTSD; -One fall with injury since admission or prior assessment. Review of the resident's medical record, dated 06/08/25, showed staff documented the resident had a fall. Review of the resident's care plan, revised 06/16/25, showed the care plan did not contain new fall interventions since 05/26/25. Review showed the care plan did not contain direction for staff in regard to resident's diagnosis of PTSD. 4. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of PTSD. Review of the resident's care plan, revised 06/25/25, showed the care plan did not contain direction for staff in regard to the resident's diagnosis of PTSD. During an interview on 6/23/25 at 2:15 P.M., the resident said he/she has a diagnosis of PTSD. He/She said his/her PTSD symptoms are triggered based on the way someone looks. 5. Review of Resident #27's admission MDS, dated [DATE], showed staff assessed the resident as: -Comatose (in a state of deep unconsciousness for an indefinite period); -Diagnosed with locked-in syndrome (patient is aware but not able to move or communicate verbally due to paralysis of all voluntary muscles in their body except for vertical eye movements and blinking). Review of the resident's care plan, dated 06/09/25, showed the care plan did not contain preferences or direction for activities. Observation on 06/23/25 at 11:05 A.M., showed the resident in bed and the bed faced the door to the hallway. The room did not have music or television on and the window curtain was open. The resident could not see out the window. Observation on 06/23/24 at 2:00 P.M., showed the resident in bed and the bed faced the door to the hallway. The room did not have music or television on and the window curtain was open. The resident could not see out the window. During an interview on 06/25/25 at 11:10 A.M., the MDS nurse said he/she did not know if activities was addressed in resident #27's care plan but would expect it to be so staff can provide the resident stimulation. 6. During an interview on 06/25/25 at 11:10 A.M., the MDS nurse said he/she is fairly new to the position. He/She uses resident and family information to complete the care plans and MDS assessments along with any historical hospital documents. He/She said activities and a diagnosis of PTSD should be addressed in the care plans as necessary to help resident mood and so staff know how to prevent and manage PTSD triggers. He/She said PTSD has not been added to the care plans but it should be. The MDS nurse said he/she had not thought to add the areas to the care plans. During an interview on 06/25/25 at 11:40 A.M., the Activity Director (AD) said he/she does not create goals and interventions for the care plans. He/She said the MDS Coordinator is responsible to keep the care plans up to date and accurate. During an interview on 06/25/25 at 1:10 P.M., the Director of Nursing (DON) said anyone can update a care plan and they should include activities and PTSD information. He/She said the MDS nurse is new to the position and is currently reviewing all care plans to ensure accuracy and personalization to each resident so staff can provide person centered care. During an interview on 06/25/25 at 2:41 P.M., the administrator said every department head is responsible for care plans and their specific sections should be updated by them. He/She said activities and PTSD should be included in care plans to ensure the residents' needs are met. He/She did not know the care plans did not contain activities or PTSD information.

Based on observation, interview and record review, facility staff failed to serve food items to residents in accordance with the nutritionally calculated recipes. The facility census was 37. 1. Review of the facility's policy titled Pureed Food Preparation, dated 2016, showed pureed food will be prepared using standardized recipes to ensure maximum nutritive value. Serve with appropriate scoop number or divide equally to provide an equal number of portions. All of the pureed food must be used in order to deliver the correct nutrient density to each resident. The number of pureed servings obtained from the pureed recipe must equal the number of servings from which started. Review of the facility's Pureed Breaded Pork Chop recipe, dated 2025, showed: -Remove portions needed from regular prepared recipe and place in a sanitized food processor; -Add broth; blend until smooth; -Portion with a #8 scoop. Review of the facility's Pureed [NAME] Beans recipe, dated 2025, showed: -Remove portions needed from regular prepared recipe and place in a washed and sanitized food processor and blend until smooth; -Portion with a #12 dip. Review of the facility's Mashed Potatoes and gravy recipe, dated 2025, showed: -Prepare mashed potatoes according to package directions; -Ladle two ounces of gravy over a #8 dip of mashed potatoes. Review of the Pureed Peanut Butter Pie recipe, dated 2025, showed: -Place prepared pie portions in a sanitized food processor and blend until smooth. Add milk as needed to achieve desired consistency; -Portion with a #10 scoop. 2. Observation on 06/24/25 at 10:45 A.M., showed [NAME] C blended two pieces of pork and a small amount of milk in a food processor. He/She poured the meat into a divided dish and added a ladle of gravy. He/She did not use the #8 scoop to serve the pork. Observation on 06/24/25 at 11:04 A.M., showed [NAME] C blended two #8 scoops of green beans and a splash of milk in a food processor. He/She poured the beans into a divided plate and a bowl and did not use the #12 dip to portion the beans. Observation on 06/24/25 at 11:12 A.M., showed the Dietary Aide J put two slices of pie in a the food processor with a splash of milk. He/She poured the servings into two dessert dishes and did not use a scoop to ensure the correct portion sizes. Observation on 06/24/25 at 11:15 A.M., showed [NAME] C pour water into a pan and placed it on the stove. [NAME] C poured an unmeasured amount of instant potato flakes into the pan and placed the potatoes on the steam table. He/She did not measure the potato flakes to ensure each portion contained the appropriate amount. Observation showed [NAME] C used a #4 scoop to serve the green beans and mixed vegetables and a #8 scoop to serve the instant mashed potatoes. 3. During an interview on 06/25/25 at 11:59 A.M., [NAME] C said he/she did not know what scoop size should be used to serve the pureed food. He/She is responsible to ensure the correct portions are given to the residents to meet their nutritional requirements. He/She said he/she was nervous and should have checked the recipe. During an interview on 06/25/25 at 12:22 P.M., the Dietary Manager (DM) said he/she expects the cooks to follow the menus and refer back to the menus during service. He/she said using the correct scoops and measuring the food ensures the residents receive the correct amount of nutrients and keeps the residents from getting overwhelmed with too much food. During an interview on 06/25/25 at 2:41 P.M., the Administrator said the DM is responsible to ensure the cooks serve the appropriate portions according to the recipes to ensure the residents get the correct caloric intake.

Based on interview and record review, facility staff failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for four residents (Resident #1, #6, #7, and #10) out of five sampled residents. The facility census was 37. 1. Review of the facility's Infection Control and Prevention program, dated 2019, showed the program defines and manages appropriate resident health initiatives such as the immunization program (influenza, pneumococcal, etc.). The program is under the direction of the Quality Assessment and Assurance (QAA) committee. The committee functions to review pneumococcal vaccine compliance. Review of the Centers for Disease Control (CDC), Adult Immunization Schedule by Age | Vaccines & Immunizations | CDC, dated 05/29/25, showed vaccines are recommended for those age [AGE] years or older who have: -Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21; -If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition (condition that weakens the immune system making one more susceptible to illness),* cochlear implant (device that stimulates the nerve in the ear), or cerebrospinal fluid leak (condition where fluid that protects the brain and spinal cord leaks through a tear in the tissue); -Previously received only PCV7: follow the recommendation above; -Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose; -Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose; -If PCV15 is used, no additional PPSV23 doses are recommended; -Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose; -Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose; -Immunocompromising conditions include chronic renal failure, nephrotic syndrome (kidney disorder causing too much protein to be excreted in the urine), immunodeficiencies (system unable to defend the body from abnormal cells), iatrogenic immunosuppression (weakend immune system caused by medical treatments), generalized malignancy (cancer that has spread), Human immunodeficiency virus (HIV) infection (a virus that attacks the immune system), Hodgkin disease (cancer of the immune system), leukemia (cancer that affects the blood and bone marrow), lymphoma (cancer that affects the lymphatic system), multiple myeloma (cancer that forms in a type of white blood cell called a plasma cell), solid organ transplant, congenital or acquired asplenia (absence of spleen function), or sickle cell disease (inherited blood disorders) or other hemoglobinopathies (inherited blood disorders that impact the production of the protein that carries oxygen in the blood). 2. Review of Resident #1's medical record showed: -date of birth [DATE]; -Resident age [AGE]; -The record did not contain documentation the resident had received, refused or been offered a pneumococcal vaccine. 3. Review of Resident #6's medical record showed: -date of birth [DATE]; -Resident age [AGE]; -The record did not contain documentation the resident had received, refused or been offered the pneumococcal vaccine. 4. Review of Resident #7's medical record showed: -date of birth [DATE]; -Resident age [AGE]; -The record did not contain documentation the resident had received, refused or been offered the pneumococcal vaccine. 5. Review of Resident #10's medical record showed: -date of birth [DATE]; -Resident age [AGE]; -The record did not contain documentation the resident had received, refused or been offered the pneumococcal vaccine. During an interview on 06/25/25 at 10:56 A.M., the Social Service Designee (SSD) said he/she has only been in the role for two weeks and is still being trained. He/She complete the residents' admission paperwork which should include immunization information. During an interview on 06/25/25 at 11:00 A.M., the Administrator said the facility recently changed health records software and the immunizations may be recorded there and would find out. During an interview on 06/25/25 at 1:10 P.M., the Director of Nursing (DON) said he/she was able to update the immunizations in the new medical record with the prior data. He/She said he/she is aware there are some immunizations missing but is fairly new to the facility and is still working on developing and reviewing the processes. The DON said immunization history and education should be completed during the admission process by the SSD and charge nurse and should be documented in the resident record. A declination should be documented in the resident record if appropriate.

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information with all the required components when the staff failed to document and update the actual hours worked. The facility census was 37. 1. Review of the facility's policy titled Posting Direct Care Daily Staffing, dated December 2024, showed facility staff will post the staffing on a daily basis at the beginning of each shift. The actual hours worked per position, and the total number of hours worked will be posted. Review of the facility's Staff hour posting, dated 06/01/25 through 06/23/25, showed the nurse staff posting did not contain documentation of actual hours worked for the entire 24-hour period for 06/01/25, 06/03/25 through 06/09/25, 06/16/25 through 06/18/25, and 06/20/25 through 06/22/25. Review of the facility's Staff hour posting, dated 06/01/25 through 06/23/25, showed the posting did not contain documentation of actual hours worked for two of three shifts during a 24-hour period for 06/02/25, 06/10/25, 06/12/25, 06/19/25 and 06/23/25. During an interview on 06/25/25 at 11:35 A.M., Licensed Practical Nurse (LPN) A said the nurses are responsible to change the posting nightly and if there are changes during the day, the day nurses are responsible to update it. He/She does not know who updates the actual hours worked on the posting. During an interview on 06/25/25 at 1:10 P.M., the Director of Nursing (DON) said the Assistant Director of Nursing (ADON) posts the hour posting daily, updates it every shift, and ensures it is completed after 24 hours. During an interview on 06/25/25 at 1:33 P.M., the ADON said he/she collects the 24-hour posting daily and is aware it is not always completed. He/She said he/she wears many hats and works the floor often and is just trying to keep up.

Based on interview and record review, facility staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment tool, for three residents (Resident #6, #21, and #32) of six sampled. The facility census was 37. 1. Review of the policies provided by facility staff showed staff did not provide a policy for the completion of MDS assessments. Review of the Resident Assessment Instrument (RAI) manual, used to facilitate accurate and effective resident assessment practices, version 1.19.1, dated October 2024, showed the manual instructed staff to not code antiplatelet medications such as clopidogrel (antiplatelet) or aspirin as an anticoagulant. 2. Review of Resident #6's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff documented the resident received an anticoagulant medication in the look-back period. Review of the resident's Physician Order Sheet (POS), dated June 2025, showed the POS did not contain an order for an anticoagulant. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff documented the resident received an anticoagulant medication in the look-back period. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for an anticoagulant. 4. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff documented the resident received an anticoagulant medication in the look-back period. Review of the resident's POS, dated June 2025, showed the POS did not contain an anticoagulant medication. 5. During an interview on 06/25/25 at 11:10 A.M., the MDS Coordinator said he/she thought aspirin and clopidogrel should be coded as an anticoagulant and coded it as such. He/She said self-studies, uses the RAI manual and reaches out to the corporate MDS Coordinator for guidance. The MDS Coordinator said it is his/her responsibility to ensure the assessments are coded correctly. He/She said he/she did not receive good training from the previous MDS coordinator. During an interview on 06/25/25 at 1:18 P.M., the Director of Nursing (DON) said he/she would expect the MDS nurse to follow the RAI manual for accurate coding and/or get help from him/her or the Corporate MDS nurse. The DON said he/she is new and interim to the role and trying to put new processes in place. He/She said aspirin and clopidogrel are not anticoagulants. During an interview on 06/13/25 at 03:51 P.M., the administrator said the MDS nurse is responsible for the MDS assessments and he/she expects the MDS nurse to use the RAI manual for accurate coding of assessments.

Based on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The census was 37. 1. Review of the facility's Activity Director (AD) Job Description, undated, showed the employee must have successfully completed all educational requirements for licensure and certification as required by federal and state regulations. During an interview on 06/25/25 09:02 A.M., the administrator said he/she thought the activity director had a certification but he/she did not. During an interview on 06/25/25 at 11:40 A.M., the AD said he/she did not have certification and had been in the role since November of last year. He/She did not know he/she should be certified until recently.

Based on interview and record review, facility staff failed to send a copy of the notice of transfer and/or discharge for four (Resident #6, #27, #32 and #35) of four sampled residents to the representative of the Office of the State Long-Term Care (LTC) Ombudsman from January 2025 to May 2025. The facility census was 37. 1. Review of the facility's admission and Discharge report, dated 01/01/25 through 05/31/25, showed 25 residents transferred or discharged from the facility. 2. Review of Resident #6's medical record showed staff documented the resident discharged on 04/07/25. The record did not contain documentation the Ombudsman was notified. 3. Review of Resident #27's medical record showed staff documented the resident discharged on 03/07/25 and 04/15/25. The record did not contain documentation the Ombudsman was notified. 4. Review of Resident #32's medical record showed staff documented the resident discharged on 03/29/25 and 05/01/25. The record did not contain documentation the Ombudsman was notified. 5. Review of Resident #35's medical record showed staff documented the resident discharged on 04/11/25. The record did not contain documentation the Ombudsman was notified. During an interview on 06/23/25 at 10:30 A.M., a representative from the LTC Ombudsman office said they had not received any transfer or discharge notifications since January 2025. During an interview on 6/24/25 at 2:30 P.M., the Social Services Designee (SSD) said he/she has only been in the role for a couple of weeks and is still in training. He/She did not know to send the transfer/discharge notification to the Ombudsman. During an interview on 06/24/25 at 2:30 P.M., the Regional Nurse said the facility had not sent the monthly notice of transfers and/or discharges to the Ombudsman. He/She was currently training the new SSD, but had not trained him/her on the process as of yet. The prior SSD did not send the reports. During an interview on 6/24/25 at 3:00 P.M., the administrator said they had not sent the notices of transfers and/or discharges to the Ombudsman.

Based on observation, interview, and records review, the facility failed to implement an effective pest control program to control flies within the facility. The facility census was 34. Review showed the facility did not provide a policy regarding pest control. 1. Review of the pest control company's summary of service, dated 04/24/24, showed the following facility recommendations: -Insect Light 001- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 4- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 003- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Needs new bulb. Review of the pest control company's summary of service, dated 05/22/24, showed the following facility recommendations: -Insect Light 001- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 4- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 003- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Needs new bulb. Review of the pest control company's summary of service, dated 06/26/24, showed the following facility recommendations: -Insect Light 001- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 4- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 003- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Needs new bulb. During an interview on 07/25/24, at 11:15 A.M., Nurse Assistant (NA) D said flies were sometimes an issue in the facility. Several residents go in and out the door at the end of 300 hall to smoke and the flies enter the building. Observation and interview on 07/25/24, at 1:07 P.M., of Resident #3 showed the following: -The resident said the flies in the facility buzz his/her face; -The resident said, I kill 50 flies a day; -Four to five flies buzzed around the resident, landing on his/her legs and bedding. During an interview on 07/25/24, at 1:15 P.M., Resident #4 said the following: -The flies have been bad in the facility for the last month and bother the resident; -The flies buzz his/her face and land on his/her skin. Observation and interview on 07/25/24, at 4:40 P.M., of Resident #5 showed the following: -The resident in his/her room with three flies buzzing around the resident; -The resident said the flies buzz his/her face and land on his/her skin; -The resident said he/she and other residents told the nurses about the fly issue, but nothing changed. Observation and interview on 07/25/24, at 4:35 P.M., of Resident #7 showed the following: -The resident lying on his/her bed while two flies crawled on the resident's blankets; -The resident said, Flies are terrible; -The facility fly issue started about one month ago; -He/she informed staff and they brought the resident a flyswatter; -The flies buzz the resident's face and land on him/her. Observation and interview on 07/25/24, at 4:45 P.M., of Resident #6 showed the following: -The resident sat in his/her room and a fly buzzed around the resident's room; -The resident said he/she usually had one to two flies in his/her room at all times; -The resident said he/she used a flyswatter to kill the flies; -The resident said there were flies in the resident dining room. During an interview on 07/25/24, at 2:15 P.M., the Social Service Director (SSD) said the following: -The facility had a fly issue due to staff and residents going in and out of the facility all the time; -Staff go in and out the exit door located in the dining room. Residents use the external door across from the dining room (the gazebo door), and the exit doors at the ends of 100 and 300 halls. During an interview on 07/25/24, at 4:00 P.M. the Maintenance Director said the following: -The facility had an issue with flies; -When the facility had a fly problem, he/she contacted the pest control company; -The pest control company came to the facility at least monthly and more often, if needed; -The facility had three bug lights located on three of the resident halls, but he/she did not think the bug lights worked; -In April 2024, the pest control company said the facility needed to replace the bug lights located on the hallways; -He/she spoke to the Administrator about the bug lights, but the Administrator said corporate did not want to replace the bug lights; -The pest control company said the bug lights would help control the flies in the facility. During an interview on 07/29/24, at 12:37 P.M., Licensed Practical Nurse (LPN) A said the following: -The facility had a fly issue; -The flies were bad in Resident #1's room due to odors in the room; -Staff were in and out the doors all day and the flies entered the building; -All the staff were aware the flies were bad. One of the nurses kept a flyswatter at the nurse's desk to kill flies. During an interview on 07/29/24, at 1:23 P.M., Certified Nurse Assistant (CNA) E said the following: -Resident #1 had a lot of flies in his/her room, the flies buzzed the resident and landed on his/her legs; -He/she talked with housekeeping about cleaning the room to help with the flies; -He/she talked with several of the charge nurses about the flies; -The pest control company comes to the facility on a regular basis. During an interview on 07/29/24, at 1:46 P.M., LPN B said the following: -The facility had a fly issue because staff and residents were constantly going in and out of the facility; -The facility tried different things over the years to control the flies and he/she had seen the pest control company at the facility; -He/she had suggested plug in fly light, but the Director of Nursing (DON) said no. During an interview on 07/29/24, at 2:13 P.M., the interim DON said he/she had not observed a fly problem in the facility and staff had not reported an issue with flies. During an interview on 07/29/24, at 3:16 P.M., the Administrator said the following: -He/she observed a few flies in the facility; -A pest control company visited the facility at least monthly; -The pest control company said the facility bug lights (located on the resident halls) were not working and they could not obtain parts for the bug lights and therefore would have to replace the entire system; -He/she had sent multiple requests to the facility corporation to notify the bug lights need to be repaired or replaced, but the facility corporate office denied the requests; -He/she tried to educate staff not to go out the dining room door to smoke. MO00239315 MO00239350

Based on interview and record review, the facility failed to have a system in placed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when four NAs (NA D, NA F, NA G, and NA H) failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test timely and continued to work providing direct care to residents. The facility's census was 34. Review showed the facility did not provide a policy related to training and certification of NAs/CNAs. 1. Review of NA D's personnel file showed the NA hired to work at the facility on 12/28/23 in the nursing department as a NA. During an interview on 07/25/24, at 11:15 A.M., NA D said he/she worked full-time at the facility for approximately six to seven months continuously as a NA. He/she was currently in online CNA class and needed to take his/her last test in class. 2. Review of NA F's personnel file showed the NA hired to work at the facility on 03/02/23 in the nursing department as a NA. During an interview on 07/25/24, at 11:30 A.M., NA F said the following: -He/she worked at the facility for approximately one and one-half years as a NA, four to five months of which he/she worked part-time and the rest of the time, he/she worked full-time; -He/she was currently in online CNA class and needed to take two more tests to complete the class. 3. Review of NA G's personnel file showed the NA hired to work at the facility on 12/20/23 in the nursing department as a NA. During an interview on 07/30/24, at 9:58 A.M., NA G said the following: -He/she finished his/her CNA class tests, but he/she was waiting for the facility to check off his/her competency sheets; -He/she spoke with the Assistant Director of Nursing (ADON) and Administrator about the need to complete the competency sheets and he/she was informed they would assist him/her with the sheets when they had time. 4. Review of NA H's personnel file showed the following: -Hired as a housekeeper on 07/27/23: -Transferred to nursing department on 01/01/24 to work as a NA. During an interview on 07/25/24, at 2:58 P.M., NA H said he/she said he/she worked as am NA at the facility since January 2024. 5. During an interview on 07/29/24, at 1:46 P.M., Licensed Practical Nurse (LPN) B said the following: -He/she was a clinical instructor and volunteered to help some of the NAs get their competencies completed for that portion of the CNA requirement; -NA D and NA F never brought their competency sheets to work with them; -NA G only brought competency sheets one day and did not complete any competencies in front of the nurse. 6. During an interview on 07/25/24, at 3:00 P.M., the interim Director of Nursing (DON) said the following: -NAs should become certified within four months of the date of hire; -The facility currently had four NAs working that had worked at the facility for longer than four months; -He/she emailed the online CNA instructor on 07/19/24 to inquire about completing the NAs' testing for CNA class. 7. During an interview on 07/29/24, at 3:16 P.M., the Administrator said the following: -NAs should become certified within four months of hire; -He/she was aware there were four NAs working in the facility had had worked for over four months; -The interim DON would need to complete the competency sheets for the NA competencies; -The DON and ADON should be tracking the CNA class progress of the NAs; -He/she asked the interim DON and ADON to get in touch with the CNA instructor to inquire on the status of the NAs.

Based on interview and record review, the facility failed thoroughly investigate all allegations of possible misappropriation and failed to take steps protect all residents during an investigation process when staff failed to document a thorough investigation of an allegation of possible misappropriation of resident's (Resident #2) property and when the alleged involved staff members (Nurse Assistant (NA) D, NA F, and NA G) continued to work independently with all residents. The facility census was 34. Review of the facility policy titled, Abuse Policy, undated, showed the following: -It is the policy of this facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, physical abuse, misappropriation of resident property and exploitation, and corporal punishment or involuntary seclusion; -All employees who have been alleged to commit abuse will be suspended immediately pending investigation; -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse, neglect or exploitation or mistreatment while the investigation is in progress. 1. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included depression, muscle weakness, diabetes mellitus, and high blood pressure. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/13/24, showed the following: -Cognitively intact; -Verbal behaviors on one to three days of review period. During an interview on 07/25/24, at 10:30 A.M., the Administrator said the following: -Sometime during 2023, the resident's family came up with a plan to rent the resident's house to an employee of the facility, NA F; -Recently, the resident's family member reported NA F was not paying rent, a vehicle was allegedly missing from the property, and the resident received a citation from the city regarding trash, tall grass, and animals on the property; -The renter of the resident's property was an employee of the facility, NA F; -NA F allegedly moved two other employees into the resident's home, NA D and NA G; -All three NAs were currently employed by the facility; -The Administrator instructed the three staff, NA D, NA F, and NA G, to avoid any interaction with the resident; -The resident was upset the day his/her family member came in to the facility and told the resident about the issues with the property; -The resident's family member alleged the tenants of the resident's home (NA D, NA F, and NA G) were not paying rent; -NA F alleged initially he/she was paying off a large back utility bill owed by the resident and performing some type of work at the property in lieu of paying the resident rent; -The arrangements for NA F to rent the resident's property were allegedly made between the former facility Social Service Director (SSD), who was a relative of NA F, and the resident's family member; -The three alleged perpetrators, NA D, NA F, and NA G, were currently working in the facility and were not suspended pending an investigation; -A documented investigation of the allegation had not been completed. During an interview on 07/25/24, at 1:00 P.M., the resident said the following: -He/she owned a property in the town of Windsor; -The property was supposed to be rented, but he/she did not know what was going on currently with the property. During an interview on 07/30/24, at 12:03 P.M., the resident's family member said the following: -He/she was not responsible for the resident's finances, as the resident was his/her own responsible party; -He/she never collected any money for rent of the resident's property; -NA F was supposed to pay rent to the resident, but that did not appear to be happening; -The NA moved more staff members into the resident's home and they were tearing up the resident's property and piled trash up in the yard; -NA F took the resident's antique truck that was located at the property; -NA F contacted the resident's family member and wanted to make an arrangement to exchange work and paying on a gas bill instead of paying rent, but the family member did not agree to any such arrangement; -The resident and the family member wanted the staff to vacate the resident's home. Review of facility provided records showed the following: -A copy of a rental agreement, dated 07/10/23, between tenant Nurse Aide (NA) F and owner of property (Resident #2) for monthly rent of the resident's property; -The tenant was to pay 350.00 dollars per month in rent commencing on 07/10/23, and in the event the rent was not paid by the 15 th of the month, the tenant agreed to pay a 25.00 dollar late charge; -The rental agreement showed amount received 350.00 dollars. Review of facility provided records showed a copy of a postal money order, dated 10/10/23, from NA F paid to the resident's family member in the amount of 350.00 dollars for rent. Review of the facility provided records showed the following: -A copy of a letter from the City of Windsor to Resident #2, dated 05/14/24, to advise the resident that his/her personal residence was in violation of a municipal code due to the residence containing a substantial accumulation of trash, garbage, and other material susceptible to fire of constituting or providing a harboring place for vermin or other obnoxious animals of insects; -Abate the unsafe condition within 10 days of a public hearing will be set which could result in the City abating the nuisance and placing a special tax bill on the property for the cost of the abatement. Review of the facility's records showed a copy of a notice to vacate the resident's property, dated 06/17/24, signed by the resident. Reason listed as no rent being paid and trash-like living conditions around and inside house. During an interview on 07/25/24, at 11:30 A.M., NA F said the following: -He/she worked at the facility for approximately one and a half years; -Several months ago, he/she needed a place to live. His/her family member worked as the facility SSD at that time and said the resident's family member was looking for someone to live in the resident's home and offered to rent the house to NA F; -He/she worked to clean up the home and paid on a previously owed gas bill instead of paying rent; -He/she had a verbal arrangement with the resident's family member to clean up the residence and pay on the gas bill, but did not get anything in writing; -The former SSD had NA F sign the lease/rental agreement; -The property belonged to the resident; -When he/she began living in the resident's property, he/she was an employee of the facility and the resident lived at the facility; -He/she had not paid any rent money to the resident or his/her family member in approximately four months; -Approximately one month ago, he/she invited two other staff members to stay at the resident's home, NA D and NA G; -A few weeks ago, he/she received a notice on the door of the home from the resident stating he/she had 30 days to move out of the residence. He/she was currently looking for another place to live; -He/she delivered the resident's tray to his/her room, answered the resident's call light, and interacted with the resident in the dining room, but the resident did not require physical assistance; -He/she did not know what misappropriation of resident property was, but said he/she knew he/she was not supposed to steal from a resident. During a phone interview on 07/30/24, at 9:58 A.M., NA G said the following: -He/she met NA F while working at the facility; -He/she and NA D needed a place to live a few months ago and NA F said the two could stay with him/her; -NA D and NA G then moved into the home with NA F. Approximately one month later, NA G found out the home belonged to the resident; -He/she was currently looking for another place to live; -He/she was unsure what misappropriation of property was, but he/she did know not to take items or money from a resident, but he/she did not know the home belonged to the resident at the time he/she moved in to the house. During an interview on 07/25/24, at 11:15 A.M., NA D said the following: -He/she worked at the facility for approximately six months; -NA F lived in a house belonging to the resident; -Approximately three months ago, he/she and another staff, NA G, needed a place to live and NA F invited the two to stay at the home belonging to the resident and the two then moved into the home; -He/she had not paid any rent to anyone since living in the home; -He/she had not seen a rental agreement and no one asked him/her for any money for rent; -He/she provided care to the resident in the past at the facility, but had not worked on the resident's hall for approximately the last month; -He/she was not instructed by staff to avoid taking care of the resident. During an interview on 07/25/24, at 12:20 P.M., Licensed Practical Nurse (LPN) B said the following: -The City of Windsor called and wanted to speak to the resident. He/she took the phone to the resident and notified the current SSD of the situation; -At the direction of the Administrator, he/she notified the three NAs (NA D, NA F, and NA G) they were not to work on the resident's hall or have any contact with the resident; -The resident was confused an forgetful at times; -The day the city called and spoke to the resident, the resident appeared nervous, anxious and upset by the call. During an interview on 07/25/24, at 2:15 P.M., the current SSD said the following: -He/she was aware NA F lived in the resident's home; -Approximately six weeks ago, a staff member asked the SSD if he/she was aware of the condition of the resident's home due to the accumulation of trash and filth outside the residence; -He/she then contacted the City of Windsor in regards of the condition of the home; -He/she also notified the Administrator, who advised him/her to contact the resident's family member; -The family member said he/she did not want to be involved in the situation, but asked if the SSD would help the resident with the matter; -The SSD spoke with the resident and the resident verbalized he/she wanted the staff out of his/her home; -The SSD contacted the City of Windsor police department and notified of the situation and asked for advise on the matter; -The SSD and resident typed up an eviction notice, on the advice of the local law enforcement, and the SSD placed the notice on the front door of the resident's home on 06/17/24; -This was a 30-day notice to the three NAs (NA D, NA F, and NA G) to vacate the premises within 30 days; -The resident's family member was given 350.00 dollars in rent money for the property in July of 2023, and nothing further; -The resident's family member asked about an antique truck that was at the property and NA F said the truck was moved to a friend's house. The resident's family member told the NA to return the vehicle; -On 06/17/24, the SSD went to the facility Administrator with the issue and the Administrator was aware NA D resided in the resident's home; -The previous SSD said the monthly rent money would be placed in the resident's account, but that did not occur; -Staff member NA F, had not compensated the resident per the rental agreement for living in the resident's home; -The Administrator reported the concern to the state elder abuse hotline, but did not conduct a full investigation into the allegation, or suspend alleged perpetrators, because the facility corporation said this was a community issue and not a facility issue. During interviews on 07/25/24, at 3:00 P.M., and on 07/29/24, at 2:13 P.M., the interim Director of Nursing (DON) said the following: -He/she became aware of staff members living in the resident's home approximately two months ago when the City of Windsor called the facility concerned about the condition of the resident's property; -The Administrator contacted the corporate director of operations at that time regarding the situation and he/she advised the Administrator the staff members living in the resident's home did not need to be suspended from work; -He/she was not involved in the plan for the three staff to avoid caring for the resident, He/she was not asked to investigate the allegation of misappropriation; -An allegation of misappropriation of property was when a resident suffered a financial or property loss; -He/she was unsure if staff living in the resident's home would constitute as an allegation of misappropriation of property, because the NA had a contract with the resident to rent to resident's property and at that time the resident was aware of what he/she was doing; -If the facility received an allegation of misappropriation of resident property, the facility should initiate an investigation, interview the resident and staff, suspend alleged perpetrators and self-report the issue to the state survey agency, the family, and police. During an interview on 07/29/24, at 3:16 P.M., the Administrator said the following: -In June of 2023, he/she was aware NA F moved into the resident's home; -In June of 2024, the City of Windsor called the facility to speak with the resident about citations at the property; -The resident was crying and yelling about the situation; -The SSD called the resident's family member about the situation and the family member reported he/she had not received rent money for the property; -The resident said he/she did not realize the NAs were not paying any rent; -The facility's Director of Operations advised to hotline the issue and to ensure the NAs residing in the resident's home were not caring for the resident; -He/she did not investigate the allegation of misappropriation of resident property, due to issue occurred in the community and not in the facility; -If the facility had an allegation of misappropriation of resident property in the facility, he/she would suspend the alleged perpetrators pending the outcome of the investigation, report the allegation to the state, police, and responsible parties, and conduct an investigation. MO00238090

Based on interview and record review, the facility to provide care for all residents consistent with standards of practice when staff failed to implement physician ordered changes for one resident's (Resident #1's) treatment order for affected areas on his/her bilateral (both sides) lower extremities. The facility census was 34. Review of the facility policy titled, Physician Orders, dated March 2015, showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Treatment orders should specify what is to be done, location and frequency, and duration of the treatment. Review of the facility policy titled, Wound Care and Treatment, dated July 2015, showed the physician will specifically order the treatment to be provided (including cleansing, ointments, gauze, dressing type, and frequency of treatments). 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included cellulitis (skin infection) of both lower extremities, schizophrenia (a mental disorder characterized by reoccurring episodes of psychoses that are correlated with a general misperception of reality), osteoarthritis, muscle weakness, edema (swelling), and pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/23/24, showed the following: -Cognitively intact; -Application of non-surgical dressings other than to feet; -Application of dressings to feet. Review of the resident's Physician Order Sheet (POS), dated 06/25/24 to 07/25/24, showed the following; -An order, dated 06/13/24, for bilateral lower extremities to be cleansed with Hibiclens (an antibacterial and antimicrobial skin cleanser), pat dry, apply baking soda paste (1/2 cup of baking soda, 2 tablespoons (TBSP) of white vinegar, than add a small amount of water until it is a paste) to toes, bottom of foot and top of foot, cover will ABD (absorbent gauze) pads, wrap with Kling (soft rolled gauze) wrap and ACE (an elastic bandage) wraps, change daily. The order was ended on 07/08/24. -An order, dated of 07/08/24, for bilateral lower extremities areas from knee down to be cleansed with soap and water, pat dry, apply A&D (protective barrier) ointment, and then apply ABD pads, and wrap with Kling wrap, and then apply ACE wrap, change daily and as needed. Review of the resident's July 2024 Treatment Flowsheet showed the following: -An ordered, dated 06/13/24, to cleanse bilateral lower extremities with Hibiclens, pat dry, apply baking soda paste (1/2 cup of baking soda, 2 tablespoons of white vinegar, than add a small amount of water until it is a paste) to toes, bottom of foot and top of foot, cover will ABD pads, wrap with kling wrap and ACE wraps, change daily; -Nurses initialed completion of this treatment every day from 07/01/24 to 07/21/24; -Nurses did not discontinue the treatment as ordered or update the treatment flowsheet with the new treatment ordered on 07/08/24, as directed by the physician. Review of the resident's weekly skin assessment, dated 07/18/24, showed the following: -Existing non-foot issue with no edema; -Existing issues with left and right foot and ankle; -Bilateral lower extremities remain red, weeping (oozing of clear fluid from the skin), dry patches of skin throughout bilateral lower extremities from knees to toes. Treatment in place. During an interview on 07/29/24, at 12:37 P.M., Licensed Practical Nurse (LPN) A said the following: -The nurse who worked on 07/08/24 probably failed to place the treatment order on the treatment flowsheet; -He/she called the Assistant Director of Nursing (ADON) for clarification of the treatment order and the ADON said facility staff were no longer using the Hibiclens, baking soda, and vinegar treatment. The ADON informed the LPN of the current treatment order. During an interview on 07/29/24, at 1:46 P.M., LPN B said the nurse that received the physician's order on 07/08/24 to change the resident's skin treatment should have placed the order into the computer, printed off a new treatment flowsheet, and discontinued the previous treatment order. During an interview on 07/29/24, at 2:06 P.M., Registered Nurse (RN) C said the following: -He/she performed the resident's skin treatment as directed on the treatment flowsheet; -He/she used Hibiclens to clean and applied the baking soda/vinegar treatment to the resident's legs. During an interview on 07/29/24, at 2:13 P.M., the interim Director of Nursing (DON) said when the physician changed the order for a resident's treatment, he/she expected the nurse receiving the order to place the new order in the computer, on the resident's treatment flow sheet, and document on a nurse's note. During an interview on 07/29/24, at 3:16 P.M., the Administrator said he/she expected that if a nurse received a new order from the physician, the nurse should place the order on a physician order in the computer, on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and make a nurse's note. MO00239315 MO00239350

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day for three of the 14 days reviewed for November and December 2023 (12/02/23, 12/03/23, and 12/09/23). The facility census was 32. 1. Review of the daily staffing for the period of 11/27/23 thru 12/09/23 showed a RN was not scheduled in the facility on 12/02/23, 12/03/23, and 12/09/23. During an interview on 12/14/23, at 9:21 A.M., the Administrator said the staffing coordinator was not present and he/she would be the person to talk to about staffing. The administrator was aware the facility had days when there was no RN coverage during a 24-hour period. Those days were most likely on weekends since the Director of Nursing (DON) was the only RN the facility had. They were able to get an agency RN through to work some shifts, but that was not always the case. It had been about six months since the facility has had a second RN other than the DON who only works Monday thru Friday. The DON was on call during the week and on weekends if when they needed an RN assessment. During an interview on 12/14/23, at 11:16 A.M., the DON said the Administrator did the scheduling. She was the only RN the facility had on schedule, but she cannot work seven days a week. She was on-call and available if there was a need. She was aware there was no RN coverage on some of the weekends and did try to work some weekends when she was available. She said the facility did not have a policy for staffing.

Based on observation, record review, and interview, the facility failed to ensure that it stored, prepared, and distributed food in accordance with professional standards for food safety when staff failed to perform hand hygiene prior to handling clean dishes, failed to follow manufacture directions for storage/dispose of supplements, and failed to keep the ice machine clean. The deficiency had the potential to affect 35 residents. 1. Review of the facility's untitled policy provided by the dietary manager from the computer, dated April 2011, showed after the first tray of dishes is washed, pull the rack out of machine to air dry. Sanitize hands between handling of soiled and clean dishes. Observations on 12/14/23, at 9:15 A.M., showed Dietary Aide (DA) 6 was loading the dishwasher with his/her bare hands, wiping her hands off on his/her shirt five times with a different rack of dishes each time from 9:18 A.M., 9:20 A.M., 9:25 A.M. and 9:30 A.M. With each dish rack entered into the dishwasher, DA 6 wiped off hi/her soiled hands as he/she unloaded the clean dishes, plate covers, silverware and more dishes. The DA did not perform hand hygiene moving from dirty to clean plates. During an interview on 12/14/23, at 9:30 A.M., DA 6 said he/she forgot to clean his/her hands before removing clean dishes. During an Interview on 12/14/23, at 10:45 A.M., the Dietary Manager (DM) said the dietary should have two people at the dishwasher, one staff loading dirty dishes and one staff unloading clean side dishes. 2. Review of the facility policy titled Supplements for Weight Loss/Skin Condition, dated May 2015, showed no direction for storing or serving supplement shakes during thawing and refrigeration. Observation on 12/15/23, at 10:00 A.M., showed supplement shakes stored in an upright top refrigerator/freezer in the freezer section. Twenty-one shakes were stored in the freezer and one was stored in the refrigerator. The shake in the refrigerator was lacking a date of thawing. The shake container read non-fat milk as the main ingredient and store frozen, thaw under refrigeration. The container directed to keep keep refrigerated 14 days after thawing. During an interview on 12/15/23, at 10:00 A.M., the DM said shake had been thawed two days ago, however there was no date to track it's thawing. The facility does not have a process for following the thawing of shakes. He/she goes by his/her memory. 3. Review of the procedure titled Ice Maker, dated April 2011, posted on the outside of the ice machine, showed monthly cleaning involving unplugging the ice machine, empty the ice, wash the inside of the machine with warm detergent solution, rinse with baking soda water and dry, and delime machine as required. Observation on 12/14/23, at 10:05 A.M., of the facility ice machine located in the kitchen showed a cleaning schedule on the side of the machine. The ice machine had brown spots on the top outside plastic section above the ice inside the top door. During an interview on 12/14/23, at 12:00 P.M., the Maintenance Director said he has not cleaned the machine since he started three months ago and has no documentation of cleaning. During an interview on 12/14/23, at 12:05 P.M., the DM said she does not remember the last time the ice machine was emptied and cleaned thoroughly.

Based on observation, interview, and record review, the facility staff failed to perform hand hygiene during one resident (Resident #20), of one resident observed, during a dressing change, and staff failed to perform hand hygiene and disinfect the glucometer when completing blood glucose monitoring for two residents (Resident #2 and #12). The facility census was 32. 1. Review of the facility policy titled, Handwashing, undated, did not address when hand hygiene is to be performed. Review of the facility policy titled, Standard and Transmission Based Precautions, undated, showed staff to wash hands after removing gloves. Review of Resident #20's Electronic Medical Record (EMR), under the census tab, showed the following: -admitted [DATE]; -Diagnoses included diabetes, non-pressure ulcer on the left leg, and a skin disorder. Observation on 12/13/23, at 10:00 A.M., of Licensed Practical Nurse (LPN) 9 showed the following: -The LPN gathered supplies from the treatment care for a dressing change; -The LPN donned gloves without performing hand hygiene; -The LPN prepared the resident for the dressing change, removed his/her gloves, and applied another pair of gloves. The LPN did not complete hand hygiene; -The LPN removed the resident's soiled dressing, removed his/her the gloves, donned another pair of gloves, and cleansed the resident's wound. The LPN did not perform hand hygiene; -The LPN removed the gloves, applied another pair, and applied a treatment. The LPN removed the gloves and put on another pair. The LPN then applied the dressing and secured the dressing. The LPN did not perform hand hygiene. During an interview on 12/13/23, at 10:15 .A.M., LPN 9 confirmed he/she failed to perform hand hygiene when changing gloves. During an interview on 12/14/23, at 12:34 P.M., the Infection Preventionist said hand hygiene is to be performed after removing gloves. 2. Review of the facility policy titled, Blood Glucometer Disinfecting, undated, showed staff to clean the blood glucose meter prior to using with approved wipes of 10% bleach. Review of the Resident #2's EMR, under the census tab, showed the resident was not diabetic, but was experiencing a change in condition. Observation on 12/13/23, at 11:30 A.M., the Director of Nursing (DON) directed LPN 9 to perform blood glucose monitoring due to a change in the resident's condition. The LPN obtained a finger-stick for a blood sample from the resident. LPN 9 did not perform hand hygiene before putting on gloves or after the sample was obtained. LPN 9 did not disinfect the glucose meter. LPN 9 applied gloves and performed a finger stick for a blood sample from Resident #12, removed the gloves, and did not clean the glucose meter. During observation and interview on 12/13/23, at 11:40 A.M., the DON observed LPN 9 cleaning the glucometer with an alcohol wipe and directed the LPN to obtain the disinfectant wipe to clean the glucose meter. LPN 9 and the DON looked in the drawer of the medication cart and were unable to locate the disinfectant wipes on the cart. The LPN and the DON confirmed there were no bleach wipes available for use on the nurses' medication cart.

Based on record review and interview, the facility failed to provide the Advance Beneficiary Notice (ABN) and Notice for Medicare Non Coverage (NOMNC) to three residents (Residents #10, #141 and #142) of three sampled residents who received Medicare part A services. The facility census was 32. 1. Review of Resident #10's Electronic Medical Record (EMR), under the census tab, showed the following: -admitted [DATE] on Medicare Part A services; -On 06/26/23, the resident was discharged from Medicare Part A services by the facility. The resident remained in the facility. Review of the resident's record showed the facility failed to provide the resident and/or their representative with ABN and NOMNC notices. 2. Review of Resident #141's EMR, under the census tab, showed the following: -admitted [DATE] on Medicare Part A services; -On 07/30/23, the resident was discharged from Medicare Part A services to receive lesser care. Review of the resident's record showed the facility failed to provide the resident and/or their representative with ABN and NOMNC notices. 3. Review Resident #142's EMR, under the census tab, showed the following: -admitted [DATE] on Medicare Part A services; -The resident was discharged from Medicare Part A services on 10/31/23 and remained in the facility. Review of the resident's record showed the facility failed to provide the resident and/or their representative with ABN and NOMNC notices. 4. During an interview on 12/14/23, at 1:08 P.M., the Director of Nursing (DON) said he/she would be the one to present the resident/representative with the ABN and/or NOMNC. The DON confirmed the documents were not available to be reviewed and confirmed the facility lacked a policy for the presentation of the ABN and/or NOMNC when a resident is discharging from a Medicare Part A skilled stay.

Based on observations, record review, and interviews, the facility failed to ensure that one resident (Resident #34) of 13 sampled residents maintained acceptable parameters of nutritional status when staff failed to identify and address the resident's weight loss for four months. The facility census was 32. Review of the facility policy titled, Weight Monitoring, original date of May 2015, showed the following: -Monthly weights will be obtained by the 7th of each month; -Weights will be monitored at least monthly; -Weight reports will be provided to the Director of Nursing (DON) within two days of weight; -Weekly weights will be completed for those with significant weight change. 1. Review of Resident #34's Profile tab in the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included restlessness-agitation, pain unspecified, constipation, depression, overactive bladder and gastro-esophageal reflux disease. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 03/06/23, and quarterly MDS, with an ARD of 09/06/23, showed the resident needed supervision and set up only for eating. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident had sever cognitive impairment; -Resident had weight loss and was not on weight loss regimen. Review of the resident's medical records, dated 07/09/23 to 12/06/23, show staff did not enter any nutritional notes into the EMR. Review of the resident's most recent nutritional assessment from the EMR Observations tab, dated 12/07/23, showed the resident's current diet level 7 with ground meat and thin liquids. Resident makes his/her own food choices with the help of staff and is happy with his/her choices. He/She usually eats a ground hot dog for lunch and supper. Review of the resident's actual weights, under the tab of Vitals, in the EMR, showed the following: -On 07/09/23, 122 pounds; -On 08/06/23, 118.6 pounds; -On 09/10/23, 118.2 pounds; -On 10/09/23, 108.6 pounds; -On 11/06/23, 101.6 pounds; -On 12/10/23, 105.4 pounds. (These totals amount to a 13.61% weight loss over six months.) Review of the resident's Physician Notes showed the following: -On 08/17/23, the resident's weight was 118.6 pounds (lb). Physician noted routine visit, no complaints, increase in agitation, well developed, and well nourished; -On 10/26/23, the resident's weight was 101.2 lb. Physician noted routine visit, well-nourished and well developed, stable and increase Seroquel (antipsychotic medication) to two times daily; On 11/16/23, the residents weight was 101.8 lb. Physician noted a routine visit, no complaints, stable and well-nourished, and developed. (The physician did not mention the resident's weight or weight loss and made no orders as a result of the visits. The physician did not address the the overall weight loss of 13.61% from July 2023 to December 2023.) Review of the resident's Physician Order, from the Orders tab, for December 2023 showed the following: -Regular diet with meals breakfast-lunch-supper; -An active order for Remeron 15 (milligram) mg by mouth one time a day at bedtime for appetite enhancement and is also an antidepressant. Review the resident's care plan in the EMR, located under the Care Plan tab, with a start date of 12/12/23, showed the resident will eat 50% of meals, snacks, and supplements. Staff to offer substitutes if resident has problem with meals served and review menu. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed the resident had not and was not receiving a health shake or supplement. Review of the resident's Progress Notes, under the Progress Notes tab, dated 12/12/23, at 11:35 A.M., showed the following; -Fax to the physician to request ST (speech therapy) eval (evaluation) for appropriate diet texture; -Staff closely monitoring resident during meals to ensure no large bites and no episodes of choking; -Notified him/her that staff are giving the resident a supplement two times daily due. Observations on 12/12/23, at 11:50 A.M., in the main dining room, showed the resident ate his/her chicken and no potato. The resident did not eat 50% of his/her meal. The resident stood up from the table and left the room. No staff member asked the resident if she wanted a substitute or something else. Observations on 12/13/23, at 11:35 A.M., in the main dining room, showed the resident ate a hot dog without the bun and did not eat potato chips. Staff gave the resident a 4-ounce cup of ice cream which she ate. The resident finished less than 50% of her meal. When finished, he/she stood up and left the room using her wheeled walker. Staff did not offer a substitute or asked if he/she wanted anything else. During an interview on 12/14/23, at 9:30 A.M., the Corporate Registered Dietician (CRD) said there is no dietician for the building. The newly hired dietician is still in training or orientation and only walked through the kitchen recently. During an interview on 12/13/23, at 10:40 A.M., Certified Medication Technician (CMT) 3 said he/she does not pass or give the resident any supplements or med pass supplements when passing her medication. During an interview on 12/14/23, at 9:15 A.M., Licensed Practical Nurse (LPN) 9 said he/she had not given the resident any supplements today or the past three days when working day shift. Nursing is responsible for administering supplements. During an interview on 12/14/23, at 10:15 A.M. Family Member (FM) 1 said he/she had spoken to the facility about the resident's weight. FM 1 has shared with staff what the resident likes such as strawberry ice cream, and nothing happened. The resident is still losing weight. During an interview on 12/14/23, at 12:20 P.M., the Director of Nursing (DON) said there was no order and no one was giving supplements to the resident. Staff were testing to see if the resident take it. Staff are now the process orders for supplement two times a day. During an Interview on 12/14/23, at 12:00 P.M., the Dietary Manager (DM) said he/she had no orders or change of orders for supplements for the resident in the past six months. Nursing would administer all supplements.

Based on interview and record review, the facility failed to document treatments of ordered wound care in accordance with professional standards for one resident (Resident #1) out of a sample of eight. The facility census was 40. Review of the facility's policy, titled Wound Care and Treatment, undated, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -Documentation of the treatment should be done immediately after the treatment. (The policy did not address documention of resident refusals of treatment.) 1. Review of Resident #1's face sheet showed the following: -Re-admitted [DATE] -Diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), cellulitis of the lower limbs (a bacterial skin infection), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/13/23, showed the following: -Cognitively intact; -Rejected cares four to six days of the seven day evaluation period; -He/she had dressings applied to his/her feet. Review of the resident's care plan, updated 09/06/23, showed the following: -Resident has venous ulcers (ulcers due to poor blood flow in the leg vein) to bilateral lower extremities and feet related to peripheral vascular disease; -Resident frequently refuses treatments; -Staff should assess and record the condition of skin surrounding the ulcer; -Assess resident's circulation, motion, and sensation of both lower extremities during dressing changes. Review of the resident's Physician Orders, dated 02/24/23, showed the following: -An order to cleanse the bilateral lower extremities (BLE) with wound cleanser and 4 inch by 4 inch gauze dressings, pat dry, apply over the counter (OTC) athlete's foot cream or powder to BLE, cover bilateral feet with ABD pads (gauze pads used to absorb discharge from heavily draining wounds), wrap with Kerlix (a stretchy rolled gauze) and then Ace wraps (elastic wraps) from toes to knee. Staff to change dressing twice daily (BID) until healed. Review of the resident's Nurse Medication Administration Record (MAR) Flowsheet, dated 08/31/23 to 08/31/23, showed the following: -An order to cleanse BLE with wound cleanser and 4 inch by 4 inch gauze dressings, pat dry, apply OTC athlete's foot cream or powder to BLE, cover bilateral feet with ABD pads, and wrap with Kerlix and then Ace wraps from toes to knee. Staff to change BID until healed; -On 08/04/23, evening shift, the facility staff did not document an entry for wound care; -On 08/05/23, evening shift, the facility staff did not document an entry for wound care; -On 08/06/23, evening shift, the facility staff did not document an entry for wound care; -On 08/24/23, evening shift, the facility staff did not document an entry for wound care; -On 08/30/23, evening shift, the facility staff did not document an entry for wound care. Review of the resident's nursing notes, dated 08/01/23 to 08/31/23, showed staff did not document regarding wound care. During an interview on 09/02/23, at 3:45 P.M., Licensed Practical Nurse (LPN) A said the resident often refused wound care and would only allow certain staff to change his/her dressings. Nurses should document the refusals on the treatment record and in the notes each time the resident refuses. During an interview on 09/06/23, at 11:20 A.M., LPN B said if a resident refuses treatment staff should re-approach them later. If the resident still won't let staff perform the task, the refusal should be documented in the treatment form and in the nursing notes. The nurse notifies the physician and the family. During an interview on 09/06/23, at 12:50 P.M., Certified Nursing Assistant (CNA) C said if a resident refuses care, they let the nurse know. They re-approach the resident later to try to do the care. If the resident still will not allow the care, the nurse contacts the physician and the family. The refusal should be documented in the chart. During an interview on 09/06/23, at 1:00 P.M., CNA D said if a resident refuses care, staff should let the nurse know. The nurse will let the physician and family know, the Director of Nursing (DON) is made aware, and the Administrator is made aware. The refusal should be documented in the chart. During an interview on 09/06/23, at 1:05 P.M., the DON said she expects staff to re-approach a resident who refuses care and provide education as to why the care is important. She expects staff to document care in the notes, MAR, and Treatment Administration Records (TAR). It is not appropriate for care or refusals to not be documented. The physician and family should be notified if a resident is refusing cares. During an interview on 09/06/23, at 1:10 P.M., the Administrator said she expects staff to document cares performed. It is not appropriate to not document. The physician and family should be notified of any refusals. MO00223882

Based on interview and record review, the facility failed to develop and implement water management policies and procedures to reduce the risk of growth and spread of Legionella (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain the bacteria) in the facility's building water system. The facility did not update their policy to include ongoing implementation of monitoring and control measures after positive Legionella samples were identified in 2019 and mitigation efforts cleared detection in 2020. Four additional residents (Resident #1, #2, #3, and #4) tested positive for Legionella beginning in March 2022. The facility had a census of 39. According to the Centers for Disease Control and Prevention(CDC) Tool kit for Legionella (which is officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Record review of the facility's undated policy titled Windsor Healthcare Control Measures, for each control point, control measures are established to reduce the risk of Legionella growth which may include: -Hardware related to water usage points, faucets, fountains, showers etc, will be monitored throughout the systems to ensure that changes i.e. biofilm, slime, lime buildup etc, that may lead to Legionella growth are not occurring; -Water heaters will be maintained at appropriate temperatures; -Laundry room water will be maintained at 135 to 140 degrees Fahrenheit (F), dietary water will be maintained at 135 to 140 degrees F, and remainder of the building will be maintained at 110 to 115 degrees F; -Water fountains (drinking) will be clean and free of visible biofilm, i.e. slime; -Shower heads, hoses, manual faucets, eye wash stations, ice machines and equipment filters shall be kept clean and free of biofilm i.e. slime; -Heating, ventilation and air conditioning (HVAC) system shall be kept clean and free of visible biofilm i.e. slime. Maintenance will monitor during routine maintenance and repairs; -Hot water temperatures will be maintained; -Housekeeping will use a de-liming cleaning agent on all faucets and will report any concerns to maintenance and/or administrator. (The facility's policy did not address actions to prevent Legionella based on the home's prior history of having Legionella.) Record review of a letter dated September 16, 2019, showed the Department of Health and Senior Services advised the facility of findings from an onsite Legionella investigation completed on July 26, 2019 that included a Legionella assessment and collection of environmental samples at the facility. The letter detailed of the samples collected, nine detected Legionella bacteria. The letter included a recommendation to establish a policy for flushing and descaling faucets on a regular basis, including flushing at least once weekly and descaling on a monthly basis. This process was noted to decrease the chance of stagnation of water in the system and prevent any biofilm from catching on the scale in the faucets. Record review of Resident #1's medical record showed diagnoses including respiratory disease, high blood pressure, and diabetes. Record review of the resident's laboratory report, dated 03/26/22, showed Legionella detected for the resident. Record review of the resident's current physician's orders (PO), dated 03/30/22 to 03/31/22, showed an additional diagnoses which included pneumonia, sepsis, and fever. The PO showed the resident was prescribed Augmentin (an antibiotic) 875-125 milligram (mg), one tab two times daily for four days beginning on 3/30/22, for pneumonia and sepsis. During an interview on 04/07/22 at 2:37 P.M., the Director of Nursing (DON) said the following: -On 04/04/22, she was notified by the hospital lab that the resident was positive for Legionnaires. Record review of Resident #2's medical record showed diagnoses including heart disease, respiratory disease, high blood pressure, and diabetes. Record review of the resident's laboratory report, dated 04/12/22, showed Legionella detected for the resident. Record review of Resident #3's medical record showed diagnoses including respiratory disease, high blood pressure, chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), chronic A-fib (irregular heartbeat), and Parkinson's (a disorder of the central nervous system that affects movement, often including tremors). Record review of the resident's laboratory report, dated 04/12/22, showed Legionella detected for the resident. Record review of Resident #4's medical record showed diagnoses including respiratory disease, Alzheimer's (a progressive disease that destroys memory and other important mental functions), and anxiety. Record review of the resident's laboratory report, dated 04/18/22, showed Legionella detected for the resident. During an interview on 04/06/22 at 5:30 P.M., the DON said there had not been any real monitoring for Legionella. The facility had Legionella in their building back in 2019 and for approximately one and one-half years they were monitored and then were cleared back in August of 2020. The DON said when they were cleared back in 2020 they did not continue monitoring- they thought the concerns for Legionella were over. During an interview on 04/07/22 at 1:15 P.M., the Maintenance Supervisor (MS) said the following: -He began job as maintenance supervisor on 2/7/22 and believed the facility was without an maintenance supervisor for some time; -The only thing he had documentation on was weekly water temperatures; -He had not done any flushes of the water system since he had been at the facility; -As far as he knew the facility had been cleared from Legionella a few years ago and they quit doing any flushing of the system; -There was no paperwork or any documentation for any monitoring for Legionella; -The hot water heater needed to be flushed daily due to the build-up and brown water; -The city water was pretty hard so the shower filters should last a month, but only last a week. During an interview on 04/07/22 at 2:15 P.M., the Administrator said the following: -She started on 4/06/22; -She did not know what preventative measures were in place to monitor Legionella; - The facility should follow their policy and procedures for monitoring. Record review of Department of Health and Senior Services (DHSS) testing of water samples, collected on 4/6/22, showed the following: -Water sample from hot water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from cold water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from hot water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from hot water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from cold water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from shower hose in shower room tested positive for Legionella; -Water sample of cold water from shower head in shower room tested positive for Legionella; -Water sample of hot water from shower head in shower room tested positive for Legionella; -Water sample of water from whirlpool tube hose in shower room tested positive for Legionella; -Water sample from cold water for whirlpool tub in shower room tested positive for Legionella; -Water sample from cold water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from hot water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from cold water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Water sample from hot water in resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Swab of resident room [ROOM NUMBER]'s hand sink tested positive for Legionella; -Swab of shower head in shower room tested positive for Legionella; -Swab of resident room [ROOM NUMBER]'s hand sink tested positive for Legionella. MO00199408

Based on observation, interview, and record review, the facility failed to perform routine skin assessments, failed to routinely assess, identify and implement treatments and interventions for pressure ulcers on two residents (Resident #1 and #2). The facility failed to prevent an avoidable pressure ulcer on one resident (Resident #2). Resident #1 required admission to the hospital resulting in bilateral lower leg amputation. Ten residents were reviewed in a facility with a census of 44. Federal guidelines define the following: -Unstageable-Slough and/or Eschar (dead tissue), known but not stageable due to coverage of wound bed by slough and/or eschar. -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II pressure ulcer - Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III pressure ulcer - Full thickness tissue loss. Subcutaneous fat (under the skin) may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (opening underneath the lip of the boarder) or tunneling (A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). -Stage IV pressure ulcer - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Record review of the facility's policy titled, Pressure Ulcer, Care and Prevention dated March, 2015, showed the following information: -The purpose of the policy is to prevent and treat further breakdown of pressure ulcers; -The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Guidelines include observing skin, with any persistent reddened area, that remains after pressure is relieved, is a high risk for a pressure ulcer to begin and use elbow and heel protectors if needed. Record review of the facility's policy titled, Admission Nurse's Note, dated March, 2015, showed the nurses are directed to document upon admission a body audit of the resident (including any rashes, pressure ulcers or stasis ulcers, general overall appearance). 1. Record review of Resident #1's facesheet, showed the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the initial Nursing Evaluation/Data Collection sheet, dated 11/11/16, showed the following information: -Swelling to bilateral (affecting both) lower legs; -Open orange-sized blister on the inside of the right leg; -Skin tear on the right leg; -The nurse did not document pressure ulcers to the resident's feet. Record review of the resident's care plan, initiated on 11/11/16, showed staff did not document a plan of care for management of the resident's pressure ulcer risk factors or the interventions to prevent a possible decline. Record review of the resident's physician order [REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/18/16, showed the following information: -Extensive staff assistance required for dressing, personal cares, and bathing; -Staff identified one unstageable (known but not stageable due to coverage of wound bed by slough (dead tissue in the process of separating from the viable portions of the body) and/or eschar (dead tissue) pressure ulcer present on admission. Record review of the resident's physician order [REDACTED]. Record review of the resident's November 2016 treatment administration record (TAR) showed the following information: -On 11/12/16, bilateral heel protectors every shift, staff performed the treatment 49 out of 52 opportunities with 5 resident refusals; -On 11/25/16, Skin Prep to the left heel daily, staff performed the treatment 3 out of 3 opportunities. Record review of the resident's E-Z Graph Wound Assessment Worksheet (a wound assessment measuring guide), dated 11/25/16 (first comprehensive assessment of the left heel ulcer, two weeks after admission), showed an unstageable pressure ulcer on the left heel measuring 2.6 centimeters (cm) by 3.3 cm, black eschar in the wound base with no drainage, odor, undermining (deep tissue damage around the wound margin), or tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). Staff did not document regarding a treatment for [REDACTED]. Record review of the resident's E-Z graph wound assessment worksheets for his/her left heel pressure ulcer showed staff documented the following changes: -On 12/02/16, staff did not specify the stage of the ulcer. Staff documented the measurement by tracing on the wound graph. Staff documented a black and pink wound base,. The treatment included Vaseline gauze 4 x 4 (a non-adherent gauze used for absorbing fluids and protecting wounds), Kling wrap (a sterile, self-adhering gauze roll that gently sticks to itself as you wrap it) and tape (Review of the POS [REDACTED]. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 12/12/17. Record review of the resident's physician order [REDACTED]. start a multivitamin daily for wound healing on 12/14/16. Record review of the resident's E-Z graph wound assessment worksheets for his/her left heel pressure ulcer showed staff documented the following changes on 12/18/16. Staff documented the ulcer as unstageable, measuring 3.8 cm by 4.4 cm with black eschar in the wound base, a scaly periwound (the tissue surrounding the wound) area and no other changes noted. The treatment included Skin Prep (film forming solution that helps toughen skin) twice a day. Record review of the resident's POS showed the resident's physician directed staff on 12/20/16 to apply Skin Prep to the left heel twice a day for wound protection. Record review of a physician's progress note, dated 12/21/16, showed the resident's left heel pressure ulcer treatment/plan as improving. The physician did not document a description or assessment of the pressure ulcer. Record review of the resident's E-Z graph wound assessment worksheets for his/her left heel pressure ulcer showed staff documented the following information: -On 12/23/16, the ulcer measured 5.0 cm by 4.3 cm. Staff documented the ulcer as unstageable with an eschar wound base. Staff documented the treatment as skin prep daily. (POS showed order for twice daily on 12/20/16). Record review of the nurses' note, dated 12/27/16, showed resident educated on need to keep pressure off area. Resident continues to be non-compliant. Record review of the resident's E-Z graph wound assessment worksheets for his/her left heel pressure ulcer showed staff documented the following information: -On 12/29/16, staff did not document the stage of the ulcer. Staff documented the measurement by tracing on the wound graph. Staff did not document a description of the ulcer. Record review of the December 2016 TAR showed the following information: -An order dated 11/12/16, for bilateral heel protectors every shift: staff performed the treatment 56 out of 72 opportunities with 18 resident refusals; -An order dated 12/20/16, for Skin Prep to the left heel twice daily: staff performed the treatment 17 out of 20 opportunities. Record review of the January 2017, TAR showed the following information: -An order dated 11/12/16, for bilateral heel protectors every shift: staff performed the treatment 48 out of 60 opportunities with 30 refusals; -An order dated 12/20/17, for Skin Prep to the left heel twice daily: staff performed the treatment 51 out of 60 opportunities. Record review of the resident's E-Z graph wound assessment worksheet, dated 01/04/17, for his/her left heel pressure ulcer showed staff documented the ulcer as unstageable. Staff described the wound base as eschar. Record review of the nurses' note, dated 1/6/17, showed staff applied skin prep to heel and elevated the resident's heels. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the following: -The week of 01/09/17; -The week of 01/16/17. Record review of a physician's progress note, dated 01/18/17, showed the physician planned a wound team consult for the resident's left heel pressure ulcer. Record review of the resident's physician order, dated 01/18/17, showed a mobile wound clinic to evaluate the resident and treat the pressure ulcer. Record review of the nurses' note, dated 1/19/17, showed the Director of Nursing (DON) documented the physician at the facility on 1/18/17 with recommendation to initiate mobile wound clinic evaluation and treatment. Heel continues to be covered in eschar with daily application of skin prep at this time. Record review of the resident's medical record showed the facility failed to document contact with the mobile wound clinic after receiving a physician's orders [REDACTED].>Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the following: -The week of 01/23/17; -The week of 01/30/17. Record review of the nurses' notes, dated 2/4/17, showed the nurse cleaned the left heel and applied a new dressing. The resident complained of pain with application of the skin prep. The ulcer remains unstageable at this time. Record review of the nurses' note, dated 2/5/17, showed a new unstageable area to the resident's right medial ball of foot. New daily treatment of [REDACTED]. Resident is noncompliant with heel protectors, so blow up boots initiated today. Record review of the resident's E-Z graph wound assessment worksheet, dated 02/05/17, showed a new unstageable pressure ulcer on the right inner ball of foot measuring 1.9 cm by 1.1 cm with redness to the periwound area with no drainage. Staff documented in the graph a black center wound bed, with an outer ring of red. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/06/17. Record review of the resident's right inner ball of foot pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/06/17. Record review of the nurses' notes, dated 2/9/17, showed resident with unstageable ulcers to bilateral feet. Dressings in place to prevent drainage and sticking of wounds to socks. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/13/17. Record review of the nurses' notes, dated 2/13/17, showed dressings changed to bilateral feet this shift. Area to outer ball of right foot appears soggy and has dark drainage to the prior dressing with odor noted at this time. 95% slough observed to the ulcer. New order obtained to cleanse wound bed, apply Santyl, and cover daily to right outer ball and left heel ulcer. Record review of the resident's right inner ball of foot pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/13/17. Record review of the February, 2017, POS showed a physician order, dated 02/15/17, to obtain a wound culture (a test that detects and identifies bacteria that cause infections) to the pressure ulcer right ball of foot and the left heel. Cleanse the pressure ulcers to bilateral lower extremities (the part of the body from the hip to the toes) with normal saline (a sterile mix of salt and water), apply a thin layer of Santyl (an ointment that cleans wounds to clear the way for healthy tissue) to the wound bed and apply Skin Prep to the periwound area, cover with a non-adherent dressing and wrap with Kling. Change the dressing daily and as needed. Record review of the physician's progress note, dated 02/15/17, showed the following information: -An unstageable left heel pressure ulcer with a foul smell and drainage; -Darkness at the base of the resident's toe; -Wound care will be consulted for care of the heel pressure ulcer and a wound culture obtained. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/20/17. Record review of the resident's right inner ball of foot pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/20/17. Record review of the February, 2017, POS showed the physician ordered on [DATE], Bactrim (an antibiotic) twice a day for ten days for the pressure ulcers. Record review of the nurses' notes, dated 2/22/17, showed left heel unstageable with eschar covering wound bed. Eschar starting to separate from the edges. Foul odor noted with small amount of purulent drainage. Right foot ulcer dressing changed, with eschar noted and small amount of serosanguinous drainage. No odor noted to the right foot ulcer. Record review of the February 2017 POS showed the following physician orders: -On 02/27/17, apply Santyl to bilateral feet for debridement (removal of damaged tissue). A wound consultation with the mobile wound clinic (ordered previously by the physician on 01/18/17, one month prior) Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/27/17. Record review of the resident's right inner ball of foot pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 02/27/17. Record review of the nurses' note, dated 3/4/17, showed dressing changed to the left heel, area is slowly being debrided with the use of Santyl. The area has yellow slough surrounding the eschar with a foul odor noted. Right foot does not have eschar at this time, but has yellow slough. Record review of the March, 2017, POS showed the following physician orders: -On 03/05/17, cleanse the pressure ulcer on the left heel with Normal Saline, wipe the outer edge of the wound with Skin Prep, apply Duoderm (a dressing used to treat pressure ulcers) to the wound bed, cover with gauze 4x4s and Kling wrap. Change the dressing every three days and as needed. Record review of the resident's left heel pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 03/06/17. Record review of the resident's right inner ball of foot pressure ulcer assessment sheets showed staff failed to document a weekly wound assessment with staging, measurement, description of the pressure ulcer and the periwound area for the week of 03/06/17. Record review of the March, 2017, POS showed the following physician orders: -On 03/15/17, obtain an X-ray of the bilateral feet to rule out osteo[DIAGNOSES REDACTED] (a bone infection). Cleanse the left heel and the right ball of the foot with Normal Saline, apply Calcium Alginate (a highly absorbent topical wound dressing), a dry dressing and wrap with Kling daily. Record review of the resident's March 2017, mobile wound clinic initial consultation note, dated 03/15/17,(two months after ordered originally by the physician) showed the following information: -A unstageable pressure ulcer on the left heel measured 5 cm by 4.3 cm by 0.1 cm, described as fully covered with eschar with a strong odor, small amount of serosanguineous (containing or relating to both blood and the liquid part of blood) drainage, redness, tenderness, infection present, periwound not intact, and palpable bone; -An unstageable pressure ulcer on the right foot plantar measuring 3.5 cm by 3.3 cm by 0.3 cm described as 50% slough, 50% dead tissue with a strong odor, moderate amount of serosanguineous drainage, periwound not intact, redness, tenderness, and infection present; -Both wounds debrided. Record review of the March, 2017, POS showed the following physician orders: -On 03/21/17, obtain a culture on the left heel and the right ball of foot area for [MEDICAL CONDITION] (MRSA- a bacterium that causes infections in different parts of the body that is resistant to some commonly used antibiotics); -On 03/22/17, culture wounds to feet; apply 2% [MEDICATION NAME] gel (a topical numbing agent to reduce pain) to the open area on the left heel and right inner foot, cleanse with Normal Saline, apply Calcium Alginate Silver (an antibacterial) and gauze dressing daily and as needed. Record review of the resident's mobile wound clinic note, dated 03/22/17, showed the following information: -Left heel pressure ulcer, deteriorated, measured 5 cm by 4.5 cm by 0.1 cm, 80% covered with eschar, 20% covered with slough, with no changes in odor, drainage, redness, tenderness, infection, periwound, or palpation; -Right foot plantar pressure ulcer, unstageable, deteriorated, measured 3.5 cm by 2.3 cm by 0.2 cm, 80% slough, 10% granulation tissue (new tissue consistent with wound healing), 10% bone exposed. No changes in odor, drainage, periwound, redness, tenderness, or infection; -Both wounds debrided. Record review of the physician's progress notes showed the following information: -On 03/26/17, the wound care clinic has been working with the resident's heel, but they continue to have difficulties. The heel shows some degree of healing and will continue with the wound care clinic for his/her heel. Record review of the March, 2017, POS showed the physician ordered on [DATE], Bactrim twice a day for ten days for treatment of [REDACTED]. Record review of the resident's mobile wound clinic note, dated 03/29/17, showed the following information: -Left heel pressure ulcer, deteriorated, measured 6.9 cm by 5.5 cm by 0.5 cm with 1.2 cm of undermining, 10% covered with slough, 10% granulation tissue, a large amount of serosanguineous and green drainage, fever present with no changes in eschar, odor, redness, tenderness, infection, periwound, and palpation; -Right foot plantar pressure ulcer, deteriorated, measured 4.4 cm by 3.2 cm by 0.3 cm, 60% slough, 20% dead tissue, denudation (the process of removing surface layers of skin), and maceration (softened skin tissue caused by moisture). No changes in granulation tissue, bone exposure, odor, drainage, periwound, redness, tenderness, and infection; -Both wounds debrided. Record review of the resident's mobile wound clinic note, dated 04/12/17 showed the following information: -Left heel pressure ulcer, deteriorated, measured 6.5 cm by 5.0 cm by 0.6 cm, 1.0 cm of undermining, 70% covered with dead tissue, 20% covered with slough, tissue, 10% bone exposed. No changes in granulation tissue, odor, drainage, redness, tenderness, fever, infection, periwound, and palpation; -Right foot plantar pressure ulcer, deteriorated, measured 2.5 cm by 2.7 cm by 0.3 cm with 0.9 cm of undermining, 30% slough, 50% dead tissue, 10% exposed bone and tendon, and a large amount of serosanguineous drainage. No changes in granulation tissue, odor, periwound, redness, tenderness, denudation, maceration, and infection; -Both wounds debrided. Record review of the physician's progress notes showed the following information: -On 04/19/17, the resident continued to have a significant increase in the pressure ulcers on his/her feet. Obtain cultures on the pressure ulcers and antibiotics will be restarted as appropriate. The wound care clinic is evaluating the resident's pressure ulcers and will continue to treat. Record review of the resident's mobile wound clinic note, dated 04/19/17, showed the following information: -Left heel pressure ulcer, deteriorated, measured 7.0 cm by 6.9 cm by 1.2 cm with 0.5 cm of undermining. No changes in dead tissue, slough, granulation tissue, bone exposure, odor, drainage, redness, tenderness, fever, infection, and periwound; -Right foot plantar pressure ulcer, deteriorated, measured 3.4 cm by 3.10 cm by 1.3 cm with 0.9 cm of undermining with no changes in slough, dead tissue, granulation tissue, bone and tendon exposure, odor, drainage, periwound, redness, tenderness, denudation, maceration, and infection; Both wounds debrided. Record review of a physician order, dated 04/26/17, showed [MEDICATION NAME] (medication used in the treatment of [REDACTED]. Record review of the resident's mobile wound clinic note dated 04/26/17 showed the following information: -Left heel pressure ulcer, deteriorated, measured 7.0 cm by 6.5 cm by 0.9 cm with 1.0 cm of undermining and 9.3 cm of tunneling, 20% covered with dead tissue, 10% covered with slough, 20% granulation tissue, 20% bone exposed, large amount of serosanguineous drainage. No changes in odor, redness, tenderness, fever, infection, and periwound; -Right foot plantar pressure ulcer, deteriorated, measured 3.4 cm by 3.10 cm by 1.3 cm with 0.9 cm of undermining described as 20% slough, 30% dead tissue, 20% granulation tissue, 30% exposed bone and tendon. No changes in odor, drainage, periwound, redness, tenderness, denudation, maceration, and infection; -Both wounds debrided. Record review of the resident's mobile wound clinic notes, dated 05/03/17, showed the following information: -Left heel pressure ulcer, deteriorated, measured 7.8 cm by 6.4 cm by 0.9 cm with 0.5 cm of undermining and 4.8 cm of tunneling, 50% covered with dead tissue, 10% [MEDICATION NAME], 10% granulation tissue, 30% bone exposed, a copious amount of serosanguineous drainage. No changes in odor, redness, tenderness, fever, infection, and periwound; -Right foot plantar pressure ulcer, deteriorated, measured 3.9 cm by 5.8 cm by 1.8 cm with 1.2 cm of undermining described as 50% dead tissue, 10% granulation tissue, 40% exposed bone and tendon. Fever present with no changes in odor, drainage, periwound, redness, tenderness, denudation, maceration, and infection; -No procedure performed, the status of the wound is not progressing even though the wound care team has tried many options of wound healing. Patient is consulting with a surgeon, who referred the patient for a second opinion. The surgeon is believing that a bilateral above the knee amputation is probable. Record review of the May, 2017, POS showed the physician ordered, on 05/03/17, to send the resident to the emergency room for an evaluation and treatment. Record review of the resident's care plan, initiated on 11/11/16 and current through 05/03/17, showed staff did not document a plan of care for management of the resident's pressure ulcer risk factors or interventions to prevent a possible decline. Record review of the nurses' notes, dated 5/4/17, showed family requested resident to be sent to the hospital. Wound Nurse Practitioner here today and concerned about possible osteo[DIAGNOSES REDACTED] and hospital admission. Record review of the May 2017 POS showed, on 05/09/17, an order to readmit the resident to the facility with a [DIAGNOSES REDACTED]. Record review of the resident's interim care plan, dated 05/09/17, showed the following information: -Dependent on staff for transfers, dressing, bathing, grooming, and toilet use; -Staff assistance required for bed mobility and eating; -Change surgical dressing daily. During an interview on 05/17/17, at 9:40 A.M., the DON said the resident admitted to the facility with a pressure ulcer on his/her left heel with eschar and redness. During an interview on 05/17/17, at 11:57 A.M., the Medical Director (MD) said the following: -The resident admitted to the facility with pressure ulcers on his/her feet; -The nurse should have documented the pressure ulcers on the initial nursing assessment; -She could not recall why she re-ordered the wound clinic to evaluate and treat one month after the initial order; -Skin Prep should not be applied directly to eschar in a wound because it causes vasospasms (condition in which an arterial spasm leads to [MEDICATION NAME] of the blood vessels which can lead to tissue death), she expected staff to apply the Skin Prep to the skin around a wound. During an interview on 05/17/17, at 4:00 P.M., the Nurse Practitioner (NP) for the wound care clinic, said the following: -When a resident is referred to the wound care clinic, the facility staff should complete the required paperwork and include the physician's orders [REDACTED]. -The wound care clinic evaluates a resident typically within 48 hours of receiving the packet; -The wound care clinic evaluates and provides treatments at the facility once a week; -Skin Prep is used for periwound area to toughen the skin; -Skin prep can be used on stable eschar (tissue that is fully attached to the wound bed) but should not be applied to unstable eschar (tissue that is undergoing a softening process caused by bacteria present in the tissues); -The resident did not have a stable eschar when the wound team initially evaluated him/her; -The resident probably would have had a better outcome if he/she had been evaluated sooner, as with any wound. During an interview on 5/18/17, at 10:40 A.M., the DON said the following: -The wound care team should have started treatment within one to two weeks following the physician's orders [REDACTED]. The administrator is responsible for faxing the required paperwork to the wound care clinic. She said the order could have gotten dropped or the required paperwork for the wound clinic was not signed by the resident's responsible party. (The resident's responsible party signed the paperwork on 2/20/17 for the wound clinic consult.) -The resident should have been seen by the wound care team in January. The resident's left heel pressure ulcer had eschar with intact edges starting to peel and an odor in January; -The DON did not know for sure why the physician's orders [REDACTED]. -She said the need for prompt care by the wound care clinic was greater due to the resident's condition. During an interview on 05/18/17, at 12:40 P.M., the administrator said she was not sure why there was a delay for the wound clinic referral for Resident #1. During an interview on 05/18/17, at 12:30 P.M., Nursing Assistant (NA) G said the following: -Pressure ulcer interventions for a resident at risk for pressure ulcers include turning and repositioning every two hours and as needed, incontinent care to keep the resident dry, heel protectors, positioning cushions and pillows to keep the resident off pressure points; -When he/she identified a change in a resident's skin, he/she would report it to the charge nurse. During an interview on 05/18/17, at 12:34 P.M., Certified Nursing Assistant (CNA) H said the following: -Pressure ulcer interventions for a resident at risk for pressure ulcers include turning and repositioning the resident every two hours, incontinent care every 2 hours and as needed to keep the resident dry, heel protectors, and to keep the resident off pressure points; -When he/she identified a change in a resident's skin, he/she would report it to the charge nurse and DON. During an interview on 05/18/17, at 12:36 P.M., Licensed Practical Nurse (LPN) F said the following: -Pressure ulcer interventions for a resident at risk for pressure ulcers include turning and repositioning the resident every two hours and as needed and keeping the resident off pressure points if possible; -When he/she identified a change in a resident's skin, he/she would assess the area, notify the resident's physician for a treatment order, notify the resident's family, and document the change in the nurses' notes; -Resident #1's heels were black on admission to the facility. During an interview on 05/18/17, at 12:56 P.M., CNA C and CNA I said the following: -Pressure ulcer interventions for a resident at risk for pressure ulcers include turning and repositioning the resident every two hours and as needed, moisture barrier cream with incontinent care, heel protectors, wedges and pillows to keep the resident off pressure points, and making sure dressings are intact; -If he/she identified a change in a resident's skin, he/she would report it to the charge nurse; -The resident had pressure ulcers on his/her heels when admitted to the facility. 2. Record review of Resident #2's admission face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by the facility staff, dated 01/04/17, showed the following information: -Cognition moderately impaired; -Staff assistance required for bed mobility, transfers, and dressing; -No impairment of range of motion; -No pressure ulcers present on admission. Record review of the resident's nurse's notes, dated 12/22/16, showed the resident's skin as warm and dry. Record review of the resident's care plan conference summary, dated 03/15/17, showed staff documented the only area of concern involved falls. Staff did not identify any skin concerns. Record review of the resident's Braden's Scale for Predicting Pressure Sore Risk, (tool for assessing a resident's risk of developing a pressure ulcer), dated 03/31/17, showed the resident at risk for skin breakdown, based on the resident's occasionally moist skin, limited physical abilities, slight