Every finding on record at Advena Living on Woodlawn

The facility identified a census of 72 residents. The sample included eight residents with three reviewed for falls. Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for Resident (R) 1. On 12/15/25 at 03:15 PM, per camera footage, Certified Nurse Aide (CNA) M propelled R1 in a wheelchair without the use of foot pedals, down an incline when the resident's right foot dropped under the wheelchair, where it became entangled, causing R1 to fall to the floor. This resulted in a right femur (thigh bone) fracture.Findings included:- R1's Electronic Medical Record (EMR) under the Physician's Orders, dated 01/08/26, documented a diagnosis of displaced fracture at the base of the neck of the right femur.R1's Quarterly Minimum Date Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R1 required substantial assistance to total staff dependence for most activities of daily living (ADL) and was wheelchair dependent. The MDS recorded she had no falls.R1's Quarterly MDS dated 01/08/26 indicated no changes in the BIMS score. R1 was dependent on staff for transfers, toileting, and showers, and dependent on staff for mobility in a wheelchair. The MDS noted R1 had a fall with a fracture since the last assessment.R1's Care Plan documented she had an activity of daily living (ADL) self-care deficit. An intervention initiated on 05/23/23 and revised on 04/20/24 directed staff to know R1 required a Hoyer lift (full body mechanical lift) with staff assistance to get out of bed. A Focus, initiated on 09/10/23 and revised on 12/17/25, documented R1 had limited physical mobility related to morbid obesity and was unable to turn and reposition in bed without staff assistance and bedrail. The resident could self-propel in a wheelchair for more independence; foot pedals were to be kept in a bag on the back of the wheelchair when not in use. Staff would monitor safety on an ongoing basis.R1's Care Plan recorded interventions dated 12/17/25, which directed the resident was non-weight-bearing, but did not list which limb. An intervention was listed as The resident requires (SPECIFY assistance) by (X) staff for locomotion using (SPECIFY). Another intervention dated 12/17/25 documented The resident uses (wheelchair) for locomotion. Clean ().R1's Care Plan lacked mention of the right femur fracture or interventions directing staff regarding the use of foot pedals.R1's late entry Nursing Progress Note dated 12/15/25 at 03:15 PM documented the resident was self-propelling on her way to activities when she began to go down the decline too fast. A CNA was not far from the resident and tried to grab the resident's chair to slow her down. By the time the CNA tried helping the resident, R1 put her foot down and toppled over.R1's late entry Nursing Progress Note dated 12/15/25 at 03:50 PM documented R1 was coming down the 200-hallway slope too fast, and her right ankle caught on the foot pedal, and she fell out of her wheelchair, landing on her right side. R1 denied hitting her head but complained of some back pain. She was able to roll from side to side. The resident was taken to her room, and the mobile X-ray provider was called.R1's Nursing Progress note dated 12/15/25 at 06:38 PM documented the mobile X-ray provider report showed a fracture of the right femur and osteoarthritic (degenerative bone changes). R1 went to the Emergency Room. R1's Discharge Notes from the acute hospital documented R1 had a right femoral neck hip fracture, and due to excessive accumulation of body fat, a non-surgical treatment was recommended.Observation on 01/21/26 at 04:58 PM of the camera footage from 12/15/25 with Administrative Staff A revealed that the staff propelled her in her wheelchair down the slope without foot pedals attached. R1's legs were straight out from the wheelchair, not resting on anything. R1's right foot dropped to the floor, and R1 fell out of the wheelchair.On 01/21/26 at 09:45 AM, R1 stated CNA M pushed her in the wheelchair, going too fast. R1 said she did not have any foot pedals on the wheelchair, and her right foot went under the chair and caused her to fall. She stated the physician at the hospital would not do surgery due to her weight, and the fracture would have to heal on its own.On 01/21/26 at 12:10 PM, Administrative Staff E revealed she was sitting in the administrator's office when R1 fell out of her wheelchair. She said she thought the CNA was either pushing or attempting to grab the resident's wheelchair, but the cameras would give the correct information.On 01/21/26 at 03:36 PM, Administrative Staff D said the facility did not have an MDS nurse to update the care plans. On 01/21/26 at 04:30 PM, Administrative Staff E revealed an incident report, witness statements, and/or education were not completed for this incident.On 01/21/26 at 04:58 PM, Administrative Staff A said the nurses' notes on 12/15/25 at 03:15 PM indicated R1 had foot pedals on her wheelchair when CNA M pushed her down the hallway but confirmed the camera footage showed R1 in the wheelchair with her legs straight out and no foot pedals on the chair. Administrative Staff A said she did not know why the nurse would write that foot pedals were in use when the video showed R1 with her legs straight out and no pedals.The facility's policy Fall and Fall Risk, managing dated 10/2021 revealed that, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling.

The facility had a census of 72 residents. The sample included eight residents, with three residents reviewed for involuntary discharge. Based on interview and record review, the facility failed to provide a complete recapitulation of Resident (R) 3's stays in the facility, including medication reconciliation, and further failed to ensure the involuntary discharge notice included the required information. Findings include:-R3's Electronic Health Record (EHR) documented a diagnosis of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and borderline intellectual functioning. R3's 09/22/25 admission Minimum Data Set (MDS) documented a Brief Interview Mental Status (BIMS) of 15, which indicated intact cognition. R3's MDS documented he had no depression, but he had verbal behavioral symptoms directed towards others during the look-back period. R3's MDS documented he required setup for activities of daily living (ADL) care. R3's MDS documented he had no plans for discharge and planned to remain at the facility. R3's 10/03/25 Cognitive Loss / Dementia Care Area Assessment (CAA), documented he had a potential for alteration in cognitive patterns, based on his diagnosis of schizoaffective disorder. R3 had verbal behaviors noted towards others, and staff would continue to observe and report any pertinent concerns and notify the provider as needed. R3's EHR lacked evidence that a comprehensive care plan was developed. R3's Physician Orders lacked a discharge order. R3's Involuntary Discharge Notice dated 12/09/25 documented the letter served as the required written notification of involuntary discharge from the facility and listed the reason or the discharge as the safety of individuals in the facility was endangered due to the behaviors of R3 when on 12/08/25, R3 engaged in actions that posed an immediate and serious risk of fire which required staff intervention to prevent a building fire. The notice cited the resident's ongoing explosive, aggressive, and unsafe behaviors. The notice included the date, 30 days from the date of the notice, as well as a discharge locations. The notice included the appeals rights but lacked the information on how to file an appeal and who in the facility would assist the resident with the appeal. The notice included the Ombudsman's telephone number but lacked the Ombudsman's name and email contact information. The notice further lacked the contact information for the State Agency (SA) responsible for the protection and advocacy of individuals with developmental disabilities and the SA responsible for the protection and advocacy of individuals with a mental disorder.R3's Progress Note on 12/9/25 at 03:30 PM documented that staff spoke with the family that R3 would return to the facility and be on one-on -one supervised care. R3 would receive an evaluation with a mental health provider, and the facility would assist in locating a new facility. R3 received an involuntary discharge notice as soon as possible, and R3 would be discharged with medication for 30 days. The note indicated that R3's family was educated that if R3 had any signs of aggression, it was recommended that they call 911. R3's Progress Note on 12/9/25 at 06:35 PM documented R3 discharged home with family members. R3 was discharged with all medications, clothing, and other items. R3's family member had all questions answered prior to leaving the facility. R3's Social Service Progress Note on 12/10/25 at 10:04 AM, documented after R3 was discharged from the facility, Social Service Designee (SSD) X contacted the hospital social worker and inquired if R3 completed a State Mental Health Screener Assessment in order to get admitted into a State Mental Health hospital. The hospital social worker was initiating the process of assessment and said it would be completed. R3's Progress Note on 12/10/25 at 03:02 PM documented that R3's family member stood in the reception area holding a bag of medications and reported she needed clarification on how to give R3's medications. The nurse was notified to assist with this request. During an interview on 01/21/26 at 09:52 AM, Licensed Nurse (LN) G stated that the administrative staff prepares the paperwork for all discharges, with two copies of all forms. LN G reported phone numbers for various resources were included in the discharge information. LN G said no narcotics are sent with residents upon discharge. During an interview on 01/21/25 at 11:55 AM, SSD X stated that upon an involuntary discharge, she followed facility policy. She said if it was a planned discharge, the discharge begins at the time of admission and involved starting certain assessments, addressing Medicare/Medicaid concerns, involving the resource team with communications regarding the resident, establishing needs for medical equipment then later, having a team meeting with resources provided at that time, and then, completion of all necessary discharge paperwork.During an interview on 01/21/26 at 04:00 PM, Consultant GG confirmed there was no recapitulation completed, and he was unable to provide a medication list of what was sent with R3 when the resident was involuntarily discharged . Consultant GG stated the resident's family member was verbally notified of the 30-day eviction notice. Consultant GG provided a copy of a progress note dated 12/10/25, which documented that R3's family member had a bag of medications at the time of discharge. Consultant GG stated the resident's family member was verbally notified of the 30-day eviction notice, and he believed the involuntary discharge paperwork was in order. The facility policy, Discharge Summary and Plan, dated October 2021, documented that when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary would include a recapitulation of the resident's stay.

The facility had a census of 72 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with interventions to address the care for Resident (R) 2.Findings included:- R2's Electronic Medical Records (EMR), documented diagnoses which included suspected adrenal insufficiency (a condition where the adrenal glands don't produce enough essential hormones like cortisol and aldosterone, leading to symptoms such as severe fatigue, weakness, weight loss, abdominal pain, and low blood pressure, sometimes culminating in a life-threatening adrenal crisis), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), myxedema (severe hypothyroidism), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).R2's 07/30/25 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R2 had an impairment on one side of her body and used a walker for mobility. R2 required supervision or touching assistance for care. R2 had a thyroid disorder. R2 took an antidepressant (a class of medications used to treat mood disorders) and an opioid (a class of controlled drugs used to treat pain).R2's 07/30/25 Visual Function Care Area Assessment (CAA) stated R2's vision in her right eye was blurry due to a previous stroke. The CAA documented visual function would be addressed in the care plan.R2's 07/30/25 CAAs for Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Pressure Ulcer/Injury, and Psychotropic Drug Use, each documented all the areas would be addressed in the care plan.R2's Care Plan dated 08/12/25, documented R2 wished to stay in the facility and was a full code. The care plan lacked any additional information.R2's Physicians Orders revealed a current order for levothyroxine sodium oral tablet 137.5 micrograms (mcg) in the morning for myxedema, start date 01/21/25. Scheduled at 06:00 Am. R2's Physicians Orders revealed a current order for trazodone (an antidepressant medication) 25 milligrams (mg) at bedtime for insomnia, ordered on 01/20/26.R2's Physicians Orders revealed a current order for Methadone (medication used to treat pain for people with opioid addiction issues) 10 mg, give eight tablets by mouth one time a day for pain, ordered on 01/10/26.R2's Physicians Orders revealed a current order for two liters of oxygen continuous, ordered on 01/08/26.On 01/21/26 at 01:35 PM, Certified Medication Aide (CMA) S stated the staff should follow the care plan to care for residents.On 01/21/26 at 03:37 PM, Licensed Nurse (LN) H stated she did not enter things in the care plan.On 01/21/26 at 04:12 PM, Administrative Nurse E stated that they had an offsite MDS person who started the care plan, and the interdisciplinary team added things as needed. Administrative Nurse E said the team had not kept up with updating the care plan, so the facility had implemented a new process where the team would look at the care plans a few days prior to the care plan meeting and update the plans at that time. Administrative Nurse E verified the facility had not actually started it yet, but it was the plan.On 01/21/26 at 05:02 PM, Administrative Nurse D said it was her expectation that the care plans reflect the resident's care, and it would be started and updated as needed.The facility's 10/2021Care Plans, Comprehensive Person-Centered policy stated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

The facility had a census of 72 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Residents (R) 2 and R4, who did not receive medications as ordered.Findings included:- R2's Electronic Medical Records (EMR), documented diagnoses which included hypothyroidism (a condition characterized by decreased activity of the thyroid gland), myxedema (severe hypothyroidism), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R2's 07/30/25 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R2 had a thyroid disorder. R2's Care Plan dated 08/12/25, documented R2 wished to stay in the facility and was a full code. The care plan lacked any additional information. R2's Encounter progress note dated 11/04/25, documented R2 had been taking levothyroxine sodium tablet 150 micrograms (mcg) for low thyroid hormone. The provider reviewed the lab results with R2 and increased the levothyroxine to 200 mcg every day. R2's Physicians Orders revealed a discontinued order for levothyroxine sodium oral tablet 200 micrograms (mcg) in the morning for hypothyroidism, start date 11/05/25. R2's Physicians Orders revealed a current order for levothyroxine sodium oral tablet 137.5 mcg in the morning for myxedema, start date 01/21/26. Scheduled at 06:00 AM. R2's Medication Administration Record (MAR) reviewed from 11/01/25 to 12/31/25 documented levothyroxine sodium oral tablet 200 mcg was ordered to be given at 08:00 AM, and was not given on 11/05/25, 11/05/25, 11/07/25, 11/08/25, and 11/09/25. R2's MAR lacked an order to hold the medication on the above-listed dates. On 01/21/26 at 09:52 AM, R2 reclined in the bed and watched television. R2 was alert and oriented. R2 stated she has had three stays in the hospital for hypothyroidism. The first time was prior to her stay here, and she was in a coma. In November, R2 stated she was in the hospital intensive care unit and remained hospitalized for 10 days. R2 reported that the staff had not been giving her the thyroid medications correctly. R2 reported that levothyroxine was to be taken before meals, and they gave it to her after meals with the rest of her medications or not at all. On 01/21/26 at 01:35 PM, Certified Medication Aide (CMA) S stated the CMA did not give the thyroid medications because the night shift nurse gave it between 05:00 AM and 06:00 AM. CNA M said she thought it was supposed to be given an hour before meals. CNA M said if a resident did not have a medication available, the staff looked for the medication and marked it as not given with a specific reason documented in a note. On 01/21/26 at 03:37 PM, Licensed Nurse (LN) H stated that if the CMA told her they could not find a medication, LN H would look for the medication and call the pharmacy to verify if it was sent to the facility. If LN H could not find it, she would get it out of the emergency medication kit on site. LN H said if the medications were not there, she would make sure they were ordered and find out if they would be coming during her shift. LN H would document on the MAR the reason it was not given and make a note as well. LN H said the MAR should never be left blank; there should always be an indication that a medication was given or why it was not given, and all medications should be given and documented as ordered and checked prior to leaving for the shift. On 01/21/26 at 05:02 PM, Administrative Nurse D expected the nurse to give medications and complete treatments when they are ordered and chart when they are completed. Administrative Nurse D said if the medication was not given, the reason for it not being given was to be documented, and a note was to be placed in the MAR. The facility's undated Administering Medications policy stated medications shall be administered in a safe and timely manner as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing the optimal therapeutic effect of the medication, preventing potential medication or food interaction, and resident preference. - R4's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R4's 06/09/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R4's MDS documented that he was administered an antianxiety medication (a class of medications that calm and relax people). R4's 06/29/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R4 was prescribed several psychotropic (alters mood or thoughts) medications related to depression and bipolar disorder; nursing would provide psychotropic medications as ordered. R4's 12/05/25 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. R4's MDS documented that he was administered an antianxiety medication. R4's Care Plan documented that staff administered medications as ordered, monitored and documented side effects and effectiveness, dated 06/02/25. R4's Physician Orders documented an order for alprazolam (anti-anxiety medication) 0.5 milligrams (mg) give every morning and bedtime for anxiety, date ordered 06/03/25. R4's Medication Administration Record (MAR) documented nine missed doses of alprazolam 0.5 mg every morning and bedtime dated 12/05/25, 12/06/25, 12/07/25, 12/08/25, and 12/09/25. R4's EMAR - Administration Note on 12/05/25 at 05:08 AM documented alprazolam 0.5 mg; pharmacy notified. R4's EMAR - Administration Note on 12/05/25 at 08:20 PM documented that alprazolam 0.5 mg medication was not on hand on order. R4's EMAR - Administration Note on 12/06/25 at 05:36 AM documented alprazolam 0.5 mg; pharmacy notified. R4's EMAR - Administration Note on 12/06/25 at 09:09 PM lacked a documentation reason why alprazolam 0.5 mg was not administered. R4's EMAR - Administration Note on 12/07/25 at 05:27 AM documented alprazolam 0.5 mg; contacted the pharmacy, who reported there was no prescription on file for the medication. Staff notified the provider regarding the issue and were awaiting a prescription to be sent to the pharmacy before the medication could be dispensed. R4's EMAR - Administration Note on 12/07/25 at 07:46 PM documented that alprazolam 0.5 mg medication had not been delivered. R4's EMAR - Administration Note on 12/08/25 at 06:19 AM documented that alprazolam 0.5 mg was ordered, and the staff waited for delivery. R4's EMAR - Administration Note on 12/08/25 at 07:50 PM lacked documentation of the reason why alprazolam 0.5 mg was not administered. R4's EMAR - Administration Note on 12/09/25 at 08:11 PM lacked documentation of the reason why alprazolam 0.5 mg was not administered. During an observation and interview on 01/21/26 at 02:25 PM, R4 lay on his bed sideways to unplug an outlet from the wall, then adjusted himself to an upright position on the side of his bed. He reported that the staff missed several doses of his alprazolam. During an interview on 01/21/26 at 12:00 PM, Certified Medication Aide (CMA) S reported that when a staff member documented a number nine above their initials on the MAR, it meant the medication was not available to administer, and the MAR would generate a progress note for staff to document why the medication was not administered. CMA S reported that she did not always document the reason why the medication was not administered, but said the EMR had the staff save the encounter or the MAR, and if it was not saved, the MAR would be blank as if not administered. CMA S reported that when a medication was not available, she would notify the nurse. CMA S reported the facility had an emergency medication kit, and the nurse would have to access the medication from the kit. On 01/21/26 at 03:37 PM, Licensed Nurse (LN) H stated that if the CMA told her they could not find a medication, LN H would look for the medication and call the pharmacy to verify if it was sent to the facility. If LN H could not find it, she would get it out of the emergency medication kit on site. LN H said if the medications were not there, she would make sure they were ordered and find out if they would be coming during her shift. LN H would document on the MAR the reason it was not given and make a note as well. LN H said the MAR should never be left blank; there should always be an indication that a medication was given or why it was not given, and all medications should be given and documented as ordered and checked prior to leaving for the shift. During an interview on 01/21/26 at 04:00 PM, Administrative Nurse E reported she expected the staff to administer the medication per the physician's orders. The facility policy Administering Medications, dated 10/2021, documented that medications were administered in accordance with prescriber orders.

The facility reported a census of 70 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses. Findings included:- During an observation on 09/03/25 at 09:53 AM, several dead roaches and live roaches were observed in different stages of life throughout the kitchen on the floor. The roaches were observed behind and on the side of the refrigerators, freezers, under the clean dish storage rack, under the meal prep counter, behind doors, and in the dry storage room. Dietary Staff CC said she had seen several roaches and had reported the concern to Dietary Staff BB, Certified Dietary Manager (CDM). Additionally, Dietary Staff CC said a person would come into the kitchen weekly to try to control all the roaches. Further observation revealed two garbage cans with no lids on them in the kitchen. Dietary Staff CC reported the lids were off, as it was easier to throw items away.During an interview on 09/03/25 at 10:00 AM, Dietary Staff BB confirmed the roaches in all stages of life throughout the kitchen in dry storage, behind fridges, freezers, under counters, and behind doors. Dietary Staff BB reported the facility had a pest control service came monthly, which was due sometime in September, and stated Administrative Staff A is responsible for calling the pest control company. Dietary Staff BB reported the kitchen staff had been dealing with roaches for about six months now.During an interview on 09/03/25 at 04:50 PM, Administrative Staff A stated he expected the kitchen to be pest-free, and the facility has tried to accomplish this. Administrative Staff A confirmed there were roaches in the kitchen.The facility's Pest Control policy dated June 2025, documented our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents.

The facility reported a census of 70 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment in two of the three shower rooms when the facility failed to ensure the walls remained free of any mildew, or unknown and unintended substances. Additionally, the facility failed to ensure the smoking courtyard and main entrance entry way area was maintained in a sanitary manner that included proper disposal of cigarette butts. This placed the affected residents at risk for decreased quality of life. Findings included:- Observation on 09/03/25 at 08:20 AM of the exterior entry way area to the facility revealed dozens of used cigarette butts littered on the ground in the area. The area did not contain a cigarette receptacle (a device used to extinguish and dispose of cigarette waste in a sanitary manner).Observation on 09/03/25 at 08:25 AM of the smoking courtyard area revealed dozens of cigarette butts littered on the ground. The courtyard contained several plastic and/or metal cigarette receptacles.Observation on 09/03/25 at 09:30 AM revealed the shower room on the 400-hall smelled of cigarette smoke with ashes on and around the toilet. There was a black/brown substance observed on the wall. The paint on the wall had bubbling consistent with water damage.Observation on 09/03/25 at 09:35 AM revealed the left shower room on the 200 hall had a black/brown substance observed on the wall beside the window, as well as the top and both sides of the wall opening where the window was mounted. Additionally, the exhaust fan was not operational.Observation on 09/03/25 at 11:00 AM with Consultant HH and Consultant II in the shower room on the 400 hallway, confirmed the presence of an odor of cigarette smoke in the bathroom and a black/brown substance on the wall.Observation on 09/03/25 at 11:05 AM with Consultant HH and Consultant II in the left shower room on the 200 hallway, confirmed the presence of a black/brown substance on the wall and area surrounding the window. During an interview on 09/03/25 at 11:00 AM, Consultant II identified the substance on the wall in the shower room on the 400 hall as mildew. Additionally, Consultant II stated the only way to definitively test the substance to identify it as mold or mildew was to send a sample to a laboratory for identification.During an interview on 09/03/25 at 11:05 AM, Consultant HH and Consultant II did not identify the substance on the wall in the left shower room on the 200 hall as mold or mildew; however, Consultant II identified the substance on the wall in the 200 hall shower room as similar to the substance on the wall in the 400 hall shower room.During an interview on 09/03/25 at 03:45 PM, Consultant GG stated that the entry way to the facility is a non-smoking area and confirmed that the area did not contain a cigarette receptacle, although one was needed for residents and visitors who are entering the building. Consultant GG stated the expectation was for smoking areas as well as the entryway to be well-maintained and clean. Consultant GG stated the expectation was for Certified Nurse Aide (CNA) staff to clean the shower rooms between each use, and housekeeping and/or environmental services (EVS) to clean/sanitize all surfaces in the shower rooms at least daily. Consultant GG revealed CNA and/or housekeeping/EVS were to report any damaged or discolored areas to maintenance staff. Consultant GG stated the expectation was for the facility to be free of black/brown substances on the walls, with repairs to be performed as needed.The facility's undated Quality of Life - Homelike Environment policy documented residents would be provided with a safe, clean, comfortable, and homelike environment. Staff and management would provide characteristics of a homelike setting that included a clean and sanitary environment. The facility's undated Smoking Policy - Residents policy documented metal containers with self-closing cover devices would be available in smoking areas. The policy did not contain additional information related to the proper disposal of cigarette buts or other used smoking materials.

The facility reported a census of 70 residents. The sample included 12 residents with six residents reviewed for abuse. Based on observation, interview and record review, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and mistreatment. This deficient practice placed the resident at risk for fear and decreased quality of life. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included chronic pain and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest)R1's 05/20/25 admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 utilized a walker or wheelchair for locomotion and required supervision or touching assistance with all activities of daily living (ADL) except oral hygiene, which required setup or clean-up assistance, and eating, which was performed independently.The 05/20/25 ADL Functional / Rehabilitation Potential Care Area Assessment documented R1 needed assistance from staff related to chronic pain.R1's 08/20/25 Quarterly MDS documented a BIMS score of 15. The assessment documented R1 utilized a walker or wheelchair and required supervision or touching assistance for putting on footwear and toileting, setup or cleanup assistance for all other ADL except lower body dressing, which was performed independently.The facility's investigation documented on 08/28/25 at an unknown time, Administrative Staff A was summoned to the parking lot by Social Services Designee (SSD) X for a verbal argument between R1 and Maintenance U. The investigation documented Administrative Staff A and SSD X observed Maintenance U arguing with R1, and the situation was successfully de-escalated by separating Maintenance U and R1. Administrative Staff A and SSD X interviewed Maintenance U and R1, as well as R2, R3, and Dietary BB, who witnessed the exchange between Maintenance U and R1. All witnesses reported yelling and an exchange of profanities between Maintenance U and R1. The investigation documented Maintenance U was immediately suspended pending the facility's investigation and terminated on 09/03/25.R1's EHR Progress Notes tab, reviewed from 08/20/25 to 09/03/25, lacked documentation of the incident on 08/28/25.Dietary BB's undated and unnotarized Witness Statement documented on 08/28/25, he observed a verbal altercation between Maintenance U and R1 and documented an exchange of profanities. Dietary BB documented they did not intervene because Administrative Staff A was approaching the situation.Administrative Staff B's unnotarized Witness Statement, dated 08/28/25, documented she overheard Maintenance U and R1 talking. Maintenance U asked R1 and R2 to move away from the area where the residents were smoking because it was too close to the door. A verbal exchange then followed, and Administrative Staff B called Administrative Staff A and asked her to come outside because Maintenance U and R1 were arguing. The verbal exchange between Maintenance U and R1 continued and included an exchange of profanities. Administrative Staff A then removed Maintenance U from the situation, and Administrative Staff A interviewed R1 and R2.SSD X's undated and unnotarized Witness Statement documented she went to the office of Administrative Staff A, where they were asked to assist in the parking lot to de-escalate a situation. SSD X and Administrative Staff A went to the parking lot and observed Maintenance U and R1 arguing. SSD X and Administrative Staff A successfully stopped the argument, and Administrative Staff A sent Maintenance U inside. The statement documented Administrative Staff A interviewed R1 and R2, who reported an exchange that included profanity. Administrative Staff A and SSD X then interviewed Maintenance U, who confirmed profanity was exchanged. Administrative Staff A then suspended Maintenance U.The facility did not obtain a witness statement from Maintenance U.During an observation on 09/03/25 at 03:05 PM, R1 sat in his motorized wheelchair smoking a cigarette in the courtyard with other residents and staff present.During an interview on 09/03/25 at 11:10 AM, Certified Nurse Aide (CNA) N revealed she had received an in-service recently that covered abuse, neglect, and exploitation.During an interview on 09/03/25 at 01:30 PM, Administrative Staff A reported the facility terminated Maintenance U for verbal abuse to R1. The investigation was unable to determine if Maintenance U or R1 started yelling first, and Maintenance U was observed by other residents and staff yelling at R1. Administrative Staff A said Maintenance U was informed the behavior was unacceptable and was immediately suspended pending the investigation and terminated effective 09/03/25.During an interview on 09/03/25 at 02:40 PM, Licensed Nurse (LN) H revealed she had received an in-service related to abuse, neglect, and exploitation within the last few days.During an interview on 09/03/25 at 03:05 PM, R1 confirmed that he was involved in a verbal exchange with Maintenance U and that voices were raised and profanities were exchanged. R1 reported no lasting ill effects as a result, and the exchange was from a personality conflict. R1 reported that in the future, if he experiences that again, he will leave the situation and notify a staff member.The facility's Recognizing Signs and Symptoms of Abuse/Neglect/Exploitation policy, dated 10/2021, documented the facility would not condone any form of resident abuse. The policy defined abuse as willful infliction of injury or intimidation that resulted in physical harm, pain, or mental anguish.

The facility reported a census of 66 residents. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate care and services provided to the residents of the facility. The facility identified five CNAs employed for more than a 12-month period. This placed the residents at risk for decreased quality of care. Findings included: - A review of employee files on 04/01/25 at 02:55 PM revealed a lack of performance evaluations signed by management for five of five CNA staff who had been employed over one year, including CNA S, CNA II, CNA LL, CNA MM, and CNA NN. During an interview on 04/01/25 at 03:05 PM, Administrative Staff A reported that producing the requested performance evaluations for CNA staff would be difficult and stated that he did know that annual performance evaluations for the CNA staff were required. The facility's policy Performance Evaluations dated 10/2024 documented the job performance of each employee shall be reviewed and evaluated at least annually. The facility's policy In-Service Training Program, Nurse Aide dated 10/2021 documented that in-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews.

The facility reported a census of 66 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. This placed the residents at risk for foodborne illness. Findings included: On 03/26/25 at 11:01 AM during an initial tour of the main kitchen and refrigerator storage areas with Dietary Staff J, the following areas of concern were observed: One tray of chocolate pie dessert, uncovered and undated, located in the fridge. Fifteen individually portioned cranberry sauces dated 3/17/25 located in the fridge. Ten barbeque-ranch dressings, individually portioned, and dated 03/07/25 located in the fridge. Staff's personal food items with no date were located in the fridge. One sealed plastic container of pumpkin pie filling dated 03/12/25 is located in the fridge. Eleven individually staff portioned individual Apple Jelly dated 3/14/25 located in the fridge. One box of bacon unsealed and undated located in the fridge. One bag of mozzarella cheese unsealed and dated 03/14/25 located in the fridge. One bag of mozzarella cheese opened and unsealed, dated 03/22/25, located in the fridge. One bag of breadsticks unsealed and dated 03/12 located in the freezer. One bag of broccoli unsealed and undated located in the freezer. One box of 50 shakes of recalled Ready Care Vanilla Mildly Nectar Thick. One bag of Oreos unsealed and undated located in dry storage. One bag of potato chips unsealed and undated located in dry storage. One bag of gelatin dessert Oreos unsealed and dated 11/28/24 located in dry storage. One unsealed container of cocoa powder dated 11/20/24. One unsealed container of baking powder dated 01/07/20 with a best-by date of 10/11/20 located in dry storage. One unsealed container of pancake mix dated 03/08/24 located in dry storage. One unsealed container of pancake mix dated 02/21/25 located in dry storage. One unsealed bag of ham dated 03/20/25, located in the fridge in a container that had meat juices at the bottom of it. One unsealed bag of ham dated 03/15/25, located in the fridge in a container that had meat juices at the bottom of it. One unsealed and undated bag of turkey located in the fridge in a container that had meat juices at the bottom of it. One unsealed bag of turkey dated 03/22/25 located in the fridge in a container that had meat juices at the bottom of it Two cutting boards were observed with cuts gashes to be half an inch thick to make them uncleanable surfaces. On 03/26/25 at 11:27 AM, an interview with Dietary Staff J revealed there would only be a problem with the meat sitting in the juice if the opened meat was touching the juice. On 10/21/24 at 02:57 PM, an interview with Dietary Staff J revealed he expected staff to label, seal food items and date opened food items. Dietary Staff J stated that the above concerns identified with kitchen and freezer storage, which included undated and unsealed items were unacceptable. The facility's policy Food Receiving and Storage dated 10/2021 revealed that dry foods that are removed from their original packaging, will be labeled and dated (use by date). These foods will be used on a rotating first in first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Other open containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. Beverages must be dated when open and discarded after twenty-four hours.

The facility reported a census of 66 residents. Five Certified Nurse Aide (CNA) staff, CNA S, CNA II, CNA LL, CNA MM, and CNA NN, who worked in the facility for over a year, were reviewed for the required annual in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. Five CNAs lacked the required training topics, and five CNAs lacked the required 12 hours per year of in-service training. Findings included: - On 04/01/25 at 02:55 PM, a review of training records for five CNAs employed by the facility for more than one year revealed all five CNAs had less than 12 hours of documented in-service training for the previous 12 months. The records that were provided by the facility and reviewed were from the year 2023. The records did indicate that on 03/12/25 CNA S and CNA II had Abuse, Neglect, and Exploitation training was the only record located for education. On 04/01/25 at 02:55 PM, a review of training records for five CNAs employed by the facility for more than one year revealed all five CNAs did not have the required topics for in-service training for the previous 12 months. During an interview on 04/01/25 at 03:05 PM, Administrative Staff A reported he was not sure if could locate the information that was requested and reported he did not realize the paperwork for the five CNAs was dated for the year 2023. The facility's policy In-Service Training Program, Nurse Aide dated 10/2021 documented all nurse aide personnel participate in regularly scheduled in-service training classes. Are no less than 12 hours per employment year and include training that addresses the care of residents with cognitive impairment; and include training in dementia management and abuse prevention.

The facility reported a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - During an observation on 03/26/25 at 11:38 AM, Resident (R) 17 and R6's room had no threshold noted in the entrance of the room, the windowsill was missing a tile and the standing floor fan was missing the front cover. During an observation on 03/26/25 at 11:39 AM the 300 hallway had large gouges missing from the wall and several areas of baseboard peeling back noted in the hallway. Observation revealed built-up dirt on the wall and floor cover. During an observation on 03/26/25 at 11:45 AM, R8 and R18's room had a ceiling tile missing. The built-in wardrobe closet and drawers had chipped paint and broken areas noted on the bottom drawers. Additionally, the windowsill tile was covered with black electrical tape. During an observation on 03/26/25 at 11:49 AM, R51 had no name on his door. He had a dresser in the room which had the three top dresser drawers missing and he had a blanket covering the window. During an observation on 03/26/25 at 11:51 AM, R28's bathroom had exposed drywall in two areas, and the metal floor vent laid on the floor near the open area. The floor vent was bent, and rust was noted on the vent. Additionally, the windowsill tile was cracked and missing in the corner of the window. During an observation on 03/26/25 at 01:41 PM, R47's room smelled of cigarettes. The bathroom floor had a few tiles missing, and the baseboard was peeled back. During an observation on 03/26/25 at 02:05 PM, R10's window blinds were broken in several areas and R10 had a blanket for a curtain. Additionally, the baseboard in the room and bathroom was peeled off and holes were noted in the walls where the baseboard would have been on the wall. There was visible built-up dirt on the flooring. During an observation on 04/01/25 at 09:10 AM, the activity room had several floor tiles missing in the entranceway. During an interview on 03/27/25 at 10:15 AM, Maintenance Staff FF reported the staff could place a work order in the computer system for any facility repairs to alert him of any concerns. During an interview on 03/27/25 at 10:46 AM, Certified Medication Aide (CMA) W reported any repairs would be placed in the computer system for maintenance called TELS. CMA W reported all staff had access to place a work order. CMA W reported that R51 would not be able to hang a blanket on his window for a covering by himself and reported that staff would hang the blankets on the windows in resident rooms that did not have a curtain. During an interview on 03/31/25 at 05:36 AM, Licensed Nurse (LN) O reported if there were any maintenance concerns, staff would place a work order in the computer system to alert the maintenance department. During an interview on 04/01/25 at 09:10 AM, Activity Staff AA reported that she had tripped over the flooring in the activity room a couple of times and reported that Administrative Staff A was aware of the missing tiles on the floor. Activity Staff AA reported that the residents do use the activity room for some activities. During an interview on 04/01/25 at 01:28 PM, Administrative Staff A reported he was aware of some environmental concerns, and the facility had begun working on them. He reported that corporate had purchased ceiling tiles for the entire facility and would start replacing the ceiling tiles on 04/03/25 but was unable to obtain the receipt upon request. Administrative Staff A reported he had been told that some residents had blankets as window coverings but he had not visualized any residents' rooms with that concern. Administrative Staff A reported that corporate had a new audit in TELS for window and curtain concerns that would be started soon. Administrative Staff A stated expected all residents to have a safe, clean, homelike environment. The facility did not provide a policy for a homelike environment.

The facility had a census of 66 residents. The sample included 18 residents, with six residents observed for accidents and hazards. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards when multiple residents had lighters in their rooms. Additionally, R45 had unsecured medications and R52 had an unsecured 1.75-liter bottle of vodka along with firecrackers and a two-inch pocketknife. Additionally, the facility failed to store chemicals in a secure safe manner. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - During an observation on 03/26/25 at 11:42 AM across from room [ROOM NUMBER] there was a workstation with a sink and an unlocked cupboard under the sink that had a spring-loaded mouse trap, a full gallon bottle of drain cleaner, a gallon bottle of disinfectant cleaner with approximately 200 ml of clear liquid in the bottle, and a one-quart spray bottle of germicidal cleaner. All the bottles had a label that read harmful keep out of reach of children. During an observation on 03/26/25 at 01:33 PM, Resident (R)48 reported and demonstrated that he had a lighter two cigarettes in his room, and a vape. R48 also had a clear box of vape supplies in his room. R48 reported he would vape in his room. R48 had an oxygen cannula laid across his bed and reported he wore oxygen at night. During an observation on 03/26/25 at 01:58 PM, R29 was not in her room, but observation revealed a lighter and cigarettes on her dresser. During an observation on 03/26/25 at 03:26 PM, R45 was sitting in his bed, observed on his bedside dresser were two Pantoprazole Sodium (Protonix) 40 milligram (mg) [a medication used to relieve symptoms such as heartburn, difficulty swallowing, and cough] and one Seroquel (Quetiapine Fumarate) 400 mg [type of medications used to treat psychosis and other mental emotional conditions]. During an observation on 03/27/25 at 09:47 AM, R52 was lying in bed. Observation revealed he had medicated chest rub and albuterol sulfate inhalation aerosol {a medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma) at bedside. R52 reported there was a 1.75-liter bottle of vodka along with two 375ml bottles of vodka which had been consumed by the resident in a bag in his closet along with firecrackers and a two-inch pocketknife. During an observation on 03/27/25 at 11:30 AM R10 reported he had a lighter and cigarettes in the room and showed the items when asked. R10 giggled when he produced the cigarettes and lighter. During an interview on 03/27/25 at 09:08 AM Certified Nurse Aide (CNA) T reported she was unaware that the cupboard below the sink at the workstation on 300 hallways had contained chemicals and reported the cupboard should have been locked. Regional Administrator HH then reported the chemicals should have been locked up in a different storage area and said they were not aware that there was a spring-loaded mouse trap in the same cupboard. He reported there were no children living in the facility regarding the chemicals labeled with the statement keep out of reach of children. During an observation on 03/27/25 at 11:34 PM, R36 sat on his bed. He had a lighter and cigarettes on his bedside dresser next to a nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) with tubing hooked up. During an interview on 03/27/25 at 09:58 AM, Certified Medication Aide (CMA) W reported residents were not allowed to have firecrackers or alcohol in their possession. On 03/27/25 at 10:14 AM Administrative Staff A went to R52's room and upon verification of the hazardous items, Administrative Staff A took possession of them. During an interview on 03/27/25 at 10:17 AM Administrative Staff A reported that R52 was his own guardian and had the ability to sign himself out of the facility. When R52 returns to the facility he can bring stuff in not allowed and staff are not allowed to [NAME] him when he enters the building. This is his right as a resident. During an interview on 03/31/25 at 05:36 AM, Licensed Nurse (LN) O reported that residents are not allowed to have cigarettes or lighters in their rooms. Staff were to take those items out of the resident's room if they found them and talk to the resident then provide them a form to sign regarding the education. LN O said that assured that residents were aware of the facility rules. LN O said CNA staff take the residents out for smoke breaks. LN O verified that residents had smoked in their bathrooms in the past. During an interview on 03/31/25 at 02:02 PM, Regional Administrator HH reported that R52 was slurring his words and that he may need an assessment for alcohol and recommended informing the doctor of the findings. During an interview on 04/01/25 at 01:19 PM, Administrative Staff A reported the smoking policy stated no resident was allowed to keep smoking materials in their possession and he expected the staff to confiscate any contraband. Additionally, he reported that the residents sign a smoking policy and follow a posted smoking schedule. The facility's policy Smoking Policy dated 10/2024, documented that residents in the facility who have independent smoking privileges and those without independent smoke privileges may not keep any smoking articles including cigarettes, tobacco, lighters, and matches in their possession. The facility's policy Storage Areas, Maintenance undated documented maintenance storage areas shall be maintained in a clean safe manner. Storage areas should be locked to prevent unauthorized access to hazardous chemicals.

The facility reported a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to ensure staff utilized acceptable infection control practices to mitigate the spread of infections when staff failed to cover clean clothes left in the folding area, and under areas with noted debris and insulation. The facility staff failed to utilize enhanced barrier precautions (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing a dressing change for Resident (R) 52 and additionally failed to use EBP for R39 when staff administered a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). The facility further failed to use proper hand hygiene and standard infection control practices for R14 and R18 when staff failed to complete proper hand hygiene and cleansing during peri-care. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 03/26/25 at 11:30 AM, no EBP signage or precautions were noted outside any of the residents' doors in any of the hallways during an initial tour of the facility. During an observation on 03/26/25 at 04:32 PM Licensed Nurse (LN) N performed a tube feeding for R39. LN N did not put on a gown. LN N only wore gloves during the observed tube feeding. During an observation of 03/31/25 at 10:02 AM Certified Nurse Aide (CNA) T applied her gloves in R14's room and grabbed the garbage can to set up on the other side of the bed to perform incontinence care. CNA T retrieved warm wash clothes from the bathroom and placed them in a lined wash basin with a plastic bag. CNA T stroked several times with the same part of the washcloth when she washed the peri-area as the washcloth hit the urine soiled brief under R14. CNA T completed the care, using the same soiled gloves pulled out a jar of unlabeled ointment, and applied that clear ointment to the resident's skin. During an observation on 03/31/25 at 10:52 AM, CNA C and CNA CC performed incontinence care for R18. CNA T dropped her glove onto the ground, picked the glove back up, and placed it on her left hand. CNA T removed R18's brief and started to perform incontinence care, CNA T used the disposable wipe in the same area for more than one stroke as she cleansed the peri-area. CNA CC returned to the room and applied new gloves then opened drawers in the bathroom. CNA T finished the front peri-area of the resident and threw soiled linen directly on the floor. CNA T removed her gloves, exited the room without washing her hands, and then returned with more supplies. The staff assisted R18 over to her right side; observation revealed R18 was incontinent of brown watery stool. CNA T cleansed R18's buttocks, legs, and hip areas, CNA T then removed the soiled linen and threw the soiled linen onto the ground. CNA T wiped the mattress off, dried it off, and then placed new linen and a brief under R18. Staff assisted R18 onto her back and CNA T used the same gloved hands to perform peri-care on R18's front area again. CNA CC had removed her gloves and then applied new gloves with no handwashing noted. During an observation on 04/01/25 at 12:59 PM, LN P did not perform hand hygiene before applying gloves to perform a dressing change for R52. During an observation on 04/01/25 at 02:00 PM Regional Maintenance Supervisor EE and Maintenance Staff FF reported they had not noticed that the residents' personal clothing that was hung up for sorting was directly underneath exposed insulation that covered duct work. Observed the area above the folding and sorting of clean linen no ceiling and the pipes were covered with dust. Regional Maintenance Supervisor EE reported that he would have the staff use an enclosed cover laundry cart to hang the residents' personal laundry until he moved the clean storage and folding table to a room that had a ceiling. During an interview on 03/31/25 at 05:49 AM CNA Y reported that the signs on some of the residents' doors with the three-drawer white cart system outside some of the residents' doors contained PPE was not in place on 03/26/25. CNA Y reported that she had worn just gloves in the past for the residents that required EBP that had an open wound, a catheter, or tube feeding. During an interview on 03/31/25 at 07:16 AM, LN N reported that the EBP had not been implemented on 03/26/25 when she administered the tube feeding to R39. LN N reported that she was unaware of the procedure for EBP on 03/26/25. During an interview on 03/31/25 at 10:12 AM, CNA T reported she completed incontinence care on R14 the way R14 wanted the care to be performed. CNA T reported that she should have not used the same part of the washcloth more than once and did not realize that she had to remove gloves, wash her hands, and apply new gloves before she applied the ointment. During an interview on 03/31/25 at 11:19 AM, CNA CC reported that she should have washed her hands when she removed her gloves before she applied new ones. She reported the soiled linen should have been placed on a barrier or in a bag and not placed on the floor. During an interview on 04/01/25 at 08:39 AM, LN N reported that once a staff member removed gloves, the staff member should complete hand washing either with hand sanitizer or soap and water at the sink. LN N said the CNA staff should just do one stroke front to back and flip to a clean area on the wipe or washcloth. LN N reported that the CNA should remove the soiled linen/brief from underneath the resident before performing incontinence care. During an interview on 04/01/25 at 02:30 PM Administrative Staff A reported that he was not aware of the exposed insulation in the clean laundry area and stated he would have that looked at. During an interview on 04/01/25 at 03:29 PM, Administrative Nurse B reported that gloves and gowns are to be worn for all residents on EBP. The facility's policy Enhanced Barrier Precautions dated 03/2024 documented the facility follows recommendations and guidance from the Centers for Disease Control (CDC). The following conditions require EBP for all care including feeding tube and urinary catheter. Post subtle, dignified, clear signage on the door or wall of the appropriate room. Make PPE available near or outside of the room. The facility's policy Policies and Practices - Infection Control dated 10/2024 documented this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel would be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. The facility's policy Hand Hygiene dated 10/2024 documented the facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene should be performed before and after removal of gloves. The facility's policy Laundry Protocols undated documented facility staff will handle, store, process, and transport linens in a method to prevent infection. Personal clothing will be stored in clean, dust-free areas. Each laundered item will be free of dirt and irritating chemical residue.

The facility reported a census of 66 residents which included a sample of three residents identified by the facility with Medicare Part A stay termination of benefits before exhaustion of Medicare Part A 100-day benefit period. Based on interviews and record review, the facility failed to provide two residents with the Centers for Medicare and Medicaid Services (CMS) form CMS- 10055 Skilled Nursing Facility Advanced Beneficiary Notice [ABN], which provides the recipient with the information related to the right to choose continued services and associated charges for continued skilled services after termination of Medicare Part A services for Resident (R) 13 and R121. This placed the residents at risk for uninformed decisions and unanticipated costs regarding skilled services. Findings included: - A review of R13's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, revealed the resident started Medicare Part A services on 12/08/24. He was discharged from Medicare A services on 01/03/25 and remained in the facility. The facility did not provide the resident with a CMS-10055 SNF ABN to allow the resident to make an informed decision regarding the continuation of skilled services and the associated costs. A review of Resident (R)121's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, revealed the resident started Medicare Part A services on 01/18/25. She was discharged from Medicare A services on 01/03/25 and remained in the facility. The facility did not provide the resident with a CMS-10055 SNF ABN to allow the resident to make an informed decision regarding the continuation of skilled services and the associated costs. On 04/01/25 at 01:49 PM, Administrative Nurse B confirmed the above findings. She reported the facility failed to provide the residents with appropriate SNF ABN notice at the termination of Medicare Part A benefits. The undated facility policy titled Medicare Denial Notices (Advanced Benefit Notification-ABN), documentation including SNF ABN (CMS-1005) is issued to the resident and/or representative to enable the resident/representative to enable to decide if the resident wishes to continue receiving the skilled services that may not be paid for by Medicare and the resident and the resident assumes financial responsibility for the items or services.

The facility had a census of 66 residents. The sample included 18 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to two residents, Resident (R) 28, and R69, and/or their representative at the time of the residents' transfers to the hospital. This placed the residents at risk for impaired ability to return to the facility in the same room. Findings included: - R28's Electronic Health Record (EHR) docuemnted R28 was admitted to the hospital on [DATE]. R28's EMR lacked evidence the facility provided a bed hold notice for the transfer/discharge to the hospital. R69's EHR documented that R69 was admitted to the hospital on [DATE]. R69's EMR lacked evidence the facility provided a bed hold notice for the transfer/discharge to the hospital. During an interview on 03/31/25 at 05:36 AM, Licensed Nurse (LN) O reported that she would not complete a bed hold form when a resident was transferred to the hospital. LN O reported she had never seen a bed hold form and was not sure who provided the bed hold to the resident. During an interview on 04/01/25 at 09:58 AM, Social Service Designee (SSD) L reported that the bed hold was not one of her responsibilities to complete. During an interview on 04/01/25 at 11:55 AM, Administrative Staff B reported the facility did not have bed holds for the requested residents and further stated the facility should have completed and provided the bed hold notice to the residents. The facility did not provide a bed hold policy.

The facility reported a census of 66 with 18 in the sample, which included Resident (R)2 reviewed for Preadmission Screening and Resident Review (PASARR). Based on observation, interviews, and record review the facility failed to obtain a PASARR Level 2 for R2. This placed R2 at risk for unidentified care needs and impaired quality of care. Findings include: - The Electronic Health Records (EHR) for R2 included diagnoses of suicidal ideations (the thoughts, fantasies, or contemplations about ending one's own life), auditory hallucinations (sensory experiences of hearing sounds that are not present in the external environment), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), generalized anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry about a wide range of events or activities), schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and bipolar disorder), and primary insomnia (a chronic sleep disorder characterized by difficulty falling or staying asleep, despite having adequate opportunity for sleep, that is not caused by other underlying medical or psychiatric). R2's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2 had no physical impairment. The 12/21/24 Psychotropic Drug Use Care Area Assessment (CAA) documented that R2 had taken high-risk antipsychotic medication, antianxiety medication, and antidepressant medication. R2's Care Plan dated 03/31/23 indicated R2 had the potential for activities of daily living (ADL) self-care performance deficit related to schizoaffective, depression, anxiety, suicidal ideation, hallucinations, and behavior problems of hoarding. R2 used psychotropic (alters mood or thought) medications related to behavior management, and had a mood problem related to schizoaffective disorder, major depression, anxiety, suicidal ideation, and hallucinations. R2's EHR documented a CARE assessment dated [DATE] with the need for further evaluation (Level 2). R2's EHR lacked documentation that the PASARR Level 2 had been completed. During an interview on 03/31/25 at 11:13 AM, Administrative Staff A reported that the Assistant Director of Nursing probably ensured PASARR compliance. During an interview on 03/31/25 at 11:25 AM, Business Office Manager DD reported that she was unable to locate the PASARR Level 2 for R2. During an interview on 03/31/25 at 11:36 AM, Social Service Designee L reported that she coordinated with the state for PASARR Level 2 to be done. She stated that she audited the residents' charts and reviewed R2's CARE Assessment. Social Service Designee L reported she discovered no Level 2 was completed and reported she sent the paperwork to the state requesting a Level 2 evaluation on 03/05/24. The facility policy title PASRR-KANSAS dated 10/2021 stated that the facility assures that a Pre-Admission Screening and Resident Review (PASARR) would be completed and submitted as required by the state. The facility policy also indicated that the business office manager was responsible for ensuring all required CARE Assessments would be completed and submitted to the Kansas Department on Aging and Disability Services (KDADS) and ensure they were loaded into the resident's EHR. The facilities policy did not address obtaining a PASARR Level 2 screening when recommended.

The facility reported a census of 66 residents. The sample included 18 residents reviewed for comprehensive care plans. Based on observation, interview, and record review the facility failed to review and revise comprehensive care plans for Residents (R)43 related to bathing. This placed the resident at risk for poor hygiene due to uncommunicated care needs. Findings Included: - R43's Electronic Health Records (EHR) Physician Orders (POS), dated 01/07/25 documented diagnoses which included disorientation (confusion), dementia (condition that causes a decline in memory, thinking, and other cognitive abilities making it harder to perform everyday tasks) with behavioral disturbances, generalized anxiety disorder (mental health disorder characterized by feelings of left artificial knee joint replacement, atrial fibrillation (irregular heartbeat), insomnia, (inability to sleep), and psychotic disorder (a mental disorder characterized by disconnection from reality) with hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that was not there). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The resident demonstrated verbal behavioral symptoms directed towards others one to three days of the look-back period. The MDS documented choosing the type of bath as very important to the resident. The MDS lacked completion to indicate the resident's level of self-care and/or required staff assistance for bathing. R43's Care Plan dated 01/09/25, directed staff R43 had impaired cognitive function/dementia and impaired decision-making skills. He had self-performance deficits. Staff should anticipate and meet the resident's needs, initiated: 01/02/24. The plan lacked guidance to staff related to R43's preferences for bathing and/or his schedule for bathing to include type, frequency, and/or time of day for bathing. The Tasks ADL [Activities of Daily Living] Bathing section of the EMR, dated 02/28/25, and Bath Sheets, indicated the resident with scheduled for showers three days a week on Monday, Wednesday, Friday, and as needed. A review of the bathing documentation for 03/01/25 through 04/01/25 revealed the staff provided five opportunities for bathing during the 30-day period rather than the resident's twelve preferred and scheduled showers. Additionally, the documentation revealed the resident did not refuse any bathing opportunities offered by staff. On 03/26/25 at 02:04 PM, R43 sat in his chair in his room. His walker was at the bedside and his clothing was disheveled. The resident reported he asked to get a bath for four days without getting a response from the staff. He stated his scheduled shower days were Monday, Wednesday, and Saturday. He did not care what time of the day but wanted at least three showers a week. R43 stated when he asked the staff for a shower, the staff just put him off. He confirmed he needed staff assistance to wash his back and lower legs and the staff said it was not safe for him to take a shower by himself. On 03/31/25 at 10:53 AM, Certified Nurse Aide (CNA) U reported that R43 needed staff assistance with showers, walking, and dressing. She stated the admission staff should interview residents when they are admitted and care plan resident preferences and choices related to bathing. CNA U stated residents should receive baths per their preferences and the schedule. CNA U said staff providing baths/showers should document in the EHR when they offer a resident a bath/or shower. If the resident refuses a bath/shower, the staff should document the resident's refusal and the nurse should be notified. CNA U said bath sheets are completed when a bath/shower is given. On 04/01/25 at 08:58 AM, Administrative Nurse D confirmed the above findings and stated residents should get baths/showers offered per their preferences for the type of bathing, frequency, and time of day. Administrative Nurse D said staff should document the offers made for bathing and any refusals in the EMR and bath sheets. The policy Comprehensive Assessments and the Care Delivery Process, dated 10/20/21, documented assessments will be conducted, to include resident interviews to assist in developing person-centered care plans.

The facility reported a census of 66 residents. The sample included 18 residents with seven dependent residents reviewed for activities of daily living (ADLs). Based on observation, interview, and record review the facility failed to provide necessary services in accordance with their preferences and in keeping with their plan of care for Resident (R)43, R51, and R28. This placed the affected residents at risk for decreased quality of care. Findings Included: - R43's Electronic Health Records (EHR) Physician Orders (POS), dated 01/07/25 documented diagnoses which included disorientation (confusion), dementia (condition that causes a decline in memory, thinking, and other cognitive abilities making it harder to perform everyday tasks) with behavioral disturbances, generalized anxiety disorder (mental health disorder characterized by feelings of left artificial knee joint replacement, atrial fibrillation (irregular heartbeat), insomnia, (inability to sleep), and psychotic disorder (a mental disorder characterized by disconnection from reality) with hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that was not there). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The resident demonstrated verbal behavioral symptoms directed towards others one to three days of the look-back period. The MDS documented choosing the type of bath as very important to the resident. The MDS lacked completion to indicate the resident's level of self-care and/or required staff assistance for bathing. R43's Care Plan dated 01/09/25, directed staff R43 had impaired cognitive function/dementia and impaired decision-making skills. He had self-performance deficits. Staff should anticipate and meet the resident's needs, initiated: 01/02/24. The plan lacked guidance to staff related to R43's preferences for bathing and/or his schedule for bathing to include type, frequency, and/or time of day for bathing. The Tasks ADL Bathing section of the EMR, dated 02/28/25, and Bath Sheets, indicated the resident with scheduled for showers three days a week on Monday, Wednesday, Friday, and as needed. A review of the bathing documentation for 03/01/25 through 04/01/25 revealed the staff provided five opportunities for bathing during the 30-day period rather than the resident's twelve preferred and scheduled showers. Additionally, the documentation revealed the resident did not refuse any bathing opportunities offered by staff. On 03/26/25 at 02:04 PM, R43 sat in his chair in his room. His walker was at the bedside and his clothing was disheveled. The resident reported he asked to get a bath for four days without getting a response from the staff. He stated his scheduled shower days were Monday, Wednesday, and Saturday. He did not care what time of the day but wanted at least three showers a week. R43 stated when he asked the staff for a shower, the staff just put him off. He confirmed he needed staff assistance to wash his back and lower legs and the staff said it was not safe for him to take a shower by himself. On 03/31/25 at 10:53 AM, Certified Nurse Aide (CNA) U reported that R43 needed staff assistance with showers, walking, and dressing. She stated the admission staff should interview residents when they are admitted and care plan resident preferences and choices related to bathing. CNA U stated residents should receive baths per their preferences and the schedule. CNA U said staff providing baths/showers should document in the EHR when they offer a resident a bath/or shower. If the resident refuses a bath/shower, the staff should document the resident's refusal and the nurse should be notified. CNA U said bath sheets are completed when a bath/shower is given. On 04/01/25 at 08:58 AM, Administrative Nurse D confirmed the above findings and stated residents should get baths/showers offered per their preferences for the type of bathing, frequency, and time of day. Administrative Nurse D said staff should document the offers made for bathing and any refusals in the EMR and bath sheets. The Policy Quality of Life-Bathing, policy dated 10/20/21, documentation includes each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, the feeling of self-worth and self-esteem. The facility culture is one that supports and encourages the humanization and individualization of residents and honors residents' choices and preferences with respect to bathing type, frequency, and time of day. 50659 - A review of R51's diagnoses from the Electronic Health Record (EHR) documented: dementia (a progressive mental disorder characterized by failing memory, and confusion), and aphasia (a condition with disordered or absent language function) The 11/10/24 Annual Minimum Data Set (MDS) for R51 documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. R51 had a total mood severity score of 00, which indicated no depression. R51 required to set up and supervision for eating. The 11/29/24 Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/29/24 documented R51 had an actual cognition issue due to diagnoses and due to the disease process. R51 would have a slow decline, and the staff avoid complications and minimize risks. R51 did not trigger for Functional Abilities (Self-Care and Mobility) or 'Nutritional Status on annual MDS. The 02/10/25 Quarterly MDS for R51 documented a BIMS of one, which indicated severely impaired cognition. R51 had a total mood severity score of nine which indicated mild depression. R51 required set-up and supervision for eating. R51's Care Plan documented R51 had a potential nutritional problem related to dementia and had the following intervention: 05/30/23 - Staff were instructed to provide one staff assistance with cutting up food, opening cartons, and cueing. The 01/31/2025 at 08:04 AM Dietary/Nutrition Progress Note documented R51 required setup assistance for meals. During an observation on 03/31/25 at 09:21 AM, R51 sat in his recliner. He had a bowl of oatmeal he was attempting to eat and a glass of juice on the counter next to him that remained with clear plastic wrap on the juice cup. During an observation on 03/31/25 at 10:22 AM, R51 sat in his recliner and leaned over to his left side with the spoon on the floor and his bowl next to him on the chair with his eyes closed. During an observation on 03/31/25 at 11:23 AM, R51 remained in the same position in his room as noted at 10:22 AM. During an observation on 04/01/25 at 08:49 AM, R51 sat in his recliner> He wore the same clothes as yesterday. R51's breakfast was on the counter next to his recliner, the juice was covered with plastic wrap; the oatmeal, sausage gravy, and biscuits were uncovered, and no silverware had been unwrapped. There was no tray table noted in the room. During an interview on 04/01/25 at 09:02 AM, Certified Nurse Aide (CNA) X reported she placed the breakfast tray in R51's room that morning on the counter. CNA X entered R51's room and looked for an over-the-bed tray but did not see one so she then assisted R51 with his breakfast. She reported that R51 should go to the dining room, but he would not always go as he would stay up at night. She also reported to find what type of care a resident required she would look on the Kardex in the computer She reported that R51 required set-up supervision and cueing to eat. During an interview on 04/01/25 at 12:50 PM, Administrative Nurse D reported she expected staff to follow the care plan and provide the required care and assistance that any resident needed. The facility did not provide a policy on ADL assistance. The facility failed to provide the assistance for eating that R51 required. This deficient practice had the potential to negatively affect the resident's physical well-being. A review of R28's diagnoses from the Electronic Health Record (EHR) documented: dementia (a progressive mental disorder characterized by failing memory, and confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) The 03/10/24 Admission Minimum Data Set (MDS) for R28, documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R28 had a total mood severity score of 12, which indicated moderate depression. R28 required maximal assistance with personal hygiene. The 03/18/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) recorded staff assisted R28 with setup, supervision, and cueing for all ADLs due to behaviors. The 03/18/24 Cognitive Loss/Dementia (CAA) documented staff would anticipate needs as needed to re-orientate the resident; staff would allow the resident time to process thoughts and feelings and allow the resident time to verbalize those thoughts. The 12/11/25 Quarterly MDS for R28, documented a BIMS score of seven, which indicated severely impaired cognition. R28's Care Plan documented the following intervention: 11/25/23 - Staff were instructed to provide assistance with R28's hygiene. The 03/08/25 through 03/27/25 Personal Hygiene tasks documented in the EHR for R28s ability to maintain personal hygiene, including combing hair and shaving, were all documented as dependent on staff to complete this task. During an observation on 03/27/25 at 07:54 AM R28 was in the dining room eating breakfast. He had approximated one-quarter-inch facial whiskers. R28 reported that he would like to have a shave but staff would not let him have a razor. During an interview on 03/31/25 at 11:53 AM, Certified Nurse Aide (CNA) BB reported R28 required staff to assist with his personal hygiene which included shaving. During an interview on 04/01/25 at 08:39 AM, Licensed Nurse (LN) N reported that the CNAs should shave the residents that required assistance on the resident's scheduled shower days or as needed. Additionally, the CNAs should follow the care plan. During an interview on 04/01/25 at 09:40 AM, CNA X reported that she had shaved R28 after his shower today and reported that she would only shave the cheeks of the residents as she did not feel comfortable shaving the remainder of facial hair as there were no clippers only straight razors. During an interview on 0401/25 at 04:00 PM, Administrative Nurse C reported she expected the staff to shave residents' facial hair as requested or as needed. The facility did not provide a policy on ADL. The facility failed to provide the assistance for removal of facial hair for R28. This deficient practice had the potential to negatively affect the resident's physical well-being.

The facility reported a census of 66 residents which included 18 residents sampled, which included two residents reviewed for functional equipment. Based on interview, observation, and record review, the facility failed to ensure Resident (R)29 and R2's bed was in safe and operable condition. This deficient practice placed the residents at risk for discomfort and decreased safety. Findings include: - Observation on 03/26/25 at 02:49 PM revealed that R2's bed frame appeared to be broken, and the bed would not sit level. The bed was a crank style. Observation on 03/27/25 at 10:40 AM revealed that the remote R29's bed was under it and stuck in the frame. The sheathing was stripped from the wires the wires were unraveled. The bed rested almost completely on the ground. During an interview on 03/27/25 at 10:40 AM, R29 reported that the bed would go up and down but the head of the bed would not work to be raised or lowered. During an interview on 04/02/25 at 4:00 PM, Maintenance/Housekeeping EE said the remote to R29's bed should have been unplugged for safety and replaced. During an interview on 04/02/25 at 4:20 PM, Maintenance/Housekeeping staff EE reported R2's bed was the old crank style He said he wasn't aware of any work areas that had been placed, but verified the bed was unacceptable, and a new one would be ordered that day. During an interview on 04/02/25 at 07:00 PM, Maintenance/Housekeeping EE reported that a new been had been ordered for R2 and it was scheduled to arrive on 04/03/25 in the morning. The facility did not provide a policy related to bed safety or maintenance.

The facility reported a census of 66 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly, and in a sanitary condition, ensuring the lids were down to cover the disposed waste. Findings included: - An initial tour of the outside trash dumpsters on 03/26/25 at 12:36 PM with Dietary Staff J revealed three bags of trash were lying next to a portable dumpster with no lid. Two doors were open on one out of the two stationary dumpsters. On 03/26/25 at 12:36 PM, Dietary Staff J revealed he was not aware of the requirement to have trash covered and that it included a portable dumpster. The facility's policy Food-Related Garbage and Refuse Disposal dated 01/2024 revealed that outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

The facility reported a census of 69 residents, with five residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired Resident (R) 1, identified at high risk for elopement. On 05/06/24 at 07:09 PM the charge nurse let R1 out the front doors of the building not realizing he was not allowed out the front doors to smoke. When R 1 went out the doors his WanderGuard (a bracelet that sets off an alarm when a resident wearing one attempts to exit the building without an escort) caused the alarm to activate, and the charge nurse located a CNA to turn off the alarm. The CNA did not check which resident cause the alarm to activate before or after turning off the alarm. The facility was not aware of R1 missing from the building until three hours later when the certified medication aide (CMA) could not find R1 to administer his 10:00 PM medications. After staff conducted a search and could not locate R1, they notified administrative staff at 10:45 PM. The facility did not notify local law enforcement until 12:03 AM. R1 returned to the facility with local law enforcement almost five and half hours after he walked out. This deficient practice placed R1 in immediate jeopardy. Findings included: - Residents (R) 1's Physician Orders dated 05/05/24 revealed a diagnosis of dementia (a progressive disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of seven, indicating severely impaired cognition. No behaviors of wandering or elopement were noted on the assessment. The Care Plan dated 05/07/24 identified R1 as an elopement risk with a history of wandering and attempts to leave facility unattended. The resident had a WanderGuard in place with the functioning to be checked each shift and documented in R1's treatment record. The Elopement assessment dated [DATE] revealed a score of 18, which indicated a high risk. The Physicians Orders dated 11/06/23 instructed staff to ensure placement and function of the resident's WanderGuard each shift, document the location, and assess if working. The Nurses Notes dated 05/07/24 at 02:00 AM revealed R1 was last seen by the charge nurse who let R1 out of the building. The CMA on duty could not locate R1 and they conducted a search for the resident. The charge nurse initiated the facility missing person policy, notified administrative staff, and the resident's family. At 12:03 AM staff contacted local law enforcement three hours after R1 was first noted as missing. Law Enforcement located R1 and returned him to the facility at 12:35 AM. Staff completed a skin assessment, and no injuries were noted. Staff placed R1 on one-to-one supervision with every 15-minute visual checks. R1 located about 8 city block away/ equaling three and one fourth miles. Review of the Weather Underground online information revealed the weather report for the area indicated on 05/06/24 at 07:09 PM the temperature was 77 degrees Fahrenheit (F), and when R1 returned at 12:36 AM it was 64 degrees F. Review of the information on CommunityCrimeMaps.com revealed the area in which R1 traversed had numerous violent, narcotic, missing person, vandalism, burglary, and assault crimes. Observation on 05/07/24 revealed the front entrance had a locked door, which required a badge or code to open the door. Observation of the area in which the resident traversed revealed R1 traveled over high traffic streets with speed of 40 miles per hour, past a six-lane interstate with speeds of 60 miles per hours. An interview on 05/08/24 at 10:34 AM with Certified Medication Aide (CMA) R revealed on the day the resident eloped from the facility they could not locate R1 to give him is 10:00 PM medications. CMA R searched for the resident and after staff could not locate the resident, CMA R notified the charge nurse and started the elopement procedure. An interview on 05/08/24 at 10:45 AM with Administrative Nurse B revealed the expectation of staff were for them to know the difference between door alarms and the WanderGuard alarm and not to shut the alarm off without checking why it sounded. Administrative Nurse B stated staff would have known R1 was missing sooner if they had done their rounds. The facility policy Wandering and Elopement dated 2021 revealed residents who are at risk of unsafe wandering or high risk for elopement will have interventions put into place to address the risk. Residents who are identified as being at high risk will have a wander alert bracelet applied to wrist or ankle. On 05/08/24 at 03:11 PM Administrative Staff A and Administrative Nurse B were provided the Immediate Jeopardy template and notified the facility failure to provide adequate supervision to prevent cognitive impaired R1, with history of wandering, from leaving the facility after a staff member let him out of the front doors to smoke and did not react to the WanderGuard alarm and R1 was outside the facility for 5.5 hours. to leave the facility by exiting out the front doors to the parking lot unsupervised. The facility identified and implemented the following corrective action on 05/07/24, which included: 1. All staff were re-educated starting on 05/07/24 at 12:40 AM and completed on 05/08/24 at 03:00 PM regarding the elopement policy, missing person policy, and resident sign out policy. 2. Elopement drills were completed on each shift. 3. All residents at risk for elopement received a WanderGuard bracelet and they were checked for function and placement. 4. All residents had updated wandering assessments completed. 5. The Risk for Elopement Book was reviewed and updated. 6. All residents identified as being at risk for elopement had care plans updated as needed. 7. Agency staff would be educated on the audible wander alarm sounds prior to working a shift. The surveyor verified the facility implemented the above corrective actions on 05/08/224 at 4:00 PM. Due to the facility corrective actions completed prior to the onsite survey, deemed the deficient practice past noncompliance and existed at a J scope and severity.

The facility reported a census of # residents with 3 residents sampled for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent the elopement of newly admitted (05/05/23), cognitively impaired Resident (1), a resident with history of elopement and assessed by the facility as high risk for elopement. On 05/06/23, R1 pushed on the north facility exit door until it opened and R1 walked out the door at around 06:30 AM. CMA R heard the alarm, looked out the window, shut off the alarm, but did not locate the resident or go out the door at that time. The resident walked about three miles to a family member's house, along a busy 4-lane road with speed limits of 40 miles per hour. This deficient practice placed the resident in immediate jeopardy. Findings included: - The signed Hospital Discharge Orders, dated 05/05/23, documented R1 admitted on [DATE] with a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive neurodegenerative disorder primarily affecting older adults. Its primary feature is cognitive decline, which can lead to hallucinations, as well as varied attention and alertness). The incomplete Annual Minimum Data Set (MDS) for R1, dated 05/12/23, documented in progress. The Admission Wander Risk Assessment, dated 05/05/23, documented R 1 exhibited signs he wanted to leave and had a score of 16, indicating he was at high risk to wander. The Brief Interview for Mental Status, dated 05/06/23, documented the resident with severely impaired cognition. The Admission Note dated 05/05/23, documented the resident arrived via transportation services at 01:20 PM from an acute hospital. The resident was alert and oriented to self with signs of confusion and wanted to leave the facility. The resident's Baseline Care Plan, dated 05/05/23, documented the resident was independent with ambulation and at risk for elopement. However, the care plan lacked instructions or interventions in place for the resident's elopement potential or wandering. Nurse's Note, dated 05/06/23 at 08:05 AM, documented as 'LATE ENTRY,' included the resident was last observed by staff prior to the alarm sounding, wearing blue jeans and a t-shirt with a flannel jacket, hood, and shoes. The weather was approximately 64 degrees Fahrenheit (F) and noted the resident admitted to the facility the day prior, on 05/05/23. Nurse's Note, dated 05/06/23 at 10:30 AM, documented as 'LATE ENTRY,' revealed the resident was moved to another room for safety, as the previous room was located next to the exit the resident eloped from. The new room was located closer to the nursing desk. Upon return to the facility staff provided one-on-one supervision to R1 and would continue for 72 hours or until reevaluation, per nursing management, related to R1's acclimation to the facility. The resident was back in the facility and stated he wanted to go for a walk and check on his dog. The nurse completed a head-to-toe assessment of R1 with no abnormalities noted. On 05/09/23 at 10:00 AM, observation of the road the resident walked along when he eloped from the facility without staff knowledge on 05/06/23 at 06:30 AM, revealed a heavily traveled four lane roadway with speed limit of 40 miles per hour. The resident walked along this road for approximately 3 miles. On 05/09/23 at 11:30 AM, Administrative Staff A related to the resident's elopement, explained on 05/06/23 at 06:28 AM, R1 exited the facility building on the north side, by pressing on the door until the 15 second egress released. Just prior to the elopement, Certified Medication Aide (CMA) R noted the resident by the north exit door and reminded him it was smoke break at 07:00 AM. At 06:29 AM, CMA R responded to the alarm, looked out the window and did not see the resident. CMA R's badge would not silence the alarm. CMA R checked the exit door on the north hall and found the door was not completely closed. CMA R advised the nurse R1 might be outside. CMA R checked R1's room and inside the facility and could not locate the resident. CMA R did not know how long the alarm sounded before she turned it off, approximately 30 minutes. At 06:33 AM, Certified Nurse Aide (CNA) M, also heard the activities door alarm sounding and turned the alarm off, opened the exit door, but only saw Licensed Nurse (LN) G on the nearby corner. Notification went out to all administrative staff. CNA M did not know there was an elopement until 07:30 AM. At 06:40 AM, LN G notified Law Enforcement (LE), who were at the facility when Administrative Staff A arrived at 07:15 AM. At 06:42 AM, the staff notified the resident's guardian. The facility and LE continued searching for R1. At 09:05 AM, R1's family member notified the facility R1 was at the family member's house. At 10:05 AM, R1 returned to the facility with LE. On 05/09/23 at 01:33 PM, Administrative Nurse D stated on 05/06/23, LN G notified LE that facility staff could not locate R1 in or outside of the facility. At that time, the staff activated the facility wide elopement emergency procedure, all staff members were mandatory to respond to the facility to assist. At approximately 09:00 AM, the resident's family member notified the facility by phone that the resident was at his house location. The staff notified Law Enforcement (LE), who picked up the resident and brought the resident back to the facility. Interview on 05/09/23 at 02:01 PM, revealed Administrative Staff A reported the staff assessed the resident on admission as being at risk for elopement. Administrative Staff A stated the resident did wander around the facility. On 05/09/23 at 11:03 AM, Maintenance staff U reported that following the resident's elopement on 05/06/23, he verified at approximately 07:00 AM that all exit doors were checked and functioning appropriately. The alarms were checked once a day then and now the door exit alarms were checked each 12-hours shift. The facility policy for, Wandering and Elopement, revised October 2011, included that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The facility failed to provide adequate supervision to prevent the elopement of the newly admitted , cognitively impaired R1, a resident with history of elopement and assessed by the facility as high risk for elopement. The staff did not know R1's whereabouts on 05/06/23 from 06:30 AM until 09:10 AM, when R1's family member called the facility notifying R1 was at his house, approximately 3 miles from the facility. This placed the resident in immediate jeopardy. The facility identified and implemented corrective actions to the deficient practice on 05/07/23 at 06:00 PM, which included the following: 1. On 05/06/23 at 07:00 AM all the alarms of the exit doors of the facility were checked and functioning. All exit doors will continue to be checked twice a day on each shift (12-hour shift) indefinitely. 2. On 05/06/23 at 09:15 AM, the facility began educating staff on the Wandering and Elopement policy. The PRN staff will not be allowed to work their shift until completed. All staff will be educated on the updated policy prior to working. 59 out of 63 staff were in-serviced completed on 05/07/23 at 06:00 PM. Four staff members were not in-serviced, three are PRN and one was out of town. The staff were informed they would not be allowed to work until in-service was complete. 3. On 05/06/23, at 10:10 AM, verified R1 had a had a WanderGuard placed on his left wrist and a Wander Guard order in the Treatment Administration Record (TAR) to check placement and function each shift. 4. On 05/06/23 all residents reassessed for risk to wander and the facility reviewed and updated the Risk to Wander Binder. 5. On 05/06/23 at 12:10 PM and 06:19 PM, Elopement Drills completed. On 05/06/23 at 6:39 PM; Elopement Drill completed. The surveyor verified the implementation of the above corrective actions completed by the facility on 05/07/23 at 06:00 PM, prior to the surveyor's arrival onsite, on 05/09/23 at 08:00 AM. Due to this, the deficient practice was deemed as past non-compliance at a J scope and severity.

The facility reported a census of 68 residents, with three sampled for wandering behaviors. Based on observation, interview, and record review the facility failed to provide a safe/secure environment for cognitively impaired Resident (R) 1, identified by the facility as at risk for wandering and exhibited exit seeking behaviors. R1 eloped on 12/24/21 through the front door of the facility. R1 was out of the facility between the hours of 12:45 PM and 01:14 PM and was within walking distance (1/4 mile) of a busy intersection (four-lane with 40 mph speeds). These failures placed R1 in immediate jeopardy. Findings included: - R1's pertinent diagnoses from the Physician's Order in the Electronic Medical Record (EMR) dated 12/15/21 included essential (primary) hypertension (elevated blood pressure), [CONDITION(S)] (a condition without enough healthy red blood cells to carry adequate oxygen to body tissues), [CONDITION(S)] with alcohol dependence, personal history of COVID-19 (infectious disease caused by coronavirus), pneumonia (inflammation of the lungs) caused by COVID-19, dysphagia (swallowing difficulty), [CONDITION(S)], Chronic Obstructive Pulmonary Disease ([CONDITION(S)]- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), [CONDITION(S)] (rapid, irregular heart beat), and nontraumatic subdural (between the dura mater and the brain) hemorrhage (loss of a large amount of blood in a short period of time). The 12/21/21 Admission Minimum Data Set (MDS) was in progress and documented a Brief Interview For Mental Status (BIMS) of 12, indicating moderately impaired cognition. The MDS indicated wandering one to three days during the seven-day review period and that wandering placed R1 at significant risk of getting to a potentially dangerous place. R1's gait was not steady, and he was only able to stabilize with staff assistance. R1 required set-up with supervision for walking in his room/locomotion off unit, and for locomotion on the unit. The MDS noted one fall with no injury and one fall with injury other than major since admission. Review of the 12/15/21, 12/20/21, and 12/21/21 Elopement Assessments identified R1 at low risk for wandering/elopement. The 12/28/21 assessment documented R1 at high risk to wander. The 12/15/21 Admission Care Plan documented R1 was not at risk for elopement. The 12/19/21 Care Plan with revision on 12/24/21 documented R1 was at risk for elopement. The 1:1 (one person deals directly with only one other person) initiated on 12/24/21 at 02:16 PM was resolved on 12/28/21. Staff moved R1 to a room closer to nurse's station on 12/26/21 for increased supervision. R1 wore a Wanderguard since 12/20/21 following attempt to exit building, at that time. R1 was to wear the Wanderguard and staff should check it per facility protocol. The 12/15/21 at 05:55 PM Nursing Note documented R1 continued to refuse care, to stay in his room, or to keep a mask on his face. The nurse explained the risk to other residents to R1 and R1 continued to ignore the nurse. The 12/16/21 at 11:27 PM Nursing Note documented R1 refused to stay in his room and yelled at a Certified Nurse Aid (CNA) when requested to go back to his room due to being on quarantine related to admission. R1 slammed the door in the CNA's face. The 12/20/21 at 02:17 PM Nursing Note documented an unidentified CNA reported that an alarm sounded, and the same CNA noted R1 half inside and half in the doorway. Staff assisted R1 back inside the building and asked what he was doing. R1 stated he wanted to go smoke. Staff placed a Wanderguard on R1's right wrist and staff informed his family. The 12/24/21 at 04:44 PM Nursing Note documented a late entry from 01:05 PM when the nurse returned to the dining room, R1's wheelchair was at the dining room table without R1. The nurse went to R1's room and down the hallway checking rooms attempting to locate R1. When she returned to the dining room, Licensed Nurse (LN) E and Certified Medication Aid (CMA) D were with R1. R1 wore jeans, long sleeved shirt, jacket, shoes, and a hat. No injuries noted by assessment. According to the national weather service the temperature was 73 degrees Fahrenheit (F), skin assessment completed with another nurse, physician notified, and message left for R1's family. The 12/26/21 10:34 AM Nursing Note documented staff observed R1 three times this shift opening doors to try to get out of the building. R1's Wanderguard triggered the alarm each time. The December 2021 daily Maintenance Morning Rounds documented daily checks of all exit doors. The Facility Investigation for the 12/24/21 elopement revealed R1 eloped after 12:45 PM and staff could not locate the resident until approximately 01:14 PM. Per Wunderground.com the temperature outside was around 73 degrees (at 12:53 PM). The high that day was 74 degrees F, with no precipitation, and wind speeds of 16 mph S/SW with gust up to 26 mph (at 12:53PM). Witness Statements documented Medical Records Staff J reported around 01:15 PM on 12/24/21 she helped locate R1 when another resident told her a man was lying on the grass by the alley. She then went out to check and no one was there at that time. A Witness Statement by CMA D documented she was told to find R1 and she found him outside on the ground. LN E's Witness Statement documented he was asked to look for R1 and received a call that he was outside and rushed out to safely return him to facility. Administrative Staff B's Witness Statement documented at 01:05 PM on 12/24/21 she went back to the dining room to check another resident and R1. R1's wheelchair was by the table she left him at eating lunch, but R1 was not in the wheelchair. She immediately started looking for him. A Witness Statement by CNA C documented another resident was returning she let him in and went to inform the nurse she was taking her break, went outside, and called the nurse to inform her R1 was sitting in the alley. Observation on 12/28/21 at 11:00 AM R1 sat in a wheelchair alone at a table in the dining room area. R1 wore tennis shoes and had a Wanderguard on his right wrist. At 04:45 PM, R1 pushed himself with his feet in the wheelchair with tennis shoes on. R1 propelled the wheelchair easily down the hall. Observation on 12/28/21 at 11:30 AM the facility front door had a sign that advised visitors and staff not to allow residents to exit with them. The door opened to a paved parking lot with a paved alley behind it and then grass for a business and a residential home. The alley led either way to two lane roads which led to the four-lane road with a speed of 40 mph. R1 was on the other side of the alley on the grass. On 12/28/21 at 02:50 PM, R1 remembered when he went out of the facility, he stated he just walked out, the door was open. He stated that there may have been another resident at the door but did not recall. He stated he was going to the store to get a lighter. On 12/28/21 at 04:49 PM CNA C revealed on 12/24/21 as she was coming down the hall, she heard an alarm sounding, as the front door came into view a resident that could sign himself in and out was signing himself back into the facility. She then disabled the sounding alarm, with her badge. She did not check outside as the Wanderguard alarm was not sounding. She then went on to inform her nurse and gather her belongings to go out on a break. Once out on her break she saw R1 sitting outside on the ground, she called the nurse as she was unsure if R1 could be outside on his own or not. The nurse and a CMA then came out and took R1 back inside. On 12/29/21 at 11:56 AM CMA D revealed on 12/24/21 she was asked to help look for R1, she walked toward the front door and met LN E and together they went outside and saw R1 on the ground. Together they brought R1 back into the facility without incident. CMA D stated R1 did not appear hurt in anyway. On 12/28/21 at 05:00 PM LN E revealed on 12/24/21 he assisted in finding R1 by Administrative Nurse B at about the same time as he received a phone call from CNA C that a resident was sitting outside. He went outside and brought R1 back into the building. LN E stated in his nursing judgement R1 had no injuries and was not anxious, but did appear to be somewhat confused. On 12/28/21 at 03:37 PM Administrative Staff B revealed on 12/24/21 she was the floor nurse and at 12:45 PM she took R1 and another resident to the dining room to eat and then went back to the hall to assist another resident. When she returned about 01:05 PM R1's wheelchair was at the table, but R1 was not. She then went to R1's room to check if he had gone to the bathroom, checked down the hall in other rooms and around the building enlisting assistance to locate R1. When she returned to the dining room R1 was there with LN E and CMA D. R1 was then assessed by Administrative Staff B and LN H noting old bruising to his head and both arms. Administrative Staff B then notified physician, called R1's family, called Administrator Staff I, and at 02:16 PM began 1:1 with R1. On 12/28/21 at 03:37 PM Administrative Staff A revealed before the elopement the Wanderguard and door alarms were checked for functioning and that all systems were working. As a precaution staff changed the codes and the alarm company came out to check the systems on 12/28/21. On 12/29/21 at 09:08 AM Maintenance Staff F revealed the alarm systems (Wanderguard alarm) and door latching devices (egress door alarm) as well as clearance were checked daily. On 12/29/21 at 09:08 AM Maintenance Staff G revealed he usually completed the door checks; however, he was on vacation the week in question and had his staff assigned to complete them. The facility's undated Missing Elder policy documented the facility wished to ensure that all departments responded immediately in the event an elder is discovered missing. In the case of a door alarm sounding, staff will immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who/why the alarm sounded. The administrator will be responsible for investigating and reporting the elopement in accordance with regulations. The facility failed to ensure a safe/secure environment for one cognitively impaired, independently mobile resident, identified by the facility as having wandering behaviors, when R1 left the facility. The resident exited out the front door of the facility without staff knowledge, in an area within walking distance (within ¼ mile) to a busy intersection (4-lane with speeds of 40 mph) and remained outside for approximately 28 minutes. This failure placed R1 in immediate jeopardy. On 12/29/21 at 11:00 AM, Adminsitrative Staff A and Administrative Nurse B were provided with the IJ template and notified that the facility failed to provide a safe/secure environment to cognitively impaired R1, identified by the facility as at risk for wandering and who exhibited exit seeking behaviors, to prevent an elopement on 12/24/21 through the front door, in which R1 was out of the facility between the hours of 12:45 PM and 01:13 PM, which constituted immediate jeopardy at F689. The deficient practice was deemed past non-compliance when the facility identified and implemented the following corrective actions: 1. Assessed the resident for injuries upon returning to the building, with no new injuries found 2. Notified the physician. 3. Placed R1 on one-on-one pending investigation on 12/24/21 at 02:00 PM. 4. Checked R1's Wanderguard for functionality, found it working appropriately, but replaced out of caution on 12/24/21 following the incident 5. Checked all doors and wander guards were checked for functionality on 12/24/21 and again on 12/27/21 by facility staff and all found to be functioning appropriately 6. Door alarm company ([NAME] alert) came to do a full functionality check on the door and wander guard system on 12/28/21. Doors again found to be functioning appropriately. 7. Starting on 12/27/21 all resident wander guards were checked on every door in the facility for functionality and all found to be functional 8. Elopement education for all staff initiated on 12/27/21 and completed in the morning of 12/29/21 9. Elopement drill conducted on 2nd shift on 12/27/21, 1st shift on 12/28/21 and 3rd shift on 12/28/21. Staff responded appropriately. 10. Door code changed on 12/27/21 by facility staff and again on 12/28/21 by [NAME] alert 11. Additional intervention to move the resident to room near nurse station, which would require the resident to walk past the nurse station to get to the front door The deficient practice remained at a J scope and severity at past non-compliance.

The facility census totaled 65 residents. Based on observation, interview, and record review the facility failed to protect female resident in the facility when staff failed to adequately monitor Resident (R)30 after an allegation of resident to resident sexual abuse (reported to the facility involving R30 and R7) on the evening of 11/18/21. Less than eight hours later, and after the facility implemented 15-minute checks, leading to a subsequent allegation of resident to resident sexual abuse alleging R30 went into R69's room for 30 to 45 minutes (as reported by R30) in the early morning of 11/19/21. R69 reported feeling unsafe and stated a man came into her room and she fought him off and said no. This deficient practice placed R69, and the other female residents in the facility in immediate jeopardy. Findings included: - The September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included R30 required supervision with walking in his room and in corridors. Review of the Annual MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition, R30 required supervision with walking in his room and in corridors. The Care Plan dated 05/04/21 revealed R30 ambulated with supervision and with a cane. R30 had a previous consensual relationship with a female resident and had visited each other in their rooms. The other resident expressed she no longer wanted R30 to visit her room. Both residents signed a contract with each other stating they would no longer visit each other in their rooms and would notify administration if at any time this changed. R30 voiced no concerns and stated he would no longer attempt to pursue their relationship. (The care plan lacked identification of the female resident mentioned in the care plan.) An interview on 11/18/21 at 11:30 AM during the initial resident screening portion of the resurvey, R31 reported there was something bad going on in the facility and residents were being harmed. He reported one male resident was taking advantage of the ladies in the facility and this has been going on for a long time. R31 stated R30 preyed on the women who go out to smoke. R31 stated he would see R30 go in the rooms of female residents and would not come out for a couple of hours. An interview on 11/18/21 at 02:10 PM, R31 stated R30 spent hours in R7's (who according to the October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R31 stated R7 told him that R30 had touched her on her breasts and pelvic area and she slapped him. Observation on 11/18/21 at 03:37 PM revealed R30 walked with a cane down the 400 hall and touched R26 on her left arm as he passed by her, when she was in her wheelchair. On 11/18/21 at 05:10 PM, Administrative Staff A and Administrative Nurse M were informed of the situation concerning R30 and the allegations of sexual abuse. Administrative Staff A stated this was, All new to them and they did not know anything about the situation. Administrative Staff A stated they would investigate these allegations and monitor R30 while they investigated the situation. The Resident Monitoring form dated 11/18/21 revealed R30 was placed on 15-minute checks starting at 06:00 PM and was completed starting at 06:00 PM on 11/18/21 through 11:00 AM on 11/19/21 when R30 was placed on one-on-one monitoring. The Health Status Note dated 11/19/21 at 05:36 PM revealed, on 11/19/21 at 10:37AM staff notified Administrative Nurse B of an abuse allegation. Administrative Nurse B and Social Services Staff K interviewed R69 at 10:40 AM. R69 stated she did not feel safe in the facility, and stated a black man came into her room and tried to touch her. R69 stated she fought him off and told him No and he left. R69 could not to give the name of this man but stated, He is a tall thin black man that I smoke with. The staff notified Administrative Staff A and R30 was changed from 15-minute checks to being monitored one-on-one pending investigation. The Health Status Note dated 11/23/21 at 03:29 PM revealed, R30 agreed with the doctor's order to go to behavioral unit. The behavioral unit was contacted, a referral was sent with labs. Facility staff transported R30 to the behavioral unit. R30 was alert, aware, and acknowledged understanding. Review of the timeline of events provided by Administrative Staff A on 11/22/21 revealed R30 told the police he went into R69's room around 12:00 AM (11/19/21) and was there for 30-45 minutes, and said he rubbed R69's back until she asked him to stop, and he then left when R31 arrived to go smoke. The Complaint Investigation Witness Statement dated 11/19/21 revealed Administrative Nurse B asked R69 if she felt safe in facility. R69 nodded no and stated, A black man came to my room and tried to touch me, I fought him off and told him no and he left. Administrative Nurse B asked for description of the alleged perpetrator and was told he was a tall, black man that I smoke with. During an interview on 11/23/21 at 09:47 AM, Administrative Staff A stated when staff informed her of the alleged incident concerning R69 and R30 on 11/19/21, the staff told R30 not to go into any female resident rooms and then initiated one-on-one surveillance for R30. Administrative Staff A affirmed R30 was on 15-minute checks at the time of this alleged incident. Review of the undated Abuse, Neglect and Exploitation policy revealed, If the suspected perpetrator is another resident, the DON or administrator shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined. The facility failed to protect female residents in the facility when staff failed to adequately monitor R30 after an allegation of resident to resident sexual abuse which potentially put all female residents in the facility at risk. The facility presented an acceptable plan for removal of the immediate jeopardy on 11/23/21 at 07:24 PM, which included the placement of R30 on one-on-one monitoring until he was discharged to a local behavior unit on 11/23/21. All female residents at the facility were interviewed by the Social Service Director and stated they felt safe. The facility notified the police department and the police interviewed the residents, and staff, and did not substantiate the allegation. The facility notified the physician about the incident and gave orders to admit R30 to a behavior unit of the R30's preference. R30 was admitted to a behavior unit on 11/23/21 due to sexual inappropriateness. The facility implemented Abuse, Neglect, and Exploitation staff training on 11/19/21 and completed on 11/23/21. The survey team validated the immediate jeopardy removal on 11/23/21 following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of an E.

The facility had a census of [AGE] residents, with three residents selected for sample. Two sampled residents developed pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and friction.) after admission to the facility. Based on observation, interview and record review, the facility failed to provide two of two residents with the necessary care and services (consistent, timely assessment of skin in an attempt to identify early onset of skin issues; thorough and timely assessment of pressure ulcers, including staging and measurements) to prevent pressure ulcers and promote healing of existing pressure ulcers. Staff failed to complete weekly skin assessments for Resident (R) 1 for extended periods of time. R1 developed a pressure ulcer to the coccyx. Then, after development of a pressure ulcer, staff failed to complete thorough and timely assessment of the pressure ulcer, including staging and wound measurements. As of 03/02/20, R1 had a Stage 4 facility acquired pressure ulcer on the coccyx (a deep, full thickness wound with extensive destruction and damage to muscle/bone/supporting structures). Additionally, the facility admitted R2 on 01/14/20 for skilled nursing services. At the time of admission, R2 had a non-pressure wound to his left leg. The facility failed to consistently complete weekly skin assessments in an attempt to identify early onset of skin issues. R2 developed two facility acquired pressure ulcers in February 2020, one identified as a Stage 3 (a wound that extends through the upper layer of skin into the second layer of skin) and the other open but not currently staged. Findings included: - Resident (R) 1's clinical record included a comprehensive Medical [DIAGNOSES REDACTED]. The 01/20/20 Quarterly Minimum Data Set (MDS) identified R1 with no cognitive impairment (Brief Interview for Mental Status score of 15), the need for extensive assistance of 1 staff for bed mobility, total dependence on two staff for transfers, and an inability to ambulate. R1 experienced functional limitations in range of motion on both lower extremities and used a wheelchair for mobility. R1 experienced frequent urinary incontinence and total bowel incontinence. According to the assessment, R1 had a current unstageable pressure ulcer which included slough (dead tissue, usually cream or yellow in color) and eschar (dead tissue). The unstageable wound was not present on admission to the facility. The 07/07/18 Care Plan noted R1's [DIAGNOSES REDACTED]. The care plan also identified R1's risk for skin breakdown and history of amputations and ulcers. According to the care plan, staff should maintain R1 in the wheelchair for two hours or less and then lay him down to relieve pressure to the coccyx. The care plan directed staff to re-approach R1 when he refused wound care, and to complete skin assessments by licensed staff per scheduled protocol. Care Plan interventions included use of a full mechanical lift and two staff for transfers and assistance of one to two staff for repositioning. The Care Plan noted R1's refusal of care. The care plan lacked resident specific information related to the presence of a current pressure ulcer, the stage of the pressure ulcer, and treatment for [REDACTED]. Braden Skin Assessments (an assessment tool used to identify the risk of skin breakdown) identified R1 as moderate risk on 0[DATE] and high risk on 02/20/20. Documentation on the Weekly Skin Observation Tools revealed staff failed to complete any weekly skin checks in the six month time period from 06/24/19 - 0[DATE]. Additional documentation included: 1) 0[DATE]: The documentation lacked notation of any open wounds and included, No new skin issues. The clinical record lacked evidence of completion of additional weekly skin assessments until 0[DATE], a time period of 14 days. 2) 0[DATE]: Described the presence of a 4 centimeter (cm) by 4 cm pressure wound to the sacrum (large triangular bone between the two hip bones) with minimum drainage and an odor. The note lacked a measurement of the depth of the wound and the stage. 3) 01/30/20: Described a right buttock pressure wound which measured 3.5 cm by 3.5 cm with a depth of 1.6 cm. Staff identified the pressure wound as a Stage 3 (a wound that extends through the upper layer of skin into the second layer of skin) with scant drainage. 4) 01/31/20: Described a Stage 3 pressure ulcer to the coccyx (small triangular bone at the base of the spine) with the same measurements as the previous day. 5) 02/03/20: Described a Stage 4 pressure ulcer (a deep, full thickness wound with extensive destruction and damage to muscle/bone/supporting structures) to the coccyx which measured 3 cm by 1.2 cm with a depth of 1.2 cm. The clinical record lacked evidence of completion of additional weekly skin assessments until 02/20/20, a time period of 17 days. 6) 02/20/20: Described a coccyx pressure ulcer which measured 3 cm by 1 cm with a depth of 0.1 cm. Documentation from the contracted wound care company included: 1) 09/13/19: Described a resolved pressure ulcer to the coccyx and included, No open wounds present. 2) 02/03/20: Described recently resurfaced pressure injuries to the coccyx area which facility staff reported presented on [DATE]. The note described the wound as full thickness (Stage 4) which measured 3 cm by 1.2 cm with a depth of 1.2 cm., with joint and necrotic bone exposed. The note also described tunneling (progression of the wound via a channel into adjacent muscle/soft tissue) of the wound for a length of 1.6 cm with a large amount of serosanguinous (semi-thick reddish drainage) drainage with a mild odor. 3) 02/24/20: Described the coccyx pressure ulcer as full thickness (Stage 4) with worsening measurements of 3 cm by 2 cm with a depth of 1.5 cm. tunneling which measured 6 cm. Wound Weekly Observation Tools included the following: 1) 09/10/19: Described an improving coccyx wound. The documentation lacked measurements of the wound and/or staging information. The clinical record lacked evidence of completion of additional Wound Weekly Observation Tools until 02/25/20, a time period of more than five months. 2) 02/25/20: Described a Stage 3 worsening pressure ulcer which measured 3 cm by 2 cm with a depth of 1.5 cm and tunneling. Progress Notes described R1's transfer and admission to an area hospital on [DATE] for an issue unrelated to the pressure ulcer. A progress note written on 02/27/20 at 05:33 PM described R1's readmission to the facility. The 02/27/20 note mentioned the presence of a dressing on R1's coccyx but lacked a description of the wound. As of 03/02/20, documentation in the clinical record from the time of R1's readmission on 02/27/20 - 03/02/20, a time period of four days, lacked evidence of assessment of the pressure ulcer on the coccyx. During an observation on 03/02/20 at 10:45AM, Licensed Nurse (LN) G and Consultant Mid-Level Practitioner GG prepared to examine R1's coccyx pressure ulcer while he lay on his side in bed. LN G removed a heavily saturated dressing from the coccyx. Consultant GG then measured the wound, including depth, and noted the presence of tunneling at various locations. Consultant GG described the pressure ulcer as Stage 4 with tunneling and the beginning of undermining (erosion of tissue around the wound edges). During an interview on 02/27/20 at 10:00 AM, Administrative Nurse E reported R1 developed a facility acquired pressure ulcer which advanced to Stage 3. During an interview on 03/02/20 at 08:30 AM, Administrative Nurse D verbalized knowledge licensed nurses failed to complete weekly skin assessments as scheduled. Administrative Nurse D also verbalized knowledge licensed nurses failed to thoroughly document assessments, including wound assessments such as R1's. On 03/02/20 at 12:20 PM, Administrative Nurse D reported she just found out the electronic health record system failed to notify licensed nurses of when weekly skin assessments came due, and that explained in part why the nurses failed to complete the assessments. On 03/02/20 at 2:30 PM, Administrative Nurse D reported R1 frequently spit at staff and/or attempted to hit them, In spite of those behaviors, Administrative Nurse D reported staff still needed to find a way to provide R1 with the care he needed rather than avoiding him. The facility's July, 2017, Prevention of Pressure Ulcers/Injuries policy directed staff to complete a comprehensive skin assessment upon admission. The policy also directed staff to inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. According to the policy, the purpose of completing the daily inspection was, in part, to inspect pressure points and identify any signs of developing pressure injuries. The facility failed to complete routine weekly skin assessments for Resident (R) 1 for extended periods of time. R1 developed a pressure ulcer to the coccyx. Then, after development of a pressure ulcer, staff failed to complete thorough and timely assessment of the pressure ulcer, including staging and wound measurements. As of 03/02/20, R1 had a Stage 4 facility acquired pressure ulcer on the coccyx (a deep, full thickness wound with extensive destruction and damage to muscle/bone/supporting structures). - Resident (R) 2's clinical record included a comprehensive Medical [DIAGNOSES REDACTED]. The 01/21/20 Admission Minimum Data Set (MDS) identified R2 with the need for extensive assistance of two staff for bed mobility, total dependence on two staff for transfers, and an inability to ambulate. R2 experienced functional limitations in range of motion to all four extremities. The assessment noted the presence of an unhealed Stage 2 pressure ulcer (a break in intact skin which exposes underlying tissue), a risk for development of pressure ulcers, and application of nonsurgical dressings to areas other than the feet. The 01/24/20 Care Plan noted R2's risk for pressure ulcer development due to a past history of ulcers as well as immobility. The Care Plan directed staff to assess, record, and monitor wound healing. Measure length, width and depth when possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. The care plan lacked specific interventions related to pressure reduction in an attempt to prevent pressure ulcer development. The 01/14/20 Braden Skin Assessment, an assessment used to measure risk for pressure ulcer development, identified R2 as moderate risk. A subsequent 01/16/20 assessment identified R2 as no risk. physician's orders [REDACTED]. Review of Weekly Skin Observation Tools revealed the following: 1) 01/14/20 (date of admission): Identified the presence of skin discoloration to toes on the left foot and a purplish scab on the right great toe. Staff failed to complete another weekly skin assessment until 01/24/20, 10 days later. 2) 01/24/20: Identified the presence of an inner left ankle laceration (wound to the skin) of unknown origin. The inner ankle wound measured 5.0 centimeters (cm) by 2.0 cm with a depth of 0.1 cm. The documentation lacked staging of the wound. The documentation also failed to indicate if the ankle wound was a pressure wound. 3) 0[DATE]: Identified the presence of a left lower extremity pressure wound which measured 2.5 cm by 3.0 cm with a depth of 0.1 cm. The documentation lacked a description of the specific location on the left lower extremity and also lacked staging of the wound. 4) 02/03/20: Referred to a Stage 3 pressure ulcer to the left lower extremity which measured 3 cm by 2 cm with a depth of 0.1 cm. The clinical record lacked evidence of completion of additional weekly skin assessments until 0[DATE], 16 days later. 5) 0[DATE]: Documented the presence of a worsening medial (middle) left lower extremity vascular wound which measured 3.5 cm by 1 cm with a depth of 0.1 cm. The assessment identified the wound as deteriorating and noted management of the wound by a contracted wound care company. According to the assessment, R2 had no wounds or skin impairment issues other than the left extremity vascular wound. The clinical record lacked evidence of completion of additional weekly skin assessments in the 14 day time period from 0[DATE] - 03/02/20. Documentation by the contracted wound care company from 0[DATE] - 0[DATE] identified R2 with one wound, a chronic full thickness wound - non-pressure to the left lower medial extremity. The contracted wound care company documentation lacked mention of any other areas of skin breakdown. Skilled Nursing Charting for the time period from admission on 01/14/20 - 02/26/20 revealed a total of 67 entries which prompted staff to assess the resident in a variety of different areas, including Wound/Skin. Of those 67 entries, 47 indicated R2 had no treatable wounds even though he had a wound on the left lower extremity which required daily dressing changes. An additional five Skilled Nursing notes lacked any documentation in the Wound/Skin section and that section remained entirely blank. Progress Notes included: 1) 02/28/20 at 02:46 PM: Described a new wound on the left heel which measured 3 inches by 2 inches. The documentation lacked information related to staging. 2) 02/29/20 at 10:07 PM: Described a Stage 3 pressure area near the coccyx. The documentation lacked measurements or other assessment information. Review of the electronic health record lacked any other documentation related to the two new facility acquired pressure ulcers from the time staff identified them on 02/28/20 (left heel) and 02/29/20 (area near coccyx) until 03/02/20. During observations on 02/27/20 at 01:00 PM and 03:10 PM, R2 lay supine (on his back) in bed with both feet sticking out from under the bed linens. The feet lacked pressure reduction devices (soft boots etc) or a pillow beneath the feet to float the heels. During the observations, R2 had the ability to verbalize his needs. He lacked the ability to move his lower extremities. Both feet were hyperextended at the ankles which caused the feet to point downward. Observation of R2's side of the room revealed no pressure reduction devices for his feet, such as soft boots, within view. When asked if staff ever attempted to place soft boots or other pressure reduction devices on his feet, R2 replied, Nope. During an observation on 03/02/20 at 10:50 AM, Licensed Nurse (LN) G and Consultant Mid-level Practitioner GG examined R2's wounds. Consultant GG initially reported R2 had only one non pressure wound to the left lower leg. Then, upon LN G's report of new wounds, stated, Well, he only had one when I saw him last time. I guess the others are new. Upon examination, R2 had a large, circular wound partially covered with eschar (dead tissue) to the inner left heel. Consultant GG confirmed the presence of eschar on part of the wound and identified the wound as a Stage 3 pressure ulcer. LN G also reported recent development of a new pressure ulcer on the coccyx which staff were unable to measure or stage due to R2's refusals. According to LN G, staff told her the coccyx pressure ulcer was also a Stage 3. At the time of the observation, R2 again refused to allow LN G and Consultant GG to observe/examine the newly developed pressure ulcer on the coccyx. During an interview on 03/02/20 at 11:00 AM, LN G confirmed R2 developed two new pressure ulcers within the last week, and at least one of those pressure ulcers was a Stage 3. According to LN G, R2 frequently refused wound treatments, repositioning and use of pressure reduction devices such as heel protectors or pillows to float the heels but she lacked awareness if anyone documented those refusals. During an interview on 03/02/20 at 08:30 AM, Administrative Nurse D verbalized knowledge licensed nurses failed to complete weekly skin assessments as scheduled. On 03/02/20 at 12:20 PM, Administrative Nurse D reported she just found out the electronic health record system failed to notify licensed nurses of when weekly skin assessments came due, and that explained in part why the nurses failed to complete the assessments. The facility's February 2014 Pressure Ulcer/Injury Risk Assessment policy directed staff to complete a risk assessment weekly for the first four weeks after admission, and to complete a comprehensive skin assessment with every risk assessment. The facility's July 2017 Prevention of Pressure Ulcers/Injuries policy directed staff to complete a comprehensive skin assessment upon admission. The policy also directed staff to inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. According to the policy, the purpose of completing the daily inspection was, in part, to inspect pressure points and identify any signs of developing pressure injuries. The facility admitted R2 on 01/14/20 for skilled nursing services. At the time of admission, R2 had a non-pressure wound to his left leg. The facility failed to consistently complete weekly skin assessments in an attempt to identify early onset of skin issues. R2 developed two facility acquired pressure ulcers in February 2020, one identified as a left heel Stage 3 at the time of discovery and the other wound near the coccyx open but not currently staged.

The facility census totaled 68 residents with 10 residents included in the sample. Based on observation, interview, and record review the facility failed to provide adequate monitoring and appropriate treatment to prevent Resident (R)1 who admitted to the facility with one stage II pressure ulcer (characterized by partial-thickness skin loss into but no deeper than the dermis.) on 9/5/19 from developing 4 stage 3 pressure ulcers (extends into the underlying subcutaneous tissue layer, but not all the way to the bone) as identified on 9/19/19 by the failure to measure new breakdown and provide physician ordered treatment. Findings included: - Review of R1's signed Physician Orders dated 09/05/19 revealed the facility admitted the resident on 8/2/19 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognition. R1 required extensive assistance of two staff with bed mobility, did not walk, and required extensive assistance of one staff with toileting and personal hygiene. R1 had one stage two pressure ulcer on admission. R1 required a pressure reducing device for bed/chair, nutritional interventions, and pressure ulcer care. Review of the Activity of Daily Living (ADLs) Care Area Assessment (CAA) dated 08/06/19 revealed the resident required extensive assistance with most ADLs. Pressure ulcer CAA dated 08/06/19 revealed the resident had a risk for skin breakdown related to requiring extensive assistance with ADLs. R1 had a pressure ulcer on his coccyx. Review of the care plan dated 08/16/19 revealed R1 had potential/actual impairment to skin integrity with stage II (partial thickness) pressure ulcer on the coccyx with the following interventions in place: 08/16/19 - Staff would encourage good nutrition and hydration in order to promote healthier skin. 08/16/19 - Staff would keep the resident's skin clean, dry, and use lotion on dry skin. 08/16/19 - Staff would monitor/document the location, size, and treatment of [REDACTED]. The care plan did not state how often the monitoring should be completed. 08/16/19 - The resident required a pressure reducing mattress. 08/16/19 - Staff would use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the comprehensive pressure ulcer care plan on 09/23/19 revealed no updated interventions completed upon readmission to the facility on [DATE] and no updates to the resident's care plan for wound care when the resident developed four stage III pressure ulcers. Review of the Nurse Progress Notes Admission Note found in R1 electronic record dated 08/02/19 at 11:42 PM indicated R1 arrived at the facility at 4:30 PM and staff attempted a skin assessment, but the resident refused, stating he was going to bed. The resident required wound care to a sacral ulcer. The clinical record lacked evidence of a skin assessment until 8/5/19 (3 days after admission). Review of the Skin/Wound Note dated 08/05/19 at 07:52 PM revealed R1 had a stage 2 pressure sore on his coccyx, which measured one centimeter (cm) by 0.3 cm. The resident refused the border dressing, so staff cleansed the site and applied moisture barrier. Review of R1's electronic record revealed no physician order for [REDACTED].>Review of the Skin/Wound Note dated 08/14/19 at 10:23 PM revealed R1 admitted to the facility with a decubitus (pressure) ulcer to his coccyx. The unidentified writer evaluated the pressure ulcer, cleaned the site, and applied barrier cream. R1was irritable at times and refused to have a dressing applied. Staff would continue to monitor the resident. Review of the Skin/Wound Note dated 08/19/19 at 06:14 PM revealed the resident refused to let the nurse assess his coccyx wound. R1 stated he was nauseated. Review of the Health Status Note dated 08/30/19 at 06:00 PM the facility sent the resident to the hospital per family request. Review of the Admission Summary Note dated 09/5/19 at 06:52 PM revealed the resident admitted to the facility from the hospital with the same pressure ulcer to the right buttock and orders for wound care. The note lacked measurement of the pressure ulcer to the right buttock. The facility did not recieve measurements of the wound from the hospital. Review of the Order Administration Note dated 09/06/19 at 01:42 PM revealed staff would clean the resident's coccyx wound and apply barrier cream one time a day. Review of the Administration Note dated 09/08/2019 at 08:42 PM revealed staff cleaned the resident's sacrum with normal saline (NS), place [MEDICATION NAME] AG (wound dressing impregnated with silver) to wound covered with Replicade (wound dressing) every 72 hours for wound healing. The note lacked any measurement of the resident's wound or condition of the surrounding tissue. Review of the Skin/Wound Note dated 09/09/19 at 08:44 PM revealed the resident had a pressure ulcer to his coccyx, which measured 2 cm x 0.5 cm. The wound had no description of the wound whether it was open or what stage the wound was. The skin on each side of his buttocks remained intact with localized areas of non-blanchable [DIAGNOSES REDACTED]. The unidentified writer educated R1 to reposition frequently and manage moisture. The unidentified writer recorded the resident had a thin build and had hospice services. Review of the Administration Note dated 09/10/19 at 08:40 AM reveled staff cleansed the resident's coccyx wound and applied moisture barrier cream one time a day for the pressure ulcer on his coccyx (which was not the current order). The current wound care orders directed staff to clean with normal saline place a wound dressing to the wound and cover the area with [MEDICATION NAME] AG to wound covered with Replicade. Review of the Administration Note 09/18/19 at 08:39 PM revealed the resident refused for staff to cleanse the right coccyx with normal saline, place a dressing to the wound, and cover the wound with a specified dressing. The resident requested to stay sitting up in his wheelchair. Review of the Health Status Note dated 09/18/19 at 10:16 PM revealed the supervisor applied dressings to the resident's wounds on his buttocks and applied barrier cream to his groin. Staff called the resident's hospice company for notification of the resident's wounds and needed supplies. The supervisor spoke with hospice and described the resident's wounds. Staff repositioned the resident on his left side and instructed the CNA to keep the resident turned every 2 hours. Review of the Hospice Note dated 09/18/19 revealed the resident's wounds to his bottom worsened. The hospice nurse measured and dressed R1's wounds. No description of the wounds provided Review of the Physician Order dated 09/18/19 directed staff to cleanse the resident's wound to the right sacrum with normal saline, place [MEDICATION NAME] AG to wound covered with Replicade. The order lacked any direction related to any other wounds for R1. Review of the Health Status Note dated 09/19/19 at 02:29 PM (10 days after the last time the facility provided measurement of the resident's wounds and the first time the facility noted the resident had multiple wounds) The Hospice Nurse assisted the facility staff nurse to clean the resident's buttock wounds, applied a dressing, and covered the sites. R1 had tunneling (wound that goes deep in the body and snakes through layers of tissue) to one wound which measured 2 cm by 2 cm with a depth of 1.5cm located by his rectum. R1 had a wound to his right buttock, which measured 5.0 cm by 2.5 cm. The resident had a wound on his left buttock, which measured 3 cm by 1.7 cm with slough (necrotic tissue in the process of separating from viable portions of the body). The resident had a wound to his coccyx, which measured 3.5 cm by 4.5 cm. Staff would turn R1 every two hours. The resident had poor diet and fluid intake and refused care at times. The notes did not identify which wound was the original wound Review of the Health Status Note dated 09/23/19 at 10:14 PM revealed the resident refused to lie down after dinner and the resident's unidentified family member asked the facility to leave the resident sitting up. At 9:45 PM, an unidentified Certified Nurse Aide (CNA) talked the resident into lying down. Staff changed the resident's dressings, which appeared with purulent (pus), serosanguinous drainage (clear liquid swirled with red blood). The facility did not give the resident an as needed pain pill prior (to the dressing change) as the resident continued to refuse treatment. The writer did not measure the wound due to the resident being uncomfortable and requesting get it done, hurry, hurry. Review of the Health Status Note dated 09/24/19 at 10:32 AM revealed the facility notified the physician they were out of R1's dressing supplies (due to running out and not reordering dressing supplies from Hospice) and the physician gave orders to the resident's hospice nurse to use a border gauze wound dressing and border gauze until they received supplies. Observation on 09/23/19 at 04:50 PM revealed R1sat in his high back wheelchair in his room. R1 reported he had a cushion in his wheelchair, although the surveyor could not visualize due to a blanket over the resident's legs. R1 reported his bottom hurt. Observation on 09/24/19 at 10:24 AM revealed R1 cried out loudly and could be heard from the hall stating his bottom hurt. R1 laid supine in bed with an air mattress on the bed. Observation on 09/24/19 at 11:05 AM revealed Administrative nurse B donned gloves, explained to R1 she needed to change his dressings, and rolled R1 over to his left side. Administrative Nurse B turned the resident by using a turn sheet under the resident and no other staff assistance (the resident required extensive assistance of two staff for bed mobility) while R1 called out in pain. Administrative Nurse B removed the dressings from the resident's 4 pressure ulcers covering his entire buttock area. There was a large exposed reddened area which measured approximately 6 inches in diameter with 4 separate wounds noted. The wounds had a foul smell to them. One wound appeared black and the size of a half dollar. The second wound appeared slightly smaller. The third wound located around the resident's rectum had visible tunneling. The resident had a fourth wound with slough present on the lower buttock. Administrative Nurse B opened a bottle of normal saline, poured it over the entire area, and used a gauze pad to rub (not pat) the entire wound with the same pad, which caught the scab as she rubbed the area. The resident cried out for the nurse to please stop. Administrative Nurse B continued with the dressing change and placed pieces of calcium alginate to cover the individual wounds. The nurse only covered 2 wounds and was reminded there were 4 wounds in the area. Administrative Nurse B then changed her gloves, covered the other wound with calcium alginate, and left the fourth wound open because she did not see an open area. She stated, calcium alginate would cause the good skin to peel off. All the resident's wounds were then covered with three overlapping border gauze dressings (which was not the current order as the current wound care orders directed staff to clean with normal saline place a wound dressing to the wound and cover the area with the specified dressing.) No measurements were taken by the nurse During an interview on 09/23/19 at 04:50 PM R1 reported staff did not like him to sit up in his chair, but he wanted to although it would cause more damage to his ulcers. R1 stated he had pain to his bottom. During an interview on 09/25/19 at 07:40 AM Certified Nurse Aide (CNA) D reported she turned and provided incontinent care toR1 every 2 hours. R1 had a lot of pain and he called out in pain, especially when staff provided care. Interview on 09/23/19 at 04:15 PM with Licensed Nurse (LN) I revealed staff nurses performed R1 dressing changes in between the facility wound nurse's weekly dressing changes. LN, I reported the nurses signed off on dressing changes on the resident's treatment administration record (TAR) but did not always document changes in the resident's progress notes. LN, I reported if there were changes to the resident's wound, she would contact the resident's doctor. LN, I felt she could remember if there were changes to a resident's wound from week to week. When R1 was first admitted to the facility his wounds were not very big, but now look awful. LN, I confirmed the resident returned from the hospital with an order for [REDACTED]. Interview with Administrative Nurse B on 09/23/19 at 04:25 PM revealed the facility did not use the specified dressing and requested the order to be changed to border gauze. Administrative Nurse B expected licensed nurses to contact the resident's doctor if a wound worsened. R1 received hospice services and his hospice nurse wrote orders for staff to follow. Interview with Administrative Nurse A on 09/23/19 at 04:50 PM revealed the charge nurse was responsible for transcribing all admission orders [REDACTED]. During a follow up interview on 09/24/19 at 02:50 PM Administrative Nurse A reported she did not know the treatment order was for the sacrum wound only. During an interview on 09/25/19 at 08:35 AM Administrative Nurse G reported the updated wound care/wounds were not care planned as ordered. On 09/24/19 at 10:57 AM the surveyor attempted to call Physician J regarding the resident's pressure ulcers, with no return phone call as of 09/25/19 at 07:00 PM. During an interview on 9/26/19 at 7:50AM Administrative Nurse A reported that the average time she would think it would take a pain medication to become effective to do a dressing change would be 30 to 45 min. If the nurse began the treatment and the resident still cried out the treatment should have been stopped until the resident was more comfortable or the nurse would assess the resident to make sure he was on the right medication and did not need something different. She would expect her nurses to follow this. Review of the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/2014 revealed nursing staff and the attending physician would assess and document an individual's risk factors for developing pressure ulcers. In addition, the nurse would describe and document/report the following: 1. Full assessment of pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue. 2. Assessment of the resident's pain. 3. Assessment of the resident's mobility status. 4. Identify current treatments, including support surfaces and all active diagnoses. 5. Staff would examine the skin of a new admission for ulceration or alteration in skin. The physician would help identify factors contributing or predisposing a resident to skin breakdown. The facility failed to provide direction to staff on the frequency of the wound assessments and measurements and provide physician ordered treatment to prevent a dependent resident who was admitted with one stage II pressure ulcer on 8/2/19 from developing four stage III pressure ulcers as identified on 09/19/19.

The facility had a census of 68 residents with 10 residents in the sample. Based on observation, interview, and record review the facility failed to manage pain for one resident reviewed for pain during observations and pressure ulcer care/treatment. Resident 1 (R1) repeatedly cried out in pain during treatment of [REDACTED]. The resident cried out in pain during the wound treatment for [REDACTED]. Findings included: - Review of R1's signed Physician Orders dated 08/09/19 revealed the resident had a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff with bed mobility, extensive assistance of one staff for toileting and personal hygiene and was non-ambulatory. R1 had one stage two pressure ulcer on admission. R1 received a pressure reducing device for his bed/chair, nutritional interventions, and pressure ulcer care. He received a scheduled pain medication regimen and denied pain at the time of assessment. Review of the Care Area Assessment (CAA) dated 08/06/19 revealed R1 had a risk for skin breakdown related to his extensive assistance needs. The resident had a pressure ulcer to his coccyx (a small triangular bone at the base of the spinal column). The pain CAA did not trigger for further review. Review of the resident's Care Plan initiated 08/16/19 revealed: 08/16/19 - The resident required extensive assist with activities of daily living (ADLs) except limited assistance with transfers. The resident's care plan lacked interventions for pain and/or pain control. Review of the Alert Note dated 09/20/19 at 10:50 PM revealed the writer administered an as needed (PRN) pain pill prior to the resident's dressing change on his bottom. R1 yelled out in pain each time he moved and/or repositioned even while no dressing change. The unidentified writer called hospice and the nurse stated she was out of the office yesterday. The facility waited for the hospice nurse to arrive and re-evaluate the resident. Review of the Order Note dated 09/21/19 at 12:01AM revealed the hospice nurse evaluated the resident and gave a new order for [MEDICATION NAME] (narcotic pain medication) 7.5 milligrams (mg) by mouth three times daily and every four hours as needed. Review of the Health Status Note dated 09/23/19 at 10:14 PM revealed the resident refused to lie down after dinner and the resident's unidentified family member asked the facility to leave the resident up. At 9:45 PM, an unidentified Certified Nurse Aide (CNA) talked the resident into lying down. Staff changed the resident's dressing, which appeared with purulent (pus), serosanguinous (fluids are composed of clotted or diluted red blood cells mixed with serum) drainage. The facility did not give the resident an as needed pain pill prior (to the dressing change) as the resident continued to refuse treatment. The writer did not measure the wound due to the resident being uncomfortable and requesting get it done, hurry, hurry. Review of the Medication Administration Record [REDACTED]. Review of the Health Status Note dated 09/24/19 at 10:49AM revealed the unidentified nurse writer placed a call to the hospice nurse to address the resident's pain control. The resident stated he had a lot of pain. The unidentified Certified Medication Aide (CMA) stated it was not time for the resident's as needed pain medication. Resident has exceeded all pain options at this time. The nurse writer offered the resident repositioning with the help of the CMA and the resident declined. The writer would continue to monitor. Review of the resident's Physician's Orders revealed the following: On 08/02/19 staff would perform a pain scale with the resident every shift. On 08/04/19 an order for [REDACTED]. On 08/21/19 an order to consult for hospice. On 09/21/19 an order for [REDACTED]. Review of the medication cards in the medication cart revealed an order for [REDACTED]. Review of the Order Administration Note dated 09/21/19 at 01:38 PM revealed the facility awaited delivery of the resident's [MEDICATION NAME] 7.5 mg-325 mg tablet for moderate pain. Observation of R1 on 09/23/19 at 4:50 PM revealed the resident sat in his high back chair and reported pain to his bottom. Unable to visualize a pressure reducing pad in the wheel chair due to the resident's blanket but the resident reported he indeed had one. Observation on 09/24/19 at 10:24 AM revealed the laying on his back, in bed and crying out, stating his bottom hurt. At 10:26 AM Administrative Nurse B exited the resident's room to retrieve pain medication for the resident. At 10:35AM Administrative Nurse B returned to the nurse's station and reported R1 could not have pain medication until 11:00 AM. Review of the MAR for (MONTH) 2019 revealed the pain medication was not signed out at given until 11:18AM. Observation on 09/24/19 at 11:05AM Administrative Nurse B entered R1's room and asked if he was feeling better. The resident did not respond. The nurse started a dressing change to the resident's buttocks for four stage three pressure ulcers. As the nurse turned R1 to his side (without any other staff assistance) the resident began crying out in pain. The nurse continued the dressing change, removed the old dressing, cleansed, and redressed the area. Throughout the procedure the resident cried out, Please stop, and continued to moan. He cried louder with movement or touch/pressure. The nurse did not seek/request further assistance from other staff to attempt to reduce his pain. Review of Medication Administration Record [REDACTED]. Interview with R1 on 09/23/19 at 4:50 PM revealed he had pain to his bottom and staff did not want him to sit in his wheelchair, but that was what he wanted. Interview with Hospice Nurse (HN) D on 09/24/19 at 09:41 AM revealed R1 admitted back to the facility with hospice services on 09/06/19 after a discharge due to a hospital stay. On 09/09/19 HN D visited the resident and checked with the facility to ensure he received his pain medication. The facility did not contact HN D to report R1 needed something more for pain. HN D stated if the facility would have contacted her, she would have obtained a fast-acting pain medication for R1, especially for premedication for dressing changes. Interview with Certified Nurse Aide (CNA) D on 09/25/19 at 07:40 AM revealed she turned and cleaned the resident every two hours. CNA D reported the resident had a lot of pain and called out quite a bit especially when staff provided cares. When the resident had pain, she reported it to the nurse. Interview with Administrative Nurse A on 09/26/19 at 07:50 AM revealed the average time she thought it took for a pain medication to become effective (to do a dressing change) would be 30 to 45 minutes. If the nurse began a treatment and the resident continued to cry out in pain, she expected the nurse to stop the treatment until the resident became more comfortable. Administrative Nurse A expected the nurse to assess the resident to ensure he was on the right pain medication and did not need something different. Review of the facility policy Pain Management with a revision date of (MONTH) 2013 revealed staff would observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing change. The facility failed to manage pain for Resident (R)1 during observations and pressure ulcer care/treatment.

The facility census totaled 59 residents. Based on interview and record review the facility failed to prevent further potential abuse when an alleged perpetrator, direct care staff E, (alleged to have slapped resident #1 on 4/26/2018 as witnessed by direct care staff F) continued to work in the facility until the administrator was made aware of the allegation of resident abuse on 4/30/2018. This failure put all 59 residents in the facility in immediate jeopardy. Findings Include: - Resident #1 admitted to the facility on [DATE] with physician's orders [REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The resident displayed mood issues of having little interest in doing things, trouble falling and staying asleep, feeling tired, poor appetite and trouble concentrating. Behaviors issues of verbal behaviors directed towards others, behaviors impact on resident assessed as to put the resident at significant risk for physical illness or injury, significantly interfered with resident care and with the resident participation in activities and social interactions. The resident required extensive assistance of one staff for bed mobility, locomotion on and off the unit, and personal hygiene. The resident required extensive assistance of two staff with transfers and toilet use, and total assistance with dressing. The resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The resident displayed no mood issues or behaviors. The resident required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further indicated resident #1 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the cognitive care areas assessment (CAA) dated 3/5/2018 revealed the resident had inattention with disorganized thinking. The resident had a [DIAGNOSES REDACTED]. The activity of daily living (ADL) CAA dated 3/5/2018 triggered for extensive to limited assist with most ADLs. The care plan updated on 4/20/2018 identified the resident with impaired cognitive function, dementia and impaired thought process. The care plan instructed staff to engage the resident in simple structured activities and provide consistent caregivers as much as possible to decrease confusion. The care plan identified the resident had impaired vision. The care plan noted the resident required pads and a check and change every 2 hours related to incontinence. Review of the facility investigation included notarized witness statement from direct care staff F revealed he/she was in the room helping to provide care to resident #1 on 4/26/2018 at 6:00 a.m. and observed direct care staff E slap the resident on the hip area while rushing the resident back to bed. Review of the nurse's progress notes dated 4/27/2018 at 2:30 p.m. revealed an unnamed direct care staff overheard resident #5 telling resident #1's family members someone hit resident #1 and resident #1 hit them back. None of this was witnessed by staff and the unnamed direct care staff overheard this all transpired yesterday (4/26/2018). Licensed nurse B notified the Administrator and ongoing monitoring continues. Review of the timecard for direct care staff E revealed he/she worked on 4/26/18 from 10:03 PM until 4/27/18 at 10:01 AM. The next clock in was on 4/28/18 at 6:06 PM and out on 4/29/18 at 6:13 AM. On 4/29/18 at 7:16 PM the timecard shows a clock in time of 7:16 PM and clock out of 11:12 PM on the same date. There was no further clock in or clock out times after 4/29/18 at 11:12 PM. Interview on 5/7/2018 at 11:20 a.m. with Licensed Nurse B (who documented the 2:30 p.m. progress note on 4/27/2018) indicated an unnamed direct care staff reported he/she heard resident #5 telling resident #1's family members resident #1 had been slapped by an unnamed direct care staff. Licensed nurse B said he/she and the unnamed direct care staff knew they both needed to report the allegation and went to the administrative staff A office and found the door closed. Licensed nurse B went to the administrative staff C and was told administrative staff A was not to be disturbed. Licensed nurse B and the unnamed direct care staff returned to the floor and returned later to report the allegation but again found the door to administrative staff A closed and received instructions from administrative staff C not to disturb him/her. Licensed nurse B returned to the floor and made a note of what he/she had heard in resident #1's chart. Licensed staff B said he/she did not report to administrative staff A on 4/27/2018 as indicated in the progress note. Interview on 5/4/2018 at 6:30 a.m. with administrative staff A revealed he/she found out about the allegation on 4/30/2018 by an anonymous note placed under administrative nurse D's door. The note described an incident on 4/26/2018 at 6:00 a.m. where direct care staff E slapped resident #1 while rushing resident #1 to get back in bed after AM care. Direct care staff F was in the room assisting direct care staff E. Direct care staff F provided the witness statement alleging direct care staff E slapped resident #1 on the hip while telling the resident, Come on (resident #1's name). The administrative staff A indicated he/she terminated direct care staff F on 4/30/2018 for not following the facility Abuse and Neglect policy by reporting the incident earlier. Interview on 5/4/2018 at 6:30 a.m. administrative staff A indicated he/she held a mandatory all staff in-service for all shifts letting staff know what happened and he/she terminated staff for not reporting timely and he/she posted information throughout the building with his/her phone number and for staff to notify him/her anytime day or night if staff suspected or observed any resident abuse. On 5/7/2018 at 10:00 a.m. a review of the facility's undated Abuse, Neglect and Exploitation policy revealed it contained the seven components of the policy that included: Screening, Training Prevention, Identification, Investigation, Protection and Reporting. The Protection section of the policy stated, If the suspected perpetrator is an employee, the administrator shall place the employee on immediate investigatory suspension while completing the investigation. It should be explained to the employee that if the conclusions of the investigation do not require additional suspension or termination, the employee will be allowed to return to work. The failure to notify the administrator immediately by direct care staff F who witnessed direct care staff E slap resident #1 put all 59 residents in the facility in immediate jeopardy when the alleged perpetrator (direct care staff E) continued to work in the facility two additional shifts until the administrator was made aware of the allegation and terminated the alleged perpetrator. The deficient practice was identified as past non-compliance and was corrected on 5/1/2018 when the facility terminated the alleged perpetrator, completed staff education to all facility staff on the review of the facility Abuse, Neglect and Exploitation policy on reporting immediately to the administrative staff A anytime day or night of any suspected or observed abuse or neglect of any resident and the Administrator posted his/her phone number on information sheet throughout the facility.

The facility census totaled 59 residents. Based on observation, interview and record review the facility failed to ensure resident #1 was free from physical abuse when direct care staff E slapped resident #1 after providing care. This deficient practice put resident #1 in immediate jeopardy. Findings included: - Resident #1 admitted to the facility on [DATE]. Physician orders [REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The resident displayed mood issues of having little interest in doing things, trouble falling and staying asleep, feeling tired, poor appetite and trouble concentrating. The MDS identified the resident exhibited verbal behaviors directed towards others, putting the resident at significant risk for physical illness or injury, significant interference with resident care and significant interference with the resident's participation in activities and social interactions. The resident required extensive assistance of one staff for bed mobility, locomotion on and off the unit, eating and personal hygiene. The resident required extensive assistance of two staff with transfers, toileting and total assistance with dressing. The resident was not steady and required human assistance with standing from seated position, moving on/off toilet and surface to surface transfers. The MDS further indicated resident #1 experienced frequent incontinence of urine and occasional incontinence of bowel and had no falls. Review of the Significant Change MDS dated [DATE], revealed resident #1 had a BIMS score of 6, indicating severely impaired cognition. The resident displayed no mood issues or behaviors. The resident required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of cognitive care areas assessment (CAA) dated 3/5/2018 revealed the resident had inattention with disorganized thinking. The resident had a [DIAGNOSES REDACTED]. The activity of daily living (ADL) CAA dated 3/5/2018 recorded the resident required limited to extensive assist with most ADLs. The care plan updated on 4/20/2018 identified the resident with impaired cognitive function, dementia and impaired thought process. The care plan instructed staff to engage the resident in simple structured activities and provide consistent caregivers as much as possible to decrease confusion. The care plan identified the resident had impaired vision. The care plan noted the resident required a check and change every 2 hours related to incontinence. Review of the nurse's progress notes dated 4/27/2018 at 2:30 PM revealed an unnamed direct care staff overheard resident #5 telling resident #1's family members that someone hit resident #1 and resident #1 hit him/her back. None of this was witnessed by staff and the unnamed direct care staff heard the incident occurred on 4/26/18. Review of the facility provided investigation revealed an undated witness statement from direct care staff F which stated direct care staff E had been rushing resident #1 to return to bed after changing the bedding. During that time, direct care staff E slapped resident #1 on the hip one time while advising the resident to come on. Review of a notarized witness statement, dated 5/8/18, from direct care staff E revealed he/she stated that if he/she had slapped the resident, why was there not a handprint left on the resident. During an interview with resident #1 on 5/2/18 at 3:42 PM, he/she reported being slapped by a direct care staff member on the face. He/she could not identify the direct care staff member, but was able to report there were 2 direct care staff members in the room providing care to him/her during the alleged battery. Observation of the resident at that time revealed he/she lay in bed in a semi-private room and the resident's roommate was not interviewable. Interview on 5/7/2018 at 11:20 AM licensed nurse B indicated an unnamed direct care staff said he/she heard resident #5 telling resident #1's family member an unidentified direct care staff member had slapped the resident. During an interview with administrative staff A on 5/4/18 at 6:30 AM, he/she reported he/she was advised of the allegation on 4/30/18 by a note left under his/her door. The note reportedly stated that direct care staff E slapped resident #1 while rushing the resident to return to bed after providing cares. Direct care staff F provided a witness statement regarding the incident and was then terminated from his/her employment on 4/30/18 for not reporting or protecting the resident. Direct care staff E was contacted and advised of the allegation and was asked to provide a witness statement regarding the incident. Direct care staff E refused and was terminated from employment with the facility on 5/1/18. Review of the undated facility policy entitled, Abuse, Neglect, and Exploitation, revealed the facility would take steps to prevent occurrences of abuse. The facility would provide training to staff on appropriate interventions to deal with aggressive and/or catastrophic reactions of resident or caregiver stress. Reasonable efforts would be taken to determine the cause of the alleged violation and the resident's care plan would be reviewed and revised to reflect the resident's condition and measures taken to prevent recurrence. The facility failed to ensure resident #1 remained free from physical abuse when he/she was slapped by direct care staff E. This deficient practice placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 5/1/2018 when the facility terminated the alleged perpetrator, completed staff education to all facility staff on the review of the facility Abuse, Neglect and Exploitation policy on reporting immediately to the administrative staff A anytime day or night of any suspected or observed abuse or neglect of any resident and the Administrator posted his/her phone number on information sheet throughout the facility.

The facility census totaled 61 residents with 17 sampled. The sample included 2 residents with pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview and record review the facility failed to implement interventions to prevent the worsening and development of pressure ulcers for 2 of 2 residents (#12 and #18). Resident #18 developed a stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle were not exposed. Slough (dead tissue, usually cream or yellow in color) may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) pressure ulcer to the coccyx. Resident #18 developed a stage 2 pressure ulcer blister on the left heel and on the right heel and a suspected deep tissue injury (SDTI -Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the outer side of the left and right foot and left heel. Resident #18 developed 5 avoidable pressure ulcers between 9/6/17 and 11/21/17 and the pressure ulcer on the coccyx worsened. The facility also failed to ensure staff implemented planned interventions for resident #12 who had a history of [REDACTED]. Findings included: - Review of resident #18's physician order [REDACTED]. The annual minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 2 indicating severely impaired cognition. The resident required extensive assistance of two or more staff for bed mobility, transfers, toilet use, and personal hygiene. He/she had impairment in range of motion (ROM) on one side of the upper extremity, both sides of the lower extremities and used a wheelchair for mobility. The resident did not have any known weight loss and received a mechanically altered diet. He/she had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) risk which staff determined by formal assessment tool, and clinical assessment. He/she was at risk for pressure ulcers with no unhealed pressure ulcers and no other skin conditions at the time of the MDS. The resident had a pressure reducing device for the chair and bed, a turning/repositioning program, applications of ointments/medications other than to feet, and application of dressings to his/her feet (with or without topical medication). The quarterly MDS dated [DATE] included the same cognition. He/she required total dependence on two or more staff for bed mobility, transfers, toilet use and personal hygiene. He/she continued with the same limitations in ROM, no weight loss and received the same diet. The resident remained at risk for pressure ulcers and had 1 or more unhealed pressure ulcers stage 1(intact skin with a localized area of non-blanchable redness) or higher. The resident had 1 stage 2 (partial thickness skin loss where the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer dated 9/10/17 which was not present on admission, 1 stage 3 (full-thickness skin loss with adipose (fat) tissue visible) pressure ulcers not present on admission, and 1 unstageable deep tissue injury (obscured full-thickness and tissue loss but the extent of tissue damage cannot be determined due to slough (dead tissue, usually cream or yellow in color) or eschar (dead tissue, usually black/brown in color)) not present on admission. The stage 3 pressure ulcer measured 5.4 centimeters (cm) by 5.8 cm and no depth with the most severe tissue type as slough. No pressure ulcers were present on the prior assessment. He/she continued with the same pressure ulcer reducing device to bed and chair, turning/repositioning program, pressure ulcer care, application of nonsurgical dressings other than to feet, applications of ointments/medications other than to feet, and application of dressings to his/her feet (with or without topical medications). Review of the care area assessments (CAAs) dated 8/21/17 revealed cognition, nutrition and pressure ulcer triggered for a further assessment. Record review revealed lack of documentation the nutrition and pressure ulcer assessments were completed to show a further assessment of status, risk factors, or other services needed. The care plan initiated on 10/8/15 and still in effect when reviewed on 12/5/17 indicated the resident required extensive and full assistance with all decision making. On 5/26/16 staff initiated an activities of daily living (ADL) deficit plan which indicated the resident required extensive assistance of 1 staff for repositioning and turning in bed, dressing, toilet use and personal hygiene with total assistance of 2 staff for transfers by a mechanical lift (a mechanical device which lifts and supports the entire body during a transfer to another surface). The resident had bowel and bladder incontinence. Staff should check the resident for incontinence every 2 hours and as required for incontinence, wash, rinse and dry perineum. On 6/13/17 application of moisture barrier after each incontinent episode was added to the care plan. The resident's 6/20/16 care plan for risk of developing pressure ulcers r/t decreased mobility, diabetes mellitus and incontinence with a goal of intact skin, free of redness, blisters or discoloration through next review date directed staff to administer treatments as ordered and monitor for effectiveness. [MEDICATION NAME] (a zinc oxide and menthol topical cream to treat rashes, minor burns, severely chapped skin or other minor skin irritations) to peri-area every shift, educate resident/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, needed assist of 1 staff to turn/reposition at least every 2 hours, more often as needed (PRN) or requested, follow facility protocol for the prevention/treatment of [REDACTED]. Staff added to care plan on 10/24/17 to apply Prevalon Boots (a soft fabric which contoured to and cradled the leg, calf, ankle and foot to help prevent rotating with the boot or sliding out of the boot-maintaining effective heel offloading) at all times except while showering. Review of the weekly skin assessments revealed the following: On 9/4/17 staff recorded the resident's skin was intact with no issues. On 9/6/17 staff assessed and recorded a stage 2 pressure ulcer on his/her left buttock which measured 1 cm in length, 1 cm in width and 0.1 cm deep and a stage 2 pressure ulcer to the left heel which measured 0.2 cm long, 0.2 cm wide and 0.1 cm deep with a 2 cm by 3 cm calloused area just below the open area. Staff failed to update the care plan with the development of the pressure ulcers to include new interventions for healing and prevention of further pressure ulcer development. On 9/10/17 staff assessed and recorded the resident had a blister on the right heel (by definition a pressure ulcer) which measured 10 cm long by 8 cm wide, a left heel blister which measured 2 cm by 2 cm, and his/her coccyx with both buttocks involved measured 8 cm by 10 cm. Staff failed to update the care plan with the development of the new pressure ulcers to the heels with no new interventions for healing or prevention of further pressure ulcer development. Nursing notes dated 9/12/17 at 3:22 PM documented staff performed wound rounds on 9/11/17 with the buttock/coccyx measurements of 5.4 cm by 5.8 cm with the wound bed 100% yellow/gray slough and moderate amount of drainage with a foul odor. The physician changed the treatment order to cleanse with normal saline, pat dry, apply calcium alginate (a wound dressing used to manage exudates in partial to full-thickness wound) and cover with a foam dressing. The right heel stage 2 pressure ulcer measured 8.6 cm by 8.3 cm with a semi-intact blister and necrotic (dead skin) center and light drainage. Staff planned to continue with [MEDICATION NAME] (topical antiseptic) application and offload with an abdominal pad (ABD- a large sized and extra absorbent gauze material) dressing. The resident developed a suspected deep tissue injury (SDTI) to the left heel which measured 8 cm by 10 cm, was very soft and mushy. Staff planned to continue Skin Prep (a liquid film-forming dressing which upon application to intact skin forms a protective film) and offload with an ABD dressing. Within the note section of the weekly skin assessment staff identified staff should place bunny boots (a padded heel protector) on the resident's feet but failed to update the care plan with the addition of the bunny boots. The weekly skin assessments after 9/10/17 no longer included wound measurements which staff then recorded in the nursing notes as follows: On 9/15/17 at 12:35 PM, nursing notes indicated staff turned and repositioned the resident every 2 hours while in bed, bunny boots remained on at all times while in bed to offload pressure, and the resident had a low loss air mattress and specialized pressure relief cushion (ROHO) in place. The care plan lacked revision with these interventions. On 9/19/17 at 3:44 PM the buttock/coccyx wound measured 10.2 cm by 5.8 cm by less than 0.1 cm depth and 50% of the wound bed with yellow/gray slough, 30% with pale white tissue and 20% with pink tissue. The area had moderate amount of red tinged drainage and a slight odor. Staff planned to continue the calcium alginate and cover with transparent dressing. The right heel measured 5.4 cm by 4.6 cm with the wound bed having 50% necrotic tissue, no drainage or odor and staff should continue current treatment. The left heel measured 3.4 cm by 5.3 cm of intact skin which was very mushy to palpation (touch) and staff planned to continue the current treatment. On 9/27/17 at 1:38 PM staff recorded wound measurements completed on 9/26/17 included buttock/coccyx wound 10.08 cm by 4.6 cm by less than 2 cm with wound bed 70% yellow/tan slough. The right heel measured 5.1 cm by 4.6 cm by 0 depth with 60% necrotic tissue present and moderate amount of drainage. The left heel measured 2.6 cm by 3.5 cm with intake wound bed and mushy feeling. The care plan lacked interventions to provide consistent care, promote healing and prevent further pressure ulcer development. The nursing notes and weekly skin assessments (as follows) lacked further wound measurements from 9/26/17 until 10/24/17. The weekly skin assessment dated [DATE] (14 days since completed on 9/25/17) notes section recorded a wound to his/her coccyx with100 % slough and a right heel pressure ulcer with no other skin issues. Assessment lacked documentation of wound on the left heel. The weekly skin assessment dated [DATE] included notes which staff recorded the resident had a wound to the coccyx, right heel and a very soft left heel with no wound measurements recorded. The nursing note dated 10/24/17 at 1:39 PM indicated the resident developed a SDTI to the right outer side of the right foot which measured 3.9 cm by 1.9 cm; the wound was intact, soft and Red/Purple in color. Staff planned to start Skin Prep to the wound and foam padding secured with gauze wrap and changed daily. Between 10/16/17 when the left heel was mushy he/she developed a SDTI to the left heel which measured 7 cm by 7 cm with 100% mushy heel and a 0.2 cm by 0.4 cm dry intact red/brown scabbed area to heel. Staff planned to continue current treatment of [REDACTED]. The note lacked a description for the buttocks/coccyx wound. Nurse's notes lacked documentation of wound measurements or weekly skin assessments between 10/24/17 and 11/6/17 (skin assessment) and 11/7/17 nursing note with measurements (2 weeks). The nursing note dated 11/7/17 included a stage 3pressure ulcer to the buttock which measured 2 cm by 2.5 cm and 100% granulation in the wound bed, a stage 2 pressure ulcer to the right heel which measured 3.8 cm by 2.1 cm and a 40% necrotic wound bed, a SDTI to left heel which measured 3.7 cm by 4.8 cm with 100% mushy wound bed and a SDTI to the outer side of the right foot which measured 4.6 cm by 1.12 cm and wound bed remained red/purple and intact. The nursing note dated 11/14/17 with a time of midnight (12:00 am) included a stage 3 pressure ulcer to his/her buttock of 2 cm by 2 cm, a stage 2 pressure ulcer to the right heel of 4 cm by 2.4 cm, a SDTI to the left heel of 4 cm by 4.8 cm, and SDTI to the outer side of the right foot of 4.6 cm by 1.4 cm. The nursing note dated 11/21/17 indicated the resident developed a SDTI to the outer side of the left foot which measured 4.5 cm by 0.7 cm of purple and pink intact skin. The care plan lacked revision with this newly developed area and no additional interventions to promote healing and prevent further pressure ulcer development were included. The nursing note dated 11/30/17 classified the buttock/coccyx wound as a stage 3 pressure sore which measured 2 cm by 2 cm, stage 2 pressure ulcer on the left heel which measured 3.5 cm by 2.5 cm with the wound bed being 60% necrotic tissue, a SDTI on the right heel measured 4 cm by 3 cm with 100% mushy heel and SDTI to the left lateral foot which measured 4 cm by 0.7 cm. Review of the treatment records (TAR) for (MONTH) (YEAR) revealed the following orders: dated 1/28/17 for staff to cleanse both heels with normal saline, pat dry, offload with a double layer hole cut in an ABD and wrap with gauze and secure with tape every 3 days PRN until resolved. This physician discontinued the treatment on 8/24/17 with no further treatments implemented on the (MONTH) (YEAR) TAR. Review of the (MONTH) (YEAR) TAR revealed staff should apply skin prep to the left heel, with a hole cut in an ABD, secure with gauze and offload daily starting 9/11/17. Staff should apply calcium alginate to the resident's buttocks topically (to the surface) after cleansing the wound with normal saline. Staff should cut the calcium alginate to fit the area and cover with a transparent dressing and change daily starting on 9/13/17. For the right heel blister, staff should cleanse with normal saline, pat dry, paint with [MEDICATION NAME], cut a hole in an ABD dressing and apply to area, secure with gauze and offload daily starting 9/11/17. Bunny boots to both feet every shift starting 9/10/17. Prevalon boots to both lower extremities at all times and staff should check for placement of the boots every shift starting 9/26/17. Review of the (MONTH) (YEAR) TAR revealed the same treatment order for the left heel. The buttocks treatment remained the same until 10/17/17 with new orders to cleanse with normal saline, pat dry and cover with transparent dressing daily. The TAR included the same treatment order for the right heel blister until 10/18/17 which changed to cleanse the right heel blister with normal saline, pat dry, apply calcium alginate on necrotic tissue only, secure with gauze and offload daily. Then on 10/20/17 the order changed to cleanse the right heel with Wound Cleanser, apply Collagen (Cut to size) on the necrotic area only and cover with bordered gauze, secure in place with 1/2 roll of gauze and change daily. The Prevalon boots remained the same until 10/24/17 when it was changed for staff to check placement every 2 hours. On 10/25/17 staff should apply [MEDICATION NAME]/Sure prep to left foot redness daily. The right foot SDTI on the outer side of the right foot staff should apply Skin Prep to the area, cover with non-adhering foam dressing, and secure in place with Gauze wrap every day. Observation on 12/4/17 at 9:40 AM revealed licensed nurse E and direct care staff C prepared to provide care and dressing changes for the resident. When direct care staff C removed the resident's incontinent brief there was an open wound on the coccyx with no dressing or cream observed. The pressure ulcer was located on the bottom of the gluteal crease with evidence of scar tissue on both buttocks of the area to the size of an average orange and about a dime sized open area with superficial depth. Licensed nurse E cleansed the area with normal saline, patted dry with a gauze pad and applied a transparent adhesive dressing. Both heels were wrapped with a gauze dressing dated 12/3/17 and upon removal revealed no redness or open areas on the left heel or foot and the nurse reported there was no mushiness to the heel. Licensed nurse E applied Skin Prep, cut a hole in a double layered ABD to place on the left heel, wrapped the heel and foot with gauze and secured with tape. The outer side of the right foot had an open area approximately half dollar size with about 50% of the wound bed with yellow/gray slough. Licensed nurse E cleansed the wound bed with wound cleanser, patted dry with a gauze pad, trimmed a piece of collagen to the size of the wound bed which he/she wet with wound cleanser and applied wet side down on the wound bed and covered with a foam dressing. He/she then applied Skin Prep to the outer edge of the foot and heel, covered with a hole cut ABD and wrapped the heel/foot with gauze wrap and secured with tape. Interview on 12/4/17 at 8:40 AM with direct care staff C revealed he/she did not know why the resident developed the pressure ulcers. He/she knew how to care for the resident from the care plan but it was confusing as to what needed done for off- loading the heels. Some staff used pillows, some used the bunny boots then the Prevalon boots came and staff started using those. Some staff still put on the bunny boots and sometimes nothing was placed on his/her feet. Interview on 12/5/17 at 10:24 AM with direct care staff KK revealed the resident was sick a couple months ago and he/she did not know if the resident developed the pressure ulcers during that time because he/she worked on all units and did not always care for the resident. He/she knew how to care for the resident from the care plan on the electronic record (Kiosk). He/she only knew pressure relief interventions of turning every 2 hours and the Prevalon boots. Interview on 12/5/17 at 4:09 PM with direct care staff JJ revealed he/she worked on all shifts and the resident just starting having a decline a few months back. He/she did not know specific interventions put into place to prevent pressure ulcers for the resident until the big boots (Prevalon) arrived and staff started using them on both heels. He/she said before the areas developed sometimes staff had placed a pillow under the feet or those small boots (Bunny boots). He/she reported the resident's record on the Kiosk (a computer terminal typically placed in high traffic areas) included what care to provide which included turning and repositioning every 2 hours. Interview with licensed nurse G on 12/6/17 at 9:08 AM revealed he/she worked at the facility prior to the resident developing pressure ulcers. He/she reported the resident had an overall health decline, was less cognitive, less physical movement and seemed to be giving up. The resident was on a turning program and wore the bunny boots on both heels all the time. He/she did not know what additional interventions were put in place to prevent further development or promote healing and reported the care plan should include those interventions. Interview with administrative nurse U on 12/6/17 at 10:13 AM revealed he/she began employment at the facility in (MONTH) (YEAR) and the resident already had a pressure ulcer on his/her buttocks. When he/she began reviewing the wound program he/she found the documentation to be disorganized or lacking and he/she attempted to organize what he/she could. Administrative nurse U and administrative nurse S (present at the interview) confirmed the care plan did not include the pressure ulcers or interventions prior to the first development or with each subsequent development until updated on 10/24/17 with the Prevalon boots. Both administrative nurses explained the Bunny boots were started when the blisters developed and the interdisciplinary team discussed the need for Prevalon boots, which were ordered, and directions to staff to continue the bunny boots until the Prevalon boots arrived. The checking for placement every 2 hours on the Prevalon boots was updated on the TAR on 10/24/17 as a result of nurse managers periodically noting the boots were not on the resident. The facility's policy titled Pressure Ulcers/Injuries Overview dated (MONTH) (YEAR) included a definition for an Avoidable pressure ulcer meant the resident developed a pressure ulcer/injury and one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors, definition or implementation of interventions which are consistent with resident needs, resident goals and professional standards of practice and monitoring or evaluation of the impact of the interventions or revision of the interventions as appropriate. The facility failed to develop interventions to prevent the development of pressure ulcers and ensure staff consistently implemented interventions after the resident developed a pressure ulcer to prevent worsening or development of further pressure ulcers for resident #18 who developed 5 avoidable pressure ulcers between 9/6/17 and 11/21/17 and 1 of the 5 worsened during that time frame. - Review of resident #12's physician's orders [REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed the resident had short and long-term memory problems with severely impaired decision-making ability. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting, extensive assistance of one staff for eating and personal hygiene. He/she was totally incontinent of bowel and bladder. The resident was at risk for the development of pressure ulcer (localized injury to the skin and /or underlying tissue usually over a boney prominence, because of pressure, or pressure in combination with shear and/or friction)and first identified with two unhealed stage 2 (partial thickness loss of dermis presenting as a shallow ulcer) pressure ulcers. The most severe tissue type of tissue being eschar (dead tissue). He/she required turning and reposition from the staff and pressure reduction devices to the bed and chair to manage his/her pressure ulcers. Review of the annual MDS dated [DATE] revealed a brief interview for mental status (BIMS) score of 3 (severely impaired cognitive ability). The resident required extensive assistance of one person for bed mobility, transfers, extensive assistance of one person for eating, toileting, and personal hygiene. He/she was totally incontinent of bowel and bladder. Staff used a formal assessment instrument tool and clinic assessment to determine the resident was at high risk for the development of a pressure ulcer. The resident had one current pressure ulcer coded as a stage 2 that healed or was at a lesser stage than indicated on the previous assessment. He/she required a pressure reducing device for his/her bed and chair, and turning and repositioning to prevent the development of pressure ulcers. Review of the cognitive loss care are assessment (CAA), urinary incontinence, nutritional status, and pressure ulcer dated 9/9/17 revealed the staff failed to complete the CAA to determine potential risk factors to assist with the development of the comprehensive care plan. Review of the pressure ulcer care plan last revised 8/29/17 revealed the facility failed to identify the resident had a current pressure ulcer. The care plan directed the staff to apply moisture barrier cream to the resident's skin, avoid massaging boney prominences, use mild cleaners for perineal cleansing, turn and reposition every 2 hours and more often as needed/requested, ensure he/she had a pressure relieving cushion when he/she sat up in the wheelchair, and to follow the facility policies for prevention and the treatment of [REDACTED]. Review of the (MONTH) certified nursing assistant (CNA) tasks electronic documentation record revealed a task for the CNAs to turn and reposition the resident every 2 hours. The facility documented the staff completed this task 88 times of the 360 opportunities or only 24% of the time. Review of the physician's orders [REDACTED]. Review of the nurse's progress note dated 9/12/17 at 4:00 p.m. during wound rounds the shearing wound to the coccyx measured 1.1 cm x 0.5 cm with a pink/red colored wound bed and the facility would continue treatment with Calazyme (a brand of moister barrier cream) ointment as ordered. Review of the nurse's progress note dated 9/19/17 at 4:07 p.m. during wound rounds recorded the shearing area to the resident's coccyx area resolved and the facility would continue with Calazyme ointment as a preventative measure. Review of the nurse's progress note dated 10/23/17 at 7:01 p.m. revealed the wound to buttocks measured 3.5 cm x 2.0 cm with yellow slough (dead tissue usually cream or yellow in color) with a moderate amount of drainage. Review of the facility skin observation tool dated 11/27/17 revealed the resident had a sheared (the separation of skin layers caused by friction or trauma) area to his/her buttocks which measured 0.7 cm x 0.5 cm. The skin tool indicated the wound bed was pale pink with the outer edge of the wound described as pale pink. The documentation revealed the facility would continue with the current treatment and continue to monitor the wound. Review of the facility records and a timeline created and provided by the facility revealed the resident develop a pressure ulcer which healed and reopened on his/her coccyx 7 times between 9/2016-12/2017. Review of the record and a wound timeline created by the facility revealed: 1/27/17-the resident had a facility acquired stage 2 coccyx wound measuring 5 cm x 3.5 cm with 100% granulation (tissue formed during wound healing) and documentation which revealed the wound developed on 10/24/17. 2/7/17-stage 2 wound 1.5 cm x 0.8 cm, 100% granulation tissue continue treatment of [REDACTED]. 2/22/17- stage 2 wound- 1.4 cm x 0.8 cm, 100% granulation tissue continue treatment of [REDACTED]. 2/28/17-coccyx wound stage 2- 0.6 cm x 0.5 cm, 100% granulation tissue continue treatment of [REDACTED]. 3/6/17-coccyx wound stage 2- 0.6 cm x 0.6 cm, 100% granulation tissue continue treatment of [REDACTED]. 3/15/17-coccyx wound stage-2- 0.4 cm x 0.1 cm, 100% granulation tissue continue treatment of [REDACTED]. 4/4/17-coccyx wound stage 2- 2 cm x 1.2 cm, treated with [MEDICATION NAME]. 4/11/17-coccyx wound stage 2- 1.6 cm x 1.2 cm, treated with [MEDICATION NAME]. 5/3/17-coccyx wound stage 2- 2.8 cm x 2.6 cm x 0.3 cm, treated with [MEDICATION NAME]. 5/16/17-coccyx wound stage 2- 2 cm x 2.3 cm x 0 cm treatment changed to Silver Alginate (a substance used for wound healing). 5/22/17-coccyx wound stage 2- 2 cm x 3 cm x 0 cm treated with Silver Alginate. 5/30/17-coccyx wound stage 2- 3 x 2 cm x 0 cm treated with Silver Alginate. 6/617-coccyx wound stage 2- 0.5 cm x 2 cm x 0 cm treated with Silver Alginate 6/8/17-Wound Clinic documentation revealed the coccyx wound was a pressure ulcer, stage 2 and a Sorbact (brand and type of wound dressing) the documentation did not contain measurement. 6/14/17-coccyx wound stage 2 -3 cm x 2 cm x 0 cm continued the Sorbact dressing. 6/21/17-coccyx wound stage 2- 2.5 cm-2.5 cm x 1.8 cm continued the Sorbact dressing. 6/29/17-coccyx wound stage 2- 3 cm x 2 cm x 0.1 cm continued the Sorbact dressing. 7/4/17-coccyx wound stage 2- 3 cm x 1.8 cm continued the Sorbact dressing. 7/6/17-coccyx wound stage 2- documentation revealed the treatment was changed to Collagen (a type of wound dressing). 7/11/17-coccyx wound stage 2- 3 cm x 2.5 cm x 0.2 cm continue with the Collagen. 7/19/17-coccyx wound stage 2- 2.5 cm x 2.5 cm x 0.2 cm continue with the Collagen. 7/25/17-coccyx wound stage 2- 3 cm x 0.5 cm x 0.2 cm 8/1/17-coccyx area resolved. 8/21/17-coccyx wound- 2 cm x 1.4 cm x 0 cm treated with [MEDICATION NAME]. 8/28/17-coccyx shearing- 3.1 cm x 0.7 cm treated with [MEDICATION NAME]. 9/5/17-coccyx shearing- 1.9 cm x 0.8 cm treated with [MEDICATION NAME]. 9/11/17-coccyx shearing- 1.1 cm x 0.5 cm treated with [MEDICATION NAME]. 9/18/17-coccyx shearing- resolved 10/24/17-buttock/coccyx shearing- 3.5 cm x 2 cm the facility covered the wounds with border gauze (a type of dressing). 10/31/17-buttocks/coccyx shearing- 2 cm x 1 cm treated with border gauze. 11/7/17-buttocks/coccyx shearing- 2.8 cm x 1.4 cm treated with border gauze. 11/13/17-buttocks/coccyx shearing- 2.4 cm x 1.6 cm treated with border gauze 11/20/17-buttocks/coccyx shearing- 2.4 cm x 1.4 cm treated with border gauze. 11/27/17-buttocks/coccyx shearing- 0.2 cm x 0.5 cm x treated with border gauze. 12/4/17-buttocks/coccyx shearing - 0.2 cm x 0.2 cm treated with border gauze. Observation on 12/4/17 at 1:20 p.m. revealed the resident lay in bed on his/her back from 1:30 p.m. until 4:33 p.m. until a skin check was completed by licensed nurse M as listed below. Observations were made at 1:30 p.m., 1:45 p.m., 2:00 p.m., 2:15 p.m., 2:28 p.m., 2:43 p.m., 3:00 p.m., 3:12 p.m., 3:30 p.m., 3:45 p.m., 4:00 p.m., and 4:15 p.m. A skin check was requested and discussed with licensed nurse Q. Observation on 12/4/17 at 4:33 p.m. licensed nurse M entered the room and performed the requested skin observation which revealed 1 cm open area to the coccyx without drainage ordered dressing was removed. During an interview on 11/29/17 at 8:50 p.m. with a family member revealed the resident developed the wound to his/her coccyx about a year ago while in the facility. The family member revealed he/she believed the resident developed the pressure ulcer from sitting in the wheelchair. During an interview on 12/4/17 at 9:57 a.m. with direct care staff O revealed the resident was incontinent of bowel and bladder. He/she fed him/herself and only required staff assistance occasionally. Staff O revealed the resident had a pressure ulcer to his/her bottom he/she developed months ago. During an interview on 12/5/17 at 11:12 a.m. with direct care staff J revealed the resident required turning and repositioned every 2 hours and as needed (PRN). During an interview on 12/4/17 at 4:48 p.m. with licensed nurse M revealed he/she did not know when the pressure ulcer developed but he/she knew the resident was on Hospice services and he/she pressure ulcer to he

The facility census totaled 61 residents with 17 sampled. The sample included 2 residents for limitation in range of motion (ROM). Based on observation, interview and record review the facility failed to provide appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 2 of 2 sampled residents with limited ROM. (#1 and #18) Resident #18 received skilled therapy services to improve his/her ROM and to establish a functional mobility plan in (MONTH) of (YEAR) and the facility failed to provide the restorative nursing services to maintain his/her level of functioning which resulted in a decline in ROM for both hips and the left knee. Resident #1 had a fractured right thigh bone and lower leg at the knee with non-surgical treatment and the facility failed to provide restorative nursing services to maintain and/or improve his/her ROM in the right hip, knee and ankle joints. Findings included: - Review of resident #18's physician order [REDACTED]. The annual minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 2 indicating severely impaired cognition. He/she required extensive assist of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene and did not walk. He/she had impairment in range of motion (ROM) for one side of the upper extremity and both sides of the lower extremities and he/she used a wheelchair for mobility. Staff did not mark the functional mobility section or whether staff believed the resident was capable of more independence. The quarterly MDS dated [DATE] included the same cognition ability as the 8/7/17 MDS. He/she required total dependence on two or more staff for bed mobility and transfers, total dependence of 1 staff for toilet use and did not walk. He/she had impairment in ROM on one side for the upper extremities and one side on lower extremity. He/she used a wheelchair for mobility. The cognition and fall care area assessment (CAA) dated 8/21/17 did not include an analysis of findings or further assessments and the activities of daily living (ADL) CAA did not trigger for a further review. Review of the care plan initiated on 10/8/15 and still in effect when reviewed on 12/5/17 revealed the following: the resident required extensive assistance of 1 staff to reposition and turn in bed, to dress, to use the toilet and personal hygiene with total assistance of 2 staff and a mechanical lift to transfer. The plan directed staff to encourage the resident to participate to the fullest extent possible with each interaction. The resident was able to identify self and needed extensive to full assistance with all decision making. Staff should engage the resident in simple, structured activities which avoided overly demanding tasks. The resident sat at the restorative dining table and was on a restorative dining program with See ADL section for specific restorative plan instructions. The ADL self-care deficit plan did not include any instructions about a restorative program. Review of a physical therapy progress note and discharge summary signed by a physical therapy staff OO on 4/14/17 revealed the resident received therapy services to improve his/her ROM in both knees and met the goal. Therapy staff OO developed a functional mobility plan (FMP) which indicated the resident could perform passive stretching with better tolerance and less pain with increased periods of flexibility and functional positioning while in bed and the wheelchair. The discharge from therapy plan directed to continue with the FMP for passive stretching. A request for documentation of restorative nursing services following the above therapy was made on 12/6/17 and the facility did not provide any evidence of staff providing restorative nursing services or the FMP. The resident again received physical therapy services between 9/1/17 and 9/22/17 with a goal to increase passive ROM both hips and both knees related to contractures in both hips and both knees. The physical therapy notes signed by therapy staff OO on 9/22/17 indicated the resident met the goal of therapy and discontinued therapy. Therapy established a FMP and instructed staff in follow-up care. The analysis of functional outcome indicated the resident gained ROM which impacted his/her ability to perform positioning. The skilled services provided included therapeutic exercise to increase passive ROM and increase positioning options. The resident's deficits in ROM persisted; however, caregivers reported ease in positioning in the bed and wheelchair. A request for documentation of restorative nursing services following the above therapy was made on 12/6/17 and the facility did not provide any evidence of staff providing restorative nursing services or the FMP. The 12/6/17 PT evaluation identified the resident needed skilled therapy services to establish a restorative nursing program related to contractures of lower extremities for passive ROM. Review of the PT evaluation revealed the resident had a deficit in ROM in both shoulder joints, right elbow and wrist, both hips, both knees and both ankles. The joint movement measurements from 12/6/17 when compared to measurements obtained on 9/22/17 showed a decline in ROM for his/her right hip from 45 degrees to 40 degrees, left hip from 30 degrees to 10 degrees and left knee from 45 degrees to 35 degrees. Observation on 12/4/17 at 8:32 AM revealed direct care staff C and direct care staff J assisted the resident from the wheelchair to the bed using a total body mechanical lift (a mechanical device to lift and support the entire body weight during a transfer). During the transfer and once in bed the resident's legs never straightened and remained bent at the knee. When direct care staff C attempted to straighten the resident's legs to adjust clothing and provide cares the staff was only able to straighten the resident's legs a few more degrees. Direct care staff C assisted the resident to roll onto his/her side in order to provide perineal care. Direct care staff C assisted the resident onto his/her right side; both of the resident's arms were drawn up tight to the body, the legs remained flexed at the hip and knees. Direct care staff C placed a flat thin pillow between the resident's knees and could only separate the knees about 6 inches. Staff C reported he/she used the pillow to keep the resident's knees apart. On 12/6/17 at 10:40 AM observation and interview with licensed nurse E confirmed the resident had contractures of both elbows, the right wrist, both hips and both knees with his/her legs drawn up. Licensed nurse E removed the thin pillow positioning device between the resident's knees and discovered it was not a pillow but 2 bath blankets in a zippered pillow case. The blankets were separated in the middle of the case and that was the portion which was between the resident's knees and licensed nurse E confirmed the item was not an effective device to maintain the resident's natural body alignment and to help promote the resident's ability to abduct (move away from the center of the body) the hips and legs. Interview with direct care staff D on 12/5/17 at 1:06 PM revealed the resident did not have a restorative program. He/she said the resident used to be on the restorative dining but he/she quit trying to feed him/herself. Direct care staff D reported the resident was not on any restorative programs following therapy treatment in (MONTH) (YEAR). Interview on 12/6/17 at 1:20 PM with administrative nurse S confirmed the resident did not have a restorative program and in fact the facility did not have a restorative nursing program when he/she began employment in (MONTH) (YEAR). He/she reported the interdisciplinary team met on 10/8/17 and discussed the restorative nursing program. The team decided the 40 residents at that time with programs were not being provided by the 1 direct care staff assigned to do restorative. The team planned for therapy to screen residents for restorative programs and resident #18 was not on the list. The facility's policy titled Goals and Objective for Restorative Services (MONTH) 2013 directed staff should develop rehabilitative goals and objectives for each resident and outline the goals/objectives in his/her plan of care relative to therapy services. The facility failed to provide appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for this resident who had limited ROM in both upper and lower extremities and received skilled therapy services to improve his/her ROM and to establish a functional mobility plan in (MONTH) of (YEAR). The facility's failure to provide the restorative nursing services resulted in a decline in ROM to both hips and left knee. - Review of resident #1's Physician order [REDACTED]. cause) [MEDICAL CONDITION] (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), [MEDICAL CONDITION] (progressive disease of the nerve fibers of the brain and spinal cord), and non-displaced [MEDICAL CONDITION] leg bone just below the knee and fracture of thigh bone. The annual minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment with no behaviors. The resident required extensive assistance of 2 staff for bed mobility, dressing, toilet use and extensive assist of 1 staff for personal hygiene with total assistance of 2 staff for transfers and used a wheelchair. He/she had functional limitation in range of motion (ROM) on both sides of the lower extremities. The resident did not receive physical or occupational therapy or restorative nursing during the 14 day observation period. The quarterly MDS dated [DATE] included a BIMS score of 6 indicating severe cognitive impairment and the resident rejected care daily. He/she required extensive assistance of two or more staff for bed mobility, dressing, personal hygiene, and toilet use, limited assistance of one staff for eating, total dependence of 2 or more staff for transfers. The resident was not steady and only able to stabilize with human assistance for moving from a seated to standing position. He/she had impaired ROM on both sides of the lower extremities and used a wheelchair. He/she received no therapy or restorative services during the 14 day observation period. The cognition care area assessment (CAA) dated 11/25/16 did not include an analysis of findings and did not have evidence of a further assessment of the resident's cognitive abilities. The activities of daily living (ADL) CAA dated 11/25/16 indicated the resident had physical limitations due to obesity and lacked motivation to get out of bed. He/she had difficulty with movement and required extensive to total assistance, even for bed mobility. The care plan initiated on 9/1/15 and still in effect when reviewed on 12/5/17 included the following: staff should provide ROM (active or passive) with morning and evening care daily. Staff should encourage the resident in daily exercise and mobility as tolerated. Encourage/provide gentle range of motion as tolerated with daily care. Use adaptive devices as recommended by therapy or physician and monitor for safe use. The resident had a history of [REDACTED]. Staff should follow physician orders [REDACTED]. Teach the purpose of and the procedure for performing isometric (muscular action in which tension is developed without contracture of the muscle) and flexion/extension exercises. Staff should provide daily ROM exercises both active and passive as tolerated and educate the resident on joint conservation techniques. Physician and occupational therapy consult may be indicated. Staff should monitor/document/report to the physician as needed (PRN) for signs and symptoms or complications related to arthritis such as: joint pain, joint stiffness which was usually worse on wakening, swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing. The resident should use supportive devices such as splints, braces, canes, crutches and such as recommended by occupation therapy. Staff should provide extensive assistance of 1 staff for mobility, extensive assistance of 2 staff for dressing and total assistance of 2 staff with transfers by total body mechanical lift (a mechanical device to lift and support the entire body weight during a transfer). Review of the scanned documents between 1/1/17 and 12/6/17 in the resident's electronic record revealed no recommendations from physical or occupational therapy or restorative nursing services. Observation on 12/5/17 at 6:41 AM revealed direct care staff HH assisted the resident back in the room from the shower in a wheeled shower chair. Direct care staff JJ and HH used a total body lift to transfer the resident from the shower chair to the bed. Once in the bed the resident could assist some with bed mobility using the upper extremities but the right leg remained fully extended and dependent on staff to move. The resident's right foot had toes and sole of the foot flexed in a downward position and which the resident could not flex the toes back to a neutral position. Observation on 12/5/17 at 7:15 AM revealed the resident in a wheelchair with his/her legs out straight on the foot pedals of the wheelchair. His/her feet were bare and both feet and toes were flexed downward without any support. The foot pedal on the wheelchair made contact with the ball of the right foot but did not put the foot into a normal flexed position. The resident's left foot could dorsiflex (flexion of the foot in an upward direction) and plantar flexion (foot or toes flex downward toward the sole of the foot) with normal movement by the resident. Interview on 11/30/17 at 8:16 AM the resident revealed he/she could state the correct day of the week, month and year. He/she provided a history of his/her health conditions and course of care at the facility. He/she reported having a decline in use of the right leg after surgery to repair the broken bones. He/she felt like he/she could not get the strength back in the leg to be able to stand or walk. He/she did not like therapy and did not know if he/she ever exercised with restorative nursing. He/she reported trying to put weight on the leg by pushing on the foot pedal of the wheelchair. Interview on 12/5/17 at 1:06 PM with direct care staff D reported about 6 months ago the resident was on a restorative program but he/she frequently refused. Staff D indicated there was no documentation about the refusals or alternative measures tried. The plan included upper and lower ROM. Direct care staff D said the resident worked with restorative for about 3 days. Direct care staff D did not know if the resident had pain medications before the attempted exercises, had warm packs or any other interventions to make the exercises easier for the resident and improve his/her compliance. He/she did not know if staff notified the nurse about the refusals or if alternative measures were attempted. He/she felt like the resident was afraid and did not want the right knee bent. He/she noticed the resident was not moving the right ankle as much as he/she used to. He/she reported therapy talked about screening the resident for a program about a week ago. Interview on 12/6/17 at 1:20 PM with administrative nurse S confirmed the resident did not have a restorative program and in fact the facility did not have a restorative nursing program until 10/8/17. Since 10/8/17 when the interdisciplinary team met to discuss the previous 40 resident who had plans and evaluate with therapy to screen residents for a restorative program the resident was not in that group. The facility's policy titled Goals and Objective for Restorative Services (MONTH) 2013 directed staff should develop rehabilitative goals and objectives for each resident and outline the goals/objectives in his/her plan of care relative to therapy services. The facility failed to provide appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for this resident who had limited ROM in the right lower extremity or evidence of trying alternative interventions to increase compliance/decrease refusals of interventions.

The facility census totaled 61 residents, with a sample of 17 residents. Based on observation, interview and record review the facility failed to identify causal factors to identify interventions to prevent falls for 2 of 6 residents sampled for accidents. The failure led to numerous falls, which caused bruising, possible concussion, and a laceration that required sutures for resident #30. The facility further failed to develop interventions to prevent multiple falls and/or failed to determine causal factors related to falls for resident #24. Findings included: - Review of resident #30's physician order [REDACTED]. repeated [MEDICAL CONDITION]). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of zero, which indicated the resident had severely impaired cognition. The resident had no falls since admission or the prior assessment. The resident had physical behaviors directed toward others 1-3 days of the look back period. The resident had no rejection of care identified on the assessment. Review of significant change MDS dated [DATE] revealed the resident had a BIMS score of 10, which indicated moderate cognitive impairment. The resident had no [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness) or behaviors identified on the assessment. The resident required extensive assistance of one to two staff for activities of daily living (ADLs). The resident had no falls since the prior assessment. Review of the fall care area assessment (CAA) dated 6/27/17 revealed the resident was unsteady and able to stabilize with staff assistance. The resident had a BIMS score of 10 which indicated moderate cognitive function. The resident had clear speech, made him/herself understood, and usually understood others. The resident had frequent pain and used as needed (PRN) medication for pain. The resident required one person assistance with activities of daily living (ADLs). The resident had incontinence of bowel and bladder. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed the resident had a BIMS of 8, which indicated moderate cognitive impairment. The resident had no change in behaviors or [MEDICAL CONDITION] since the prior assessment. The resident fell on ce with no injury and once with injury (except major) since the prior assessment. Review of the resident's admission care plan dated 12/22/16 revealed the following interventions: Staff would evaluate for unsteady gait. The resident used ambulation devices as necessary. Staff instructed the resident on appropriate safety measures. Staff assessed the resident's cognitive status and ability to ask for assistance. Staff assessed the resident's footwear for fit and non-skid soles. The resident had a high fall risk. Review of the resident's care plan revealed the resident had no fall interventions initiated on his/her comprehensive care plan, due 1/11/17 until 2/8/17. Review of the resident's comprehensive care plan revealed the following interventions dated 2/8/17: Staff would know the resident had [MEDICAL CONDITION]. Staff provided activities that promoted exercise and strength building when possible. Physical therapy consults for strength and mobility if needed. Review of the nurse's note dated 1/4/17 at 11:50 AM revealed staff found the resident on the floor of his/her bedroom on his/her left lateral side, at the foot of his/her bed with his/her head facing the door. The resident had a small raised area the nurse felt just under his/her left eyebrow. The resident had no other signs of injury identified on the assessment. The resident stated, I just was walking around my bed and slipped and fell . The resident further stated he/she lost his/her footing and hit his/her head. Review of the fall investigation dated 1/4/17 revealed the resident fell from bed. The resident had on slipper socks (the investigation did not specify if the resident's socks had grips present at the time of the fall) and no shoes at the time of the fall. Staff found the resident on the floor alone and unattended. The staff visualized and toileted the residents 3 to 5 minutes prior to his/her fall. The resident fell while staff obtained coffee for the resident. The intervention identified on the investigation stated the resident would be provided education to utilize shoes, grip socks and call staff for assistance. Review of the resident's admission care plan dated 12/22/17 revealed an intervention in place to use non-skid soles, the same as the intervention for the 1/4/17 fall. Review of the Morse Fall Scale dated 1/4/17, completed post fall revealed the resident had a high risk for falls. The Morse fall scale assessment evaluated the resident's history of falling, diagnoses, intravenous access, the resident's gait and mental status. Review of the nurse's note dated 1/15/17 at 9:17 AM revealed staff found the resident on his/her right side on the floor in his/her bedroom. The resident stated he/she slipped and fell . The resident had no injury identified. Staff assisted the resident up and sat him/her on his/her bed. The note stated the resident had nothing on his/her feet when he/she fell and his/her bed sheet and blankets were tangled on the floor. The resident could not state the cause of the fall. Review of the fall investigation dated 1/15/17 revealed the resident wore regular socks without slip prevention grips on the bottom. The fall investigation lacked a full assessment of the fall, which included evaluation of all causal factors that led to the resident's fall and/or interventions to prevent further falls. Review of the Morse Fall Scale dated 1/15/17, completed post fall revealed the resident had a high risk for falls. Review of the fall investigation dated 1/17/17 at approximately 10:30 AM revealed the resident fell from the wheelchair unwitnessed in the hallway. The resident sat in the wheelchair waiting to go outside alone and unattended. The fall investigation lacked a full assessment of the fall, which included evaluation of all causal factors that led to the resident's fall, identification of a root cause of the fall and/or interventions to prevent further falls. Review of the late entry nurse's note dated 1/17/17 revealed the resident fell in the social service office. The resident stood up, became dizzy, and fell backwards. The resident hit the back of his/her head on the wall. Review of fall investigation dated 1/17/17 with no time (of fall recorded) revealed the resident had dizziness at the time of his/her fall, was last toileted at 11:30 AM, was wet, and had dizziness while direct care staff assisted with incontinence care. The resident had slippers (the investigation did not specify if the resident's slippers had grips or soles present) on at the time of the fall. The resident stood up and fell straight back between a chair and the wall. The fall investigation lacked a full assessment of the fall, which included evaluation of all causal factors that led to the resident's fall, identification of a root cause of the fall and/or interventions to prevent further falls. Review of the Morse Fall Scale dated 1/18/17, completed post fall revealed the resident had a high risk for falls. Review of the resident's care plan lacked an intervention for the fall dated 1/17/17. Review of the nurse's note dated 1/18/17 at 11:28 AM revealed the resident fell from his/her wheelchair and stated he/she tried to scoot back in his/her wheelchair and fell out on the floor. The resident hit the left side of his/her forehead and had a red left eye. The resident's pupils measured 4 millimeters (mm) on the right eye and 3 mm on the left eye. Staff notified the resident's provider of the different pupil sizes, who gave instruction to monitor the resident and notify him/her of any changes in the resident's condition. Review of the fall investigation dated 1/18/17 lacked a full assessment of the fall, which included evaluation of all causal factors that led to the resident's fall, identification of a root cause of the fall and/or interventions to prevent further falls. Review of the Morse Fall Scale dated 1/18/17, completed post fall revealed the resident had a high risk for falls. Review of the resident's care plan lacked an intervention for the fall dated 1/18/17. Review of the nurse's note dated 1/24/17 at 11:37 AM revealed the resident fell while propelling his/her wheelchair into the dining area of the facility. Dietary staff reported the resident leaned forward which caused the resident to fall onto the floor. The nurse writer found the resident on his/her left side. The resident stated he/she tried to get hold on to the wall to help move his/her wheelchair and fell . The nurse writer spoke with therapy services because the wheelchair pad the resident used did not fit his/her chair appropriately. Staff noted as a potential intervention, therapy would evaluate and change the resident's wheelchair pad for safety and positioning. Review of the fall investigation dated 1/24/17 with a time of 11:00 AM revealed the causal factor observed at the time of the fall was an equipment malfunction/wheelchair pad the wrong size. The resident had on slippers (the investigation did not specify if the resident's slippers had grips or soles present) at the time of the fall. Review of the resident's admission care plan revealed an intervention dated 1/24/17 for therapy to change the resident's wheelchair cushion to fit appropriately. Review of the nurse's note dated 1/28/17 at 6:19 PM revealed the resident fell in the dining room. Staff witnessed the resident start to stand up, turned and sat down on the floor. Review of the fall investigation dated 1/28/17 revealed staff witnessed the resident attempt to stand up and sat down on the floor. The resident stated he/she fell out of his/her wheelchair. The fall investigation lacked a full assessment of the fall, which included evaluation of all causal factors that led to the resident's fall, identification of a root cause of the fall and/or interventions to prevent further falls. Review of the nurse's note dated 2/1/17 at 4:28 PM revealed the resident continued to show a decline in his/her activities of daily living (ADLs). Review of the nurse's note dated 2/23/17 at 7:00 PM revealed the resident fell in the dining room and staff found him/her on his/her left side with his/her left arm cradling his/her head. The resident had his/her eyes closed, but responded appropriately when spoken to. The nurse writer noted a bump to the left side of the resident's forehead. The resident stated he/she wanted to go back to his/her room and could not pass the dining table so he/she stood up and attempted to move the table out of his/her way and fell . Review of the fall investigation dated 2/23/17 at 5:45 PM identified the root cause of the resident's fall as trying to move table. The resident's wheelchair brakes were unlocked. The investigation identified the resident as unattended, but not alone. The resident waited in the dining room for his/her dinner. Direct care staff reported they thought the resident fell for attention. The fall investigation identified the resident as able to toilet self and last toileted at 3:30 PM. The resident identified the dining table as too heavy for him/her to move when he/she wanted to return to his/her room. Staff educated the resident to ask for assistance. Review of the resident's care plan lacked an intervention related to the fall dated 2/23/17. Review of the fall dated 3/1/17 at 6:15 PM revealed the writer walked past the resident's room and heard a noise of something falling, opened the resident's door and found the resident on his/her side. The resident had his/her knees curled to his/her chest with his/her jacket half on. The resident reported he/she stood up to put on a thicker jacket, lost his/her balance and fell . The resident stated he/she hit his/her head on the closet door. Review of the fall dated 3/1/17 identified the root cause of the resident's fall as the resident not calling for help. The intervention placed to prevent future falls would be educate resident to call for help and to make sure the resident had a thicker jacket. Review of the resident's care plan lacked an intervention related to a fall on 3/1/17. Review of the nurse's note dated 3/7/17 at 8:02 AM revealed the resident fell on [DATE]. Staff notified the nurse writer the resident had bruising to his/her bilateral thighs, left buttock, left rib area and abdomen. Review of the fall investigation dated 5/27/17 revealed the resident had a witnessed fall in the hallway attempting to self-transfer. The investigation identified the resident as more confused than normal and with a change in mental status. Staff found the resident sitting on the floor with his/her wheelchair behind him/her near the entry way. The resident wanted out of the building and purposefully threw him/herself on the floor and landed on his/her hands and knees. The investigation further stated, 10 minutes after the resident's first fall, staff found the resident next to his/her wheelchair in the dining room. The resident slid him/herself from the wheelchair. Staff noted the intervention they implemented as staff would do 15 minute visual checks and obtain a urinalysis test as ordered by the resident's physician. The facility identified the root cause of the falls as confusion and behaviors. Review of the nurse's note dated 5/28/17 at 4:16 AM revealed the resident fell at around 7:05 PM (5/27/17). Direct care staff reported the resident threw him/herself to the floor attempting to go out of the building. Review of the nurse's note lacked an observation of the resident sliding him/herself from the chair in the dining room, which led to the second fall. Review of the resident's care plan revealed an intervention dated 5/27/17 to place the resident on 15 minutes visual checks and do a urinalysis with culture and sensitivity as indicated. Review of the nurse's note date 6/4/17 at 7:38 PM revealed the resident fell in the main dining room. The resident reported he/she leaned forward to pick up something from the floor and fell . Review of the fall investigation dated 6/4/17 identified the root cause of the fall as the resident leaned too far trying to reach for something on the floor. Staff educated the resident on fall prevention. Review of the resident's care plan lacked an intervention related to the fall on 6/4/17. Review of the nurse's note dated 6/5/17 at 6:05 PM revealed the resident fell after becoming angry. Another resident witnessed the fall and felt the resident threw him/herself onto the floor, straight onto his/her buttocks. Review of the fall investigation dated 6/5/17 revealed the resident became restless and kept leaving the dining room after staff brought him/her in for dinner. Staff redirected the resident multiple times. The investigation identified the root cause of the fall as the resident was mad he/she could not go outside again so he/she threw him/herself on the floor. Staff noted the intervention placed after the fall instructed staff to do 15 minute visual checks of the resident, though the intervention was care planned on 5/27/17. Review of the resident's care plan lacked any update for the fall dated 6/5/17. Further review of the care plan lacked intervention related to the resident's behavior of throwing him/herself on to the floor. Review of the nurse's note dated 7/16/17 at 8:49 AM revealed the resident fell from his/her bed. Staff observed the resident on the floor between the bed and nightstand. The resident stated he/she rolled from the bed while he/she attempted to transfer him/herself from the bed to the wheelchair. Review of the fall investigation dated 7/16/17 revealed the resident slipped from his/her bed when he/she attempted to transfer him/herself. The resident wore socks at the time of the fall. The investigation identified the root cause of the fall as the resident lost his/her balance when attempting to self-transfer. Direct care staff reported the resident's feet were tangled in his/her covers. The intervention placed at the time of the fall included to remind the resident to call for help and wait for help to arrive to prevent further falls. The interdisciplinary team recommended putting a comforter on the resident's bed. Review of the fall dated 7/16/17 at 10:01 PM revealed staff found the resident half way between his/her wheelchair seat and the floor. The resident stated he/she slipped halfway and could not stand up. Staff educated the resident not to get up without help and showed him/her how to use his/her call light and placed a bed alarm (a personal alarm that allows staff to monitor the activity of a resident in bed) on the resident's bed. Review of the resident's care plan revealed an intervention dated 7/19/17 (3 days after the fall) to place a fall mat on the resident's floor and use a comforter to help with reduction of risk for body entanglement. The care plan lacked an intervention related to the use of a bed alarm for the resident. Review of the nurse's note dated 8/23/17 at 7:39 PM revealed the resident sat in his/her wheelchair and asked for another blanket. Staff went to get the resident a blanket and the resident stood up, tripped on the fall mat and fell to the floor where he/she hit his/her head on the tile. The resident had a hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma) that measured 6 centimeters (cm) by 5 cm by 1 cm to right side of his/her forehead. Staff applied ice to the hematoma. Review of the nurse's note dated 8/23/17 at 8:41 PM revealed the administrative nursing staff told the nurse writer to send the resident to the hospital for an x-ray (a photographic or digital image of the internal composition of something, especially a part of the body). Review of the fall investigation dated 8/23/17 revealed the resident fell at 7:15 PM. The resident tripped on a mat on the floor and hit the right side of his/her head. Staff last toileted the resident at 4:00 PM. The investigation revealed the resident had a chair alarm (a sensor pad placed in a resident's wheelchair or standard chair that alerts staff with a sounding alarm when weight is lifted from the sensor pad) in place, but it had been taken off. The investigation identified the root cause of the fall as staff would assure the resident had an alarm on. Staff would not leave the resident in his/her room by him/herself in the wheelchair and staff assisted the resident to bed before leaving. Staff placed the resident's body alarm back on as an initial intervention to prevent future falls. Review of the nurse's note dated 8/24/17 at 1:30 AM revealed the resident returned from the hospital. The resident's hematoma had decreased in size to his/her right forehead. The injured area turned different shades of purple. The hospital reported to staff the resident's x-ray came back negative. The hospital further stated the resident might have a slight concussion, but no acute bleeding. Staff were instructed to ensure the resident had a chair alarm on when in his/her wheelchair and ensure the alarm activated. The resident would not to be left in his/her wheelchair in his/her room alone. Staff had to change alarm clasps to ensure the resident could not remove it and throw it away. Review of the resident's care plan revealed an intervention dated 8/24/17 after the resident self-transferred and fell in his/her room. The resident went to the emergency room for an x-ray, and the hospital reported the results were negative. Staff placed a sensor alarm on the resident's wheelchair. The care plan lacked interventions to ensure the resident would not be left alone in his/her wheelchair in his/her room or to change alarm clasps to ensure the resident did not remove/throw it away. Review of the nurse's note dated 8/28/17 revealed the resident had bruising to his/her right shoulder, a right black eye and a raised area to the right side of his/her forehead. The resident was noted to walk in his/her room without assistance and the writer reminded the resident to use his/her wheelchair at all times. Review of the resident's care plan revealed the facility discontinued the resident's sensor alarm on 10/9/17 when the resident removed the alarm multiple times. Review of the nurse's note dated 10/13/17 at 10:53 AM revealed staff entered the resident's room to perform a skin assessment and found the resident in his/her bed with blood running down the right side of his/her head from a laceration above the right eye. Staff cleansed the area and applied pressure. The writer received an order to transport the resident to the emergency room for evaluation and treatment. The resident stated he/she went to the bathroom and lost his/her balance. Staff reported finding blood spots on the floor between the resident's bed and the bathroom door. Review of the fall investigation dated 10/13/17 revealed the resident attempted to self-transfer, while alone and unattended. The resident fell when he/she attempted to go to the bathroom. The resident had a working bed alarm on at the time of the fall, although the investigation lacked evidence the alarm sounded when the resident got up from the bed. Staff last toileted the resident at 7:00 AM and took the resident to breakfast. When the resident returned to his/her room at 8:00 AM the resident denied the need to toilet and attempted to take him/herself to the bathroom at approximately 10:00 AM (per nurse's note). The facility identified the root cause of the fall as the resident got up without assistance. The resident had a fall mat on the floor that created an uneven surface and he/she lost his/her balance. The facility moved the fall mat as an initial intervention to prevent further falls. Review of an interdisciplinary team note dated 10/13/17 revealed the resident was very unstable with his/her transfers and ambulation and attempted to transfer him/herself. The note stated the resident had several falls and had 2 [MEDICAL CONDITION] on his/her face. The interdisciplinary team recommended to send the resident to the emergency room for treatment. Staff would place the resident's fall mat under the bed during day hours and beside the bed at night. Review of the hospital discharge instructions dated 10/13/17 revealed the resident had a head injury; laceration of the right eyebrow and periorbital (skin and tissues in the front of the eye) hematoma of the right eye. The resident's sutures needed to be removed in 5 days. Review of skin observation tool dated 10/13/17 revealed the resident had a face laceration and black right eye. The resident had swelling to both eyes. The resident had 4 sutures to a laceration in his/her right eyebrow, bruising to right forehead and small bruises to upper extremities. Review of the resident's care plan dated 10/13/17 revealed staff would put the resident's fall mat under his/her bed during day hours and beside the bed at night. Review of the nurse's note dated 11/20/17 at 7:40 AM revealed the resident fell in the dining room. The resident sat at the dining room table, stood up, tried to walk and fell . The resident landed on his/her back with his/her head off the floor. Further review of the interdisciplinary team meeting at 3:14 PM revealed they recommended the resident have a medication review with his/her provider. Review of the fall investigation dated 11/20/17 revealed the root cause of the fall as the resident attempted to ambulate without assistance. The facility moved the resident to a more visible table in the dining room as an intervention to prevent a future fall. Review of the resident's care plan updates dated 11/20/17 revealed the following: The resident fell in dining room. Perform medication review with labs. Review of the nurse's note dated 11/26/17 at 2:18 PM revealed the resident had an unwitnessed fall. Review of the fall investigation dated 11/26/17 revealed the resident fell at 11:00 AM after he/she lost strength/appeared to get weak. Staff found the resident on the floor in the dining room. The resident had on regular socks at the time of the fall. Staff would make more frequent rounds while the resident was in the dining room and assure proper non-skid socks/shoes in place. The investigation identified the root cause of the fall as the resident's footwear, weakness and he/she walked with non-grip socks. Review of the resident's care plan revealed the following interventions. 11/26/17 - Resident would wear gripper socks or shoes with rubber soles. This intervention was originally placed on the 12/22/17 admit care plan, added again to the 1/4/17 fall and did not make it to the comprehensive care plan until 11/26/17. 11/27/17 - Nursing would make frequent rounds in the dining room during meal times Observation of the resident on 11/29/17 at 9:36 AM revealed the resident sat in his/her wheelchair in the hallway outside of his/her room. The resident had his/her chin on his/her chest with eyes closed. Direct care staff C attempted to wake the resident by touching his/her shoulder and stating his/her name. The resident continued to sleep. Licensed nurse staff G walked up and stated the resident appeared very sleepy. Staff G stated he/she thought the resident did not sleep the night before. Staff G and C wheeled the resident to his/her room. During interview with direct care staff L on 12/6/17 at 12:42 PM revealed the resident had not had too many falls, however he/she had a few falls in the last month. Staff L stated he/she checked on the resident more. He/she stated as interventions to prevent falls he/she offered the resident more help with ADLs, the resident has a fall mat on the floor and he/she believed the resident had some medication changes recently. During an interview with licensed nursing staff G at 12:43 PM on 12/6/17 revealed the resident had several falls. The resident often tried to transfer him/herself. The resident had an alarm on at one time. The resident had a fall that required 4 stitches above the eye, but no broken bones. Facility staff re-evaluate effectiveness of interventions by watching the resident and changing interventions as needed. Staff G stated there were times residents thought they were independent when they were not. During an interview with licensed nursing staff M at 2:24 PM on 12/6/17 the resident had several falls. The resident required a low bed and fall mat as fall interventions to prevent future falls. The facility did not use restraints or alarms. The resident had a room near the nurse's station and staff left the door open so they could view the resident when they checked on him/her a little more frequently. Staff M stated facility nurses placed interventions on the care plan immediately after a resident's fall. They assess the resident/circumstances to find out the root cause of the fall. The nurses then looked at appropriate interventions such as shoes or gripper socks after a fall. He/she tried to place appropriate interventions to keep the resident safe. He/she believed the resident had no major injuries with his/her falls. During an interview with administrative staff S at 12:50 PM on 12/6/17 revealed staff evaluated falls in daily clinical meetings. Staff S stated the clinical team discussed the root cause of resident falls in their daily clinical meetings, however they were not documenting the root cause they establish as a result of the meeting anywhere or updating fall investigations with the root cause of a fall after the interdisciplinary team reviewed the fall. Staff S stated after a resident fell he/she expected nursing staff to put an immediate intervention on a resident's care plan to keep the resident safe/prevent a fall. He/she stated if nursing staff could not identify an appropriate intervention after a fall he/she expected staff to call him/her and discuss the circumstances around the fall. Review of the policy Falls - Clinical Protocol revised 9/2012 revealed for an individual who has fallen, staff would attempt to define possible causes within 24 hours of the fall. If underlying causes could not be readily identified or corrected staff would try various relevant interventions based on assessment of the nature of the falls, until falls reduced or stopped or until the facility identified a reason to continue the intervention (example: if the resident continued to try to get up and walk without waiting for assistance). The facility failed to evaluate causal factors, identify root cause and place appropriate interventions to prevent falls which led to multiple episodes of bruising, a possible concussion, and a laceration, which required sutures for resident #30. - Review of resident #24's signed physician orders [REDACTED]. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 0, which indicated severe cognitive impairment. The resident had no behaviors. The resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use. The resident had no history of falls. Review of the quarterly MDS dated [DATE] revealed a BIMS of 6, which indicated severe cognitive impairment. The resident had no behaviors. The resident required extensive assist of one staff for bed mobility, dressing, and toilet use and two staff assistance for transfers. The resident had two non-injury falls and one minor injury fall since the last assessment. Review of the cognitive loss/dementia care area assessment (CAA) dated 7/4/17 revealed the resident was alert to person, had clear speech, made him/herself-understood and usually understood others. The resident admitted to hospice related to his/her cognitive decline. The resident required extensive assist of 1-2 staff for activities of daily living (ADLs). Review of the falls CAA dated 7/4/17 lacked a further analysis of findings to include risk factors and causes and contributing factors. Review of the resident's care plan revealed the following interventions: 4/20/17 - Staff would provide activities that promoted exercise and strength building where possible. Physical therapy (PT) consult for strength and mobility. Review of the nurse's note dated 5/3/17 at 2:52 AM revealed the resident's roommate put on his/her call light to report the resident fell . Staff found the resident on his/her left side, next to his/her bed. The resident had a small abrasion noted to the corner of his/her left eye with a moderate amount of bleeding noted. Review of the resident's care plan revealed an intervention to put the resident's bed in lowest position dated 5/12/17, 9 days after the resident fell . Review of the nurse's note dated 8/23/17 at 8:30 PM revealed the resident fell . The resident remained confused and able to answer question. The resident stated he/she reached for the box to crawl through. The nurse writer provided reorientation to the resident. Staff were educated on more visual checks and fall prevention. Review of the fall investigation dated 8/23/17 revealed the root cause of the resident's fall as the resident was more awake and talkative from his/her shower. The intervention placed to prevent further falls was positional pill(TRUNCATED)

The facility census totaled 68 residents with 1 resident reviewed for an allegation of abuse. Based on observation, interview, and record review the facility failed to provide adequate supervision to a mobile resident (#3) who was found sexually abusing resident #5. The facility also failed to immediately report an allegation of resident-to-resident abuse which involved resident #3 to the state agency, failed to thoroughly investigate the incident, and failed to submit the results of an investigation to the state agency within 5 working days. The failure to implement appropriate actions to protect all residents after the allegation of resident-to-resident sexual abuse placed all the residents in immediate jeopardy. Findings included: - Review of resident #3's signed physicians orders dated 4/18/17 included [DIAGNOSES REDACTED]. Review of the significant change minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 14, which indicated intact cognition. The resident had no behaviors, no [MEDICAL CONDITION] and prior behaviors improved. The resident required limited assistance of 1 staff for all activities of daily living (ADLs) except extensive assistance of 1 staff for personal hygiene and locomotion. The resident used a wheelchair for mobility. The resident received an antipsychotic, antidepressant, and hypnotic (medication used to induce sleep and treat [MEDICAL CONDITION]), daily for 7 days of the observation period. Review of the [MEDICAL CONDITION] (a medication capable of affecting the mind, emotions, and behavior) drug use care area assessment (CAA) dated 2/8/17 revealed the resident received antidepressant, antianxiety, antipsychotic and hypnotic medications to treat the residents different diagnoses. The resident had a BIMS of 14 and no cognitive impairment. He/she exhibited unsteady balance at times and needed limited assistance with transfers and mobility. Review of the ADL functional CAA dated 2/8/17 revealed the resident needed limited assistance of 1 staff for most ADLs but needed extensive assistance with locomotion and personal hygiene. The resident walked with limited assistance of 1 staff. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 0, which indicated severe cognitive impairment. The resident had adequate hearing with clear speech and was able to understand others and make self-understood. The resident had physical behaviors directed toward others 1-3 days of the 7 observation days. The resident also required extensive assistance of 1 staff with all ADLs except supervision and set up with eating, and required a wheelchair for mobility. The resident received an antidepressant and hypnotic daily for 7 days of the observation period and received an antibiotic 2 out of 7 observation days for a urinary tract infection. Review of the care plan revised on 2/8/17 revealed the resident had a [DIAGNOSES REDACTED]. Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Monitor/document /report to the physician any changes in cognitive function. Administer medications as ordered and monitor/document side effects and effectiveness of medications. Monitor/record occurrences of target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.) Behavioral health consults as needed. Monitor/record/report to the physician as needed any risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone. Review of a witness statement provided by direct care staff A dated 5/29/17 revealed at 10:05 PM staff A walked into resident #3's room and saw him/her standing beside his/her roommates bed, leaning over and trying to get resident #5 to perform a sexual act. Staff asked resident #3 what he/she was doing and resident #5 said No, no, no and explained to staff A what resident #3 tried to get him/her to do. Resident #3 pulled his/her shirt back down and went to his/her bed. Staff A then went and told one of the nurses what happened. Review of licensed nursing staff B's witness statement dated 6/1/17 revealed direct care staff A reported to staff B that he/she found resident #3 standing beside resident #5's bed with his/ her shirt pulled up. Staff A heard resident #5 say No, no and asked resident #3 what was going on. Resident #3 did not respond and resident #5 described the sexual act that resident #3 tried to get him/her to do. When staff B got to the room to assess the situation both residents were in their own beds. Staff B notified administrative staff C who instructed staff B to temporarily move resident #3 to a private room on a different hall. Observation on 6/26/17 at 9:46 AM revealed direct care staff D pushed resident #3 in his/her wheelchair throughout the facility. Staff D told an unidentified nurse aide he/she had to provide one-on-one supervision with the resident. Observation on 6/26/17 at 10:39 AM direct care staff D brought the resident to the hall 3 nurses station and the resident visited with the nurse and other staff. The resident said he/she wanted a cup of coffee so staff D and the resident sat and drank a cup of coffee. Observation on 6/26/17 at 10:53 AM direct care staff D took the resident outside the east side doors for some fresh air. Observation on 6/26/16 at 11:25 AM direct care staff D brought the resident out of his/her room and took the resident to the main dining room for lunch. Staff sat with the resident while the resident ate his/her lunch providing encouragement during the meal. During an interview on 6/20/17 at 1:53 PM resident #5 reported resident #3 was mean to him/her. Resident #3 kissed resident #5 on the lips and tried to get him/her to do something sexually he/she did not want to do. Resident #5 said he/she was afraid of the other resident. The resident reported it to the nurse and the staff moved the other resident out of his/her room. During an interview on 6/20/17 at 3:51 PM social service staff G reported there was 1 incident where resident #3 stood over resident #5 with his/her private parts in resident #5's face. Staff moved the resident to a different hall the night that it happened. During an interview on 6/21/17 at 3:01 PM direct care staff F reported the resident used a wheelchair for mobility and had no difficulty getting around in the facility in his/her wheelchair. The resident could also walk a short distance if he/she desired. During an interview on 6/21/17 at 5:18 PM direct care staff H stated he/she arrived to work at 10:00 PM the night the sexual incident between resident #3 and #5 occurred. Right after the incident staff moved resident #3 to a different hall where staff H worked. The nurse told staff H to make sure the resident did not come out of the room. Staff H said he/she did 15-minute visual checks of the resident to make sure he/she was OK and that he/she stayed in the room. During an interview on 6/21/17 at 2:13 PM licensed nursing staff I stated he/she worked the night of the sexual incident and received a report that resident #3 was very confused and wanted his/her roommate to perform a sexual act. During an interview on 6/21/17 at 4:18 PM licensed nursing staff J reported he/she did not witness the incident but the direct care staff A told him/her what happened. Staff J reported he/she went and checked on the residents just minutes after it happened and both residents were in their own beds. Staff J asked resident #5 what happened and he/she told staff J what resident #3 tried to get him/her to do. Resident # 5 did not act scared but stated he/she did not want it to happen again. Staff J notified administrative staff C and staff C instructed staff J to move resident #3 to a different room. The resident remained in the room the rest of the night. During an interview on 6/26/17 at 5:11 PM licensed nursing staff K stated direct care staff A reported the sexual incident and staff K went to the room and resident #3 was in bed and under the covers. Resident #5 did not say anything about the incident but stated he/she was OK. Staff then moved resident #3 to a different room. During an interview on 6/21/17 at 12:45 PM with administrative staff C and administrative nursing staff L, administrative staff C stated from the report he/she received, staff observed no contact made between the 2 residents and staff moved one of the residents. Staff C stated since there was no actual contact, he/she did not report it. Staff C and staff L both stated they were unaware resident #5 was afraid of resident #3. Administrative nursing staff L confirmed the facility did not protect all of the other residents in the facility by just moving resident #3 to a different room where he/she would have had access to residents on that hall. Administrative staff C thought the issue was just between the 2 residents and moving one resident was appropriate. Review of the facility's undated policy for Abuse, Neglect, and Exploitation (ANE) revealed staff would report all allegations of ANE immediately to the administrator. The administrator would ensure all alleged violations needed to be investigated and reported immediately to the state agency complaint hotline. If any suspected resident to resident abuse, staff would provide continual, uninterrupted 1:1 supervision of the resident until the physician, family and facility management staff assessed the resident and provided treatment to stop any further incidents. The facility failed to report the allegation of sexual abuse to the appropriate state agency, failed to investigate the allegation of abuse, and failed to protect all of the residents in the facility after the sexual abuse occurred. The deficient practice to take appropriate actions to protect all residents from the potential of sexual abuse placed all 68 residents in immediate jeopardy. The facility abated the immediate jeopardy on 6/27/17 at 4:20 PM by the implementation of the following actions: The facility would place the resident on one-on-one monitoring for 72 hours upon return from the hospital until seen by a physician to have lab levels monitored and monitor for behaviors. In-serviced all staff on the proper notification of the administer and director of nursing for all incidents as well as placing the alleged perpetrator on a 1 on 1 supervision to ensure the safety of other residents until an investigation could be completed according to facility policy. Staff were in-serviced on different types of abuse including resident to resident, staff to resident, and visitor to resident and ways to ensure safety of all residents in the facility. The administrator/director of nursing/or designee will ensure proper investigation and appropriate follow up of all allegations and will conduct 2 chart reviews weekly. The deficient practice remained at a scope/severity of a F.

The facility census totaled 68 residents with 1 resident reviewed for an allegation of abuse. Based on observation, interview, and record review the facility failed to ensure resident #5 remained free from sexual abuse when resident # 3 placed his/her private parts in resident #5's face and tried to get resident #5 to perform a sexual act. This deficient practice placed resident #5 in immediate jeopardy. Findings included: - Review of resident #5's history and physical dated 5/13/17 included [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive of 2 staff with bed mobility, transfers, dressing, and toileting. Review of the [MEDICAL CONDITION] drug care area assessment (CAA) dated 5/31/17 revealed the resident received medications to treat his/her [MEDICAL CONDITION] disorder. The resident also needed extensive assistance of 2 staff for bed mobility, transfers. Review of the initial care plan dated 5/18/17 revealed the resident was oriented x 3 and required assistance of 1 using a gait belt for transfers. The resident used a wheelchair for mobility. Review of the comprehensive care plan initiated on 6/2/17 revealed the resident had limited physical mobility and required assistance of staff to complete activities of daily living (ADLs). Review of a witness statement provided by direct care staff A dated 5/29/17 revealed at 10:05 PM staff A walked into resident #3's room and saw him/her standing beside resident #5's bed, leaning over with his/her private parts exposed and trying to get resident #5 to perform a sexual act. Staff A asked resident #3 what he/she was doing and resident #5 said No, no, no and explained to staff A what resident #3 tried to get him/her to do. Resident #3 pulled his/her shirt back down and went to his/her bed. Staff A then went and told one of the nurses what happened. Review of licensed nursing staff B's witness statement dated 6/1/17 revealed direct care staff A reported to staff B that he/she found resident #3 standing beside resident #5's bed with his/her shirt pulled up. Staff A heard resident #5 say No, no and asked resident #3 what was going on. Resident #3 did not respond and resident #5 described the sexual act that resident #3 tried to get him/her to do. When staff B got to the room to assess the situation both residents were in their own beds. Staff B notified administrative nursing staff C who instructed staff B to temporarily move resident #3 to a private room on a different hall. Observation on 6/26/17 at 11:33 AM revealed the resident sat in the dining room waiting for lunch. Resident #3 sat at a table across from resident #5, who ate his/her lunch without any communications with resident #3. During an interview on 6/20/17 at 1:53 PM resident #5 reported resident #3 was mean to him/her. The resident stated resident #3 had kissed him/her on the lips and tried to get him/her to perform a sexual act. The resident stated he/she was afraid of resident #3 and the staff moved resident #3 to a different room. During an interview on 6/20/17 at 3:51 PM social service staff G reported there was 1 incident where resident #3 stood over resident #5 with his/her private parts in resident #5's face. Staff moved the resident to a different hall the night that it happened. During an interview on 6/21/17 at 2:13 PM licensed nursing staff I stated he/she worked the night of the sexual incident and received a report that resident #3 was very confused and wanted his/her roommate to perform a sexual act. During an interview on 6/21/17 at 4:18 PM licensed nursing staff J reported he/she did not witness the incident but direct care staff A told him/her that resident #3 stood beside resident #5's bed and exposed his/her private parts and tried to get resident #5 to perform a sexual act. Staff J checked on the residents just minutes after it happened and both residents were in their own beds. Staff J asked resident #5 what happened and he/she told staff J what resident #3 tried to get him/her to do. Resident # 5 did not act scared but stated he/she did not want it to happen again. Staff J notified administrative staff C and staff C instructed staff J to move resident #3 to a different room. During an interview on 6/21/17 at 12:45 PM with administrative staff C and administrative nursing staff L, administrative staff C stated from the report he/she received, staff observed no contact made between the 2 residents and staff moved one of the residents. Staff C stated since there was no actual contact, he/she did not report it. Staff C and staff L both stated they were unaware resident #5 was afraid of resident #3. Administrative nursing staff L confirmed the facility did not protect all of the other residents in the facility by just moving resident #3 to a different room where he/she would have had access to residents on that hall. Administrative staff C thought the issue was just between the 2 residents and moving one resident was appropriate. Review of the facility's undated policy for Abuse, Neglect, and Exploitation (ANE) revealed staff would report all allegations of ANE immediately to the administrator. The administrator would ensure all alleged violations needed to be investigated and reported immediately to the state agency complaint hotline. If any suspected resident to resident abuse, staff would provide continual, uninterrupted 1:1 supervision of the resident until the physician, family and facility management staff assessed the resident and provided treatment to stop any further incidents. The facility failed to provide an environment free from sexual abuse when resident # 3 placed his/her private parts in resident #5's face and tried to get resident #5 to perform a sexual act. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 6/27/17 at 4:20 PM by the implementation of the following actions: The facility would place the resident on one-on-one monitoring for 72 hours upon return from the hospital until seen by a physician to have lab levels monitored and monitor for behaviors. In-serviced all staff on the proper notification of the administer and director of nursing for all incidents as well as placing the alleged perpetrator on a 1 on 1 supervision to ensure the safety of other residents until an investigation could be completed according to facility policy. Staff were in-serviced on different types of abuse including resident to resident, staff to resident, and visitor to resident and ways to ensure safety of all residents in the facility. The administrator/director of nursing/or designee will ensure proper investigation and appropriate follow up of all allegations and will conduct 2 chart reviews weekly. The deficient practice remained at a scope/severity of a G.

The facility census totaled 69 residents. The sample included 7 residents, of which 1 was sampled for change in condition related to his/her urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview and record review, the facility failed to assess/re-assess a catheter for 1 of 1 residents reviewed for urinary catheters after he/she experienced decreased level of consciousness, which led to emergency transport to the hospital, intubation (placement of a flexible plastic tube into the windpipe to maintain an open airway) and admittance to the critical care unit with a [DIAGNOSES REDACTED]. (#1) Findings included: - Review of resident #1's signed physician orders [REDACTED]. Review of the resident's admission MDS (minimum data set) dated 8/27/16 revealed the resident had long/short term memory problems. The resident required an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Review of the resident's quarterly MDS (minimum data set) dated 11/25/16 revealed a BIMS (brief interview for mental status score) of 9 which indicated moderate cognitive impairment. The resident required an indwelling urinary catheter. Review of the Urinary Incontinence CAA (care area assessment) dated 8/27/16 revealed the resident had an indwelling catheter and the resident received care from an urologist. Review of the resident's care plan revealed interventions with dates of initiation and directed staff to: 8/31/16 - Monitor, document and report to the physician any changes in the resident's cognitive function. Staff specifically would report to the physician, changes in: decision making ability, memory, recall/general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Administer medications as ordered. 12/2/16 -Never allow the resident's catheter bag or tubing to touch the floor. The resident required an 18 French (measurement used to determine the size of a catheter) catheter. The Foley catheter and bag needed changed every 2 weeks and PRN (as needed) per physician orders. The resident's catheter was always to be located below the level of his/her bladder. Provide catheter care and clean around the catheter entrance when they provided incontinence care and PRN. Report any cloudy urine, sediment in urine and/or dark/foul odor to the charge nurse immediately. Review of the resident's physician orders [REDACTED]. 8/19/16 - Irrigate urinary catheter with 30 Milliliters (ml) normal saline-PRN for blockage or sluggishness. 11/5/16 - Facility staff were directed by the resident's physician, to change the resident's Foley catheter and bag every 14 days and PRN to prevent reoccurring UTIs. 12/4/16- The resident received an order for [REDACTED]. Further review of the resident's TAR (treatment administration record) revealed facility staff did not document any irrigation of the resident's catheter during the months of November or December 2016. Review of the resident's progress notes revealed on 12/16/16 at 5:26 AM staff administered [MEDICATION NAME]-[MEDICATION NAME] Tablet (medication used for pain) 10-325 mg 1 tablet by mouth for pain. The progress note lacked a location of pain. Follow up from the pain medication revealed it had been effective. Review of the resident's health status note dated 12/16/16 at 1:53 PM revealed the resident continued with antibiotic therapy for a UTI. Facility staff encouraged fluids. The resident remained afebrile with a temperature of 99 degrees F (normal body temperature can range from 97.8 degrees F to 99 degrees F for a healthy adult). Staff provided catheter care per facility protocol. The note contradicted evidence on the resident's MAR indicated [REDACTED]. The note also lacked documentation of the resident's lethargy/restlessness at lunch time or documentation of the resident's catheter being empty when observed by the nurse. Review of the resident's health status note dated 12/16/16 at 3:59 PM entered by licensed nurse B, revealed staff identified the resident as lethargic and restless during lunch, which he/she identified as normal for this resident. The note stated a physical assessment of the resident had been done (the note lacked specific assessment details or a time the nurse completed the actual assessment). The resident's vital signs were within normal limits. The nurse noticed the resident's catheter was clogged. He/she unclogged the catheter and urine started draining as usual. The writer identified physician extender A as in the facility and stated physician extender A saw the resident with no new orders received. The resident's DPOA (durable power of attorney) arrived at the facility and tried to wake up the resident. The resident lethargically responded to him/her. The resident's visitor called 911 without talking to the writer/nurse. EMS (Emergency Management Service) arrived to the facility. Nurse B explained to EMS what happened to the resident. The note lacked any evidence of follow up assessment from the time the resident was identified as lethargic at lunch time (the resident's record lacked a specific time) and when EMS arrived to the facility at 2:40 PM. The note lacked documentation of interventions to unclog the catheter or the amount of urine drained from the catheter at the time staff discovered the resident's catheter was clogged. Review of the notarized statement from licensed nurse B on 12/21/16 he/she stated physician extender A notified him/her that the resident was lethargic during lunch . When nurse B saw the patient, he/she noticed an empty catheter bag. He/she told physician extender A he/she planned to change the resident's catheter because it was not draining urine. Physician extender A instructed him/her to change the catheter and notify him/her when he/she changed the catheter and completed the full assessment of the resident. Nurse B urged the aide on duty to take the resident to his/her room while he/she obtained the catheter equipment. When he/she got to the resident's room, he/she followed the procedure and tried to deflate the catheter balloon. Nothing came out of the balloon. Upon further assessment nurse B noticed the catheter had a clip (clamp device) attached to it which prevented urine from draining. He/she removed the clip from the catheter and urine started draining. Nurse B reported five or ten minutes after he/she drained the catheter the resident's DPOA arrived and complained to the nurse that the resident was lethargic. Nurse B, explained to him/her what happened with the resident's catheter. Direct care staff (unidentified in the notarized statement) notified nurse B that the DPOA's family member called 911. The timeframe is unclear of how long between unclipping the catheter and when the family arrived. The notarized statement written by staff B contradicted what staff B wrote in a health status note dated 12/16/16. Staff B referred to the catheter as clogged in the health status note and clipped in the notarized statement. The notarized statement also contradicted a statement from physician extender A, (see interview dated 12/21/16 at 12:29 PM) where he/she stated he/she did not physically assess the resident at the time the facility identified the resident as lethargic and the catheter as clogged or clipped. An interview with licensed nurse B on 12/20/16 at approximately 4:20 PM revealed staff fed the resident in the dining room and he/she went lethargic, usually when that happened he/she first looked at his/her catheter. When nurse B looked at the resident's catheter bag it was empty. He/she then tried to irrigate the catheter and found out it was clogged (this contradicts nurse B's notarized statement that the resident's catheter had been clipped). He/she stated after he/she unclogged the catheter, approximately 10 minutes after he/she opened the catheter, the resident's DPOA arrived and nurse B tried to explain to him/her what happened and the person with the DPOA had already called 911 . He/she reported physician extender A went in to see the resident that day and was still at the facility when he/she noticed the clogged catheter. Physician extender A wanted him/her to monitor the resident to see how the catheter worked. The resident's clinical record lacked evidence staff monitored the functioning of the catheter after opening. An interview on 12/19/16 at 10:01 AM with the resident's DPOA revealed on 12/15/16 the resident was confused and he/she had purulent drainage (yellow pus) from his/her genital area around his/her catheter. The DPOA went back later that day and the resident slept. He/she brought the drainage to the nurse's attention on 12/15/16 and the nurse told him/her it was normal. The incident happened on Friday 12/16/16 when the resident was unresponsive, pale as a sheet, burning up, really hot and trying to talk, but no words were coming out. The DPOA told facility staff there was something wrong with the resident and asked them to call 911. The nurse said the resident had a kink in his/her catheter and once his/her bladder drained he/she would be fine. The DPOA reported the person with him/her called 911. He/she reported the resident was in the hospital on a breathing machine at the time of the interview. An interview with physician extender A on 12/21/16 at 12:29 PM revealed he/she did not physically assess the resident the day he/she went to the hospital (12/16/16). He/she had just finished rounds when he/she saw licensed nurse B. Nurse B reported to physician extender A he/she had been in with the resident and his/her catheter had been clogged so he/she changed the catheter. He/she stated the resident had this happen multiple times. Physician extender A said give it some time and give him/her a call back if the resident had not improved since he/she just unclogged the resident's catheter. He/she was surprised by the resident having such a decreased level of consciousness and having to be intubated in the emergency department at the hospital. He/she reported he/she left the facility by 11:30 AM - 12:00 PM that day (12/16/16) and the resident just had lunch and he/she believed the resident was sent to the hospital at approximately 2:00 or 3:00 PM. This interview further contradicts all previous reports that physician extender A physically assessed the resident as a result of his/her lethargy and clogged or clipped urinary catheter, which identified the resident to be fine prior to EMS being called. Review of the resident's clinical record lacked any evidence of the physician extender's assessment of the resident on 12/16/16. Although requested by the surveyor on 12/21/16 and 12/22/16, the facility failed to provide a note from the physician extender's visit on 12/16/16. Review of the EMS report dated 12/16/16 revealed they received the call at 2:30 PM and arrived on-site at 2:40 PM. The caller stated he/she came in to see the resident and was unable to wake him/her. Facility staff reported to EMS the resident saw the physician extender today who stated he/she did not see anything wrong with the resident. Physical assessment of the resident by EMS staff revealed the resident had a urinary catheter in place. EMS noted the resident's urine to be very cloudy with a substantial amount of sediment present. They identified the resident's pupils as pinpoint and his/her skin to be very hot to the touch. The resident was unresponsive with a severely impaired level of consciousness. EMS recorded the resident's body temperature at 3:03 PM was elevated at 100.7 and a heart rate of 100. EMS transported the resident to the hospital. Review of the emergency department physician note dated 12/16/16 at 3:36 PM revealed the physician extender saw the resident in the facility because the resident's catheter had been clamped and bent. The resident's DPOA called EMS because the resident mumbled incoherent words and became unresponsive. The resident's rectal temperature in the emergency department read 102.7 degrees Fahrenheit. The physician noted the resident's level of consciousness as unresponsive. After his/her assessment of the resident, chart, past medical history, physical exam, laboratory work and/or radiology imaging findings he/she became concerned the resident [MEDICAL CONDITION] (systemic infection of the blood) from either UTI or [MEDICAL CONDITION]. The resident was intubated (insertion of a tube into a person or a body part, especially the trachea for ventilation) because of his/her decreased level of consciousness. The physician started the resident on a broad-spectrum antibiotic and admitted him/her to the intensive care unit at the hospital. An interview at 3:30 PM on 12/20/16 with emergency department physician E revealed the resident's level of consciousness was completely altered with severe impairment of his/her level of consciousness. The resident's DPOA reported he/she came to see the resident and reported he/she wanted him/her transferred to the hospital but received some backlash from the facility. The facility reported the resident was fine and reported he/she was afebrile (not feverish). The resident's DPOA was concerned about the resident's altered mental status. The resident in fact was febrile (had a fever) and had [MEDICAL CONDITION](rapid heartbeat greater than 100 beats per minute). The physician reported the resident's temperature measured 102 in the ER. Physician E did not believe the resident could have changed condition so rapidly, especially if the DPOA noted increased lethargy the day before. The facility reported, to the DPOA and EMS, the resident was fine when they assessed the resident earlier in the day, leading physician E to question how much the facility truly assessed the resident prior to the call to EMS. Review of the health status note dated 12/16/16 at 9:32 PM revealed the nurse called the hospital and discovered the resident was admitted for severe UTI. Observation of the resident on 12/20/16 at 12:15 PM revealed the intubated resident lay in a hospital bed, in the critical care unit of the hospital. The resident responded to questions by blinking his/her eyes and remained awake during observations. An interview with hospital nursing staff D on 12/20/16 at 12:15 PM revealed the resident admitted to the critical care unit for UTI [MEDICAL CONDITION] (systemic infection of the blood). Although requested on 12/22/16, the facility failed to provide policies regarding catheter care and nurse assessment/documentation. The facility failed to assess/re-assess resident #1's urinary catheter after he/she experienced decreased level of consciousness, which led to emergency transport to the hospital, intubation and admittance to the critical care unit with a [DIAGNOSES REDACTED]. The immediate jeopardy was abated on 1/6/17 when the facility implemented the following interventions: Education for all staff regarding identifying changes in condition. Education for all staff regarding charting on changes in condition. Requiring physicians to use the physician order [REDACTED]. Requiring medical records to request transcripts of all ER visits, hospitalization s, and behavioral overnight stays to ensure continuity of care. The deficient practice remained at a scope and severity of a G.

The facility had a census of 78 residents with 29 residents included in the sample. Based on observation, interview and record review, the facility failed to provide adequate monitoring of water temperatures to maintain safe water temperatures in resident areas. The facility allowed the water to reach 141 degrees Fahrenheit in a common resident shower as well as resident rooms in 1 of 3 units. This had the potential to affect all 29 residents in unit 2 by potentially causing 3rd degree burns (a severe burn characterized by destruction of the skin through the depth of the dermis and possibly into underlying tissues). (#74, #28, #19, #16, #50, #37, #6, #22, #100, #92, #54, #46, #71, #57, #115, #43, #47, #15, #67, #9, #49, #62, #88, #95, #52, #91, #68, #55, #25) The facility also failed to ensure one resident unsampled did not have unsafe gaps between his/her mattress and positioning bar. (#116) The facility also failed to secure hazardous chemicals and reduce the resident's risk for injury related to an unsecured staircase. This had the potential to affect 26 residents who the facility reported were independently mobile and cognitive impaired. Finding included: - Observation on 5/24/16 at 11:10 AM revealed the shower water temperature in the unit 2 shower room across from room 315 measured 141 degrees Fahrenheit (F). On 5/24/16 at 3:42 PM the water temperatures in resident bathroom sinks in unit 2 measured (Room: water temperature measured in degrees F: (resident #)): 1st resident room: 130.6 F (#74, #28) 2nd resident room: 132.3 F (#16, #50) 3rd resident room: 128.1 F (#37, #6) 4th resident room: 131.7 F (#22, #100) 5th resident room: 122.5 F (#54, #92) 6th resident room: 127.6 F (#46) 7th resident room: 134.2 F (#43, #47) 8th resident room: 133.8 F (# 67, #9) 9th resident room: 132.1 F (#62) 10th resident room: 130.7 F (#95) On 5/24/16 at 7:38 PM observations revealed water temperatures in 3 rooms on unit 2 measured 120.7 degrees F, 121.7 degrees F, and 126.3 F. During an interview on 5/24/16 at 2:03 PM, direct care staff U revealed resident # 95 recently had a shower in the unit 2 shower room. Staff U stated the resident could shower independently and staff provided setup help and waited in the area outside the shower room until the resident completed his/her shower. During an interview on 5/24/16 at 2:08 PM, resident #95 revealed he/she completed a shower and stated he/she always turned it hot to start and adjusted it down from there. He/she reported he/she had not experienced any burns. Resident #95 reported he/she was blind. Interview with Administrative staff A on 5/24/16 at 12:30 PM revealed staff A retrieved a shower water temperature of 135.7 degrees (F) and the surveyor recorded a temperature of 137.8 degrees F. Staff A revealed the facility just hired one maintenance staff who walked off the job 5/20/16 and he/she hired another maintenance staff on 5/24/16. Staff A further revealed he/she did not know when water temperatures were checked, the location of the water temperature documentation, and the acceptable range for water temperatures and reported he/she did not know of the elevated water temperature. Interview with Administrative staff A on 5/24/16 at 1:48 PM revealed he/she did not know what other items were on the same water line as the unit 2 shower room. Staff A further stated direct care staff T checked the hot water boiler and it was set to 120 degrees F. Interview on 5/24/16 at 1:53 PM with direct care staff T revealed he/she worked as a maintenance assistant for 6-7 months and staff T further stated he/she did not take water temperatures during that time. Staff T stated the director of maintenance measured the water temperatures, but he/she did not know where, when, or how those were documented. An interview with direct care staff Z on 5/24/16 at 2:50 PM revealed the water in the shower room on unit 2 got very hot. He/she monitored the water and turned it down if it got to hot. He/she stated no one checked the water temperatures at the facility that he/she knew of. During an interview on 5/24/16 at 2:52 PM, direct care staff Y revealed the water from the shower on unit 2 became hot enough it turned residents' skin red at times. There were not any burns that he/she knew of. Staff Y stated the residents liked the water hot, but at times it became too hot and he/she had to explain why he/she turned the hot water down. Staff Y stated he/she did not know of anyone checking the water temperatures. During an interview on 5/24/16 at 2:55 pm direct care staff J revealed the water in the shower on unit 2 did become too hot, to the point of scalding. Staff J stated first thing in morning he/she turned the water on to warm up and it became very hot so he/she had to turn it down. During an interview on 5/24/16 at 3:00 PM, resident #88 stated the bathtub got very hot. He/she stated he/she checked the water before getting into the bathtub because it could burn someone. The resident stated he/she did not know if the cold water even worked in the bathtub because the water got so hot. Observation of the water temperature in the resident ' s sink at that time measured 132.6 degrees F and the bathtub measured 134.2 degrees F. During an interview on 5/24/16 at 2:58 PM, resident #115 revealed the hot water took a long time to get hot, but when it did then it was very hot and required adjustment. Observation of the bathroom sink temperature at that time revealed it measured 127.4 degrees F. During an interview on 5/24/16 at 3:01 PM, resident #52 stated his/her hot water got extremely hot. Observation of the bathroom sink temperature at that time revealed it measured 134.6 degrees F. During an interview on 5/24/16 at 3:02 PM, resident #46 stated the water was hot and he/she had to turn it down. Observation of the bathroom sink temperature at that time measured 132.6 degrees F. During an interview on 5/24/16 at 3:15 PM, administrative staff A revealed the temperature logs were not completely filled out and stated the previous maintenance worker only recorded average temperatures and did not record where he/she checked the water. Staff A reported the facility could not locate the logs from February 2016 onward and the facility did not know where they were since maintenance staff left. Staff A stated the plan of correction would be to properly train the new maintenance staff and review the temperature logs weekly. During an interview on 5/24/16 at 6:36 PM, maintenance staff X the facility staff did not know about the boiler settings. Staff X revealed the boiler that controlled the hot water to the unit 2 (300 hallway) shower had just been adjusted to 120 degrees F. Staff X further reported the staff should take water temperatures daily and the facility needed to ensure proper training of maintenance staff. Staff X revealed the pipe that carried water to the shower from the boiler was too hot to touch, but was cooling. During an interview with Administrative staff A on 5/25/16 at 7:34AM staff A revealed the staff in the facility had ran a lot of water to purge the line, took temperatures all night, but the thermostat would be adjusted and he/she would like the hot water temperature to be no more than 110F. During an observation on 5/31/16 at 7:46 AM revealed the temperature reached 124.1 degrees F in the unit 2 shower room. On 6/1/16 at 6:57 AM Administrative staff A presented an updated in-service education signature sheet where 57 out of 68 (84%) employees had been updated on the revised April 2010 policy on the safety of water temperatures. Review of the direct supply logbook documentation for the facility revealed one temperature recorded for each of the three units on the following days that measured 116 degrees F or less: 4/9/15, 9/21/15, 11/12/15, 11/24/15, 11/30/15, 12/10/15, 1/6/16, and 2/16/16. Review of the American Burn Association Scald Injury Prevention Educator ' s Guide, updated in 2002, revealed a 3rd degree burn can happen after exposure to 140 degrees F hot water temperatures after 5 seconds. Review of the facility policy on the safety of water temperatures revised April 2010 revealed water heaters that serviced resident rooms, bathrooms, common areas, and tub/shower areas would be set to temperatures of no more than 120 degrees F or the maximum allowable temperature per State regulation. The facility failed to provide accurate hot water temperature monitoring, which had the potential to affect all of the residents in the facility. This failure placed residents in immediate jeopardy related to the risk of significant burns from the hot water. The facility abated the immediate jeopardy on 5/31/16 5:44 PM when the facility immediately suspended all resident showers until water temperatures were safe, provided education to all cognitive residents to be careful when using the water, provided education to employees regarding checking hot water temperatures prior to each use and immediately reporting hot water temperatures, developed a plan for the monitoring of hot water throughout the facility for 2 hours for a 6 hour time period, then every 4 hours for 8 hours, and then every 8 hours for 16 hours, and revised their policy regarding the monitoring of water temperatures to include weekly monitoring of the shower rooms and rooms on each unit. The facility also lowered the temperature on the facility mixing valves for all 3 facility water heaters. This deficient practice remained at a scope and severity of an E. - Review of resident #116's record revealed he/she admitted from 5/21/16 to 5/26/16 for respite care. Review of the resident's care plan dated 5/21/16 revealed the resident was totally dependent on staff for repositioning and turning in bed requiring a minimum of one staff for assistance and the resident needing a safe environment, including side rails as ordered. Review of the resident's clinical record from 5/21/16 to 5/26/16 revealed no assessment for side rail safety. Observation on 5/25/16 at 2:36 PM revealed the resident's bed had bilateral positioning bars (small side rails used to assist with repositioning the resident) located on the bed frame at the head of the bed. The positioning bars were secured; however, the mattress did not fit the bedframe. As the mattress lay in the bedframe, a 4 inch gap measured between the mattress and the positioning bar. With the mattress pushed all the way to one side, an 8 inch gap measured between the mattress and the positioning bar. Interview on 5/25/16 at 2:54 PM with administrative staff A revealed he/she had the same numeric results when measuring the distance between the mattress and positioning bars. Administrative nursing staff B stated he/she would look for a better fitting mattress. At 3:01 PM, staff A revealed the bed frame had extensions that were applied to increase the width of bed. Staff A said he/she removed the extenders and positioning bars. According to the FDA (Food and Drug Administration) reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/2006, We recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment . The FDA recommended gaps of no more than 4 ¾ inches between the bedrail and the mattress. Facility failed to ensure the bed mattress fit the frame to ensure there were no unsafe gaps (greater than 4 ¾ inches) between the mattress and positioning bar. - On 6/2/16 at 7:45 AM observation revealed an unlocked door (without a locking mechanism) in the hall that led to the kitchen. Just inside the kitchen, another unlocked door led down a flight of stairs to the basement storage area. The basement storage area revealed a room approximately 15 foot by 15 foot. The room had a box containing 6 quart size plastic bottles of sulfuric acid (highly corrosive chemical) drain cleaner and a 5 gallon container approximately 3/4 full of Laundry De-stainer and Brightener with a Corrosive Chemical label that read may cause severe burns, harmful if swallowed. On 6/1/16 at 10:15 AM interview with dietary staff RR said the door into the kitchen from the hallway used to be locked but when the facility installed a new door it did not have a lock. When asked if residents were ever in the kitchen he/she stated he/she did not know but when he/she closed up at night he/she made sure the coffee pots were off and unplugged and then when he/she returned the next morning the coffee pots would be on and used and the kitchen would be a mess. Staff RR could not determine if staff or residents were in the kitchen. On 6/1/16 at 11:10 AM interview with administrative staff A revealed the previous administrator ordered the kitchen door before he/she started and installed after he/she started in February 2016. Staff A said the door never had a lock and reported it should have a lock because he/she would not want anyone in the kitchen who should not be because of hazards like burning, knifes, chemicals, and the stairs to the basement. He/she stated there were no residents who went to the basement to do their own laundry and he/she did not know of residents going in the kitchen. Review of the policy titled: Safety and Supervision of Residents revealed the environment needed to maintain as free from accident hazards as possible. The facility failed to secure hazardous chemicals and stairs leading to the basement.

The facility census totaled 78 with 29 included in the sample and one resident reviewed for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of pressure, or pressure in combination with shear and/or friction. Based on interview and record review, the facility failed to implement effective interventions to prevent the development of an avoidable stage 3 (full thickness tissue loss; fat located beneath the skin may be visible but bone, tendon or muscle are not exposed) pressure ulcer, that developed 15 days after admission, for this dependent resident (#111- closed record)), identified at risk for pressure ulcers. The facility further failed to thoroughly assess the wound at the time of discovery (measurements). Finding included: - Resident #111's signed physician orders dated 12/15/15 revealed the following Diagnoses: [REDACTED]. These changes result in the loss of muscle function, sensation, or autonomic function in parts of the body served by the spinal cord below the level of the injury) and [MEDICAL CONDITION] (loss of ability to move arms, legs and trunk of the body below the level of the spinal cord injury ). The admission MDS (minimum data set) dated 11/19/15 revealed the resident had a BIMS (brief interview for mental status) score of 13, which indicated intact cognition. The resident required total dependence of 2 or more staff for ADLs (activities of daily living) and mobility. The MDS documented the resident was at risk for pressure ulcers. The resident had no unhealed pressure ulcers at the time of the assessment. The resident required pressure reducing devices for his/her chair and bed. Further review of the MDS revealed the resident was not on a turning/repositioning program. The Pressure Ulcer CAA (care area assessment) dated 11/19/15 recorded the resident with the [DIAGNOSES REDACTED]. The resident had bowel and bladder incontinence and required total care from staff for all ADL functioning. The facility provided a pressure relieving mattress to the resident's bed. The CAA noted the facility would develop a care plan with interventions to prevent pressure ulcers. Review of the resident's medical record information from his/her admission on 11/13/15 lacked an initial care plan with interventions to prevent the development of pressure ulcers. The resident's care plan revised 11/30/15 directed staff to implement the following interventions: The resident needed (blank) to turn/reposition at least every 2 hours or more often as needed (PRN) or requested. Avoid positioning the resident on his/her left side as much as possible. The resident, family and caregivers were educated about the causes of skin breakdown (including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning.) Float heels while in bed as tolerated. Heel Protectors on when in bed. The resident, family and caregivers would be informed of any new area of skin breakdown. Monitor the dressing (the care plan lacked a specific frequency) to ensure it remained intact and adhered. Loose dressings would be reported to the treatment nurse. Monitor the resident's nutritional status. Serve a diet as ordered and monitor and record intake. Monitor, document and report to the resident's physician, PRN, changes in skin status including: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), and stage. Pressure reduction cushion placed in the resident's wheelchair when up in wheelchair. Pressure reduction mattress would be placed on the resident's bed. The resident required (no specific device identified) on (no specific location identified). Provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. The care plan did not address the physician prescribed pressure ulcer treatment. 12/15/15 - The resident was identified with a stage IV pressure ulcer to his/her left buttock related to his/her immobility/[MEDICAL CONDITION] and poor nutrition. Further review of the resident's clinical record identified the resident's pressure ulcer at a stage 3. 12/30/15 - Staff were to assess, monitor and record wound healing. Facility staff would measure length, width and depth where possible. The status of the wound perimeter, wound bed and healing progress would be assessed with [REDACTED]. The care plan did not specify the frequency of the assessment. The care plan lacked appropriate interventions to prevent the development of a pressure ulcer prior to the identification of a pressure ulcer on 11/29/15 for the resident. Review of the nursing admission data collection form dated 11/13/16 documented the resident had intact skin with no open areas. On 11/13/15 the facility completed an assessment used to determine the resident's risk of pressure ulcer development (Braden Scale). According to the assessment the resident had a score of 13 which indicated the resident was a moderate risk for pressure ulcer development. On 11/20/15 the Braden Scale assessment documented the resident had a score of 12 which indicated the resident was at high risk for pressure ulcer development. A weekly skin check dated 11/27/15 revealed the resident had intact skin with no open areas. Review of a progress note dated 11/29/15 at 1:08 PM revealed the resident had pressure ulcer to his/her buttocks. Nursing staff notified the resident's physician and received new treatment orders. The resident's clinical record lacked evidence of any measurement or staging of the pressure ulcer identified on 11/29/15. Review of the facility's pressure ulcer weekly wound evaluation dated 12/3/15 revealed staff assessed the resident with a stage 3 pressure ulcer to the left buttock and notified the physician of the new wound on 11/29/15. A facility nurse discovered the open area while providing care to the resident. Staff identified the area as moist with granulation tissue present and no drainage or odor. The length of the wound measured 2 cm (centimeters), the width measured 1.5 cm and the depth measured 0.2 cm. Review of the pressure ulcer treatment plan directed nursing staff to cleanse the area with normal saline, pat the area dry, apply hydrogel (90% water in a gel base dressing, which helps regulate fluid exchange from the wound surface) and change the dressing every 3 days and PRN. Review of a progress note dated 12/3/15 at 6:09 PM revealed the facility dietitian recommended supplemental nutrition 3 times a day for wound healing. Review of a progress note dated 12/7/15 at 9:45 AM revealed the resident wanted to lie down and did not want to get up into his/her chair for breakfast. Review of the facility's pressure ulcer weekly wound evaluation dated 12/10/15 recorded the resident had a stage 3 pressure ulcer on the left buttock. The wound measurements were unchanged from 11/29/15. Review of a progress note dated 12/16/15 (late entry for 12/15/15) (revealed facility staff spoke with the resident about the importance of being turned and repositioned. The resident stated he/she sat in his/her chair all day over the previous weekend while he/she visited with family. Staff educated the resident on the importance of not sitting up too long in his/her wheelchair related to the difficulty to relieve pressure when he/she sat up in his/her wheelchair. Review of a progress note dated 12/16/15 at 7:53 AM revealed staff repositioned the resident every two hours and as needed during the night and the resident refused be turned. Staff educated the resident of the importance of turning and repositioning to prevent further skin breakdown. The resident verbalized understanding and agreed to comply. Review of a progress note dated 12/16/15 at 9:00 AM revealed the resident's left buttock wound had deteriorated. Nursing staff assessed the wound with necrotic (cell injury which results in the premature death of cells in living tissue) tissue. The resident consumed less than 25% of meals, refused medication and supplements ordered for wound healing. The facility contacted the resident's physician (and physician's assistant) for an order to transfer to another facility for management of the wound. Review of the facility's pressure ulcer weekly wound evaluation dated 12/16/15 revealed the resident's stage 3 pressure ulcer on the left buttock measured 2 cm long, 3 cm wide and 1.8 cm deep and the wound edges were rolled under. The treatment plan was changed to an ointment that removed dead tissue from wounds to promote healing. Staff identified the wound as worse related to the resident's poor nutritional intake per oral or tube. Review of a progress note dated 12/16/15 at 10:15 AM revealed the resident's physician assistant discontinued hydrogel order and started an ointment that removed dead tissue from wounds to promote healing, to be changed every 3 days and PRN. Review of a progress note dated 12/17/15 at 7:30 AM revealed the resident was discharged from the facility the hospital. During an interview on 6/1/16 at 10:20 AM with direct care staff T revealed the resident required total assist for all cares and had a pressure ulcer. Staff T did not remember if the resident required turning or positioning. During an interview on 6/2/16 at 12:07 PM nursing staff AA revealed night shift completed skin checks on residents. When nursing staff identified a resident at risk for development of pressure ulcers interventions were put into place which included pressure relieving pads for the bed and chair, a 2 hour turning program, and reminders/assistance when the resident needed to be repositioned. When staff identified a new area of concern on a resident's skin he/she would make sure the resident was safe, notify the resident's physician, and implement any new treatment as ordered by the resident's physician. He/she thought administrative nursing staff C started resident's care plans on the computer and nursing staff updated the care plan as needed. During an interview on 6/2/16 at 1:35 PM administrative nursing staff C revealed the resident was at risk for pressure ulcer development related to his/her [MEDICAL CONDITION]. He/she thought the resident had an air mattress and feeding tube in place prior to the development of the pressure ulcer. Staff C thought he/she had placed interventions on the care plan to prevent pressure ulcer development prior to the development of any pressure ulcer. At this time administrative nursing staff C reviewed the resident's care plan on the computer and did not to find any documentation of an air mattress on the care plan. He/she stated he/she would expect to find an air mattress on the care plan if it were in place. He/she stated he/she would not expect there to be any further interventions on the care plan related to the pressure ulcer until after one developed. He/she stated the resident was noncompliant with repositioning and dietary requirements. Staff C stated the resident's pressure ulcer was not assessed (measured) from 11/29/15-12/3/15 because he/she was the wound nurse and liked to measure wounds his/herself. He/she also staged all wounds him/herself. During a follow-up interview with administrative nursing staff C on 6/7/16 at 8:43 AM, he/she did not remember if the resident had an initial care plan on paper or in the electronic medical record. He/she stated the facility switched computer documentation programs in October 2015 and started all computer documentation around that time. He/she believed the admitting nurse completed the resident's care plan on the computer and the licensed nurses on duty updated it as needed. Staff C stated the company that owned the facility provided wound care training during an in-service sometime during the previous year. Review of the facility policy Pressure Ulcer Treatment lacked pressure ulcer prevention measures. The facility failed to implement appropriate interventions to prevent an avoidable stage 3 pressure ulcer on this dependent resident's left buttock 15 days after admission. The facility further failed to thoroughly assess the wound at the time of discovery (measurements).

The facility census totaled 85 residents with 6 included in the sample. Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions, ensure staff used proper transferring techniques to prevent falls for 3 of 3 sampled residents. (#5 who ' s fall resulted in an ankle fracture, #6 who sustained a fractured foot during an unsafe staff transfer, and #1) Findings included: - Review of resident #5's signed physician orders dated 8/26/14 revealed the following Diagnoses: [REDACTED]. Review of resident #5 ' s annual MDS (minimum data set) dated 11/17/13 revealed a BIMS (brief interview for mental status) score of 14, indicating no cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had not had any falls since the previous MDS assessment. Review of the quarterly MDS dated [DATE] revealed resident #5 had a BIMS score of 13, indicating no cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had 1 non-injury fall since the previous assessment. Review of the discharge MDS dated [DATE] revealed resident #5 had an injury fall. The resident ' s BIMS score remained 13 and mobility assistance unchanged from 8/20/14 assessment. Review of the ADL (activities of daily living) Functional/Rehabilitation Potential CAA (care area assessment) dated 11/18/13 revealed the resident needed assistance with some of his/her ADLs. Resident #5 used an electric wheelchair for ambulation He/she was at risk for functional decline related to his/her disease process. Review of resident #5 ' s Falls CAA dated 11/18/13 revealed the resident scored high on his/her fall risk assessment. At that time he/she had not had any falls. He/she was at risk for falls related to his/her impaired mobility, UTIs (urinary tract infections), and unsteady gait. Review of the resident ' s care plan, initiated 10/3/13, revealed resident #5 was at risk for falls related to a high risk score as evidenced by a history of CVA (cerebrovascular accident-(stroke) a blood clot in the brain), MS (multiple sclerosis- an [DIAGNOSES REDACTED] condition that affects the brain and spinal cord), neuropathy (a condition that results from nerve damage and often causes numbness, weakness, and pain), and unsteady gait. Interventions added on 11/17/13 directed staff to encourage the resident to use environmental devices such as hand grips and hand rails, allow the resident to use his/her electric scooter and to keep it charged up and next to the resident while in his/her room, keep the call light within reach at all times, keep the resident ' s personal and frequently used items within reach, provide the resident with proper, well-maintained footwear, assure the floor was free of glare, liquids, foreign objects, and remind the resident to call for assistance before self-transfers. On 8/20/14, staff added an intervention to remind and encourage the resident to call for assistance before transferring if he/she felt weak, which was already in place from 11/17/13. On 8/22/14, staff added an intervention for staff to send the resident to the ER (emergency room ) for evaluation of weakness and confusion, which was abnormal for the resident. After the resident returned from the hospital on [DATE], staff added interventions directing staff to not allow the resident to bear weight on his/her left lower extremity due to an ankle fracture, have PT/OT (physical therapy/occupational therapy) evaluate and follow up with the orthopedic doctor, ensure a CAM walker/foot stabilizer (a brace) remained in place to his/her left ankle, and assist the resident with transfers and ADLs until the resident was back to his/her normal ability. Staff added an intervention on 8/29/14 to alert staff the resident was not safe to use. Review of the CNA (certified nurse aide) ADL care plan book revealed staff indicated resident #5 was a fall risk on the summary page. The resident required transfer assistance of one person. The book also contained a temporary admission care plan form dated 6/19/14 which indicated the resident had no fall risk and required no interventions for the CNAs to implement for fall prevention, contraindicating the CNA ADL care plan. Review of the resident ' s most recent fall assessment completed 8/16/14 revealed the resident scored a 12, with a score of greater than 10 indicating a high risk for falls. Staff documented the resident was on a fall prevention program, nursing rehabilitation, and for staff to continue the current plan of care. Review of the nursing progress note dated 8/6/14 at 7:27 AM revealed resident #5 had confusion and foul smelling urine. Staff obtained an order for [REDACTED]. Review of the nursing progress note dated 8/6/14 at 10:29 AM revealed staff observed resident #5 to have increased confusion. Staff obtained an order for [REDACTED]. Review of the event note dated 8/9/14 revealed resident #5 ' s urine culture was positive and the antibiotics were changed to a different medication for 10 days. Review of the fall investigation dated 8/20/14 for resident #5 ' s fall on 8/19/14 revealed the resident required the assistance of one staff member for transfers and was not identified as a fall risk prior to the fall. Interventions already in place prior to the fall included keeping the call light within reach and to assist the resident with transfers. The new interventions added were to update the care plan and remind the resident to call for assistance. Staff identified a possible factor contributing to the fall was mental conditions related to the inability to understand or follow instructions. Staff identified the resident ' s prior mental status as alert and oriented. The resident had an unattended fall and reported he/she fell as he/she independently attempted to transfer himself/herself. Review of the nursing progress note dated 8/20/14 at 3:35 p.m. as a late entry for 8/19/14 at 4:15 PM revealed a CNA discovered resident #5 lying on the floor in front of the bed sitting upright with his/her back against the bed. The resident stated he/she was transferring himself/herself from the bed to the wheelchair and slipped off the wheelchair, landing on the floor. The resident denied pain from the fall and denied hitting his/her head. Staff assessed the resident and the resident did not have any apparent injury. The clinical record lacked evidence that staff developed and implemented interventions to prevent future falls after the resident fell on [DATE]. Review of the nursing progress notes dated 8/21/14 at 9:46 AM revealed the resident complained of feeling fatigued. The resident ' s blood pressure was low at 92/43. Review of the nursing progress notes dated 8/21/14 at 2:00 PM revealed staff found resident #5 sitting on floor in his/her room. The resident stated he/she tried to transfer by himself/herself without calling for assistance. The resident was confused and oriented only to self. Staff did not identify any injuries. Staff educated the resident on using the call light and to ask staff for assistance. Staff identified the resident ' s range of motion to be within normal limits. Staff notified the PA (physician assistant) and obtained an order to send the resident to the hospital. Review of the nursing progress note dated 8/21/14 at 2:05 PM revealed staff received an order to send resident #5 to the hospital for evaluation and treatment secondary to a fall and possible sepsis. Review of the radiology report dated 8/22/14 revealed a CT (computerized tomography-a series of x-rays) scan indicated resident #5 had a non-displaced fracture of the medial malleolus (ankle), and a likely tiny avulsion fracture of the distal fibula (fracture located where the tendon attach to the bone). Review of the fall investigation dated 8/26/14 for resident #5 ' s fall on 8/21/14 revealed the resident required the assistance of one staff member for transfers and staff identified the resident as a fall risk. Interventions in place prior to the fall included; keep the call light in reach, frequent observation, and provide verbal cues/reminders related to safety. Interventions added after fall included evaluation by therapy, update the care plan, and staff to assist the resident with all transfers. Staff identified mental conditions related to impaired memory/judgment as possible contributing factors to the fall. Staff identified the resident ' s prior mental status as alert and oriented. The resident had an unattended fall with no apparent injury. The resident fell in his/her room as he/she was weak and unable to transfer himself/herself. The resident had just completed antibiotics for a UTI. Staff sent the resident to the emergency department for evaluation. Observation on 9/3/14 at 12:57 p.m. revealed resident #5 lay flat in bed without any foot coverings or CAM walker in place as directed in the care plan. Observation on 9/4/14 at 8:07 a.m. revealed resident reported to staff that his/her call button did not work. Nursing staff alerted maintenance staff who went to the resident ' s room at 8:15 a.m. to fix the call light. The resident did not have a CAM walker in place as he/she lay in bed and did not have any footwear on. Interview with the resident on 9/3/14 at 12:50 p.m. revealed the resident fell a while ago on a Friday, had to go to the hospital, and broke his/her ankle in 3 places. Resident #5 reported he/she has slipped right out of the bed. Interview with direct care staff G on 9/3/14 at 2:53 p.m. revealed the resident fell and fractured his/her ankle. The resident could transfer independently really well before the fall. Staff G reported since the resident had fallen, staff watched him/her more closely to try to prevent him/her from falling and helped the resident with transfers. The resident could use the call light when he/she needed anything. Staff G reported resident #5 did not really have any interventions in place before the fall for fall prevention. Interview on 9/4/14 at 8:30 a.m. with direct care staff H revealed resident #5 ' s fall prevention interventions mostly included reminders about safety and cuing the resident. Staff H reported the resident had slight confusion at times, was very stubborn and used to get up on his/her own. Staff H reported the resident could transfer to his/her wheelchair independently with supervision before the falls, but sometimes got up without notifying the staff. Staff H reported the resident was capable of using the call light. Staff H reported the resident was not a fall risk prior to the accident when the resident tried to get up on his/her own and just slipped. Staff H reported the resident had some confusion the week before the falls and staff had checked him/her for a UTI. Interview on 9/4/14 at 1:40 p.m. with direct care staff I revealed he/she did not know the resident fell nor had a fracture. Interview on 9/4/14 at 1:50 p.m. with licensed nursing staff K revealed prior to resident #5 ' s fall the resident did not have fall precautions in place. Staff K reported the resident was cognitive, used the call light for assistance, and received assistance with transfers. Staff K reported the resident was good with verbalizing needs. Staff K did not know of the fall on 8/19/14. Staff K reported they checked on the resident more frequently since the fall as the resident preferred to stay in his/her room. Prior to the fall, staff K reported the resident had a UTI with confusion, and the confusion was not the resident ' s normal cognition. Staff K reported the resident ' s cognition had returned to his/her normal, with no impairment at that time. Interview with licensed nursing staff L on 9/4/14 at 3:57 p.m. revealed he/she worked during the shift of the resident ' s first fall on 8/19/14. Staff L reported the resident transferred to the chair and then slid out and he/she found the resident on the floor. Staff L reported the resident was not injured and slightly confused at the time. Staff L encouraged the resident to use his/her call light. The resident then fell again on the 21st. Staff L reported the resident was not a fall risk prior to the first fall. Interview with administrative nursing staff C on 9/5/14 at 1:46 p.m. revealed resident #5 had 2 falls in one week. Staff C reported the resident was a fall risk prior to the fall and he/she must have made a mistake on the first fall investigation form. Staff C reported the resident was generally cognitively intact. Staff C reported at the time of the first fall, resident #5 did not call for help and attempted to take him/her to the bathroom and the second fall was the same situation. Staff C reported at the time of the second fall, however, the resident was confused. After the fall, staff C reported staff sent the resident out to the hospital and the hospital determined the resident had a UTI, ARF (acute renal failure-a sudden onset of the inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), and left medial (inside) ankle fracture. Before both falls, staff C reported staff treated the resident for a UTI. Staff reported during the time of the first fall, the resident was not confused. Staff C reported after the resident fell , he/she tried to find an individualized intervention based on why the resident fell to try to prevent further falls. Staff C felt like since the resident was cognitively intact, re-education was appropriate. Review of the facility policy for the undated Fall Prevention Program revealed the interdisciplinary team would review fall risk assessments and if appropriate, initiate a fall prevention protocol. The Director of Nursing/designee would be responsible for ensuring resident who were identified as at risk or who experienced a recent fall had all recommended interventions in place as well as current assessments. The facility failed to develop an appropriate intervention for resident #5, who had confusion at the time of the first fall, to prevent a second fall with injury. - Review of resident #6 ' s signed physician orders dated 8/5/14 revealed the following Diagnoses: [REDACTED]. Review of the annual MDS (minimum data set) dated 4/25/14 revealed a BIMS (brief interview for mental status) score of 6, which indicated severe cognitive impairment. The resident had total dependence on two or more staff for bed mobility and extensive assistance of one staff for transfers and toileting. The resident had functional limitation in range of motion in both lower extremities and used a wheelchair for mobility. The resident had not had any falls since the last quarterly assessment. Review of the quarterly MDS (minimum data set) dated 7/26/14 revealed a BIMS (brief interview for mental status) score of 6, which indicated severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers and toileting, and did not walk. The resident had one injury fall since the annual assessment completed on 4/25/14. The resident had functional limitation in range of motion in both lower extremities and used a wheelchair for mobility. Review of the Falls CAA (care area assessment) dated 5/7/14 revealed the resident had a history of [REDACTED]. Review of the ADL (activities of daily living) Functional/Rehabilitation Potential CAA dated 5/7/14 revealed the resident needed extensive to total assistance with most of his/her ADLs. He/she was wheelchair bound, incontinent of bowel and bladder, and had impaired cognition. He/she was at risk for functional decline related to his/her disease process. Review of the resident ' s care plan dated 5/7/14, revealed the resident had a history of [REDACTED]. to determine patterns or trends. The care plan also directed staff to assure the floor was free of glare, liquids, and foreign objects, encourage the resident to stand slowly and to use hand grips or hand rails and to give verbal reminders not to ambulate or transfer without assistance. The care plan continued to direct staff to keep the bed in the lowest position, keep the call light within reach at all times, keep personal items and frequently used items within reach, observe the resident frequently when he/she was out of bed, keep the environment free of clutter and provide with proper, well-maintained footwear. The care plan lacked specific information regarding transfer technique used for this resident. Review of the resident ' s ADL/functional potential care plan dated 5/7/14 revealed the resident had a decreased ability to perform ADLs and needed extensive to total assist for ADLs. The care plan directed staff to provide him/her assistance of one nursing staff to complete ADLs. Review of a Fall Trend Investigation Report dated 6/16/14 revealed the resident fell in his/her room. The resident ' s call light was in reach, but the resident had impaired memory. The resident had not previously been identified as a fall risk. The attached Unusual Occurrence Record of the same date revealed the resident ' s fall was unattended as he/she attempted to transfer him/herself to the wheelchair to use the bathroom. The resident had scratches on his/her back from sliding off the wheelchair. A new intervention included to get the resident out of bed between 5 and 6 a.m. and toilet him/her. Review of a nurse ' s note dated 6/16/14 revealed staff reported the resident sat on the floor beside his/her bed. The resident stated he/she had to use the bathroom and tried to transfer him/herself from the bed to the wheelchair and slid on the floor. Multiple scratches with minimal amounts of blood were noted to the left side of his/her back. The resident stated he/she scratched his/her back on the wheelchair while sliding to the floor, the resident was alert and oriented and stated he/she hit his/her head, no open areas noted, the call light noted to be within reach on the bed. Staff re-educated the resident to use the call light and ask staff for help. Review of an occupational therapy evaluation dated 7/16/14 revealed the resident required increased assistance from staff due to decline with his/her basic ADLs due to decreased activity tolerance and decreased balance. The resident required moderate assistance with transfers. The resident was at risk for falls. Review of the fall risk assessment dated [DATE] revealed the resident had a fall risk score of 15, in which a score over 10 indicated high risk for falls. Review of a nurse ' s note dated 8/14/14 at 1:34 a.m. revealed staff identified the resident ' s right foot was discolored, bruised and swollen. Review of a nurse ' s note dated 8/14/14 at 6:22 a.m. revealed the facility received an order to obtain an x-ray of the resident ' s right lower extremity due to pain and swelling. Review of a nurse ' s note dated 8/14/14 at 12:55 p.m. revealed the resident x-ray report returned to the facility was positive for displaced intra articular fracture (fracture that involved a joint space) to right foot, involving the bases of the right fourth and fifth phalanges (bones of the toes). Review of a nurse ' s note dated 8/14/14 at 2:19 p.m. revealed a fall. A direct care staff reported to the nurse that day that the night shift aide lowered the resident to floor on 8/8/14. Interview of direct care staff O revealed he/she transferred the resident from the bed to the wheelchair, the resident was heavy and he/she lowered the resident to the floor, he/she then got the resident up from the floor and moved the resident to the chair. The resident ' s range of motion to the upper and lower extremities was within normal limits. The resident complained of pain to his/her right foot related to recent injury from a fall on 8/8/14 which resulted in a fracture. Review of an x-ray report dated 8/14/14 revealed the resident had displaced intra articular fractures involving the bases of the right fourth and fifth phalanges of the foot. Review of a Fall Trend Investigation Report dated 8/14/14 (of the fall on 8/8/14) revealed the resident had a fall from the wheelchair in his/her room. Staff identified the resident as a fall risk prior to the fall. A comment included the resident ' s fall was related to staff " (he/she was dropped on the floor) " . On the Unusual Occurrence report attached to the fall investigation report, staff marked the resident had an attended fall with a fracture. The description of the occurrence included the resident was dropped to the floor by a 3rd shift direct care staff during a transfer. The resident sustained [REDACTED]. Review of the Event Report dated 8/14/14 revealed staff attempted to transfer the resident and lowered the resident to the floor. The resident complained of right foot pain related to the fall at 4 out of 10 on the pain scale. The resident also had swelling to the right lower extremity. Review of the complaint investigation dated 8/14/14 revealed Direct Care Staff O worked the night of the incident and at 5:30 a.m. attempted to get the resident up for the morning. Staff O reported the resident as being a bit heavy for him/her and therefore lowered to the floor. Staff O requested help with getting the resident into the wheelchair. Staff O did not report it to the nurse. Review of the termination notice dated 8/14/14 revealed staff C terminated employment of staff O for violation of company rules of conduct related to staff O dropping a resident to the floor and not reporting the incident which resulted in a fracture of the right fourth and fifth toes. An observation on 9/3/14 at 1:06 p.m. revealed the resident sat in his/her wheelchair and visited with people who went by. The resident wore a cam walker boot (a boot used to protect an injury to the foot or leg) on the right foot. An interview with the resident on 9/4/14 at 4:00 p.m. revealed he/she thought someone had rolled over his/her foot and that was why it broke. The resident reported the foot seemed to be getting better and healing. An interview with direct care staff A on 9/4/14 at 1:34 p.m. revealed the resident had a boot on his/her right foot, but did not know what had happened with his/her foot. Staff assisted the resident with transferring. An interview with licensed nursing staff E on 9/4/14 at 2:51 p.m. revealed the resident had a recent fall and fractured his/her toes. Staff E reported he/she had worked 10 p.m. -6 a.m. the night of the incident. Administrative nursing staff C called him/her into the office on 8/14/14 and told staff E the resident fell . Staff E confirmed no direct care staff reported it to him/her during the night it happened (8/8/14), but reported it after the resident had a fracture as the cause of the fracture (8/14/14). An interview with administrative nursing staff C on 9/5/14 at 1:46 p.m. revealed he/she expected staff to use a gait belt with any transfer unless a resident was independent. He/she reported staff kept a gait belt in every resident room. Staff C reported the resident had a broken foot. Staff C reported he/she got a phone call from the night shift nurse at 4:00 a.m. on 8/14/14 and asked him/her to look at the resident ' s foot as it was bruised. The nurse reported an aide had talked to him/her and gave two staff names that may have had information about a resident fall. Staff C reported direct care staff P reported to him/her direct care staff O had asked for help getting the resident up as the resident had fallen. Direct care staff P reported the resident was in the bed when he/she went in the resident ' s room. Per report from staff C, direct care staff O confessed and reported the resident got very heavy and he/she dropped the resident on the floor. Staff O reported he/she did not report to the nurse. terminated staff O. Staff C reported staff O said he/she had used a gait belt, but he/she did not write that on his/her statement. Review of the facility policy for the undated Fall Prevention Program revealed the interdisciplinary team would review fall risk assessments and if appropriate, initiate a fall prevention protocol. The Director of Nursing/designee would be responsible for ensuring residents who were identified as at risk or who experienced a recent fall had all recommended interventions in place as well as current assessments. The facility failed to use safe transfer techniques to transfer resident #6 resulting in staff dropping the resident resulting in two broken bones in the resident ' s right foot. - Review of resident #1's signed physician order summary dated 8/5/14 revealed the following Diagnoses: [REDACTED]. Review of the admission MDS (minimum data set) for resident #1 dated 9/20/13 revealed the resident had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident had total dependence on two or more staff for bed mobility, transfers, dressing, toileting, and bathing. The resident did not walk and had functional limitation in his/her range of motion on bilateral upper and lower extremities. The resident had not had any falls since the previous quarterly assessment. Review of the ADL (activities of daily living) Functional/Rehabilitation Potential CAA (care area assessment) for the admission MDS dated [DATE] revealed the area did not trigger for further assessment. Review of the Falls CAA dated 9/25/13 revealed resident #1 had a high score on his/her fall risk assessment. The resident had a [DIAGNOSES REDACTED]. He/she was wheelchair bound and needed total assistance from staff with his/her ADLs. The resident could not communicate his/her needs. All of those reasons put the resident at risk for falls. Review of the quarterly MDS dated [DATE] revealed the resident had a short and long-term memory problem and severely impaired cognitive skills for daily decision making. The resident had total dependence on two or more staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The resident did not walk and had functional limitation in his/her range of motion of bilateral (both sides) upper and lower extremities. The resident had not had any falls since the previous quarterly assessment. Review of resident #1 ' s care plan, dated 9/19/13, revealed the resident was at risk for falls related to high risk score, inability to ambulate, [DIAGNOSES REDACTED], and a [DIAGNOSES REDACTED]. of bed (added 9/30/13), provide with proper well-maintained footwear (added 9/30/13), assure the floor was free of glare, liquids, and foreign objects, avoid the use of restraints, encourage the resident to use environmental devices such as hand grips and hand rails, keep the bed in the lowest position with brakes locked, leave a night light on in the room, orient the resident if there were new furniture placement or other changes in the environment, and provide an environment free of clutter. On 7/29/14, staff added an intervention for PT (physical therapy) to evaluate for a no-slide cushion and on 7/30/14 to have PT/OT (occupational therapy) evaluate for positioning when the resident sat in the wheelchair. During an observation on 8/26/14 at 3:26 p.m., resident #1 lay in bed with the bed in the highest position, his/her call light within reach, and without a fall mat or other fall precautions in place. Observation on 9/3/14 at 9:18 a.m. revealed the resident lay in bed with the top of the mattress approximately 2 ? feet from the floor. There were not any fall mats in place. At 12:42 p.m., the resident and the bed remained in the same position. Observation on 9/4/14 at 7:55 a.m. revealed administrative nursing staff S stood at the resident ' s bedside and looked at the resident ' s tube feeding pump. The resident ' s bed was not in a low position. At 7:57 a.m., staff left and the resident lay in bed on his/her right side with the top of the mattress approximately 2 ? feet off the floor. At 8:33 a.m., the resident lay on his/her back with a pillow along his/her right side. The bed remained up and not in a low position. At 11:40 a.m., the resident's bed remained in the same position. At 11:41 a.m., direct care staff Q demonstrated the bed would not go any lower than 2 1/2 feet off the ground. Interview with direct care staff Q on 9/4/14 at 11:41 a.m. revealed resident #1's bed would not go any lower. Staff Q reported the resident had been on a lower bed, but someone must have changed it out, as it was different than it had been previously. Interview with direct care staff A on 9/4/14 at 1:34 p.m. revealed the resident was confined to the bed and the wheelchair. Staff A reported the resident was not considered a fall risk. Staff A reported staff used pillows for positioning the resident in the bed to prevent him/her from rolling off the bed, put pads down on the floor, and kept the bed in the low position. Interview with licensed nursing staff E on 9/4/14 at 2:51 p.m. revealed the staff were to be sure the resident sat in a place where staff could see him/her and not leave him/her alone in the wheelchair. At 3:33 p.m., staff E confirmed the resident's bed, even in the low position, was high and did not go low at all. Staff E reported having the resident ' s bed at the current lowest height would not prevent injury for the resident. Interview with administrative nursing staff C on 9/5/14 at 1:46 p.m. revealed since the resident was immobile, the bed being low was an irrelevant fall intervention and could probably be taken off the care plan. Review of the facility policy for the undated Fall Prevention Program revealed the interdisciplinary team would review fall risk assessments and if appropriate, initiate a fall prevention protocol. The Director of Nursing/designee would be responsible for ensuring resident identified at risk or who had experienced a recent fall had all recommended interventions in place as well as current assessments. The facility failed to ensure staff implemented the planned intervention of a bed in low position.

The facility census totaled 87 residents with 32 included in the sample. The sample included the review of 3 residents for pressure ulcers. Based on observation, interview and record review the facility failed to provide services to prevent pressure ulcers for 1 of 3 sampled residents. (#112) The facility failed to provide the appropriate sized equipment for resident #112 who developed 2 avoidable pressure ulcers. Findings included: - Review of the Admission MDS (Minimum Data Set 3.0, a required assessment) dated 3-28-2012 revealed resident #112 with a BIMS (Brief Interview for Mental Status) score of 15 (indicated little to no cognitive impairment), required total assistance with transfers, extensive assistance with bed mobility and personal hygiene. It also revealed the resident used a wheelchair for mobility, at risk for development for pressure ulcers, with two stage 1 ulcers and three stage 2 ulcers upon admission into the facility. The MDS revealed the resident had [MEDICAL CONDITION] but did not have venous or arterial ulcers. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15, required total assistance with transfers, toileting, bathing and extensive assistance with bed mobility, and personal hygiene, used a wheelchair for mobility, remained at risk for the development of pressure ulcers and had two unhealed stage 2 ulcers that were not present on previous assessment. It revealed the resident had pressure reducing device on the chair and bed, received a repositioning program, nutritional interventions, and pressure ulcer care. Review of the ADL (activity of daily living) CAAS (care area assessment summary) completed on 5-25-12 revealed the resident needed total assist with most ADL's, had a partial amputation of the left foot, a [MEDICAL CONDITION] to the right leg, required a mechanical lift for transfers, bore no weight and with [MEDICAL CONDITION]. Review of the Pressure Ulcer CAAS completed on 5-25-2012 revealed the resident had pressure ulcers upon admission to the left foot, left knee, and coccyx. It also identified risk factors that included the resident's dependence on staff for most ADL's and bed mobility, the use of a wheelchair, was bedbound at all times, required a special mattress or seat cushion to reduce pressure and staff had placed the resident on a regular scheduled turning program. The summary also revealed the resident needed turned and repositioned every 2 hours. Review of the care plan dated 4/24/12 revealed a problem of actual skin breakdown related to pressure ulcers and indicated "I have a pressure area on my left hip which was caused by my wheelchair". It directed staff to complete weekly skin assessments, reposition every 2 hours, have Occupational Therapy evaluate the resident's positioning while in the wheelchair to minimize skin breakdown, apply a mattress on the bed and a cushion in the wheelchair to reduce pressure and provide supplements as ordered to help in the healing process. The care plan had a revision dated 6-20-2012 to indicate the resident's wheelchair did not fit on the facility's bus lift and directed staff to make sure the resident used an EMS (emergency medical system) vehicle to go to any appointments out of facility. Review of the nurse progress notes dated 3-23-2012 at 5:52 PM revealed the nurse documented a skin assessment that measured pressure areas to the top of the left foot, a surgical site to the left outer foot (5th digit and partial foot amputated), two stage 2 areas below the left knee, a blackish colored scab to the back of the left ankle, and one to the resident's coccyx. The identification of the resident's pressure ulcers revealed the resident at high risk for the development of further pressure areas. Review of a nurse's progress note dated 4-24-2012 at 8:50 AM revealed a nurse documented "Staff discovered an open area to the resident's right hip, stage II, measured 2.3 x 1cm (centimeters) 100% red with minimal amount of clear exudate, without odor. Two red spots also identified on the resident's right hip-upon interview the resident stated that his/her w/c (wheelchair) had been rubbing the area when he/she sat in it causing the sore, notified physician GG and family. Physician GG gave an order to apply Xeroform and bordered dressing daily until resolved, OT (Occupational Therapy) to evaluate w/c positioning". The documentation showed the resident developed two pressure ulcers on the right hip as a result from sitting in a wheelchair that was too small for the resident's size. Review of a nurse's note dated 5-16-2012 at 9:22 AM revealed staff documented "transportation called the resident's orthotic company to see if they can come to facility and see (gender) so we don't have to use the smaller wheelchair for (gender) when we go out to appts (appointment). It has caused sores on (gender) right hip area. ... The resident has had to use the smaller chair only when going out to appts, as (gender's) regular chair is too wide and will not fit on the lift of the bus." Review of a nursing progress noted dated 5-16-2012 at 11:38 revealed the following skin assessment: "Left hip wound measures 2.4cm x 2.2cm. Small amount of serous exudate noted. Skin around the wound indurated with mild [DIAGNOSES REDACTED] noted. 15% yellow slough, 85% pink granulation tissue." The documentation showed the resident now had three pressure areas, two on the right hip and one on the left hip. Review of the weekly pressure ulcer report revealed the staff identified the wound on the left hip/thigh as an acquired pressure ulcer. Review of the report revealed that the staff monitored the pressure ulcer weekly. The report also showed the staff monitored and measured the acquired pressure ulcers on the right hip weekly, also. Observation on 6-18-2012 at 4:00 PM revealed the resident laid in bed with a pillow under each leg. Observation on 6-19-2012 at 7:18 AM revealed Administrative nursing staff E and Administrative nursing staff F prepared to remove current wound dressings and apply clean ones. Administrative nurse E reported the left thigh pressure ulcer was unstageable because the wound bed was covered with slough. Observation revealed the wound bed covered with yellow slough and measured 5.8 cm (centimeters) X 6.8 cm X 0.2 cm. Administrative nurse E then completed the dressing change as ordered and with the appropriate use of gloves and hand washing. Observation on 6-19-2012 at 7:35 AM revealed Administrative nursing staff E and Administrative nursing staff F prepared to change the wound dressings to two areas on the right thigh. The upper wound had a covering of black eschar and measured 2.8 cm X 6.1 CM. The mid-thigh wound covered with black eschar, no drainage, and measured 1.5 cm X 0.8 cm. Observation revealed part of the eschar had come off the lower portion of the wound bed. Administrative nurse E reported he/she would be calling the physician to obtain orders to treat the area. Observation on 6-19-2012 at 8:00 AM nursing staff G and nursing staff H assisted the resident from the bed to a large wheel chair (not bariatric, and smaller than his/her bariatric chair) using the full maxi mechanical lift. The resident sat snug in the chair. The resident complained the chair put pressure on his/her thighs, wiggled around a bit in chair, and then said, "That's better". Observation on 6-19-2012 at 12:30 PM revealed the resident had a room tray. The resident reported that he/she had eaten a late breakfast on the way to the wound clinic. During an interview on 6-18-2012 at 12:30 PM the resident reported the food tasted good and had no complaints, He/she reported that he/she liked to stay up in the wheelchair until after lunch and had a cushion in the chair and it was comfortable. During an interview on 6-18-2012 at 4:00 PM the resident reported that he/she got the sores on his/her thighs when he/she came to the facility because the wheelchair was too small and caused pressure on his/her thighs. The resident also reported the facility found a little larger one (w/c) from another resident that they now used to go to appointments since it fits in the van and they ordered an even larger one (w/c) for him/her to use when up in the facility. He/she reported that when he/she gets to the physician's office they remove the arm rests so there would not be any pressure but the van driver had to put them back on for the trip home. On 6-20-2012 at 7:55 AM the resident reported that he/she was in the regular sized wheelchair for about a week or so and used it for appointments and to go to therapy before the facility got the one that was a little bigger. During an interview on 6-18-2012 at 4:35 PM direct care staff I reported he/she used the care plan summary notebook to check what the resident needed and voiced awareness of the pressure ulcer. He/she identified the resident as able to turn using the side rails but staff encouraged him/her to reposition at least every 2 hours. During an interview on 6-18-2012 at 2:35 PM licensed staff J reported the resident had a large wheelchair but it was not large enough and caused the pressure ulcer on left thigh. He/she also reported they now have a larger bariatric wheelchair. During an interview on 6-20-2012 at 9:25 AM therapy staff K reported that the resident did not use the wheelchair until April to start working on using a slide board for transfers in the wheelchair. He/she reported the resident never complained about the wheelchair being a problem until the resident went to the prosthetic appointment and had to sit in the chair for 3-4 hours. Therapy staff K reported that when the resident came to therapy he/she was only in the chair for about 20 minutes at a time. During an interview on 6-20-2012 at 2:50 PM therapy staff K and administrative nurse F reported they found the wheelchair used to transport the resident to appointments measure 25 inches. They thought the resident had used the same wheelchair since admission. During an interview on 6-19-2012 at 7:30 AM administrative nurse E confirmed the wounds on both thighs had been caused by sitting in a wheelchair that was too small for over two hours. He/she explained the resident had a large chair, but it did not fit on their van lift. He/she reported that about a month or so after the resident came and had a doctor's appointment they had to put her in a regular wheelchair to get in the van. This caused pressure against the resident's thighs and when returned from the appointment the resident complained of thighs hurting and staff saw the red areas. The facility then purchased a larger chair that would still fit in the van so they could take the resident to appointments. On 6-20-2012 at 4:20 PM Administrative nursing staff E reported the resident always had the 27 inch wheelchair but it would not fit in the van. After explaining to staff E that the resident and therapy staff reported the resident used 3 different wheelchairs during the span from the time he/she got out of bed to currently, staff E reported that he/she would have to talk to therapy for clarification. At 4:45 PM staff E returned and spoke with another therapy staff on the phone and reported he/she thought there were 3 wheelchairs, a 23 inch, 25 inch, and a 27 inch one. During an interview on 7-3-2012 at 1:22 PM Physician P reported the cause of the pressure ulcers to the resident's thighs was because he/she sat in a wheelchair that was too small for over a 2 hour period. The facility's Pressure Ulcer Treatment Policy, pages 12-15, revised on 10 - 2012 with a purpose to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers lacked any possible interventions the staff should take to prevent the development of pressure ulcers. The facility failed to thoroughly assess a resident's equipment needs for the appropriate sized wheelchair in order to prevent the resident from developing avoidable pressure ulcers. The resident developed three pressure ulcers, two on the right thigh and one on the left thigh as a result of sitting in the wheelchair that was too small, for an extended amount of time.

The facility reported a census of 88 residents with 1 resident sampled for review of surgical wound care. Based on observation, interview, and record review the facility failed to ensure a resident with surgical wounds received the necessary care and treatment to attain the highest practicable physical well being, by failing to keep skin dry from incontinence, by failing to reposition frequently, and by failing to accurately assess a surgical wound for 1 of 1 sampled residents (#124). Finding included: - Review of resident #124's admission MDS (Minimum Data Set, a required assessment) 3.0 with an Assessment Reference Date of 2-25-11 identified the resident with a BIMS (Brief interview of mental status) score of 15/15 (cognitively intact) and total dependency on 2 staff members for all transfers and activities of daily living. The MDS identified the resident with an indwelling urinary catheter and a [DIAGNOSES REDACTED]. Interventions identified on the assessment included pressure reducing device for chair and bed, turning repositioning program, pressure ulcer care, surgical wound care, and application of dressings non surgical, ointments and creams. Review of the resident's care plan dated 2-23-11 revealed staff failed to include interventions for the resident's identified wound care needs, including the identified interventions on the admission assessment. Observation on 3-28-11 at 9:29 a.m. revealed the resident in bed with their sheet wet with urine from the resident ' s shoulders down to the foot of the bed. The resident's urine saturated the resident's linens, clothes, and the foam dressing on the coccyx. On the resident's back and rib areas, observation revealed red areas and indentions of the sheet. The resident reported that they were numb from the nipple line down from [MEDICAL CONDITION] but could still feel some sensations. The resident reported that their bottom area burned from lying in urine. Observation of the coccyx, revealed a recent incision from the right hip to the coccyx with a surgical wound on the coccyx. The surgical wound had an open area with a black center with pink and brown areas around the wound with a smaller unopened red area under the larger area. Nurse S provided treatment to the wound on the coccyx. Observation of the resident on 3-28-11 at 12:46 p.m. revealed the resident in the wheelchair in their room. At 1:40 p.m. observation revealed the resident sitting in the wheelchair, leaning back, sleeping in their room. At 2:00 p.m. the resident remained in the same position. At 2:30 p.m. the resident remained in the wheelchair sleeping in their room. At 2:55 p.m., the resident remained in the same position. At 3:15 p.m. the resident remained in the same position. At 3:31 p.m. observation revealed the resident awake and sitting in the wheelchair watching television in their room. At 3:55 p.m., the resident remained in the same position. (The resident remained in the same position for over 3 hours, which put pressure on the wound). At 4:09 p.m. observation revealed the resident in bed on the left side with a baseball size amount of bloody drainage on the dressing on the coccyx and skin pink on the coccyx area. During interview with administrative nurse B on 3-29-11 at 1:22 p.m. confirmed the wound on the coccyx began when the wound clinic took out staples from the resident's surgery. The nurse reported the area as a pinpoint open area to the coccyx and failed to document a date or assessment in the resident's record. Administrative nurse B expressed unawareness in regards to the increase in bloody drainage from the surgical wound on the intact dressing on the coccyx. Review of the weekly surgical wound report dated 3-23-11 revealed a surgical wound to the coccyx measured 3 cm. (centimeters) in length by 3 cm. in width with no depth recorded. Observation of weekly wound measurement rounds on 3-30-11 at 9:35 a.m. with administrative nurse B and administrative nurse R revealed the resident had one surgical wound to the coccyx, black and pink in color with a scar from the right hip to the coccyx. Administrative nurse B acknowledged the surgical wound to the coccyx was larger in size, prior to measuring, compared to the observation of the area on 3-28-11. The surgical wound measured 3.5 cm. in length by 2.5 cm. in width by 0.8 cm. in depth. Administrative nurse B reported that they would notify the physician of the increase in size of the surgical wound and would obtain new orders for the surgical wound on the coccyx. Review of weekly skin assessments in March revealed assessments on 3-5-11, 3-12-11, and 3-26-11. The assessments revealed that the resident's dressing to the coccyx remained in place. The staff failed to document any measurement or description of the wound. Interview on 3-30-11 at 10:51 a.m. with administrative nurse B acknowledged nursing staff were not accurately documenting weekly resident skin assessments and that they should be removing the dressing to accurately assess the condition of the skin. Administrative nurse B confirmed that the facility failed to have a system in place to thoroughly check skin weekly. The facility failed to accurately assess a surgical wound on a regular basis, failed to develop a care plan for the healing of the surgical wound, failed to ensure the surgical wound and dressing covering it remained free of urine and failed to reposition the resident off the surgical wound, to promote wound healing.

The facility reported a census of 88 residents with 3 residents sampled for the review of pressure ulcers. Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing regarding positioning changes for one sampled resident(#101). The facility also failed to ensure that an avoidable increase in the number of pressure ulcers did not occur for 1 of 3 sampled residents (#124) regarding positioning change and incontinent care. Findings included: - Review of resident #124's admission MDS (Minimum Data Set, a required assessment) 3.0 with an Assessment Reference Date of 2-25-11 identified the resident with a BIMS (Brief interview of mental status) score of 15/15 (cognitively intact) and total dependency on 2 people for all transfers and activities of daily living. The MDS revealed the resident had an indwelling urinary catheter due to [MEDICAL CONDITION]. The MDS also revealed the resident had one stage 2 pressure ulcer and one stage 4 pressure ulcer. Interventions addressed on the MDS were pressure reducing devices for chair and bed, turning/repositioning program, pressure ulcer care, and application of non surgical dressings, ointments and creams. Review of the resident's CATs (care area triggers) dated 2-25-11 identified the need for a further assessment of pressure ulcer care areas. The CAAs (care area assessments), a further assessment used to document supporting reasons for identified risk factors, dated 2-25-11, lacked supporting documentation for the identified risk factors of the resident's pressure ulcer care needs to develop an individualized plan of care. Review of the Braden Scale of Predicting Pressure Ulcer Risk revealed the resident had a high risk for developing pressure ulcers with a score of 11/20. Review of the resident's care plan dated 2-23-11 failed to include interventions for the resident's identified pressure ulcer care needs. Observation on 3-28-11 at 9:29 a.m. revealed the resident in bed with their sheets wet with urine from their shoulders down to the foot of the bed. The resident's bed presented with urine pooled from the resident's shoulders down to the resident's feet. The resident's urine saturated the resident's linens, clothes, and foam dressing on the coccyx. During incontinence care, the resident reported to nurse S their suprapubic catheter (a surgically created connection between the urinary bladder and the skin which is used to drain urine from the bladder into a collection bag) failed to function properly the night before around 10:30 p.m. The resident told nurse S they reported it to the nurse working at the time and failed to receive further care. The resident's back and rib areas presented with red areas and indentions of the sheet. (The resident reported they laid in bed in the same position without incontinence care for 11 hours). From observation 3-28-11 at 9:29 a.m., the resident's low air loss mattress had the static (firm) button pushed on (which is the hardest setting). The resident reported that the mattress was very hard and uncomfortable. Nurse S reported that they did not know how to operate the mattress and had not received training on the mattress. Administrative nurse B reported the facility did not have the manual on the mattress. The resident reported numbness from the nipple line down due to [MEDICAL CONDITION] but could still feel some sensations. The resident reported their bottom area burned from laying in urine. Nurse S provided treatment to the coccyx. Observation revealed an open pressure ulcer under the left buttock. Nurse S did not identify, measure or provide treatment to the area under the left buttock. Observation of the resident on 3-28-11 at 12:46 p.m. revealed the resident in the wheelchair in their room. At 1:40 p.m.,observation revealed the resident seated in the same position. At 2:00 p.m. the resident remained in the same position. At 2:30 p.m. the resident remained in the same position. At 2:55 p.m. observation revealed the resident seated in the same position. At 3:15 p.m. the resident remained in the same position. At 3:31 p.m., observation revealed the resident in the same position. At 3:55 p.m. observation revealed the resident seated in the same position. (The resident remained in the same position for over 3 hours). At 4:09 p.m. observation revealed the resident in bed on the left side with pink colored skin to the coccyx and buttocks. A physician's orders [REDACTED]. Observation on 3-30-11 at 9:35 a.m. with administrative nurse B and administrative nurse R revealed measurements of the resident's pressure ulcers. The resident had 2 stage one pressure ulcers (intact skin with non blanchable redness, NPUAP (National pressure ulcer advisory board)) to the left lateral ankle. One new area observed on that day administrative nurse B confirmed with both areas pink and red in color. Observation revealed the resident had 4 pressure ulcers to the right lateral ankle. One suspected deep tissue injury (purple or maroon localized area of discolored intact skin, NPUAP) and three new stage one pressure ulcers observed on that day, administrative nurse nurse B confirmed. The pressure ulcers to the right lateral ankle were purple, pink and red in color. Observation revealed 2 pressure ulcers to the groin area. 1 stage four pressure ulcer (full thickness tissue lost with exposed bone, tendon,or muscle, NPUAP) and one new stage one pressure ulcer observed on that day, administrative nurse B confirmed, with red and pink color. Observation revealed 1 stage two pressure ulcer (partial thickness loss of dermis presenting as a open shallow ulcer) under left buttock. The pressure ulcer under the left buttock was newly observed that day administrative nurse B confirmed and was pink in color. Administrative nurse B reported that they would notify the physician and obtain orders for the new pressure ulcers to the left lateral ankle, right lateral ankle, right groin area, and left buttock area. The resident had a total of 8 new pressure ulcers identified on the weekly wound measurement rounds on this day compared to the previous week. Interview on 3-29-11 at 1:22 p.m., administrative nurse B expressed unawareness about a pressure ulcer to the left lateral ankle noted on the physician's orders [REDACTED]. Review of weekly skin assessments in March revealed assessments on 3-5-11, 3-12-11, and 3-26-11 only noted the dressing to the coccyx was in place. The staff failed to document any measurements or description of the pressure ulcers. On 3-30-11 at 10:51 a.m., administrative nurse B acknowledged nursing staff failed to accurately document weekly resident skin assessments and staff failed to take off dressings to assess the condition of the skin. Administrative nurse B confirmed the facility failed to have a system in place to accurately check skin weekly. The facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing and prevent new sores from developing by the facility's failure to develop a careplan for the prevention and treatment of [REDACTED]. - Review of the admission assessment dated [DATE] identified resident #101 with one stage 4 (full thickness tissue loss with exposed muscle), two stage 3 ( full thickness tissue loss) and two stage 2 (partial thickness tissue loss) pressure ulcers. The resident recently experienced a hospitalization for amputation of the left leg (previously the right leg also) and returned to the facility on [DATE] with an infected surgical wound on the left stump, which often prevented the resident from changing positions, due to pain. The assessment identified the resident required extensive assistance with bed mobility and transfers. Review of the current plan of care identified actual skin breakdown to the sacral and right buttocks areas related to impaired mobility and circulation. The care plan also identified potential for further skin breakdown related to the resident's non-compliance with smoking and refusal to lay down between meals. On 12/2/10 staff added interventions that included instructions for staff to assist the resident with positioning every 2 hours and as needed. When first seen on 3/28/11 at 9:30 a.m., observation revealed the resident in the facility courtyard in their wheelchair. A family member wheeled the resident into the activity room. At 11:22 a.m., the resident remained in the wheelchair in their room. At 11:48 a.m. the resident remained in the wheel chair in the activity room again, talking with staff and other residents. Observation at 12:15 p.m., revealed the resident remained in the wheelchair in their room for lunch. On 3/28/11 at 1:30 p.m., the resident reported staff assisted them into the wheelchair around 8:00 a.m. that morning and had not assisted the resident to change their position since that time. The resident reported a nurse aide "is going to help me to bed as soon as (gender) is finished helping another resident". At the same time, as the resident propelled their wheelchair down the hall to find the nurse aide, nurse aide T walked toward the resident in preparation to assist the resident to bed. The resident reported they usually stayed in bed because of the pressure ulcers and wanted to try to stay up for at least a couple of hours a day. When nurse aide T assisted the resident to bed, they positioned the resident on their back and did not encourage the resident to lay on their side to remove pressure from the pressure ulcers on their buttocks. Observation revealed a dressing dated 3/28/11 on the resident's buttocks that covered the pressure ulcers. The resident used a urinary catheter to keep the area dry. Nurse aide T explained they had not assisted the resident to "get out of the wheel chair because (gender) has a catheter". Observation on 3/28/11 at 3:45 p.m., revealed the resident remained lying in the bed on their back. The resident reported they try to turn themselves from their back to their right side. The resident reported they recently had "more removed from the left stump and cannot lay on that side because I still have the stitches and staples". The resident reported they cannot stay in one position very long due to the pain at the surgical site on the left stump and the pressure ulcers on their buttocks. The resident further reported they recently quit smoking to help with healing the pressure ulcers and knew they needed to stay off the areas as much as possible. Observation on 3/29/11 at 8:30 a.m., revealed nurse W provided the treatment/dressing change to buttocks and left stump. The nurse identified improvement in the areas on the buttocks. Administrative nurse B measured the areas weekly on Mondays and review of the documentation showed a decrease in size of the areas when measured on 3/23/11. Interview with Administrative nurse B on 3/30/11 at 7:45 a.m., revealed the resident was admitted to the facility with pressure ulcers and at first would not comply with staff requests to change positions, or lie down off the areas and was still smoking. The resident "developed another pressure ulcer on the right ischium and the physician ordered a urinary catheter to keep the area dry". Staff documented the resident's non compliance and interventions attempted in the nurses' notes, but failed to consistently encourage and assist the resident to change positions to prevent pressure on the ulcers. The facility failed to ensure staff consistently encouraged and assisted the resident to change positions to remove pressure from their pressure ulcers to promote healing and prevent further skin breakdown.