**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a process in place to routinely and thoroughly track and assess pressure sores and failed to administer Augmentin (a broad spectrum antiinfective) as ordered for one resident (Resident #1). The resident was admitted to hospital and diagnosed with acute osteomyelitis (infection of the bone), involving the right ankle and foot, and required an above the knee amputation. The facility failed to follow acceptable infection control practices when providing wound care, failed to follow physician orders for wound care, and failed to routinely track/assess wounds for one resident (Resident #2). The facility census was 141. The Administrator was notified on 2/10/23, at 7:45 P.M., of an Immediate Jeopardy which began on 12/26/22. The Immediate Jeopardy was removed on 2/10/23, as confirmed by surveyor onsite verification. 1. Record review of the facility policy titled, Skin Evaluation, last reviewed on 12/28/22, showed the following: -The facility may conduct head-to-toe skin evaluation performed and documented on a weekly basis. The weekly skin evaluation will be documented electronically or on the Skin Observation Tool; -Licensed Nurses, Wound Care Nurse, Administration, and Director of Nursing (DON) are responsible; -Residents will have head-to-toe skin evaluation performed and documented on a routine basis. The evaluation will be documented electronically or on the Skin Observation Tool; -Any skin abnormality identified through this evaluation may be documented in the interdisciplinary notes. Physician, resident representative, wound nurse, and DON will be notified of any abnormalities; -Treatment will be initiated per the physician's order; -The unit manager/wound nurse will review and sign the skin observation tool if documented manually. The signature indicates follow-up, documentation, and care plan interventions have been implemented; -Manual Skin Observation Evaluations are to be kept with the treatment record and filed in the medication/treatment section of the medical record. Record review of the facility policy titled, Wound Management, last reviewed on 11/15/22, showed the following: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound documentation included location of the wound, pressure injury and stage, size (shape, depth, tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) and/or undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface), volume and exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) characteristics, pain evaluation, presence of infection, condition of wound bed and wound edges, condition of peri-wound; -The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Record review of the facility policy titled, Physician Orders, last reviewed on 9/28/22, showed: -The facility is to ensure orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Licensed nurses, nursing administration, and DON are responsible; -Physician orders shall be provided by licensed practitioners authorized to prescribe orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record; -Physician order sheet (POS) will be maintained with current physician orders as new orders are received; -Physician orders will be transcribed to the appropriate administration record, medication administration record/electronic medication administration record (MAR/eMAR) or treatment administration record/electronic treatment administration record (TAR/eTAR); -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the emergency drug supply (E-Kit) or Automatic Dispensing Unit shall be utilized for the first dose until a supply arrives from pharmacy, if available. Record review of Resident #1's admission record showed the following: -admitted to the facility from the hospital on [DATE]; -Diagnoses included metabolic encephalopathy (brain dysfunction caused by other health condition), alcohol abuse, dementia, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), and muscle weakness. Record review of the resident's pressure injury risk assessment, completed on 11/28/22, showed the resident at high risk for the development of pressure ulcers. Record review of the resident's nursing admission screening/history, dated 11/28/22, showed the following: -Open area to the right outer ankle that measured 0.8 centimeters (cm) long by 1.0 cm wide with redness surrounding area. -Staff did not document wound stages, descriptions of wound bed, or the presence of any drainage or odor. Record review of the resident's November 2022 medication review report showed the following physician order: -An order, dated 11/28/22, for a body audit every seven days for skin observation; -Staff documented a check mark and initials indicating the audit was completed on 11/29/22. Record review of the resident's progress note dated 11/29/22, at 4:03 P.M., showed Licensed Practical Nurse (LPN) D (the wound nurse) documented the following: -Resident lying on the bed and skin assessment completed; -Left foot red old wounds; -Right lateral side toward pinky toe old wound; -Right outer ankle open area 1 cm x 0.8 cm x 0.1 cm, left hip scratches; -No other wounds at this time. -The wound nurse did not document wound stages, descriptions of wound bed or peri-wound appearance, or the presence of any drainage or odor. Record review of the facility skin log, dated 11/30/22, showed the resident had the following: -Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right outer ankle wound that measured 1.0 cm long by 0.8 cm wide by 0.1 cm deep; -Treatment order of calcium alginate (an absorbent wound dressing material)/dry dressing. -The nurse did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's December 2022 medication review report showed the following physician orders: -An order, dated 11/30/22, for wound care to right outer ankle. Clean with wound cleanser, pat dry, collagen/calcium alginate (a wound dressing used to support healing), border bandage (a bandage with an adhesive edge), keep in soft boot as needed; -An order, dated 11/30/22, for wound care to right outer ankle. Clean with wound cleanser, pat dry, collagen/calcium alginate, border bandage, keep in soft boot one time a day. Record review of the resident's progress note dated 12/3/22, at 8:35 P.M., showed the DON documented the following: -Resident was admitted to the facility on [DATE]. He/she has a wound to his/her right outer ankle that measures 1.0 cm long by 0.8 cm wide by 0.1 cm deep. Treatment is for calcium alginate. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 12/5/22, showed the following: -admitted to the facility on [DATE] from the hospital; -Total dependence on two or more staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; -Diagnoses of metabolic encephalopathy, dementia, alcohol abuse, and muscle wasting; -Risk of pressure ulcer development; -No unhealed pressure ulcers; -Other open lesion on the foot; -Application of dressings to the feet. Record review of the resident's skin observation tool, dated 12/5/22, showed the following: -Open areas to the right outer ankle, right lateral foot, and right pinky toe. -Staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the December 2022 Treatment Administration Record (TAR) showed a check mark and nurse initials, indicating completion of a body audit, on 12/6/22. There was no accompanying documentation. Record review of a handwritten note provided by the wound nurse, dated 12/7/22, showed the following wound measurements for the resident: -Right outer ankle 2.0 cm long by 1.2 cm wide by 0.1 cm deep; -Lateral foot 2.2 cm long by 2.0 cm wide by 0.5 cm deep; -Pinky toe 0.5 cm long by 0.2 cm wide; -The nurse did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the facility skin log, dated 12/8/22, showed the following: -The resident had a Stage 2 pressure ulcer of his/her right outer ankle, measured 1.0 cm long by 0.8 cm wide by 0.1 cm deep; -Treatment of calcium alginate/dry dressing; -Staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's skin observation tool, dated 12/12/22, showed the following: -Open areas to the right outer ankle and right lateral foot. -The staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's December 2022 TAR showed a check mark and nurse initials, indicating completion of a body audit, on 12/13/22. There was no accompanying documentation. Record review of the resident's progress note dated 12/14/22, at 10:50 A.M., showed the facility's Advanced Practice Registered Nurse (APRN) I documented following: -Resident seen for continued open wound to right lateral ankle; -Resident followed by the wound nurse with treatment orders in place, current wound approximately 0.5 cm long by 0.5 cm wide; -Wound care for right outer ankle - clean with wound cleanser, pat dry, apply collagen/calcium alginate, cover with border bandage, and keep foot in soft boot. -The APRN did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of a correction of the 12/14/22 wound assessment, dated 2/10/23, showed the following: -Right outer ankle 1.0 cm long by 0.8 cm wide by 0.1 cm deep with 90% necrotic (dead) tissue; -Right pinky toe 0.5 cm long by 0.2 cm wide with 95% necrotic tissue; -Both wounds with no change in measurement noted; -Left lateral foot with intact scab noted. Record review of the facility skin log, dated 12/15/22, showed the following: -The resident had a Stage 2 pressure ulcer to the right outer ankle wound, measured 2.0 cm long by 21.2 cm wide by 0.1 cm deep; -Treatment of calcium alginate/dry dressing. -The staff did not document a description of the wound bed or peri-wound appearance, or presence of any drainage or odor. Record review of the resident's progress note dated 12/16/22, at 1:59 P.M., showed the wound nurse documented the following: -Resident's wound is red and warm to touch, localized infection around area of right lateral foot. Physician notified. Starting Keflex (an antibiotic) 500 milligrams four times per day for seven days. Record review of the resident's December 2022 Registered Nurse (RN) / Licensed Practical Nurse Medication Administration Record (MAR) showed the following: -On 12/16/22, staff did not begin administration of the resident's Keflex; -On 12/17/22, staff administered Keflex four times, as ordered; -On 12/18/22, staff administered Keflex three of four ordered doses, but did not initial administration the fourth dose of Keflex. Record review of the resident's progress note dated 12/18/22, at 8:36 P.M., showed the DON documented the following: -Wound to the right outer ankle, measuring 2.0 cm wide by 21.2 cm long by 0.1 cm deep, deteriorated; -New order for Keflex 500 mg, four times per day for seven days for wound infection. Record review of the resident's progress note dated 12/19/22, at 5:17 P.M., showed a nurse documented the following: -Resident on alert charting for diagnosis of cellulitis (an infection of the tissue). Resident has a new order for Keflex. Wounds cared for by the wound nurse. No signs of symptoms of adverse reaction. Will continue to monitor. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/19/22, staff administered Keflex four times, as ordered; -On 12/20/22, staff administered Keflex two times and then the resident left the facility that day for the hospital. Record review of the December 2022 TAR showed a check mark and nurse initials, indicating completion of a body audit on 12/20/22. There was no accompanying documentation. Record review of the resident's progress note dated 12/20/22, at 10:07 A.M., showed staff transferred the resident to the emergency room due to displacement of his/her gastric feeding tube. Record review of the hospital discharge information, dated 12/26/22, showed the following: -Discharge plan instructions - Complete antibiotics. Continue wound care per wound specialty direction. Follow up with wound center in one to two weeks, outpatient; -An order for Augmentin 875/125 mg one tablet, by mouth, every 12 hours for 10 days. Record review of the resident's December 2022 medication review report, showed the following: -An order, dated 12/26/22, for a body audit every day shift for skin observation order dated 12/26/22; -Staff initialed completion of a body audit every day from 12/26/22-12/31/22. Record review of the resident's December 2022 RN/LPN MAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day for a urinary tract infection (UTI) for 10 days; -On 12/26/22, staff did not document administration of the antibiotic, area left blank; -On 12/27/22, Certified Medication Technician (CMT) L documented a '4' indicating other/see nurse notes for both ordered doses. Record review of the resident's nurses' notes, dated 12/27/22, showed staff did not address if the Augmentin was administered. Record review of the resident's progress note dated 12/27/22, at 2:20 P.M., showed a nurse documented the following: -Skin/Wound Note - Resident on charting for wound to right outer foot. Wound nurse to see. Record review of the resident's nurse admission screening/history dated 12/27/22 ,at 4:31 P.M., showed the following: -A pressure ulcer (no stage listed) to the left, lower extremity, measured 6 cm long by 4 cm wide by 0.1 cm deep; -Right lateral foot pressure ulcer, stage 3 (full thickness tissue loss. subcutaneous fat may be visible but bone tendon or muscle are not exposed. Slough (non-viable yellow, tan, gray, green or brown tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling), measured 7.5 cm long by 2 cm wide by 0.3 cm deep; -Treatment ordered or required. Record review of the resident's December 2022 TAR showed the following: -No treatment to the resident's left lower extremity; -No orders for treatment to the resident's right outer ankle or lateral foot on 12/27/22 or 12/28/22. Record review of the resident's progress note dated 12/28/22, at 4:16 P.M., showed the wound nurse documented the following: -Resident seen by wound physician today and he/she assessed the resident's right ankle/lateral foot, open areas, infected. Treatment changed to Dakin's (a topical antiseptic) wet to dry dressing daily until the wound physician sees the resident again in one week. Staff to monitor for redness to the foot. Record review of an untitled form, dated 12/28/22, with Pressure written on side of form showed the following: -Resident's right outer ankle, Stage 3, measured 2.8 cm by 2 cm by 0.3 cm, worse'; -Resident's right lateral foot, Stage 3, measured 12 cm by 3.3 cm by 0.3 cm, worse. -Staff did not document a description of the appearance of the wound bed or peri-wound, or the presence of any drainage or odor. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/28/22, CMT L documented a '4' indicating other/see nurse notes for the evening dose of Augmentin. Record review of the resident's nurses' notes, dated 12/28/22, showed staff did not address if the Augmentin was administered. Record review of the resident's re-admission history and physical, completed on 12/29/22, by Family Nurse Practitioner (FNP) H showed the following: -The resident was admitted to the hospital on [DATE] with a dislodged gastric (PEG) tube and low blood pressure; -The resident had excoriation from suspected scratching of the upper torso with signs of cellulitis to the left lower flank (side); -Right, lateral, lower leg and foot also had ulcerations with purulent (contains pus), odorous drainage; -He/she was started on vancomycin (antiinfective) and rocephin (antibiotic) for wounds; -Right foot MRI showed no osteomyelitis (infection of the bone); -His/her antibiotics were transitioned to oral; -Assessment and plan: Right foot wound cellulitis, continue Augmentin and continue wound care and off-loading; -Diagnosis of cellulitis of right foot. Record review of the resident's December 2022 medication review report showed the following order: -An order, dated 12/29/22, for right ankle/lateral foot. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day related to local infection of the skin and subcutaneous tissue. Record review of the resident's December 2022 TAR showed the following treatment order: -An order, dated 12/29/22, for right ankle/lateral foot treatment. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day, related to local infection of the skin and subcutaneous tissue. Record review of the resident's December 2022 RN/LPN MAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day; -On 12/29/22, CMT L documented a '4' indicating other/see nurse notes for both doses; -On 12/30/22, CMT L documented a '4' indicating other/see nurse notes for the evening dose. Record review of nurse notes (progress notes), dated 12/29/22 and 12/30/22, showed staff did not document regarding why staff did not administer the Augmentin as ordered. Record review of the resident's progress note dated 12/30/22, at 5:52 P.M., showed a nurse documented the resident is on alert charting for a new order for Augmentin. No adverse reaction have been noted. Record review of the resident's December 2022 RN/LPN MAR showed the following: -On 12/31/22, CMT L documented a '4' indicating other/see nurse notes for both doses. Record review of the resident's progress note dated 12/31/22, at 3:59 P.M., showed a nurse documented the following: -The resident continues on alert charting for a new order for Augmentin . No signs or symptoms of adverse effects thus far; -Staff did not document a rationale for why staff did not administer the Augmentin as ordered. Record review of the resident's January 2023 TAR showed the following: -An order, dated 12/26/22, for Augmentin 875/125 mg, staff to give one tablet by mouth two times per day for a urinary tract infection (UTI) for 10 days; -On 1/1/23, staff did not document administration of the ordered morning dose of Augmentin 875/125 mg. Record review of the resident's January 2023 medication review report showed the following: -An order, dated 12/26/22, for body audit every day shift for skin observation. Record review of the wound physician's progress note dated 2/15/23, as a late entry for 12/28/22, showed the physician documented the resident was seen on 12/28/22 and his/her wound assessed with the wound care nurse present. Due to the concern of an acute (severe and sudden in onset) infection, staff considered starting the resident on an oral antibiotic regimen of Levaquin (antiinfective) and doxycycline (antiinfective), but were advised that the resident had already been started on Augmentin. With that understanding, we acceded to the previous order. The impression overall was that this situation was grave and that amputation of the extremity was a very possible outcome. Record review of the resident's January 2023 medication review report showed the following: -An order, dated 12/29/22, for right ankle/lateral foot. Clean wound with Dakin's solution, pat dry, Dakin's soaked gauze to ankle/lateral foot, ABD pad, wrap with Kerlix, place boot on foot, two times per day related to local infection of the skin and subcutaneous tissue. Record review of the resident's January 2023 TAR showed the following: -Staff initialed completion of a body audit every day on 1/1/23 and 1/2/23. Staff did not document any further information regarding the resident's wounds. -On 1/3/23, staff did not document administration of the morning dose of Augmentin 875/125 mg. Record review of the resident's progress note dated 1/3/23, at 12:02 P.M., showed a nurse documented the following: -Order to send the resident to the emergency room due to resident's gastric tube displaced. Record review of the resident's re-admission history and physical, completed on 1/23/23, by the resident's primary physician/medical director, showed the following: -The resident was re-admitted to the hospital on [DATE], diagnosis of acute osteomyelitis (infection of the bone), involving the right ankle and foot. The resident underwent right above the knee amputation (AKA) without complications. Post-operative course was uneventful. He/she was discharged back to the facility on 1/20/23. Record review of the resident's progress note, dated 1/23/23, showed APRN I documented the resident with a right above the knee amputation (AKA) of the right leg. During an interview on 2/9/23, at 9:50 A.M., Certified Nurse Aide (CNA) B said staff should inform the charge nurse if they noticed a pressure ulcer. During interviews on 2/9/23, at 10:53 A.M., and on 2/10/23, at 3:13 P.M. Registered Nurse (RN) E said the following: -If the shower aide discovered a resident had a new wound, then he/she filled out a shower sheet form and gave to the charge nurse; -RN E assessed a resident if staff reported a new wound to him/her. He/she informed the wound nurse of any new resident wound; -Staff should report a pressure ulcer to the wound nurse and unit manager and document the wound in the resident's progress notes; -He/she would measure the pressure ulcer and document what he/she observed and notify the physician for orders to treat the pressure ulcer; -Nurses should notify the physician, if the pressure ulcer or wound looks worse; -He/she did not remember the resident's wounds. During interviews on 2/9/23, at 11:52 A.M., and 2/10/23, at 11:57 A.M., RN C said the following: -Nurses should enter an antibiotic order into the computer system and check the facility's medication system to pull the first couple of doses. If the medication was not available, the nurse should send order to the pharmacy to be filled; -Nursing staff monitored residents' skin when providing incontinent care and repositioning every two hours; -Nurses should notify the physician and the wound nurse with signs of wound infection; -Nurses notify the physician by text or phone call; -The wound nurse usually entered an order in the electronic medical record, if the physician ordered an antibiotic; -The wound nurse informed the nurses of new orders for a resident. During an interview on 2/9/23, at 12:55 P.M., LPN D (wound nurse), said the following: -His/her responsibilities include weekly wound assessments, weekly skin assessments, and all skin treatments for the entire facility; -Residents with significant pressure ulcers were referred to the wound physician, by the wound nurse. The wound physician visited the facility weekly, on Wednesdays, and assessed and measured wounds for those residents on his/her caseload; -If residents were not in the facility during the wound physician's visit, the wound nurse did not measure those residents' pressure ulcers for the week; -In the past, the facility did not provide any training to the wound nurse on pressure ulcer staging or assessment; -The wound nurse did not begin staging pressure ulcers until sometime in January 2023; -On the wound nurse's days off from the facility, some of the other nurses were not completing resident skin treatments/pressure ulcer treatments as ordered; -The wound nurse said the resident's right outer foot wound contained some black tissue in the wound bed, since his/her admission, but on 12/15/22 or 12/16/22, the resident's wounds had deteriorated significantly with black and yellow tissue present to the wound bed and the wounds were much larger in size. The surrounding intact skin became red and warm to touch. The wound nurse contacted the resident's physician and obtained antibiotic order; -The wound physician saw the resident one time only, on 12/28/22; -On 12/28/22, the resident's right foot was swollen, red, and painful to touch. The right foot pressure ulcers were necrotic and draining serosanguineous (containing blood and serum) drainage of varying amounts, with no odor. During an interview on 2/10/23, at 9:45 A.M., LPN J said the following: -He/she completed skin treatments, if the treatment was ordered to be completed at night or as needed if the dressing became soiled; -If a staff member documented a '4' code on the TAR or MAR that meant the nurse did not complete the treatment or administer the medication; -The LPN said he/she had experience staging pressure ulcers, but the facility administration staff did not provide the nurse with wound care training; -The wound nurse completed the weekly skin assessments; -If the nurse observed a new pressure ulcer, he/she would notify the physician for treatment, but the physician usually referred to the wound nurse to assess and recommend a treatment; -The wound nurse then obtained the physician order and placed the order into the electronic health record; -A body audit was the same thing as a bath aide shower sheet, which was completed by the CNA/shower aide and reviewed by the nurse; -A check mark on the body audit section of the TAR, meant no new observed skin issues; -Skin treatments were the responsibility of the wound nurse or charge nurses. -He/she did not know why the CMT would sign a '4' for the resident's medications on the RN/LPN MAR indicating medication not administered; -Licensed nurses should administer any resident medications listed on the RN/LPN MAR, and CMTs administer medications listed on the regular MAR; -The nurses, not the CMTs, should have administered medications to the resident via gastric tube. During an interview on 2/10/23 at 10:28 A.M., LPN K said the following: -The facility admitted the resident from the hospital on [DATE], but LPN K did not complete the admission assessment until 11/29/22; -He/she documented the resident had a an area to his/her right outer ankle, measured 0.8 cm by 1.0 cm with redness surrounding the area; -He/she did not stage pressure ulcers; -If he/she observed a pressure ulcer, he/she informed the wound nurse; -If the resident was admitted without a treatment for an existing pressure ulcer, he/she would notify the nurse of the need to obtain a treatment order; -On the resident's re-admission assessment, dated 12/27/22, he/she documented the resident had a stage 3 pressure ulcer to the right lateral foot that measured 7.5 cm long by 2.0 cm wide by 0.3 cm deep and left lower extremity pressure ulcer measured 6.0 cm long by 4.0 cm wide by 0.1 cm deep; -He/she may have been mistaken when he/she documented left lower extremity, instead of right, but was unsure. During an interview on 2/10/23, at 11:10 A.M., CMT L said the following: -On the December 2022 RN/LPN MAR for the resident, the CMT documented a '4' meaning other. This meant he/she did not administer the medication, therefore it would be the responsibility of the charge nurse to administer the resident's medication because a nurse needed to administer the resident's medication via gastric tube; -The tube feeding medication should go on the RN/LPN MAR for the nurse to administer; -For some reason, the resident's Augmentin popped up on the computer for the CMT to administer, but he/she did not give the medications; -The CMT documented a code '4' and said the nurse should then know to give the resident medications; -The medication comes in plastic strips. The CMT would take the plastic strips of medications and hand the plastic strips of medication for any medications that the nurse was responsible for administering the following day and give to the nurse; -The nurse would place these medication strips into the top drawer of their nurse medication cart. The CMT did not document which nurse that he/she handed the medication to. During an interview on 2/10/23, at 11:32 A.M., and 2/15/23, at 10:19 A.M., LPN G/Unit Manager said the following: -Nurses enter an antibiotic order into the EMAR and can pull a medication from the facility medication system; -Staff can print and fax a medication order to the pharmacy, to ensure a medication will be delivered, but the electronic order goes directly to the pharmacy, once staff places the order into the electronic medical record; -He/she prints a new order listing, from the previous day, to review ordered medications. He/she then looks at the resident's MAR which was automatically populated, if the order was entered; -The nurse who took the order or recommendation from the physician, should enter the order into the system; -Staff should contact the resident's primary physician with any new treatment or medication order; -Staff can contact the physician by fax, phone call, or in-person; -Staff should document the physician order in the resident's progress note; -Staff should obtain medications for residents who have tube feeding from the facility medication system and staff should enter the order on the nurse MAR; -The order should show the route by tube or peg tube and a nurse would then be responsible for administration of any gastric tube medication. During a phone interview on 2/10/23, at 12:36 P.M., Family Nurse Practitioner (FNP) H said the following: -The facility should assess and measure resident pressure ulcers on admission and weekly thereafter; -The wound nurse should complete weekly wound documentation to include: measurements, wound bed and peri-wound appearance, any redness to surrounding skin, any odor, any necrotic tissue or slough; -If a resident's wound deteriorated, the wound nurse or assessing nurse should notify the primary physician, the wound physician, or the FNP within the same day as the nurse observed the change; -The wound physician communicates recommendations to the wound nurse; -The wound nurse should notify the primary care physician of all wound physician recommendations for change in pressure ulcer treatment or recommendations for antibiotics; -If the facility staff lacked to properly assess a resident's pressure ulcer, failed to treat a resident's pressure ulcer as ordered, or failed to administer antibiotics to a resident as ordered, these failures could contribute to the decline of the resident's pressure ulcer. During an interview on 2/10/

Based on observation, interview, and record review, the facility failed to ensure all residents were free from manual restraint for the convenience of staff when two staff members (Certified Nurse Aide (CNA) X and Registered Nurse (RN) V) physically restrained one resident (Resident #1) against the resident's wishes and without physician's orders. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home or must be paged and informed of such incident; -Staff shall provide a safe environment for the resident. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. Record review of the facility's Employment Policies and Procedures, located in the facility's most current employee handbook, page 48, included the following information: -The facility strictly prohibits the abuse of dependent adults. All residents in the facility are considered to be dependent adults. It is the responsibility of all employees to safeguard residents from abuse and to report any knowledge or suspicion of abuse to the facility's Administrator or to the state's Department of Health and Senior Services (DHSS) immediately; -The following is a non-inclusive list of abusive conduct: the willful, negligent act or omission by an individual that results in physical or mental injury to a dependent adult; unreasonable confinement, restraint or corporal punishment of a dependent adult. Record review of the facility's physical Restraint Management Guidelines, revised 9/2017, showed the following definition of a physical restraint per the Centers for Medicare & Medicaid Services (CMS): -A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admit date of 6/7/21; -Diagnoses included pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin), anxiety, mild cognitive impairment (decline in the mental ability affecting memory, language, thinking, or judgment), chronic obstructive pulmonary disease (COPD - chronic lung disease that makes it hard to breathe), hypertension (high blood pressure), heart failure, urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra); -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's progress notes, dated 6/7/21 through 7/22/21, showed no documentation of combative behavior. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed registered nurse (RN) V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During an interview on 7/13/21, at 12:45 P.M., certified nursing assistant (CNA) U said the following: -Although he/she did not work when the resident apparently fell (7/11/21), facility staff told him/her that the resident sustained bruising on his/her arms as a result of a fall, or from the transfer after the fall; -The CNA asked the resident how he/she got the bruises on his/her arms and the resident said staff hurt him/her and caused the bruises; -The resident did not identify the staff that hurt him/her. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and Plavix (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V reported the fall to DON, physician, and son of the resident; -RN V completed a skin assessment which showed the resident's arms were pink, but not enough to imply there would be bruising; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident; -RN V denied any prior known combative behavior from the resident; -RN V would make sure a combative resident was in safe area, talk to de-escalate, put in a safe position, and monitor until they are calm; -RN V would try to hold the hand(s) of a combative resident, and walk away if not working. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet; -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. Sometimes, he/she hugged the agitated resident; -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. At the time, CNA X thought the night shift staff caused the bruising because, when he/she left the facility after his/her shift about ended at 6:30 P.M., the resident did not have bruising on his/her arms; -CNA X immediately reported the resident's bruises to RN V. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand were exposed revealing dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and on 7/15/21, at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her, and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. Record review of the resident's Skin Assessments showed the following: -On 7/14/21, left forearm bruising, left upper arm bruising, right forearm bruising, right upper arm bruising; -On 7/16/21, left hand (back) bruising 5 cm length (L) x 6 cm width (W), right forearm (outer) bruising 10 cm (L) x 6 cm (W), left forearm (distal post) bruising 11.5 cm (L) x 7 cm (W). During an interview on 7/14/21, at 3:05 P.M., Restorative Care Aide (RNA) S said the following: -The resident had no known history of combative behavior; -The resident told RNA S he/she did not want to talk about how he/she got the bruises; -He/she would not cross the arms of a combative resident; -He/she would document and report any combative resident behavior. During an interview on 7/15/21, at 9:20 A.M., licensed practical nurse (LPN) E said the following: -He/she observed bruises to both of the resident's forearms and left hand; -He/she asked the resident about his/her bruises and was told the girl, but could not provide any additional information. -He/she would step away from a combative resident, leave alone to calm down and attempt later; -He/she would never cross a resident's arms to calm them down; -He/she would step in, remove staff, and report if he/she witnessed a staff cross a resident's arms; -He/she would ask a resident about any observed bruises and, if unknown how the bruises were obtained, start an investigation. During an interview on 7/21/21, at 1:20 P.M., RN EE said the following: -The resident's bruises were dark purple in color on left forearm and hand; -The resident does not have a history of combative behavior. During an interview on 7/15/21, at 10:20 A.M., CMT Z said the following: -The resident has never been observed being combative. -He/she would ask for help if resident became combative; -He/she would try to calm a combative resident, then leave and return later to attempt; -He/she would never touch or cross the arms of a combative resident. During an interview on 7/15/21, at 11:30 A.M., Social Services Director (SSD) J said the following: -The resident had been upset lately; -He/she heard of alleged abuse towards the resident; -He/she saw the resident's bruises, but did not ask him/her about them; -He/she had been vaguely told details of the resident being held down; -He/she did not speak with the resident about being held down; -He/she thought another Social Worker had spoken with the resident concerning bruises and allegations; -He/she would see a resident if he/she was made aware of behavioral changes. During an interview on 7/15/21 at 12:40 P.M., SSD L said the following: -The resident has never been observed with combative behavior to SSD L's knowledge. -He/she would step out of reach and would not physically touch a combative resident; -He/she would document any combative behavior and report it to a nurse. During an interview on 7/15/21, at 12:00 P.M., LPN AA said the following: -The resident had been confused and combative two weeks prior and staff redirected the resident, then walked away to allow the resident to calm down. -He/she would walk away from a combative resident; -He/she would not cross the arms of a combative resident; -He/she would report if he/she witnessed a staff crossing the arms of a resident. During an interview on 7/16/21, at 8:50 A.M., LPN D said the following: -The resident was never observed as combative; -He/she did not observe any bruises to the resident prior to 7/12/21; -He/she observed bruises to the resident's forearms and left hand. -He/she would step away from a combative resident, if talking or distraction did not calm down; -He/she would notify physician of combative behavior and document; -He/she would consider this a physical restraint, would stop the staff and report it. During an interview on 7/16/21, at 12:47 P.M., CNA BB said the following: -He/she had never seen or heard of the resident being combative. -He/she would never touch a combative resident, but rather give them space, and notify the nurse; -He/she considered holding arms across the stomach or chest of a combative resident as a restraint and if witnessed he/she would stop the staff then report it; -He/she would not touch a resident who was upset and on the toilet; -He/she would not leave the resident, but would stand around the corner or crouch down to the resident's level to let them calm down. During an interview on 7/21/21, at 2:42 P.M., CMT FF said the following: -He/she did not recall the resident having combative behavior. -He/she would step back from a combative resident, attempt to approach later, and report the behavior to a nurse; -He/she would never hold or cross arms of combative resident. This is considered a restraint; -He/she has never witnessed a staff cross the arms of a combative resident and would stop it if witnessed. During interviews on 7/16/21, at 3:22 P.M., and 7/22/1, at 12:57 P.M., the DON said the following: -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She attempted to interview the resident who said it happened at nighttime and was a staff person, but did not know the name and was unable to describe; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -DON asked RN V why he/she thought it could have caused bruises, RN V said the bruises were where the resident was told to hold his/her arms; -The resident had some redness to arms, but no signs of bruising; -DON requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -The resident took blood thinners, which would have caused the bruising; -Facility staff are trained to back off and step away from an abusive resident, but not to leave them to make sure they are safe; -Facility staff should care for combative residents by taking a step back and allow the resident to calm down, reproach at a later time, ensure the resident is safe, and document any behavior of resident; -Holds that prevent a resident from getting hurt (like a fall) are not considered a restraint; -He/She would require documentation any time a resident is combative; -He/She would require documentation any time a resident is held during combative behavior; -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -He/She said if a resident is fighting against the hold it would be considered a restraint; -Restraints are not appropriate. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -The resident fell on 7/11/21 at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child was upset and reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up. -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -Facility staff should back away from a combative resident, but stay with resident if unsafe; -Residents who take blood thinners can bruise easily. During an interview on 7/16/21, at 4:55 P.M., the Advance Practice Register Nurse said the following: -Staff holding a resident's arms across a resident's body would not be appropriate and doing so could cause bruising on the resident, especially if the staff held the resident this way for two to three minutes; -If staff have a resident who is combative, he/she would need to step back, allow the resident to calm down and approach the resident in a different manor. During an interview on 7/26/21, at 12:39 P.M. the Medical Director said the following: -If staff held a resident's arms across their body, he/she would consider that a physical restraint. This would be appropriate if a resident's safety was at risk. If staff held a resident like this, they could definitely cause bruising; -He/she did not recall any reports of the resident being combative; -He/she did not know what kind of restraints the facility allowed. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00187969

Based on observation, interview, and record review, the facility failed to start an immediate investigation and take steps to protect all residents when an allegation of a manual restraint, type of abuse, involving two staff (Registered Nurse (RN) V and Certified Nurse Aide (CNA) X) and one resident (Resident #1) was reported. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; -Employees shall be able to identify abuse, neglect, exploitation, and misappropriation of resident property; -Employees shall report to facility management any suspected or determined resident abuse, regardless of the time lapse since the incident occurred; -The facility will put into place steps to prevent further potential abuse, including but not limited to, staffing changes, increased supervision, protection from retaliation, and follow-up counseling for the resident(s); -The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Any employee suspected of allegation of abuse, or neglect, misappropriation or exploitation must result in his/her immediate suspension to protect the resident; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency; -Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -An admit date of 6/7/21; -Diagnoses included pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin), anxiety, mild cognitive impairment (decline in the mental ability affecting memory, language, thinking, or judgment), chronic obstructive pulmonary disease (COPD - chronic lung disease that makes it hard to breathe), hypertension (high blood pressure), heart failure, urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra), -The resident was responsible for him/herself. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 6/20/21, showed the following: -Severely impaired cognition; -Independent with toileting and bed mobility; -Required supervision from one person for transfers, personal hygiene, and dressing; -No aggressive behaviors exhibited; -Occasional urinary incontinence; -Used a walker for a mobility; -Moving off/on toilet - not steady, but able to stabilize without staff assistance. Record review of the resident's current physicians' orders showed no order for use of a restraint. Record review of the resident's nurses' notes dated 7/11/21, at 12:01 P.M., showed a nurse documented staff found the resident on the bathroom floor, between the toilet and his/her wheelchair, after an apparent fall while attempting to transfer himself/herself from the toilet to the wheelchair. Record review of the resident's skin assessment, dated 7/11/21, showed RN V documented the resident, after a fall, had no new skin issues at that time. He/she continued with resolving bruising on his/her buttocks and posterior (the back part of) thigh with slight redness observed on his/her left forearm/hand. During interviews on 7/13/21, at 3:26 P.M., and 7/16/21, at 11:32 A.M., RN V said the following: -On 7/11/21, around 12:00 P.M., staff found the resident confused and agitated on the bathroom floor after an apparent fall; -He/she entered the bathroom and assessed the resident, then he/she and CNA X assisted the resident off the floor; -When the resident became combative, RN V held the resident's hands, crossing the resident's arms over one another; -RN V placed his/her hands, flat open-handed, on the resident's forearms; -RN V demonstrated how he/she crossed the resident's arms, with one arm on top of the other, placed in front of the stomach area; -RN V did not think his/her actions caused bruising on the resident's arms; -The resident took aspirin and Plavix (a blood thinner); -The resident stood at the sink and became anxious with fear of falling due to weak knees and feet slipping, even with non-skid socks; -The resident had soiled clothing that fell to floor when he/she stood up; -The resident held on to the sink, but then began swinging at staff; -The resident began slapping at staff and pulling their clothing; -RN V and CNA X sat the resident on the toilet to clean him/her and the resident continued slapping at them; -RN V and CNA X did not leave the resident as they felt he/she was unsafe and the priority was to prevent the resident from hurting him/herself; -RN V did not believe the resident was safe sitting on the toilet; -RN V held the resident's hands to de-escalate, then crossed his/her arms across the stomach; -RN V held the resident's arms down flat handed for approximately two to three minutes; -RN V had used this method previously on other residents without bruising as a result; -RN V had received training for this hold from a memory unit; -RN V did not document the resident's combative behavior or the hold placed on the resident; -RN V did not report the hold to the DON, physician or the son; -RN V self-reported and demonstrated to the DON on the morning of 7/12/21 how he/she held the hands and crossed the arms of the resident. Record review of written statements from RN V, dated 7/12/21, showed the following: -RN V held the resident's hand placing the resident's arms crossed across his/her stomach; -The resident calmed slightly, but did continue to resist; -When finished the resident's arms were pink, but no indication of bruising. During interviews on 7/13/21, at 4:17 P.M., and 7/14/21, at 3:00 P.M., CNA X said the following: -On 7/11/21, at 10:30 A.M., a certified medication technician (CMT) found the resident on the bathroom floor and immediately reported it to CNA X; -When the CNA entered the resident's room, he/she saw the resident lying on the bathroom floor; -CNA X and RN V transferred the resident from the floor to the toilet; -The resident became combative when they attempted to transfer him/her from the toilet to the wheelchair; -CNA X and RN V both crossed the resident's arms across his/her chest with open hand placement; -CNA X demonstrated on the surveyor how he/she and RN V held the resident by crossing (restraining) the surveyor's arms across his/her chest placing the surveyor's left hand on her right shoulder and right hand on her left shoulder and held the resident from both sides while the resident sat on the toilet. -The resident had soiled his/her brief which was near his/her ankles; -CNA X attempted to prevent the resident's fecal matter from getting on the resident and surroundings. The CNA was trying to sit the resident on the toilet so he/she could change the resident's brief. The resident became combative. Staff tried to reassure the resident who can't hear well. The resident got more agitated; -The resident grabbed at his/her clothing, and grabbed at the sink; -The resident did not want his/her brief to drop on the floor and became combative while trying to assist with his/her brief and clothing; -CNA X and RN V crossed the resident's arms over his/her body and gently told him/her to calm down. CNA X and RN V held the resident's shoulder and forearm with an open hand on each side of the resident. They held the resident this way for approximately two minutes. During the time the CNA and RN held the resident's arms, the resident asked them what they were doing; -After RN V and CNA X let go of the resident, they noticed the resident's arms were red; -CNA X thought the redness came from resident flailing his/her arms in the bathroom, but then the CNA said he/she did not think the resident hit anything with his/her arms; -After CNA X and RN V cleaned up the resident, they transferred him/her to a wheelchair; -If a resident became combative when he/she assisted him/her, CNA X would put his/her hands up (not touching the resident) and reassure the resident, then report the behavior to a nurse. -On 7/12/21, at 6:30 A.M., CNA X arrived to work and observed bruising on the resident's top of forearms and hand. -CNA X immediately reported the resident's bruises to RN V. Record Review of written statements from CNA X, dated 7/12/21, showed the following: -Because of the resident hitting, staff began to gently cross his/her arms; -He/she had red marks, but no bruising. Observation and interview on 7/13/21, at 10:50 A.M., showed the resident sat in his/her wheelchair in the hallway with a lap blanket covering his/her lower extremities and right arm. The resident's left arm and hand revealed dark purple and black bruising. The resident did not want to tell how he/she received the bruising, became visibly upset, and began rubbing bruises to the left arm and hand. Observation and interview on 7/13/21, at 11:20 A.M. with the resident, showed the following: -The resident said he/she did not remember a recent fall. The mean girl who was too rough caused his/her bruises. The resident did not name or describe the mean girl; -The resident had black and purple bruising to the posterior part of his/her left forearm that measured approximately 8 centimeters (cm) by 5 cm, with a 1 cm skin tear in the center, black and purple bruising that covered the back of his/her left hand, black and purple bruising to the medial (towards the center or middle) portion of his/her right forearm that measured approximately 8 cm x 4 cm. Observation and interview on 7/14/21, at 11:45 A.M., and at 12:15 P.M. with the resident, showed the following: -The surveyor asked the resident what caused the bruising and he/she said he/she did not fall or bump himself/herself. He/she did not cause the bruising, she did this to me; -The resident did not want to talk about it at first, but then said somebody hurt me and pointed to a place on his/her hand and said those are finger marks; -The resident said he/she did not want her (the staff member) around him/her or taking care of him/her anymore; -The resident said he/she did not feel comfortable talking about it and that staff member was not a good person; -The resident said he/she felt nervous and frightened talking about what happened to him/her and became very tearful; -The resident said they crossed his/her arms and held his/her arms and hands tightly. During an interview on 7/14/21, at 1:28 P.M., the DON said RN V had been suspended pending investigation and he/she would notify CNA X that he/she would also be suspended pending investigation (three days after the incident and two days after statements were requested by the DON and provided by RN V and CNA X.) During interviews on 7/16/21, at 3:22 P.M., and 07/22/21, 12:57 P.M., the DON said the following: -He/She would consider it a restraint and abuse if someone were to constrict a resident's movement; -The resident's child reported during a visit on 7/12/21 the resident said his/her bruises were caused by someone who beat him/her up; -He/She spoke with RN V on 7/12/21 who said the resident had become combative while getting the resident off the toilet to clean him/her up post fall; -RN V told and demonstrated to the DON how he/she had put the resident's arm on top of the other one across the abdomen area; -RN V told the DON he/she had hoped he/she did not cause the bruises to the resident's arms; -He/She asked RN V why he/she thought it could have caused bruises, RN V said the bruises where resident was told to hold his/her arms; -He/She requested RN V and CNA X provide written statements of the resident's alleged fall on 7/11/21; -He/She thought he/she had read RN V and CNA X's statements prior to leaving for an out of town meeting; -He/She did not think of abuse when he/she received the statements, but helping the resident; -He/She would have suspended CNA X and RN V if he/she thought the staff were holding the resident down; -He/She denied knowing on 7/14/21 there was an issue with the two staff who said they crossed the resident's arms, as the two staff reported they had only crossed the resident's arms. During an interview on 7/16/21, at 4:52 P.M., Regional Nurse Consultant (RNC) said the following: -Combative residents are to never be held down, as that is a restraint which is a form of abuse; -The resident fell on 7/11/21 at 10:30 A.M.; -The resident had a visit from his/her child on 7/12/21; -The resident's child reported the resident said he/she got the bruises from someone who had hurt him/her; -RNC had not been made aware of RN V or CNA X's verbal or written statements prior to 7/14/21; -RNC interviewed CNA X on 7/14/21 who said the resident became combative during assistance after the resident fell; -CNA X told RNC they crossed the resident's arms and held them to keep the resident from grabbing the staff and hurting their self while cleaning him/her up; -RNC said if he/she had seen the statements, both staff would have been suspended pending investigation for restricting the resident's movement. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint: MO00187969