Every finding on record at Andbe Home, Inc

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen. Findings included:- On 05/05/26 at 08:18 AM, during the initial tour of the facility's kitchen, observation revealed the following;1. Dietary Staff (DS) BB prepared and served breakfast without a hairnet.2. The double-door stainless refrigerator had the following:A quart-size heavy whipping cream with an expiration date of 01/04/26.Deli-style sliced ham in a gallon-size bag with no open date and not sealed.A yellow-square sliced cheese stored in a gallon bag without an open date or expiration date.Three sausage patties and links were stored in a sandwich-sized bag without a label of contents or an open date.White round sliced cheese stored in a gallon-size bag without a label of contents or an open date.Shredded white and yellow shredded opened and taped shut without an open date.Swiss cheese slices were stored in a gallon-size bag without an open date.Oven-roasted deli-style turkey slices stored in a gallon-size bag without an open date.3. The fryer oil was dark and had debris floating on the surface.4. The floor of the walk-in freezer had a hash brown patty and a potato cube sitting on the floor.5. The walk-in refrigerator had three boxes, each containing four gallons of ice cream liquid/mix, stored directly on the floor, and a bag of lettuce, which had brown, slime-like contents.6. The metal shelving sitting outside the walk-in refrigerated, which stored fruit juices, was rusted throughout the surface of the shelves.7. The dry storage had cardboard boxes of potato chips sitting directly on the floor and a #10 can of Sloppy [NAME] sauce that was dented.8. The dry storage room shelving had vanilla icing labeled with the open date of 10/29/26.9. The floor baseboards and equipment throughout the kitchen had dark, blackish, greasy material surrounding the edges. On 05/05/26 at 08:30 AM, DS BB verified that food should be stored in a closed container and labeled with open dates. DS BB disposed of unlabeled items. On 05/06/26 at 11:33 AM, DS CC wore a hairnet that covered the top half of her head, with hair exposed on the lower half of her head. DS CC verified staff should have hairnets on while in the kitchen. Upon walking through the kitchen, the fryer continued with dark colored oil and debris floating on the top. The fryer baskets had crusty material attached. The plastic container on the shelf near the hot steam location, where clean cooking utensils were stored, was unclean and had food debris inside. In dry storage, a bottle of strawberry syrup had an open date of 07/05/25. The three steam table lids were unclean on the top surface. DS CC reported the cleaning schedule delegated to the kitchen staff should be followed and completed to maintain a clean sanitary kitchen. On 05/07/26 at 01:30 PM, Administrative Staff A verified the kitchen cleaning schedule should be followed. The facility's Food Storage policy dated 2019, documented that all foods should be off the floor, and all foods will be checked to ensure that foods will be consumed by their safe use-by dates. All foods shall be covered, labeled, and dated. The facility's Employee Sanitary Practices policy, dated 2019, documented employees will wear a restraint and clean and sanitize equipment and work areas after use. The facility's General Sanitation of the Kitchen policy, dated 2019, documented food and nutrition service staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

Based on observation, record review, and interviews. The facility failed to ensure their Quality Assessment and Assurance (QAA) Committee adequately identified deficient areas of practice to develop and implement appropriate plans of action to correct the deficient practices. Findings included: - The facility failed to provide the Medicare/Medicaid Coverage Liability Notice from 10055, and the form 10123 to the resident and//or representative regarding non-coverage of skilled services. Refer to F582. The facility failed to ensure a stop date for Resident (R)5 who had as-needed antianxiety medication without a 14 day stop date or a definitive stop date. Refer to F605. The facility failed to provide R23 or representatives with a bed hold notification when he was admitted to the hospital. Refer to F628. The facility failed to report R4's change of condition following an unresponsive episode and failed to follow up on charting after the incident. Refer to 684. The facility failed to assist R7, R14, and R31 in determining the root causes of the falls, failed to implement effective interventions, and lacked adequate investigation of the falls to prevent further falls and accidents. Refer to F689. The facility failed to provide nutritional care or notify the physician of R6's weight loss. Refer to F692. The facility failed to provide pre and post dialysis assessments for R41 , who received dialysis treatment, failed to have a contract with the dialysis center and failed to have a care plan for staff to follow for R41 who received dialysis. Refer to F698. The facility failed to wear hairnets, clean the kitchen, and discard unlabeled food. Refer to F812. The facility failed to complete and develop the facility assessment to determine what resources were necessary to provide cares and services completely during both day-to-day operations and emergencies for the 35 residents who reside in the facility, placing the residents at risk for inadequate care. Refer to F838. The facility failed to provide Enhanced Barrier Protection for R8, who had a foley catheter. Refer to F880. On 05/07/26 at 01:30 PM, Administrative Staff A stated the QAA meetings were held monthly and included the medical director. Administrative Staff A verified the deficiencies and confirmed the facility had not self-identified and corrected through performance improvement plans with monitoring done by the QAA committee. The QAPI policy, dated 2026, documented QAPI is the coordinated application of two mutually reinforced aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. The QAPI program would focus on outcomes of the residents' care and quality of life. The performance improvement plan is designed to be ongoing, comprehensive, and address the full range of care and services provided by the facility. The plan is designed to include all clinical care, quality of life, and resident choice.

Based on record review and interview, the facility failed to provide Resident (R)42 or their representative the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055 or the CMS Notice of Medicare Non-Coverage (NOMOC) form 10123, and failed to provide R6 and R7 with the CMS 10055 form. Findings included: - R42's skilled services ended on 12/26/25. R42 remained in the facility. Upon request, the facility was unable to provide evidence R42 received the CMS 10055 form and the CMS Form 10123. R6's skilled services ended on 03/26/26. R6 remained in the facility. Upon request, the facility was unable to provide evidence R6 received the CMS 10055 form. R7's skilled services ended on 02/03/26. R7 remained in the facility. Upon request, the facility was unable to provide evidence that R7 received the CMS 10055 form. On 05/06/26 at 03:50 PM, Administrative Staff A verified the facility did not provide R42 the CMS Form 10123 and the CMS Form 10055, and did not provide R6 and R7 with the CMS Form 10055. The facility did not provide beneficiary notification policy.

Based on observation, interview, and record review, the facility failed to obtain a stop date for three sampled residents, Resident (R) 13, R31, and R5, as needed (PRN) Ativan/lorazepam (a medication that calms and relaxes people). Findings included:- The Electronic Medical Record (EMR) for R13 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), violent behavior (the intentional use of physical force or power, either threatened or actual against oneself, another person, or a group), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required substantial staff assistance with toileting, bathing, and personal hygiene. R13 had physical and verbal behaviors and rejected care four to six days a week. R13's 04/02/26 Care Plan included the following interventions for R13: 03/20/26- Administer medications as ordered and chart refusals, allow her time in the Special Care Unit (SCU) to wander more freely without the risk of elopement. 03/31/26- Provide consistent staff as much as possible, rule out physiological causes for the behavior. If R13 resists care, stop, and try the task later. Do not force her to do the task unless necessary. Avoid rushing, abrupt changes in care, or environment, to prevent the frustration that results in agitation. Monitor her mood and response to the medication and monitor for drug use effectiveness and adverse effects. The Physician's Order, dated 04/07/26, directed staff to administer Ativan, 0.5 milligrams (mg), three times a day PRN for violent, aggressive behaviors. The order lacked a stop date for the PRN Ativan. On 05/06/26 at 08:00 AM, R13 ambulated up and down the hall in the SCU. Certified Medication Aide (CMA) R stated that R13 had a lot of behaviors and would scream, stating she was going to kill us or that the staff would kill her. As CMA R stated this, R13 walked by and stated, Can you do that to my son? CMA R stated that R13 often paced the hallway, and they tried to keep the other residents' door shut so she would not go in and out of the room. CMA R stated R13 had scheduled and PRN Ativan that they administered to her. On 05/05/26 01:00 PM, Administrative Nurse D stated she could not find any response from the physician regarding the Ativan stop date and would contact the physician. On 05/07/26 at 10:00 AM, Licensed Nurse H stated R13 had a lot of behaviors and would often refuse her medications, but they continued to try to get her to take them. LN H stated she had scheduled Ativan and had a prn Ativan they could administer to her. The facility's Psychotropic Medication Use policy, undated, documents that psychotropic medications are not prescribed or given on a PRN basis unless that medication was necessary to treat a diagnosed, specific condition that was documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it was appropriate to extend the prn order beyond the 14 days, he or she would document the rationale for extending the use and include the duration for the prn order. - The Electronic Medical Record (EMR) for R31 documented diagnoses of memory deficit, pain, muscle weakness, and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. R31 was independent with transfers and mobility, and transfers. R31 had no behaviors, wandered daily, and received an antianxiety (a class of medication that calms and relaxes people). The Annual MDS dated 03/14/26, documented R31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. R31 was independent with transfers and mobility, and transfers. R31 had inattention and disorganized thinking continuously, delusions, wandered daily, had no behaviors, and received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety medications. R31's 03/19/26 Care Plan documented the following interventions: 04/22/25- Attempt non-pharmacological interventions, monitor mood and response to the medication, monitor her behaviors, monitor medication for effectiveness, R31 will reside in the Special Care Unit (SCU) 09/29/25- Administer medications as ordered and monitor adverse reactions. The Physician Orders, dated 04/23/25, directed staff to administer Ativan, 0.25 milligrams (mg), by mouth, three times a day PRN for anxiety. The order lacked a stop date for the PRN Ativan. On 05/05/26 at 12:13 PM, R31 sat in a recliner in the SCU watching television. She was pleasant to the staff and other residents. On 05/05/26 at 03:30 PM, Administrative Nurse D stated the physician had provided a stop date when the pharmacist made the recommendation, but the stop date was never documented in the EMR. On 05/06/26 at 07:45 AM, Certified Medication Aide (CMA) R stated R31 could have behaviors at times, and staff redirected her. CMA R said R31 did not usually have aggressive or violent behaviors, but if needed, she had medication staff could give her. On 05/07/26 at 10:00 AM, Licensed Nurse (LN) H stated R31 had PRN medication that could be given for any behaviors. The facility's Psychotropic Medication Use policy, undated, documents that psychotropic medications are not prescribed or given on a PRN basis unless that medication was necessary to treat a diagnosed, specific condition that was documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it was appropriate to extend the prn order beyond the 14 days, he or she would document the rationale for extending the use and include the duration for the PRN order. - R5's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, irrational fear). R5 Quarterly Minimum Data Set (MDS) dated [DATE], recorded R5 had moderately impaired cognition. The MDS recorded that she required staff assistance with bed mobility and transfers. The MDS documentation R5 received an antianxiety medication during the observation period. R5's Care Plan, dated 04/10/26, recorded R5 required staff assistance with activities of daily living (ADL) care. R5's Care Plan documented the resident received lorazepam (antianxiety medication) and staff would observe for side effects and effectiveness. R5's Physician's Order, dated 04/08/26, directed the staff to administer lorazepam 0.5 milligrams (mg) PRN. The order lacked a stop date. R5's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam. On 05/06/26 at 08:30 AM, R5 sat in a wheelchair at the dining room table. Certified Medication Aide (CMA) R administered the resident's medication. On 05/05/26 at 02:25 PM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 04/08/26. Administrative Nurse D verified the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rationale. The Psychotropic Medication Use policy dated July 2022 documented residents would only receive antipsychotic medications to treat a specific condition. Considerations of the use of any psychotropic mediation is based on comprehensive review of the residents, that includes evaluation of the residents' signs and symptoms in order to identify underlying causes. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosis specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days; he or she will document that rationale for extending the use to include the duration of the PRN order.

Based on observation, interview, and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for Resident (R) 38. Findings included:- The Electronic Medical Record (EMR) for R38 documented diagnoses of fracture of the upper end of the left humerus (broken upper arm), displaced fracture of the distal phalanx of the right ring finger (broken finger), and pain. The admission Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition. R38 required substantial staff assistance with toileting hygiene, showers, and lower-body dressing. R38 required partial staff assistance for upper body dressing, personal hygiene, mobility, and transfers. R38 had upper and lower functional impairment on one side. The Quarterly MDS, dated 01/05/26, documented R38 had intact cognition. R38 required partial staff assistance for upper body dressing, showers, and mobility. R38 required supervision with transfers, toileting hygiene, mobility, and ambulation. R38 had upper and lower functional assessment on one side. R38's 02/27/26 Care Plan documented the following interventions: 10/02/25- Administer medications as ordered and offer non-medicated pain relief measures. 10/06/25- R38 would work with therapy five times a week, and staff will assist with all her care. Encourage her to do as much as possible independently, and when she can't, let staff assist with it. 10/13/25- R38 will rehab at home as soon as she can take care of herself. The Nurse's Note, dated 02/26/26 at 03:42 PM, documented that staff received an order for R38 to be discharged to home in the current condition with an immobilizer (a device or apparatus used to restrict or eliminate the movement of a specific body part in place. The Nurse's Note, dated 02/28/26 at 11:40 AM, documented R38 signed the inventory list and left the facility with her medications R38's EMR lacked a complete recapitulation of her stay in the facility. On 05/06/26 at 11:50 AM, Administrative Nurse D stated the nurses usually did the recapitulation but confirmed she was unable to find one. Upon request, a policy for recapitulation or discharge summary was not provided by the facility. - The Electronic Medical Record (EMR) for R23 documented diagnoses of hydrocephalus (excessive accumulation of fluid within cavities of the brain, the excess fluid puts harmful pressure on the tissues of the brain,) chronic kidney disease (moderate decline in kidney function), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and atherosclerotic heart disease ( a buildup of fats, cholesterol, and other substances in an don the artery walls). The admission Minimum Data Set (MDS), dated [DATE], documented R23 had moderately impaired cognition. R23 required staff set up assistance with oral and personal hygiene and atrial to moderate assistance with toileting. R23's Care Plan, dated 02/18/26, directed staff to assist R23 as needed. R23 ambulated with a standard walker in the hallways and was independent with transfers and ambulation. R23's Progress Notes dated 01/30/26 at 10:31 AM, documented R23 was out of the building with a family member for a procedure. R23's Progress Notes dated 02/02/26 at 03:08 PM, documented R23 would have a shunt placed on 02/03/26 and be in the hospital for three days for adjustment as needed. R23's Progress Notes dated 02/18/26 at 09:30 AM, documented R23 returned from the hospital for skilled care. R23 ambulated with a front wheeled walker. R23's clinical record lacked evidence that a copy of the bed hold policy was provided to the resident or representative when he was transferred to the hospital. On 05/06/26 at 07:45 AM, observation revealed R23 ambulated from his room to the dining room with a walker, dressed in street clothes and nicely groomed. On 05/06/26 at 11:50 AM, Administrative Staff A stated they should have had a bed hold notice provided to R23 or the representative before discharge to the hospital, and stated the resident went to a doctor's appointment, then was admitted to the hospital for elevated blood pressure. Administrative Staff A confirmed the facility did not provide the bed hold upon his admission to the hospital. Upon request, the facility lacked a Bed Hold Notification policy.

Based on observation, interview, and record review, the facility failed to apply the standards of practice as related to a change of condition for Resident (R) 4, who had a history of vasovagal response (a reflex of the involuntary nervous system that causes a sudden drop in heart rate and blood pressure, often leading to fainting or lightheadedness) when staff failed to follow the care plan on the use of a full-body mechanical lift and instead used a sit-to-stand lift. R4 lost consciousness and staff failed to contact the physician or family and did not assess R4 after the initial incident. Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of hypotension (low blood pressure, dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin) type two, chronic kidney disease (long term condition where kidneys are damaged and gradually lose their ability to filter waste, toxins, and excess fluid from the blood), and hypertension (high blood pressure).The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 was dependent upon staff for transfers, lower body dressing, and toileting hygiene. R4 had no upper or lower functional impairment and did not ambulate.R4's 03/04/26 Care Plan documented the following interventions:05/28/21- Administer medication as ordered and monitor for any adverse reaction.03/09/26- Transfer R4 with two staff and a full lift (total body mechanical lift) until further notice. Physical therapy will work with R4 due to weakness and strengthening. R4's Care Plan lacked documentation to direct staff should R4 have a vasovagal response.The Physician Orders, dated 04/16/26, directed staff to administer metoprolol (a blood pressure medication), 25 milligrams (mg), by mouth, twice a day, for hypertension.The Nurse's Note, dated 04/16/26 at 03:39 PM, documented that the physician came for rounds and was unable to figure out what caused R4's vagal responses, as nothing cardiac showed. R4 took medication for high blood pressure that can cause orthostatic hypotension, so the medication dose would be cut in half. Staff would monitor the resident's blood pressure and pulse and then report to the physician. If her blood pressure remained managed, then the physician would discontinue the medication and readdress using the sit-to-stand lift (a motorized or hydraulic mobility device that helps individuals with limited lower-body strength transition safely from a seated to a standing position), but would only use the full lift until the sit-to-stand lift was deemed safe.The Nurse's Notes, dated 04/25/6 at 12:27 PM, documented that staff called a nurse into R4's room. The resident passed out on the sit-to-stand. She had a large, loose bowel movement; her vital signs were obtained and were normal for baseline. The note stated R4's lungs were clear in all lobes, and the nurse would monitor R4. The nurse asked R4 to squeeze her hands bilaterally, and she was weak on both sides. R4 slowly came around and was able to state her full name. R4 was able to drink a juice supplement independently, but fell asleep every time she was woken up. The Vital Signs report for 04/25/26 documented the following blood pressures:04/25/26 at 12:22 PM- 112/8304/25/26 at 05:55 PM- 108/62The EMR lacked documentation of further follow-up charting regarding the incident.On 05/6/26 at 07:50 AM, Licensed Nurse (LN) G stated staff used to call the physician after R4 passed out, but it had become normal, so they stopped. LN G stated she did not have any documentation that the physician did not want to be called, but she does not call because it happened so frequently. LN G further stated the Certified Nurse Aides (CNAs) took it upon themselves to use the seat to stand when R4 was supposed to have a full lift for transfers, and R4 passed out. LN G stated that there should be follow-up charting after R4 passed out. On 05/06/26 at 11:30 AM, R4 sat in her wheelchair in her room. She stated she preferred surveyors not watch her transfer. On 05/06/26 at 11:45 AM, CNA N stated the CNA staff had been using the full lift for R4's transfers because she had passed out when they used the sit-to-stand lift. On 05/06/26 at 03:45 PM, Administrative Nurse D stated that staff were to use the full lift for transfers; when R4 passed out on the sit-to-stand lift, it was considered a change in condition, and the nurse was supposed to contact the physician and continue to take R4's blood pressure every 30 minutes. Administrative Nurse D said the nurse should also be monitoring and charting for several days after the event. Administrative Nurse D further stated that there should be documentation in R4's plan of care regarding the vasovagal episodes to provide directions to staff on what they should do when she has an episode.The facility's Change in a Resident's Condition or Status policy, dated 02/21, documented that the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would call the physician if there were a significant change in the resident's physical/emotional/or mental condition, an accident or incident involving the resident, or if there is a need to transfer the resident to a hospital or treatment center. The nurse will record in the resident's medical records relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record, the facility failed to accurately investigate a root cause and implement effective interventions to prevent falls for Residents (R) 7 and R31, who had numerous falls. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of unspecified dislocation of the hip, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and syncope (fainting or passing out) and collapse. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R7 had intact cognition, functional range of motion impairment on one side of the upper and lower extremities, and utilized a wheelchair for mobility. The MDS lacked documentation of R7's functional abilities. The MDS further documented that R7 received a scheduled pain medication regimen, as-needed (PRN) medication, and non-medication interventions for pain. R7 had almost constant pain and a fall the previous month. R7 received occupational and physical therapy services. R7's Care Plan dated 04/20/26, documented R7 was at risk for falls, had a potential alteration in the ability to perform activities of daily living (ADL) related to weakness and urinary incontinence, with the following documented approaches: On 11/21/25, ensure R7 was wearing proper, non-skid, well-maintained footwear. Keep the call light in reach at all times. Provide an environment free of clutter. On 01/03/26, R7 was sent to the emergency room related to falling and re-dislocating the hip. No changes to the care plan at that time. On 01/17/26, R7 had right hip precautions. The directed R7 not to cross legs, move leg backwards, and point toe out to the side. Do not turn from the operative leg with foot planted. Two staff assist with a full lift, do not ambulate. R7's knees give out at random times, then fall. On 01/21/26, have an abductor pillow/brace/ball in place at all times except when bathing. On 01/22/26, nursing will check and change at night during rounds per R7 request. R& was not to be taken to the bathroom at night. On 01/25/26, exit alarm at all times, and check to make sure each shift is functioning properly. On 01/29/26, no plastic chucks in the recliner or wheelchair. Use the commode in the room instead of the toilet to limit backward stepping. On 02/09/26, 30-minute safety checks, place a noodle (round Styrofoam tube) at the outer edge of the bed, and a full mattress next to the bed as an extension. On 04/17/26, staff will transfer with two-person assistance and a full lift. The Progress Note dated 01/03/26 at 02:09 AM documented staff taking R7 to the toilet. R7 was not standing or walking. Another staff member came to help and used the sit-to-stand lift when R7's foot came off the foot stand. Staff tried to get the foot back on the stand, but R7 started to sit down and was lowered to the floor. The nurse came to the room, and R7 was lying on the floor, and the right leg looked like the letter L backwards, as if the hip was popped out of the socket. R7 screamed when staff touched the leg and hip. R7 was sent to the emergency room. The Fall Investigation documented the incident as isolated, with no harm factors having contributed, with a summary as a witnessed fall, lowered to the floor by staff after R7's foot came off the foot stand of the lift. Active range of motion (AROM) to upper and lower extremities at baseline. The care plan was reviewed, and an adjustment for fall prevention was added to the care plan. The fall investigation lacked root cause analysis. The Progress Note, dated 01/17/26 at 11:07 AM, documented that staff walked R7 to her bed when her knees went out on her. Staff lowered R7 to the floor in front of the bed. R7 was not hurt, and the new intervention at the time was to pivot transfer to a wheelchair and then take her to where she needed to go. The Fall Investigation Note documented R7 had a witnessed fall, no harm, and transfer status of two staff with a sit-to-stand lift or two-person pivot transfer. AROM to the upper and lower extremities at baseline. The intervention of the care plan was reviewed, and adjustments for fall prevention were added to the care plan. The fall investigation lacked root cause analysis. The Progress Note dated 01/20/26 at 03:49 PM, documented that occupational therapy staff notified the nurse that R7 believed her hip was dislocated and R7 wanted to be evaluated by a doctor. The nurse was then told that the staff was assisting R7 to the toilet when R7 was lowered to the floor to prevent a fall. R7 was assisted by two staff from the floor to the toilet, then assisted by occupational therapy staff and two staff to the wheelchair. R7 left with the emergency medical service (EMS). The Fall Investigation documented that R7 had a witnessed fall, no harm, and the event was ongoing. No factors in the facility had contributed to concern. R7 transfer status of two staff with a sit-to-stand lift or a two-person pivot transfer. R7 was lowered to the floor when staff attempted to pivot transfer to the toilet, and R7 became weak. AROM to both lower and upper extremities with R7 at baseline. The intervention was a review of the care plan and adjustments for fall prevention added to the care plan. The fall investigation lacked root cause analysis. The Progress Note dated 01/29/26 at 07:22 AM, documented that R7 was attempting to recline in the recliner and hit the wrong button, causing the chair to go to a standing position, and R7 slid onto the floor. Upon assessment, R7 had an internal rotation of the right leg. R7 left the facility with EMS. The Fall Investigation documented an unwitnessed fall, no harm ongoing event, transfer status two staff with a sit-to-stand lift or two-person pivot transfer. The motion chair was elevated, and the resident slid down to the floor. AROM to both upper and lower extremities. The right lower extremity abduction brace was unfastened, and the right lower extremity was misaligned. EMS was notified, and R7 was transferred for a reduction of the right lower extremity. The intervention of the care plan was reviewed, and adjustments for fall prevention were added to the care plan. The fall investigation lacked root cause analysis. The Progress Note dated 02/08/26 at 09:43 PM documented R7 lying on her left side on the floor. R7 reported rolling out of bed. No external rotation to lower extremities, and R7 was able to move all extremities without complaints of pain. A pool noodle was put under the edge of the sheet, and a fall mat was put on the floor next to the bed. The Fall Investigation documented an unwitnessed fall, no harm, and an ongoing event. R7 reported rolling over and falling out of bed. Head-to-toe assessment by nurse, AROM to both upper and lower extremities, abduction (movement of a limb away from the body) device in place, no apparent injuries. Three staff assisted from the floor and returned to bed. The intervention of the care plan was reviewed, and adjustments for fall prevention were added to the care plan. The fall investigation lacked root cause analysis. The Progress Note dated 05/01/26 at 02:50 AM, documented at 11:30 PM, R7 was noted on her knees next to the bed, holding onto the bed rail. R7's room was rearranged due to R7's history of rolling out of bed. No injuries were noted, and staff transferred her back into bed. Upon request, no Fall Investigation was provided for the fall on 05/01/26. On 05/05/26 at 02:37 PM, R7 sat in her room in a recliner with the foot of the chair elevated. She was covered with a blanket and had her eyes closed. She had a mattress on the floor beneath the elevated footrest, and the call light was attached to chair. On 05/07/26 at 07:30 AM, Certified Nurse Aide (CNA) M reported staff used the alarm, took R7 to activities, and used a full body lift for all transfers to prevent falls. CNA M said staff also ensured a brace to R7's right leg was in place at all times, ensured the fall mat was in place, and made sure the resident was in bed or recliner when in the room with the fall mat on the floor to prevent falls. On 05/07/26 at 08:00 AM, Licensed Nurse (LN) G reported the staff stopped using the sit-to-stand lift and used a full-body lift for transfers for R7. LN G said staff had also tried multiple braces to the right leg, and were careful when transferring R7, ensuring she was in bed or the recliner with a fall mat on the floor. On 05/07/26 at 11:30 AM, Administrative Nurse D reported that the facility did not utilize a root cause analysis related to falls, and the facility did not have a structured fall committee or investigations related to falls. Administrative Nurse D verified that some of R7's interventions were repeated and not effective for the prevention of falls. The facility's Assessing Falls and Their Causes policy, dated 03/2018, documented falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence, including medical history, known functional impairments, etc. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. - The Electronic Medical Record (EMR) for R14 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), repeated falls, restlessness, and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Quarterly Minimum Data Set (MDS, dated [DATE]) documented R14 had long and short-term memory problems with severely impaired decision-making skills. R14 required staff assistance with transfers and was independent with mobility and transfers. R14 had upper functional impairment on both sides, wandered daily, and did not have any falls. The Quarterly MDS, dated 02/26/26, documented R14 had long and short-term memory problems with severely impaired decision-making skills. R14 required substantial staff assistance with transfers and was independent with mobility and ambulation. R15 had upper functional impairment on both sides, wandered daily, and had one non-injury fall. The Fall Risk Assessments, dated 05/22/25, 07/15/25, 08/22/25, 10/20/25, 11/11/25, 02/22/26, and 02/27/26 documented R14 was at risk for falls. R14's 02/18/26 Care Plan included the following interventions for R14: 09/28/21- 30-minute safety checks, provide R14 with an environment free of clutter, always keep the call light within reach, and ensure she wears proper nonskid, well-maintained footwear. 06/23/24- Place a pool noodle in bed at nighttime and place bed in the lowest position. 11/20/24- 30-minute safety checks, ensure she wore shoes and slipper socks while resting in bed. 07/15/25- shut her closet doors. 08/12/25- no changes to the care plan. 10/20/25- Maintenance will fix the bed or change out the bed. 11/11/25- no changes to the care plan. The Fall Investigation, dated 07/15/25 at 08:35 PM, documented that R14 was on the floor in her closet with her legs outstretched. The fall was unwitnessed, and R14 could not give a description of what she was doing. R14 was assessed, and no injury was found. The Fall Investigation, dated 08/12/25 at 07:51 AM, documented R14 walked with staff in the TV room and started to sit down before she reached her recliner. Staff lowered R14 to the floor. The Fall Investigation, dated 10/20/25 at 05:15 AM, documented R14 sat on the edge of the bed as staff tried to change her soiled shirt. R14 started to get combative with the staff, and she slid off the bed. R14 did not sustain any injury and was assisted by staff. The Fall Investigation, dated 11/11/25 at 11:31 PM, documented R14 was found on the floor in her room. R14 could not give a description of what she was doing. R14 was assessed, and no injury was found. The Fall Investigation, dated 11/26/25 at 04:33 PM, documented R14 was on the floor in her room in front of the closet. R14 could not give a description of what she was doing. R14 was assessed, and two staff members assisted her off the floor and placed her in her recliner. The Fall Investigation, dated 02/27/26 at 01:38 PM, documented Staff lowered R14 to the floor to prevent her from slipping from a dining room chair to the floor. R14 was assessed and did not sustain any injury. The Fall Investigation, dated 04/28/26 at 04:19 PM, documented R14 appeared to have fallen asleep in a recliner in the TV room and fell forward out of the recliner. R14 sustained an abrasion on her forehead. Staff assisted R14 off the floor. On 05/06/26 at 08:15 AM, R14 independently ambulated down the hall to go to the dining table for breakfast. On 05/06/26 at 07:45 AM, Certified Medication Aide (CMA) R stated R14 was independent with transfers and ambulation. CMA R stated R14 had fallen, did not know what fall interventions were in place for her, but staff walked with her as needed. On 05/07/26 at 10:00 AM, Licensed Nurse (LN) H stated she had a recent fall that they had charted on last week. LN H said she thought R14 had a bed alarm, but was not sure what fall interventions were in place for R14. On 05/07/26 at 11:14 AM, Administrative Nurse D stated there was no fall committee to go over interventions for falls. She stated she did the investigations but did not do root cause analysis when there was a fall. The facility's Assessing Falls and Their Causes policy, dated March 2018, documented if the resident had a fall, staff try to identify possible or likely causes of the incident o likely causes of the incident. The facility would continue to collect and evaluate information until the cause of the fall was identified or it was determined that the cause could not be found. After a fall, the resident's family, physician, and director of nursing would be notified. - The Electronic Medical Record (EMR) for R31 documented diagnoses of memory deficit, pain, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. R31 was independent with transfers and mobility, and transfers. R31 had no upper or lower functional impairment, wandered daily, and had no falls. The Annual MDS dated 03/14/26, documented R31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. R31 was independent with transfers and mobility, and transfers. R31 had no upper or lower functional impairment, wandered daily, and had one fall with injury. The Fall Risk Assessment, dated 09/13/25, 11/19/25, 12/14/25, and 03/12/26, documented R31 was at risk for falls. The 03/19/26 Care Plan included the following interventions for R31: 03/07/25- Always keep call light in reach, ensure she wears proper, non-skid, well-maintained footwear. 04/16/25- Provide her with an environment free of clutter. 04/20/25- 30-minute safety checks 11/19/25- No changes to the care plan at this time. 03/16/26- Remove all regular socks from the room and replace them with slipper socks. The Fall Investigation, dated 11/19/25 at 5:03 PM, documented R31 had an unwitnessed fall after she attempted to sit in her wheelchair that was full of books. R31 stated she tried to sit for a minute and slid out of the wheelchair. R31 did not sustain any injury, and her wheelchair was removed from her room. The Fall Investigation, dated 03/12/26 at 04:32 AM, documented that staff heard someone screaming for help. R31 was on the floor in front of her chair and stated she tried to grab her shoes and slid off the bed. R31 had a large lump on the right side of her forehead and complained of pain in her neck and back. R31 was sent to the hospital for an evaluation. R31 returned to the facility without new orders. On 05/05/26 at 12:10 PM, staff walked beside R31down the hall to the dining room table. On 05/06/26 at 07:45 AM, Certified Medication Aide (CMA) R stated R31 has had recent falls, and they told her to try to call for assistance when she ambulated. When asked if she was oriented enough to remember to call, CMA R stated that it depended upon the day On 05/07/26 at 10:00 AM, Licensed Nurse (LN) H stated R31 had not had any recent falls that she was aware of and was not sure what fall investigations were in place for R31. On 05/07/26 at 11:14 AM, Administrative Nurse D stated there was no fall committee to go over interventions for falls. She stated she does the investigations, but does not do root cause analysis when there is a fall. The facility's Assessing Falls and Their Causes policy, dated March 2018, documented if the resident had a fall, staff try to identify possible or likely causes of the incident o likely causes of the incident. The facility would continue to collect and evaluate information until the cause of the fall was identified or it was determined that the cause could not be found. After a fall, the resident's family, physician, and director of nursing would be notified.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 6 received the necessary care and services to prevent an ongoing insidious weight loss when staff failed to notify the physician of the weight loss and failed to ensure the physician received the dietician's recommendations for an appetite stimulant. Findings included:- R6's Electronic Medical Record (EMR) included diagnoses of dehydration, low back pain, repeated falls, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypokalemia (low level of potassium in the blood), and heartburn. R6's admission Minimum Data Set (MDS), dated [DATE], documented that R6 had severe cognitive impairment, hallucinations (sensing things while awake that appear to be real, but the mind created), and delusions (untrue, persistent belief or perception held by a person although evidence shows it was untrue). R6 utilized a walker and wheelchair for mobility and required supervision/touching assistance with eating, personal hygiene, upper-body dressing, bed mobility, and lying-to-sitting on the edge of the bed. R6 required partial/moderate assistance with sit-to-standing, bed-to-chair transfers, and walking ten to 50 feet. R6 was 60 inches tall, weighed 87 pounds (lbs.), and had one stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters). The MDS further documented that R6 received an antidepressant (a class of medications used to treat mood disorders). The Nutrition Care Area Assessment (CAA), dated 03/10/26, lacked an analysis or summary. R6's Nutritional Status Care Plan dated 03/12/26, directed staff to encourage R6 with adequate fluid intake at meals and ensure fresh water in the room, encourage eating meals in the dining room, and off-menu selections daily. The plan noted R6 was on a regular texture diet as tolerated, and directed staff to weigh weekly. The Physician Order dated 03/03/26, documented R6 had a regular soft-texture diet as tolerated with regular fluids with meals. The Registered Dietitian (RD) Progress Notes dated 03/04/06, documented R6 had been admitted on [DATE], had a height of 60 inches, and weighed 87.6 lbs. R6's food preferences included orange juice, coffee, and Coke. R6 had very few food dislikes and reported liking food. The RD suggested adding a 120 cubic centimeter (cc) protein supplement drink twice a day. The protein supplement had been implemented. The RD Nutritional Progress Note dated 03/18/26, documented a follow-up to the initial nutritional assessment, that R6's weight on 03/11/26 was 80 lbs., down 8.7%. The RD suggested increasing the protein supplement drink to three times a day and adding 120 cc of Gelatin (a high protein, ready-to-eat gelatin supplement) at lunch. These RD's suggestions had been implemented. R6's EMR lacked evidence staff notified the physician of the weight loss. The RD Nutritional Progress Note dated 04/01/26, documented a follow-up to the 03/18/26 regarding weight status. The note documented that R6 had been refusing the Gelatin. R6's current weight was 73.2 lbs., a weight loss of 14.6 lbs. The RD suggested increasing the protein supplement drink to four times a day.R6's EMR lacked evidence staff notified the physician of the continued weight loss.The RD Nutritional Progress Note dated 04/15/26, documented R6's current weight was 73.2 lbs. R6 ate 1-25% of meals and ate more than that at times, but also ate nothing at other meals. The RD documented consideration of whether the physician desired to try medication to increase appetite, noting poor intake and weight loss. The EMR, dated 04/29/26, recorded R6's weight of 69.4 lbs., a 20.6% weight loss since admission on [DATE].R6's EMR lacked physician notification of the continued significant weight loss, a reevaluation, or new recommendation from the RD. On 05/06/26 at 10:20 AM, R6 remained in bed with her eyes closed and in night clothing. On 05/06/26 at 10:45 AM, Licensed Nurse (LN) I reported R6 had refused earlier attempts to eat breakfast or get out of bed. LN stated the resident was awake at night quite a bit. LN I did not know if R6 was offered anything to eat or if care plan interventions addressed weight loss. LN reported R6 would drink the supplement while taking her medication in the morning. On 05/06/26 at 11:37 AM, Dietary Staff CC reported she usually tried to review the weights and attempted to be part of the care plan team, but recently had not been able to due to staffing issues in the kitchen. Dietary Staff CC reported the facility did not have an always-available menu, and the alternative menu consisted of what may have been left over from the previous day's menu, but staff could offer sandwiches to residents if the residents did not like what was on the menu. Dietary Staff CC could not verify if staff offered R6 alternatives or snacks. On 05/06/26 at 11:39 AM, Consultant Staff GG reported coming to the facility every other week, reviewing weights, and making recommendations as needed. Consultant Staff GG verified R6 had significant weight loss and verified she had made recommendations. Consultant Staff GG reported it was the responsibility of the nursing staff to notify the physicians of significant weight loss and recommendations so could not say if R6's physician had been notified of the continued significant weight loss. On 05/06/26 at 01:17 PM, Certified Nurse Aide (CNA) N reported R6 enjoyed going to a local restaurant with a friend and would eat well there. CNA stated R6 would eat poppers and hamburgers. On 05/06/26 at 03:49 PM, Administrative Nurse D verified R6's physician had not been notified of continued significant weight loss. Administrative Nurse D confirmed R6's care plan lacked resident-centered interventions including R6's preferences. Upon request, the facility did not provide a weight loss policy.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 41 received care and services for dialysis (a procedure where impurities or wastes are removed from the blood) consistent with professional standards of practice, which included a contract for service, nursing assessments, or ongoing communication and collaboration with the dialysis facility. Findings included:- R41's Electronic Medical Record (EMR) documented diagnoses of chronic hypertensive(elevated blood pressure) heart disease, end-stage renal disease (ESRD-a terminal disease of the kidneys), depressive disorder, stage three pressure ulcer (full-thickness pressure injury extending through the skin into the tissue below) to the sacral (large triangular bone/area between the two hip bones) region, and shock. R41's admission Minimum Data Set (MDS), dated [DATE], documented that R41 had intact cognition. R41 had functional range of motion impairment of the upper extremity on one side and required substantial/maximal assistance with toilet hygiene, lower body dressing, and personal hygiene. R41 required supervision/touch assistance with bed rolling, sit to lying on the side of the bed, chair/bed to chair transferring, and walking ten to 50 feet. R41 was continent of urine and bowel, had occasional pain and shortness of breath. The MDS further documented that R41 had difficulty or pain with swallowing. R41 had nutritional approaches and had a pressure ulcer. She received an anticoagulant, opioid, and antidepressant medications. The MDS lacked coding for dialysis in special treatment or procedures. The Care Area Analysis (CAA), dated 04/28/26, lacked an analysis or summary of findings for all triggered areas. R41's Care Plan dated 04/30/26, documented that she had end-stage renal failure and dialysis. The care plan directed staff R41 had a 1.5-liter fluid restriction in 24 hours. It instructed staff to keep the port clean, dry, and covered and to follow recommendations and instructions from dialysis. Staff was to obtain a weight on Monday, Wednesday, and Friday before leaving for dialysis, and to send evening medications. The care plan lacked interventions related to access site assessment, the location of the dialysis center, the appointment (chair) time, and the specific instructions for allocation of fluids between the dietary and nursing departments. The Physician Order dated 04/23/26, directed staff to weigh R41 before the dialysis appointment, put the weight on the paperwork, and to get the evening medications ready, then place them in a to-go envelope on Mondays, Wednesdays, and Fridays for diagnosis of end-stage renal disease. The Physician Order dated 04/29/26, directed staff to record intake at the end of each shift related to a fluid restriction of 1.5 liters every 24 hours. The Physician Order, dated 05/04/26, directed staff to increase the fluid restriction to two liters in 24 hours. R41's Physician Orders lacked a specific dialysis facility that R41 was attending. The Progress Note dated 04/21/26 at 02:24 PM, documented R41 admitted to skilled care for physical and occupational therapy following hospitalization for end-stage renal failure, cardiac failure, and shock. R41 will do hemodialysis (a procedure where impurities or wastes are removed from the blood) three days a week in Nebraska, where her significant other or family would take her. R41 was on a renal diet with a 1.5-liter fluid restriction, received wound care, and interventions were in place, including strict monitoring for infections since R41 had dialysis. The EMR had documented R41's weights before the dialysis appointment, but lacked documentation of an assessment of the dialysis port for signs and symptoms of infection and bleeding. The EMR fluid intake tracking revealed R41 had not reached the designated intake of fluid intake and/or restriction. On 05/06/26 at 08:59 AM, staff delivered a breakfast tray to R41's room, and reported R41 would be leaving for dialysis at 09:30 AM. R41 had a visitor in the room. On 05/06/26 at 11:59 AM, Dietary Staff (DS) CC reported R41 received room trays at mealtimes. DS CC reported the dietary department provided 400 milliliters (ml) for each meal, and the nursing department provided the remaining fluids of the fluid restriction. DS CC stated the nursing department was responsible for the documentation of the intake of residents who had room trays. On 05/06/26 at 09:03 AM, Licensed Nurse (LN) H reported R41's dialysis appointment was at 02:30 PM. LN H stated the facility sent a transfer form with R41's weights, vital signs, and any other changes to orders or condition. R41's family or significant other took R41 to the dialysis center but did not know the specifics of the dialysis center's address or phone number. LN H stated no communication was returned with the resident following the dialysis treatment or regarding the condition or tolerance of treatment. LN H was uncertain who was responsible for monitoring the fluid restriction total intake for 24 hours, and the nursing staff. On 05/06/26 at 03:16 PM, Administrative Nurse D verified R41's physician orders and care plan lacked dialysis-specific instruction for the related assessment of shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) care, signs and symptoms of infection, fluid delegation between the dietary and nursing staff, and conditions reported nursing staff should be tracking the fluid intake. On 05/06/26 at 03:50 PM, Administrative Staff A verified the facility lacked contractual services with the dialysis center, and lacked information related to where R41 had been receiving dialysis treatment following admission of R41to the facility. Upon request, the facility did not provide a dialysis policy.

Based on observation, record review, and interview, the facility failed to adhere to infection control procedures related to Enhanced Barrier Precautions (EBP -an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), when emptying the indwelling catheter for Resident (R)8. Findings included: - On 05/07/26 at 12:55 PM, observation revealed R8 sat in a wheelchair in his room. Certified Medication Aide (CMA) R entered the room and donned gloves only, no gown. CMA R cleansed the end of the R8's catheter tubing, drained the amber urine from the catheter collection bag into the urine collection container, then wiped off the catheter spout with alcohol. She replaced the end of the catheter spout and closed the clamp. CMA R then removed her gloves and washed her hands. Further observation revealed R8's room lacked a sign posted on the inside of the resident's room that provided instructions on EBP and the use of personal protective equipment (PPE - gown and gloves) when staff provided R8 catheter care. R8's room lacked the necessary PPE equipment, including gowns. On 05/07/26 at 10:30 AM, Administrative Nurse D verified that the staff should wear PPE when providing R8 with catheter care. Administrative Nurse D said the facility would post signage and provide the resident's rooms with PPE. Administrative Nurse D said she would provide education to the staff regarding EBP and when the staff should wear PPE for resident care. The facility's Infection Prevention and Control Program policy dated 2026, documented the facility would provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The Infection Prevention and Control program establishes a facility-wide system to prevent, identify, investigate, report, and control communicable diseases and infections among residents, staff, and visitors. The Infection Prevention Nurse would conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have a substantial impact on potential residents' outcomes, and that may require transmission-based precautions and other preventative measures.

Based on interviews and record review, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. Findings included: - On 05/05/26 at 10:00 AM, Administrative Staff A provided an undated Long-Term Care Self-Assessment. Review of the assessment revealed the assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse's Aide (CNA) needed for each unit, patient acuity, and census. The assessment also lacked staffing levels required for each shift to include evenings and weekends. The assessment did not document the staff competencies and skill sets necessary to provide the level and types of care needed for the specific resident populations and did not fully document any contractual agreements to outside providers for services available to residents in the facility for laboratory, radiology, therapy, hospital or transportation. On 05/07/26 at 09:10 AM, Administrative Staff A stated she had reviewed the assessment. Administrative Staff A stated staffing breakdown per unit should be completed and confirmed the assessment did not contain that information. Administrative Staff A confirmed the facility assessment lacked completion. She said she needed to work on the assessment and stated she would try to find some outside sources to help her with the review and update.Upon request, the facility lacked a Facility Assessment Policy.

The facility had a census of 34 residents. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the facility failed to ensure water temperatures in areas with resident access and in Resident (R)18, R17, R25, R1, and R4's rooms remained at a safe temperature when temperatures above 140 degrees Fahrenheit (F) were recorded. This common area and sink were open to the center hallway and accessible to any independently mobile residents. The facility identified seven independently mobile, cognitively impaired residents. This placed twelve residents in immediate jeopardy. The excessively high hot water temperatures of 128-139 degrees F were also recorded in resident room sinks, placing an additional seven residents at risk for burns. The facility failed to identify and implement interventions to prevent R8 from falling which placed the resident at risk of further falls and injuries. Findings included: - On 06/12/24 at 07:53 AM, observation revealed the water temperature of the center living room/cafe area sink was 152.6 degrees F by surveyor thermometer. On 06/12/24 at 08:00 AM, Certified Nurse Aide (CNA) N obtained a facility thermometer and tested the sink at 161 degrees F and verified the temperature was too hot. On 06/12/24 at 08:05 AM, an assessment of other resident room sink water temperatures were performed to ascertain the extent of the problem. The following sink water temperatures were found: R18's room measured 147 degrees F. R4's room measured 143.4 degrees F. R17's room measured 139.2 degrees F. R7's room measured 138.2 degrees F. R20's room measured 129.8 degrees F. R9's room measured 129.4 degrees F. R8's room measured 129.2 degrees F. R2's room measured 129 degrees F. R22's room measured 128.5 degrees F. R21's room measured 129 degrees F. R27's room measured 124.5 degrees F. R11's room measured 122.4 degrees F. On 06/12/24 at 08:07 AM, Maintenance Staff U stated the water heater that runs the north resident rooms, north shower bathroom, and common area quit working a couple of days ago, 06/09/24. He stated he opened the valve to the laundry heater to go through the resident hot water heater system. After switching the line, he stated he tested the common area but did not document that and did not test the common areas or resident rooms daily while the line was coming from the laundry heater. On 06/12/24 at 08:30 AM, Administrative Staff A was informed of the hot water temperatures, and she reported the maintenance person stated he repaired the resident hot water heater on 06/11/24 but had not turned the valve to stop the laundry water heater hot water from going to the resident lines. On 06/12/24 at 9:24 AM, R18 stated he had not noted the water to be too hot. On 06/12/24 at 09:38 AM, R31 stated she had no problems with hot water being too hot to touch. On 06/12/24 at 09:40 AM, R22 stated she had not had any issues with the water being too hot. On 06/12/24 at 09:44 AM, R17 stated her bathroom sink water was scalding hot, every morning when the girls (CNAs) get her up, she warns them to be careful the hot water temperature is really hot, because they let it run for a while, and one of them put her hand underneath it and told her she was right it was very hot. On 06/12/24 at 09:30 AM, Licensed Nurse (LN) H stated she had not noted any issues with the water being too hot and would inform maintenance if she thought the water temperature too hot. She stated no staff nor residents had complained about the water being too hot. On 06/12/24 at 09:50 AM, Administrative Staff A stated the maintenance person informed her he checked water temperatures weekly but did not document them. On 06/12/24 at 04:45 PM to 05:00 PM, Re-check of water temperatures indicated the following: R17's room measured 149 degrees F. R4's room measured 144 degrees F. R25's room measured 150.3 degrees F. R28's room measured 139.6 degrees F. R1's room measured 141 degrees F. On 06/12/24 at 05:00 PM, surveyors notified the administrator who checked the temperatures and verified they were still too hot for some of the rooms. She contacted the maintenance person who informed her there was a separate water heater for those rooms. The administrator stated she would ensure the heater was turned down or off immediately. On 06/12/24 at 05:45 PM, Administrative Staff A obtained water temperatures from resident rooms and all temperatures were below 114.2 F. The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) recorded temperatures at 124 degrees F can cause a third-degree burn (serious burn which affects the outer layer of skin as well as the entire layer beneath and requires immediate medical attention) in three minutes of exposure; temperatures at 127 degrees F can cause third degree burn with one minute of exposure; temperatures at 133 degrees F can cause third-degree burn in 15 seconds of exposure, and water temperatures at 140 degrees F can cause a third-degree burn in five seconds of exposure. The facility's Safety of Water Temperatures policy, dated 12/2009, stated the tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and shower areas would be set to temperatures of no more than 120 F. Maintenance staff were responsible for checking thermostats and temperature controls in the facility and recording those checks in a maintenance log. Maintenance staff would conduct periodic tap water temperature checks and record the temperatures in a safety log. If hot water temperatures felt excessive to the touch staff were to report that to the immediate supervisor. On 06/12/24 at 11:26 AM, Administrative Staff A received the Immediate Jeopardy Template and was informed the facility's failure to ensure the environment remained free of accidents when unsafe hot water temperatures were found in the handwashing sink in R18, R17, R25, R1, and R4's room, placing the five residents in immediate jeopardy related to potential burns from the hot water. Unacceptably hot water was also found in seven other resident rooms placing the twelve affected residents at risk for hot water related burns and/or injuries. On 06/13/24 the surveyor verified the following corrective actions to remove the immediacy: Maintenance Staff U immediately adjusted the valve on the hot water line so the excessively hot water for the laundry would not go into the residential hot water line which was set at 120 degrees F. The water heaters were adjusted to maintain an acceptable level between 105-120 degrees F. Education was provided to the maintenance supervisor of the water temperature requirements and documentation of auditing water temperature. Accident education was assigned to all staff to be completed by 08:00 AM Monday 06/17/2024. Medical Director was notified. The scope and severity remained at the level of E, after removal of the immediacy. 37450 - R8's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), chronic pain, chronic kidney disease, dementia (a progressive mental disorder characterized by failing memory, confusion), muscle weakness, difficulty in walking, and neurocognitive disorder (dysfunction with ability to think and reason). R8's Annual Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R8 rejected care four to six days of the observation period and had wandering behavior which occurred one to three days of the observation period, and behavioral symptoms that had worsened. R8 had no functional range of motion impairment and used a walker and wheelchair. R8 was independent with bed rolling, sitting on the edge of the bed, and sit-to-stand transfers, and required set-up assistance with walking 10 to 50 feet. The MDS further documented R8 was frequently incontinent of urine and bowel. R8 had two or more non-injury falls and used bed and chair alarms daily. R8 also received scheduled pain medication and took an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and an antiplatelet (medication used to slow blood from clotting). R8's Care Plan, dated 05/15/24, documented R8 was at risk for falls. The care plan direct staff R8 should have slipper socks on at night and a gripper strip placed beside the bed. The plan directed staff to ensure the alarm was with the resident at all times, functioning properly, plugged in and out of reach. The plan directed staff should strongly encourage the use of a call light, and keep the environment clutter-free with frequently used items within reach. R8 should use a wheelchair to go to meals. The Progress Notes and Investigation Notes documented the following falls: On 08/18/23 at 07:45 PM, staff were called to R8 rooms and found the resident sitting on the floor next to the bed. R8 reported he was getting up to go to the bathroom. The investigation, dated 08/19/23, documented the care plan was followed and remained appropriate, an exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 08/19/23 at 02:00 AM, R8's alarm sounded, and the resident was sitting on the floor next to the bed. R8 was incontinent of urine and reported he slipped on blankets. Staff assisted the resident to the bathroom. The investigation, dated 08/19/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 08/31/23 at 05:52 PM, R8's roommate told staff R8 had been leaving the bathroom, had a misstep, and fell . The facility failed to provide an investigation and the care plan lacked new resident-specific intervention related to the fall. On 09/10/23 at 11:13 AM, R8 reported heading to the bathroom and R8's feet got caught in the blanket causing the fall. The investigation, dated 09/20/23, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning. The care plan lacked a new resident-specific intervention related to the fall. On 10/03/23 at 04:20 AM, staff found R8 on the floor by staff. The note further documented the care plan was followed and the alarm was in place but did not sound when the resident got up. The investigation, dated 10/03/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 10/03/23 at 06:38 PM, R8 was lowered to the floor by staff while assisting to transfer to a wheelchair and fell on to his knees. The investigation, dated 10/03/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/06/23 at 03:30 AM, R8 had been getting up to use the bathroom and staff saw R8 lying on the floor. R8 reported he hit his head when he fell . The investigation, dated 11/06/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/15/23 at 03:29 PM, the nurse was called to R8 room where R8 fell on to his knees and then lowered himself onto his buttocks on the floor. R8 reported his knees were sore. The investigation, dated 11/15/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/19/23 at 02:16 AM, R8 got up to the bathroom, unplugged the bed alarm, and stood up. R8's roommate reported the fall and that R8 hit his head. The investigation, dated 11/19/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 12/29/23 at 03:41 PM, R8 was found on his hands and knees on the floor, leaning his head on his roommate's reclining chair. The investigation, dated 12/29/23, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 01/04/24 at 07:00 AM, R8 fell out of bed and the alarm sounded. The investigation, dated 01/04/24, documented the care plan was followed and remained appropriate, the exit alarm was in place and, functioning, and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 02/14/24 at 07:10 AM, R8 was sitting on the floor next to his bed. R8 reported he was getting up. The investigation, dated 02/14/24, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning, and R8 was noncompliant with interventions. A care plan update, dated 02/22/24, documented R8 had a room change to be closer to the nurse's station. On 02/20/24 at 07:56 PM, R8 was found on his hands and knees, next to the bed. R8 reported he was getting out of bed. The investigation on 02/20/24 documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning, and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 06/11/24 at 09:42 PM, observation revealed R8 remained in his room, in bed, leaning over to eat breakfast in bed. R8's bed was flat. R8 ate independently by leaning over to his left side. On 06/11/24 at 10:01 AM, Certified Nurse Aide (CNA) M reported to prevent falls for R8, staff were to make sure the alarms were in place. CNA M stated that R8 wore gripper socks and the staff checked on the resident frequently. On 06/12/24 at 10:08 AM, Licensed Nurse (LN) H reported staff could look over the care plan for intervention to prevent falls. LN H reported R8 had alarms which staff monitored to ensure function and properly placed. LN H verified R8 had numerous falls and the interventions were not changed and were not effective in preventing falls until R8 was moved closer to the nurse's station. On 06/12/24 at 04:02 PM, Administrative Nurse D verified new interventions should have been implemented to prevent falls for R8. Administrative Nurse D verified interventions were not always created or implemented. The facility's Falls-Clinical Protocol policy, dated 03/2018, documented the treatment and management the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions. The facility failed to identify and implement interventions to prevent R8 from falling which placed the resident at risk of further falls and injuries.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 34 residents who received their meals from the facility's kitchen. This placed the 34 residents at risk for foodborne illness. Findings included: - On [DATE] at 08:10 AM. observation revealed the nourishment refrigerator/freezer on the right lacked a thermometer. The second refrigerator on the left lacked a thermometer in the freezer and had an expired package of simply steamed cauliflower with an expiration date of [DATE]. On [DATE] at 08:10 AM, Certified Nurse Aide (CNA) O verified the finding above and stated dietary staff was responsible for placing the thermometers in the nourishment refrigerator/freezers and discarded the simply steam cauliflower. On [DATE] at 11:11 AM, observation in the kitchen revealed the following: The two-door silver fridge lacked a backup thermometer inside it. The fridge had two unlabeled. undated eggs in a plastic bowl, four slices of undated, unlabeled yellow cheese in plastic wrap. Dietary Staff (DS) CC verified the above findings and discarded the food items. An unlabeled, undated powered milk bin, noodle bin, and flour bin. Two ceiling vents, one by the entrance door and one above the cupboard had a gray fuzzy substance that flared onto the ceiling approximately four inches. On [DATE] at 03:00 PM, observation revealed staff passing uncovered bowls of ice cream on a cart in the facility halls. Certified Nurse Aide (CNA) Q verified the ice cream was uncovered and stated it should be covered. On [DATE] at 11:15 AM Dietary Manager (DM) BB verified the issues in the kitchen and stated staff should label and date all food items when placed in the refrigerator and the powered milk bin, noodle bin, and flour bind should be labeled and dated. On [DATE] at 02:00 PM, Dietary Manager (DM) BB verified the lack of thermometers in the nourishment room and stated nursing was responsible for obtaining them and placing them in the refrigerator/freezers, then they reported the temperatures to her. On [DATE] at 04:10 PM, Administrative Nurse D stated she would expect staff to cover food items when transporting them down the hall and nursing was responsible for placing thermometers in the nourishment center refrigerators. The facility's Cleaning and Sanitation of Dining and Food Service Areas Policy, revised [DATE], documented the food and nutrition services staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility's Food Storage Policy, documented that food would be stored in an area that is clean, dry, and free from contaminants. food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. food should be dated as it is placed on the shelves. Every refrigerator must be equipped with an internal thermometer. All foods should be covered, labeled, and dated. frozen food must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. The facility kitchen staff failed to prepare food in accordance with professional standards for food service safety when staff failed to cover bowls of ice cream when transporting them down the hall on the snack cart. The facility failed to place backup thermometers in refrigerators and freezers. This placed the 34 residents who received their food from the facility's kitchen at risk for foodborne illness.

The facility had a census of 34 residents. Based on interviews and record review the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). This placed the residents in the facility at risk for Legionella pneumonia Findings included: - The facility's Water Temperature Check Log documented temperature checks of laundry, kitchen, common areas, and resident rooms weekly. The facility did not have documentation of Legionella preventative measures including risk assessments and identification of potential problem areas and actions taken. On 06/10/24 at 03:36 PM, Administrative Staff A stated the city came to the facility yearly and tested the water. The facility uses an osmosis water filtration system for drinking water. She verified the facility lacked a Legionella or waterborne pathogen prevention plan. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to dispose of expired medications appropriately. This deficient practice placed residents at risk of receiving ineffective medication. Findings included: - On 06/10/24 at 08:15 AM, observation revealed the north medication cart contained the following expired medications: One bottle of stool softener, 50 milligrams (mg)/8.6 mg senna (laxative), with an expiration date of 12/2023. One bottle of calcium complete, 250 mg, plus 2.5 micrograms (mcg) of vitamin D, with an expiration date of 06/2023. One bottle of liquid Gerilanta (used to treat the symptoms of too much stomach acid) with an expiration date of 12/2023. On 06/10/24 at 08:15 AM, Licensed Nurse (LN) J verified the above expired medications should have been disposed of. On 06/10/24 at 08:52 AM, observation revealed the east medication room contained the following expired medications: One bottle of extra strength pain relief Tylenol/diphenhydramine (Benadryl), 500/25 mg, with an expiration date of 05/2024. One bottle of gas relief, 80 mg, with an expiration date of 02/2024. On 06/10/24 at 08:52 AM, LN J verified the above expired medications should have been disposed of. On 06/13/24 at 10:10 AM, Administrative Nurse D verified staff were to check the medication carts and rooms for expired medications twice weekly and dispose of expired medications. The facility's Medication Labeling and Storage policy, dated 02/2023, stated if the facility had discontinued, outdated medications the staff would contact the dispensing pharmacy for instructions regarding returning or destroying those items. The facility failed to dispose of expired medications appropriately, placing residents at risk of receiving ineffective medication.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff stood over two residents, Resident (R) 5 and R33, while assisting them to eat. This placed the residents of the facility at risk for impaired dignity. Findings included: - On 06/10/24 at 11:48 AM, observation revealed Certified Nurse Aide (CNA) O assisted residents in the dining room. CNA O stood up while feeding R5 a few bites of food and then walked over and stood over R33 while assisting him to eat. At 12:18 PM, CNA O sat next to R5 and fed her a few bites of food, then at 12:20 PM, she got up and assisted R33 again. At 12:21 PM, CNA O stood over R5 and gave her a bite of food, walked away from the table, came back, and gave her another bite while standing over her. At 12:23 PM, CNA O stood beside R33 to assist him with a drink and cut up his chicken into smaller pieces. At 12:24 PM CNA O sat by R5 and fed her pureed eggroll. At 12:28 PM, CNA O stood over R33 and fed him a bite or two of cake, then sat by R5 at 12:30 PM, and assisted her again. At 12:38 PM, CNA O stood over R5 again to give her a couple of bites of her meal, and at 12:40 PM, CNA O walked away. At 12:41 PM, a different aide sat with R5 to assist her and at 12:44 PM, the aide took R5 back to her room. On 06/11/24 at 08:50 AM, observation revealed R5 sat in her wheelchair at the dining table independently drinking thickened grape juice. The CNA that had been assisting her to eat was helping others. R5 had eaten approximately 50 percent (%) of her pureed breakfast. At 09:00 AM, CNA O stood over R5 and fed her two spoonfuls of sausage, and then some eggs. CNA O then walked over to assist R33 in eating while standing over him. CNA O walked back and assisted R5 again. On 06/11/24 at 12:19 PM, observation revealed CNA O sat with R5 and offered a drink of her vanilla shake. CNA O tried to get her to drink the supplement through a straw without success. At 12:38 PM, the dietary staff served her a meal of pureed pork chop, mixed vegetables, sweet potato, and a dessert. Further observation during the meal revealed CNA O got up and assisted R33 with cutting up his food and she stood over him to feed him a bite of food at least three times in between assisting R5 to eat her meal. At 12:51 PM, CNA O went to another table, talked to R25, and offered her assistance before returning to assist R5 again. On 06/11/24 at 02:04 PM, Dietary Staff BB stated staff should not stand over residents while assisting them to eat. On 06/11/24 at 02:27 PM, Administrative Nurse D verified staff were not to stand over residents while feeding them. The facility's Assistance with Meals policy, dated 03/2022, stated residents would receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves would be fed with attention to safety, comfort, and dignity for example: not standing over residents while assisting them to eat. The facility failed to promote care in a manner that maintains and enhances dignity and respect when staff stood over R5 and R33 while assisting them to eat. This placed the residents at risk for impaired dignity.

The facility had a census of 34 residents. The sample included 12 residents with two reviewed for urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI). Based on observation, record review, and interview, the facility staff failed to ensure sanitary catheter care for Resident (R)11. This placed the resident at risk for infection and catheter-related complications. Findings included: - R11's Electronic Medical Record (EMR) documented R11 had diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and urine retention (when your bladder doesn't empty completely or at all). R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R11 had a urinary catheter and no UTI during the observation period. R11's Care Plan, revised 07/07/24, documented the resident had poor kidney health, and a urinary catheter, and instructed staff to change the catheter monthly per physician order. The care plan instructed staff to soak the graduated cylinder and the catheter holder in vinegar weekly for 20 minutes, get new ones monthly, and record intake and output and provide catheter care every shift. The Nurse's Note, dated 01/13/24 documented R11 admitted to the hospital with a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) secondary to UTI. A review of R11's clinical record revealed R11 had positive UTIs on 01/13/24, 03/16/24 and 03/27/24. On 06/11/24 at 08:27 AM, observation revealed R11 self-propelled down the hall to the dining room with his urinary catheter tubing touching the floor underneath the seat of his wheelchair. On 06/11/24 at 11:44 AM, observation revealed R11 self-propelled in a wheelchair down the hall from his room to the dining room with his catheter tubing hitting the back of his shoes and touching the floor, underneath the seat of his wheelchair. On 06/11/24 at 02:00 PM, observation revealed R11 self-propelled down the hall from his room with his urinary catheter tubing touching the floor all the way to the dining room. On 06/11/24 at 03:26 PM, observation revealed R11 self-propelled from his room into the hall with his catheter tubing touching the floor underneath the seat of his wheelchair. Licensed Nurse (LN) I verified the tubing was touching the floor and stated staff should keep R11's catheter tubing off the floor. LN I retrieved a clip and secured the tubing off the floor. On 06/12/24 at 01:24 PM, Certified Nurse Aide (CNA) P, entered R11's room and asked if he was ready for her to provide catheter care and the resident replied Yes. CNA P cued R11 to self-propel in a wheelchair into the bathroom, lock the wheelchair brakes, and use the grab bar on the wall to stand by the toilet. CNA P assisted R11 in pulling down his incontinent brief and pants, then applied gloves, and removed the incontinent brief which contained a bowel movement (bm)in it. Further observation revealed CNA P provided catheter care with premoistened wipes, then with the same soiled gloves touched the wheelchair arms and moved it back from the toilet. Further observation revealed CNA P, with the same soiled gloves, placed a new incontinent brief on the resident, touching his pant legs, then CNA P cued R11 to stand and, with the same soiled gloves, pulled up R11's incontinent brief and pants. Observation revealed CNA P, with the same soiled gloves, moved the wheelchair closer to the resident, touching the arms of it and brakes, then removed and discarded the gloves. R11 self-propelled out of the bathroom and CNA P followed him and asked R11 if he needed anything else. CNA P left the room without washing her hands. On 06/12/24 at 01:30 PM, CNA P verified she had not changed her gloves after providing perineal care and had not washed her hands prior to leaving the resident's room. CNA P stated she should have. On 06/12/24 at 04:10 PM, Administrative Nurse D stated she expected staff to change gloves immediately after providing catheter care and staff should position R11's catheter tubing under his wheelchair to keep it off the floor. The facility did not provide a policy regarding how to position a resident's catheter tubing, change gloves, or wash hands when providing catheter care. The facility staff failed to ensure staff provided sanitary catheter care for R11. This placed the resident at risk for infection and catheter-related complications.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure Resident (R) 5 received the required staff assistance with meals in an uninterrupted manner that promoted intake. This deficient practice placed the resident at risk for weight loss. Findings included: - R5's Electronic Health Record (EHR) documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness), history of cerebral infarction (stroke), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99 and severely impaired decision-making. The MDS documented R5 required maximal staff assistance for eating. She weighed 93 pounds (lbs.), had weight loss, and was not on a physician-prescribed weight loss regimen. R5's Care Plan, dated 05/01/24, directed staff to provide a pureed diet with nectar thick liquids, a 120 milliliter (ml) dietary supplement four times daily, 120 ml juice supplement three times daily, Med-plus supplement as ordered, and encourage 120 ml of water between meals. The care plan directed staff to encourage R5 to eat the high-protein food first, offer menu selections daily, and help mark choices as needed. Staff were to obtain weekly weights. The Physician Order, dated 07/20/22, directed staff to assist the resident at all meals to aid in safe swallowing and to increase intake. Provide nectar thick liquids, and extra juice at meals and place water in a six-ounce cup. The Nutrition Note by the registered dietician (RD), dated 1/22/24, documented R5's weight was 106 lbs. which was lower than desirable for her age. R5's diet was regular with the meat cut into small bite-size pieces and nectar liquids. R5 ate 26 to 50% of the meals and ate at the assisted table in the main dining room. The Nutrition Note, dated 2/5/24, documented a four-ounce Gelatein (gelatin-like protein supplement) was added daily in addition to other multiple interventions. The physician had no new orders other than the Gelatein. R5's weight was 106 lbs., and her current meal intakes were fair, 51 to 75% of meals. The Physician Order, dated 02/16/24, directed staff to ensure the resident was up in a wheelchair for meals. The Nutrition Note, dated 04/01/24, documented R5's current weight was 95.8 lbs. and lower than desirable for age. Her diet was regular with meats cut into small bite-size pieces and nectar thick fluids. R5 ate 26 to 50% of meals at the assisted table. Staff tried to help the resident with eating and drinking, but she refused to let them help her. Estimated intakes were meeting estimated nutritional needs, but weight loss was noted. The note suggested increasing the juice supplement to four ounces four times daily, increasing the dietary supplement drink to 120 ml four times daily, and notifying the physician of weight loss. The note suggested if continued weight loss occurred, may consider seeing what R5's family wishes were regarding tube feeding. The Nutrition Note, dated 05/20/24, documented R5's current weight was 89.8 lbs. R5's diet changed to pureed with nectar liquids earlier in the month and the resident was allowing staff to assist. On 06/10/24 at 11:48 AM, observation revealed Certified Nurse Aide (CNA) O assisted residents with eating in the dining room. CNA O stood up while feeding R5 a few bites of food and then walked over and stood over R33 while assisting him to eat. At 12:18 PM, CNA O sat next to R5 and fed her a few bites of food, then at 12:20 PM, she got up and assisted R33 again. At 12:21 PM, CNA O stood over R5 and gave her a bite of food, walked away from the table, came back, and gave her another bite while standing over her. At 12:23 PM, CNA O stood beside R33 to assist him with a drink and cut up his chicken into smaller pieces. At 12:24 PM CNA O sat by R5 and fed her pureed eggroll. At 12:28 PM, CNA O stood over R33 and fed him a bite or two of cake, then sat by R5 at 12:30 PM, and assisted her again. At 12:38 PM, CNA O stood over R5 again to give her a couple of bites of her meal, and at 12:40 PM, CNA O walked away. At 12:41 PM, a different aide sat with R5 to assist her and at 12:44 PM, the aide took R5 back to her room. On 06/11/24 at 08:50 AM, observation revealed R5 sat in her wheelchair at the dining table independently drinking thickened grape juice. The CNA that had been assisting her to eat was helping others. R5 had eaten approximately 50 percent (%) of her pureed breakfast. At 09:00 AM, CNA O stood over R5 and fed her two spoonfuls of sausage, and then some eggs. CNA O then walked over to assist R33 in eating while standing over him. CNA O walked back and assisted R5 again. On 06/11/24 at 12:19 PM, observation revealed CNA O sat with R5 and offered a drink of her vanilla shake. CNA O tried to get her to drink the supplement through a straw without success. At 12:38 PM, the dietary staff served her a meal of pureed pork chop, mixed vegetables, sweet potato, and a dessert. Further observation during the meal revealed CNA O got up and assisted R33 with cutting up his food and she stood over him to feed him a bite of food at least three times in between assisting R5 to eat her meal. At 12:51 PM, CNA O went to another table, talked to R25, and offered her assistance before returning to assist R5 again. On 06/11/24 at 08:42 AM, Licensed Nurse (LN) J verified staff should not stand over a resident while assisting them to eat. On 06/11/24 at 02:04 PM, Dietary Staff BB stated she and the RD monitored weights and would question Administrative Staff D regarding any fluctuations. Dietary Staff BB stated R5 had lost quite a bit of weight prior to getting pureed foods in early May and now ate better. She said R5 also quit spitting out food if the CNAs fed her. On 06/12/24 at 01:13 PM, LN H stated if R5 was hungry and interested, she ate well though at other times she may not eat much. LN H said R5 sometimes would hold her lips closed when she did not want to eat more. On 06/12/24 at 04:03 PM, Administrative Nurse D verified that R5 might eat better some days if a staff person could sit next to her, visit with her, and assist her without interruption. Administrative Nurse D verified staff were not to stand over residents while feeding them. The facility's Assistance with Meals policy, dated 03/2022, stated residents would receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves would be fed with attention to safety, comfort, and dignity for example: not standing over residents while assisting them to eat. The facility failed to ensure R5 was assisted with meals in an uninterrupted manner, placing the resident at risk for weight loss.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure adequate pain management was available for Resident (R) 27 who had chronic pain. This placed the resident at risk for unrelieved pain. Findings included: - R27's Electronic Medical Record (EMR) documented R27 had diagnoses of peripheral (outside, surface, or surrounding area of an organ, other structure, or field of vision) neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) and absence of left leg below the knee. R27's Quarterly Minimum Data Set (MDS), dated [DATE], documented R27 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R27 required moderate staff assistance with personal hygiene and toileting. R39 had lower extremity impairment on one side and was independent with activities of daily living (ADLs) except showering. The MDS documented R27 received scheduled and as-needed (PRN) pain medications, frequently and had pain that rated seven on the pain intensity scale; pain occasionally made it hard for R27 to sleep at night. The MDS documented R27 received an opioid (narcotic) pain medication daily during the observation period. R27's Care Plan, revised 03/07/24, documented R27 had frequent, all-over joint pain and phantom leg syndrome( a condition in which patients experience sensations, whether painful or otherwise, in a limb that does not exist). The care plan instructed staff to administer Norco (opioid pain medication) twice a day. The Physician Order, dated 03/11/24, instructed staff to administer Norco, one to two tablets 10-325 milligrams (mg), every six hours PRN for pain. The Physician Order, dated 03/20/24, instructed staff to administer, Norco, two tablets, 10-325 mg twice a day at 08:00 AM and 08:00 PM. The Progress Note, dated 06/10/24 at 01:19 PM, documented the nurse received a fax from the physician with a new order to discontinue R27's PRN Norco and change the scheduled Norco, 10-325 mg, two tablets, to three times a day and schedule them for 08:00 AM, 02:00 PM, and 08:00 PM. R27'se Medication Administration Record (MAR) documented the nurse did not administer R27 his Norco, 10-325mg, two tablets on the following dates and times due to it being unavailable: 06/10/24 at 08:53 AM, 01:05 PM, and 08:00 PM, and on 06/11/24 at 08:00 AM and 10:57 AM. The Medication Order Book documented that staff reordered R27's Norco on 06/02/24 The Progress note, dated 06/09/24 at 02:59 PM, documented the nurse sent a fax to the physician requesting R27's Norco, be changed to three times a day due to R27 having been requesting a PRN dose frequently the last few weeks. The Progress Note, dated 06/11/24 at 04:12 AM, documented the pharmacy did not send R27's Norco, tablets the previous day so R27 had not received his scheduled pain medication that morning. The note documented R27 complained of significant generalized pain and stated he had not slept all night. The note documented the resident statement was true as his light had been on since midnight. R27 requested ibuprofen (pain medication), however there was no standing order for it. The nurse offered Tylenol 1000mg, instead and R27 agreed to take it. Tylenol,1000mg, was administered to R27 as a one-time order at 04:00 AM per standing order for significant pain. The Progress Note, dated 06/11/024 at 04:52 AM, documented R27 was out in the hallways roaming in his wheelchair and complaining of pain. R27 was rubbing his leg and grimacing. The nurse assured R27 that the medication would be sorted out as soon as possible and he would be able to have his Norco soon. The note documented R27 stated, I know it's not your fault. I'm just really hurting. R27'se Medication Administration Record (MAR) documented the nurse did not administer R27 his Norco, 10-325mg, two tablets on the following dates and times due to it being unavailable: 06/10/24 at 08:53 AM, 01:05 PM, and 08:00 PM, and on 06/11/24 at 08:00 AM and 10:57 AM. On 06/11/24 at 08:04 AM, observation revealed R27 sat in a wheelchair by the nurse's cart at the end of the west hall. R27 told the nurse that he had pain all over. The nurse stated she would call the pharmacy and find out why R27's Norco was not delivered the previous night, as soon as she was done checking his blood sugar. On 06/11/24 at 10:00 AM, LN G stated the facility had not received R27's Norco; the physician had increased the Norco the previous day but failed to send it to the pharmacy. LN G stated R27 had not received his Norco since the previous day and he was having pain. LN G stated if staff see that a resident is getting low on medication and the facility still has not received it, staff can call the pharmacy and reorder it again. LN G verified staff had not followed up on the Norco. On 06/12/24 at 11:43 AM, Licensed Nurse (LN) G stated staff should reorder residents' medication seven days prior to them running out. LN G verified it was ordered on 06/02/24 and staff did not follow up when it was not delivered. On 06/12/24 at 04:10 PM, Administrative Nurse D stated she expected staff to reorder a resident's medication seven days in advance or if the medication was scheduled twice a day, they should order it 14 days in advance. Administrative Nurse D stated if the pharmacy had not delivered the resident's medication after two days, she expected staff to follow up with the pharmacy to see why the facility had not received it. Upon request, the facility did not provide a policy regarding reordering medications. The facility failed to follow up on R27's Norco medication reorder causing the resident to run out of the medication. This placed the resident at risk for unrelieved pain.

The facility had a census of 34 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing the pureed diet. This placed the resident at risk for impaired nutrition. Findings included: - On 06/11/24 at 11:55, Dietary Staff (DS) CC with Dietary Manager (DM) BB overlooking, stated the facility had one resident who received a pureed diet and five residents who received mechanical soft diets. DS CC placed six three-ounce (oz) pork chops into a steam table pan, transferred them into a blender using tongs, and blended to a mechanically soft consistency. DS CC then transferred an unmeasured amount of mechanical soft pork chop into a steam table pan and placed it on the steam table. Observation revealed DS CC placed the rest of the mechanical soft pork chop in the blender container, added an unmeasured amount of milk, blended the meat to the consistency of mashed potatoes, then transferred the pureed pork chops into a steam table pan, and placed it on the steam table. DS CC said he knew the portions were accurate by estimating the serving size of both the mechanical soft and pureed portions. Observation revealed DS CC placed five three-ounce servings of mixed vegetables into a clean blender container, blended, then added an unmeasured amount of water from the sink and blended to the consistency of pudding. On 06/11/24 at 12:00 PM, DS CC verified he had not followed a recipe and stated the facility's dietary department did not have a recipe to follow. On 06/11/24 at 12:05 PM, DM BB stated the facility did not have recipes for pureed diets. She stated staff uses different liquids to puree food items and said that for meats, staff should use gravy, and for chicken, staff should use chicken broth. DM BB said if a food item had milk in it, staff should use milk for the liquid, and if for vegetable food items, staff should use the juice from the vegetables to get the right consistency. On 06/11/24 at 2:00 PM, DM BB provided a sheet of paper with the batch recipe and stated the pureed recipe was at the bottom of the recipe. A review of the recipes for the batch food items revealed the bottom included instructions to kitchen staff describing how to puree food items to the right consistency but did not have a specific recipe for each pureed food item. The facility's Following Recipes for Pureed Diets Policy, revised 09/15/17, documented that dietary staff would prepare pureed diets according to the pureed diet recipes provided with the facility menus. Staff would measure the food, liquid, and thickener according to directions. The facility kitchen staff failed to follow a recipe when preparing one resident's pureed diet. This placed the residents at risk for impaired nutrition.

The facility identified a census of 36 residents with three reviewed for neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from neglect when staff failed to apply a gait belt (walking belt-used to steady a person who had mobility issues) before staff attempted to transfer and ambulate R1 to the bathroom. The facility staff member let go of R1 to move the wheelchair, and R1 fell into her bedside table resulting in R1 acquiring a right displaced rib fracture. Findings included: - R1's Electronic Medical Record under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Its primary feature is cognitive decline, which can lead to hallucinations, as well as varied attention and alertness), and major depressive disorder (major mood disorder). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated R1 was cognitively intact. The MDS documented R1 required extensive assistance of one staff for transfer, ambulation, locomotion, toileting, and dressing. The MDS further documented R1 had not had any falls since the previous assessment. R1's Activity of Daily Living Care Area Assessment (CAA), dated 12/20/21, documented R1 was able to reposition herself, but could not transfer or ambulate without assistance related to poor coordination secondary to [CONDITION(S)]. The CAA further documented R1 was unsteady and required one staff assistance, walking belt, and two-wheeled walker for transfers and ambulation. R1's Fall CAA, dated 12/20/21, documented R1 was not steady and only able to stabilize with staff assistance moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. R1's Fall Care Plan, dated 02/19/21, informed staff R1 was at risk for falls related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Fall Risk Assessment, dated 03/20/21, documented R1 was a high risk for falls. The Progress Note, dated 06/13/22 at 10:41 PM, documented at 06:15 PM Certified Nurse Aid (CNA) M walked R1 to the restroom. CNA M assisted R1 using the two-wheeled walker, but failed to place a gait belt on R1. CNA M let go of R1 to move a wheelchair out of the way. R1 took a couple of steps and fell , hitting her right side on her bed side stand. R1 had an abrasion to her right side. R1's representative requested R1 be transported to the emergency room for x-rays. Staff transported R1 to the emergency room by ambulance at 07:22 PM. At 08:45 PM the hospital called and informed the facility R1 sustained a ninth lateral rib fracture to her right side. The Progress Note, dated 06/14/22 at 10:07 PM, documented R1 complained of right rib pain and rated her pain at an 8 on a scale of 0-10 (pain scale where zero represents no pain and 10 represents the worst pain imaginable). R1 received pain medication. Two hours later, R1 still had pain, but it was better. The Facility Investigation documented on 06/13/22 CNA M walked R1 to the bathroom. CNA M used the walker, but did not follow the care plan and did not use a gait belt. CNA M let go of R1 to move a wheelchair. R1 took a step and fell to the right, hitting her rib on the bedside table. CNA M was unable to prevent the fall. R1's representative requested R1 go to the emergency department for evaluation. R1 received an x-ray which revealed a right rib fracture. A Witness Statement from CNA M recorded on 06/13/22 R1 called to go to the bathroom. CNA M helped the resident from her wheelchair to her walker. CNA M stated he forgot to put the gait belt on. CNA M stated when he moved the wheelchair, R1 tried to take a step and toppled sideways. CNA M stated R1 hit her right side on the table which caused an abrasion to her rib area. On 06/14/22 at 01:00 PM, observation revealed R1 laid in bed. R1 guarded (involuntary reaction to protect an area of pain) her right side with her left arm and grimaced. On 06/14/22 at 01:00 PM, R1 stated that she had a lot of pain on her right side and it hurts a lot. On 06/14/22 at 01:10 PM, CNA N stated he would never transfer R1 without a walking belt because R1 was too unsteady on her feet. CNA N stated R1's care plan directed staff to transfer and ambulate R1 with a walking belt and a two-wheeled walker. On 06/14/22 at 01:20 PM, CNA O stated she always used a walking belt to transfer and ambulate R1 because R1 was so wobbly and unsteady on her feet. CNA O stated R1's care plan directed staff to transfer and ambulate R1 with a walking belt and a two-wheeled walker. On 06/14/22 at 01:45 PM, CNA M stated he went into R1's room to take her to the bathroom after supper. CNA M stated he felt rushed because he was the only CNA on the floor to care for all the residents and there were four call lights going off at that time. CNA M said due to the rush, he did not put the gait belt on R1. CNA M said he assisted R1 out of the wheelchair up to her walker and let go of her to move the wheelchair, the next thing he knew R1 fell . CNA M stated there were three CNAs to care for the residents until 06:00 PM and then one CNA went home, and the other CNA went on break. This left CNA M caring for the residents by himself. On 06/14/22 at 05:30 PM, R1's representative stated when the nursing facility called him to inform him of the fall, he asked the nurse what she was going to do about R1 having an abrasion and pain on her right side. R1's representative stated R1 had a high tolerance for pain and if she had pain, that indicated something was wrong. On 06/14/22 at 02:15 PM, Administrative Nurse D verified CNA M should have followed R1's care plan and staff should transfer R1 with a walking belt. Administrative Nurse D stated CNA M should not have let go of R1 while she was still standing. The facility's Abuse Prevention Program Policy, dated 05/2022, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker of goods and services that are necessary to attain or maintain physical, mental, or psychological well-being. The facility failed to protect R1 from neglect when staff failed to use a walking belt when transferring R1 as directed in R1's plan of care. As a result, R1 fell and sustained a right rib fracture which caused unnecessary pain.

The facility reported a census of 50 residents, with 50 residents testing positive for Covid-19. The facility had four hallways and a Special Care Unit (SCU). Based on observation, interview, and record review the facility failed to follow standards of practice based on The Centers for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC) to reduce the risk and potential for transmission of infectious diseases, which included the highly contagious Covid-19 (a potentially fatal respiratory virus). The facility further failed to implement a system to prevent transmission of Covid-19 when two residents started showing symptoms of [MEDICAL CONDITION] on [DATE] and had positive [MEDICATION NAME] (test that detects Covid-19 proteins) tests, which the lab confirmed on [DATE]. The facility failed to quarantine the two positive residents and continued to cohort Covid-19 positive residents with Covid-19 negative residents. The facility failed to stop communal dining or place all residents on quarantine until [DATE], two days after the initial positive results. The facility failed to test all of the residents in the facility until [DATE], 7 days from the first two resident's positive [MEDICATION NAME] results to identify the extent of the outbreak. Ultimately all 61 of the facility residents exposed from [DATE] to [DATE] tested positive for Covid-19, with 10 residents who died of Covid-19 related symptoms, one who required hospitalization , and others who reported various signs/symptoms related to [MEDICAL CONDITION]. This placed all 50 residents in Immediate Jeopardy. Findings Included: - An interview with Administrative Staff A on [DATE] at 10:14 AM revealed the facility tested all residents and staff for Covid-19 from [DATE] to [DATE] and all the tests came back negative. On [DATE] two residents developed fevers along with other signs and symptoms of Covid-19. The two residents were tested with the facility's [MEDICATION NAME] Machine (test that detects the Covid-19 proteins) and both tested positive. The two residents were then tested by the hospital and on [DATE] the results also came back positive. On [DATE] (two days after the first two residents started showing symptoms) all residents were placed in quarantine in their rooms and the facility stopped communal dining. On [DATE] two more residents tested positive on the facility [MEDICATION NAME] Machine. On [DATE] (4 days after the first two resident's tested positive and the day R1, (a Covid-19 positive resident died ), she talked to Physician JJ regarding the positive residents and the situation at the facility. On [DATE] (one week after the first two resident's tested positive) the facility tested everyone for Covid-19 and on [DATE] and [DATE] all resident tests came back positive for [MEDICAL CONDITION]. All staff were tested again on [DATE], with 37 testing positive. Review of the Covid-19 Adult Care Home Checklist Form dated [DATE] revealed in the event of a Covid-19 positive resident the facility would initiate a plan to move residents currently residing in the facility Special Care Unit (SCU) to the nursing home part of the facility. Resident's who were positive for Covid-19 would then be moved to the SCU where the best isolation can take place. The residents would be quarantined to their room and staff would use isolation Personal Protective Equipment (PPE - mask, gloves, gown, face shield or goggles, shoe protection). Staff would be dedicated to care for only the Covid-19 positive residents and would enter the building through the SCU back door, so they did not have to enter the nursing home. The facility failed to initiate their plan when two residents in the facility started showing symptoms of Covid-19 and tested positive for the highly contagious virus. Review of the CDC guidance Responding to Covid-19 in Nursing Homes revised [DATE] revealed the facility would isolate a newly diagnosed Covid-19 positive resident and care for using all recommended PPE. Staff would place the positive/suspected resident in a single room, if possible. The document stated cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents. If a resident had confirmation of Covid-19, regardless of symptoms they were to be transferred to a designated Covid-19 care area. Roommates of the positive resident would be considered exposed, should remain on quarantine for 14 days, and could only cohort with other exposed (not positive) residents if no other rooms were available. Review of facility documentation from [DATE] to [DATE] lacked evidence the facility isolated the first two Covid-19 positive residents, only cohorted residents who were Covid-19 positive with each other, and/or made arrangements for Covid-19 positive resident's roommates who were negative to be moved into a separate room. A follow up interview with Administrative Staff A on [DATE] at 6:33 PM revealed the facility had two residents who were at a high risk for elopement and the only place she had to secure them was on the SCU. Administrative Staff A decided not to utilize the SCU (as stated in the facility plan), left the Covid-19 positive residents in their rooms, and if they had a roommate they would try to keep them each quarantined to their side of the room. Observation of the facility on [DATE] revealed shared rooms were only separated by a privacy curtain. Review of the facility Electronic Health Record (EHR) on [DATE] revealed the following: 1. R12 and R1 cohorted in the same room. On [DATE] R12 received a positive Covid-19 test result. R1 admitted to the hospital on [DATE] and died in the hospital on [DATE], where she tested positive for Covid-19. 2. R13 died on [DATE] at 04:45 PM and had a positive Covid-19 test result. 3. R14 died on [DATE] at 01:12 PM and had a positive Covid-19 test result. 4. R8 and R9 cohorted in the same room and on [DATE] both received positive Covid-19 test results. R9 died on [DATE]. 5. R4 and R5 cohorted in the same room and on [DATE] both received positive Covid-19 test results. R5 died on [DATE]. 6. R6 and R7 cohorted in the same room. R6 tested positive for Covid-19 on [DATE]. R7 tested positive for Covid-19 on [DATE] and died on [DATE]. 7. R15 died on [DATE] at 08:06 PM and had a positive Covid-19 test result 8. R10 and R11 cohorted in the same room. On [DATE] R10 and received positive Covid -19 test results. R11's record lacked a positive test result, although the facility reported all resident tested positive for Covid-19. R11 died [DATE]. 9. R2 and R3 cohorted in the same room and on [DATE] both received positive Covid-19 test results. R3 died on [DATE]. 10. R16 died on [DATE] at 09:50 AM and had a positive Covid-19 test result. Further review of the facility EHR on [DATE] revealed residents with various symptoms of Covid-19 ranging from asymptomatic to severe symptoms (pain, difficulty breathing, weakness), which led to resident deaths. Review of the Staff Testing Document provided by the facility revealed out of 70 staff tested as of [DATE], 55 staff had tested positive for Covid-19. An observation provided during an interview with Consultant GG on [DATE] at 11:15 AM revealed she entered the facility on [DATE] with Physician JJ to evaluate residents who were positive with Covid-19 and had a full code status (a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action) to see if they needed hospitalization or other interventions. During her visit to the facility she observed six different (unidentified) staff at various times with their masks removed. Consultant GG further observed one unidentified staff in a resident's room with her mask pulled down around her chin, not wearing goggles, and sitting next to the resident (failed to social distance) discussing getting the resident ready for bed. An interview with Resident Representative KK on [DATE] at 2:45 PM revealed he/she and two other family members went to the facility on Labor Day ([DATE]) weekend to visit their family member during the afternoon. The facility had a table set up in the entry way for screening but there were no staff available to assist the visitors. After waiting quite some time, they walked down a hall to find someone to help them. Representative KK stated they had to go quite a ways, but found a staff member and when they asked about screening and what they needed to do, the staff member said I don't know the policy. He/she was not sure what department the staff member worked in, but the staff member wore a mask. They went on down to the nurse's station where there were three staff sitting, none wearing masks, but did put them on when he/she asked questions about visiting her family member. Representative KK stated they all looked at each other and one said she wasn't sure what they needed to do, and she would have to ask the nurse. The nurse said she wasn't sure, but thought they were to check their temperatures. Representative KK asked all three of the staff members if they could go to the resident's room and the staff member said she did not know, but the week before it was just one visitor allowed. The nurse then said it would be ok if they all went to the resident's room. When they got to the resident's room, his roommate was present. Neither the resident nor his roommate wore masks. They did not stay in the room, but went to the activity room to visit. Representative KK stated her family member did not wear a mask when he left the room and went to the activity room. The resident told Representative KK wearing a mask did not really matter because most of the nursing staff did not wear them all of the time, and he had mentioned that to other family members several times before. An interview on [DATE] at 8:31 AM with R17 revealed staff wore masks when they came into her room, but moved the mask around at times. R17 stated she did not wear a mask at any time, and no one ever told her she should. An interview on [DATE] at 8:40 AM with R12 revealed he thought he felt better from having Covid-19, but still felt a little weak. R12 reported he did not wear a mask and the facility never offered him one. The resident reported his wife passed away at the hospital and tested positive for Covid-19. An interview with Certified Nurse Aide (CNA) M on [DATE] at 08:05 AM revealed if a Covid-19 positive resident had a roommate the facility did not move either resident, both residents stayed in the room. An interview with CNA N on [DATE] at 08:10 AM revealed residents did not wear masks or cover their face with a tissue when staff provided cares. If a Covid-19 positive resident had a roommate the facility did not move either resident, they both quarantined in their room. An interview with Licensed Nurse (LN) G on [DATE] at 7:55 AM revealed if a resident had signs or symptoms of Covid-19 and had a roommate the facility did not move the roommate they just kept them to their side of the room, divided by a curtain. An interview with LN H revealed staff only wore N-95 masks when they gave nebulizer treatments, otherwise they wore surgical masks when working with Covid-19 positive residents. Covid-19 positive residents who had a roommate were not moved, they both quarantined in their rooms and had a curtain to divide them. Review of the unsigned policy Covid-19 Policy and Procedure dated [DATE] revealed elderly and those with chronic medical conditions demonstrated more severe illnesses than other populations at this time. The facility would implement surveillance, and infection control prevention strategies to reduce the risk of transmission of Covid-19. The facility would implement their actions according to the CDC, State, County and local Health Departments, State Survey Agencies and the World Health Organizations recommendations. The policy further described the plan to move SCU residents to the nursing home part of the facility and to isolate Covid-19 positive residents in the SCU. Review of the undated Covid-19 Surveillance Policy revealed residents would be tested for Covid-19 with the facility [MEDICATION NAME] Machine and positive residents would be retested through the local hospital and placed in quarantine. If the facility had an outbreak (2 residents or more) all residents would be tested through the local hospital and put on quarantine. The facility failed to follow standards of practice to reduce the risk and potential for transmission of Covid-19. On [DATE], the facility reported all 50 residents tested positive for Covid-19. The facility further failed to implement a system to prevent transmission of Covid-19 when two residents started showing symptoms of [MEDICAL CONDITION] on [DATE] and had positive [MEDICATION NAME] tests, which the lab confirmed on [DATE]. The facility failed to quarantine the two positive residents and continued to cohort Covid-19 positive residents with Covid-19 negative residents. The facility failed to stop communal dining or place all resident's on quarantine until [DATE], two days after the initial positive results. The facility did not test all residents until [DATE], 7 days after the first two residents showed signs/symptoms of [MEDICAL CONDITION]. The facility further failed to properly utilize PPE and screen all visitors before entering the building. Ultimately all 61 of the residents exposed from [DATE] to [DATE] tested positive for Covid-19, with 10 residents who died of Covid-19 related symptoms, one who required hospitalization , and many others who reported various signs/symptoms related to [MEDICAL CONDITION]. This placed all 50 residents in Immediate Jeopardy.

The facility had a census of 63 residents. Based on observation, record review, and interview the facility failed to implement The Centers for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC) recommended infection control practices to control and prevent potential spread of COVID-19 (a mild to severe respiratory illness caused by a new strain of coronavirus, characterized by fever, cough, shortness of breath.) between residents and staff. The facility staff lacked appropriate facemask covering for source control while in the facility, COVID-19 infection control staff education, and a COVID-19 policy to prevent the potential spread of the disease placing all 63 residents in the facility in immediate jeopardy. Findings included: - On 05/20/2020 at 10:30 AM, review of the facility's infection control program revealed lack of action and education to prevent the spread of COVID-19. The facility had no documented residents with respiratory illness. Review of the CDC recommendations, dated 4/02/2020, Key Strategies to Prepare for COVID-19 in Long Term Care Facilities, documented to following to prevent the spread of COVID-19: Ensure all residents wear a face covering for source control whenever they leave their rooms or are around others, including whenever they leave the facility for essential medical appointments. Ensure all Health Care Personnel wear a face mask or cloth face covering for source control while in the facility. Cloth face coverings are not considered personnel protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. Cloth face mask coverings should NOT be worn instead of a respirator or facemask if more than source control is required. On 05/20/2020 at 09:35 AM, observation revealed all facility staff, except one, walked up and down the halls, in the dining room, in residents' rooms, and at the nurse's station lacked a face mask covering. On 5/20/2020 at 11:30 AM, observation revealed Housekeeping Staff (HS) U, cleaning the handrails on the Greenacres hall with bleach water. On 05/20/2020 at 09:35 AM, Administrative Staff A verified staff did not wear a mask in the facility and had not since the COVID-19 disease precautions started in March. Administrative Staff A verified the facility had not provided training, classes, or in-services regarding COVID-19 to inform staff of recommended precautions. Administrative Staff A verified the Administrator had a notebook in her office with COVID information, but they had not developed any COVID-19 policies. On 05/20/2020 at 09:40 AM, Administrative Nurse D verified she did not have staff wear mask, and stated the facility was putting together a COVID-19 training notebook but had not completed any training. On 05/20/2020 at 10:10 AM, HS U, verified she was not told to wear a mask. HS U stated she had not received training on COVID-19, however housekeeping staff were using more bleach on the handrails when cleaning. On 5/20/2020 at 10:30 AM, Certified Nurse Aide (CNA) M verified she had not received training on COVID-19, did not know if staff should wear mask, and had not been informed by management. On 05/20/2020 at 10:40 AM, Activity Staff (AS) Z verified the facility had discussed COVID-19 in the morning Department Head meetings but lacked any COVID training. AS Z stated he wore a mask by choice, and it was not mandated by the facility. On 05/20/2029 at 10:45 AM, Licensed Nurse (LN) G verified she had not received training regarding COVID-19 and none of the facility staff wore masks. On 05/20/2020 at 03:35 PM, Administrative Nurse D verified the facility had not provided staff COVID-19/infection control education in March, April, or May 2020. Administrative Nurse D verified the facility had no residents with active COVID -19. Upon request the facility lacked a policy for COVID-19. The facility failed to develop and implement COVID-19 policies and procedures, as well as education to staff to prevent transmission of COVID-19 which can cause serious or fatal respiratory illness. This deficient practice placed the 63 residents in the facility in immediate jeopardy. The facility removed the immediate jeopardy on 05/21/2020 at 10:48 AM, when the facility implemented a COVID-19 policy according to CDC/CMS guidance, educate and train staff on COVID-19 guidelines, and required all staff to wear a facial mask. The deficient practice remained at a scope and severity of a F.

The facility had a census of 62 residents. The sample included 10 residents, with 3 reviewed for assessment after change in condition. Based on record review and interview, the facility failed to complete an assessment for 1 of 3 sampled residents, when the resident hit his/her head on the wall while staff provided cares, and licensed nursing staff failed to complete a thorough nursing assessment after the incident. (#10) Findings included: - Resident #10's admission (MDS) Minimum Data Set assessment, dated [DATE], documented the resident had a (BIMS) Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, supervision of 1 staff for eating, and used a wheelchair for mobility. The MDS documented the resident received an anticoagulant (medication that treats, prevents, and reduces the risk of blood clots) medication. The [DATE] revised care plan documented the resident received [MEDICATION NAME] (anticoagulant), 2.5 (mg) milligrams daily, with a black box warning (warnings that highlight serious and sometimes life-threatening adverse drug reactions within the labeling of prescription drug products) for bleeding risk. The care plan documented the resident had fragile skin with skin tears, and directed staff to encourage the resident to wear long sleeved shirts, gowns, or T-shirt's to bed. The [DATE] at 8:40 PM, nurse's note documented Licensed Nurse I, the day shift nurse, reported the resident hit his/her head on the wall when staff provided cares. The note documented at 7:40 PM, staff noted a large bruise to the center and the right side of the resident's forehead, and staff contacted the day shift nurse to verify what had happened. The note documented the resident had open skin tears, abrasions, and several bruised areas to his/her back. Staff notified the hospital and received an order to send the resident to the hospital for evaluation. The note documented staff transferred the resident to the hospital by ambulance at 8:35 PM. The [DATE] at 9:52 PM, nurse's notes documented at approximately 7:30 PM, Licensed Nurse G was called to the resident's room, when staff rolled the resident over, blood was noted on the sheet, and the nurse noted bruising and skin tears on the resident's back. Licensed Nurse G called for Licensed Nurse H to come to the resident's room to assess the resident, The note documented the resident's blood pressure and pulse were low (no documentation of the readings) and the resident was transported to the hospital by ambulance at 8:35 PM. The [DATE] at 8:00 PM physician order, directed staff to send the resident to the emergency room for evaluation of low oxygen saturation and bruising to forehead. The [DATE] at 12:42 PM, nurse's note documented the hospital staff reported the resident admitted with a plural effusion (abnormal accumulation of fluid in the lungs), probable pneumonia (inflammation of the lungs), and dehydration. The note documented the resident was placed on comfort care. The [DATE] at 9:03 PM, nurse's note documented the resident died at the hospital at 7:56 PM. The resident's medical record lacked documentation staff completed an assessment of the resident at the time of the incident on [DATE] (time unknown but sometime between 6AM and 12:00 PM), until 7:40 PM, and lacked documentation of neurological assessments or vital signs. The facility transfer sheet to the hospital, dated [DATE], documented the reason for the transfer as head trauma, bumped head, and skin tears. The [DATE] at 9:15 PM, emergency room physical examination, documented the resident was brought to the emergency room by ambulance with a reported history of bumping his/her head earlier today (unclear if he/she fell or hit his/her head while being wheeled through a doorway in a wheelchair), and deteriorating. The physical examination documented the resident had multiple skin tears on his/her arms and back, and a quarter sized ecchymosis (bruising) on the center of his/her forehead. The [DATE] hospital discharge summary included the [DIAGNOSES REDACTED]. On [DATE] at 4:45 PM, Licensed Nurse G stated he/she was called to the resident's room on [DATE] to assist with the resident. Licensed Nurse G stated when staff turned the resident over, blood was noted on the sheet, with bruises and skin tears on his/her back, and a bruise on his/her forehead. Licensed Nurse G stated he/she asked Licensed H to come to the resident's room to assist in the assessment. Licensed Nurse G stated Licensed Nurse I worked the day shift and reported the resident hit his/her head during cares. Licensed Nurse G stated due to the bruise on his/her forehead and the fact he/she received a blood thinning medication, the resident was sent to the hospital. On [DATE] at 5:10 PM, Licensed Nurse H stated he/she was called to the resident's room by Licensed Nurse G to assess the resident's skin tears and bruises, including a large bruise on his/her forehead. Licensed Nurse H verified he/she contacted Licensed Nurse I to verify what had happened during the day shift. The resident was transferred to the hospital emergency room because of the bruises and his/her medications. On [DATE] at 8:25 AM, Licensed Nurse I verified he/she was in the resident's room with other staff, providing care and repositioning the resident, when the resident hit the front and left side of his/her forehead on the wall. Licensed Nurse I verified there was no documentation of the incident, neurological checks, or vital signs in the resident's record. Licensed Nurse I stated he/she was aware the resident received a blood thinner but did not see any reason to document anything. Licensed Nurse I stated he/she did not remember what time of day the incident occurred, stated staff should have been more careful when they repositioned the resident, and he/she should have completed an assessment. On [DATE] at 9:30 AM, Administrative Nurse D verified the resident's record lacked documentation of an assessment, including vital signs and neurological checks. Administrative Nurse D stated staff should have assessed the resident after the incident, and documented the findings in the medical record. The facility's undated event form for bruises documented staff should complete the form with the event date, description, location, shape, color and character of the bruise, pain, and activity of the resident at the time of the occurrence. If the bruise is of unknown origin, the nurse should initiate an investigation and obtain witness statements from staff. The form should include interventions to prevent reoccurrence, and should notify the physician, facility on-call nurse, and the resident's representative. The facility did not provide a policy. The facility failed to assess Resident #10, who received [MEDICATION NAME], after the resident hit his/her head on the wall while staff provided cares, causing ecchymosis, bruises, and skin tears.

The facility had a census of 63 residents. The sample included 15 residents of which 4 residents were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of facility acquired pressure ulcers for 3 of 4 sampled residents for pressure ulcers. (#47, #50, and #41) Findings included: - Resident #47's [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/10/17, revealed the resident sometimes understood others, recorded no short and long term memory deficits, modified independent cognition, and required extensive assistance of 1 staff with bed mobility, locomotion off the unit, dressing, and personal hygiene. The assessment recorded extensive assistance of 2 staff with transfers, toilet use, at risk for developing a pressure ulcer, pressure reducing device for bed and lacked a turning/repositioning program. The quarterly MDS, dated [DATE], recorded the resident had one stage 3 pressure ulcer (a pressure sore extends into the tissue beneath the skin, forming a small crater, and fat may show), that measured 3 (cm) centimeters x 4 cm, with granulation tissue (tissue formed during wound healing). The resident received pressure ulcer care, application of ointments and used a pressure reducing device for his/her bed. The (CAA) Care Area Assessment for pressure ulcers, dated 10/24/16, indicated the resident had abnormal gait and mobility, at risk for pressure ulcers, no pressure ulcers during this review, had a pressure reducing mattress and weekly skin audits completed by licensed nurses. The 4/6/17 Braden scale for predicting pressure ulcers score was 13 - at moderate risk. The 4/17/17 care plan directed staff to assist/remind the resident to change position every 2 hours, complete weekly skin assessments, and provide a pressure reducing mattress on the bed. The care plan lacked direction to staff on how to care for the facility acquired pressure ulcer, the physician ordered boot for the left heel, or floating of heels. The 4/11/17 nurse's note, revealed staff completed a skin assessment and no new skin issues were noted. The 4/18/17 at 9:25 AM, nurse's note documented staff completed a skin assessment and an open ulcer was found on his/her left heel, that measured 1.5 cm x 1 cm, partially scabbed/abrasion, and no drainage or surrounding redness. The note directed staff to float the resident's heels off the bed with pillow support, and cover the wound with a [MEDICATION NAME] dressing. The 4/18/17 at 1:55 PM, nurse's note documented the resident's foot slides off the pillow. Staff examined the resident's shoes, and the nurse aides stated the resident's shoes became too tight and his/her heel area broke down. The 5/2/17 at 10:06 AM, nurse's note documented a skin assessment was completed and the left heel open area measured 2.2 cm x 1 cm with no redness or drainage. The 5/7/17 at 9:50 AM, nurse's note documented the resident's left heel boot was on after breakfast but he/she was able to get his/her foot out of it. The 5/22/17 at 2:24 PM, nurse's note documented a fax was sent to the physician which questioned the need for wound care supplements (34 days after the pressure ulcer was identified). The 5/23/17 at 10:10 PM, nurse's note documented the resident's left heel wound, Stage 3, was debrided, he/she used a left ankle boot, and the resident should have it on most of the time except for changing clothes and showering. The 5/25/17 at 11:15 AM, nurse's note documented the resident kicked off his/her left foot boot. The 5/28/17 facility fax to the physician indicated the resident had a start of a new open area, more on the heel, which measured 3 cm x 2.5 cm (unstaged) with redness and a layer of skin gone. The 6/9/17 at 11:05 AM, nurse's note documented the physician was in the facility for rounds and he/she debrided the left heel ulcer which measured 2.5 cm, and addressed the left heel ulcer superior to the old ulcer which measured 1 cm x 2 cm. The 6/13/17 at 11:32 AM, nurse's note documented the left heel ulcer measured 3.5 cm x 3.5 cm, with an irregular shape, and the 2 ulcers became 1 ulcer. The 6/14/17 at 10:29 AM, nurse's note documented the resident received [MEDICATION NAME] (an antibiotic), 750 (mg) milligrams, (BID) two times a day, for 14 days, for an infection in the resident's heel. The 6/28/17 at 10:01 AM, nurse's note documented the resident removed the dressing and boot. Review of the medical record revealed on 7/13/17 the registered dietician (RD) completed a quarterly nutritional review. (12 weeks after the heel ulcer developed). The RD suggested to start 4 (oz) ounce Ensure (a liquid nutritional supplement) three times a day, to help increase protein intake, and to help promote healing. On 7/20/17 at 7:10 AM, observation revealed the resident lying in his/her bed on his/her back with his/her eyes closed. Further observation revealed the resident's left foot with a black boot on it, the boot was twisted and off to the side of the left foot, and the resident slid his/her feet on the bed. On 7/20/17 at 7:29 AM, observation revealed Nurse Aide A and Nurse Aide B entered Resident #47's room and Nurse Aide A verified the resident's boot on his/her left foot was twisted and should be straight on the resident's left foot. On 7/19/17 at 10:11 AM, Nurse D stated the resident liked to lay in his/her bed, did not want to sit up, and attempted to float the resident's heels before the pressure ulcer started but the resident would not leave the pillows underneath his/her ankles. Nurse D verified the care plan lacked direction to the staff regarding the resident's pressure ulcer. On 7/19/17 at 9:19 AM, Nurse G verified the resident's first pressure ulcer was on the heel of his/her foot and the second pressure ulcer was above the first. Nurse G stated the resident would rub and try to get the dressing off of his foot which caused the 2nd open area. The resident's heels were not floated prior to the pressure ulcer developing. On 7/20/17 at 10:24 AM, Administrative Nurse H verified all nurses should update the care plans and the resident's care plan did not have any documentation of or direction to staff regarding the resident's pressure ulcer. On 7/20/17 at 11:34 AM, Physician I stated the resident developed a pressure ulcer because he/she would lie in bed a lot and would rub his/her heels against the bed. Physician I stated the facility placed padding on the resident's heels, he/she would rub it off and when staff placed blue foam boots on the resident, he/she kept kicking them off. On 7/20/17 at 2:04 PM, Nurse Aide A verified he/she observed the resident's left boot twisted on his/her foot prior to today's observation. Nurse Aide A verified the resident would rub his/her heels on the bed a lot and could not remember if the staff put a pillow under the resident's heels before the pressure ulcer developed. On 7/20/17 at 2:30 PM, Nurse E verified on 4/18/17, staff discovered the pressure ulcer during a skin assessment, and the heels of his/her shoes were broken down. Nurse E stated staff should have noticed redness on the resident's heels before staff discovered the pressure ulcer. Nurse E verified the staff were not floating the resident's heels before the resident developed the pressure ulcer. Nurse E further stated staff assessed the resident as a moderate risk for pressure ulcer. Nurse E verified the resident only liked to lie in bed on his/her back and physical therapy has not been involved with the resident to help with positioning. On 7/24/17 at 10:44 AM, Nurse Aide C stated the resident moved his/her feet in the bed a lot and dragged his/her heels on the sheet. On 7/24/17 at 2:16 PM, Administrative Nurse H verified all staff were to monitor the resident's skin and verified the resident did slide his/her heels on the bed. Administrative Nurse H verified staff should have floated the resident's heels prior to the development of the pressure ulcer and notifiy the registered dietician immediately when staff observed the resident's heel on 4/18/17 with a pressure ulcer. The facility's Decubitis Ulcer Prevention policy, dated 3/8/2002, indicated areas to be assessed upon admission and at least annually are mobility status, incontinence of bowel or bladder, limitation in range of motion, nutrition/hydration status, condition of skin at admission and use of physical restraints. If any of the areas assessed indicate a risk for skin breakdown, the following measures may be implemented as appropriate: pressure reducing wheelchair cushion, pressure reducing devices for specific areas of concern (i.e. heel protectors, handrolls, etc), pressure reducing mattress, review of diet by registered dietician, review of restorative nursing programs by Physical Therapist, and increase frequency of bathing. The policy directed staff to turn resident at least every 2 hours and position residents with pillows protecting bony prominences. The facility failed to develop and implement interventions to prevent the development of 2 facility acquired pressure ulcers, one Stage 3 and one unstaged, for Resident #47. This placed the resident at risk for further skin breakdown, infections and pain. - Resident #41's physician order sheet, dated 6/14/2017, documented the resident had [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 3/27/2017, recorded the resident had a (BIMS) Brief interview for Mental Status score of 15, cognitively intact. The MDS documented the resident required limited assistance of one person with locomotion on and off the unit, dressing, toilet use, and extensive assistance of one person with bed mobility and transfers. The MDS indicated the resident was at risk for pressure ulcers, and had no pressure ulcers. The MDS lacked any pressure relieving devices for bed or chair or any skin preventative devices. The significant change (MDS) Minimum Data Set assessment, dated 6/15/2017, recorded the resident had a BIMS of 12, cognitive intact. The MDS documented the resident required extensive staff assistance of two people with (ADLs) Activities of Daily Living, including bed mobility, transfers, locomotion off the unit, dressing and toilet use, had no (ROM) Range of Motion limitations, and weighed 214#. The MDS documented the resident was at risk for pressure ulcers, had no pressure ulcers, and had a pressure reducing device to his/her bed and chair. The 6/23/2017 (CAA) Care Area Assessment summary for skin indicated the resident was at risk for pressure ulcers due to his/her recent acute illness, decreased mobility, and required extensive staff assistance with most ADLs. The 6/15/2017 care plan instructed the staff to assist the resident with transfers, bed mobility, and recorded the resident was at risk for skin breakdown due to left sided weakness. The care plan instructed the staff to ensure the resident had adequate personal cares and hygiene after toilet use, and to report any redness and changes in skin integrity to the charge nurse. The care plan recorded the licensed nurse would document weekly skin assessments. The care plan lacked update after the significant change MDS, since hospitalization , and after the resident developed a pressure ulcer on his/her buttocks. The 6/10/2017 Braden scale (predicting pressure ulcer risk), documented a score of 15. (15-18 represents at risk) The medical record revealed the resident was in the hospital from 5/21/2017 to 5/23/2017, 6/05/2017 to 6/10/2017, and from 6/15/2017 to 6/24/2017 and at that time he/she had a feeding tube. The 5/23/2017 (RD) registered dietician progress notes documented the nursing staff reported the resident weighed 222 pounds (with clothes on), a 6 pound gain, prior to hospitalization , likely due to intravenous fluids and his/her clothes. The dietician documented he/she would return in two weeks and reevaluate the resident. The 6/24/2017 skin assessment documented the resident had no pressure or skin issues, related to his/her coccyx. The 6/27/2017 registered dietician progress notes documented the resident weighed 216# had a peg tube (a tube is passed into a resident's stomach through the abdomen, that provides a means of feeding when oral intake is not adequate) and nothing by mouth. The registered dietician progress notes documented the resident received [MEDICATION NAME] 1.0 calorie (a liquid nutritional supplement) to provide 1975 calories a day. The 7/3/2017 at 11:23 AM, nurse's notes recorded the resident had a dry flaky area on his/her left buttock, measuring 1 (cm) centimeter by 1 cm by 1 cm, and a 2 cm by 1 cm open area on his/her right buttock, with no drainage noted. The notes documented staff encouraged the resident to change positions frequently, staff placed a gel cushion in his/her wheelchair (new intervention), and would continue to monitor. The note's documented staff left a message on the primary care physician's answering machine and sent a fax to his/her office regarding the resident's skin issues on his/her coccyx. The 7/4/2017 at 9:24 AM, nurse's notes recorded the resident's skin warm, dry, with skin breakdown on his/her coccyx, and staff continued to monitor. The 7/5/2017 at 1:59 PM, nurse's notes recorded the physician returned the 7/3/2017 fax regarding the skin breakdown on the resident's buttocks, and directed staff to apply skin protectant three times a day to his/her buttocks, and administer Vitamin C 500 mg (milligrams) daily and Zinc 50 mg per peg tube, until the pressure sores healed. The 7/9/2017 at 1:42 PM, nurse's notes recorded staff sent a fax to the physician documenting the resident had a pressure ulcer on his/her coccyx, 1 cm scabbed area. The staff had applied A&D ointment, and initiated the order Zinc 50 mg daily, Vitamin C 500 mg daily and frequent change of position. The physician responded to use Hydrogel two times a day to the area and cover with a [MEDICATION NAME] pad. The 7/11/2017 at 1:49 PM, nurse's notes recorded the physician returned the following orders regarding the resident's coccyx; apply Hydrogel dressing (a dressing which contains a large amount of water that keeps ulcers moist rather than letting them become dry) to the area, twice a day, with [MEDICATION NAME], and requested measurements of the wound. The nurse sent a fax documenting the resident had two 1 cm scabbed areas on his/her coccyx, no new skin abnormalities at this time, and requested to continue with the A&D ointment (a skin protectant, moisturizes and sealing the skin, and aids in skin healing). The 7/11/2017 at 9:30 PM, nurse's notes recorded the nurse would discontinue the A&D ointment and initiate the Hydrogel twice a day and cover with [MEDICATION NAME] until healed. The 7/24/2017 at 3:22 PM, nurse's notes recorded staff notified the dietician by phone of the resident's current PEG tube orders, and he/she recommended to increase the [MEDICATION NAME] dosage to 1.5 calorie and reviewed the pressure ulcer status. The resident's medical records lacked documentation of the residents coccyx wound from 7/11 until 7/24/2017. On 7/17/2017 at 3:09 PM, observation revealed the resident sat on the bed with the head of bed elevated 30 degrees. Continued observation revealed Nurse Aide Q and Nurse Aide V assisted the resident to stand with use of a gait belt, and ambulated to the bathroom with a walker. Observation revealed the resident voided in the toilet, staff assisted the resident to stand and revealed an area on his/her right buttock, approximately 1 cm x 1 cm, reddish, purple skin, the skin was not open. The aides continued to cleanse the resident's perineal area with personal wipes, applied A&D ointment to his/her coccyx area, and applied a new attends. The resident did not have a [MEDICATION NAME] pad on the coccyx area before or after using the toilet and the staff did not apply the hydrogel after cares. On 7/1/2017 at 3:30 PM, Nurse Aide V stated the resident required a total body lift for transfers, since he/she returned from a recent hospital stay. Nurse Aide V stated the resident received physical therapy and he/she was getting stronger however depending on the day and his/her breathing status, sometimes staff used a sit to stand lift. Nurse Aide V verified he/she used A&D ointment on the resident's coccyx/bottom area. Nurse Aide V stated the coccyx ulcer area had developed after his/her hospital stay, became reddish purple, the wound improved for a short time, however the wound has increased in redness. On 7/19/2017 at 3:50 PM, Administrative Nurse H verified the resident had a recent hospital stay and became weak, developed aspiration pneumonia, and required a feeding tube for feedings and medication administration. Administrative Nurse H verified the resident had his/her head of the bed elevated 30 degrees all of the time due to breathing difficulties and felt that could of contributed to the development of the facility acquired pressure ulcer. Administrative Nurse H verified the resident had a pressure relieving mattress on his/her bed and a gel cushion in his/her wheelchair and recliner. Administrative Nurse H verified the staff had not updated the care plan with new treatment and services to promote healing, and prevent new pressure ulcers from developing. On 7/26/2017 at 4:21 PM, Physician I verified the resident returned to the facility after a hospitalization and he/she did not have any skin issues or concerns, and had developed the pressure areas on his/her right buttock near the coccyx upon return. Physician I verified the staff were to use Hydrogel on the areas and cover with [MEDICATION NAME], and he/she did not want the staff to use A&D ointment. Physician I states the resident liked to be left alone and may become resistant to cares and the staff reminding him/her to reposition. Physician I expected the staff to check the residents skin with cares, and bathing and if they developed any skin issues to contact him/her immediately. Physician I stated the nurses may not convey the order to the aides because they are busy. The facility's 3/2002 Pressure Ulcer prevention policy directed the staff to identify residents at risk for skin breakdown and to prevent the development of pressure ulcers. The policy directed the staff to assess the resident's skin upon admission and at least annually. If any of the areas assessed indicate a risk for skin breakdown, the following measures would be implemented if appropriate, pressure reducing wheelchair cushion, press reducing devices for specific areas of concern, pressure reducing mattress, review of diet by registered dietician, review of restorative nursing program by the Physical Therapist, and increased the frequency of bathing. The facility failed to develop and implement timely and effective interventions, to prevent the development of the pressure ulcer for Resident #41 who was at risk and developed a facility acquired, pressure ulcer on his/her coccyx. The facility lacked consistent weekly wound assessment. - Resident #50's annual (MDS) Minimum Data Set assessment, dated 8/22/16, documented the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented the resident required extensive assistance of 1 staff for bed mobility, locomotion on the unit, personal hygiene, limited staff assistance for transfers, walking in the room, corridor, locomotion off the unit, dressing, and toilet use. The MDS documented the resident used a wheelchair for mobility and was at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS documented the resident had no pressure ulcers, had pressure reducing devices for the bed and chair, and was on turning/repositioning program. The 9/23/16 pressure ulcer (CAA) Care Are Assessment documented the resident had no pressure ulcers, history of developing pressure ulcers, instructed staff to place a pressure reducing pad in the resident's chair, apply a pressure reducing mattress to his/her bed, float his/her heels while in bed, place heel protectors on the resident's feet, and apply skin protectant to the resident's skin. The CAA instructed staff to conduct weekly skin assessments. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, required extensive assistance of 1 staff with bed mobility, transfers, toilet use and personal hygiene, limited assistance of 1 staff with dressing, did not walk, and used a wheelchair for mobility. The MDS documented the resident was at risk for developing a pressure ulcer, had a pressure reducing device for bed and chair, on a turning/repositioning program, and had a stage 1 (intact skin with non-blanching (does not fade when pressed) redness) or greater pressure ulcer with no documentation of the size. The 5/5/17 care plan documented the resident was always in his/her recliner and instructed staff to ensure /encourage the resident to change his/her position every 2 hours, float heels while in the recliner, use pillows to elevate legs, keep bony prominences from direct contact with one another, and a licensed nurse to conduct weekly skin audit/diabetic foot checks. The care plan lacked instructions to staff for providing care of a pressure ulcer on the resident's left heel. The most recent nutritional assessment, dated 11/29/16, by the registered dietician, documented the resident received a (LCS) Low Concentrated Sweets diet, and recommended staff cut up the resident's meat in small pieces with gravy over the meat. The note documented the resident consumed 26-75% of meals, and fluid intake of 1,000-1,499 (cc) cubic centimeters. The note documented the resident's height 65 (in) inches, weight 172.5 (lbs) pounds and the ideal body weight range was 122-150. The note documented the resident required 1563.9 calories, 66 grams of protein, and 1978 cc of fluids, based on adjusted weight of 145 lbs. The note documented the resident was diabetic, had a beneficial weight loss of 12 lbs in the past 3 months, would continue current approaches and monitor his/her weight. The note instructed staff to continue the current plan of care. Review of the medical record revealed no documentation the registered dietician was notified after the residetn acquired his/her left heel pressure ulcer. The 2/5/17 quarterly Braden scale (a tool to assess a patient's risk of developing a pressure ulcer) documented the resident had a score of 16, which indicated mild risk for developing pressure ulcers. The 4/21/17 at 1:53 PM nurse's note, documented the resident's left ankle swollen, tender, increased pain with movement, pedal pulse (pulse felt on the top of the foot) present, and the staff sent the resident to the hospital for an x-ray (photographic or digital image of the internal composition of something, especially a part of the body). The 4/24/17 at 1:39 PM, nurse's note documented a facsimile was received from the resident's clinic visit on 4/21/17 and the physician ordered the resident to be seen by physical therapy, directed staff to apply a ACE wrap to the resident's left ankle, and [DIAGNOSES REDACTED]. The 4/24/17 at 1:05 PM nurse's note, documented the resident wore a walking boot for 3 weeks, was not to have physical therapy, and he/she to be reevaluated in 3 weeks. The 4/24/17 physician order instructed staff to place a walking boot on the resident's left foot in the morning and remove it at night. The 4/26/17 at 1:05 PM, nurse's note documented physical therapy evaluated the boot on the resident's left foot. His/Her foot turned inwards and staff placed a pillow to keep the foot and leg in alignment. The 4/27/17 quarterly Braden scale documented the resident had a score of 15, which indicated moderate risk for developing pressure ulcers. The 5/10/17 at 10:27 AM, nurse's note documented the nurse completed the diabetic foot check and no skin issues were noted. The note documented the left outer ankle remained swollen with improvement noted. Review of the medical record revealed no assessment of the resident's left heel from 5/10/17 until 5/17/17. The 5/17/17 at 1:30 PM, nurse's note documented the resident's left heel was black, spongy and measured 4 (cm) centimeters by 3.5 cm. The note documented the resident's primary physician was unavailable and his/her clinic nurse directed staff to keep the ace wrap on the resident's foot and have the resident continue wearing the left ankle boot until the physician could see the resident on Friday.(5/19/17) The 5/17/17 physician order instructed staff to assess the resident's skin at least daily and measure and document the progress of the pressure ulcer weekly. The 5/19/17 at 12:40 PM, nurse's note documented the physician was in the facility and instructed staff to float the resident's heel, take the boot off, physical therapy to evaluate and treat, and repeat a left ankle X-ray on Monday. The note documented the physician stated the wound area was a blood blister and instructed staff to continue applying ACE (elastic bandage) wrap but not to cover the resident's heel. The 5/24/17 at 11:27 AM, nurse's note documented the nurse completed the resident's skin assessment and diabetic foot check, the resident's left ankle remained swollen, toes appeared less swollen, and the resident had a left ankle fracture. The note documented the resident's left heel had an area with a blood blister that was black/spongy and measured 5.5 cm by 6 cm. The 5/31/17 at 1:04 PM, nurse's note documented the nurse completed the resident's skin assessment and diabetic foot check, the resident's left ankle remained swollen, toes appear less swollen, and the treatment was an ACE wrap, on in the morning and off at bedtime. The note documented the resident's left heel pressure ulcer was black, measured 7 cm by 6 cm with serosanguinous (semi-thick reddish) drainage. The nurse's note lacked documentation staff notified the physician of the change in the pressure ulcer. The 6/2/17 at 12:26 PM, nurse's note documented the physician was in the facility, examined the resident's left heel, and made no changes to the treatment. The 6/7/17 at 12:26 PM, nurse's note documented the nurse completed the skin assessment and diabetic foot check, and the resident's left heel pressure ulcer measured 5 cm by 5.5 cm. The note lacked documentation of a description of the pressure ulcer including color, odor, pain, or drainage. The 6/11/17 at 11:02 AM, nurse's note documented the resident's left heel had two dark areas with a spongy center, and measured 5.5 cm by 6 cm. The 6/14/17 at 1:05 PM, nurse's note documented the resident's left heel pressure ulcer measured 5 cm by 5 cm and had no drainage. The 6/20/17 at 2:30 PM, nurse's note documented the resident's left heel pressure ulcer was dry, intact, stable, had eschar which measured 2.5 cm by 2.5 cm, without drainage, and the resident wore shoes when out of his/her room. The 6/26/17 facsimile to the physician documented physical therapy recommended to discontinue the ACE wraps, apply Ted hose on both legs and a brace to the resident's left ankle, and the physician approved the recommendation. The 6/28/17 at 1:55 PM, nurse's note documented the resident's left heel pressure ulcer dark colored with no drainage, measured 2.8 cm by 2 cm, and the resident wore Ted hose and a heel brace on his/her left foot. The 7/5/17 at 1:55 PM, nurse's note documented the nurse completed the skin assessment diabetic foot check. The resident's left heel pressure ulcer was a dry callus, no drainage, redness or swelling, and measured 3 cm by 2 cm. The 7/19/17 at 1:55 PM, nurse's note documented the nurse completed the skin assessment diabetic foot check, the resident's left heel pressure ulcer had a dry scab, no surrounding redness, no drainage, and measured 2 cm by 1 cm. On 7/20/17 at 9:30 AM, observation revealed the resident seated in a recliner, a nurse was in the room with the resident, the resident had no dressing on his/her left heel, and the pressure ulcer had black eschar, surrounding area pink, no drainage, no odor, and measured approximately 2 cm long by 1.5 cm wide. According to the nurse in the room at the time of the observation there was not suppose to be a dressing on the resident's left heel pressure ulcer, and there was no physician order for [REDACTED].>On 7/20/17 at 9:48 AM, Nurse G stated the resident acquired his/her left heel pressure ulcer from the walking boot he/she was wearing after the resident fractured his/her foot. Nurse G stated the resident had no pressure ulcer dressing or care instructions, and staff were to float his/her heels. On 7/20/17 at 3:20 PM, Nurse J stated the facility had no wound nurse, and the floor nurses were responsible to complete the weekly skin assessments. Nurse J stated every day the nurses were given a list of residents who they were responsible for conducting skin assessments. On 7/24/17 at 10:20 AM, Nurse G stated when the resident had the walking boot on, staff assessed the resident's skin under the boot weekly, during the resident's weekly skin assessment. On 7/24/17 at 3:02 PM, Nurse J stated he/she was unaware how the resident acquired the pressure ulcer on his/her left heel. Nurse J stated he/she started working for the facility a month ago and at that time staff treated the resident's heel with a meplix dressing and staff now left it open to air. Nurse J stated there was not a physician order in the medical record. On 7/24/17 at 4:00 PM, Administrative Nurse H stated the resident had an injury to his//her left ankle, so the resident wore a boot, which caused the resident to acquire the pressure ulcer on his/her left heel. Administrative Nurse H verified the medical record lacked documentation the staff notified the physician on 5/31/17, when the pressure ulcer had serosanguinous drainage. Administrative Nurse stated he/she would expect staff to monitor the skin under the resident's walking boot, daily, when placing the boot on in the morning and when taking the boot off at night. On 7/25/17 at 11:50 AM, Physician K stated the resident had a walking boot placed on around 4/25 or 4/26/17, developed a blood blister after the resident started wearing the boot, and he/she would have expected staff to monitor the resident's skin when the boot was placed on and when it was taken off. The facility's 3/8/2002 Decubitus Ulcer prevention policy documented staff should assess the resident's skin upon admission and at least annually. The facility failed to provide care and services to prevent Resident #50 from acquiring an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer on his/her left heel, by not properly monitoring the resident's skin under his/her walking boot.

The facility had a census of 60 residents. The sample included 3 residents sampled for abuse. Based on observation, record review and interview, the facility failed to protect the residents in the facility after the allegation of abuse, and failed to thoroughly investigate and report to the state agency, allegations of abuse and neglect of 1 sampled resident. (#1) This deficient practice placed all the residents in the facility in immediate jeopardy. Findings included: - Resident #1's (POS) physician's orders [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 1/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further revealed the resident had functional upper impairment on both sides, and had moderate pain. The (ADLs) Activities of Daily Living (CAA) Care Area Assessment, dated 5/6/16, indicated the resident had limited range of motion to his/her upper and lower extremities which made it difficult for him/her to perform ADL's without staff assistance. The CAA stated the resident was cognitively aware and able to use his/her call light for assistance. The CAA further stated the resident required the use of a sit-to-stand lift for transfers, due to him/her no longer able to independently ambulate. The 1/26/17 care plan stated the resident had decreased range of motion in his/her upper and lower extremities, and directed staff to use the sit-to-stand lift for transfers, due to pain. The 12/1/16 Physical therapy notes stated the resident had bilateral (affecting both sides) knee pain, required moderate staff assistance with bed mobility, and used a sit-to-stand lift for transfers. The physical therapy long term goal for the resident was to safely transfer with the sit-to-stand lift with very light facial grimacing, and complaint of knee pain. The 1/25/17 Physical therapy notes stated the resident was discharged from therapy due to lack of progress and the resident's multiple refusals during the week. Review of the medical record lacked documentation of an allegation of staff to resident abuse. Although requested, the facility failed to provide an investigation regarding an incident of alleged abuse that occurred involving Resident #1 and Nurse Aide C. On 4/24/17 at 1:05 PM, observation revealed the resident sat in his/her wheelchair waiting for Nurse Aide B to assist him/her into bed to rest. Nurse Aide B instructed the resident to lift his/her feet onto the foot stand platform on the sit-to-stand lift and attached the sling around the resident's waist and onto the lift. Nurse Aide B asked the resident if he/she was comfortable and the resident responded, yes. Further observation revealed Nurse Aide B raised the resident from a sitting to a standing position and asked the resident if he/she was ok and if he/she was up too high in the lift. The resident stated he/she was ok. Continued observation revealed Nurse Aide B pulled down the resident's pants and incontinent product and lowered the resident onto the commode. Observation further revealed Nurse Aide B lifted the resident, performed pericare, removed his/her soiled gloves, pulled up the resident's incontinent product and pants, and moved him/her over the side of the bed. Nurse Aide B told the resident that he/she was going to pick up the resident's feet and put them onto the bed, placed a cushion under his/her knees, and covered up the resident with a blanket. On 4/20/17 at 9:00 AM, Nurse Aide C stated he/she could not remember the date of the incident, but he/she raised Resident #1 up too high in the sit-to-stand lift, and the resident lifted his/her feet off the platform. Nurse Aide C stated he/she asked the resident to please put his/her feet down. Nurse Aide C stated he/she did not know the resident did not like to be stood up that high and the resident cried because Nurse Aide C had hurt his/her legs. Nurse Aide C stated Nurse Aide D was in the room the entire time, had witnessed the incident and knew everything that had happened. Nurse Aide C stated, later in the evening, Licensed Nurse E talked to him/her about the incident and told him/her to give the resident a few days and to let someone else answer his/her call light. On 4/20/17 at 11:10 AM, Resident #1 stated Nurse Aide C did not pay attention how high he/she stood the resident in the lift and it hurt the resident. Resident #1 stated he/she would say nice things to Nurse Aide C so he/she would focus on something else, because he/she was worried that Nurse Aide C would hurt him/her. Resident #1 stated Nurse Aide C would kick at his/her feet if they were not where Nurse Aide C wanted them. Resident #1 stated he/she would tell Nurse Aide C how high to raise him/her in the lift, but Nurse Aide C would raise the lift so high, his/her knees wobbled around and it would hurt. On 4/20/17 at 12:53 PM, Nurse Aide D stated, on the day of the incident, he/she was in the hallway and the resident stopped him/her and said he/she did not like Nurse Aide C. The resident stated Nurse Aide C stood him/her up too high, knocked his/her legs away from the platform and caused the resident to cry. Nurse Aide D stated he/she took Nurse Aide C back into the resident's room to show him/her how to correctly transfer the resident with the lift and settle the resident into bed. Nurse Aide D stated the resident's care plan was behind the door and gives instructions how to care for the resident. Nurse Aide D stated he/she was not in the room during the incident and went to Administrative Nurse E to report the incident, but could not remember the exact date of the incident. On 4/20/17 at 5:34 PM, Administrative Nurse E stated he/she could not remember the date of the incident, but remembered talking with the resident about care given by Nurse Aide C. Administrative Nurse E stated Nurse Aide D reported the resident was upset and Nurse Aide D was unable to find the Director of Nursing, so Administrative Nurse E went to visit with the resident. The resident stated Nurse Aide C was loud, and did not know how to use the lift correctly on him/her. Administrative Nurse E stated he/she told Nurse Aide C to let someone else answer the resident's call light, but did not specify how long Nurse Aide C was to not care for the resident. Administrative Nurse E stated he/she talked to the former Director of Nursing about the incident and was not sure if it was investigated. On 4/20/17 at 3:32 PM, Administrative Staff F stated he/she was unaware of the incident between the resident and Nurse Aide C and Administrative Staff F stated the DON at the time of the incident no longer worked at the facility. Administrative Staff F further stated to keep the resident's safe, he/she would have another staff member be with Nurse Aide C during cares or suspend the nurse aide. The 4/18/13 facility Preventing Abuse policy stated any staff member suspected of abuse will be put on a leave of absence until an investigation can be completed. All staff were responsible for ensuring that any allegations of abuse, neglect, or exploitation are investigated and reported immediately to the Administrator and to the state agency. Staff should report suspicions of abuse to their immediate supervisor or the charge nurse on duty. The 4/18/13 facility's Abuse, Preventing and Reporting Policy stated, the resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion. The resident must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Any staff member suspected of abuse will be put on leave of absence until an investigation can be completed, if the allegation is substantiated, the employee will be terminated, if it is not substantiated, the employee will return to work for their next scheduled shift. Residents will be protected from harm during the investigation. Supervisors are responsible for identifying and correcting inappropriate behavior such as the use of derogatory language, rough handling, ignoring residents while giving care, misuse of resident belongings, etc. Employees are instructed to report concerns according to the chain of command. The administrator must be notified of any incidents that could be determined to be abuse, neglect, or exploitation. The policy further stated, it is the responsibility of all staff members, families and visitors to be [MEDICAL CONDITION] of resident abuse and report it to the administrator DON, charge nurse, or department supervisor. All cases of abuse should be reported immediately and the investigation will be completed within 5 days of the incident. If the resident is in immediate danger, the situation must be adjusted immediately to ensure the safety of the resident. All reports must include written documentation of the alleged incident. The administrator and/or DON must be notified via telephone if they are not in the facility and staff will be trained upon employment on how to deal with aggressive resident, abuse from staff or a family member. Staff will be trained on how to report and how to recognize signs of possible abuse. Staff will be oriented to report any signs of burnout , frustration, and exploitation. The facility failed to protect, thoroughly investigate, and report an allegation of abuse regarding Resident #1, placing all the residents at risk for abuse. The facility abated the immediate jeopardy on 4/23/17 at 8:05 PM after the facility suspended Nurse Aide C, and after completion of face to face training of all staff regarding abuse, neglect, and exploitation. This training also included the importance of following the abuse, neglect, and exploitation policy and the protection of residents. The deficient practice remains at the scope and severity of F.

The facility had a census of 60 residents. The sample included 3 residents sampled for abuse. Based on observation, record review, and interview the facility failed to provide an environment free from abuse for 1 of 3 sampled residents which put Resident #1 in immediate jeopardy. Findings included: - Resident #1's (POS) physician's orders [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 1/23/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further revealed the resident had functional upper impairment on both sides, and had moderate pain. The (ADLs) Activities of Daily Living (CAA) Care Area Assessment, dated 5/6/16, indicated the resident had limited range of motion to his/her upper and lower extremities which made it difficult for him/her to perform ADL's without staff assistance. The CAA stated the resident was cognitively aware and able to use his/her call light for assistance. The CAA further stated the resident required the use of a sit-to-stand lift for transfers, due to him/her no longer able to independently ambulate. The 1/26/17 care plan stated the resident had decreased range of motion in his/her upper and lower extremities, and directed staff to use the sit-to-stand lift for transfers, due to pain. The 12/1/16 Physical therapy notes stated the resident had bilateral (affecting both sides) knee pain, required moderate staff assistance with bed mobility, and used a sit-to-stand lift for transfers. The physical therapy long term goal for the resident was to safely transfer with the sit-to-stand lift with very light facial grimacing, and complaint of knee pain. The 1/25/17 Physical therapy notes stated the resident was discharged from therapy due to lack of progress and the resident's multiple refusals during the week. Review of the medical record lacked documentation of an allegation of staff to resident abuse. Although requested, the facility failed to provide an investigation regarding an incident of alleged abuse that occurred involving Resident #1 and Nurse Aide C. On 4/24/17 at 1:05 PM, observation revealed the resident sat in his/her wheelchair waiting for Nurse Aide B to assist him/her into bed to rest. Nurse Aide B instructed the resident to lift his/her feet onto the foot stand platform on the sit-to-stand lift and attached the sling around the resident's waist and onto the lift. Nurse Aide B asked the resident if he/she was comfortable and the resident responded, yes. Further observation revealed Nurse Aide B raised the resident from a sitting to a standing position and asked the resident if he/she was ok and if he/she was up too high in the lift. The resident stated he/she was ok. Continued observation revealed Nurse Aide B pulled down the resident's pants and incontinent product and lowered the resident onto the commode. Observation further revealed Nurse Aide B lifted the resident, performed pericare, removed his/her soiled gloves, pulled up the resident's incontinent product and pants, and moved him/her over the side of the bed. Nurse Aide B told the resident that he/she was going to pick up the resident's feet and put them onto the bed, placed a cushion under his/her knees, and covered up the resident with a blanket. On 4/20/17 at 9:00 AM, Nurse Aide C stated he/she could not remember the date of the incident, but he/she raised Resident #1 up too high in the sit-to-stand lift, and the resident lifted his/her feet off the platform. Nurse Aide C stated he/she asked the resident to please put his/her feet down. Nurse Aide C stated he/she did not know the resident did not like to be stood up that high and the resident cried because Nurse Aide C had hurt his/her legs. Nurse Aide C stated Nurse Aide D was in the room the entire time, had witnessed the incident and knew everything that had happened. Nurse Aide C stated, later in the evening, Licensed Nurse E talked to him/her about the incident and told him/her to give the resident a few days and to let someone else answer his/her call light. On 4/20/17 at 11:10 AM, Resident #1 stated Nurse Aide C did not pay attention how high he/she stood the resident in the lift and it hurt the resident. Resident #1 stated he/she would say nice things to Nurse Aide C so he/she would focus on something else, because he/she was worried that Nurse Aide C would hurt him/her. Resident #1 stated Nurse Aide C would kick at his/her feet if they were not where Nurse Aide C wanted them. Resident #1 stated he/she would tell Nurse Aide C how high to raise him/her in the lift, but Nurse Aide C would raise the lift so high, his/her knees wobbled around and it would hurt. On 4/20/17 at 12:53 PM, Nurse Aide D stated, on the day of the incident, he/she was in the hallway and the resident stopped him/her and said he/she did not like Nurse Aide C. The resident stated Nurse Aide C stood him/her up too high, knocked his/her legs away from the platform and caused the resident to cry. Nurse Aide D stated he/she took Nurse Aide C back into the resident's room to show him/her how to correctly transfer the resident with the lift and settle the resident into bed. Nurse Aide D stated the resident's care plan was behind the door and gives instructions how to care for the resident. Nurse Aide D stated he/she was not in the room during the incident and went to Administrative Nurse E to report the incident, but could not remember the exact date of the incident. On 4/20/17 at 5:34 PM, Administrative Nurse E stated he/she could not remember the date of the incident, but remembered talking with the resident about care given by Nurse Aide C. Administrative Nurse E stated Nurse Aide D reported the resident was upset and Nurse Aide D was unable to find the Director of Nursing, so Administrative Nurse E went to visit with the resident. The resident stated Nurse Aide C was loud, and did not know how to use the lift correctly on him/her. Administrative Nurse E stated he/she told Nurse Aide C to let someone else answer the resident's call light, but did not specify how long Nurse Aide C was to not care for the resident. Administrative Nurse E stated he/she talked to the former Director of Nursing about the incident and was not sure if it was investigated. On 4/20/17 at 3:32 PM, Administrative Staff F stated he/she was unaware of the incident between the resident and Nurse Aide C and Administrative Staff F stated the DON at the time of the incident no longer worked at the facility. Administrative Staff F further stated to keep the resident's safe, he/she would have another staff member be with Nurse Aide C during cares or suspend the nurse aide. The 4/18/13 facility Preventing Abuse policy stated any staff member suspected of abuse will be put on a leave of absence until an investigation can be completed. All staff were responsible for ensuring that any allegations of abuse, neglect, or exploitation are investigated and reported immediately to the Administrator and to the state agency. Staff should report suspicions of abuse to their immediate supervisor or the charge nurse on duty. The facility failed to protect Resident #1 from staff to resident abuse, placing him/her at risk for further abuse. The facility abated the immediate jeopardy on 4/23/17 at 8:05 PM when the facility suspended Nurse Aide C, and after completion of face to face training of all staff regarding abuse, neglect, and exploitation. This training also included the importance of following the abuse, neglect, and exploitation policy and the protection of residents. The deficient practice remained at the scope and severity of a D.

The facility had a census of 64 residents. The sample included 20 residents of which 3 were reviewed for hydration. Based on observation, record review and interview, the facility failed to provide adequate fluids and monitor hydration status for 3 of the 3 sampled residents. (#75, #42, #40) #75 admitted to the hospital with [REDACTED]. Findings included: - Resident #75's medical record revealed the facility admitted the resident into skilled nursing on 10/20/15. The resident's (POS) physician's orders [REDACTED]. The 5 day Medicare (MDS) Minimum Data Set assessment, dated 10/27/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 13 which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, personal hygiene, and independent with supervision for eating. The assessment further revealed the resident had a functional impairment of the lower extremity on 1 side, and received speech, occupational, and physical therapy 5 days a week. The assessment did not indicate the resident's type of diet. The 14 day MDS, dated [DATE], indicated the resident had a BIMS of 13 which indicated intact cognition. The assessment revealed the resident remained the same except was on a mechanically altered diet. The Nutritional (CAA) Care Area Assessment, dated 11/2/15, indicated the resident had a [DIAGNOSES REDACTED]. The CAA further indicated the resident's fluid daily totals were 700-800 (ml) milliliters. The 10/20/15 temporary care plan directed staff to provide fresh water of thin consistency, three times a day, encourage adequate fluid intake, and notify the physician of significant changes. The 10/29/15 updated care plan stated the staff planned to talk with the resident's primary physician regarding the resident's request for a feeding tube. Review of the medical record lacked an (RD) Registered Dietician's nutritional assessment to direct staff of the estimated fluid needs of the resident from his/her admission to the facility to the present. A general guideline for determining baseline daily fluids is to multiply the resident's body weight in kilograms and times by 30 cc. The resident's admission weight was 239 pounds, therefore the resident required 3240 cc of fluid per day to prevent dehydration. Review of the facility's fluid intake record from 10/20/15 through 10/29/15, when the physician assistant evaluated the resident, revealed the following daily fluid intake: 10/20/15- 540 (ml) milliliters 10/21/15- 680 ml 10/22/15- 740 ml 10/23/15- 870 ml 10/24/15- 10 ml 10/25/15- 670 ml 10/26/15- 770 ml 10/27/15- 430 ml 10/28/15- 840 ml 10/29/15- 350 ml Review of the urine output record revealed the resident had urine output on 10/21/15 and 10/23/15 but lacked documentation of any other days the resident had any output from 10/24/15 to 11/3/15. The 10/13/15 hospital laboratory report, prior to admission, revealed the resident's (CMP) comprehensive metabolic panel (a blood test that serves as a initial broad medical screening tool) was within normal limits. The 10/22/15 at 2:12 PM, nurse's note indicated the resident would take sips of water between small bites of food. The 10/23/15 at 9:44 PM, nurse's note stated the resident complained of his/her spit going down his/her throat, and gagging him/her after a coughing spell. The note further stated the staff notified the physician but received no new orders. The 10/27/17 fax communication to the physician stated the resident had a resting heart rate of 115 (normal 60-100). (The fax lacked documentation of the resident's decreased daily fluid intake) The 10/28/15 laboratory report revealed the resident's chloride level of 98, (normal 100-116), carbon [MEDICATION NAME] 33, (normal is 18-29), creatinine 0.49, (normal 0.6-1.3), and calcium 11.20 (normal 8.60 - 10.40). The 10/28/15 untimed, speech therapy note stated the resident was very tired and had no energy. The note further stated the resident had possible thrush (white, cottage cheese appearance) on his/her tongue and the therapist reported it to nursing staff. (The medical record lacked documentation staff notified the physician or completed any other assessment of the resident) The 10/28/15 untimed, physical therapy note stated the resident had a resting heart rate of 117 (bpm) beats per minute during the therapy session. The 10/29/15 untimed, speech therapy note indicated the resident's spouse stated the physician assistant would talk to the resident's primary care physician regarding a feeding tube for extra nutrition but would wait until the resident had seen an ear, nose and throat specialist the following week. The 10/29/15 physician assistants' notes indicated the resident had slightly dry oral mucosa and difficulty swallowing fluids due to a lot of thick phlegm and stated he/she would be talking with the resident's primary care physician regarding a feeding tube. The note further stated he/she would order [MEDICATION NAME] ER, (an [MEDICATION NAME] that thins mucus and sputum) 600 (mg) milligrams), twice a day, to help with secretions. Review of the facility's fluid intake record from 10/30/15 to 11/3/15 revealed the following daily fluid intake: 10/30/15-360 ml 10/31/15-220 ml 11/1/15-240 ml 11/2/15-330 ml 11/3/15-150 ml The 10/31/15 at 8:18 PM, nurse's note stated the resident refused all food and had taken only sips of liquid that shift, due to extreme dysphagia and fear of aspiration (choking). The 11/2/15 untimed, speech therapy note stated the resident seemed pale and exhausted, and nursing staff reported the resident had consumed 240 ml of fluid in the last 24 hours. The note further stated the resident's resting heart rate was 114 (bpm) beats per minute and the therapist reported to nursing staff the concern of possible dehydration. The note further stated staff would fax the physician. The 11/2/15 at 1:33 PM, fax communication to the physician stated the resident had a resting heart rate of 114 which increased with movement and exercise. The note stated the resident had lost 11 pounds in 10 days but lacked any mention of the resident's fluid status. The physician stated insertion of a feeding tube was being arranged. Review of the medical record lack documentation any further assessment completed for the resident. The 11/2/15 untimed, physical therapy note stated the resident had a heart rate of 110-114 bpm, and required several rest breaks due to fatigue and shortness of breath. The note stated he/she limited the resident's exercises due to the resident's high heart rate. The physical therapist voiced concern to nursing staff of the resident's heart rate and dehydration, weight loss, decreased oxygen level. The note stated the physician assistant was to consult with the resident's primary care physician regarding a feeding tube but there had not been any new orders. The note further stated the therapist voiced concern over the resident traveling for an appointment the next day due to the resident's declining condition. The 11/3/15 untimed, physical therapy note stated the therapist talked with the charge nurse and stated the resident needed to be seen by a physician due to dehydration, and high resting heart rate. The note stated the therapist met with the director of nursing and indicated the resident required hospitalization with (IV) intravenous fluids. The note stated the director of nursing would contact the primary care physician regarding his/her concerns with the resident. The note later stated the resident would be admitted to a local hospital later in the afternoon. The 11/3/15 untimed, speech therapy note stated the resident was pale and exhausted with a resting heart rate of 125. The note further stated the resident's tongue had a coating and very dry lips. The note stated the speech therapist had the resident swab his/her mouth with a toothette and put chapstick on his/her lips. The note stated the therapist spoke with nursing staff about the concern for dehydration, high heart rate, no energy, and always tired. The note further stated the nursing staff had notified the physician and the plan was to put in a feeding tube on 12/6/15. The 11/3/15 History and Physical from the local hospital stated the resident had difficulty swallowing and had not taken any solid food for 4 days, additionally, he/she choked easily even though nursing staff tried thickening his/her liquids. The H & P further stated the resident would be admitted due to dehydration and for IV fluids as his/her oral mucosa was dry and his/her calcium level was high at 12 (normal 8.60-10.40) due to dehydration. (Review of the medical record lacked documentation the staff thickened the resident's liquids) The resident did not return to the facility after his/her hospital admission. On 12/14/15 at 3:03 PM, Nurse Aide N stated the resident needed total care for all activities of daily living. Nurse Aide N stated the staff documented all fluid intakes into the computer. On 12/14/15 at 4:00 PM, Dietary Manager D stated the dietician had not assessed the resident and the speech therapist had directed the dietary staff to mechanically alter the resident's diet. Dietary Manager D stated he/she did not monitor the resident's fluids. On 12/15/15 at 8:36 AM, Social Service Staff I stated he/she had taken the resident to his/her appointment out of state on 11/3/15. Social Service Staff I further stated the resident's spouse went along to the appointment and they had stopped several times on the way back because the resident was uncomfortable from the long drive due to sitting up for an extended time. Social Service Staff I stated the hospital admitted the resident to the local hospital for fluids after they returned. On 12/5/15 at 11:00 AM, Licensed Nurse M stated staff tried to encourage the resident to eat and drink, and even used tomato juice in his/her foods. Licensed Nurse M further stated the resident did not look dehydrated, and verified the staff did not monitor the resident's fluid intake. On 12/15/15 at 2:30 PM, Registered Dietician L stated he/she came to the facility on ce a month and relied on the dietary manager to tell him/her if any residents were at risk. Registered Dietician L further stated he/she did not assess the resident while at the facility. On 12/16/15 at 10:30 AM, Physician J stated he/she was unsure how often the facility notified him/her of the resident's hydration status. Physician J further stated it might have made a difference in the outcome if the resident would have been admitted sooner to the hospital but could not say that for sure. On 12/16/15 at 1:57 PM, Administrative Nurse A stated the nursing staff should have monitored the resident' s fluid intake and documented any contact made to the physician notifying him/her of the resident's hydration status and increased heart rate. Administrative Nurse A further stated he/she was aware of the resident's risk for dehydration due to ALS and thought the facility could take care of the resident. Administrative Nurse A stated, although it was not documented, the resident should have received at least 1,000 ml of fluid daily. The 5/5/99 facility's Fluid Encouragement Policy stated the facility should provide fluid intake based on individual needs to prevent dehydration. The policy directed staff to be gentle, be persistent, and encourage the resident to take adequate fluids and to offer fluids frequently. The facility failed to monitor, and assess Resident #75, who showed signs of dehydration and required hospitalization . - Resident #42's significant change (MDS) Minimum Data Set assessment, dated 8/10/2015, indicated the resident had short and long term memory loss and severely impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff for eating, transfers, bed mobility, dressing, toilet use and personal hygiene. The assessment further revealed the resident received a mechanically altered diet. The 11/02/2015 care plan directed the staff to assist the resident and encourage good meal intake. The care plan indicated the resident received a regular pureed diet, appetite had declined, and he/she was no longer able to independently eat or drink. The care plan directed the staff to monitor the resident for signs and symptoms of dehydration, thirst, poor skin turgor, dry skin/mucous membranes, concentrated/decreased urine output, elevated heart rate, constipation, increase in falls, and sudden mental changes. On 12/10/2015 at 12:00 PM, observation revealed the resident seated in a broda chair in the special care unit dining room. Observation revealed the resident pursed his/her lips together and frowned when Nurse Aide W attempted to assist him/her to eat a spoonful of pureed food. Further observation revealed the Nurse Aide W placed his/her right hand around the back of the resident's neck and pulled him/her forward to sit the resident up straight, Nurse Aide W and assisted the resident to drink the beverages from a cup, the resident pursed his/her lips together and drank a small amount of fluid, and some ran out of his/her mouth. Continued observation revealed the resident had cracked, dry peeling lips. The 11/04/2015 Certified Dietary Managers nutritional notes indicated the resident received a regular pureed diet and a supplemental shake 1 time a day for weight maintenance. The notes indicated the resident's food intake was 76-100%, and fluid intake was approximately 1287 (cc) cubic centimeters. A general guideline for determining baseline daily fluids is to multiply the resident's body weight in kilograms and times by 30 cc. The resident weight was 138 pounds, therefore the resident required 1875 cc of fluid per day to prevent dehydration. Review of the medical records revealed the following intakes: 12/02/15- 980 12/04/15- 780 12/05/15- 720 12/07/15- 940 12/08/15- 720 12/09/15- 900 12/11/15- 840 The medical record revealed no documentation of a nutritional assessment by a registered dietician in the last year to indicate the resident's nutritional needs including calories, proteins, and fluids. On 12/15/2015 at 2:40 PM, Registered Dietician L stated the Certified Dietary Manager would do a dietary evaluation after the resident's admission to the facility, and he/she would complete his/her dietary evaluation within 30 days of the resident's admission. On 12/15/2015 at 3:00 PM, Dietary Manager D stated he/she completed the resident's initial dietary evaluation and if he/she determined the resident was at risk he/she would contact Registered Dietician L. Dietary Manager D was unable to provide the survey team a list of the criteria for a resident at risk. On 12/15/2015 at 3:15 PM, Administrative Nurse A verified the certified dietary manager would complete the initial dietary evaluation to include height, weight, and the diet ordered when the facility admitted the resident. Administrative Nurse A verified the Registered Dietician only comes to the facility on ce a month to do the dietary assessments for new admissions, review the residents with weight loss, and residents at risk. Administrative Nurse A was unable to provide a criteria for a resident at risk and when the registered dietician should be contacted with a new admit. The facility's 5/05/1999 fluid encouragement policy indicated the purpose is to provide fluid intake based on the resident's individual needs, to prevent dehydration, and to provide nutrition. The assessment would include hydration status, difficulty chewing and swallowing, nutritional status, hand dexterity, reason for fluid refusal, need for dietary and fluid restriction's food preference, food allergies [REDACTED]. The sign and symptoms include dry skin and/or mucous membranes, cracked lips, poor skin turgor, thirst and fever. The staff would position the resident in Fowler's (the upper half of the resident's body is 60 and 90 degrees in relation to the lower half of his/her body.) Have the fluids at the proper temperature, be gentle, be persistent and encourage the resident to take adequate fluids and offer fluids frequently. The policy states to record date, time, amount and types of fluid taken, if indicated. Record the amount of the resident's cooperation and encouragement needed. The facility failed to ensure the provision and monitoring of sufficient fluid intake to maintain proper hydration for Resident #42. - Resident #40's medical record revealed the following [DIAGNOSES REDACTED]. weakness, hypertension (high blood pressure) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). The quarterly (MDS) Minimum Data Set, dated dated [DATE], indicated the resident scored 5, on the (BIMS) Brief Interview for Mental Status, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of 1 staff with bed mobility, transfers, walking, locomotion, dressing, toilet use, personal hygiene, and supervision with set up help only for eating. The MDS further indicated the resident weighed 208 pounds and received a regular diet. The nutritional (CAA) Care Area Assessment, dated 3/5/15, indicated the resident eats independently in the main dining room, and dietary assessments and dietician reviews would be completed quarterly and as needed. The dehydration and fluid maintenance CAA did not trigger. The care plan, dated 11/9/15, instructed staff to encourage adequate fluid intake, monitor and report any signs/symptoms of dehydration (thirst, pallor, elevated heart rate, constipation, increase in falls, change in mental status, decreased urinary output or concentrated urine, dry skin/mucous membranes, fever, abnormal lab values, postural [MEDICAL CONDITION]), weigh the resident weekly, ensure the resident's plate is set up, and provide prompting to eat as necessary. The medical record revealed the most recent Nutritional History Form completed by the (RD) Registered Dietician, on 4/30/13, identified the resident's total caloric needs, estimated protein needs and estimated fluid needs (2 ½ years ago). Review of the facility's intake record for December 1st through 15th, 2015 revealed the following total daily fluid intake: 12/1/15- 900 (ml) milliliters 12/2/15- 610 ml 12/3/15- 835 ml 12/4/14- 870 ml 12/5/15- 990 ml 12/6/15- 660 ml 12/7/15- 930 ml 12/8/15- 135 ml 12/9/15- 210 ml 12/10/15- 880 ml 12/11/15- 580 ml 12/12/15- 725 ml 12/13/15- 445 ml 12/14/15- 565 ml 12/15/15- 835 ml Review of the facility's urinary output record for December 1st through 15th, 2015 revealed the following: on 12/5/15, 12/6/15, and 12/7/15 the record lacked documentation for urinary output for the resident. On 12/9/15 the record indicated the resident had urinary output twice. On 12/12/15 the record indicated the resident had urinary output 3 times. For all other days the record indicated the resident had urinary output once per day. On 12/14/15 at 12:45 PM, observation revealed the resident, seated in his/her wheelchair at the dining room table with his/her eyes closed and food and fluids placed on the dining room table in front of the resident. Further observation revealed staff prompted him/her on two occasions in which the resident briefly opened his/her eyes and made no further response. The resident did not eat any of his/her lunch meal. On 12/15/15 at 8:38 AM, observation revealed two staff members transferred the resident from his/her wheelchair to the recliner, approximately 8 feet away from his/her dresser where the water pitcher was placed, outside of the resident's reach. On 12/14/15 at 8:40 AM, Nurse Aide H stated the resident usually eats fairly well but he/she didn't eat well that morning. Nurse Aide H further stated the resident gets food at night when he/she is awake, the resident eats better during the night and the resident doesn't prefer water but does like to drink coffee. On 12/15/15 at 9:50 AM, Nurse B stated the resident is able to eat independently and sometimes needs verbal prompting by staff. Nurse B further stated that breakfast and daytime in general was not the resident's best time of day and there are always snacks available for the resident to eat during nighttime hours. Nurse B verified the nurse aide staff are to document in the record, the percentage of meals and snacks the resident consumes, the amount of fluids the resident drinks, as well as refusals of food and fluids. On 12/16/15 at 2:00 PM, Administrative Nurse A stated that he/she knows the resident often refuses daytime and afternoon snacks and nursing staff monitors for dehydration. Administrative Nurse A verified nurse aide staff are to document each time a resident has urinary output, and stated as a general rule, residents should receive 1,000 (ml) milliliters per day. The facility's 4/19/13 Aide Charting policy instructed staff to record each time nourishment is offered, accepted or refused, and the amount consumed. The facility's 5/5/1999 Fluid Encouragement policy instructed staff to be gentle, be persistent and encourage the resident to take adequate fluids, to offer fluids frequently, and to record the date, time, amount and type of fluid taken. The facility failed to ensure Resident #40 had sufficient fluid intake to maintain proper hydration and health.

The facility had a census of 64 residents. The sample included 14 residents of which 4 were reviewed for accidents. Based on observation, interview and record review the facility failed to provide care and services to prevent injuries during transport with a wheelchair, which resulted in a fracture, for 1 of 4 residents reviewed for accidents. (#33) Based on observation, record review and interview the facility failed to adequately monitor the water temperature on 1 of 4 halls to ensure the hot water temperature was within safe, acceptable ranges for the residents residing on the hall. Findings included: - The (POS) Physician order [REDACTED].#33, dated 9/18/14, indicated [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 7/28/14, indicated the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, required extensive assistance of 2 staff with bed mobility and transfers, and was independent with locomotion. The MDS indicated the resident's balance during surface to surface transfer was unsteady and he/she required assistance to balance, the resident had impaired (ROM) Range of Motion in 1 upper and 1 lower extremity. The MDS indicated the resident used a wheelchair for mobility, had no falls since the previous MDS, received (OT) Occupational Therapy and restorative range of motion exercises over 4 days of the look back period. The 7/28/14 (CAA) Care Area Assessment for falls stated the resident had no falls this review period, was non-ambulatory and status [REDACTED]. The summary indicated the staff used the sit to stand lift for all transfers and the resident was able to hold on with his/her right arm. The summary indicated the resident used an electric wheelchair for his/her primary mode of locomotion, and the staff encouraged the resident to wear nonskid footwear or socks at all times. The 7/28/14 care plan for falls indicated the resident used an electric wheelchair for locomotion and directed the staff to use a sit to stand lift with 1 staff assistance during the day and 2 staff assistance at night for all transfers. The care plan lacked updates regarding the use of the manual wheelchair during periods when the electric wheelchair was not working. The care plan lacked instruction for the staff to ensure the resident's left leg (which had muscle weakness and [DIAGNOSES REDACTED]) was appropriately secure during transport in the manual wheelchair. The 8/1/14 at 12:41 PM, nurse's note indicated the resident's electric wheelchair was working, but not completely fixed and would sometimes quit working. The note further stated the resident was unable to wheel a manual wheelchair and did not like to have help. The 8/10/14 at 4:34 PM nurse's note indicated at 4:00 PM, the staff pushed the resident, in his/her manual wheelchair, out into the hall while the resident positioned his/her weak left foot (affected by [DIAGNOSES REDACTED]) over his/her right foot, with no wheelchair foot pedals in place. The note indicated the resident's left foot slipped off his/her right foot and was bent under the wheelchair. The note indicated the resident expressed pain and a nurse assessed the resident's ankle and found no swelling, redness or bruising at that time. The resident stated it was okay and independently propelled his/her wheelchair down the hall. The 8/11/14 at 3:30 AM, nurse's note indicated the resident complained of pain in his/her left ankle and reported he/she bumped it on his/her wheelchair yesterday. The note indicated the staff noted the resident's left ankle was swollen and painful to touch when the staff barely touched the area. The note indicated the nurse administered Lortab (narcotic pain medication), as needed, to the resident and the staff applied an ice pack to the resident's left ankle. Review of the medical record revealed no documentation the staff reassessed the resident's ankle until approximately 11 later. Further review of the medical record revealed no documentation the staff notified the physician regarding the incident and the resident's increased pain or swollen left ankle. The 8/11/14 at 4:00 PM, the physician's telephone order directed the staff to transport the resident to the hospital for an x-ray of his/her left ankle. (more than 23 hours after the accident and more than 12 hours after the staff noted the resident ' s left ankle was painful and swollen) The 8/11/14 at 8:35 PM, nurse's note indicated the resident stated the pain in his/her left ankle had increased despite the ice packs the staff applied and he/she received Tylenol (pain relief medication), as needed. Review of the medical record revealed the resident received scheduled Lortab at bedtime. The note indicated the nurse notified the resident's family who agreed the resident's ankle should be x-rayed and the staff transported the resident to the hospital at 4:30 PM. The note stated the staff continued to apply ice packs, as needed, and Lortab as scheduled. The 8/13/14 facility report stated the staff pushed the resident, in his/her wheelchair, into the hallway while the resident held up his/her weak left foot with his/her right foot. The report indicated the resident's left foot slipped off his/her right foot, was caught on the carpet and bent under the wheelchair or bumped the wheelchair wheel. On 10/14/14 at 10:50 AM, observation revealed the resident was in the beauty shop, in his/her electric wheelchair, his/her feet on a single full foot platform, with shoes on. On 10/14/14 at 4:39 PM, observation revealed Nurse Aide K and L used a sit to stand lift to transfer the resident from his/her recliner to the toilet. Observation during the transfer revealed the resident's left arm hung down, limp and he/she used his/her right arm to hold on to the lift with both feet positioned forward on the lift platform. After the CNAs assisted the resident with toileting needs, they transferred the resident to his/her electric wheelchair and the resident independently propelled the wheelchair down the hall, at a slow to moderate speed, with both feet centered on the foot platform. On 10/14/14 at 4:00 PM, Nurse Aide M stated the resident always had both foot pedals on his/her wheelchair at all times, when being pushed by the staff. He/She stated the resident had left sided weakness, but was able to stand for transfers in the sit to stand lift. On 10/16/14 at 8:44 AM, Administrative Nurse F stated the resident was able to report what happened when he/she hurt his/her ankle. He/she verified the staff had not changed the care plan either before the accident to reflect the use of the manual wheelchair, or after, to ensure the staff positioned the resident's feet appropriately when using the wheelchair. He/She stated the accident happened on the evening shift, the resident did not complain of pain until the night shift and the physician and family were notified the next day. Administrative Nurse F verified the day shift nurse had not documented any assessment and the facility had no documentation the staff notified the physician until the following day at 4:00 PM, on the second shift. Administrative Nurse F stated the day shift nurse should have followed up and assessed the resident after he/she received a report that the resident received as needed pain medication and ice packs during the night for a painful, swollen ankle. Administrative Nurse F verified the day shift nurse should have notified the physician of the accident and painful, swollen ankle. He/she stated the facility's fall policy was also used for accidents. On 10/21/14 at 2:15 PM, Physician G stated he/she would expect the staff to notify him/her of an accident involving the resident, especially if there was an injury, and the staff should reassess the injury at the beginning of each shift Physician G stated he/she would expect the staff to use appropriate safety precautions when transporting the resident in any wheelchair. The facility's 2007 fall policy directed the staff to notify the resident's family and physician of falls/accidents and update the care plan. The facility failed to transport this dependent resident via wheelchair, in a safe manner, which resulted in a fracture of his/her left ankle/foot. - On 10/14/14 at 8:38 AM, observation revealed the hot water in multiple resident bathrooms had visible steam and was too hot for this surveyor to place his/her hands under the faucet stream. The hot water temperatures were checked in the following rooms: East 2 - 138.0 degrees East 3 - 134.8 degrees East 5 - 138.7 degrees East 6 - 137.6 degrees East 8 - 134.6 degrees East 9 - 132.8 degrees Therapy room on east hall - 133.8 degrees On 10/14/14 at 8:46 AM, the hot water temperatures in the residents' bathrooms were reported to the maintenance department and the staff turned off the hot water to the east hall. Review of the facility's Weekly Water Temperature Checklist form revealed no documentation the staff had checked the hot water temperatures on the east hall on the following days: 09/12/14 09/19/14 09/26/14 10/02/14 10/09/14 On 10/14/14 at 8:46 AM, Maintenance Staff A stated the maintenance staff had checked the hot water temperature weekly in random resident rooms and recorded the water temperature and room number on the facility's Weekly Water Temperature Checklist form. Maintenance Staff A also stated there was no documentation the staff had checked water temperatures on the east hall in the past month. On 10/15/14 at 10:30 AM, Nurse Aide B stated the hot water temperature had been elevated in the residents' bathrooms on the east hall for at least a week. Nurse Aide B also stated he/she was not aware if the hot water temperature had been reported to the maintenance department. On 10/15/14 at 10:45 AM, Housekeeping Staff C stated the hot water temperature had been elevated on the east hall for several days and he/she had not reported the unsafe hot water temperature to the nursing or maintenance staff. On 10/15/14 at 11:02 AM, Administrative Staff H stated the staff should check the hot water temperature on each hall weekly and address immediately if unsafe water temperatures were noted. Administrative Staff H also stated the direct care staff should report elevated/unsafe hot water temperatures to administration or the maintenance staff. The facility failed to adequately monitor the water temperature on 1 hall to ensure the hot water temperature was within safe, acceptable ranges.

The facility census totaled 70 residents with 7 residents included in the sample. Of those, 3 residents were reviewed for nursing assessment after change in condition. Based on interview and record review, the facility failed to identify and respond promptly to a significant change in respiratory status after a change in condition for 1 of 3 sampled residents. This failure lead to a delay in resident #1 receiving further respiratory care. The resident received increased breathing treatments, and oxygen began to cough up sputum and blood and required hospitalization . Findings included: - Review of resident's #1's physician's orders [REDACTED]. Review resident #1's admission MDS (minimum data set) dated 2/6/12 revealed the resident had a BIMS (brief interview for mental status) score of 14 (cognitively intact), required set up help with meals and remained independent for all ADLs (activities of daily living). Review of resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact) required set up help for meals and dressing, one person assist for dressing, and extensive assist of one staff member for bathing. Review of the resident's Activities of Daily Living CAA (care area assessment) dated 2/6/12 revealed the resident was hard of hearing, wore hearing aids in his/her right ear and glasses. The resident was independent with transfers and ambulation, using rolled walker and staff was to assist as needed. Review of the resident's care plan dated 2/10/12 revealed altered tissue perfusion (the passage of blood through the vessels of a specific organ) related to decreased metabolism alteration in cardiac output (inadequate blood pumped by the heart). The care plan directed the staff to give [MEDICATION NAME] (mist breathing treatment) every 4 hours prn (as needed) for coughing/wheezing. Review of resident #1's record revealed a nurse's note entry dated 12/12/12 at 9:00 p.m. Which documented a temperature of 99.5 degrees Fahrenheit. The note identified the resident was confused and experienced wheezing lung sounds to the upper lobes. The staff administered a [MEDICATION NAME] treatment to address the wheezing but failed to address the temperature. Review of the nurses notes dated 12/12/12 at 11:30 p.m., 2 1/2 hours after the last [MEDICATION NAME] treatment, staff documented the resident complained of shortness of breath, had a productive cough with thick yellow sputum, and oxygen saturation level of 79% (normal is 98 to 100%) on room air after ambulation. Staff assessed the lung sounds and identified a change that included diminished sounds to the left and right lower lobes with wheezing noted on expirations. The staff administered a [MEDICATION NAME] treatment and placed the resident on oxygen per nasal cannula. The staff failed to provide any other respiratory care. Further review of the Nurses Notes revealed an entry on 12/13/12 at 6:00 a.m. When staff assessed the resident with a temperature of 101.5 degrees Fahrenheit (above 100 degrees is abnormal), oxygen saturation 94% on 2 liter of oxygen per nasal cannula, pulse 118 (60-100 normal), blood pressure 175/103 (above 140/80 is considered high), and the resident coughed up blood. The staff noted the resident had diminished lung sounds throughout the lung fields. At that time, 9 hours after the resident started showing symptoms and had increased need for breathing treatments, oxygen, exhibited confusion, and productive cough with yellow sputum, staff called the physician and obtained an order to send the resident to the emergency room for a chest x-ray. The resident was admitted to the hospital for pneumonia. Interview on 3-6-13 at 4:22 p.m. with Licensed nurse D revealed the resident normally had periods of confusion and that night the wheezing cleared with a [MEDICATION NAME] aerosol treatment. Nurse D revealed he/she would have notified the physician if the resident had continued to have wheezing or altered mental status. The nurse failed to identify the failure to address the increased temperature, increased breathing treatments, the need for oxygen, shortness of breath and productive cough all signs of significant respiratory change. Interview on 3-7-13 at 10:54 a.m. with Nurse Practitioner E revealed the expectations of his/her office was the facility would call or page the office if the resident had signs and symptoms of illness or significant change in condition for the physician to address. The facility failed to identify and respond to a significant change in the resident's respiratory status including increased breathing treatments, need for oxygen, shortness of breath and productive cough. This delay in prompt treatment lead to the worsening of the resident's respiratory status and a hospitalization .

The facility reported a census of 67 residents with 18 sampled for review. The facility identified 18 residents residing in North, South, and East halls as cognitively impaired and independently mobile. Based on observations, interview and record review, the facility failed to ensure 2 residents receiving therapeutic hot packs remained free from injury (12, 23), failed to have a system in place to ensure the 18 cognitively impaired, independently mobile residents remained safe from injuries related to hazardous chemicals, and failed to ensure the security of compressed oxygen cylinders during van trips. Findings included: - A 2/17/11 annual MDS (minimum data set) identified resident 12 with slight cognitive impairment and required extensive assistance with activities of daily living. The 12/2/10 care plan included an intervention to offer nursing measures for discomfort such as warm or cold therapy and may give warm packs for bladder spasms. A 2/15/11 nursing note from 1:45 pm stated, "Warm rice bag caused 12 x 5 cm reddened area on lower back." The record lacked evidence of when staff placed the rice bag and any further assessments of the area. On 4/7/11 at 7:45 am, licensed nurse K, the nurse on duty at the time of the incident, stated, "One of the girls made it too hot and put it on (the resident)." She stated staff should heat the bag for 30 seconds, remove the bag, rotate and move the rice in the bag to distribute the heat, and heat for another 30 seconds if needed. The nurse reported the burn had no blistering but a red, painful burn when the nurse aide reported the burn to her. On 4/7/11 at 9:30 am, nurse aide P stated she heated the rice bags 30 - 60 seconds at a time and then placed them on her own skin. She stated if the bag felt too hot, she wrapped the bag in a towel. On 4/7/11 at 10 am, licensed nurse B reported staff should heat the rice bags for 1 minute then check the bag prior to placing to ensure a safe temperature of the bag. She reported the facility lacked a system to make sure the rice bags remained in a safe temperature range prior to placing the bags on a resident. The Warm/Cold Pack policy revised 4/23/04 stated, "1. Heat rice pack 1 1/2 - 2 minutes in microwave. 2. If too hot, let cool to a comfortable temperature prior to use. 3. Never use (sic) if too hot... 5. Never overheat, as this may cause injury to the skin and may also damage the pack. " In summary, the facility failed to ensure resident 12 received therapeutic hot packs in a manner that prevented burns. The resident sustained [REDACTED]. - A facility incident log showed on 1/7/11 and on 2/16/11, during van trips, oxygen cylinder tanks fell over in the van. Both investigations lacked evidence of interviews with residents and staff present at the time. Both indicated staff should secure the tanks while in the van. Safe Cylinder Handling guidelines recommended by Airgas.com stated, " Transporting cylinders in cars, vans or in any enclosed vehicle is extremely dangerous and should be avoided. Never transport flammable gases in the trunk or passenger compartment of a vehicle. Many persons disregard this warning every year, and there are many vehicle explosions as a result. " The guidelines further stated, "Secure your cylinders. The Department of Transportation (DOT) regulations require that all compressed gas cylinders be secured from movement during transportation. cylinders that can move can open accidentally..." On 4/11/11 at 10 am, administrative nurse B stated the facility lacked a policy for securing oxygen tanks in the van. In summary, the facility failed to keep residents safe during van rides by securing oxygen cylinders. - Resident #23's clinical record included a Quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 2/11/11 which identified the resident with no memory problems, independent with eating, and required limited assistance with bed mobility, transfers, walking, dressing, and toilet use. The 2/11/11 care plan included an intervention to offer nursing measures for discomfort such as: back rub, warm/cold pack, change position, and whirlpool. A 3/3/11 nurses note from 12:20 AM stated, "fall follow up, continue neuro checks within normal limits, increased pain related to fall at mid and low back. I'm fine if I don't move. Heat pack offers relief." A 3/3/11 nurses note from 7:00 AM stated, "Aides were getting resident up and noticed 7cm(centimeter) by 4cm red area on back." On 4/7/11 at 7:45 AM, licensed nurse T, the nurse on duty at the time of the incident, stated the aides notified her on the morning of 3/3/11 and she assessed and measured the burn from the rice bag and notified the physician. A 3/3/11 nurses note from 11:00 AM stated, "Faxed Physician and faxed back stated monitor healing." A 3/4/11 nurses note from 3:40 AM stated, "...Rice bags warmed and placed to low back for discomfort." A 3/9/11 nurses note from 9:30 AM stated, "- Red area - scabbed new 2 x 1cm Left side of back - no surrounding redness no drainage noted. " A 3/12/11 nurses note from 5:30 AM stated, "...low back gradually fading." A 3/16/11 nurses note from 11:20 AM stated, "Continue to have dry flat scab on the Left side of lower back and 1 x 1cm no redness no drainage. " A 4/6/11 nurses note from 11:00 AM stated, "...back healed." On 4/7/11 at 7:45 AM, licensed nurse T reported the rice bags should be heated for 30 seconds, check it, and can heat for 30 more seconds if need to. On 4/7/11 at 9:30 AM, nurse aide P stated she heated the rice bags for 30 - 60 seconds at a time and then placed them on her own skin. She stated if the bag felt too hot, she wrapped the bag in a towel. On 4/7/11 at 10:00 AM, licensed nurse B reported staff should heat the rice bags for 1 minute then check the bag prior to placing to ensure a safe temperature of the bag. She reported the facility lacked a system to make sure the rice bags remained in a safe temperature range prior to placing the bags on a resident. The Warm/Cold Pack policy revised 4/23/04 stated, "1. Heat rice pack 1 1/2 - 2 minutes in microwave. 2. If too hot, let cool to a comfortable temperature prior to use. 3. Never use (sic) if too hot... 5. Never overheat, as this may cause injury to the skin and may also damage the pack." In summary, the facility failed to ensure resident #23 received therapeutic hot packs in a manner that prevented burns. The resident sustained [REDACTED]. - Initial tour of the facility on 4/4/11 at 4:23 pm revealed an unlocked laundry room door with a note posted on the door that stated, "Make sure door is locked." Observation inside the laundry room revealed 3 bottles of Betco Speedex Degreaser located on the sink, Betco Green Earth Drain Maintainer, Floor Cleaner and Spotter, Betco Disinfectant Germicidal, 1.4 gallon of Dollar General Home Bleach, Whink Rust and Iron Stain Remover, 1 bucket of powdered bleach located on the table beside the washer, and Clean Dust Mop Treatment located at the table beside the window of the laundry room, all identified warnings to keep out of reach of children (harmful or fatal if swallowed). Additional observation in the middle of the 2nd hallway on 4/4/11 at 4:23 pm revealed a 16 fluid ounce bottle of CliniShield moisturizing lotion with Vitamin E that identified a warning of keep out of reach of children, if swallowed contact poison control and physician. The utility room in the middle hallway also contained a large container of floor finish that revealed a warning to keep out of reach of children. During an interview with administrative staff A and B on 4/6/11 at 4:30 pm they both confirmed that chemicals should be locked up and not accessible to residents. In summary, the facility failed to ensure that all potentially hazardous chemicals remained in locked areas and not accessible to 18 independently mobile, cognitively impaired residents.

The facility reported a census of 68 residents with 9 sampled for review. The facility identified 12 residents residing in the North, South, and East halls as cognitively impaired and independently mobile. Based on observation and interview, the facility failed to ensure that potentially hazardous chemicals remained in locked, secured areas not accessible to 12 cognitively impaired independently mobile residents. Findings Included: - On 5/23/11 at 12:55 pm observation revealed an unlocked cabinet in the activity room with 4 cans of Salon Nail Dryer, 90 bottles of Nail Polish/Hardner, 2-16 ounce bottles of Nail Polish Remover, and 1-10 ounce bottle of Nail Polish Remover, all labeled keep out of reach of children. Additional observations on 5/23/11 at 1:17 pm revealed an unlocked beauty shop door with an unlocked cabinet door that contained 1-6 ounce can of Citrus Breeze Air Freshner labeled keep out of reach of children. During an interview on 5/24/11 at 11:50 am with activity staff C, she confirmed that the facility should keep the cabinet doors locked. In summary, the facility failed to store chemicals in a locked area, not accessible to 12 cognitively impaired independently mobile residents.