Every finding on record at Alcester Care And Rehab Center, Inc

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) and was outside of the building approximately 18 minutes when a basement door was left unalarmed. Failure to ensure the alarm was activated may have contributed to his elopement. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/9/24 at 3:13 p.m. the facility received a phone call from a community member alerting them that resident 1 was sitting outside the facility in the apartment parking lot close to the street. *Resident 1 was brought back to the facility by staff, was assessed, was not injured. The provider implemented systemic changes to ensure the deficient practice does not recur was confirmed after: record review revealed the facility had followed its quality assurance process, education was provided to all staff regarding the elopement process including ensuring the basement door alarm was to always be properly engaged. resident 1, was re-educated that he was to let staff know when he would like to go outside, observations and interviews revealed staff understood how to engage the door alarm system, how to respond to the door alarms, and to implement their process to ensure an elopement does not occur, review of staff schedules confirmed staffing levels met residents' assistance needs, verifying the elopement procedures including the activation of the basement door alarm was conducted and audits were being performed. Based on the above information, non-compliance at F689 occurred on 6/9/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 6/11/24, the non-compliance is considered past non-compliance.

Based on record review, interview, and policy review the provider failed to follow physician orders for one of one sampled resident (237). Findings include: 1. A review of resident 237's electronic medical record (EMR) revealed: *She had diagnoses of: -Generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities). -Paroxysmal anxiety (unpredictable recurrent attacks of severe anxiety). -Bipolar disorder, depressed, severe without psychotic features (mood swings ranging from depressive to manic high episodes). * She returned to the facility on [DATE] following a hospital stay with a physician's order for quetiapine (Seroquel) (a medication to stabilize mood) 25 milligrams (mg) one tablet by mouth three times daily as needed (PRN) for anxiety or agitation for 14 days. That order had ended on 4/25/24. *On 4/26/24 resident 237's physician extended that order for another 14 days. *There was no face-to-face visit completed by physician for the 4/26/24 order. *The order was faxed to [NAME] Pharmacy. *The order was not in resident 237's EMR. *An interdisciplinary progress note on 4/27/24 at 9:51 p.m. Resident given PRN Seroquel 25 mg at 2010 [8:10 p.m.]. Resident does have a PRN order, is not in TAR [treatment administration record]. Resident requests for anxiety. *The resident's 4/29/24 physician order summary did not include that Seroquel order. *A progress note on 4/29/24 at 1928 [7:28 p.m.] Resident requested PRN Seroquel with HS [hour of sleep] medication. Administered 25 mg PRN dose with HS medication. Observation and interview on 4/30/24 at 8:19 a.m. of the medication cart containing resident 237's medications with licensed practical nurse (LPN) C revealed: *Resident 237's medication card of the PRN Seroquel was still available for administration. *LPN C verified there was no physician's order in the EMR for that medication. Interview on 4/30/24 at 1:57 p.m. with director of nursing (DON) B revealed: *The pharmacy puts all orders into the EMR system. *She verified there was no face-to-face visit by resident 237's physician for the 4/26/24 Seroquel PRN order. *Staff were to use a checklist to process physician orders as follows: -Fax pharmacy. -eMAR/eTAR [electronic medication administration record/electronic treatment administration record]. -Removed medication/tx [treatment]. -Notify POA [Power of attorney]. -Progress note. -Report book. -Charting list. -Other. *No interdisciplinary progress note were in the resident chart except for the PRN doses given after original PRN order had been discontinued. *There was no system in place to monitor PRN psychotropic medications. *She confirmed the checklist had not been completed for resident 237's 4/26/24 Seroquel physician order and staff did not follow the physician's order. Review of provider's 7/7/23 Antipsychotic Medication Policy revealed: *PRN antipsychotic drug administration, in the event that a resident has a prn antipsychotic medication order, the following will apply: -Before an as needed or PRN antipsychotic drug is administered, multiple non-pharmacological interventions are to be attempted and documented. -Non-pharmacological interventions will be documented on the eMAR with the antipsychotic medication's progress notes.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) had an updated care plan that reflected the following: *Interventions for missed dialysis treatments. *Current individualized care needs regarding activities of daily living and how to appropriately care for the resident. Findings include: 1. Observation and interview on 9/26/23 at 9:00 a.m. in resident 1's room with certified nursing assistant (CNA) D and another unidentified CNA indicated they were just finishing up care provided to the resident. The resident was lying in bed on his back. 2. Observation on 9/26/23 at 10:00 a.m. the resident was lying on his back in his bed. 3. Interview on 9/26/23 at 10:15 a.m. with LPN B nurse manager and LPN C regarding resident care plans revealed: *There were staffing concerns. *The updating of resident care plans were not completed. *Many of the management staff had to work on the floor due to staff shortages. 4. Interview on 9/26/23 at 10:30 a.m. with administrator A revealed the MDS (Minimum Data Set) coordinator worked approximately 12 hours per week. She was the one responsible for updating the resident care plans. 5. Observation and interview with resident 1 at 11:00 a.m. revealed: *He ate all meals in his room. *He was in the same position in bed as previously observed. *There had been no staff that had entered his room since the 9:00 a.m. observation. *He stated that he usually got his noon meal around 11:00 a.m. 6. Observation and interview with resident 1 at 11:30 a.m. revealed he: *Was sitting on the edge of the bed eating his noon meal. *Stated staff had assisted him to a sitting position at the edge of the bed. *Stated no staff had assisted him with his incontinent brief or asked if he had to use the restroom. 7. Interview and observation on 9/26/23 at 1:00 p.m. with CNA D regarding resident 1 and the above observations revealed: *Staff were supposed to check and change residents who were incontinent every two hours. *She confirmed she had not completed the checking and changing of resident 1 since 9:00 a.m. *She stated, I need to get in there. *When asked how she knows what care to provide to residents, she provided a piece of paper with the names of the residents and their room numbers but no other indicant information related to each residents individual care needs. 8. Interview and observation with travel CNA E on 9/26/23 at 1:15 p.m. regarding care provided to the residents revealed: *She was a traveling CNA. *She stated she used the provided cheat sheet that had the residents name, room number, and minimal information related to the individual care needs of the residents. 9. Review of the provider's cheat sheet related to resident 1 revealed: *There was no date on the cheat sheet and no title on the form. *The only information on the form for resident 1 was the following: -His name. -The room number. -1-2 staff assist. -Wheelchair. -Eats meals in room. -Needs Hoyer sling under him when goes to dialysis (M,W,F [Monday, Wednesday, Friday]). -L[large]/XL[extra large] brief. *There was a lack of information for direct care staff related to toileting, bathing, mobility, transfers, personal grooming, communication, hygiene, and any assistance required for eating. 10. Review of resident 1's comprehensive care plan revealed: *There was no information related to the discontinuation of his 1800 fluid restriction. *There was minimal information related to his dialysis. *Encourage resident to go to the scheduled dialysis appointments. *There was no information related to interventions when the resident missed the scheduled dialysis treatments. *There was no information related to assessments and monitoring of the residents condition when those dialysis treatments were missed. *There was no information regarding the residents care needs for direct care staff to have followed to provide the appropraite care. Refer to F698, finding 2 11. Review of the provider's reviewed 5/5/23 Care Plan Policy and Procedure revealed: *It was the basic responsibility of the MDS or designee. *Care plans should have been developed by an interdisciplinary team with participation of the resident, family, and or representative. *Care plans should include active and historical diagnoses, goals, and/or expected outcomes, specific nursing interventions so that any nursing staff member was able to quickly identify a resident's individual needs and to decrease he risk of incomplete, incorrect, or inaccurate care and to enhance continuity of nursing care. *Care plans should have been reviewed quarterly, annually, and with any significant change in the residents condition. *Care plans were written by exception from the Residents Centered Care Plan Facility Standards and Short Term Care Plans.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (1) who had a witnessed fall had the following completed: *A thorough head to toe assessment completed by the nurse at the time of the fall. *A fall assessment. *Vital signs obtained every shift for 72 hours after the fall. *Physician and family notification of the fall. *An update to the care plan to include new interventions to prevent another fall. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He had a witnessed fall on 8/23/23 at 3:55 a.m. -The resident had called to use the restroom; the registered nurse (RN) on the night shift was assisting him. -The resident was using his walker and there was a gait belt used by the RN. -The resident was having difficulty turning himself and the residents legs had become tired. -The nurse lowered the resident to the floor. -There were no injuries documented. -The staff transferred the resident back to his bed with a Hoyer lift. *On 8/25/23 at 11:36 p.m. were the only set of vital signs that were found in EMR. *There was no documentation the following had been completed by the RN: -A full head-to-toe assessment. -No vital signs. -No physician notification. -No notification to the family. *There was no indication that the residents care plan was reviewed or revised related to the residents fall that should have included interventions to prevent another fall. Interview on 9/26/23 at 12:20 p.m. with administrator A confirmed that she was unable to find the above information in resident 1's EMR related to the fall on 8/23/23. Review of the provider's undated Fall policy revealed: *The purpose of the policy was to have provided a safe living environment for the residents and to protect them from injury. *The policy was to ensure that a resident who had sustained a fall would have been thoroughly assessed by an RN or an LPN [licensed practical nurse]. *Thoroughly assess the resident by completing a head-to-toe assessment. *Notify the physician and the family of the fall and the residents condition as soon as possible. *Document in the nurses notes the following: -Date and time of the fall. -Residents activity prior to the fall. -Condition of the resident. -Date and time the physician was notified. -Date and time the family was notified. *A licensed nurse would update the care plan to reflect interventions instituted to prevent further falls. *Completed vital signs would have been placed in the residents medical record.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) who required dialysis three times a week at an off-site contracted end stage renal disease facility: *Had the appropriate transportation arrangements set up to ensure dialysis was completed as ordered by the physician. *Had ongoing assessments and monitoring of the residents condition for complications related to missed dialysis treatments. *Physician was notified of the missed dialysis treatments. 1. Observation and interview on 9/26/23 at 9:00 a.m. with resident 1 in his room revealed: *He was lying in bed on his back. *The CNA D and an unidentified CNA had just performed peri care due to a bowel movement. *There was a 16 ounce can of beer with a straw, a can of soda with a straw, and a clear plastic mug of water that was on his bedside table. *He stated he would drink two cans of beer a day, and soda pop. *He was aware of the date and his whereabouts but was slow to answer. *When asked about his dialysis he stated he had not gone to dialysis on Monday, September 25, 2023 because there was no transportation available. *He stated he felt fine. No complaints of pain or shortness of breath. *He would eat meals in his room. *He had a central line in the upper left chest area that was used for dialysis and there was a transparent dressing secured to the site. *The dialysis staff was responsible for the care of that central line. 2. Interview with licensed practical nurse (LPN) B who was the nurse manager and LPN C regarding resident 1 revealed: *He had been hospitalized until September 23, 2023 when he returned to the facility. *The resident missed dialysis on Monday, September 25, 2023 due to no transportation was available. *The resident refused dialysis treatments at times. *The physician was not notified of the missed dialysis treatment. *They thought the family had been notified. *There had been no assessments or monitoring of the residents condition when dialysis treatments were missed. *The fluid restriction had been discontinued by dialysis. *The only fluids the residents drank was beer and soda pop. He never drank water. *The dialysis access site was a central line and the staff at the dialysis treatment center were the only ones that cared for the site. *LPN B nurse manager stated the nursing staff would not do anything with that dialysis access site. 3. Interview with administrator A regarding resident 1's missed dialysis treatments: *The resident had refused to go to dialysis quite frequently. *He was his own power of attorney and made all his medical decisions. *The family had been notified of the missed dialysis treatment on Monday, September, 25, 2023. *There had been no assessment or monitoring of the residents condition when missing dialysis treatments. *She stated that she could have let the family take the facility van to transport the resident to dialysis but that thought never crossed her mind. *There was no extra staff that day that could have transported the resident to dialysis. 4. Review of the resident 1's electronic medical record revealed: *He was admitted on [DATE]. *He was [AGE] years of age. *His diagnoses included the following: -Displaced right shoulder fracture of the coracoid process (the anterior portion of the scapula that stabilizes the shoulder joint). -Type II diabetes. -Cerebral infarct. -End stage renal disease. *He had an order for dialysis three times a week (Monday, Wednesday, and Friday). *He was usually cognizant but had times of confusion. *There was no documentation related to assessments or monitoring of the residents condition due to missed dialysis treatments. *There was no documentation that the physician had been notified when the resident refused to go to dialysis or missed due to transpiration issues. 5. Telephone interview on 9/26/23 at 11:15 a.m. with lead driver G from Rural Office of Community Services (ROC) regarding the transpiration service for resident 1 revealed: *The hours of operation were 7:30 a.m. to 4:30 p.m. Monday through Friday. *A facsimile had been sent by the provider on 9/23/23 regarding resident 1's return from the hospital. *The facsimile must have come in after hours on Friday, September 23, 2023. *They could not provide transpiration for resident 1 due to multiple transfers scheduled for that day. 6. Review of resident's 1 comprehensive care plan with an initiated date of 7/29/22 revealed: *Check and change dressing daily at access site as needed. *Encourage resident to go to the scheduled dialysis appointments. *Monitor vital signs before dialysis. Notify MD (medical doctor) of significant abnormalities. *There was no information related to interventions when the resident missed the scheduled dialysis treatments. *There was no information related to assessments and monitoring of the residents condition when those dialysis treatments were missed. 7. Interview on 9/26/23 at 1:30 p.m. with LPN B nurse manager regarding the above care plan inconsistencies indicated due to the staffing challenges care plans were not updated to reflect the current resident care needs. 8. Review of the provider's 5/5/23 Dialysis and Fistula Intervention policy and procedure revealed there was no documentation related to missed dialysis treatments and interventions that should have been put in place when a resident missed a scheduled dialysis treatment.

Based on incident report review, interview, observation, record review, and policy review, the provider failed to: *Properly measure the bedrail safety zones for eleven of eleven residents with bedrails (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11), which resulted in resident injury for one of one sampled resident (11) when his head got wedged in an area of the bedrail that had not been measured. *Complete assistive device assessments for three of eleven sampled residents with bedrails (1, 3, and 9). *Obtain informed consent for the use of a bedrail for one of eleven sampled residents (3) with bedrails. *Update care plans to reflect the use of bedrails for four of eleven sampled residents (3, 8, 10, and 11). *Obtain physician's orders, per the provider's policy, for the use of bedrails for ten of eleven sampled residents with bedrails (1, 2, 3, 5, 6, 7, 8, 9, 10, and 11). Findings include: 1. Review of the provider's 6/2/23 Healthcare Online Self Reporting incident report submitted to the South Dakota Department of Health revealed: *On 5/28/23 at 6:10 a.m., resident 11 was heard moaning from his room by facility staff. *Upon entering his room, staff found [resident 11's] face into side of bed frame/side rail . He was on his knees. His head was between the bed frame and side rail, face down against the railing. *[Resident 11's] mouth was bleeding and tooth was crooked. *[Resident 11] was assisted out of the position with the assist of three staff, with his neck being stabilized during the change of position to the floor. *[Resident 11] was laid down on his back with his neck being stabilized. *The call light was found near him, but resident 11 had not turned it on. *He was talkative, and in a good mood with no complaints of pain. *There was no discoloration to his face and he did have a cut to his [NAME]; this cut on his [NAME] was slightly bleeding and was cleaned and gauze was held on the area. *[Resident 11] stated he was trying to sit up at side of bed, and that his mouth was open when he fell . *He was transported to a local emergency room for evaluation. -Assessments from the emergency room indicated no significant injuries .other than a broken tooth. *The provider reeducated resident 11 on using his call light to call for and then wait for assistance before trying to get up and or out of bed. *Resident 11 declined the provider's offer to have him evaluated by a dentist. *He had no complaints of pain or difficulty with eating and has continued to eat his normal diet. *The provider gave resident 11 a different bed, mattress, and different set of half bedrails. 2. Interview on 6/6/23 at 10:30 a.m. with administrator A about resident bedrails revealed: *After resident 11's incident, they removed that set of bedrails from his bed. -They disposed of those bedrails by the time of the survey. *They had performed safety measurements on his bedrails prior to the incident. *She said, Everything was within measurements, so I do not know how he got his head stuck. Interview on 6/6/23 at 10:38 a.m. with certified nurse assistant/certified medication aide (CMA) E about resident 11's incident revealed: *She and some other staff (licensed practical nurse (LPN) C and registered nurse (RN) F) had heard yelling coming from resident 11's room. *When they entered the room, it looked like resident 11 was in a praying position with his knees on the floor and his head leaning off to one side. *His call light was near him, but it had not been turned on. *There was blood on his bed sheets and face. *It took three staff members to help lift his head out from the bedrail. *They used pillows to stabilize his neck. *She stayed with resident 11 the entire time while the nurse manager called the ambulance. *During the above-described process, CMA E said that resident 11 was alert and acting like his normal self. Interview on 6/6/23 at 10:44 a.m. with LPN C about resident 11's incident revealed: *She was conducting the morning shift report when they heard yelling. *When she, CMA E, and RN F entered resident 11's room, he looked like he was praying; his head was down. *His head was lodged in between the bed frame and bedrail. *They gently lifted his head out of the wedged position. -They stabilized his neck and head with a pillow as they lowered him to a laying position on the floor. *There was blood on the bedrail and his bed sheets. *When she assessed resident 11, she noted blood on his [NAME] and mouth, swelling to the back of his head, and a broken crooked tooth. *She instructed CMA E to remain with resident 11 while she went to call an ambulance. *Resident 11 had not sustained any fractures. *He declined to go to a dentist to fix his broken tooth. 3. Interview on 6/6/23 at 10:59 a.m. with director of nursing/Minimum Data Set coordinator (DON) B about their process for assessing bedrails revealed: *When a new resident was admitted and received physical therapy (PT), PT generally recommended bedrails for assistance with repositioning in bed. -Most of their bedrails were used based on PT recommendations. *When she received a recommendation from PT for a resident to use bedrails, she would inform maintenance director D to install the bedrails according to the recommendation. *Maintenance director D would install the bedrails and perform his safety measurements to ensure it was installed properly. *She would then use the provider's Assistive Device Assessment to determine if the resident was able to use the bedrail safely and correctly to the reduce the risk of entrapment. -If a resident was deemed not safe to use the bedrail, she would refer the resident back to PT for further recommendations. *During her assessment, she obtained the consent from either the resident or their representative. *She would then obtain a physician's order for the bedrail and update the resident's care plan. *She reassessed the use of bedrails with each of the resident's Minimum Data Set (MDS) assessments. -The MDS assessments were completed quarterly, annually, and any time a significant change occurred. *She acknowledged that they had recently been cited on bedrails with their previous recertification survey (completed on 3/9/23), and part of their plan of correction was to complete the steps mentioned above. Interview on 6/6/23 at 11:21 a.m. with maintenance director D about his role with installing resident bedrails revealed: *He installed and removed bedrails when DON B requested. *They used bedrails at the head of the bed (HOB), not at the foot of the bed. *He used the provider's Bed Rail Safety Assessment to measure different zones in the bedrail, bed frame, and mattress to reduce the risk of entrapment. *Prior to resident 11's incident, he was measuring zones one and three only. -Refer to finding 13 for zone descriptions. *As a result of the incident, he edited the Bed Rail Safety Assessment to include measurements for Zones 1, 2, 3, and 4. -He removed Zones 5, 6, and 7 from the form. -Resident 11 had gotten his head stuck in Zone 4. 4. Interview on 6/6/23 at 2:09 p.m. with resident 11 about his incident revealed: *It happened early in the morning. He had just woken up, so he was still groggy and not fully awake. *He rolled over to his left side in bed to get up. *His knees slipped off the bed, and the rest of his body fell with. *At that time, his head got stuck under the bedrail. *He stated he was stuck for about five to ten minutes before the staff heard his yells for help. -He was scared because he did not know how long it would take until someone found him. -He said he felt like he was stuck in the bedrail for a long time. *He bruised both sides of the back of his head and his upper neck. *His tooth was broken and bleeding. -That broken tooth had later fallen out completely. *After the incident, he received a new bed with a different set of bedrails. 5. Observations on 6/6/23 from 1:23 p.m. through 3:12 p.m. of each resident's room in the building revealed the following residents had bedrails: *Residents with half-bedrails to both sides of their bed included the following residents: 1, 4, 6, 8, 9, and 11. -Resident 11's bed had a metal tube sticking out of the left-side HOB wheel. -The tube appeared to not serve any purpose. -It had sharp edges. *Residents with a half-bedrail to one side of their bed included residents 2, 3, 5, 7, and 10. -Resident 10's bedrail was very loose upon physical inspection. -Resident 3 stated she mainly used the bedrail to clip her bed remote to, but at times she would use it to reposition herself. 6. Interview on 6/6/23 at 3:57 p.m. with DON B about their procedure for bedrails and resident 3's bedrail revealed she: *Acknowledged that she missed adding bedrail use on care plans for residents 3, 8, 10, and 11. -She indicated she updated all their care plans that day to reflect the use of bedrails. *Knew she had gotten faxes with physician's orders for bedrails for some of the residents, but the orders had not been entered into the corresponding resident's electronic medical record and she could not locate the paper or scanned copies of their physician's orders. *Confirmed there were no physician orders for the use of bedrails for residents 1, 2, 3, 5, 6, 7, 8, 9, 10, and 11. *Confirmed that she knew resident 3 had the bedrail on her bed. -Resident 3 had told her that she would only use it for storing her bed remote. *Confirmed they had not completed the following for safe bedrail use: -Assessed the resident using the provider's Assistive Device Assessment. -Measured the bed safety zones using the provider's Bed Rail Safety Assessment. -Obtained informed consent for the use of the bedrail. -Updated the care plan indicating that resident 3 had the bedrail and what she was using it for. -Obtained a physician's order for the use of the resident's bedrail. *Acknowledged that they had been cited on inappropriate bedrail use during their previous recertification survey from 3/9/23. 7. Interview on 6/6/23 at 4:40 p.m. with administrator A and maintenance director D about their updated bedrail procedures revealed: *As a result of their previous survey, they updated their bedrail policy and implemented the Assistive Device Assessment and the Bed Rail Safety Assessment. *Maintenance director D confirmed that prior to resident 11's incident, he had not been measuring the space between the edge of the bedrail and the bed frame, which was the zone that resident 11 had gotten his head stuck. -Prior to the incident, he had misinterpreted the different bed safety zones and as a result had not been completely assessing each potential zone of entrapment for the residents with bedrails. --He said that the bed measurements diagram had zones two and four pointing to the foot of the bed, so he thought he did not need to measure those zones. -He was in the process of updating the Bed Rail Safety Assessment to include the relevant bed zones. 8. Review of resident 3's medical record revealed that the provider had not completed the following: *The Assistive Device Assessment. *Measured areas of possible entrapment on the provider's Bed Rail Safety Assessment. *Obtained an informed consent from the resident for the use of a bedrail. *Updated her care plan to reflect that she was using a bedrail. *Obtained a physician's order for the use of the bedrail. 9. Review of the provider's Bed Rail Safety Assessment revealed the assessment was missing measurements for the following residents: 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11. *Resident 1: The form was dated 4/3/23. There were measurements for zones one, three, four, and six. There was a handwritten NA in the space for zone two measurements. There were no measurements for zone seven. There was no need for a zone five measurement because the provider was not using foot rails. *Residents 2, 5, 6, and 8: Their forms were dated 4/3/23. There were measurements for zones one, three, and four. There was a handwritten N/A in the space for zone two measurements. There were no measurements for zones six and seven. *Resident 4: The form was dated 6/2/23. There were measurements for zones one, two, three, and four. Zones six and seven had been removed from the form. *Resident 7: The form was dated 3/22/23. There were measurements for zones one, two, three, six, and seven. There was a handwritten No Footrail for zone four, and N/A for zone five. *Resident 9: The form was dated 5/19/23. There were measurements for zones one, two, three, and four. Zones six and seven had been removed from the form. -Zone four was measured at 2 3/4 inches, which is larger than the recommended distance of 2 3/8 inches or less. -For the question, Are there any gaps of recommended space or larger when the resident is in the bed? the box for yes was checked. -Below the question, the form read, If Yes, the resident is at risk for being trapped. -In the Analysis(Assessment) section, there was a handwritten Good. *Resident 10: The form was dated 4/3/23. There were measurements for zones one and three. There were handwritten notes of N/A for zone two, and Even [with] mattress for zone four. There were no measurements for zones six or seven. *Resident 11: There were two forms dated 4/3/23 and 5/29/23. -On the form from 4/3/23, there were measurements for zones one and three. There were handwritten notes of NA for zone two, and N/A for zone four. There were no measurements for zones six or seven. -On the form from 5/29/23 (the day after resident 11 got his head stuck in zone four of his bed), there were measurements for zones one, two, three, and four. There were no measurements for zones six or seven. 10. Review of the resident's care plans revealed the following residents had no mention of bedrails on their care plans: Residents 3, 8, 10, and 11. 11. Review of the resident's physician's order revealed the following residents had no physician's orders for bedrails: 1, 2, 3, 5, 6, 7, 8, 9, 10, and 11. 12. Review of the provider's Assistive Device Assessment forms for residents 1 and 9 revealed: *Both forms were completed on 4/4/23. *Questions 5, 6, and 7 had not been answered. -The section stated, Resident can demonstrate proper use of the device when: --5. Turning from side to side? Yes, No, Not applicable. --6. Rising to sitting position? Yes, No, Not applicable. --7. Transfer into and out of bed? Yes, No, Not applicable. 13. Review of the provider's undated Bed Inspection and Bed Rail Policy revealed: *Policy: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bedrail use. *Procedure: Identifications of risks and benefits pertaining to bedrails, use bedrails, mattresses, and bed frame. *Under the Resident Assessment section of the policy: -B. Upon admission, readmission [or] change [of] condition, residents will be screened to determine: --1) Level of independence with bed mobility --2) Bed comfort level --3) If bed meets [manufacturer's] recommendations and specifications pertaining to resident height and weight --4) Assess the need for special equipment or accessories ---i. [Assess] the resident to identify appropriate alternative prior to installing bed rails ---ii. Assess the resident for risk of entrapment from bed rails prior to installation ---iii. [Review] the risk and benefits with resident and resident representative ---iv. Obtain informed consent --5) The facility will document ongoing need for the use of a bedrail quarterly --6) Obtain physician order for medical symptom assessed for need for bed rail use --7) Resident care plan will include use of bed rails as assessed. --8) The facility will fill out the '[Facility name] Assistive Device Assessment' upon bed rail implementation. *Under the Equipment Management and Maintenance section of the policy: -A. When installing or maintaining bedrails, the maintenance department staff will follow the [manufacturer's] recommendations and specifications, or provide another bed or appropriate alternative in accordance with individual bed inspections. -B. The maintenance department will conduct annual inspection of all bed frames, mattresses, and bedrails, as part of a regular maintenance program to identify areas of possible entrapment. --a. When bedrails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bedframes that are compatible. --b. The interdisciplinary team will identify resident-specific bed adaptations and pertinent safety risks on the resident care plan. *At the bottom of the second page of the policy, there was a diagram of a standard nursing home bed which included a headboard, a footboard, and the seven zones of bedrail safety as recommended by the Food and Drug Administration (FDA). -Zone 1: Within the Rail. Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. A loosened bar or rail can change the size of the space. The recommended space should be less than 120 mm [millimeters] (4 3/4 inches), representing head breadth. --On the diagram, the area pointing to Zone 1 was on the bedrail at the HOB. -Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support. Preventing the head from entering under the rail would most likely avoid neck entrapment in this space. FDA recommends this space be small enough to prevent head entrapment, less than 120 mm (4 3/4 inches). --On the diagram, the area pointing to Zone 2 was the bedrail towards the footboard. -Zone 3: Between the Rail and the Mattress. FDA is recommending a dimensional limit of less than 120 mm (4 3/4 inches) for the area between the inside surface of the rail and the compressed mattress. --On the diagram, the area pointing to Zone 3 was on the bedrail at the HOB. -Zone 4: Under the Rail, at the Ends of the Rail. FDA recommends the dimensional limit for this space also be less than 60 mm (2 3/8 inches). --On the diagram, the area pointing to Zone 4 was the bedrail towards the footboard. -Zone 5: Between Split Bed Rails. This zone occurs when partial length head and foot side rails (split rails) are used on the same side of the bed. The space between the split rails may present a risk of either neck entrapment or chest entrapment between the rails if a patient attempts to, or accidentally, exits the bed at this location. --On the diagram, the area pointing to Zone 5 was in the middle of the bed, in between the bedrails at the HOB and foot of the bed. -Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board. This space may present a risk of either neck entrapment or chest entrapment. --On the diagram, the area pointing to Zone 6 was at the HOB. -Zone 7: Between the Head or Foot Board and the Mattress End. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. --On the diagram, the area pointing to Zone 7 was at the HOB.

Based on interview and staff schedule review the provider failed to ensure a registered nurse (RN) had been scheduled for eight hours of coverage for two of four weekends in February 2023. Findings include: 1. Interview and staff schedule review on 3/9/23 at 11:00 a.m. with director of nursing (DON) B revealed she: *Had worked full time Monday through Friday completing Minimum Data Set (MDS). *Was available to staff by phone twenty-fours hours per day seven days per week. 2. Interview and staff schedule review on 3/09/23 at 12:43 p.m. with administrator A regarding RN coverage revealed: *She had been aware that they did not have eight hours per day of RN coverage seven days per week. *She was attempting to hire an RN.

A. Based on observation, interview, and policy review, the provider failed to ensure appropriate disinfection after resident use for of one of one whirlpool and furnishings in the one of one tub room by one of one certified nursing assistant (CNA) E. Findings include: 1. Observations on 3/7/23 at 11:19 a.m. and 3:59 p.m. of the whirlpool room revealed: *The door to the room was open. A sign on the door stated to keep the door locked. *A stack of towels was setting on top of a short gray plastic storage cabinet against the right wall inside the room. The towels were out in the open and uncovered. *A reception-style chair was positioned against the right wall beside the storage cabinet with towels laid out on the seating surface of the chair. The towels were flattened in the center and appeared as if someone had been sitting on them. *Water was pooled on the floor in the center of the room and around the whirlpool located on the left side of the room. *The safety strap on the whirlpool lift chair was lying in the pool of water. The length of the strap had frayed edges. Observation and interview on 3/8/23 at 10:06 a.m. with certified nursing assistant (CNA) E revealed: *She had started working for the provider two weeks ago. *Her orientation to the role of bath CNA included how to sanitize the whirlpool tub and the location of lotions and shampoos for individual residents stored in a tall gray plastic storage cabinet. *Laundry supplied the stack of towels that were setting on top of the short gray plastic storage cabinet, and she was unable to find another location in the whirlpool room to store them *Most residents undressed and dressed in the whirlpool room, and some would sit in the reception chair while undressing and dressing. *She would change the towels on the seat of the reception chair between residents. *She demonstrated the steps to disinfectant the whirlpool tub between residents, as follows: -Sprayed the inside of the tub with an unlabeled spray bottle that she stated contained water mixed with disinfectant. She pointed to a labeled disinfectant gallon jug setting on floor next to the front of the whirlpool. -Brushed the inside of the tub while using the sprayer hose to rinse the tub. -Used a washcloth with disinfectant that she sprayed on it from the unlabeled spray bottle to wipe the outside corner of the tub on the end where the whirlpool lift chair was attached. -Used a towel that was on the floor to mop up some of the water on the floor. *She disinfectant kept working while she went to get the next resident, and that would have given the disinfectant five minutes to continue working. She then left the room to assist another resident to the whirlpool room. *She had not wiped down the whirlpool lift chair or the safety strap on the lift chair. *She had not wiped down the reception chair or changed the towels in the chair before leaving the whirlpool room. Review of the provider policy, Whirlpool and Bath Chair Disinfecting, dated 11/28/21, revealed the steps for cleaning and disinfecting the whirlpool tub after every bath included: 1. Drain the water from the tub. 2. Press the Shower Button and rinse the inside surfaces with the shower sprayer. 3. Close the drain. 4. Press and hold the Disinfect Button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. 5. Using a long-handled brush, thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot of the tub. 6. Disinfect the [NAME] Transfer [lift chair] by positioning it over the tub. Use the brush to scrub its surfaces with the remaining solution. Allow the proper disinfectant contact time which is 10 minutes as recommended by the disinfectant's manufacturer. Rinse the seat. 7. Remove the plug from the drain. 8. Rinse the tub's interior surfaces thoroughly with the shower sprayer. 9. Spray water from the shower sprayer to rinse out most of the disinfecting solution. 10. Finish rinsing the interior surfaces of the tub with the shower sprayer. Interview on 3/8/23 at 5:00 p.m. with director of nursing (DON) A and nurse manager C revealed: *CNA E was temporarily completing resident baths while their full-time bath CNA was on leave. *The CNA who provided orientation to CNA E was not their full-time bath CNA, and the training given was probably not accurate or complete. *They agreed the whirlpool tub had not been disinfected according to the policy. *They were not aware of the following:: -The exposed stack of uncovered towels. -The use of towels to cover the reception chair and mop the floor. -The frayed edges of the safety strap on the whirlpool lift chair. 45383 B. Based on observation, interview, and policy review the provider failed to ensure the facility response plan to COVID-19 was up to date and followed current Center for Disease Control (CDC) guidelines and recommendations for two of two sampled residents (1 and 22) with a diagnosis of COVID-19. Findings include: 1. Observation on 3/7/23 at 10:17 a.m. with resident 22 in the dining room revealed: *She had been sitting at the dining table with a staff member. -No other residents were in the dining room. -Staff had been wearing a N-95 mask. *She had been in isolation for COVID-19. *Staff had been wheeling her back to her isolation room. -She was wearing a N-95 mask during the wheelchair transport back to her room. 2. Observation on 3/7/23 at 11:00 a.m. with resident 1 while he was in a wheelchair revealed he: *Had been in isolation for COVID-19. *Was independently able to self-propel his wheelchair throughout the facility. *Had been wearing an N-95 mask while outside of his room. Interview on 3/7/23 at 11:00 a.m. with licensed practical nurse (LPN) H regarding COVID-19 positive residents who were in isolation and leaving thier rooms revealed: *Resident 1 had been non-compliant with staying in his room. *He had been diagnosed with COVID-19 on 2/28/23 and received an antiviral treatment. -He could only be out of his room if he had worn an N-95 mask. *Resident 22 had been having a decline in health. -She had been a picky eater. *Administrator A, nurse manager C felt that resident 22 could have come out of her room with an N-95 mask. Interview on 3/7/23 11:03 a.m. with nurse manager C regarding COVID-19 positive resident's wearing N-95 masks revealed: *They only had one kind of N-95. *She was not sure what it meant to fit test the resident's for N-95 mask use. Interview on 3/7/23 at 11:06 a.m. with administrator A regarding infection control practices for COVID-19 positive residents revealed: *None of the residents had been fit tested for N-95 mask use. *Resident 22 was never by other residents and was allowed to come out of her room. *She had not realized that resident 1 was out of his room. Interview on 3/8/23 at 9:00 a.m. with LPN D regarding infection control practices revealed she: *Had completed the online training for the Infection Preventionist education. *Was only able to dedicate two hours per week for infection control. *Had not been receiving any current guidelines and recommendations from the Center for Disease Control (CDC) for care of residents with COVID-19. Review of provider's undated policy for COVID positive residents revealed: *Infection prevention and control considerations for residents of long-term care facilities engaging in isolation due to positive COVID-19 results. *Positive residents would have been isolated to their rooms for ten days. *Residents would have plastic placed in front of their doors. *Residents would have personal protective equipment (PPE) containers placed outside of the their rooms for staff use. *Residents would have a sign on the door informing staff to wear PPE before entering the room. *Residents who were showing a dramatic decline in cognition/physical function, the interdisciplinary team would have discussed letting them come out of their rooms with a mask on at day five. -They must remain socially distant from other residents. *All close contacts would have been tested on day one, three, and five. Review of provider's January 2021 N-95 Mask policy revealed: *Infection prevention and control of N-95 mask wearing during outbreak mode. *Employees would wear an N-95 mask when they were aware of residents in the building with COVID-19. Review of provider's June 2021 COVID-19 Positive Residents-Notifying Personnel revealed: *Residents would have been notified of their positive test results. -Social services designee or designated personnel would act in informing POA/Emergency contacts of a positive resident via telephone. -Administrator, or designated personne would have reported within the requirements to National Healthcare Safety Network (NHSN) and displayed on the front door COVID was in the building. -Nurse managers would inform staff of which residents had tested positive.

Based on interview, record review, and policy review the provider failed to ensure one of one sampled resident's (4) advanced directives had been followed. Findings include: Record review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Past medical history included: -Atrial fibrillation *Her code status was do not resuscitate (DNR) {do not perform cardiopulmonary resuscitation}. -Had not been updated to indicate DNH (do not hospitalize) and DNI (do not intubate) {inserting a breathing tube}. *On10/1/22: - At 11:25 a.m. and unidentified CNA had notified licensed practical nurse (LPN) G that the resident was not acting right, her skin was clammy and hot to the touch, her checks were flushed, and had labored breathing. - At 11:26 a.m. resident 4 was assessed by LPN G and the assessment revealed: -Blood pressure of 106/62 (normal blood pressure is 120/80). -Temperature of 98.7 (normal temperature is 98.6) -Respiratory rate of 24 respirations per minute (normal respiratory rate is 12-16 breaths per minute). -The resident had not been complaining of any pain. -Heart rate had been taken by a pulse oximetry and ranged from 90-150 beats per minute (BPM). -Listened with a stethoscope to assess the heart rate (HR) was 146 (BPM) {normal heart rate would be 60-100 BPM} and irregular. -Resident 4 was refusing to answer questions at that time but when asked if she wanted to go to the hospital states, No I don't want to go. -At 11:30 a.m. a phone call had been placed to the resident's son and a voicemail had been left to call the facility as soon as possible. -At 11:35 a.m. the resident's daughter had been contacted and informed on resident's condition. The resident's daughter requested the resident to be sent to hospital. -At 11:37 a.m. report had been given to the emergency room (ER) at the receiving facility notifying the ER staff that the resident had possible a-fib (atrial fibrillation which is an irregular heart rhythm) and history given. -At 12: 00 p.m. the resident had left the facility by ambulance and was transferred to the hospital. -At 12: 10 p.m. the resident's physician had been notified of the emergent transfer to the hospital. -At 12:15 p.m. nurse manager C and administrator A had been notified of resident 4's transfer to the hospital. Review of the requested copy of resident 4's advance directive revealed: *She had signed a DNR/DNH/DNI order on 8/27/21 and had been signed by her physician on 8/30/21. Interview on 3/9/23 at 11:00 a.m. with director of nursing (DON) B regarding resident 4's advance directive revealed: *She agreed resident 4 should not have been transferred to the hospital. *The nurse who had been taking care of resident 4 was no longer employed at the facility. *Agreed that resident 4's advance directive had not been followed as the resident had requested. Interview on 3/9/23 at 12:00 p.m. with administrator A regarding resident 4's advanced directive revealed: *Nurse manager B had been unavailable for interview as she had been working on the floor. *Staff should have followed the provider's policy. Regarding the residents advanced directive. *She thought that there were other circumstances that regarding this event. No further information had been provided by administrator A before exiting the facility. Review of the provider's undated Advanced Directive policy revealed: *Advanced directives would have been respected in accordance with state law and facility policy. *In accordance with current omnibus budget reconciliation act (OBRA) definitions (to improve the quality of care in nursing homes) and guidelines governing advanced directives, the facility has defined advanced directives as preference regarding treatment options and include, but not limited to: -DNR. -DNH. *The director of nursing or designee would have notified the attending physician of the resident's advance directive so that the appropriate physician orders could have been documented in the resident's medical record and the care plan. *The nurse supervisor would have been required to inform the emergency medical personnel of a resident's advanced directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made.

Based on record review, observation, interview, and policy review the provider failed to ensure oxygen tubing had been changed per facility policy every two weeks for one of three samples residents (12). Findings include: 1. Review of resident 12's medical record revealed: *The resident had diagnosis of: -Chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. -Chronic diastolic (congestive) heart failure. -Chronic kidney disease, stage 3 unspecified. *She used oxygen to keep saturation above 90% (normal oxygen saturations are 90%-100%). *She had a physician's order to replace and date humidifier on the oxygen concentrator monthly at bedtime. *She had recent hospitalization for acute COPD exacerbation. Observation and interview on 3/8/23 at 8:53 a.m. of resident 12 in her room revealed: *She was sitting in her recliner watching television. *She was using a nasal canula for oxygen. *An oxygen concentrator was located next to her bed set at two liters. *She was not sure when the tubing had been changed. *The oxygen tubing had tape wrapped around it that was dated 2/6. Interview on 3/9/23 at 9:12 a.m. with nurse manager C regarding resident 12's oxygen tubing revealed: *The tubing should have been changed every other week as scheduled. *The date on the tubing was 2/6. *Some staff would date the tubing when they change it and others would have documented the tubing was changed in the treatment administration record (TAR). *The last documentation on the TAR was 2/6/23. Interview on 3/9/23 at 10:19 a.m. with director of nursing B regarding resident 12's oxygen tubing revealed: *The tubing should have been changed every other week by the nursing staff. *That should have been documented on the TAR when the task was completed. *Her expectation would have been that the nursing staff would have followed the policy to prevent any problems with infection control. Review of the provider's undated Oxygen policy revealed: Changing tubing, cannula or mask every other week as scheduled or prn.

Based on observation, record review, interview, and policy review the provider failed to ensure safety assessments had been completed and documented for three of eight sampled residents (8, 20, and 23) who had half side rails attached onto their beds. Findings include: 1. Observation on 3/7/23 at 11:50 a.m. of resident 20's room revealed he had one half side rail on the left side of his bed. Review of resident 20's medical record revealed: *He had been admitted on [DATE]. *His 10/4/22 Brief Interview of Mental Status (BIMS) revealed no cognitive impairment. *His last revised care plan was dated 1/18/23 revealed he used one-half side rail to encourage independence with turning and re-positioning in his bed. *There had been no documentation that a side rail safety assessment for his one-half side rail had been completed. 2. Observation on 3/7/23 at 12:44 p.m. of resident 8's room revealed she had bilateral half side rails on her bed. Review of resident 8's medical record revealed: *She had been admitted on [DATE]. *Her BIMS completed on 9/17/22 revealed severe cognitive impairment. *Her last revised care plan dated 2/11/23 revealed she used the bilateral half side rails to encourage independence with turning and re-positioning in bed. *There had been no documentation that a side rail safety assessment had completed. 3. Observation on 3/7/23 at 12:50 p.m. of resident 23's room revealed she had a half side rail on the right side of her bed: Review of resident 23's medical record revealed: *She had been admitted on [DATE]. *Her BIMS completed on 10/4/22 revealed severe impairment. *Her last revised care plan dated 1/19/23 revealed she used one-half side rail to encourage independence with turning and repositioning in bed. *There had been no documentation that a side rail safety assessment had been completed. Interview on 3/9/23 at 10:23 a.m. with maintenance supervisor F revealed: *He did safety assessments for the resident beds in the facility. *Staff did move beds around so they were hard to track. *He confirmed he had not completed side rail safety assessments for residents 8, 20, and 23. Interview on 3/9/23 at 1:13 p.m. with administrator A revealed: *She expected side rail safety assessments to have been completed on all beds with side rails. *She confirmed side rail safety assessments had not been completed for residents 8, 20, and 23. Review of the providers revised 12/1/2021 Side Rail policy revealed: .4. Side rail use is evaluated by a facility assessment to address if this would be a safety option for the resident. 5. Alternative options for side rails for safety and/or definition of mattress borders including pool noodles around the mattress border, scoop mattresses, etc, should be utilized if appropriate.

Based on interview, record review, and policy review, the facility failed to ensure one of one resident (33) received a new order for antipsychotic medication to treat aggressive behaviors resulting in harm to others. Findings include: 1. Review of progress notes for resident 33 in the closed electronic medical record (EMR) revealed a pattern of increasingly aggressive behaviors: *On 9/16/21, resident is resistive with repositioning/transfers and yells out at that time. *On 9/24/21, continues to resist and yells out with transfers and repositioning. *On 9/26/21, the resident was seen kicking and swinging at another resident. *On 9/27/21, hitting at staff with clinched fists when turning resident in bed. Question if resident is in pain .or behavioral as resident is noted at times to get self up without concerns. *Between 9/29/21 and 10/2/21, resistance and yelling out during transferring and repositioning. *On 10/4/21, struck a certified nursing assistant (CNA) in the face while assisting the resident. *On 10/6/21, Physically abusive to staff with transferring as resident did hit staff multiple times today. *On 10/7/21, Pleasant except for transfers and repositioning as resident will resist and yell at staff. *On 10/10/21, resident hit two CNAs in the face or side of the head with closed fists and grabbed their hair, yelling profanity at them, while assisting him to bed. *On 10/11/21: -At 5:56 p.m., four staff assisted with toileting and perineal care due to yelling, screaming, and resistance. -At 7:46 p.m., the resident was heard yelling and found swinging a closed fist at another resident. -At 11:55 p.m., very combative with staff hitting and punching staff when they offer or attempt to assist resident. The resident told staff to leave him alone. *On 10/12/21: -At 3:25 a.m., combative and yelling as two staff assisted with incontinence care and getting him into bed. -At 5:26 a.m., two staff held the resident's arms while a third cleaned him, and he attempted to hit staff and bite the arms. *On 10/14/21, CNA's report resident continues to yell out with transfers and toileting. MA (medication aide) reports she did not even touch him and he started yelling out. *On 10/17/21, the resident swung at another resident but was not close enough to hit the resident. *On 10/19/21: -At 9:53 a.m., the bath aide reported the resident swung out at her and punch [sic] her in her face. The resident also told another resident to move/get out of the way in a mean way. -At 10:16 a.m., CNA reported the resident punched her in the stomach during a transfer .he would not stay sitting up in bed and resistive with transfer. -At 7:28 p.m., the resident's chair alarm was sounding and was found in his bathroom by CNA and nurse standing on the foot pedals of his wheelchair by the toilet. He became physically aggressive swinging closed fists . The nurse was hit in the side of head to knock glasses off to floor. *On 10/21/21: -At 8:36 a.m., resident was yelling out and screaming when assisted by staff. -At 11:29 a.m., CNA reported to nurse about 9:15 a.m. that the resident kicked (another resident) in the right shin and attempted to punch the resident. Further review of the EMR revealed an antipsychotic medication was ordered but not started for seven days: *On 10/13/21, an order note documented a new order for an antipsychotic medication related to agitation. *On 10/13/21, the order summary report included monitor & document mood/behaviors/agitation .every day and night shift for monitoring for 14 days. *On 10/21/21, a physician communication note documented: -The physician responded to the fax sent yesterday re: Residents [sic] behaviors with an order to increase the dose of the antipsychotic medication. -The increase dose order was faxed to (facility) pharmacy. -The pharmacy called and said they never filled any (antipsychotic medication) for him yet. -The nurse looked back and discovered the medication was never rec'd (received) and never started. -The physician was notified and he re-ordered the original dose of the antipsychotic medication. A behavioral expression note on 10/21/21 summarized actions taken in response to his behaviors: -Administration (admininstrator, assistant DON, and social services designee) informed of the (behavior pattern). -The antipsychotic medication was started in the morning. -The resident's respresentative and physician were informed of the resident's behavior patterns. -Orders received to transfer to (emergency room ) for evaluation due to increased behaviors and aggression. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/04/21 at 12:00 p.m. with interim DON/MDS coordinator B revealed: *The pharmacy receives and processes orders every day. *It is very rare that a pending order would pass onto the next shift. *After this medication delay, she and the nurses got together and decided the nurses would monitor the pending order report and follow-up if the order was not processed the same day. *She said it was unknown if the resident's behaviors would have been better if he had been started on it sooner. *The resident had the same medication in the hospital before he transferred to the facility, but the order did not carry over to his admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the policy for processing medication orders at the pharmacy revealed: *New orders will be received and processed daily until the close of business and processed for normal delivery. *Any orders after normal business hours will be processed as STAT order for immediate delivery.

Based on observation, interview, record review, and policy review, the facility failed to revise the care plans to address: *The use of physical devices to reduce the risk of falls for three of four sampled residents (20, 21, and 33). *Communication needs and discharge plan for one of one sampled resident (18). *Behavior symptoms for one of three sampled residents (33). *The use of bed rails for one of six sampled resident (25) with bed rails. *Risk of accidents related to wandering for one of three sampled residents (33). *The use of assistive devices with transferring for one of one sampled resident (22). *Pressure ulcer healing for one of one sampled resident (25). Findings include: 1. Observation on 11/2/21 at 9:00 a.m. of resident 20 while he was seated in a wheelchair in the dining room for morning exercises revealed: *A cushion in a pillowcase was set on top of the right wheelchair arm rest. *The resident's right arm was resting on top of the pillowcase. *A buckled black strap was wrapped across the top of his right arm and under the arm rest holding his arm on the top of the pillow. Review of resident 20's electronic medical record (EMR) care plan focus for limited range of motion of the right upper extremity, initiated on 10/2/20 and revised on 9/29/21, revealed neither the cushion nor the black strap were listed as interventions. (Refer also to F604, finding 1.) 2. Observation of resident 21 revealed: *On 11/2/21 at 9:15 a.m., she was lying in bed on her back with a positioning alarm clipped to her gown on her left side. The resident was awake, talking nonsensically while looking at the wall, moving her legs up and down under her covers. *On 11/2/21 at 1:00 p.m., she was at the nurses desk with eyes closed in a reclined position sitting in a wheelchair that had a padded full upright back supporting her head while she was humming along with music playing through headphones. *On 11/3/21 at 11:20 a.m., she was sitting in the same wheelchair at the dining room table and rocking back and forth in it. A positioning alarm was clipped to her shirt on the left side. Review of resident 21's care plan in the electronic medical record (EMR) revealed the following focuses did not specify the use of a reclining wheelchair nor the use of a positioning alarm in bed: *Resident wanders aimlessly, initiated on 7/8/21. *Activities of daily living (ADL) self-care performance deficit, initiated on 8/30/21. *Actual fall with a minor injury, initiated on 7/21/21, with interventions initiated on 10/1/21: -May require the use of a wheelchair. -While in a wheelchair, TABS alarm at all times for safety & [and] to notify staff during self-transfers. Interview on 11/3/21 at 4:49 p.m. with interim director of nursing (DON)/minimum data set (MDS) coordinator B confirmed the care plan in the EMR was current through 12/29/21. (Refer also to F604, finding 2.) 3. Observation of resident 18 revealed: *On 11/1/21 at 5:20 p.m., he sat in his wheelchair outside the kitchen serving window. The cook asked him if he was ready for his supper tray. He responded with a slurred word and nodded his head. *On 11/2/21 at 4:12 p.m., the resident responded to questions with guttural sounds and body movements that indicated he understood. Review of resident 18's care plan in the EMR revealed: *A focus for communication problem, initiated on 3/2/21 and revised on 3/24/21, with a goal target date of 6/22/21 to improve communication by: -Making sounds. -Using appropriate gestures. -Responding to yes/no questions appropriately. -Using communication board. -Writing messages. *A focus initiated on 3/2/21 and revised on 3/24/21 that family would like resident to remain here, discharge unknown at this time, and a statement regarding a 100 day PASRR (pre-admission screening, determined by the state) upon admission to facility, with: -A goal for surgical abdominal wound to heal before discharge is feasible. -An intervention to establish a pre-discharge and revise plan according to the state's PASRR guidelines. Interview on 11/3/21 at 2:01 p.m. with social services designee (SSD) X revealed: *The staff do not need to use the communication board as they can understand resident 18's communication methods. *The 100-day PASRR limit was resolved and the state determined the resident needed long-term care. *She will get the care plan revised for both the communication board and reference to discharge related to the 100-day PASRR. Interview on 11/03/21 at 4:49 p.m. with interim DON/MDS coordinator B revealed: *She had multiple care plans that have been reviewed but she was behind getting the revisions in the EMR. *The care plan in the EMR for resident 18 is the current care plan, updated on 9/30/21 and through 12/30/21. Comparison review of the EMR care plan and a paper copy of it provided by interim DON/MDS coordinator B on 11/4/2021 revealed: *The communication board was still listed on both as part of resident 18's goal for communication. *The 100-day PASRR had been removed from the focus for remaining in the facility. 4. Closed record review of resident 33's progress notes between admission on 9/14/21 and his discharge to the emergency roiagnom on [DATE] revealed: *He was admitted with a cognitive decline and a history of frequent falls. *He attempted to exit the building in his wheelchair without supervision on 9/15/21. *He needed assistance with repositioning and transferring safely due to his impaired cognition and impulsive attempts to transfer himself. *His bed was in the lowest position with a pressure alarm and a fall mat on the floor beside his bed. *The use of a wheelchair for mobility with pressure alarms when in his wheelchair. *He was found in remote locations having a confrontation with other residents on 9/26/21 and 10/11/21. *He had an unwitnessed fall on 10/11/21 at 7:35 a.m., when the staff responded to the wheelchair alarm and found the resident on his back on the floor in his room by the window. *He had a near fall on 10/19/21 when staff responded to the alarm to find the resident standing on his wheelchair foot rests in his bathroom. *A pattern of increasingly aggressive behaviors that put other residents at risk for injury and resulted in injury to some staff. (Refer also to F760, finding 1). Review of the care plan initiated on 9/15/21 revealed no focuses, goals, or interventions related to:*Prevention of falls, nor revisions to address the unwitnessed fall on 10/11/21 and the near fall on 10/19/21. *Assistance with daily living tasks. *Behavior management related to cognitive impairment and how staff should approach him to minimize the risk of injury to the resident and staff related to his aggressive behaviors. *Risk of wandering and exit seeking, nor revisions to address the three times, he was found in potentially unsafe locations. Review of the admission MDS assessment dated [DATE] and signed as completed on 9/30/21 revealed: *He had a fall in the last month before admission. *Bed rail, bed alarm, and chair alarm were coded as used daily. The floor mat was coded as not used. *He needed staff assistance of two or more persons for bed mobility, transferring, mobility, dressing, and using the toilet. *No behaviors were coded. *The resident scored as being moderately cognitively impaired. *He reported having pain occasionally and gave an intensity rating of 5 out of a scale of 10. The care plan was not revised after the MDS was completed to address the fall risk, preventive devices used, staff assistance, behavior management, nor pain management. 5. Observation on 11/2/21 at 9:45 a.m. of resident 22 revealed he had: *Been sitting in a rocking wheelchair, in the dining room. *A mechanical lift sling underneath of him. Review of resident 22's medical record revealed his EMR care plan had not been updated since 9/29/21. Interview on 11/4/21 at 10:38 a.m. with interim DON/MDS coordinator B regarding resident 22's care plan revealed she: *Had a printed copy of his care plan from his EMR. -Had made changes to this printed care plan in writing. -Agreed the written changes had not been updated in the EMR. *Stated there was an internal communication book for staff to be aware of any changes to resident cares. -Some of the information that had been included in the internal communication book had not been added to residents EMR. *Had a 10/14/21 physical therapy communication on her desk. -It stated, Patient should have Hoyer [mechanical] lift strap underneath him at all times (in bed, wc [wheelchair], recliner, etc.) in case Hoyer is needed for safety with transfers. If Hoyer is not needed, patient can transfer with FWW [front wheeled walker] and/or EZ [mechanical] stand lift, whichever is safest for staff/patient at that time. -This had not been included in his current written or EMR care plan. Review of resident 22's current paper care plan revealed: *It had been updated in writing to include: *He had been a high risk for falls. -He had fallen at the assisted living center before admission to this facility. -His bed was to be left in a low position. -He was to have had a pressure alarm on at all times. -Keeping the mechanical lift sling under him while in a chair had not been on the care plan. *Antipsychotic use. -There had been no goals or interventions listed. *Antidepressant use. -There had been no goals or interventions listed. *The electronic record had not been updated with this information. 6. Observation on 11/03/21 at 8:58 a.m. of resident 25 revealed he: *Had been in the hallway, sitting in his wheelchair. *Did not have foot pedals on the wheelchair. *Feet did not touch the floor. *Had on blue gripper socks. *Had not been wearing any leg braces. Interview on 11/03/21 at 9:03 a.m. with certified nursing assistant (CNA) DD revealed she: *Had started her employment at the facility, A couple weeks ago. *Had thought she had access to residents care plans through the electronic medical records system, but was not certain. *Was not aware that resident 25 had leg braces. Interview on 11/3/21 at 9:07 a.m. with certified nursing assisant (CNA) DD regarding resident 25's leg braces revealed: *She had checked with a nurse and found out he did have leg braces. -The braces were not currently being worn due to his having a pressure ulcer on his right foot. --They would have been used to assist in transferring him. --She did not know how he transferred without the braces as she had not transferred him. Review of resident 25's current care plan revealed: *Staff were to assist him to put on leg braces before getting him out of bed. -There was nothing in the care plan about the braces not being used. *He had the potential for pressure ulcer development due to his obesity, immobility, and diabetes. -There was nothing in the care plan about currently having a pressure ulcer. Interview on 11/4/21 at 10:40 a.m. interim DON/MDS coordinator B regarding resident 25's care plan revealed she: *Thought he had been wearing, Blue boots as a protectant for the pressure ulcer on his right heel and to prevent one from developing on the left foot. *Thought his heels should be, Floated while in bed on a pillow. -Agreed these interventions were not on his care plan. -Agreed his using the braces had remained on the care plan and should not have been. 7. Observation on 11/2/21 at 10:13 a.m. of resident 25 revealed the bed had one siderail on the side of the bed nearest the wall in the up position. Interview on 11/4/2021 at 2:45 p.m. with licensed practical nurse (LPN) M revealed: *Resident 25 did have a siderail that he used for repositioning in bed and turning when he was being helped with personal cares. Review of resident 25's medical record revealed: *The quarterly MDS dated [DATE] was marked no for siderail use. *There was no mention of siderail use in the care plan initiated 3/1/21. Under the focus for self-care performance deficit, the intervention for bed mobility does not include the bed rail. *There was no documentation of a siderail assessment in the chart. Review of the provider's updated 11/8/18 Care Plan policy revealed: *Each discipline would update the care plan as changes occur between assessments and scheduled care conferences. Those disciplines included: -Social services. -Dietary. -MDS Coordinator. -Activities.

Based on interview, record review, and policy review the provider failedto test all unvaccinated staff per their county positivity rate to detect COVID-19 in staff members. 1. Interview on 11/2/21 at 10:38 a.m. with administrator A regarding COVID-19 testing for non-vaccinated employees revealed she: *Stated testing was based upon county positivity rate. -The county positivity rate was above 10% from 8/8/21 through 10/31/21. *Had scheduled testing two times per week since 8/8/21, typically on Wednesday and Fridays. -Stated when staff was not able to test at the scheduled time, We try to catch them, probably miss occasionally. *Stated the social services designee, director of nursing, and all nurses knew how to test staff for COVID-19. *Stated staff who refuse testing would be required to wear an N95 mask while at work. *Thought there had been additional testing done that had not been placed in their documented testing binder. Interview on 11/3/21 at 1:03 p.m. with administrator A revealed she: *Had not been able to find additional test results. -Thought they had been done at the nurses station. Review of provider's employee vaccinated listing revealed there had been 19 of 51 employee's (C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, and U) who had not been vaccinated. Review of the provider's COVID-19 documented testing for staff from 10/1/21 through 10/31/21 revealed: *Testing had been completed on the following dates. -10/1/21 for one unvaccinated staff person (U). -10/7/21 for two unvaccinated staff persons (C and F). -10/9/21 for one unvaccinated staff person (F). -10/12/21 for one unvaccinated staff person (F). -10/15/21 for two unvaccinated staff persons (N and U). -10/20/21 for three unvaccinated staff persons (C, R, and U) and one vaccinated employee (V). -10/27/21 for two unvaccinated staff persons (F and R) and 3 staff persons of unknown vaccination status, (V, W, and X). -10/29/21 for one unvaccinated staff person (J) and one staff person of unknown vaccination status (X). -10/31/21 for one unvaccinated staff person of unknown vaccination status (X). -11/1/21 for one unvaccinated staff person (F) and one staff person of unknown vaccination status (Y). *Review of provider's Staff/Resident Testing During COVID-19 Pandemic policy revealed: -Policy: ACRC [Alcester Care and Rehab Center] policy on staff testing for COVID-19 to prevent spread of infection into facility. -Purpose: Appropriately implement safe infection control procedures. a. Administrator will document county positivity rate every week. i. If positivity rate is 5-10% the facility will test unvaccinated staff once a week. ii. If the positivity rate is above 10%, the facility will test unvaccinated staff 2x [times] a week. iii. If the positive rate returns to a lower rate, the facility must remain resting [testing] at the same frequency for 2 weeks. Review of Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing homes <www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> 9/10/21 guidance revealed: *Unvaccinated staff were to be tested based off county level positivity rates. *Healthcare personal (HCP), residents and families were to be notified of an outbreak in the facility. *An outbreak consisted of: -One resident or HCP *A person should be designated as the infection control person to oversee the COVID-19 effort and management of infection control program.

Based on observation, interview, record review, and policy review, the provider failed to ensure safety assessments had been completed and documented for: *Four of four sampled residents (2, 22, 25, and 27) who had side rails on their beds. *One of one sampled resident (4) who used a rock in place wheelchair. Findings include: 1. Observation on 11/3/21 at 10:42 a.m. of resident 2's room revealed she had bilateral half side rails on her bed. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her brief interview of mental status (BIMS) completed on 10/25/21 revealed she had severe cognitive impairment. *Her care plan for activities of daily living had initiated the use of bilateral half side rails for bed mobility on 8/6/20. *There had been no documentation of a side rail safety assessment being completed. *There had been no documentation of risk of use education versus benefit of use education being completed. 2. Observation and interview on 11/2/21 at 4:07 p.m. revealed resident 27 had bilateral half side rails. She was not able to tell me how she used them. Was very confused of what they were even for. Review of resident 27's medical record revealed: *She had been admitted on [DATE]. *Her BIMS completed on 10/12/21 revealed he had moderate cognitive impairment. *Her last revised care plan 02/24/21 revealed she used bilateral one-half siderails to encourage independence with turning and red-positioning in bed. *There had been no documentation of risk of use education versus benefit of use education being completed. Interview 11/3/21 with interim director of nursing B revealed she did have an assessment tool to use for siderails. She had not been using the assessment tool. 3. Observation on 11/2/21 at 9:42 a.m. of resident 22's room revealed his bed frame had side rails attached to the upper half of his bed. *He had not been in his room. Review of resident 22's medical record revealed: *He had been admitted on [DATE]. *His brief interview of mental status completed on 9/13/21 revealed he had severe cognitive impairment. *His handwritten care plan included the use of one-half side rails for bed mobility. *There had been no documentation of a side rail safety assessment being completed. *There had been no documentation of education of the risk of use versus benefit of use being completed. Interview on 11//3/21 at 11:37 a.m. with interim DON/MDS coordinator B regarding side rail assessments revealed: *They had not documented completion of a safety assessment. *They had obtained physician orders. *She had a sample of a side rail safety assessment. -The medical director needed to review and approve the form. *They did not provide informed consent for side rail usage. *She stated they did provide a verbal risk of use education versus benefit of use education. -They did not document that this education had been provided. 4. Observation on 11/2/21 at 10:13 a.m. of resident 25 revealed his bed had one siderail on the side of the bed nearest the wall in the up position. Interview on 11/4/2021 at 2:45 p.m. with licensed practical nurse (LPN) M revealed resident 25 did have a siderail that he used for repositioning in bed and turning when he was being helped with personal cares. Review of resident 25's medical record revealed: *The quarterly MDS dated [DATE] was marked no for siderail use. *There was no mention of siderail use in the care plan initiated 3/1/21. Under the focus for self-care performance deficit, the intervention for bed mobility does not include the bed rail. *There was no documentation of a siderail assessment in the chart. Surveyor: 5. Observation on 11/3/21 at 10:30 a.m. of resident 4 revealed he used a rock in place wheelchair. He was able to transfer himself out of the chair onto the couch. Staff were required to assist him with transfers to other surfaces. Review of resident 4's medical record revealed: *He had been admitted on [DATE]. *His BIMS completed on 8/2/21 revealed he had severe cognitive impairment. *His last revised care plan on 8/2/21 had no documentation on the use of the rock in place wheelchair. *There had been no documentation of risk of use education versus benefit of use education being completed. Review of the provider's revised June 2019 Physical Restraint policy revealed: *Prior to physical restraint application (other than emergency), the Assistive Device Assessment will be completed in PointClickCare. *The assessment will be reviewed by the Interdisciplinary Team, Resident/Representative, and the physician. *There was no mention of the use of assistive devices, such as side rails or rock in place wheelchairs.

Based on observation and interview, the facility failed to ensure food safety during two of two meal services observed. Findings include: 1. Observation on 11/1/21 at 5:00 p.m. revealed unsafe serving and distribution of food: *Cook II moved between touching food items and non-food items using her gloved hands without hand hygiene and changing gloves throughout the meal service, including: -Shuffling through the residents' diet cards with both hands as she prepared to dish up the next group of residents' dishes. -Touching plates and serving utensils with her left hand and the handles of the delivery carts with her right hand to reposition them closer to her. -Picking up buttered bread slices with her right hand to place them on plates. -Using her right thumb to position the green beans that she scooped onto the plates with her left hand. -Getting the tip of her right forefinger into the applesauce in a small bowl as she picked it up to put it on the delivery cart. *After a resident requested a hamburger instead of the main entree, cook II: -Used the same gloved right hand to reach into the plastic bag with hamburger buns and removed one bun out of the bag. -Took off the top half of the bun with her left hand and laid it on the stainless steel counter opposite the stove top where the hamburgers were being kept warm. -While holding the bottom half of the bun in her right gloved hand, she used her left hand to scoop a hamburger from the pan onto the bun. -While holding the bottom bun and hamburger in her right hand, she used her left hand to pick up the top of the bun and move it towards the corner of the same stainless steel counter onto the top of papers in an open red binder. -Set the bottom bun and hamburger on a plate then used both gloved hands to squeeze ketchup onto the hamburger. -Used her right hand to place the top bun onto the completed hamburger. *A plate of food dished up for a resident was incorrectly placed in front of another resident: -Dietary aide (DA) E served a plate of food from the delivery cart to resident 6. -Resident 6 repositioned herself up to the table and faced the plate while DA E walked away from the table toward the kitchen. -Before DA E got to the kitchen, cook II told her that plate was for resident 9. -DA E immediately turned around, walked back to the table, and removed the plate from in front of resident 6. -She then delivered the same plate of food to the resident 9. Observation on 11/2/21 at 11:07 a.m. revealed dietary aide F distributed beverages in an unsanitarty manner: -She touched various unclean surfaces, such as beverage containers and delivery cart handles. -She touched the rims (drinking surface) of glasses and cups when she placed them on the delivery cart in the kitchen and then placed them onto the table in front of the residents. -She did not practice hand hygiene between touching the unclean surfaces and the rims of the glasses and cups. Inteview on 11/3/21 at 2:20 p.m. with dietary manager HH revealed the above were unsafe food practices, and she had provided education to staff about hand hygiene and glove use.

Based on observation, interview, and policy review, the provider failed to ensure proper infection control practices were completed for one of one observation of whirlpool tub cleaning by certified nursing assistant (CNA) (Z) had been completed correctly. 1. Observation, interview, and product directions review, 11/2/21 at 8:38 a.m. with CNA Z revealed she: *Rinsed the whirlpool tub with clean water and then began cleaning the tub. -Filled the whirlpool approximately half full of fresh water. -Had a gallon of Classic disinfectant. -Poured a capful of disinfectant into the tub. -Stated, A capful is about 2 ounces. --Thought this is the amount needed. -Turned the jets on in the tub. *Upon review of directions from the gallon of disinfectant, she agreed the directions stated to add two ounces of disinfectant per gallon of fresh water. Interview on 11/4/21 at 8:44 a.m. with maintenance director AA revealed the whirlpool tub contained approximately 60 gallons of water when full. Interview on 11/4/21 at 8:46 a.m. with CNA Z revealed she thought she had filled approximately 1/2 full when she added the disinfectant to it. Interview on 11/2/21 at 10:36 a.m. with licensed practical nurse M regarding the training of bath aide revealed she: *Had thought they were cleaning it correctly. *Had been doing random disinfecting audits. -Had not provided education to CNA Z on the appropriate way to disinfenct the whirlpool. *Thought the regular bath aide would have known how to correctly do the disinfecting. -The regular bath aide was not working for one month. Review of manufacturer's directions for use of Classic disinfectant revealed 2 ounces of the disinfectant should have been added to each gallon of water. Review of provider's Revised October 2010 Whirlpool and Shower Cleaning/Disinfecting policy revealed: *Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Properly cleaning a whirlpool tub is necessary to prevent growth of microorganisms and prevent cross-contamination from one resident to another. -For internal piping and pump disinfecting: Fill whirlpool to top of water inlet, add 10 oz [ounces] whirlpool disinfectant, circulate pump for one minute and let set for 10 minutes.

Based on interview and policy review the provider failed to notify residents, their representatives, or families when the facility was in a COVID-19 outbreak. Findings include: 1. Interview on 11/2/21 at 3:25 p.m. with administrator A revealed: *A contracted speech therapist had tested positive for COVID-19 on 10/27/21. -Three residents had been exposed to this therapist and notified of same. --No other residents, their representatives or families had been notified of the outbreak status of the facility. *A dietary employee had tested positive for COVID-19 on 11/1/21. --No residents, their representatives, or families had been notified of this update in outbreak status of the facility. *She stated no notification was sent because the current positive cases did not provide direct patient care. *Administrator A provided, to the survey team, an undated letter notifying families that an employee had tested positive for COVID-19 on 10/31/21. Interview on 11/02/21 at 4:38 p.m. with administrator A revealed: *No staff had exposure to the speech therapist who had tested positive on 10/27/21. *Two staff members had been exposed to the dietary employee who had tested positive for COVID-19 on 10/31/21 -These two staff members were tested for COVID-19 on 11/1/21. *She would be sending the undated letter to families notifying them of an employee testing positive for COVID-19 on 10/31/21. -She sent this letter after speaking with this surveyor on 11/2/21 at 3:25 p.m. Review of Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality/Quality, Safety & Oversight Group QSO-20-29-NH memo of May 6, 2020 <https://www.cms.gov/files/document/qso-20-29-nh.pdf> regarding notification of confirmed or suspected COVID-19 cases among resident and staff in nursing homes revealed: *The facility must inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19. Review of Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing homes <www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> 9/10/21 guidance revealed: *Healthcare personal (HCP), residents and families were to be notified of an outbreak in the facility. *An outbreak consisted of: -One resident or HCP.

Based on observation, interview, record review, and policy review, the facility failed to document medical symptoms for two of two residents (20, 21) with physical devices that could restrict their free movements. Findings include: 1. Observation on 11/2/21 at 9:00 a.m. of resident 20 while he was seated in a wheelchair in the dining room for morning exercises revealed: *A cushion in a pillowcase was set on top of the right wheelchair arm rest. *The resident's right arm was resting on top of it. *A buckled black strap was wrapped across the top of his right arm and under the arm rest holding his arm on the top of the pillow. Interview with the resident at that time about the strap revealed he had no comment on it. Review of the 9/19/21 quarterly minimum data set (MDS) assessment in resident 20's electronic medical record (EMR) revealed: *Limb restraint was checked as not used. *The resident: -Had impaired range of motion on an upper extremity on one side of his body. -Was dependent on staff for all activities of daily living (ADL). -Had moderately impaired cognitive abilities. -Clearly understood conversations and was understood when he spoke. Review of the care plan focus for limited range of motion of right upper extremity, initiated on 10/2/20 and revised on 9/29/21, revealed neither the cushion nor the black strap were listed as interventions. Observation on 11/3/21 at 11:16 a.m. revealed certified nursing assistant (CNA) DD picked the arm rest cushion off the dining room floor and placed it under resident 20's right arm. The black strap was not in place. Interview on 11/3/21 at 3:20 p.m. with interim director of nursing (DON) and MDS coordinator B revealed: *Therapy had recommended the cushion for positioning of his arm. *She had never seen a black strap being used. *They do not have a documented assessment of the strap as a potential restraint. Interview on 11/4/21 at 12:45 p.m. with interim DON/MDS coordinator B revealed she learned that activity director EE put the black strap on the resident on 11/2/21. Interview on 11/4/21 at 12:57 p.m. with activity director EE revealed: *The therapist instructed her how to put the black strap on. *She took photos to show others how to put the strap on. *The photos were posted in resident 20's room. Observation at that time with activity director EE revealed three photos hanging on the wall in resident 20's room. 2. Observation of resident 21 revealed: *On 11/2/21 at 9:15 a.m., she was lying in bed on her back with a positioning alarm clipped to her gown on her left side. The resident was awake, talking nonsensically while looking at the wall, moving her legs up and down under her covers. *On 11/2/21 at 1:00 p.m., she was at the nurses desk with eyes closed in a reclined position with feet on the floor in a wheelchair that had a padded full upright back supporting her head while she was humming along with music playing through headphones. *On 11/3/21 at 11:20 a.m., she was sitting in the same wheelchair at the dining room table and rocking back and forth in it. A positioning alarm was clipped to her shirt on the left side. Review of resident 21's care plan in her EMR revealed the following focuses but did not specify the use of a reclining wheelchair nor the use of a positioning alarm in bed: *Resident wanders aimlessly, initiated on 7/8/21. *ADL self-care performance deficit, initiated on 8/30/21. *Actual fall with a minor injury, initiated on 7/21/21, with interventions initiated on 10/1/21: -May require the use of a wheelchair. -While in a wheelchair, staff were to use an alarm at all times for safety & [and] to notify staff during self-transfers. Review of incident progress notes in the EMR revealed resident 21 had fallen on: *6/30/21 at 4:05 a.m., an unwitnessed fall with a cut above her left eye. *8/30/21 at 10:15 a.m., an unwitnessed fall with resident found scooting on her bottom across the floor in her room. *9/13/21 at 2:10 a.m., a witnesssed fall in the dining room when resident tripped over the foot rest of another resident's reclining chair. *9/23/21 at 1:20 p.m., an unwitnessed fall with resident found scooting on her bottom across the floor in her room. *9/23/21 at 2:55 p.m., an unwitnessed fall in the hallway. She appeared weaker with ambulation and leaning more to the left. Will obtain a rocker WC [wheelchair] .due to weakness and leaning. Review of the 9/19/21 quarterly MDS assessment revealed: *Chair prevents rising and alarms for bed and chair were each checked as not used. *Mobility devices, such as a walker or wheelchair, were not checked as used. *The resident: -Had fallen before that MDS was completed. -Needed guided assistance with transferring and walking. -Had severely impaired cognitive abilities. Review of the EMR also revealed an in progress significant change MDS dated [DATE]. Interview on 11/3/21 at 2:03 p.m. with social services designee (SSD) X revealed: *There seemed to be a sudden change recently with the resident's gait from walking to small steps to shuffling. *The rocker wheelchair keeps her from getting up and the rocking seems to be a calming movement for her. Interview on 11/3/21 at 3:20 p.m. with interim DON/MDS coordinator B revealed: *There were no assessments of the positioning alarm and rocker wheelchair as potential restraints. *They did not have a tool for assessment of potential restraints. Interview on 11/3/21 at 4:49 p.m. with interim DON/MDS coordinator B confirmed the care plan in the EMR was current through 12/29/21.

Based on interview, record review, and policy review, the facility failed to investigate an incident of alleged abuse that involved two sampled residents (4 and 14). Findings include: 1. 1. Review of residents 4's and 14's medical record revealed a interdisciplinary notes revealed: *On 7/31/21 at 6:32 p.m. Resident [4] is found sitting in tv area next to a female resident holding her unclothed breast. Resident did not appear to be making any further advancements and does not appear distressed about the situation but was separated from the other resident. ADON [assistant director of nursing] and Administrator notified. *On 7/31/2021 at 6:29 p.m. Resident [14] is found sitting in tv area with shirt unbuttoned next to another male resident while he was holding her breast. Resident did not appear to be distressed about the situation but was separated from the other resident. ADON and Administrator notified. *Continued review of residents 4 and 14's progress notes revealed their representative and physicians had not been notified of the above incident. Interview on 11/3/21 at 12:58 p.m. with administrator A revealed she had not reported the above incident to the SDDOH. That was because resident's 4 and 14 had not appeared upset about the incident she did not feel it was necessary. Interview on 11/3/21 at 2:00 p.m. with interim director of nursing (DON)/ Minimum Data Set (MDS) coordinator B stated she had not remembered having been contacted regarding the above incident. She had not been involved with the investigation. Review of the investigation documentation provided by administrator A revealed: *On 7/31/21 at 6:00 p.m. Nurse called due to [resident 4] touching [resident 14] breast while shirt was unbuttoned. Educated nurse to separate the residents and monitor throughout the evening to observe any further direction towards each other. *Investigated [investigation] conducted by asking nurse about incident. Nurse stated they were in the lobby, both smiling and pleasant, not in distress. They both were easily separated and asked if anything was wrong. Both were pleasant about situation. *When resident residents were checked on later, they did not seem unusual in any sense. *Residents have been living across the hall in the same facility for 3 years, have never made accusations for/against one another. *8/6/21Two residents have not had any further accusations since incident. Review of the provider's revised 5/19/21 Abuse, Neglect, and Exploitation policy revealed: *All reports of abuse, neglect, and exploitation will be taken seriously with a thorough evaluation. *The department of Health will be informed within 24 hours by Administrator, Director of Nursing, or Social Worker. *Facility Ombudsman will be contacted by Social Worker. *The police may be contacted at the discretion of the Administrator. *Family will be notified by Administrator, Director of Nursing, or Social Worker

Based on observation, interview, employee personnel files review, in-service record training review, manufacturer's recommendations review, and policy review, the provider failed to ensure all employees were competent who utilized the mechanical lifts. That failure created a situation of immediate jeopardy that had the potential for causing harm to all of the residents who utilized a mechanical lift. NOTICE: Notice of immediate jeopardy was given verbally to the administrator and director of nursing (DON) on 3/9/20 at 4:10 p.m. The administrator was asked for an immediate plan of correction (POC) to ensure all staff who utilized the mechanical lifts received education and demonstrated competencies for the use of the mechanical lifts and overall safety review and documentation of the mechanical lifts being utilized. PLAN: On 3/9/20 at 9:39 p.m. administrator provided the surveyor with an email that included the written (POC). The written POC dated 3/9/20 was accepted by the surveyor on 3/10/20 at 8:08 a.m. That immediate POC included: Immediate Jeopardy Action Plan: DON, Administrator, and interdisciplinary team reviewed and revised as necessary the policy and procedure for resident accident and prevention, proper mechanical lift transfers for the three types of mechanical lifts which include the manufacture guidelines for competency checks. Policy and procedure for each lift will be reviewed and revised to include proper positioning of the lift legs. DON or licensed nurse or a licensed therapist will provide immediate re-education for all staff and each staff member's competency relating to each of the three make/model mechanical lifts. Before each staff member with job duties relating to mechanical lift transfers are able to work their scheduled shift, mandatory competency training will be performed until 100% of the staff responsible for mechanical lift transfers are in compliance. Staff members will be taken off their scheduled shift(s) until training is completed first. Administrator re-educated the Maintenance Director on policy and procedure for monthly preventative maintenance checks relating to lifts. A step-by-step guideline by the manufacture's recommendation will also be signed off to indicate that each part was visibly and specifically checked. Maintenance director will complete preventative maintenance checks on the three make/model mechanical lifts by 3/10/20 and perform checks on all other mechanical lifts. Additional instruction provided to the administrator and the director of nursing included completing a thorough investigation with resident 2's 3/3/20 incident and continue to set-up frequent monitoring of the mechanical lifts. During the survey on 3/10/20 at 8:08 a.m. the surveyor confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 3/9/20 at 1:45 p.m. in resident 2's room with certified nursing assistants (CNA) F and L revealed: *They had resident 2 attached to the mechanical EZ lift (total lift). *CNA F walked over to wheelchair (w/c) that had been positioned in the middle of the room. *CNA L pulled the EZ lift with the resident in the sling out from the bed and pushed it to the w/c. -The legs of the EZ lift were not in a widened position. *When CNA L got the EZ lift to the w/c she looked at CNA F and asked what to do next. *CNA F told her to open the legs to the EZ lift. *CNA L opened the legs to the EZ lift, and then pushed it, so it was surrounding the w/c. -Lowered resident 2 into the w/c. Interview on 3/9/20 at 1:55 p.m. with CNA F revealed: *She had been employed with the facility since June 2018. *She had worked at different nursing homes prior to her employment here. *She confirmed the EZ lift could have been used with the legs closed or opened. *Usually placed the lift between the w/c with the legs closed. *She had received education on the proper use of the EZ stand (sit-to-stand) following the incident on 2/28/20 with resident 1. -She had not received education on the proper use of the EZ lift. *She demonstrated back to the director of nursing (DON) with a verbal response on how to properly use the EZ stand. -She had not completed any physical operation of the EZ stand. *She had received some type of training on the mechanical lift after she had started but had not received any further training. Review of CNA F's personnel file had no documentation that training or competencies had been completed for the use of all mechanical lifts. Interview on 3/9/20 at 2:00 p.m. with CNA L revealed: *She had been working as a CNA for five years. *She usually worked the day shift. *She had been trained a long time ago on both types of lifts. *She had been retrained last week on the EZ stand but not the EZ lift. *She had not competed a verbal demonstration or a physical demonstration on how to use the EZ stand lift following the retraining last week. Interview on 3/9/20 at 2:10 p.m. with CNA O revealed: *She had been hired in November 2019. *She had completed her certified nursing assistant training from the provider. *She had received some training on the use of the mechanical lifts and had completed return demonstrations on how to use them. *She had received training on the EZ stand last week but not on the EZ lift. -She had not completed a demonstration on the EZ stand. Interview on 3/9/20 at 2:20 p.m. with administrator A and DON B regarding the mechanical lifts revealed: *They had done retraining and reeducation with staff on the EZ stand but not the EZ lift. *They had done a demonstration on the EZ stand and provided a sheet for the employee's to read. *The staff were given the opportunity to ask questions and have a dialogue regarding the mechanical lifts. *The staff then signed a document they had read the information. *CNA E was the only employee who had completed a return demonstration on the EZ stand. *Registered nurse M and CNA N had worked at the facility following the incidents on 2/28/20 and 3/3/20 without being retrained prior to operating any mechanical lifts. *They had made an attempt to get as many employees retrained on the EZ stand before their next scheduled work shift. *The company that provided the mechanical lifts offered additional services. -They would complete annual maintenance checks. *Lift training was provided by physical therapy and occupational therapy. Interview and document review on 3/9/20 at 2:40 p.m. with administrator A regarding the mechanical lift training revealed : *It had been done last on 8/20/18. *There had been no staff competencies completed. Interview on 3/10/20 at 1:10 p.m. with physical therapy assistant H regarding mechanical lift training revealed she had: *Been working as a contracted employee since 2/1/20. *Not done any mechanical lift training with the staff. Interview on 3/10/20 at 2:05 p.m. with CNA G regarding lift training revealed: *He had worked at the facility five or six years. *He had received training on the mechanical lifts two years ago. *The DON had shown him a few days ago how to use the EZ stand but not the EZ lift. *He had not completed a return demonstration. Interview on 3/10/20 at 3:25 p.m. with occupational therapist I regarding mechanical lift training revealed: *She had been the former director of therapy until 1/31/20. -They were a contracted service. *She was at the facility weekly. -It depended how many residents she had on case-load regarding how many days she would be in the facility. *She had not been involved with the mechanical lifts for staff training. -If they had a specific resident they had been working with who was going to use a mechanical lift they would do specific training with the CNAs for that specific resident. -They always did the sit-to-stand lift and not the total lift. -They had no involvement in care plans. -They might make recommendations. Interview on 3/10/20 at 4:35 p.m. with CNA D regarding the mechanical lift training revealed she had: *Worked at the facility for a year. *Completed her CNA training at the facility. *Received training on the mechanical lifts. *Done a return demonstration on the EZ stand during the testing phase of her CNA training. *Not completed a return demonstration on the EZ lift during the testing phase of her CNA training. Review of the following CNAs employee files revealed: *CNA D:-Hired on 3/25/19. -There was no documentation she had completed or demonstrated appropriate use of the mechanical lifts. *CNA E:-Hired on 4/1/19. -There was no documentation she had completed or demonstrated appropriate use of the mechanical lifts. *CNA G: -Hired on 4/10/15. -There was no documentation he had completed or demonstrated appropriate use of the mechanical lifts. Interview on 3/9/20 at 3:20 p.m. with administrator A revealed he could not verify if training had been done as there was no documentation of competencies in CNA D, E, and G's personnel files. Review of the provider's reviewed and revised 3/10/20 In-Service Training policy revealed: *Every staff member is required to attend to be reeducate. -If a staff member is unable to make it to the meeting, handouts and/or competency checks will be required. -These topics include the following subjects: --(11) Use of mechanical lift(s) training to be conducted on an annual or PRN (as needed) schedule to include the sit-to-stand and hoyer lifts. Refer to F610, findings 1 and 2. Refer to F657, findings 1, 2, and 3. Refer to F689, findings 1, 2, and 3. Refer to F865, findings 1, 2, 3, and 4.

Based on observation, interview, record review, manufacturer's review, in-service review, personnel file review, policy review, and job description review, the provider failed to ensure: *One of one sampled resident (1) was safely transferred with the use of a mechanical EZ Stand lift by two of two certified nursing assistants (CNA) (D and E) that resulted in a head injury. *One of one sampled resident (2) was safely transferred from the bed to a wheelchair (w/c) with the use of a mechanical EZ Lift lift by two of two certified nursing assistants (F and G). *Ongoing assessment and documentation had been completed for two of two sampled residents (1 and 2) who required the use of a mechanical lift. *All staff were competent who utilized all mechanical lifts. Findings include: 1. Review of the 2/28/20 Facility Self-Reporting Form submitted to the South Dakota Department of Health (SD DOH) regarding resident 1 revealed:*The incident had occurred on 2/28/20 at 7:00 p.m. *The initial report revealed she .was in a sit-to-stand machine being transferred off the commode into her wheelchair. The machine upended and the resident fell backwards with the lift following. The lift struck the resident in the forehead and causing an open gash. Injury noted to the head and needed stitches. Transferred to the (hospital name) at 1950 (7:50) after using the hoyer lift to get her off the floor and back into the wheelchair. *The final report revealed: -CNA D had .indicated that the white strap of the sling was used for this resident and the Administrator assumed the green strap would have been used. The green strap is a tighter and snugger fit than the white strap, but unable to determine if this was the sole factor causing the lift to fall over. *The director of nursing (DON) had interviewed CNAs D and E. -They stated that the leg strap was utilized, but it was not tightened/snug against the Resident's legs. -They also reported that the legs of the stand were used correctly to help give the lift balance. *Administrator took the sit-to-stand away from use for this resident and other residents until it can be concluded the integrity of the machine is not malfunctioning. It was replaced by a spare EZ Way, different manufacture and model machine. Interview on 3/9/20 at 5:00 p.m. with resident 1 regarding the above incident revealed: *She had been sitting in her room on the commode with the lid closed. *She had been taking a break from sitting in her w/c. *She had just transferred from her w/c to the commode. *The EZ stand had been sitting in front of her. -She was not connected with a sling to the lift. *One CNA had been sitting beside her. *She looked up and saw the lift coming towards her. *She looked down, and the lift hit her on the top of her head. *She had not fallen to the floor. *They used the same lift to transfer her from the commode back to her w/c. *She could not recall if anyone had checked the lift prior to transferring her with it back to her w/c. *She went to the hospital emergency department and received stitches to the top of her head. Review of resident 1's medical record revealed: *[DIAGNOSES REDACTED]. *The 3/1/20 five day Minimum Data Set (MDS) assessment revealed she:-Scored fifteen on the Brief Interview for Mental Status (BIMS) examination indicating she was cognitive. -Required total assistance of two staff for transfers and toilet use. -Was unsteady moving from a seated to a standing position, moving on and off the toilet, and transferring between a bed and chair or w/c. *The 2/24/20 Morse Fall Scale score was sixty indicating a high fall risk. *There was no assessment completed by the nursing staff or the therapy department regarding which mechanical lift to use or what sling was to be used prior to the 2/28/20 incident. *The DON had completed a Volaro Lift/Transfer Assessment Form for her on 3/5/20. Review of the following 12/31/19 through 1/22/20 occupational therapist progress notes regarding resident 1 revealed there was no documentation to use a mechanical lift. Review of the 2/21/20 hospital occupational therapist progress notes regarding resident 1 revealed: *She had been admitted to the hospital. *Prior to two weeks ago patient was up with 1 to commode. *Pt (resident) is dependent on dressing. *For the past two weeks patient has been using the EZ stand. Review of resident 1's 9/2/18 care plan revealed:*Focus: -Is at risk for falls r/t (related to) deconditioning. -4/18/18: Sometimes refuses to allow nursing staff to use a gait belt during transfers. *Interventions: -9/2: Fall in room during transfer: 2A (two assist) with gaitbelt or EZ stand with transfers. --There was no documentation of what size sling to use. Review of the 12/11/19 pocket care plan for resident 1 indicated she transferred with two staff with the EZ stand. There was no documentation found regarding what size of sling was to be used. Review of resident 1's 2/28/20 incident report revealed: *At about 7 p.m, CNAs came and got writer on fall. CNA stated that they were using the EZ stand and the stand tipped forward without warning/happened fast. When writer came in, the EZ stand was upright again. Resident was sitting upright on floor. Injury noted to top of forehead, middle. Laceration about an inch in length. Bleeding did stop, open gash. Needed stitches. Resident was taken to hospital. Review of resident 1's 2/28/20 at 8:47 p.m. physician's emergency department report revealed: *Brought in for evaluation of a laceration of the scalp after a fall. -Patient was in a device designed to allow standing when she was left unattended and it apparently fell over. -She either struck her head on the frame or on the floor. -She was also noted here to have an abrasion to the back of her head. *Plan: -After confirmation of the anesthesia 5 staples were used to close the wound without difficulty. -Dressing would be used on the abrasion to the occiput. -The abrasion measured 2 cm in the laceration 3 cm. -Staples will be removed in 1 week. Interview and record review on 3/9/20 at 2:50 p.m. with maintenance director K regarding the EZ stand lift revealed: *He had documented with the date and his initials that he had completed monthly inspections for proper functioning of all mechanical lifts. -There was no further documentation on what he had inspected with the mechanical lifts. *He had not seen any issues with any of the mechanical lifts during the monthly inspections. Interview on 3/10/20 at 8:20 a.m. with DON B regarding resident 1 revealed: *The type of mechanical lift to use was decided by the nurse. -If a resident was on a therapy case load then the therapist would decide. *He was unaware of the manufacturer's guidelines on which sling to use for the mechanical lifts. *He confirmed they had used the correct sling for resident 1. *They used different brands of mechanical lifts. Interview on 3/10/20 at 9:07 a.m. with DON B regarding resident 1 revealed: *He was not sure who had made the decision on what sling to use with the mechanical EZ stand. *There was no documentation from the nursing department on what sling to use. -He wanted to trust that the nurses made correct decisions. Interview on 3/10/20 at 1:10 p.m. with physical therapy assistant H regarding lift training revealed she had: *Been working as a contracted employee since 2/1/20. *Not done any mechanical lift training with the staff. Interview on 3/10/20 at 3:10 p.m. with licensed practical nurse (LPN) J regarding resident 1 revealed she: *Had previously assessed resident 1 for the use of the mechanical EZ stand. *Was not sure on what sling to use with the mechanical EZ stand. -Would use the smaller of the two slings that had been available. Interview on 3/10/20 at 3:25 p.m. with occupational therapist I regarding mechanical lift training revealed: *She had been the former director of therapy until 1/31/20. -They were a contracted service. *She was at the facility weekly. -It depended how many residents she had on case-load regarding to how many days she would be in the facility. *She had not been involved with the mechanical lifts for staff training. -If they had a specific resident they had been working with who was going to use a mechanical lift they would do specific training with the CNAs for that specific resident. -They always did the sit-to-stand lift and not the total lift. -They had no involvement in care plans. -They might make recommendations. Interview on 3/10/20 at 4:35 p.m. with CNA D regarding resident 1 revealed she: *Had assisted with the transfer for resident 1 on 2/28/20. *Was unable to confirm if the strap had been secured around the resident's back leg since CNA E had done that. *She had just assumed the strap had been secured around the resident's back leg. *CNA E was unavailable for interview during the survey. Review of the provider's 4/17/10 E-Z Stand policy and procedure revealed: *Preparation: -Check care plan for equipment use on resident. *Procedure: -5. Apply belt around legs and snap buckle. Tighten buckle. Review of the PA800 Operator's Manual manufacturer's instructions for the EZ lift used for resident 1 on 2/28/20 revealed: *Attaching Sling to Lift: -Adjust the shin rest up or down. -Locate the top of the shin rest two inches below the knee cap. -At this point you can lock the brakes on the lift to prevent the person from pushing the lift away from them. -The shin rest has a built-in safety support strap. -The strap helps those who need the added security and support. -This will keep their shins and feet securely in place. -It is not necessary to use the strap on everyone. 2. Observation on 3/9/20 at 1:45 p.m. in resident 2's room with CNAs F and L revealed: *They had resident 2 attached to the mechanical EZ lift. *CNA F walked over to the w/c that had been positioned in the middle of the room. *CNA L pulled the EZ lift with the resident in the sling out from the bed and pushed it to the w/c. -The legs of the EZ lift were not in a widened position. *When CNA L got the EZ lift to the w/c she looked at CNA F and asked what to do next. *CNA F told her to open the legs to the EZ lift. *CNA L opened the legs to the EZ lift, and then pushed it, so it was surrounding the w/c. -Lowered resident 2 into the w/c. Interview on 3/9/20 at 1:55 p.m. with CNA F revealed: *She had been employed with the facility since June 2018. *She had worked at different nursing homes prior to her employment here. *She confirmed the EZ lift could have been used with the mechanical lift legs closed or opened. *Usually placed the lift between the w/c with the legs closed. *She had received education on the proper use of the EZ stand following the incident on 2/28/20 with resident 1. -She had not received education on the proper use of the EZ lift. *She demonstrated back to DON B with a verbal response on how to properly use the EZ stand. -She had not completed any return demonstration of the EZ stand. *She had received some type of training on the mechanical lift after she had started but had not received any further training. Review of the 3/3/19 initial Facility Self-Reporting Form submitted to the SD DOH regarding resident 2 revealed: *Resident had a witnessed fall in her room. -Resident was being transferred from her bed to her w/c via Hoyer lift and CNA x2. -Hoyer began to tip over, and CNA G, placed himself between the Resident and the floor and gently lower the Resident to the ground. -Resident was found on the floor on her back with the Hoyer lift still connected to her sling. -Lift noted to not have legs open during the transfer (CNAs educated real time to always have the legs spread on the lift while transferring residents). -Assist of 4 with hoyer lift to w/c. -When lifting Resident with Hoyer, it was noted to be unsteady. -Hoyer lift was taken off the floor and immediately evaluated further by the Maintenance Director, Administrator, and DON. -When attempting to lift stationary item (Facility trailer), it was noted that one of the legs was not staying locked open/wide. -This was causing the lift to be unsteady and tip when weight was applied to the lift arm. -Maintenance staff took the lift apart, and noted that the primary bolt in the leg had come loose. -Upon further assessment, the threads that the bolt attaches to had stripped out causing the leg to be unsteady. Review of resident 2's medical record revealed: *[DIAGNOSES REDACTED]. *The 2/16/20 quarterly MDS assessment revealed: -A BIMS score of nine indicating she was cognitively impaired. -Required total assistance of two staff with transfer, dressing, and toilet use. *The Morse Fall Scale had a score of seventy-five indicating she was a high fall risk. Review of the 10/2/19 occupational therapy plan of care (evaluation only) for resident 2 revealed: *Is referred to therapy due to poor wheelchair positioning noted by some staff members and question if current chair is too large. -Patient is also occasionally not positioned appropriately in chair by staff members which places her at risk for skin issue or postural abnormality. -Education has been provided to facility staff and they have expressed understanding of recommendations. *'Precautions: -Hoyer lift for all transfers. *There was no documentation provided to staff on the appropriate use of the mechanical EZ lift or which sling to use. Review of resident 2's 3/3/20 at 3:13 p.m. nursing progress notes documented by registered nurse (RN) Q revealed: *Called to residents room per DON and ADON (assistant director of nursing), resident lying supine on the floor. -DON states that the CNAs were transferring the resident with the hoyer lift and the lift tipped over. -DON stated that when he entered residents room the lift was on top of the resident on its left side. -Lift noted to not have the legs spread during the transfer (CNAs educated to all ways have the legs spread on the lift while transferring residents). Review of resident 2's 6/27/19 care plan revealed: *Focus: -The resident has an ADL (activities of daily living) self-care performance. *Interventions: -Transfer: --The resident is totally dependent on 2 staff & Hoyer for transfers. *There was no documentation indicating what size of sling to use. Review of the 12/11/19 CNA pocket care plan revealed: *2 assist w/Hoyer. *There was no documentation indicating what size of sling to use. Interview on 3/9/20 at 1:55 p.m. with CNA F regarding resident 2 revealed: *She had assisted with the EZ lift transfer of her on 3/3/20. *CNA G and her had completed checking and changing her. *They transferred her with the EZ lift from the bed to the w/c. *The base of the legs had not been opened to a wide position. *CNA G went between the w/c with the legs closed. *Before CNA G could lower her into the w/c, he turned the Hoyer lift, and it started to tip towards the window. *The entire lift went on the floor on it's side with the resident still attached to it. *She confirmed the mechanical lift could be used with the legs open or closed. Interview on 3/9/20 at 2:45 p.m. with DON B regarding resident 2 revealed: *Following the 3/3/20 incident with her the administrator, maintenance director, and himself took the Hoyer lift outside. *They determined the cause of the above incident was due to equipment failure. *They had not provided any follow-up training for the staff regarding of the above incident. *Their policy stated to have the base of the legs open during transfers. *He had been told after the incident the base of the legs had not been opened wide during the transfer. Interview on 3/10/20 at 2:05 p.m. with CNA G regarding resident 2 revealed: *He had assisted with the EZ lift transfer of her on 3/3/20. *They had hooked her up to the lift, lifted her up in to the air, began to pull the EZ lift from under the bed, it had got stuck, began to pull the EZ lift from under the bed again. -Once the EZ lift was out from under the bed he started to turn the lift, it began to tip, and then went onto the floor with her still attached. *He confirmed the legs to the base of the mechanical EZ lift had not been open. 3. Review of the provider's 4/17/10 E-Z Lift policy and procedure revealed: *Preparation: -Check care plan for equipment use on resident. *Procedure: -8. Check that base legs are spread wide. Review of the manufacturer's EZ lift operating instructions revealed: *Adjust lift legs. -Using the spreader bar, adjust the legs of the lift to go around the wheel chair. Review of the provider's 2/1/15 Resident Accident Prevention policy and procedures revealed: *To ensure the resident's environment remains as free as possible of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. *Procedure:-1) All facility staff will continuously monitored for unsafe/hazardous conditions and corrections will be made promptly when area of concern is identified to ensure a well maintained and safe environment for residents. -7) All residents are assessed quarterly for their risk of accidents and fall, and receive individualized care planning related to their individualized needs. -10) Members of the management team review all incidents and changes will be made to plan of care as needed. Review of the provider's 3/9/20 initial Preventative Maintenance policy revealed:*Policy: -To provide for early detection of potential maintenance problems as well as proper care and routine maintenance of all equipment in possession of (facility name). *Procedure: -4. Procedure: --a. The list will include a description of the equipment, location, type of service due, date of last service, and a place to sign off indicating the work completed. Review of the undated provider's Administrator job description revealed: *Coordinates and integrates the total overall program of the facility. *Interprets and transmits policies of the governing board/management to the medical staff and personnel of the facility to assure compliance with polices. -Make sure residents are meeting their highest level of professional care needed. *Develops and monitors all department within the facility to meet the standards put forth by the governing board, management, and state and federal regulations. Review of the undated Director of Nursing job description revealed: *Essential Duties: -Monitors the job performance of the nursing staff by use of performance evaluations and completes performance evaluations of all nursing department staff. --Staff performance evaluations will be brought to the Administrator for review. -Develops and directs nursing services objectives, policies and procedures. -Develops in-service educational programs geared to the specialized needs of geriatric individuals and meets regulatory annual requirements. Review of the undated Nursing Assistant job description revealed: *Works under the supervision of the charge nurse and performs routine resident care duties and procedures. -Assist residents with mobility: --Turn and position residents, transfer residents to chair/bed. --Use appropriate gait belts, equipment, body mechanics per resident care plan. -Assist residents in promoting safety. Review of the provider's undated Maintenance Supervisor job description revealed: *Essential Duties: -Overall maintenance of the entire facility. -Preventative maintenance and repair to assure efficient operating equipment. Refer to F610, findings 1 and 2. Refer to F657, findings 1, 2, and 3. Refer to F726, finding 1. Refer to F865, findings 1, 2, 3, and 4.

A. Based on record review, interview, and policy review, the provider failed to: *Obtain medical services for one of two sampled residents (4) who had a fall with an injury. *Completely document pain assessments for one of one sampled resident (4) who had complaints of wrist pain. Findings include: 1. Review of resident 4's medical record revealed: *On 1/8/16 at: -1: 30 p.m. she had an unwitnessed fall. -3:30 p.m. she had complained of right hand pain. -11:00 p.m. there was slight swelling noted above R (right) thumb on hand. *On 1/9/16: -Her physician was notified of the 1/8/16 fall. -She had complained of R (right) wrist pain - tender and swollen. *On 1/10/16: -Her right hand was wrapped in an elastic bandage (ACE). -She refused to let staff unwrap it for assessment. *1/11/16: -A physician's orders [REDACTED]. -Physical therapy was to assess and treat the right wrist that day. -She refused assistance with personal care. -It was documented that she had manipulative behaviors. *The 12/1/15 Minimum Data Set (MDS) assessment indicated she was cognitively intact. *The 2/20/16 MDS indicated she had disorganized thinking and modified independence (some difficulty in new situations only). *She had complained specifically of right wrist pain on six days from 1/8/16 to 1/22/16. *There was no documentation that had rated her pain on a pain scale on the above days. *The 12/1/15 and 2/20/16 MDS assessments indicated frequent pain with a pain rating of 8 on a 0 to 10 scale. *She had swelling of her right hand, wrist, arm, or fingers on nine days from 1/8/16 to 1/25/16. *On 1/11//16 she had refused personal care and had Manipulative behaviors. *On 1/14/16 she had requested her right wrist to be wrapped and wanted pain medications twice. *On 1/15/16 she had refused personal care. *On 1/19/16 she: -Was lethargic (tired, fatigued). -Had requested more medication. -Had refused to move her right hand. On 1/22/16 she had been seen by her physician, and an X-ray of her right wrist was ordered. *On 1/25/16 she had refused care. *On 1/26/16: -An X-ray was performed on her right wrist at an emergency department. -The emergency department discharge instructions had shown a closed extra-articular fracture of distal end of right radius (broken wrist). *A Y was written on the pain assessment area on her January 2016 treatment form on days 7, 14 and 21. Day 28 area was blank. *There was no documentation on her January 2016 pain management flowsheet. *She had verbal aggression and/or refusal of care documented on her January 2016 mood and behavior flowsheet on days 4, 17, 21, and 28. Interview on 5/18/16 with the interim director of nursing (DON) regarding resident 4 revealed: *If a Y was written on the pain assessment area on the treatment form she would have expected to see further documentation on the pain management flowsheet. *A Y was written on the pain assessment area on her January 2016 treatment form on day 7, 14, and 21. Day 28 area was blank. *There was no documentation on her January 2016 pain management flowsheet. *The resident was able to rate her pain verbally on a 0 to 10 pain scale (0 meaning no pain and 10 meaning severe pain). *There was no documentation with specific number ratings for her complaints of right wrist pain. *She had been given PRN (as needed) pain medications based on her complaints of right wrist pain. *She confirmed: -The behaviors documented on her behavior sheets did not indicate her complaints of pain were behavior issues. -They had not followed their pain assessment policies regarding documentation and assessment of her pain. The physician had ordered an X-ray if there were no signs of improvement on 1/11/16. -Complaints of pain, swelling, refusals of care and behaviors might have been indications of a potential injury. -The X-ray was not obtained until 1/26/16. She had symptoms that had indicated the 1/11/16 physician's orders [REDACTED]. Review of the provider's 8/20/12 Weekly Pain Assessment policy revealed: *Pain assessments were done to assess pain on a routine and ongoing basis .according to the resident's cognitive abilities. *If the resident's pain level is less than or equal to 3 on a 0-(to)10 scale, mild, or a 1 or less on a 0-5 scale than (then) proceed with your routine pain assessment protocol. *If the resident's pain is greater than or equal to 4 on a 0-10 scale, moderate to severe, or greater than 1 on a 0-5 scale than (then) evaluate need for administration of current pain intervention and/or need for further/different interventions. Review of the provider's 4/10/10 Intense Pain Weekly Pain Assessment policy revealed: *In addition to weekly pain assessments, a nurse can check a resident's intense pain during pill passes, checking of weekly B/Ps (blood pressures) or any other time throughout the day. *If the resident's pain level is less than or equal to 3 on a 0-10 scale, mild, or a 1 or less on a 0-5 scale than (then) proceed with your weekly routine pain assessment protocol. *If the resident's pain is greater than or equal to 4 on 0-10 scale, moderate to severe, or greater than 2 on a 0-5 scale than (then) initiate a pain flow sheet. *Pain flow sheets need to be completed every 4 hours for 24 hours. If anytime in that 24 hours the resident is not getting satisfactory pain relief with non-pharmacological (not medication) and/or pharmacological (medication) interventions, the physician should be contacted. *The pain flow sheet may be discontinued at the end of 24 hours if the resident has achieve appropriate pain relief within the 24 hour assessment period. *Document all findings in the nurse's notes in the resident's chart. (Initiation of the 24 hour pain flow sheet and why, if the physician was called for inadequate pain control, and any changes in pain regime). A policy for following physician's orders [REDACTED]. B. Based on observation, record review, interview, and policy review, the provider failed to: *Ensure necessary care and services related to dietary needs, activities, and physicians services for 1 of 11 sampled residents (6) were identified and addressed. *Ensure the care plan had emergency interventions for the potential of sudden bleeding from the [MEDICAL TREATMENT] shunt site for one of one sampled resident (8) who received [MEDICAL TREATMENT]. *Ensure a coordinated plan of care was in place for one of one sampled resident (9) who received hospice services. Findings include: 1. Observation and interview with resident 6 on 5/16/16 at 2:20 p.m. revealed: *She had been admitted on [DATE] for rehabilitation. *She had an ankle fracture that had not healed correctly and was causing pain when walking was attempted. *She had been living in an apartment that had a flight of stairs that she had difficulty maneuvering. *She was laying on top of her bed. Her hair was in a loose braid with several stands of hair out of the braid. *She was not happy with how she had been treated. *Regarding food and drink: -She had been told they were out of yogurt, and she would have to buy her own. She would also have to buy her own real fruit juice. -On admit she had informed them she drank a certain diet soda. They did not have that in the pop machine but would get it. She was later told they had the pop, but she would have to wait for a space in the pop machine to empty out. She had not received any as of yet. -She was placed on a constant carbohydrate diet that she had not been instructed on. She received bread at every meal which she usually had not eaten. -She had not been asked her food preferences. If she had been asked she would have informed them she did not eat bread. -On 5/16/16 at breakfast she was told her fluid limit had been cut in half and was served no fluids at breakfast. She had no fluids from breakfast to lunch. At lunch that same day she was told it was an error, and she was given fluids. *Regarding physician choice: -She had not selected her present physician. She had another physician who had agreed to accept her as a patient, but that physician had not been contacted. -Her present physician was not accessible to her. She had repeatedly asked for the physician's phone number and was refused. She asked for a phone book and was refused.*She was not sure why the isolation sheet was on her door. Interview on 5/16/16 at 2:35 p.m. with the interim director of nursing (DON) revealed she was not aware of where resident 6's infection was. Observation on 5/16/16 at 5:40 p.m. of resident 6 at dining room table revealed: *She received a sandwich, baked beans, tomato juice, milk, and diced pears. *She requested assistance from dietary staff serving the diced pears and stated she did not want all that bread. She also requested a banana instead of pears. Continued record review and interview with resident 6 on 5/17/16 at 11:00 a.m. revealed: *She still had not received any of her pop of choice. She had been told it was in the facility but not in the pop machine. *She went to activities if she was aware of them, but she had difficulty reading print. -She could not read the activities calendar taped to the wall at the end of the bed. *She had not been able to get to the circle activity due to conflicts with her therapy schedule. *She had been told there was praying of the rosary. There was no rosary prayer time listed on the May 2016 schedule posted. *One piece of her mail had been opened by the facility staff. The social services designee had told her they had read the first line of the address only. The first line had been the name of the facility. The second line had been the resident's name. *She had no living relatives to speak for her. *Her assigned physician had visited her the previous week and told her she was not changing any medication orders. -The resident started experiencing bladder spasms the weekend after the physician visit. -The resident had been told the physician had discontinued the medication for bladder spasms on the visit the previous week. -The medication was restarted. *She had a history of [REDACTED]. -She was on hospice for four weeks, then the kidneys started to function again. *There was no [DIAGNOSES REDACTED]. *She had a history of [REDACTED]. She was told [MEDICAL CONDITION] was not related to her rehabilitation, so she would not be going to that appointment. *She had an appointment tomorrow to see an orthopedic surgeon. She was seeking a second opinion to see if she would be able to get the ankle repaired so she would be able to walk. *Her hair had been in the same condition as yesterday, a loose braid with several strands of hair outside of the braid. -She stated only certain staff members would braid her hair. Observation on 5/17/16 at 12:16 p.m. of resident 6 revealed: *She had ordered tomato soup for lunch. *She was served chicken soup that she refused. She stated she had ordered tomato soup. She was told they ran out of tomato soup. *The table she was seated at was served last at lunch. Observation and interview on 5/17/16 at 4:00 p.m. with resident 6 and the activities coordinator revealed: *She had heard the activities coordinator was taking a group out to see a movie. *She had told the activities coordinator she had not known there was a movie outing. *The activities coordinator told her she had not told her, because she was on Medicare A and could not leave for outings. 1. Interview on 5/18/16 at 9:40 a.m. with the social services designee regarding resident 6 revealed: *The resident repeatedly had been calling physicians. The provider preferred to have nursing fax physicians questions instead of residents calling physicians. *The resident repeatedly had been calling the ombudsman. *The resident was assigned her present physician by the social worker at the hospital she was transferred from. Her present physician was one of two physicians who came to the facility from Canton. *The social services designee had given the resident the social history form to fill in on admission. -The social service designee had not received the form back from her, nor had asked her about it since giving her the form. *The social services designee talked to the resident once or twice daily, but had not documented the daily visits. *If the resident wanted to see her physician of choice she would have had to pay for the transportation to Sioux Falls. The Minimum Data Set (MDS) coordinator would explain the reason for that. *The resident got a bath twice a week, and her hair was braided then. *The social services designee stated the diet pop the resident liked was in the facility, but the resident had not received any yet. Interview on 5/18/16 at 10:00 a.m. with the dietary manager regarding resident 6 and her diet revealed: *She and the dietitian had attempted to visit with the resident yesterday, but the resident was on the telephone when they had attempted. *The dietitian had educated the dietary staff on the constant carb diet yesterday. No one had asked the resident about questions regarding the constant carb diet or her food preferences yet. *The resident had requested yogurt at every meal. They had run out of yogurt and had to wait for supplies. The type of yogurt she wanted was not an item they could order from their supplier. *When asked how the resident received her bedtime snack the dietary manager said she assumed the certified nursing assistant (CNA) had brought it to her. *The dietary manager had not known if the resident was instructed she would need to ask for snacks to be brought to her room. She supplied the snacks and nursing was responsible after that. Interview on 5/18/16 at 10:10 a.m. with resident 6 revealed: *She had awoken at 2:30 a.m. and was hungry and in pain. *She had called for assistance, and CNA B responded. *She requested he tell the nurse she needed something for pain and also needed a snack. *She received neither. *The dietary manager had spoken to her yesterday, and the dietary manager was aware she wanted an afternoon snack. She had not received one. *At supper the previous evening she had eaten a banana, a yogurt, and coffee. She had refused the sandwich. She had no bedtime snack. *She was not aware there were bedtime snacks made for the residents. *She was not aware she had to ask for those snacks to be brought to her room. Interview and activity calendar review on 5/18/16 at 10:40 a.m. with the activities coordinator regarding resident 6 revealed: *She was aware the resident needed large print books to read. She would get an activity calendar at the bedside for the resident. *There was a volunteer that would say the rosary with people. That was not on the calendar. *There was now a Catholic mass scheduled twice a month. She had not added that on the May 2016 calendar. Interview on 5/18/16 at 10:53 a.m. with the MDS coordinator regarding resident 6 revealed: *The resident had requested to see her psychologist but was not going to be able to go while she was on Medicare A. *The resident had requested to see a physician she had contacted in Sioux Falls. She would not be able to, because the facility would have to pay for the transportation. They used the physicians in Canton who came to the facility. *Resident 6 would not be going on outings while on Medicare A, because the only outings allowed were those related to rehabilitation. *When documentation was requested to support the above the Medicare Benefit Policy Manual, chapter 8, coverage of extended care was provided. Observation and interview on 5/18/16 at 1:00 p.m. with resident 6 revealed: *She had missed her appointment with her orthopedic surgeon. *The facility van had been sent elsewhere. *She believed she would be out of rehabilitation benefits before she would be able to see the orthopedic surgeon again. Interview on 5/18/16 at 1:35 p.m. with the administrator revealed the facility van driver had taken another resident to Canton. Instead of returning to take resident 6 to her appointment in Sioux Falls, the driver had waited for the other resident at Canton. Interview and record review on 5/18/16 at 3:00 p.m. with the administrator regarding resident 6 revealed he agreed: *The resident was not satisfied with her present treatment. *Agreed the resident should not have missed her appointment with the orthopedic surgeon. *Agreed Medicare A was not a reason to withhold short outings or previous physician appointments. *Thought the resident was agreeable to waiting for her pop until a space became available in the pop machine. *Thought the resident had agreed to the present physician assigned to her. *Was not aware staff had refused to provide the physician's phone number and/or a phone book to her. *Was not aware she had not been instructed in her new diet. *Was not aware the social services designee was not documenting all visits with residents regarding their needs. Review of the provider's 4/17/10 Physician Services policy revealed the resident had a right to choose a personal attending physician. Review of the 10/16/15 Medicare Benefits Policy Manual supplied by provider revealed a resident was able to be granted a pass to attend outings while on Medicare A. Review of the 8/15/13 Social Services Designee job description revealed she was expected to: *Work with interdisciplinary team to provide psychological support to residents. *Counsel the resident and assist in development of needs. *Assist in organizing all social services needs of the resident including completion of required forms. *Develop and maintain involvement with residents. *Assess resident's social, emotional, and psychological needs throughout their stay and utilize resources to meet needs. *Continually maintain contact with residents concerning all aspects of their residency. *Gather resident's social history during admission process. *Ensure resident's needs are met. *Communicate pertinent information to essential personnel. *Able to express self in writing. *Documentation of plan and progress. *Be the resident advocate at all times. *Identify psychosocial needs of the resident and make referrals as necessary. *Assist with taking residents to appointments as necessary. *Assist in coping with and solving issues with resident's every day lives and relationships. *Inform residents of their rights. Review of the provider's 10/30/15 MDS Coordinator job description revealed she was to: *Assist in planning, organizing, and directing the activities of the nursing department. *Work towards the goal of reaching the highest level of functioning and independence for each resident. Review of the provider's undated dietary department information in the admission packet revealed: *If at any time meal options were not appealing, the resident should request short order items in advance and the kitchen staff would do their best to accommodate the request. *There was no information on snacks provided. Review of the provider's undated Meal Times policy revealed bedtime snacks were available at the nurses station. 2. Review of resident 8's undated care plan revealed there was no emergency intervention for sudden bleeding from the [MEDICAL TREATMENT] shunt site documented. On 5/18/16 at 2:05 p.m. the administrator was asked for a policy on [MEDICAL TREATMENT] resident care or [MEDICAL TREATMENT] shunt care. Interview and record review on 5/18/16 at 3:00 p.m. with the administrator revealed he: *Was unable to locate a policy or procedure on [MEDICAL TREATMENT] resident care or [MEDICAL TREATMENT] shunt care. *Agreed there was no emergency intervention for sudden bleeding from the [MEDICAL TREATMENT] shunt site documented on the care plan. 3. Review of resident 9's medical record revealed: *She had started hospice services on 1/5/16. *Her undated care plan had the following hospice interventions: -For mood and behaviors it stated On hospice care. -For weight loss it stated Hospice is involved in my care. -For communication it stated On hospice care. -For social history it stated On hospice care. -For discharge planning it stated On hospice care. -For terminal prognosis it stated Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. *The hospice provider had a separate care plan that had not been individualized to resident 9. Interview on 5/18/16 at 10:00 a.m. with the MDS coordinator revealed the care plans were not coordinated and had not identified the specific roles of each provider. She was unaware of who was providing what cares each day. Review of the provider's 2/1/15 services agreement with the hospice agency revealed the plan of care should have reflected the participation and services of the Hospice, Facility, and Hospice patient and family to the extent possible.

Based on record review, interview, and policy review, the provider failed: *To ensure documentation was complete for one of one sampled resident (11) with a fall and a head injury. *To follow the residents care plan that had resulted in a fall with an injury for one of one sampled resident (11). Findings include: 1. Review of resident 11's complete closed medical record revealed: *On [DATE] at 1:05 p.m. the resident had a fall. *The resident was in the geri-chair in a sitting position. *The resident had fallen forward out of the geri-chair, hitting the floor face down. *The charge nurse was summoned to the room by the certified nursing assistant (CNA) after the fall. *A large goose egg sized bump was noted on the right side of the forehead. *She had been bleeding from her nose. *The resident's blood pressure (BP) was ,[DATE] (normal blood pressure is ,[DATE]). *On [DATE] at 1:20 p.m. the residents power of attorney (POA) was notified of the fall. -The POA gave the okay for the resident to be transferred to the hospital. *On [DATE] at 1:25 p.m. a message had been left for the on call physician to return a phone call to the charge nurse. *On [DATE] at 1:42 p.m. a second phone call had been placed to the on call physician and the physician had given permission to transfer the resident to the hospital. *On [DATE] at 1:45 p.m. the ambulance was called. *On [DATE] at 1:55 p.m. the ambulance arrived and transported the resident to the hospital. *On [DATE] at 9:30 p.m. the hospital notified the facility the resident had expired. Review of resident 11's Neurological Assessment Flowsheet revealed the resident had one entry where the nurse on [DATE] at 1:55 p.m. had checked the following: -Level of consciousness had been drowsy. -Pupils were sluggish to react to light. -The resident had been unable to follow the command to squeeze her hands. -The resident had no response to pain. -B/P was ,[DATE], heart rate was sixty beats per minute, respirations were twenty-four per minute. *There was no further documentation the residents neurological status and vital signs (B/P, pulse, and respirations) had been checked after 1:05 p.m. Review of resident 11's Resident Behavior/Mood/Change ADL (activities of daily living) Function Flowsheet revealed on [DATE] "In the a.m. resident was jumping and sitting up a lot in the geri-chair and in bed." Review of resident 11's Fall Risk Assessment on [DATE] revealed the resident scored thirteen; that placed the resident at high risk for falls. Review of resident 11's care plan dated [DATE] revealed: *She required the assistance of two for transfers. *Two staff would be needed to transfer her from the geri-chair to the bed. *Two staff were suppose to safely cradle lift her for transfers. Interview on [DATE] at 12:30 p.m. with certified nursing assistant/medication aide (CNA/MA) A, the administrator, and the director of nursing (DON) regarding the fall of resident 11 on [DATE] revealed: *CNA A had taken the resident to her room to lay her down. *She had positioned her in the geri-chair beside her bed. *She had placed the resident from a reclining position to a sitting position. *She had realized the CNA that was to assist her was not in the room. *She had turned around and she walked to the resident's door. *She said the resident fell forward out of the geri-chair landing face down on the floor. *She stayed with the resident while the other CNA summoned the nurse. *She did not move the resident. *She agreed the resident should not have been left unattended. *She had been trained on transfers. Interview on [DATE] at 12:45 p.m. with licensed practical nurse (LPN) B, with the administrator, and the DON present regarding resident 11 revealed: *She had been summoned by the CNA to come to resident 11's room. *She had entered the room and she found the resident lying face down on the floor. *She had obtained the resident's vital signs, checked her neurological status, and had performed range of motion to the residents' arms and legs. *She had noted the resident had a goose egg sized bump on the right side of her forehead and had been bleeding from the nose. *She and two CNAs had placed a gait belt around the residents waist, and then had transferred the resident to her bed. *She had placed pillows around the resident's neck to stabilize the neck. *She thought she had obtained the resident's B/P a few times but was unsure. *She thought the DON had taken the B/P a few times also. *She had called the physician on call and had left a message for the physician to return a call to her. *She had called the physician again and had obtained an order to transfer the resident to the hospital. *She stated it was normal for the resident to have sluggish pupils and no hand grasps. *She had been concerned about the resident's low B/P. *The ambulance arrived and the resident was transferred to the hospital. Review of the five working day investigation for resident 11 revealed: *"The CNA had not followed the resident's care plan when she placed the resident in the geriatric chair in an upright position and walked to the doorway. Leaving the resident unattended." *"All resident's current care plans, with use of geriatric chairs, will be updated and revised in regards to transfer safety of residents from geriatric chairs." Review of the provider's [DATE] Neurological checks policy and procedure revealed: *"Neurological assessment should be done on any resident that has hit their head or on any unwitnessed fall where the resident is unable to tell you when ever they hit their head or not." *"Neurological assessment will be assessed: -Every hour for two hours. -Then every two hours for two hours. -Then every shift for seventy-two hours or until stable. -Physician to be notified with any abnormal Neurological Assessment that is not within normal limits for the resident." Review of Patricia A. Potter and Ann Griffin Perry, Fundamentals of Nursing, 6th edition, Mosby, St. Louis, Mo, 2005, revealed: *Page (p) 261: -"Nurses were responsible for making accurate and appropriate clinical decision." -"The nurse would take immediate action when a client's clinical condition deteriorated, and who decided if a client was experiencing complications that warranted notification of the physician." *P. 279: -"The nurse follows the nursing process to organize and deliver nursing care. Use of the process allows the nurse to integrate elements of critical thinking to make judgements and take actions based on reason. The nursing process is used to identify, diagnose, and treat human response to health and illness. The process includes five steps: assessment, nursing diagnosis, planning, implementation, and evaluation." *P. 293: -"Data documentation is the last part of a complete assessment. A thorough, concise, and accurate documentation of facts is necessary when recording patient data. Observation and recording of patient status a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Policy Statement (2003) and Standards of Clinical Nursing Practice (1998) mandate accurate data collection and recording as independent functions essential to the role of the professional nurse." *P. 419: -"The physician was responsible for directing medical treatment." -"Risk Management required good documentation. The nurse's documentation could be the evidence of what actually was done for a client and could serve as proof the nurse acted reasonably and safely. Documentation should have been thorough, accurate , and performed in a timely manner. To protect the nurse and the client the nurse should have documented the care given and details associated with it." -"When a lawsuit was filed, very often the nurse's notes were the first thing reviewed by an attorney. The nurse's assessments and the reporting of significant changes in the assessments were very important factors in defending a lawsuit."

Based on observation, interview, record review, and policy review, the provider failed to ensure a resident at risk for pressure ulcers: *Had preventative measures in place for one of one sampled resident (1). *Turning and repositioning scheduled had been followed for one of one sampled resident (1). Findings include: 1. Review of resident 1's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *Review of the 4/16/12 Minimum Data Set (MDS) revealed she: -Required extensive assistance for transfers and bed mobility. -Was at risk for developing a pressure ulcer. -Had a pressure reducing device for her wheelchair. -Was on a turning and repositioning program. -Had been receiving an application of nonsurgical dressings. -Had applications of ointments/medications other than to her feet. *Review of the 7/15/12 MDS revealed she: -Required extensive assistance for transfers and bed mobility. -Was at risk for developing a pressure ulcer. -Had a stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough, and might also present as an intact or open ruptured serum-filled blister) that had developed on 7/5/12. -Had a pressure relieving device for her wheelchair. -Had an application of nonsurgical dressing (with or without topical medications) other than to her feet). *Review of the 4/24/12 Braden Scale (had predicted the risk of obtaining a pressure ulcer) revealed a score of twelve that placed the resident at high risk. *Review of the 7/18/12 Braden Scale revealed a score of twelve. -A score of sixteen or lower would have reflected the need for interventions in the resident's care plan. *Review of the resident's progress notes revealed: -On 7/5/12 at 2:45 p.m. she had an open area to the left side of her coccyx that measured 1.5 centimeters (cm) by 0.4 cm. -A [MEDICATION NAME] dressing was being applied and changed every three days and as needed. -Area to left heel was healed. -On 7/17/12 at 3:00 p.m. the [MEDICATION NAME] had been discontinued and area had been healed. -[MEDICATION NAME] ointment had been applied. -On 7/18/12 at 3:16 p.m. the quarterly MDS nursing assessment had been done from 7/09/12 through 7/15/12 and revealed no documentation of her skin issues. *Review of the care plan dated 5/2/12 revealed she: -Had no skin issues at that time. -had a history of [REDACTED]. -Was not to have any skin breakdown. -Required assistance of one to two staff to complete her activities of daily living (ADL) -Needed her skin monitored closely for signs and symptoms of breakdown such as redness and [MEDICAL CONDITION], and to notify the nurse if those symptoms were present. -Was on a turning and repositioning program. *Review of resident 1's Pressure Ulcer/Wound Flowsheet revealed she: -Had developed a pressure ulcer to the right heel on 5/27/12. -Had developed a pressure ulcer to the left side of her coccyx area on 7/5/12. *Review of the resident's repositioning record for July 2012 revealed: -From 7/1/12 through 7/8/12 there was no charting the resident had been turned and repositioned. -On 7/9/12, 7/13/12, and 7/14/12 there was documentation of the resident being repositioned at 12:00 midnight, 2:00 a.m. and 4:00 a.m. -From 7/15/12 through 7/17/12 there was no charting the resident had been turned and repositioned. Interview on 7/31/12 at 3:00 p.m. with the administrator regarding resident 1's July 2012 Turning and Repositioning record revealed she would expect the direct care staff to ensure the resident's care records were completed each shift. Interview on 7/31/12 at 3:30 p.m. with the director of nursing (DON) revealed she was unsure if resident 1 had a pressure relieving device for the bed. Interview on 7/31/12 at 3:40 p.m. with the administrator and the activities director confirmed all residents had pressure reducing mattresses for their beds. Interview on 8/1/12 at 1:25 p.m. with the DON regarding resident 1 revealed: *The July 2012 Turning and Repositioning sheet was incomplete. *Her expectations would have been for the staff to initial the form if it had been completed. *The care plan was not current to include the residents skin issues and current needs due to her history of pressure ulcers. Observation on 7/31/12 from 9:45 a.m. through 2:40 p.m. revealed the resident had been laid down after meals and was always placed on her left side. Review of the provider's June 2011 Pressure Ulcer Prevention policy revealed: *The purpose of the policy was to prevent skin breakdown and the development of pressure ulcers. *The procedure included: -Assess the resident for the risk of pressure ulcer development on admit of new residents, quarterly and with any change of conditions. -Use pressure reducing or relieving devices as necessary. -Turn and reposition any resident that was unable to reposition themselves as needed for any other resident every two hours in bed and chair. -All residents would be monitored for decline in functional status and mobility. *Documentation guidelines included: -Date, time, and treatment to the pressure ulcer. -Preventative measures used. -Condition of the resident's skin.

A. Based on observation, interview, record review, and policy review, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical well being for two of three sampled residents (1 and 7) who had skin issues. Findings include: 1. Observation of resident 1 on 6/6/11 at 1:30 p.m. revealed: *She was sitting in her recliner. *There was a pressure relieving device in the recliner. Interview on 6/6/11 at 1:30 p.m. with resident 1 revealed: *She had just gotten a pain pill for shoulder and arm discomfort. *She had not slept in her bed because of a sore on her right hip. *She slept in her recliner. *She stated she also had a sore on her right foot. Interview on 6/6/11 at 1:45 p.m. with the assistant director of nursing (ADON) revealed: *There was not a pressure relieving device on resident 1's bed. *She was not aware the resident had been sleeping in her recliner. Interview with certified nursing assistant (CNA) on 6/6/11 at 3:15 p.m. regarding resident 1 revealed: *She had been sleeping in her recliner because of the sore on her hip and foot. *She had been sleeping in her recliner for a few months. Observation and interview on 6/6/11 at 6:05 p.m. with resident 1 revealed: *She was sitting in her recliner. *She was complaining of feeling tired. *She had ordered a room tray. Interview and observation on 6/7/11 at 8:35 a.m. revealed: *She had been sitting in her recliner. *There was a pressure relieving device in the chair. *She had not slept well last night. *She thought she should start sleeping in her bed. *She stated the bed was not comfortable and she needed a new mattress. *She was going to be eating breakfast in her room, because she had not slept well. Review of resident 1's physician's nursing home visit assessment dated [DATE] revealed: *The resident was on hospice. *She had a "Grade 1 pressure sore on her right hip." *She had a "corn or bunion on the right 5th metatarsal" (the side of her foot). *The physician was relying on the nurses' notes for the evaluation of the pressure ulcer on the hip and foot as she had not removed the dressings. *She had [DIAGNOSES REDACTED]. *The plan was to not get overly aggressive with any treatment for [REDACTED]. Interview on 6/6/11 at 3:30 p.m. with the assistant director of nursing revealed: *Weekly pain assessments were completed. *Pressure ulcer/2ound assessments were done weekly. Review of resident 1's nursing progress notes on 12/22/11 at 9:00 a.m. revealed "Reported per noc (night) nurse that res. (resident) has baseball size lump on Rt. (right) lateral thigh, area assessed large lump to the Rt. lateral upper thigh, no redness, no warmth res. denies pain to this area at this time, Hospice nurse called et. message left to return call at this time." Review of the provider's Pressure Ulcer/Wound Assessment Record form described the various stages of pressure ulcers: *Stage 1: Intact skin with non-blanchable redness of a localized area over a bony area. *Stage 2: Partial thickness of skin presenting as a shallow open pressure ulcer with a red or pink wound bed. May also present as an intact or open serum-filled blister. Review of resident 1's Pressure Ulcer/Wound Assessment record for the following dates revealed: *1/30/11 Was the first entry of the noted right hip skin problem. -The area was staged a 1 on the wound stage scale. -The area measured 2 x 2 centimeters (cm), there was no depth, no odor, there was no drainage, and the peri-wound skin was normal. *2/6/11 The area had increased in size to 2.8 cm x 2.8 cm, the area was red, no drainage, no odor. The resident complained of pain only when the area was bumped, and the treatment was skin prep to the area. *2/20/11 There was no entry made on the Pressure Ulcer/Wound Assessment Record, and the form was not completed. *2/27/11 The area on the right hip was described as unstageable due to a scab, measured 1.3 cm x 2 cm, unknown depth, unknown condition to the wound base, no drainage, no odor, area around the area was "cellulitic" (inflamed) and hard. A foam dressing was applied and a hospice referral was to be made. *3/6/22 The right hip wound was described as a scab and measured 1.1 cm x 1.3 cm, condition of wound base unknown, no drainage, and no odor. The resident was having pain. [MEDICATION NAME] had been applied to the area, and a hospice referral was to be made. *3/07/11 The area on the right hip was staged as a 2. The right hip had a blister, the area measured 0.8 cm x 0.5 cm, G (granulation), ulcer margins smooth, no odor, no complaints of pain, Opsite to area, and change every 7 days. *3/13/11 The right hip ulcer, was unstageable, measured 0.8 cm x 1 cm, unknown depth, unknown wound base condition, area around the wound was "cellulitic" (inflamed). The resident was having pain. [MEDICATION NAME] had been applied, and there was a need for a hospice referral. *3/14/11 The area was described as a right hip blister, stage 2, measured 1 cm x 1.2 cm, condition of wound base was described as granulation, area around the wound was normal, and no odor. There were no complaints of pain, and the treatment was unchanged from 3/7/11. *3/20/11 The right hip ulcer was unstageable, measured 0.7 cm x 1.2 cm, depth unknown, condition of wound base unknown, no drainage, no odor, and the area around the pressure ulcer was normal. The resident was having pain. [MEDICATION NAME] was on, and there was a need for a hospice referral. *3/21/11 The area was recorded as healed on the Pressure Ulcer/Wound Assessment Record. *3/27/11 The area on the right hip was unstageable, measured 2 cm x 3 cm, unknown depth, area of wound based described as necrotic, ulcer margins smooth, no drainage, and area around wound was normal. The resident was having pain. The treatment had been changed to iodine and gauze, and there was a need for a hospice referral. *4/3/11 The area on the right hip was unstageable, measured 2 cm x 3 cm, depth unknown, wound base described as necrotic, area around would normal, no odor, and no drainage. The resident was experiencing pain. Iodine and gauze was the treatment for [REDACTED]. *4/10/11 The right hip wound was now described as a stage 1, measured 2.3. cm x 3.4 cm, no depth, wound base was described as necrotic, ulcer margins described as rough, and the area around the wound was normal. The resident was having pain. The treatment was unchanged from 4/10/11, and a hospice referral was needed. *4/17/11 The right hip area was not staged, measured 2 cm, unknown depth, wound base was necrotic, ulcer margins rough, no odor, and the area around the wound was normal. The resident was having pain, the treatment was unchanged, and a hospice referral was needed. *4/24/11 The right hip wound area was unstageable, measured 2 cm x 2.8 cm, unknown depth, wound base necrotic, ulcer margins smooth, no drainage, no odor, and the area was normal around the wound. The resident was having pain, and the treatment was unchanged. *5/1/11 The right hip was described as unstageable due to the scab, measured 2 cm x 2.8 cm, unknown depth, scabbed over and questionable necrosis, smooth ulcer margins, no odor, and the area around the wound was normal. The resident was having pain, and the treatment unchanged. *5/8/11 The right hip area was unstageable, measured 2 cm x 2.6 cm, unknown depth, necrotic wound base, ulcer margins smooth, and the area around the wound was normal. The resident was having pain, and the treatment remained unchanged. *5/15/11 The right hip was unstageable, measured 1.6 cm x 2.4 cm, depth unknown, wound base necrotic, ulcer edges were smooth, and area was normal around the wound. The resident was having pain, the treatment remained unchanged, and there was a need for a hospice referral. *5/22/11 The right hip wound was unstageable, measured 1.5 cm x 2.1 cm, unknown depth, wound base was described as scabbed over, no drainage, ulcer margins curled up, no odor, and the area around the wound was normal. The resident was not having pain, and the treatment had changed to [MEDICATION NAME] wash and gauze. *5/29/11 The right hip wound was unstageable, measured 1.6 cm x 2 cm, depth unknown, condition of wound based described as a scab, ulcer margins curled, no drainage, no odor, and the area around the wound normal. The resident was not having pain, and the treatment remained the same as 5/22/11. *6/5/11 The right hip wound was unstageable, measured 1.6 cm x 2 cm, depth was unknown, condition of wound base described as scabbed, ulcer margins curled, no drainage, no odor, area around wound was normal, and the treatment remained unchanged. Review of resident 1's 4/4/11 revised care plan revealed: *The resident was at risk for alteration in skin integrity. *"Does have open areas at this x (time)." *"Skin integrity will be restored as evidenced by gradual healing of ulcer. Through next review. 7-4-11." *"Skin assessment weekly and prn (as needed)." *"Wound care as ordered." *Pressure relieving cushion in w/c (wheel chair). Review of the resident 1's hospice care plan updated on 4/4/11 revealed: *The nursing facility's responsibilities included: -Continue to provide the same level of services as provided before hospice care was elected. -Routine assessment, vitals, and personal care. -Notify hospice of uncontrolled symptoms, eg. dyspnea (labored breathing), pain, anxiety, other changes in patient condition, patient/family concerns, falls, equipment needs, death, and all other concerns. -Notify hospice of medication changes, outpatient treatments, ambulance transfers, hospitalization s, x-rays and laboratory tests. -Nursing facility would provide medication administration, or call hospice if assistance was needed with refill (with prior notice) such as compounded prescriptions or intravenous prescriptions. -Arrange for medications and treatments not related to the terminal diagnosis. -Arrange for supplies and equipment not related to the terminal diagnosis. -Skin-wound care and dressing changes. -"Coccyx-[MEDICATION NAME] TID (three times daily)." -"Rt. (right) hip-[MEDICATION NAME] BID (twice daily) see order 3/31/11." -Pain management. -Routine assessment. -Call hospice with concerns. -Appropriate nutrition. -Fall prevention measures. *Responsibility of the hospice agency included: -RN (registered nurse)/LPN (licensed practical nurse) would visit two times per week. -Therapy services related to the terminal [DIAGNOSES REDACTED]. -IDT(Interdisciplinary team) members would make every effort to attend the resident's NF (nursing facility) care conferences when notified to assist with joint care planning. -Provide supplies and/or equipment related to the terminal [DIAGNOSES REDACTED]. -Skin/wound care for assessment and evaluation of current tx (treatment) plan as needed. They would assess the area twice a week. Interview on 6/7/11 at 9:15 a.m. with RN H revealed she had not been aware of how resident 1 had gotten her open areas. She stated "I know I should but I don't." Observation on 6/7/11 at 9:20 a.m. of resident 1's dressing change to her right hip by RN H revealed: *The area on the right hip appeared necrotic with the ends of the wound curled upwards. *The area measured 2 cm by 2.8 cm. *The area was cleansed, [MEDICATION NAME] was applied, and the area was redressed with a 4 x 4 gauze dressing and tape. Interview with the director of nursing (DON) on 6/7/11 at 9:30 a.m. revealed: *She was aware of resident 1's skin issues. *She was aware there was no pressure relieving device on the resident's bed. *She had known the resident was sleeping in her recliner. *She thought hospice would have provided the pressure relieving device for the bed. *Hospice had provided the cushion for the chair. Review of resident 1's nursing hospice visit assessments on the following dates revealed: *1/31/11- "Pt. (patient) has a skin area on her right hip that is red. It is not open. The area looks like a boney area but it is on a spot on her hip that would not have a bone. Hospice nurse has assessed this area in the past. It is tender to touch when pressure is applied to the area. Hospice RN discussed the area with the bath aide at the nursing facility. She states that the area has not changed in size or color. It is not open. Hospice RN discussed the area with the DON. Hospice RN explained that the pt. does not want to use the hipsters that were suggested. DON was able to verbalize understanding. Hospice RN and the DON discussed using skin prep to the area to prevent skin breakdown. Hospice RN will continue to monitor." *2/3/11- There was no mention of an assessment of the right hip area. *2/8/11- "Pt. remains to have the spot on her right hip. The area is not open but staff puts skin prep on this area to prevent skin breakdown. Hospice RN will continue to monitor." *2/21/11- There was no documentation regarding the right hip area. *2/24/11- "Pt. has a red area on her right hip that has turned black due to pressure. The facility has been putting skin prep to the area daily but has stated that it is black now. Hospice RN assessed the area. It is the size of a half dollar. There is [MEDICAL CONDITION] above that area. The area that was red is now red around the edges but black in the center. Hospice RN feels that the area is now black due to pressure that she has with her wheelchair. She has not allowed the hospice RN to change anything to her wheelchair or her recliner at this time. Hospice RN and the facility RNA found a wheelchair that more room in the seat to relieve the pressure to her right outer hip." *3/3/11- "Pt. has a pressure on her right hip. The area is about half a dollar in size. The area is black. She has slight swollen area about the wound. The area is not open and is not draining. It has no signs of infection. Staff applies skin prep to the area, lets it dry and then applies a [MEDICATION NAME]. The dressing was changed today since the pt. had a bath." *3/7/11- "Pt. has an area on her hip that seems to be broken down per pressure. The hospice RN applied skip prep to the area and [MEDICATION NAME]. The area does not seem to be healing but is not getting worse. The area has no signs of infection. Skin has a slight red blister above this area. Staff states that pt. has a skin breakdown to her coccyx. The area is red and is sluffing (sloughing) of skin. The hospice RN ordered [MEDICATION NAME] BID and PRN. Hospice nurse will see if this will help with preventing other skin breakdown to this area. Hospice RN will continue to monitor." *3/10/11- "Pt. has skin breakdown on her right hip and her coccyx. Hospice RN assessed the area. There is no healing but they are not getting worse and there is no sign of infection." *3/14/11- "Pt's right hip sore is starting to be smaller after she has completed her course of antibiotics. The dressing was changed by the hospice RN. Pt's coccyx is still red and having skin breakdown. There are areas where the [MEDICATION NAME] is not sticking to the area. Hospice RN will write orders for stoma adhesive to be applied to the area and then the [MEDICATION NAME] to be applied. Hospice RN will see if this will be better for the area." *3/17/11- "She states that she has an increase in pain when she is up an ambulating on her hip." No assessment of the area was documented. *3/21/11- "Pt's hip sore is healing. The scabbed area is getting better and there is no longer a red area around the scab area. The hospice RN changed the dressing to this area." *3/24/11- "Pt. still has her sores on her right hip. She also has some skin breakdown in her coccyx. She has scheduled [MEDICATION NAME] to this area. Hospice RN will continue to monitor." *3/31/11- "Pt. remains to have the skin wound on her right hip. It is circular in shape. There is an area in the middle of the circle shape that is changing color. It is looking like it is breaking down more in this area. She also has an area above the circle area that was red and swollen but now is turning black. Hospice RN discussed this with the hospice [MEDICATION NAME] Therapist (ET) RN. The hospice ET RN looked at the area with the hospice RN. She feels the area is not just a pressure area that has started to breakdown. She feels that it could be something else going on. She wrote orders to change the dressing treatment to this area from [MEDICATION NAME] to [MEDICATION NAME] to be applied to the area and covered with gauze and limited tape." *4/4/11- "PT's coccyx is intact at this time. Pt. has an area on her hip. It is circular in shape and it is black. It remains to have the small area that is different color in the middle. The area around the black circular area is swollen but it is not red as it was last week. Staff have been putting [MEDICATION NAME] to the area and covering it with gauze which was the recommendation of the hospice ET RN. Hospice RN will continue to monitor these areas for healing, worsening or signs or symptoms of infection." *4/7/11- "Pt. has sore on her right hip. The area around the sore is not as swollen and is no longer red. It is also not as hard as was before she started on her [MEDICATION NAME]. Pt. was on this antibiotic before. When she was taken off of the antibiotic the sore worsen greatly. Hospice RN discussed the above with the clinic per a fax to the Physician Assistant. She ok'd the use of [MEDICATION NAME] for another 10 days. Hospice RN will continue to monitor. Pt. remains to have the [MEDICAL CONDITION] her right buttock. Staff has been applying stoma powder to this area and the [MEDICATION NAME]." *4/11/11- "Pt. continues to have the open area on the right hip. The area has decreased in size from two weeks ago. She continues to be on her antibiotic for this area. Her dressing was changed per orders by the facility nurse. Pt. continues to have [MEDICAL CONDITION] her right buttock. Hospice RN applied stoma powder to the area and reapplied the [MEDICATION NAME] to this area also." *4/15/11-Routine visit showed no documentation of an assessment to the right hip. *4/18/11- "Pt. remains to have the sore on her right hip. The area is smaller then last week. It still remains black with a small open area at 1500. She had taken a bath in which the area is covered with a [MEDICATION NAME] due to increased pain that pt. has if the area is in contact with water. The [MEDICATION NAME] was taken off by the hospice RN. Pt. remains to have [MEDICAL CONDITION] her right buttock." *4/21/11- "Skin assessment: Warm, Dry, Pressure ulcer: [MEDICATION NAME] and [MEDICATION NAME] are applied BID (twice per day) to Rt. (right) buttocks wound." *4/25/11-There was no documentation of the right hip wound. *5/2/11- "Pt. has skin wound on her right hip. The area is not bigger but yet not smaller than last week. The area is about the size of a kiwi and black in color. The area is not open and has no drainage. She continues to have [MEDICATION NAME] treatment to the area BID." *5/5/11- "Skin: Within normal limits for this patient." *5/9/11- "The area on her hip is about a size of a walnut. It remains black. There is no red or swelling around this area anymore. Hospice RN applied [MEDICATION NAME] to the area and covered with gauze." *5/12/11- "Pt did the dressing changes to the pt's right hip. These areas are healing yet very slowly. They have no signs or symptoms of infection. Hospice RN will continue to monitor." *5/16/11-No assessment of the right hip wound was noted. *5/19/11- "Facility med (medication) aide did pt's dressing this am. She states that there was no change with the skin wounds. Hospice RN will continue to monitor." *5/23/11- "She has a right hip skin sore that has stayed the same in size for the last couple of weeks. Hospice RN and staff will continue to do the ordered treatment to this area. Hospice RN will continue to monitor." *6/2/11- "Staff will do pt's dressing changes today to her skin wounds on her right hip." No assessment of the right hip wound was documented. Review of resident 1's Minimum Data Sets (MDS) revealed: *10/08/10 The resident was coded at risk for pressure ulcers. Skin and ulcer treatments included a pressure relieving device for chair, nutrition or hydration intervention, and applications of ointments/medications. *1/7/11 the MDS revealed: -Resident was at risk for pressure ulcers. -Coded for an unhealed pressure ulcer. -Pressure ulcer coded as a stage 2. -Skin and ulcer treatments included a pressure relieving device for chair, nutrition or hydration intervention to manage skin problems, ulcer care, applications of ointments/medications other than to feet, and application of dressings to feet. *3/25/11 the MDS revealed: -The resident was at risk for pressure ulcers. -The resident coded for an unhealed pressure ulcer. -There were two pressure ulcers staged at a 2. -The resident coded for one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. -The most severe tissue type for any pressure ulcer was coded a 2. -Worsening in pressure ulcer status since prior assessment was coded 2 under stage 2. -Pressure ulcers were present on the prior assessment. -Skin and ulcer treatments included pressure relieving device for chair, nutrition or hydration intervention to manage skin problems, ulcer care, application of nonsurgical dressing, application of ointments/medications other than to feet. -Application of dressings to feet. Review of resident 1's Braden scale dated 3/30/11 gave the resident a score of 16. That score placed the resident at risk for skin breakdown, and the care plan should have reflected the need for intervention/s. Review of resident 1's nursing home visits by the primary care physician revealed: *3/15/11- There was no documentation regarding the assessment of the right hip wound. Under the chronic problems list it was noted the right hip lesion was stable. *5/17/11-"She does have a Grade 1 pressure sore on her right hip although I did not have a chance to look at that. She was not undressed for this visit so I am relying on nurses notes for this evaluation." Review of resident 1's hospice progress notes on the following dates revealed: *2/24/11-The provider had "called and stated that pt's (patient's/resident's) area on her right upper leg looked worse. It was red but the center was black. Hospice RN instructed them to continue with the skin prep daily and hospice RN would conference with the hospice ET RN. Hospice RN explained that she would be at the facility tomorrow 2/24. Facility nurse was able to verbalize understanding. Hospice RN discussed the pt's skin area with the hospice ET RN. She stated that the skin prep was still appropriate treatment for [REDACTED]. Hospice RN will assess the area tomorrow while she is at the facility." *3/4/11-The resident was seen by the Certified Wound/Ostomy Nurse. "Pt. was seen today re:deep tissue injury to right trochanter-total area measures 7 cm x 8 cm with very ecchymotic (discolored) area in nucleus (center) which measures 1.5 cm x 1.3 cm, remainder of area is erythremic(reddened)/sl. ecchymotic (discoloration)/intact. Pt has been sleeping in her recliner, will send out a Gay-Mar cushion. Tx. (treatment) is transparent drsg. (dressing) et. (and ) will continue with that. Staff/primary enc. (encouraged) to notify us with changes." *3/31/11-"Pt. seen today re. (regarding) tissue trauma (injury) right hip-total area of induration (hardened) measures 6 cm x 6 cm, open area measures 3 cm x 3.5 cm with soft black eschar (lesion) tissue base with smaller open area @ (at) approx. ( approximately) 3:00 which measures .5 x .6 cm with red tissue base et sm.(small) amt. (amount) red drng (drainage). Peri-wound skin sl. (slight) erythemic/intact. Tx. had been transparent drsg. Pt has received 2 courses of antibiotics, has Gay-Mar chair cushion ER (and) spends much of her time in the recliner. Pt. states that area doesn't hurt except when you mess with it." Review of resident 1's 4/5/11 Review of Indicators of Pressure Ulcers revealed: *Risk factors include pressure: -Requires staff assistance to move sufficiently to relieve pressure over any one site. -Needs special mattress or seat cushion to reduce or relieve pressure. Interview with the DON on 6/8/11 at 9:00 a.m. revealed: *She agreed there should have been more interventions in place to prevent skin breakdown on resident 1. *The goal would always have been to prevent a pressure ulcer. Review of the provider's 4/8/10 Pressure Ulcer, Prevention of Policy and Procedure revealed: *Use appropriate support surface in the resident's bed or chair. *Use pressure reducing or relieving devices as necessary. *Establish a turning and positioning schedule in bed and chair to meet the resident's needs. *Position with appropriate surfaces to protect bony areas. *Whenever possible teach the resident to change position at regular intervals and to shift his/her weight in wheelchair. Use of supportive devices. B. Based on record review, observation, and interview, the provider failed to use alternative interventions for the prevention of skin tears for one of one sampled resident (7) with skin tears. Findings include: 1. Review of resident 7's nursing progress notes revealed he received skin tears on the following dates: *3/25/11 at 1600 (4:00 p.m.) "Resident hits top of right hand on bathroom bar, 7 centimeter (cm) skin tear obtained, cleaned with NS (normal saline) and steri-strips applied, wife aware." *3/25/11 at 2030 (8:30 p.m.) "2.7 x 2.5 cm skin tear and 5 cm long skin tear noted above (R) right elbow. Skin tears acquired in bathroom. See previous entry. Area cleaned with NS, covered with opsite, wife notified." *3/28/11 at 1300 (1:00 p.m) "Staff reports increase in resident's aggressive behaviors." *3/29/11 at 10:20 a.m. "Received faxed orders to increase resident's [MEDICATION NAME] (antidepressant) to 20 milligrams (mg)." *4/18/11 at 1630 (4:30 p.m.) "Resident was combative during w/p (whirlpool) this A.M. received skin tear to top of (R) right hand. Measures 4.0 cm long. Cleansed, steri-strips applied, covered with [MEDICATION NAME] wrap with kerlix, check daily until healed." *4/23/11 at 1545 (3:45 p.m.) "D/C (discontinue) treatment to (R) elbow. Area healed.". *4/25/11 at 1530 (3:30 p.m.) " Resident received skin tear (to) right upper arm, measures 4.0 cm x 2.0 cm, cleaned with wound wash, apply bacitracian with [MEDICATION NAME] and herlix., wife updated on skin tear." *5/6/11 at 1430 (2:30 p.m.) "Hospice to evalueated resident orders received from physician." *5/15/11 at 11:00 a.m."Discontinue treatment to right (R) upper arm, Area healed." *5/27/11 at 11:00 a.m. "Certified nurse assistant (CNA) comes to this nurse and states resident left arm is bleeding. Resident observed to have two skin tears to (L) forearm, measures 1.0 cm and 0.9 cm, cleansed with wound wash applied steri strips, skin prep with opsite, change every 3 days and as needed. wife updated." *5/30/11 at 0100 (1:00 a.m.) "CNA notified nurse resident suffered a skin tear while removing resident's shirt. Nurse saw resident in bed. 1.2 cm skin tear noted below left elbow. geri sleeves were worn at the time of incident, cleansed area, opsite applied, physician notified." *5/30/11 at 6:30 a.m. Family and wife notified. *6/8/11 (late entry for 5/27/11) "Resident received skin tears to left forearm during transfer. Resident bumped arm on wheelchair." Review of resident 7's medical record and the June 2011 Treatment Flowsheet revealed he had orders for "Geri sleeves (to be worn) to bilateral arms at all times to prevent skin tears." The order was dated 12/04/09 and was open ended. Review of resident 7's care plan dated 3/22/11 revealed: *Problem: Alzheimers and behaviors. *Problem: Potential for skin breakdown. *Goal: No skin breakdown for 90 days. *Approaches included: Geri-sleeves at all times. Interview at 11:45 a.m. on 6/8/11 with the director of nursing revealed: *She was aware resident 7 had frequent skin tears. *She was aware his skin was very thin, and he had lost weight. *She thought they always had the Geri-sleeves on resident 7, *She was aware the Geri-sleeves were made of a thin material.and the resident could still get skin tears with the Geri-sleeves on. *She stated the staff had started using the Hoyer lift beginning in May 2011. They had moved the commode out into the room, since skin tears occurred often in the bathroom. *She was aware resident 7 had gotten skin tears on 5/27/11 and again on 5/30/11. *When asked what else they could do to prevent skin tears since the resident received skin tears while wearing the Geri-sleeves, she revealed: -She was aware there were heavier protective sleeves on the market. She thought they had thick padding and would not be so thin. -She had never considered them before, but she was willing to purchase and try them.