Every finding on record at Azria Health Great Bend

The facility had a census of 61 residents. The sample included 17 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure staff provided adequate supervision to prevent the elopement of Cognitively Impaired Resident (R) 37, who was at risk for wandering/elopement, falls, and used a walker for mobility. The facility also failed to conduct a complete investigation when R48 obtained skin tears of unknown origin. This placed the resident at risk for abuse.On 07/15/25 at approximately 07:35 PM, facility staff could not find R37 in the building and reported seeing R37 in the lobby approximately 5-10 minutes prior. The staff found R37's walker in the lobby, but not R37. The staff located R37 outside in the facility van, seated in the front seat, in approximately 95-degree Fahrenheit (F) weather. The facility did not know how R37 got outside without staff knowledge. The failure to prevent a cognitively impaired resident from exiting the facility without staff supervision or knowledge and entering an unsafe location placed R37 in immediate jeopardy and other wandering residents at risk.Findings included:- R37 Electronic Medical Record (EMR) documented R37 had diagnoses, which included: a history of falling and dementia (a progressive mental disorder characterized by failing memory and confusion). R37's admission Minimum Data Assessment (MDS), dated [DATE], documented R37 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R37 used a walker for mobility and required staff supervision with ambulation. The MDS documented R37 had a fall in the last two to six months. R37's Care Area Assessment(CAA), dated 11/07/24, documented the CAA triggered due to R37 was at risk for falls. R37's risk for falls included: generalized weakness, decreased safety awareness, a history of falls before admission, and psychotropic (alters mood or thought) medications. The CAA documented R37 had a BIMS of three and a diagnosis of dementia. R37's Quarterly MDS, dated 05/28/25, documented R37 had a BIMS score of five, which indicated severe cognitive impairment. R37 used a walker for mobility and required supervision with ambulation. The MDS documented R37 had no falls since the prior assessment. R37's Care Plan, revised 05/31/25, documented R37 had limited physical mobility and instructed staff to provide R37 with one staff assistance, using a walker for ambulation. The plan lacked interventions regarding R37's elopement risk. The plan documented R37 had impaired cognitive function related to dementia and instructed staff to cue, reorient, and supervise her as needed. The plan documented R37 as at risk for falls, instructed staff to anticipate and meet the resident's needs, and offer and assist R37 with ambulation. The Elopement Evaluation dated 11/05/24 documented R37 with a history of elopement or attempted elopement while at home and wandering behavior. The Elopement Evaluation dated 05/31/25 lacked documentation regarding whether R37 had a history of elopement. On 07/15/25 at approximately 07:35 PM, facility staff could not find R37 in the building and reported seeing R37 in the lobby approximately 5-10 minutes prior. The staff found R37's walker in the lobby, but not R37, and reported that the door alarm did not activate. The staff located R37 outside of the building, in the facility van, and seated in the front seat in approximately 95 degrees Fahrenheit (F) weather. The facility did not know how R37 got outside without their knowledge. The National Weather Service table titled Temperature Inside a Vehicle noted an ambient temperature outside of 93 degrees F, the temperature inside a vehicle can rise up to 130 degrees F within 60 minutes. According to Weather Underground, the weather outside at the time R37 left the building, unsupervised, was approximately 95 degrees Fahrenheit and sunny. The staff found R37 in the front seat of the facility van. Observation revealed the facility is located near a highway, with speed limits of 40 miles per hour (mph), approximately 100 feet from the building. Cognitively impaired R37 is at a fall risk and did not have her walker with her. During a phone interview on 07/27/25 at 09:42 AM, Certified Nurse Aide (CNA) O stated she was working on 07/15/25 when R37 left the building without staff supervision. CNA O stated prior to the elopement, R37 sat in the lobby on the couch by the entrance door. CNA O went down the southwest hall of the facility to answer a couple of call lights, and when she came back, R37 was not on the couch, but her walker was beside it. CNA O started looking for R37 because R37 was known to wander. CNA O stated CNA P went outside looking for R37 and noted the front entrance door was not alarming. On 07/28/25 at 09:06 AM, Administrative Nurse D stated on 07/16/25, the night of R37's elopement, the door alarm was not sounding when staff noticed R37 was missing from inside the facility. Administrative Nurse D stated she did not know how R37 exited the building without staff supervision, but thought R37 might have followed a family member out the door. The facility's Wandering and Elopement Policy, revised 06/17/20, documented if a resident was determined to be at risk for wandering and elopement, educational materials would be available concerning the risk for eloping. Specific intervention(s) would be provided to the resident and family and would be documented in the resident's record. A wandering /elopement risk evaluation, too, would be completed by a licensed member of the clinical staff for each resident to identify the level of risk which may lead to elopement upon admission or readmission, quarterly, upon a change in status or condition as it related to unsafe wandering, post-elopement or elopement attempts, and as required by state regulation. On 07/28/25 at 12:33 PM, Administrative Staff A and Administrative Nurse D were provided the IJ template and notified that the facility's failure to provide safe, adequate supervision for cognitively impaired R37 to prevent the elopement placed the resident in immediate jeopardy. The facility's corrective measures, completed on 07/25/25, included the following: In-service on elopement policy. Checked all door alarms Conducted elopement drill, and four drills will be held annually at each community: One drill will be held each shift, including one weekend day. An elopement evaluation tool was completed by a licensed member of the clinical staff for each resident identified as a risk for elopement. In-service for transportation driver regarding the facility van would be locked at all times. The surveyor verified the implemented corrective actions while on site; the deficient practice was deemed past non-compliance and remained at a J scope and severity. - R48's Electronic Medical Record documented diagnoses of a stable burst fracture of two vertebra (bone of the spinal column), chronic respiratory failure, chronic lymphocytic leukemia (a cancer that develops in the bone marrow, where blood cells are produced) in remission, pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and dorsalgia (back pain). R48's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate impairment. The MDS documented R48 was dependent on staff for transfers and had no falls since admission. R48's Fall Care Area Assessment (CAA), dated 07/14/25, stated contributing factors include weakness, reliant on staff for Activities of daily living (ADL), and mobility. R48's Care Plan, dated 07/11/25, directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan laid out staff direction for transfers and mobility. The 07/16/25 update stated two skin tears on the left lower leg, with a treatment plan and monitoring plan, initiated 07/18/25. The Progress Note, dated 07/16/25 at 05:00 PM, documented Certified Nurse Aides (CNA) were getting R48 up for supper and noted two bruised areas that were bleeding on her left lower leg. The bruised areas with one 2 centimeters (cm) skin tear and one 3 cm skin tear. Staff cleansed the area with wound cleanser, patted dry, and applied steri-strips and a dry dressing. R48 said her leg bumped something during the transfer. The Incident Report, dated 07/16/25, did not include a dated witness statement even though the resident claimed it happened during a transfer. On 07/28/25 at 10:23 AM, R48 laid in bed with the head of the bed elevated and blue pressure relief booties on her feet. R48 stated the pain in her back was better today. On 07/28/25 at 03:28 PM, Administrative Nurse D stated the interdisciplinary team (IDT) reviewed the incident. She provided an undated witness statement from the CNA who found the skin tears, but no witness statement documenting what happened. On 07/29/25 at 09:05 AM, Administrative Nurse D stated she thought the CNA wrote a statement that she was transferring the resident when her leg bumped the wheelchair but did not provide that witness statement. The facility's Abuse, Neglect, Exploitation policy, dated 10/2023, stated all reports of resident abuse (including injuries of unknown origin), neglect, and exploitation were to be reported to local, state, and federal agencies and thoroughly investigated by facility management. The findings of all investigations would be documented and reported. All allegations would be thoroughly investigated. the administrator initiated investigations. Upon conclusion of the investigation, the investigator records the findings on approved documentation forms.

The facility had a census of 62 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 61 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.Findings included:- On 07/27/25 at 08:45 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 07/27/25 at 12:00 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had three residents with a pureed diet and 15 with a mechanical soft diet. On 07/29/25 at 09:15 AM, Administrative Nurse D verified Dietary Staff BB was not certified.Upon request, the facility lacked a Certified Dietary Manager policy.

The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) when providing care with close contact to residents with an open wound or an indwelling device and failed to properly disinfect a blood glucose meter used for more than one resident. This deficient practice placed all residents at risk for infection.Findings included:- On 07/27/25 at 12:28 PM, Licensed Nurse (LN) G obtained a blood sugar (BS) reading with a facility glucometer for Resident (R) 31. LN G did not clean or disinfect the glucometer before putting it away in the drawer on top of the other glucometer. On 07/28/25 at 09:05 AM, observation revealed a sign on R11's door directing staff to use EBP during cares. On 07/28/25 at 09:05 AM, Certified Nurse Aide (CNA) M and CNA N used a total mechanical lift to transfer R11 from her wheelchair to her bed. The CNAs did not don EBP gowns before providing incontinence cares. R11 had a dressing with drainage on her right buttock. At 09:20 AM, LN H performed wound care for R11 and did not don an EBP gown. R11's right buttock had an irregular shaped open wound and another open wound to her coccyx area. On 07/28/25 at 09:20 AM, LN H stated EBP was used when R11 had a foot wound before amputation. She stated that staff no longer used the EBP for this resident. On 07/28/25 at 09:54 AM, Administrative Nurse E stated EBP should be worn during cares for any resident with an open wound. On 07/28/25 at 12:50 PM, Administrative Nurse E verified staff were to disinfect the glucometer after each use. The facility had two glucometers used for seven residents on the north halls. The Assure Prism BG monitoring system (blood glucose meter) instruction manual stated the meter should be cleaned and disinfected after use on each patient. The BG system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. The manufacturer validated Clorox Healthcare Bleach Germicidal wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes 1, and PDI Super Sani Cloth Germicidal disposable wipes used for disinfecting the Assure Prism multi-meter. Allow the disinfectant to stay wet for 1-2 minutes. The facility's Cleaning and Disinfection of Resident Care Items policy, dated 10/2023, stated resident care equipment, including reusable items and durable medical equipment, would be cleaned and disinfected between residents per current Centers for Disease Control (CDC) recommendations for disinfection. The facility's Enhanced Barrier Precautions policy, dated 04/2024, stated EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care. Examples of high contact resident care requiring the use of a gown and gloves for EBP included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care, and wound care for pressure ulcers, diabetic ulcers, surgical wounds, and venous stasis ulcers. - R2's Electronic Medical Record (EMR) documented that R2 had a diagnoses of acquired absence of kidney (one of a pair of organs in the abdomen), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and other problems), and benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). R2's Medicare Five Day Minimum Data Set (MDS), dated [DATE], documented that R2 had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R2 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). R2's Care Plan, revised 05/20/25, documented R2 dependent on staff assistance with toileting. The plan instructed staff to provide R2 catheter care every shift, monitor and document intake and output as per facility policy. The plan documented R2 was on EBP related to his urinary catheter and instructed staff to use appropriate personal protective equipment (PPE). On 07/27/25 at 03:37 PM, R2 sat in a recliner in his room with the door open. Certified Nurse Aide (CNA) Q entered the room, went into R2's bathroom, retrieved a graduated cylinder, then, without gloves or gown, emptied R2's urine from his catheter into the graduated cylinder. CNA Q took the urine-filled graduated cylinder to the bathroom and emptied it into the toilet, rinsed it out using water from the sink, and poured the water into the toilet. When CNA Q was asked what the EBP sign posted beside R2's room entrance door, she stated that staff have to place gloves and a gown on when providing catheter care. CNA Q verified she had not applied gloves or a gown when emptying R2's urinary catheter bag and stated she should have. On 07/29/25 at 09:57 AM, Administrative Nurse D stated if a resident is on EBP, staff should place a gown and gloves on before providing any catheter care. The facility's EBP policy, dated 04/2024, documented EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident are activities that provide opportunities for transfer of Multidrug-Resistant Organism (MDRO- standard medications used to treat infections caused by these organisms are ineffective, making infections difficult to treat.)to staff hands and clothing. Gloves and a gown are applied before performing the high-contact resident care activity (as opposed to before entering the room). PPE is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high contact resident care activities requiring the use of a gown and gloves for EBP's include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, or device care of use (urinary catheter, etc.). Wound care (wounds generally include chronic wounds, not shorter-lasting wounds, such as skin tears or skin grafts covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)5 and R69s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. The facility failed to ensure medications were only accessible to licensed staff when the treatment cart was left unlocked without licensed staff supervision. Findings included: - On [DATE] at 11:38 AM, the Northeast Hall nurse treatment cart was found in the hall, unlocked with insulin and other medication accessible to anyone. At that time, no staff were in sight of the treatment cart. Licensed Nurse (LN) G was located in a resident room, out of sight of the cart. When LN G came out of the resident's room, she verified that she should have locked the cart. On [DATE] at 09:05 AM, Administrative Nurse D verified that staff should not leave the treatment cart unlocked when out of sight of licensed staff. The facility's Administering Medications policy, dated 06/2022, stated during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. - On [DATE] at 08:45 AM, observation of R5's Lantus (long-acting insulin) flex pen was labeled with a date opened [DATE] and an expired date of [DATE] (46 days outdated) and still in use. Observation of R69's Mounjaro (Long-acting medication) lacked a date opened or a date expired. On [DATE] at 08:50 AM, License Nurse G verified that the nurses should label and date the insulin flex pens with the date opened and should discard expired insulin flex pens. On [DATE] at 09:20 AM, Administrative Nurse D verified that the nurse should label and date the insulin flex pens with the date opened and discard expired insulin flex pens. Medlineplus.gov directs open, unrefrigerated Lantus can be used within 28 days; after that time, they must be discarded. Moujaro should be used within 30 days; after that time, it should be discarded. The facility's Storage of Medications policy, dated [DATE], documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing, discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

The facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with a rationale for Resident (R) 61's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R61 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.Findings included:- R61's Electronic Health Record (EHR) revealed diagnoses of 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), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty).R61's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R61 had severely impaired cognition. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS documented R61 received an antianxiety medication during the observation period.R61's Care Plan, dated 04/02/25, recorded R61 required extensive staff assistance with his activities of daily living (ADL) care. R61's Care Plan documented the resident received Ativan (an antianxiety medication) for end-of-life restlessness.R61's Physician's Order, dated 01/30/25, directed the staff to administer lorazepam (Ativan) 1.0 milligram (mg), one tablet as needed for agitation. The order lacked a stop date.R61's EHR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam.On 07/28/25 at 07:40 AM, R61 sat in a broad chair at the dining room table. Certified Medication Aide (CMA) R administered the resident's medication, which included lorazepam 1 mg. On 07/27/25 at 11:00 PM, Administrative Nurse D verified R61 received lorazepam PRN, with a physician order date of 01/30/25. Administrative Nurse D verified that the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rationale. The facility's Antipsychotic Medication Use policy, dated July 2022, recorded the residents would not receive medications that were not clinically indicated to treat specific conditions. Diagnosis of a specific condition for which antipsychotic medications was necessary to treat would be based on comprehensive assessment of the resident. Antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-view. Residents would not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific that is documented in the clinical record. PRN orders for antipsychotic medications would not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and document the rationale for continued use. The duration of the PRN order would be indicated in the order.

The facility had a census of 61 residents. The sample included 17 residents, with two reviewed for abuse, neglect, or exploitation. Based on observation, interview, and record review, the facility failed to thoroughly investigate in a timely manner the injury of unknown origin to Resident (R) 48, who stated it happened when staff were transferring her.Findings included: - R48's Electronic Medical Record documented diagnoses of a stable burst fracture of two vertebra (bone of the spinal column), chronic respiratory failure, chronic lymphocytic leukemia (a cancer that develops in the bone marrow, where blood cells are produced) in remission, pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and dorsalgia (back pain).R48's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R48 was dependent on staff for transfers and had no falls since admission. R48's Fall Care Area Assessment (CAA), dated 07/14/25, stated contributing factors included weakness, reliance on staff for Activities of daily living (ADL), and mobility.R48's Care Plan, dated 07/11/25, directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan lacked staff direction for transfers and mobility. The 07/16/25 update stated two skin tears on the left lower leg, with a treatment plan and monitoring in place, initiated 07/18/25.The Progress Note, dated 07/16/25 at 05:00 PM, documented Certified Nurse Aides (CNA) were getting R48 up for supper and noted two bruised areas that were bleeding on her left lower leg. The bruised areas with one 2-centimeter (cm) skin tear and one 3 cm skin tear. Staff cleansed the area with wound cleanser, patted dry, and applied steri-strips and a dry dressing. R48 said her leg bumped something during the transfer.The Incident Report, dated 07/16/25, did not include a dated witness statement even though the resident claimed it happened during a transfer. On 07/28/25 at 10:23 AM, R48 laid in bed with the head of the bed elevated and blue pressure relief booties on her feet. R48 stated the pain in her back was better today. On 07/28/25 at 03:28 PM, Administrative Nurse D stated the interdisciplinary team (IDT) reviewed the incident and should have investigated the incident as an injury of unknown origin. She provided an undated witness statement from the CNA who found the skin tears, but no witness statement documenting what happened. On 07/29/25 at 09:05 AM, Administrative Nurse D stated she thought the CNA wrote a statement that she was transferring the resident when her leg bumped the wheelchair, but did not provide that witness statement.The facility's Abuse, Neglect, Exploitation policy, dated 10/2023, stated all reports of resident abuse (including injuries of unknown origin), neglect, and exploitation were to be reported to local, state, and federal agencies and thoroughly investigated by facility management. The findings of all investigations would be documented and reported. All allegations would be thoroughly investigated. the administrator-initiated investigations. Upon conclusion of the investigation, the investigator records the findings on approved documentation forms.

The facility had a census of 61 residents. The sample included 17 residents, with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) for two sampled residents, Resident (R) 42 and R6. This placed the residents at risk for uninformed care choices.Findings include:- The Electronic Medical Record (EMR) for R42 documented diagnoses of displaced fracture of the base of the neck of the left femur (a break in the left thigh bone), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the inulin) type two. The admission Minimum Data Set (MDS), dated [DATE], documented R42 had moderately impaired cognition. R42 was independent with toileting hygiene, dressing, personal hygiene, mobility, transfers, and ambulation. The MDS further documented R42 had no functional impairment and had no falls. The Quarterly/Five Day Medicare MDS, dated [DATE], documented R42 had intact cognition. R42 required substantial staff assistance for transfers and showers. R42 required partial staff assistance for dressing, personal hygiene, and mobility. The MDS further documented R42 had lower functional impairment on one side, a fall with a major injury, and did not ambulate. R42's Care Plan dated [DATE], initiated on [DATE], directed staff to be sure his call light was within reach and encouraged him to use it for assistance as needed. The care plan directed staff to ensure R42 wore appropriate footwear when ambulating or mobilizing in his wheelchair. R42's Progress Note, dated [DATE] at 02:23 PM, documented R42 was admitted to the hospital with a fracture of the left femur. R42's clinical record lacked evidence that the Ombudsman was notified of the hospital transfer. R42's Progress Note, dated [DATE] at 04:24 PM, documented R42 was readmitted back into the facility. On [DATE] at 09:23 AM, R42 sat in his recliner, hair disheveled, greasy, and unshaven. R42 stated he had no pain and was independent with transfers and ambulation. On [DATE] at 01:30 PM, Social Service X stated the Ombudsman had not been notified of the hospital transfer, R42 had been mistakenly missed when the notice to the Ombudsman was sent at the end of June. On [DATE] at 08:53 AM, Administrative Nurse D stated the Ombudsman should be notified when a resident is transferred to the hospital. The facility's Transfer or Discharge Notices policy, dated 03/25, documented residents or resident representatives were notified of an impending transfer or discharge in writing and a language and manner they would understand. A copy of the notice was sent to the Office of the State Long-Term Care Ombudsman. - R6's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure) with behavioral disturbance, encephalopathy (inflammatory condition of the brain), and acute bronchitis (inflammation of the lining of bronchial tubes which carry air to and from the lungs). R'6s Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident had occasional incontinence and ambulated with a wheelchair. The Care Area Assessment (CAA), dated [DATE], recorded R6 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had incontinence of urine with a diagnosis of chronic kidney disease and required assistance with toileting, transfers, and hygiene. R6's Care Plan, dated [DATE], recorded R6 required staff assistance with most ADL care. R6's Care Plan documented the resident required staff assistance with incontinent cares and assistance. The care plan documented staff were to allow the resident privacy when using the restroom; however, stay near the bathroom and ready to provide assistance when R6 required it. The care plan documented R6 had the potential for falls related to needing assistance with ADL's and staff would encourage her to call for assistance when needed. On [DATE] at 08:56 AM, Nurse's Notes documented R6 had a wet cough, warm to the touch, and had had confusion. The note documented R6 was in bed and had been incontinent and needed more assistance with cares. The resident's vital signs were temperature 100.7 (normal 97.9to 98.6), blood pressure 134/99 (normal 120/80), pulse 101 (normal 60-100), respirations 20 (normal 12-20), and oxygen saturation was 96 percent (normal 95-100). On [DATE] at 04:21 PM, Nurses Notes documented R6 had been shaky, with clammy skin, yellowish looking skin, and had not been making very good words with talking today. The notes documented R6 had been incontinent, weak, not eating much, with a moist wet cough, her blood sugar reading was 105 (normal 70-99), the facility called her primary care physician, and sent the res to the emergency room by ambulance to be treated and evaluated. The primary care physician ordered the resident to be sent to the hospital. The notes documented R6 left with EMS at 04:20 PM. R6's niece was contacted with the information. On [DATE] at 04:37 AM, Nurse's Notes documented the facility received an admission history and physical from the primary care physician for R6's admission to the hospital. On [DATE] at 04:16 PM, Nurse's Notes documented the resident was admitted back to the facility with a diagnosis of acute metabolic encephalopathy hypoxia, urinary tract infection, and rhinovirus. The resident was transported from the transport van to the facility in a wheelchair. The resident had a foley catheter and had oxygen per nasal cannula set at 2 liters continuous flow. The resident was admitted on antibiotics for lower respiratory infection for seven days and had a non-productive cough. R6's clinical record lacked documentation staff notified the LTCO of R6's discharge from the facility. On [DATE] at 10:40 AM, Social Service X stated she would send notification of discharge to the Ombudsman regarding the resident's discharge from the facility to home, hospital, and if they had expired, once a month. Social Service X verified she failed to include R6 in the [DATE] discharges. On [DATE] at 09:30 AM, Administrative Nurse D verified that the social service designee would send monthly reports to the Ombudsman office that included residents who were discharged , went to the hospital, and expired residents from the facility. Administrative Nurse D verified SSD X notified her she failed to include R6 in the [DATE] report to the Ombudsman office. The facility's Transfer or Discharge Notice policy dated [DATE] documented residents or residents' representatives are notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the Ombudsman. A copy is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility will send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman. Notice to the Office of the State LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and the resident's representative.

The facility had a census of 61 residents. The sample included 17 residents, with three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 27 and R42. This placed the residents at risk for complications related to poor hygiene.Findings included:- The Electronic Medical Record (EMR) for R27 documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of his fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Annual Minimum Data Set (MDS), dated [DATE], documented R27 had intact cognition. R27 was independent with eating, toileting hygiene, dressing, personal hygiene, mobility, and transfers. R27 required supervision with ambulation and bathing.R27's Care Plan, dated 05/19/25, initiated on 04/18/24, documented R27 preferred three baths per week and required staff assistance.The May 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:05/05/25 - 05/17/25 (13 days)05/19/25 - 05/29/25 (11 days)The EMR documented R27 refused bathing on 05/07/25, 05/08/25, 05/11/25, and 05/14/25.The June 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:06/01/25 - 06/19/25 (19 days)06/21/25 - 06/30/25 (10 days)The EMR documented R27 refused bathing on 06/01/25, 06/06/25, 06/08/25, 06/11/25, 06/22/25, 06/25/25, and 06/29/25.The July 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:07/21/25 - 07/28/25 (8 days)The EMR documented R27 refused her bathing on 07/23/25.On 07/28/25 at 12:30 PM, R27 sat at the dining room table, hair uncombed. When R27 was asked any questions, she would not respond.On 07/29/25 at 09:10 AM, Licensed Nurse H stated R27 refused bathing. Staff offered alternative days and times, but R27 would continue to refuse.On 09/29/25 at 09:20 AM, Certified Nurse Aide (CNA) N stated R27 usually took her showers if she was working but would often refuse other staff. If a resident refused, they would tell the nurse, and the nurse would talk with the resident. CNA N further stated res are offered alternative bathing dates or times.On 07/29/25 at 09:53 AM, Administrative Nurse D stated residents who refused bathing were offered a different option, such as bed baths or provided with a wash rag. The CNA would chart on the bath sheet that the resident refused, and then the nurse was notified so the nurse could talk with the resident.The facility Shower/Tub Bath policy, dated 10/10, documented that the facility promoted cleanliness and provided comfort to the resident. Staff were to observe the condition of the resident's skin and notify the supervisor if the resident refused the shower or bath. The physician was notified if the resident had any areas that may need to be treated. Staff are to report other information according to facility policy and professional standards of practice.- The Electronic Medical Record (EMR) for R42 documented diagnoses of displaced fracture of the base of the neck of the left femur (a break in the left thigh bone), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure, hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the inulin) type two.The admission Minimum Data Set (MDS), dated [DATE], documented R42 had moderately impaired cognition. R42 was independent with toileting hygiene, dressing, personal hygiene, mobility, transfers, and ambulation. R42 received partial assistance with bathing.The Quarterly/Five Day Medicare MDS, dated 06/27/25, documented R42 had an intact condition. R42 required substantial staff assistance for transfers and showers. R42 required partial staff assistance for dressing, personal hygiene, and mobility.R42's Care Plan, dated 06/29/25, initiated on 04/11/25, documented R42 required partial to moderate assistance with bathing. R42 required cueing and reminders to complete self-care and hygiene tasks.The May, June, and July 2025 Bathing Sheets documented R42 had not received a shower on the following days:05/06/25 - 06/08/24 (34 days)06/10/25 - 06/19/25 (10 days)R42 was hospitalized from [DATE] - 06/25/2506/25/25 - 07/13/25 (19 days)07/15/25 -07/28/25 (14 days)The EMR documented R42 refused bathing on 05/19/25, 05/27/25, 06/09,25, 06/16/25, 06/30/25, 07/07/25, and 07/21/25.On 07/28/25 at 09:23 AM, R42 sat in his chair in his room. His hair was uncombed, greasy, and he was unshaven. R42 had on yellow socks; both socks were very soiled with a dried substance all over the socks. R42 stated he did not know what was all over his socks. When R42 was asked about his bathing and if staff offered different choices, he stated, I don't know. On 07/29/25 at 09:10 AM, Licensed Nurse H stated R42 refused bathing, but he had said he would take his shower sometime today. Staff offered alternative days and times, but R2 would continue to refuse.On 09/29/25 at 09:20 AM, Certified Nurse Aide (CNA) N stated R42 refused his showers all the time, no matter how many staff talked to him. If a resident refused, they would tell the nurse, and the nurse would talk with the resident. CNA N further stated that residents were offered alternative bathing dates or times.On 07/29/25 at 09:53 AM, Administrative Nurse D stated residents who refused bathing were offered a different option, such as bed baths or provided with a wash rag. The CNA would chart on the bath sheet that the resident refused, and then the nurse was notified so the nurse could talk with the resident.The facility's Shower/Tub Bath policy, dated 10/10, documented that the facility promoted cleanliness and provided comfort to the resident. Staff were to observe the condition of the resident's skin and notify the supervisor if the resident refused the shower or bath. The physician was notified if the resident had any areas that may need to be treated. Staff are to report other information according to facility policy and professional standards of practice.

The facility had a census of 61 residents. The sample included 17 residents, with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide ROM services to improve or maintain Resident (R) 56's ROM in his partially contracted (abnormal permanent fixation of a joint or muscle) right hand.Findings included:- R56's Electronic Medical Record documented a diagnosis of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke) affecting his right dominant side.R56's Minimum Data Set (MDS), dated 05/26/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R56 required moderate staff assistance for mobility and dressing, and did not receive splint or brace therapy or restorative services.R56's Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 02/27/25, documented he required assistance with ADL's due to hemiplegia and generalized weakness. R56's Care Plan, dated 05/19/25, lacked interventions related to the prevention of contractures. The care plan stated R56 had limited physical mobility related to hemiplegia from a cerebral vascular accident affecting his right dominant side. Staff were to monitor, document, and report any signs of immobility, such as contractures forming or worsening, initiated 03/11/25. The care plan stated R56 would receive appropriate specialized services to attain or maintain his highest practicable psychological, physical, functional, and psychosocial well-being, initiated 03/16/24. The Physician Order, dated 02/28/24, directed staff to perform brace skin care, check skin covered by the brace every shift, and report any changes to the physician.On 07/27/25 at 09:32 AM, R56 sat in his recliner in his room. R56 stated he had a stroke with right sided paralysis. R56's hand was in a fist without a splint (it was on his bed, out of reach). He stated he required assistance to place the splint. R56 stated staff did not provide ROM for his right hand or any other restorative exercises. On 07/28/25 at 09:45 AM, Licensed Nurse (LN) H stated the facility did not have restorative aides. She stated they used to, but the aides were usually busy doing regular aide work. She did not know if R56 was supposed to have the hand splint on. LN H entered his room and asked him if he wanted to wear the splint and offered to put it on if he put it out every morning. LN H then placed one of the two braces he had in his room on his right hand/wrist. On 07/28/25 at 10:00 AM, Administrative Nurse E stated the facility had not had a restorative program for the past few years. She verified that the care plan did not include interventions to prevent contractures.On 07/28/25 at 10:06 AM, Therapy Consultant GG stated R56's right hand did not open to full extension. He was admitted with a splint, and the facility got him a softer splint after he complained about the original one. Therapy Consultant GG stated he was educated on donning/doffing a splint and said he could do it himself. He was to use it for two to five hours as tolerated.On 07/29/25 at 09:00 AM, Administrative Nurse D verified that the facility should provide restorative services to maintain or improve residents' range of motion. The facility's Restorative Nursing Services policy, dated 07/2022, stated residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of their stay, or when discharged from rehabilitative care.

The facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide interventions for bowel management for one resident, Resident (R) 9. This placed R9 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move).- The Electronic Medical Record for R9 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and constipation (difficulty passing stool).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had moderately impaired cognition. R9 was independent with toileting hygiene, personal hygiene, mobility, transfers, and dressing. R9 was always continent of bladder and bowel and did not have constipation.R9's Care Plan, dated 07/23/25, initiated on 06/28/22, documented R9 had a history of constipation and directed staff to administer medications as ordered. Staff were directed to monitor medications for side effects of constipation and keep the physician informed of any problems. The care plan further directed staff to report to the physician any changes in bowel patterns and record the bowel movement pattern each day.The Standing Orders, dated 12/01/23, for R9 directed staff to administer Milk of Magnesium (MOM), 30 milliliters (ml), as needed for up to twice daily or Dulcolax suppository (inserted into the rectum), one daily, as needed for constipation. Notify the physician if no results after two doses of MOM with a full bowel assessment.The Physician's Order, dated 04/15/25, directed staff to administer DOK (docusate sodium-a stool softener), 100 milligrams (mg), two capsules, daily, for constipation.R9's Bowel Monitoring Record, dated June and July 2025, documented R9 did not have a bowel movement for the following days:06/30/25 - 07/07/25 (8 consecutive days)R9's Medication Administration Record (MAR) for June and July 2025 lacked documentation of the staff providing interventions during the lack of bowel elimination on the above dates.The EMR lacked documentation that a bowel assessment was completed for the dates of 06/30/25 to 07/07/25.On 07/28/25 at 12:15 PM, R9 left the dining room table in his wheelchair to go to the bathroom.On 07/29/25 at 09:00 AM, Licensed Nurse (LN) H stated night shift received a report for the residents who had not had a bowel movement for three days, and notified Administrative Nurse D of any resident who had not had a bowel movement in three days, and standing orders were started.On 07/29/25 at 09:18 AM, Certified Nurse Aide (CNA) N stated R9 told the staff when he had a bowel movement and to document it in the computer.On 07/29/25 at 09:53 AM, Administrative Nurse D stated that there are standing orders for residents who have not had a bowel movement after three days, and bowel sounds are assessed.The facility's Bowel (Lower Gastrointestinal (GI) Tract) Disorders policy, dated 09/17, documented that as part of the initial assessment, the staff and physician would help identify individuals with previously identified lower GI tract conditions and symptoms. The staff and physician would identify risk factors related to bowel dysfunction. The staff would check for diffuse or localized tenderness and listen for bowel sounds. The physician would identify and order pertinent cause-specific and symptomatic interventions to institute a regimen to prevent constipation.

The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11's medication administration was free from significant errors when staff crushed one extended-release medication. This placed R11 at risk for the medication being improperly released.Fincings included:- On 07/28/25 at 08:52 AM, Certified Medication Aide (CMA) R crushed medications for R11, including metoprolol (medication used to treat chest pain (angina), heart failure, and high blood pressure) extended release (ER), 25 milligrams (mg). CMA R placed the crushed medications in applesauce and administered them to R11, even after being asked if it was okay to crush metoprolol ER. CMA R stated she would ask the nurse later. On 07/28/25 at 11:25 AM, Administrative Nurse E verified R11's metoprolol pill card stated ER Do not crush. Administrative Nurse E verified the physician order of 06/13/25 was not metoprolol ER, but the earlier 06/11/25 re-admission orders had been for ER metoprolol. Administrative Nurse E verified the 06/13/25 order was currently in effect. On 07/28/25 at 11:32 AM, LN H contacted the pharmacy regarding the order and stated she would fax the latest order to them. On 07/29/25 at 09:09 AM, Administrative Nurse D verified that nursing should have notified the pharmacy of the change in the metoprolol order in a timely manner and ensured the Medication Administration Record (MAR) was correct. The facility's Administering Medications policy, dated 06/2022, stated medications are administered in accordance with prescriber orders. The individual administering the medication would check the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication.

The facility had a census of 61 residents. The sample included 17 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 6. This placed the residents at risk for inadequate end-of-life cares. Findings included:- R6's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure) with behavioral disturbance, encephalopathy (inflammatory condition of the brain), acute bronchitis (inflammation of the lining of bronchial tubes which carry air to and from the lungs), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid).R6's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident had occasional incontinence and ambulated with a wheelchair. The MDS did not document the resident received hospice service due to the fact it was ordered on 07/16/25.The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 09/27/24, recorded R6 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had incontinence of urine with a diagnosis of chronic kidney disease and required assistance with toileting, transfers, and hygiene. R6s Care Plan, dated 04/23/25, recorded R6 required staff assistance with most ADL care. R6's Care Plan documented the resident required staff assistance with incontinent cares and assistance. The care plan documented staff were to allow the resident privacy when using the restroom; however, stay near the bathroom and ready to provide assistance when R6 required it. The care plan documented R6 had the potential for falls related to needing assistance with ADL's and staff would encourage her to call for assistance when needed. The Nurse's Notes, dated 07/14/25 at 11:14 AM, documented the facility received orders from the primary care physician to consult hospice care and discontinue skilled therapy. R6's Physician Order dated 07/16/25, documented the resident would receive hospice services. Review of R6's clinical record revealed the resident was admitted to hospice care on 07/14/25 with a diagnosis of congestive heart failure, chronic kidney disease Stage 3, and Alzheimer's. The facility had a care plan provided by hospice in the electronic health records. On 07/27/25 at 11:50 AM, R6 was dressed in street clothes in a wheelchair at the dining room table with oxygen on per nasal cannula, eating lunch.On 07/27/25 at 12:25 PM, Administrative Nurse D verified the facility lacked a facility care plan that indicated R6 was on hospice services.The facility's Care Plans, Comprehensive policy, dated March 2022, documented a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan included measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being which included services that would otherwise be provided but are not provided due t the resident exercising his or her rights, including the right to refuse treatment.=, any specialized services to be provided as a result of the PASARR recommendations, which professional services are responsible for each element of care. This included the resident's stated goals upon admission and desired outcomes, building on strengths and reflecting on currently recognized standards of practice for problem areas and conditions. Assessments were outgoing, and care plans were revised as information about the residents in the resident conditions changed. The ID team reviewed and updated the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident has been admitted /readmitted to the facility from a hospital stay, and at least quarterly, and in conjunction with the required quarterly assessment.

The facility had a census of 61 residents. The sample included 17 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents a risk for inadequate staffing.Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for fiscal Year (FY) 2025, Quarter (Q) 1 and FY 2025 Q 2 indicated excessively low weekend staffing.Review of the facility's Nursing staffing schedule for the above quarter revealed adequate staff on duty was provided.On 07/28/25 at 01:39 PM, Administrative Nurse D stated that the daily schedule sheets with updates are sent to the regional office. If there were any changes to the schedule, they would also be sent with the updates to the regional office.The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, dated 08/22, documented that direct staffing information was reported to CMS electronically through the payroll-based journal system. Complete and accurate direct care information was reported in a uniform format specified by CMS. The staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The data was submitted only by designated personnel with training on the PBJ user interface.

The facility identified a census of 62 residents, with three residents 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 record review, observation, and interview, the facility failed to provide necessary care, consistent with professional standards of practice, to prevent pressure ulcers including offloading for Resident (R) 1 who developed a facility-acquired unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on her left heel. This deficient practice also placed R1 at risk for infection and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of a pubic fracture, pressure ulcers, weakness, abnormality of gait and mobility, and need for personal care. R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R1 required substantial/maximum staff assistance with dressing, donning (putting on) footwear, and bed mobility. The MDS noted R1 was dependent on staff for all transfers. The MDS documented R1 was at risk for developing pressure ulcers; R1 was admitted with two Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers and one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer. The MDS documented R1 had pressure ulcer treatments including nutrition and hydration management, pressure ulcer care, and application of ointments/medications. The Functional Abilities Care Area Assessment (CAA), dated 02/13/25, documented R1 had an alteration in self-care and mobility function with altered elimination, a risk for falls, and a risk for skin breakdown. The CAA identified R1 admitted with a Stage 3 pressure ulcer to her coccyx (tailbone area) and a Stage 2 pressure ulcer to her right and left buttocks. The CAA noted R1 received antibiotics for positive wound cultures and infection. The Pressure Ulcer/Injury CAA, dated 02/13/25, documented R1 entered the facility with pressure ulcers, and had contributing factors of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, and immobility. R1's Care Plan documented R1 required substantial to maximum assistance from one to two staff for bathing, bed mobility, and transfers; R1 was dependent on one to two staff for toileting. The care plan directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown, administer treatments as ordered, monitor for effectiveness, and provide pressure relieving/reducing devices on R1's bed and chair (02/10/25). The plan documented R1 was to wear heel protectors at all times (03/27/25). The plan directed staff to use caution during transfers and bed mobility to prevent R1 from striking her arms, legs, and hands against any sharp or hard surfaces (04/11/25). R1's Care Plan lacked interventions related to repositioning and lacked interventions related to offloading until 03/27/25. The Braden Scale for Predicting Pressure Sore Risk, dated 02/18/25, documented R1's score as 18, which indicated R1 was at low risk for pressure ulcer development. The Braden Scale for Predicting Pressure Sore Risk, dated 03/08/25, documented R1's score as 17, which indicated R1 was at low risk for pressure ulcer development. The Incident Note, dated 03/15/25 at 12:44 AM, documented the nurse was called into R1's room by the Certified Nurse Aides (CNA) who reported R1 had blood by her left heel. The note documented the nurse found R1 had five centimeters (cm) by three cm Stage 3 pressure ulcer on her left heel. The staff cleansed the wound with wound cleanser and applied Xerofoam (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) and a border dressing to R1's left heel. The Order Note, dated 03/20/25, documented a left heel dressing change. Staff were to cleanse the wound with wound cleanser, apply calcium alginate (highly absorbent dressing), cover with a bordered adhesive foam dressing and change daily and as needed. The Wound Assessment Note, dated 03/20/25, documented R1's left heel wound measured 5 cm by 6 cm by 0.2 cm deep. The IDT Note, dated 03/21/25, documented R1 had a new pressure ulcer on her left heel. Staff received orders to start calcium alginate to aid in the formation of granulation tissue (new tissue formed during wound healing) and to debride (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) areas of loose skin. The note documented the treated area had no signs or symptoms of infection. The Wound Assessment Note, dated 03/26/25 documented R1's left heel wound measured 5.5 cm by 7.4 cm and was mostly necrotic (pertaining to the death of tissue in response to disease or injury). The IDT Note, dated 03/26/25, documented R1's left heel treatment started the previous week. The peri-wound (tissue surrounding the wound) was opening up and increased in size. The wound had no signs or symptoms of infection noted to the area. The Wound Assessment Note, dated 04/03/25, documented R1's left heel wound measured 6 cm by 8.5 cm and had progressed to an unstageable ulcer. The IDT Note, dated 04/03/25 documented R1's left heel ulcer progressed in normal stages for pressure ulcers, the peri wound was sloughing (dead tissue, usually cream or yellow in color) off and the wound was expanding in size. The Wound Assessment Note, dated 04/11/25, documented R1's left heel ulcer measured 5.7 cm by 8.5 cm and continued to be necrotic and unstageable. The Wound Assessment Note, dated 04/17/25, documented R1's left heel wound measured 5.6 cm by 8.3 cm. The wound was necrotic, unstageable, and had a foul odor. The IDT Note, documented all of R1's pressure sores showed signs of improvement except the left heel ulcer. Staff requested and received an order for a wound culture due to the wound's odor. The EMR lacked evidence of the culture results that were ordered. The Skin/Wound Note, dated 04/21/25, documented R1 had a large injury to her left leg. R1 obtained a laceration (cut) to her left inner calf during a transfer with a Hoyer lift (total body mechanical lift) caused by R1's leg rubbing on the back of the foot pedal. Staff called Emergency Medical Services (EMS) and sent R1 to the emergency room for suture (stitches) placement. The Hospital Progress Note, dated 04/22/25, documented the hospital placed nine sutures on R1's left anterior shin laceration to R1's leg that grazed the back of the foot pedals on her wheelchair. The note documented the hospital had concerns about R1's left heel wound due to the malodorous smell, and an X-ray was done that showed a large soft tissue wound posterior (back) to the calcaneus (heel bone) with adjacent soft tissue swelling, osseous (hard, mineralized tissue that provides the skeletal structure of the human body) destruction of the posterior calcaneal (heel bone) cortex (outer layer of any part) adjacent to the wound consistent with acute osteomyelitis (local or generalized infection of the bone and bone marrow). R1 received vancomycin (antibiotic) and Zosyn (antibiotic) at the transferring hospital. R1 was transferred to a higher-level hospital for surgical evaluation. R1's age, multiple comorbid conditions, and lack of mobility as well as dementia, resulted in a conservative treatment plan. R1's responsible party discussed the options to discharge back to long-term care on hospice versus continuation of intravenous (IV) antibiotics for six to eight weeks and see how R1 did. The General Progress Note, dated 04/28/25, documented R1 arrived from a higher level of care with diagnoses of failure to thrive, wounds, and frail elderly. R1 was admitted back to the facility on hospice. The Infection Note, dated 04/30/25, documented R1 continued an antibiotic for her left heel wound. There were no signs and symptoms of infection to left heel. The staff changed the dressing, and the area was without odor. On 05/07/25 at 11:30 AM, observation revealed R1 lay in bed sleeping. R1 had oxygen tubing pulled down below her chin. R1 had blue pressure-relieving boots on both feet. R1 lay on a low-air mattress. On 05/07/25 at 11:30 AM, R1 stated she did not know how she got the sore on her left heel, but it hurt. R1 apologized for being sleepy, saying she had just received a pain pill, which made her sleepy. On 05/07/25 at 01:00 PM, CNA O stated she could not remember if R1 had pressure-relieving boots prior to her obtaining the heel wound. CNA O stated she did not know if turning and repositioning was on R1's Care Plan but staff would turn and reposition anyway regardless of if it was on the care plan. CNA O stated R1 had been on an air mattress since R1's admission to the facility. On 05/07/25 at 01:10 PM, CNA P stated she did not think R1 had pressure-relieving boots on her feet before she developed the left heel pressure ulcer. CNA P stated there was nothing that alerted or informed staff which residents needed to be turned or repositioned, but the CNA just knew and did it anyway. On 05/07/25 at 01:20 PM, Licensed Nurse (LN) G stated she was sure R1 had been on an air mattress since admission, but she could not accurately say whether R1 had pressure-relieving boots to her feet prior to getting the pressure wound on the left heel. On 05/07/25 at 02:30 PM, Administrative Nurse D stated she did not know why R1's Care Plan did not include pressure-relieving boots as an intervention until 03/27/25 after R1 had sustained the left heel ulcer. Administrative Nurse D stated the facility was in between MDS nurses at that time, and training new MDS nurses about care plan interventions was complicated. Administrative Nurse D stated she thought R1 had pressure-relieving boots in place from admission. Administrative Nurse D stated she knew R1 had an air mattress since her admission to the facility. Administrative Nurse D stated she thought R1 had possibly been in the dying process since her admission, and that is why she obtained the pressure ulcer. Administrative Nurse D stated she expected that residents would develop facility-acquired pressure ulcers unless they were unavoidable. The facility did not provide a policy on pressure ulcer prevention.

The facility identified a census of 58 residents with three residents reviewed for elopement and wandering. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to prevent cognitively impaired Resident (R)1 from exiting the facility without staff knowledge and supervision. On 06/13/24 at approximately 07:55 AM R1, who was at risk for elopement, propelled his wheelchair from the dining room to the smoker's room on the south hall. R1 went into the smoker's room and said that it was his home. Housekeeping Staff U removed R1 from the smoker's room and told Certified Nurse Aide (CNA) N what R1 was doing. R1 reentered the smoker's room and CNA N went in and tried to convince R1 to leave but R1 again stated it was his home. Since R1 was not attempting to exit, CNA N left him to go answer call lights. Both CNA N and CNA M began assisting other residents. At 08:20 AM, Administrative Staff A entered the parking lot and headed to the door of the facility. She heard someone say, Good Morning. When she looked back to the east, she saw R1 in the parking lot, sitting in his wheelchair. Administrative Staff A approached R1 and asked what he was doing outside, and he said, I am going home to see my wife and brother. Administrative Staff A called Administrative Nurse D and she came to assist R1 back into the facility. The investigation revealed the door alarm to the smoker's room sounded, but staff could not hear it. The facility's failure to provide adequate supervision to prevent R1 from eloping placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, history of falling, difficulty in walking, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair for locomotion and required moderate to maximum assistance from one staff for toileting, dressing, bed mobility, and bathing. R1 was able to use his wheelchair to move from one place to another without assistance. The MDS documented R1 had no behaviors. The Functional Abilities Care Area Assessment (CAA), dated 11/29/23, documented R1 required assistance with bed mobility, transfers, dressing, bathing, and personal hygiene tasks. The CAA documented R1 was able to eat independently with set-up assistance as needed. The CAA documented R1 was able to self-propel independently for short distances. The Fall CAA, dated 11/29/23, documented R1 was at risk for falls due to generalized weakness, unsteadiness, decreased safety awareness, and actual falls. R1's Care Plan documented R1 was an elopement risk/wanderer, and his safety would be maintained (06/11/24). R1's information was added to the elopement risk binder. The care plan directed staff to identify a pattern of wandering and intervene as appropriate and provide R1 with structured activities like toileting, walking inside and outside, and reorientation strategies. The care plan directed staff when R1 wanted to go home or stated that he needed to go home, to use redirection and remove R1 away from the door. The Elopement Risk Evaluation, dated 06/10/24, documented R1 had a score of three which indicated R1 was at risk for elopement. The Fall Risk Evaluation, dated 06/10/24, documented R1 had a score of twenty which indicated he was at risk for falls. The Facility Incident Report, dated 06/13/24, documented at approximately 07:55 AM on 06/13/24, R1 was seen in the facility's smoking room by CNA N. CNA N stated R1 was not exit seeking so she left him in the smoking room and went to answer call lights. At 08:20 AM, Administrative Staff A observed R1 sitting in the parking lot in his wheelchair. R1 told Administrative Staff D he was waiting for his family. R1 was easily redirected. R1 had on a sweatshirt, pants, socks, and shoes. The temperature outside was 71 degrees, sunny, with a light breeze. R1 was taken back into the facility and a head count of all residents was performed. A head-to-toe assessment of R1 revealed no injuries. R1 went outside through the smoke room door. The door alarm was alarming, but the staff did not respond to the door alarm because they could not hear the alarm where they were. Staff were in residents' rooms and two CNAs were in the dining room. Interventions included R1 was one-to-one with staff until it was determined he was not exiting seeking. All the door alarms were checked and functioning properly. Education was performed with all staff to respond to door alarms. Maintenance is looking for ways the smoking-room door alarm can be made louder. CNA M's Witness Statement, dated 06/13/24, documented CNA M had just finished giving another resident a shower and walked the resident out of the shower room and to their room. CNA M saw R1 heading from the dining room onto the south hall at 07:50 AM. Housekeeping Staff U's Witness Statement, dated 06/13/24, documented at around 07:55 AM Housekeeping Staff U saw R1 in the smoke room. R1 stated he was going home. Housekeeping Staff U removed R1 from the smoke room and R1 said the smoke room was his home. A couple of minutes later, R1 went back into the smoke room and Housekeeping Staff U notified CNA N of R1's location. CNA N's Witness Statement, dated 06/13/24, was documented at around 07:55 AM Housekeeping Staff U informed CNA N R1 was in the smoke room, and she attempted to keep R1 out of the room, but he had gone in again stating the room was his home. CNA N attempted to remove R1 from the smoke room but R1 refused to come out. R1 was just sitting in the room and not attempting to leave. CNA N stated she made sure R1 was just sitting there and left to go answer call lights. Administrative Staff A's Witness Statement, dated 06/13/24, documented she pulled into the facility parking lot around 08:20 AM. Administrative Staff A stated she walked to the front door of the facility when she heard someone say, Good morning. Administrative Staff A looked to her right and saw R1 sitting in his wheelchair in the middle of the parking lot. Administrative Staff A asked R1 where he was going and R1 said to see his wife and his brother. Administrative Staff A asked R1 how he got outside and R1 said the back door. Administrative Staff A called Administrative Nurse D at 08:23 AM and informed her of the situation. Administrative Staff A then moved R1 out of the parking lot and onto the sidewalk. Administrative Nurse D arrived to assist R1 back into the facility. On 06/17/24 at 09:15 AM, observation revealed a sidewalk leading out to the parking lot which was full of cars. There was multiple car-stops. The pavement in the parking lot had cracks and weeds growing up in the cracks. On 06/17/24 at 09:30 AM, observation revealed R1 sat up in his bed drinking water. R1 was very pleasant and friendly. R1 was not oriented to time or place. A CNA sat outside of R1's room providing one-on-one supervision. On 06/17/24 at 09:15 AM, CNA O stated R1 could not walk and used a wheelchair for locomotion but R1 had poor safety awareness and had falls where he had tried to stand up and walk. On 06/17/24 at 10:30 AM, CNA M stated she was working the day R1 eloped, and she did not hear the door alarm sound when she was in another resident's room. CNA M stated she thought R1 would be safe in the smoke room, or she would not have left him there. On 06/17/24 at 11:30 AM, Administrative Nurse D stated when she was outside with R1 she could hear the alarm sounding outside, but as soon as she came into the building, the alarm was not sounding at the alarm panel to alert staff. Maintenance fixed the alarm so it was sounding at the alarm panel and staff could hear the alarm throughout the building. Administrative Nurse D stated she expected all staff to respond to door alarms and provided education to all the staff regarding elopements and conducted elopement drills twice a day to ensure everyone knew what to do. The facility Wandering and Elopement Policy, dated 07/01/24, documented the purpose of the policy is to provide a system of identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize the risk of resident elopements, improve resident safety through timely investigations of elopements and elopement attempts, and provide staff education in effective wandering/elopement management through in-services and elopement drills. On 06/17/24 at 01:06 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to provide adequate supervision to prevent R1 from eloping placed R1 in immediate jeopardy. The facility identified and implemented immediate corrective actions, which were completed on 06/13/24 and included: All nursing staff were re-educated on wandering/elopement. R1 is one-on-one with staff until it is determined he is not exiting seeking. Maintenance fixed the smoke room door alarm, so it would alarm not only in the room and outside but at the alarm panel to alert staff. Maintenance staff and the manager on duty on the weekends are checking all door alarms twice a day. Care plans of residents at risk for elopement were reviewed and new elopement risk evaluations were completed on all residents. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 65 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to follow the physician's orders for Resident (R)1's insulin (a hormone that lowers the level of glucose in the blood) administration which resulted in R1's blood sugar decreased to 44 milligrams per deciliter (mg/dl) and had to be transferred to a higher level of care. On 12/17/23 Licensed Nurse (LN) G administered eight units of insulin aspart (short-acting insulin) to R1 right as R1 started to eat supper, despite the physician's order which directed staff to only give insulin aspart if the resident ate greater than 50% of the meal. R1 only ate three to four bites of her supper. This deficient practice resulted in a hypoglycemic (less than normal amount of sugar in the blood typically less than 70 mg/dl) episode and placed R1 at risk for other related complications. Findings included: - R1's Electronic Medical Record (EMR) documented that R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 was rarely/never understood and had short and long-term memory problems. The MDS further documented R1 was dependent on staff for personal hygiene, bed mobility, transfer, toileting, and bathing. R1 required moderate assistance for eating. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/27/23, documented R1 had a Brief Interview for Mental Status score of six which indicated severely impaired cognition. The Activities of Daily Living (ADL)/Rehabilitation Potential CAA, dated 06/27/23, documented R1 required assistance with bed mobility, transfers, dressing, bathing, and mobility. The CAA documented R1 used the sit-to-stand lift to transfer and was able to verbalize her needs to staff. R1's Care Plan, revised on 12/21/22, documented R1 was at risk for alterations in her blood sugar levels and hypoglycemia. The care plan directed staff to monitor for any signs and symptoms of hypoglycemia, administer medications as ordered, and notify the physician if R1's blood sugar was less than 70 mg/dl or greater than 350 mg/dl. The Order Summary Tab documented the physician's order, dated 07/12/23, which directed licensed staff to administer eight units of insulin aspart subcutaneously (under the skin) three times a day and to hold the dose if R1 ate less than fifty percent of her meal. The Weights and Vitals Tab documented on 12/17/23, R1's blood sugar was 80 mg/dl at 07:26 AM, 132 mg/dl at 11:07 AM, and 200 mg/dl at 05:01 PM. The electronic Medication Administration Record (MAR), dated December 2023, documented R1 received eight units of insulin aspart on 12/17/23at 05:30 PM by LN G. The General Progress Note, dated 12/17/23, documented R1 was found non-responsive and diaphoretic (sweaty) at 08:15 PM. R1's blood sugar was 44 mg/dl. Staff administered R1 a tube of glucose gel (gel used to increase blood sugar) and R1 moaned and opened her eyes. Staff notified Emergency Medical System (EMS) and EMS arrived at 08:44 PM. R1's blood sugar at the time was 29 mg/dl. EMS started an intravenous line (IV) gave R1 D10 (dextrose 10%) and transported R1 to the hospital. Five different staff tried to assist R1 with supper and she refused to eat except for three to four bites. The Conversation with Practitioner Note, dated 12/17/23, documented staff notified R1's primary care physician that R1's insulin was given to her before supper and R1 only ate three to four bites. Multiple staff tried to assist her and R1 refused to eat any more supper; R1 had a low blood sugar of 44 mg/dl. The Facility Incident Report, dated 12/22/23, documented on 12/17/23 at approximately 08:15 PM, R1, a COVID-19 (highly contagious respiratory virus) positive resident, was found to be less responsive and diaphoretic. Upon evaluation by the charge nurse, R1's blood sugar was 44 mg/dl. Staff notified R1's primary care physician and received a new order to administer one tube of dextrose gel and send R1 to the emergency room (ER) for evaluation and treatment. Upon review, R1 had an order for insulin aspart eight units subcutaneously three times a day and to hold the dose if R1 ate 50% or less of her meals. R1 was administered her insulin before supper and R1 only ate three to four bites of supper. R1 had a decrease in mental status and meal intake due to being COVID-19-positive. ER documentation noted R1 was hypoglycemic but became more responsive with the dextrose gel and D10 treatment. The Hospital Health and Physical, documented R1 was at the emergency department due to a low blood sugar of 29 mg/dl and hypotension (low blood pressure) with systolic blood pressure in the 70's. R1 was transferred to a higher level of care. On examination, R1 had diagnoses of septic shock due to cystitis (inflammation of the bladder), hypoglycemia, and infection. On 01/11/24 at 09:00 AM, observation revealed R1 laid in bed with an oxygen cannula in her nostrils. R1 slept soundly. On 01/11/24 at 09:15 AM, CMA R stated that R1 could not eat by herself and had to be fed by staff. On 01/11/24 at 10:00 AM, Administrative Nurse D stated that she expected all of her nurses to follow physicians' orders exactly as written to ensure the safety of the residents. Administrative Nurse D stated all of the nurses at the facility were re-educated regarding following physician orders and insulin administration. Administrative Nurse D stated LN G was suspended pending the investigation but returned to work after re-education. Administrative Nurse D stated LN G did not know why she gave R1 her insulin before she ate that day because she had never done that before. The facility's Insulin Administration Policy, dated September 2014, documented the purpose of the policy was to provide guidelines for the safe administration of insulin to residents with diabetes. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to ensure that it corresponds with the order on the medications sheet and the physician's order. The facility failed to follow the physician's orders for R1's insulin administration. This deficient practice resulted in a hypoglycemia episode which required emergent treatment and placed R1 at risk for related complications. On 12/21/23 the facility identified and completed the following corrective actions: All nurses received education regarding physician orders and insulin administration. All residents who received insulin were reviewed and had care plans updates as needed. A risk meeting was held and presented to Quality Assurance and Performance Improvement (QAPI), and insulin orders were audited. All corrective actions were completed prior to the onsite survey, therefore the deficient practice was deemed past noncompliance at a G scope and severity.

The facility had a census of 64 residents. Based on observation, interview, and record review the facility failed to provide adequate nutritional servings during a meal, as specified in the recipe. This deficient practice placed residents who received their meals from the facility kitchen at risk for inadequate nutrition. Findings included: - The facility's recipe from DiningRD.com for pureed Chicken Penne Pasta-No Bacon stated the portion size after the pureed process was a #6 dip (equal to 4.58 ounces). The recipe for regular diet Chicken Bacon Penne Pasta stated the portion size was an 8-ounce spoodle (cross between a serving spoon and a ladle). On 11/02/23 at 11:20 AM, observation revealed Dietary Staff (DS) CC prepared pureed diets for three residents, including the following food: Chicken alfredo with penne noodles: three one-half cups of the pasta, three-quarters of a cup chicken broth, and one tablespoon of thickener. On 11/02/23 at 11:35 AM, observation revealed DS CC served meals from the steam table. She used a four-ounce gray colored scoop to dish up the chicken alfredo pasta for the pureed diets and a different four-ounce gray scoop to dish up the chicken alfredo pasta for the regular diets. On 11/02/23 at 03:15 PM, DS BB verified staff did not provide the serving size at lunch as specified in the recipe for the chicken bacon pasta. The facility's Kitchen Weights and Measures policy, dated April 2007, stated food services staff would be trained in proper use of cooking and serving measurements to maintain portion control. The policy stated staff would be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators on utensils would be prominently displayed for reference. The facility failed to provide adequate nutritional servings during a meal, as specified in the recipe, placing residents who received their meals from the facility kitchen at risk for inadequate nutrition.

The facility had a census of 64 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard expired stock medication. These deficient practices placed the affected resident at risk for ineffective medications. Findings included: - On 11/01/2023 at 08:50 AM, observation of the medication cart for the Southwest hall revealed the following: One bottle of Melatonin (sleep supplement,) 1 milligram (mg), 180 tablets, expired 06/2023 One bottle of Oyster shell calcium, 500 mg, 100 tablets, expired 07/2023 One bottle of Thera-M- multivitamin 100 caplets, expired 09/2023 On 11/01/23 at 08:55AM, Certified Medication Aide (CMA) R verified the nurses were to discard expired medications. CMA R said staff had recently went through the medications carts and stated the expired medications must have been missed. On 11/02/23 at 8:30 AM, Administrative Nurse D verified the nurses should look at the stock bottles and verify the medication expiration date with each administration and discard expired medications. The facility's Storage of Medications policy, dated November 2020, documented the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The facility failed to dispose of expired medication placing the residents at risk for ineffective medication.

The facility had a census of 64 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to honor resident rights when the facility revoked Resident (R) 31's smoking privilege as a form of reprisal for the facility's inadequate supervision which allowed R31 to obtain cigarettes and a lighter from another resident's room; R31 lit a cigarette in the hall outside of the smoking room. (See F689). This deficient practice placed R31 at risk for impaired self-determination about things that were important to her, including smoking. Findings included: - R31's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), nicotine dependence (an addictive organic compound found in tobacco plants), mild intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acquired absence of left leg above knee. The Annual Minimum Data Set (MDS) dated [DATE] documented R31's had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R31 rejected cares four to six days of the observation period but not daily. She had no wandering during the observation period. The Behavioral Care Area Assessment documented R31 had diagnoses of schizophrenia, bipolar disorder, anxiety, psychosis, and mild intellectual disabilities; R31's behavior and noncompliance were chronic. The MDS recorded R31 had current tobacco use. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition with a BIMS of 14. She had no delirium (sudden severe confusion, disorientation and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS recorded R31 had no wandering or rejection of cares during the observation period, but she did exhibit physical and verbal behaviors directed toward others which occurred one to three days during the observation period. The MDS further documented R31 required partial/moderate assistance with sit to lying and lying to sitting and substantial/maximal assistance with chair to bed to chair transfers; R31 used a manual wheelchair. R31 received insulin (hormone that lowers the level of glucose in the blood), antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), and antibiotic (medication to treat infections) on a routine basis. The question regarding current tobacco use on the MDS was unanswered. R31's Care Plan, initiated on 02/17/21 and revised on 08/31/23 documented R31 had impaired cognition or thought processes due to dementia. The plan listed an intervention initiated on 07/13/21 and revised on 12/05/22 which documented R31 had tobacco use and would adhere to the tobacco and smoking policies of the facility. The care plan listed an intervention dated 07/13/21 which directed staff to conduct a smoking evaluation on admission and as needed; educate the resident and responsible party on the facility's tobacco and smoking policies. R31's Care Plan further documented R31 had a history of hoarding behavior, dated 08/17/21 and directed staff to provide alternative activities to use for meaningful work/tasks and distraction. The plan further listed an intervention dated 03/25/22 which documented R31 had a history of going into other residents' rooms at times and directed staff to re-orient R31 as indicated. R31's Care Plan recorded an intervention dated 08/31/23 which directed that due to R31's use of psychotropic (alters mood or thought) medication, R31 had times for smoking cigarettes. The nurse would monitor and give R31 three cigarettes every two hours. R31's Smoking and Safety Evaluation dated 05/16/23, documented R31 did not demonstrate safe smoking behavior in interacting with peers and required an assistive device for smoking. Other risk level considerations included R31 had diagnoses of dementia/memory impairment. The team deemed R31 unsafe to smoke, therefore she required staff supervision for smoking. R31's Smoking and Safety Evaluation dated 08/14/23, documented R31 used tobacco two to five times a day, morning, afternoon and evening. The assessment recorded R31 was not on a smoking cessation plan and was not interested in quitting. The assessment documented R31 understood the community safety rules and articulated an understanding of the danger of smoking near flammable materials or a resident wearing oxygen. According to the assessment, the team decided the resident could smoke with a safe smoking care plan. Due to R31's diagnosis of dementia/memory loss impairment and psychotropic medications use, staff would light the cigarette for R31. A nurse's note in the Progress Notes section recorded on 06/29/23 R31 went into R43's room and took his cup of medication that was left in his room. Staff educated R31 on not going into another resident's room and that she cannot take medication that she does not get from staff. The facility's Investigation report, dated 11/02/23, documented R31 had been smoking in the South hallway. R31 took cigarettes and a lighter from another resident's room and lit the cigarette in the hallway. Staff put the cigarette out. Staff informed R31's guardian that the resident's smoking privileges had been removed as R31 was unable to follow policy and was not safe to smoke. R31 denied taking cigarettes out of another resident room and did not realize what she did. On 11/02/23 at 12:24 PM, observation revealed R31 sat in R43's room. R43 was in the bathroom and yelled at R31 to get out of his room stating that R31 was not to be in his room. R31 left the room stating she was confused and thought she was in her room. On 11/02/23 at approximately 12:28 PM, R31 sat in the hallway outside the smoking room with a lit cigarette. Staff intervened immediately and put out the cigarette; staff retrieved the cigarettes and lighter which belonged to another resident. On 11/06/23 at 09:47 AM Certified Medication Aide (CMA) S reported R31's smoking routine was she could get two cigarettes and her lighter every two hours. On 11/07/23 at 10:30 AM, Licensed Nurse (LN) G stated R31 could no longer smoke because R31 was able to get cigarettes from someone else's room and lit up and smoked in the hallway. LN G stated occasionally R31's visitor would bring in lighters and R31 would stash them in her room. LN G reported R31 had been known to take things from R43's room in the past. On 11/07/23 at 11:27 AM Administrative Nurse D verified R31's smoking privileges were revoked because she obtained cigarettes and a lighter from another resident's room and lit a cigarette in the hallway. Administrative Nurse D provided documentation of notifying R31's physician of offering R31 Nicorette gum which was refused and requested nicotine patches. Administrative Nurse D verified the facility had not provided/offer R31 with alternative options with safe smoking practices. The facility's Resident Rights policy, date 12/2016, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination, to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The revoking of R31's smoking privileges as a form of reprisal placed the resident at risk for loss of self-determination related to what was important to the resident.

The facility had a census of 64 residents. The sample included 19 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide the care planned amount of staff assistance for Resident (R) 29 to prevent falls, and failed to provide supervision for R31, who entered another resident's room and engaged in unsafe activity. These deficient practices placed the affected residents at risk for further falls and preventable injury. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of cerebral infarction due to embolism of cerebral artery (the pathological process that result in an area of necrotic tissue in the brain), hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), repeated falls, and difficulty walking. R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS recorded ambulation only occurred once or twice with two staff assistance. The MDS further documented R29 had upper and lower functional impairment on one side, unsteady balance, and had one fall with injury. The Fall Risk Assessments, dated 10/18/23 and 10/26/23, documented the resident was at risk for falls. R29's Care Plan, dated 08/28/23, initiated on 06/02/23, educated R29 to call for assistance. It directed staff to obtain therapy referrals as ordered by physician, provide the resident with a safe environment free of clutter, and ensure R29 wore appropriate shoes and clothing. The update dated 06/06/23, documented R29 required assistance of one or two staff for transfers. The update, dated 06/20/23, directed staff to use two staff for transfers, and have R29 call staff for assistance. The update, dated 08/25/23, directed staff to ensure cords were not under the bed prior to leaving the room. The update, dated 09/05/23, directed staff to provide R29 with a reacher. The update, dated 10/16/23, directed staff to keep a wheelchair within reach until R29 stated he felt steady while standing. The update, dated 10/26/23, directed staff to reeducate R29 to call for assistance and place signage in his room for extra reminder. The update, dated 11/02/23, directed staff to use one staff member with transfers. The Nurse's Note, dated 10/16/23 at 05:31 PM, documented R29 was on the floor next to his recliner. Hehad both shoes on, and a gait belt. His bottom legs faced forward, and the bedside table was broken. The note further documented the Certified Nurse Aide (CNA) stated R29 broke the table as he reached for it during the fall. The Fall Investigation, dated 10/16/23 at 04:07 PM, documented R29's right leg went weak and he fell down. The investigation further documented R29 did not sustain any injury, and was educated to tell staff when he felt weak. The investigation further recorded staff were reeducated to transfer R29 with two staff when he was weak or unsteady. On 11/06/23 at 09:00 AM, observation revealed R29 sat on the toilet, CNA N placed a gait belt around R29's waist, and instructed him to grab onto the bar in front of him and stand up. Continued observation revealed CNA N had to cue R29 to take his time, turn, reach back to feel for the recliner, and sit down. On 11/06/23 at 09:10 AM, CNA N stated R29 used to be a two person transfer but he worked with therapy and was now a one person assistance for transfers and ambulation. On 11/07/23 at 11:20 AM, Licensed Nurse (LN) H stated she encouraged staff to use two staff for R29's transfers and ambulation because the resident's cognition had declined, he was weak, and unpredictable. On 11/07/23 at 11:45 AM Administrative Nurse D stated R29 received therapy and was now a one person staff assistance with transfers, and ambulation. Administrative Nurse D stated she felt the care plan had incorrect documentation but stated staff should follow the care plan. The facility's Fall and Fall Risk policy, dated 03/2018, documented based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The facility failed to follow R29's plan of care to ensure two staff for transfers, which resulted in a fall. This placed the resident at risk for further falls and preventable injury. 37450 - R31's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), nicotine dependence (an addictive organic compound found in tobacco plants), mild intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acquired absence of left leg above knee. The Annual Minimum Data Set (MDS) dated [DATE] documented R31's had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R31 rejected cares four to six days of the observation period but not daily. She had no wandering during the observation period. The Behavioral Care Area Assessment documented R31 had diagnoses of schizophrenia, bipolar disorder, anxiety, psychosis, and mild intellectual disabilities; R31's behavior and noncompliance were chronic. The MDS recorded R31 had current tobacco use. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition with a BIMS of 14. She had no delirium (sudden severe confusion, disorientation and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS recorded R31 had no wandering or rejection of cares during the observation period, but she did exhibit physical and verbal behaviors directed toward others which occurred one to three days during the observation period. The MDS further documented R31 required partial/moderate assistance with sit to lying and lying to sitting and substantial/maximal assistance with chair to bed to chair transfers; R31 used a manual wheelchair. R31 received insulin (hormone that lowers the level of glucose in the blood), antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), and antibiotic (medication to treat infections) on a routine basis. The question regarding current tobacco use on the MDS was unanswered. R31's Care Plan, initiated on 02/17/21 and revised on 08/31/23 documented R31 had impaired cognition or thought processes due to dementia. The plan listed an intervention initiated on 07/13/21 and revised on 12/05/22 which documented R31 had tobacco use and would adhere to the tobacco and smoking policies of the facility. The care plan listed an intervention dated 07/13/21 which directed staff to conduct a smoking evaluation on admission and as needed; educate the resident and responsible party on the facility's tobacco and smoking policies. R31's Care Plan further documented R31 had a history of hoarding behavior, dated 08/17/21 and directed staff to provide alternative activities to use for meaningful work/tasks and distraction. The plan further listed an intervention dated 03/25/22 which documented R31 had a history of going into other residents' rooms at times and directed staff to re-orient R31 as indicated. R31's Smoking and Safety Evaluation dated 05/16/23, documented R31 did not demonstrate safe smoking behavior in interacting with peers and required an assistive device for smoking. Other risk level considerations included R31 had diagnoses of dementia/memory impairment. The team deemed R31 unsafe to smoke, therefore she required staff supervision for smoking. R31's Smoking and Safety Evaluation dated 08/14/23, documented R31 used tobacco two to five times a day, morning, afternoon and evening. The assessment recorded R31 was not on a smoking cessation plan and was not interested in quitting. The assessment documented R31 understood the community safety rules and articulated an understanding of the danger of smoking near flammable materials or a resident wearing oxygen. According to the assessment, the team decided the resident could smoke with a safe smoking care plan. Due to R31's diagnosis of dementia/memory loss impairment and psychotropic medications use, staff would light the cigarette for R31. A nurse's note in the Progress Notes section recorded on 06/29/23 R31 went into R43's room and took his cup of medication that was left in his room. Staff educated R31 on not going into another resident's room and that she cannot take medication that she does not get from staff. The facility's Investigation report, dated 11/02/23, documented R31 had been smoking in the South hallway. R31 took cigarettes and a lighter from another resident's [R43] room and lit the cigarette in the hallway. Staff put the cigarette out. Staff informed R31's guardian that the resident's smoking privileges had been removed as R31 was unable to follow policy and was not safe to smoke. R31 denied taking cigarettes out of another resident room and did not realize what she did. On 11/02/23 at 12:24 PM, observation revealed R31 sat in R43's room. R43 was in the bathroom and yelled at R31 to get out of his room stating that R31 was not to be in his room. R31 left the room stating she was confused and thought she was in her room. On 11/02/23 at approximately 12:28 PM, R31 sat in the hallway outside the smoking room with a lit cigarette. Staff intervened immediately and put out the cigarette and retrieved the cigarettes and lighter which belonged to another resident. On 11/06/23 at 09:47 AM Certified Medication Aide (CMA) S reported R31's smoking routine was she could get two cigarettes and her lighter every two hours. On 11/07/23 at 10:30 AM, Licensed Nurse (LN) G stated R31 could no longer smoke because R31 was able to get cigarettes from someone else's room and lit up and smoked in the hallway. LN G stated occasionally R31's visitor would bring in lighters and R31 would stash them in her room. LN G reported R31 had been known to take things from R43's room in the past. LN G also reported the smoke room was not equipped with a camera. On 11/07/23 at 11:27 AM Administrative Nurse D verified R31's smoking privileges were revoked because she obtained cigarettes and a lighter from another resident's room and lit a cigarette in the hallway. Administrative Nurse D provided documentation of notifying R31's physician of offering R31 Nicorette gum which was refused and requested nicotine patches. Administrative Nurse D verified the facility had not provided/offer R31 with alternative options with safe smoking practices. The facility's Smoking Policy-Residents, dated 08/2022, documented the facility has established and maintains safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated resident smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking, regardless of method of tobacco consumption is only permitted in designated resident smoking area. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The facility failed to provide adequate supervision to R31, who had a history of taking unsafe items from R43's room, which allowed her to wander into R43's room, obtain smoking materials, and light a cigarette in the hall outside the smoking area. This deficeint practice placed R31 at risk for preventable accidents and injuries.

The facility had a census of 46 residents. The sampled included 15 residents, of which 4 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 provide necessary care and services to prevent the development of pressure ulcers for 1 of the 4 residents reviewed for pressure ulcers. Resident #46 developed 3 avoidable stage 3 pressure ulcers. Findings included: - Resident #46's signed admission physician's orders [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 3/29/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 9, which indicated moderately impaired cognition. The assessment revealed the resident required extensive staff assistance of 2 with bed mobility, repositioning and transfers. He/she had a surgical incision, was at risk for pressure ulcer development, and had no pressure ulcers. The resident used a pressure mattress and turning and repositioning program. The 3/29/18 pressure ulcer (CAA) Care Area Assessment documented the resident required a special mattress and a cushion in his/her wheelchair. The resident was bedfast, chair bound, and nursing assessed his/her skin for breakdown on a routine basis. The 3/22/18 temporary admission care plan, directed the staff to reposition the resident every 2 hours and as needed. Staff were to provide pressure reducing devices to prevent skin breakdown. The 3/29/18 care plan directed the staff to assist the resident with bed mobility ,and reposition using a wedge cushion to assist the resident on his/her side. The care plan directed 2 staff to provide assistance to transfer the resident using a full lift (a mechanical lift that raises the body from one surface to another). The facility wound/skin healing record, dated 4/3/18, recorded the resident developed three Stage 3 pressure ulcers (full thickness skin loss, in which subcutaneous tissue may be visible) on his/her buttocks. One pressure ulcer on the right buttock measured 3.3 (cm) centimeters by 2.9 cm with 0.1 cm depth. The superior (above) left buttock measured 2.5 cm by 1.5 cm with 0.1 cm depth. The inferior (below) left buttock measured 1.3 cm by 0.6 cm with 0.1 cm depth. Further review of the wound/skin healing record revealed staff notified the physician of the pressure ulcer development on 4/9/18 (6 days after staff identified the wounds). The Wound/Skin healing record documented the following measurements of the pressure ulcers: 4/11/18 right buttock, 3.1 cm by 2.0 cm with 0.1 cm depth, serosanguineous (semi-thick reddish drainage). Superior left buttock, 0.1 cm by 2.0 cm, less than 0.1 cm depth, Inferior left buttock, 0.3 cm by 0.5 cm, less than 0.1 cm depth. On 4/18/18 right buttock, 2.0 cm x 1.0 cm, less than 0.1 cm depth, serosanguineous drainage. Superior left buttock, 1.0 cm by 0.8 cm, less than 0.1 cm depth, inferior left buttock, 0.2 cm by 0.5 cm, less than 0.1 cm depth. On 4/24/18 right buttock, 2.0 cm x 0.4 cm, less than 0.1 cm depth, no drainage. Superior left buttock, 0.1 cm by 0.1 cm no depth, inferior left buttock, 0.2 cm by 0.4 cm, no depth. The 4/5/18 (RD) Registered Dietician documentation recorded the resident received Glucerna (a dietary supplement used for diabetics) two times a day, to promote wound healing. The facility's standing orders, for development of a stage 3 pressure ulcer, directed staff to cleanse the areas with wound cleanser, pat dry with gauze, apply silver hydrogel (a wound dressing for light draining wounds), secure the area with dressing, rolled gauze or tape, and change every 3 days and as needed. The 4/17/18 orthopedic physician (bone doctor), progress notes documented the resident needed a referral to a wound clinic for pressure wounds. The 4/26/18 wound clinic progress notes documented the resident was seen for treatment of [REDACTED]. The right gluteal measured 0.8 cm by 0.3 cm by 0.1 cm. Left gluteal measured 0.4 cm by 0.2 cm by 0.1 cm. On 4/24/18 observations at 11:00 AM, 1:30 PM, 2:20 PM and 4:00 PM, revealed the resident seated on a lift sling in a bariatric (a larger seated chair) wheelchair, in his/her room. On 4/30/18 at 1:30 PM, observation revealed Nurse G and Certified Medication Aide M entered the resident's room, and then positioned him/her the on his/her left side, Nurse G measured the 3 pressure areas on the resident buttocks. Right buttock area measured 0.3 cm by 0.3 cm, no depth. Left inferior buttock measured 0.7 cm by 1.2 cm, no depth. The left superior buttock measured 0.5 cm by 0.2 cm, no depth. On 4/30/18 at 9:15 AM, Administrative Nurse E verified the resident developed pressure ulcers on his/her buttocks after admission to the facility. On 4/30/18 at 9:45 AM, Nurse G verified the pressure ulcers on the resident's buttocks were not there when the resident was admitted to the facility . Nurse G also verified when the resident had no bariatric bed (a wider and longer bed) and used a regular facility bed which had been not wide enough to reposition the resident on his/her side. Nurse G stated it was approximately a week after the resident was admitted before a bariatric bed was delivered for the resident to use. Nurse G stated the resident sat in his/her wheelchair on the lift sling most of the day, which is on top of the pressure cushion. On 4/30/18 at 10:30 AM Certified Medication Aide M verified the resident had pressure ulcers on his/her buttocks. Certified Medication Aide M stated the staff were to reposition the resident every 2 hours when in bed. On 4/30/18 at 1:15 PM, the resident stated, I have some sores on my bottom. On 5/2/18 at 7:35 AM, Nurse H verified the resident was admitted to the facility for recovery from a fracture, he/she had regular bed, and it was almost impossible for the staff to reposition him/her in the smaller bed. Nurse H also verified the resident had a urinary catheter (a tube in the bladder which drains urine into a bag) it was removed on 4/2/18, and the resident was incontinent of urine and needed staff to change him/her every 2 hours when in bed. On 5/2/18 at 9:50 AM, Administrative Nurse D stated the facility was unable to rent a bariatric bed for the resident on admission to the facility. Administrative Nurse D verified the resident was at risk for developing pressure ulcers due to immobility and needed staff assistance with repositioning and incontinent care. Administrative Nurse D verified the resident developed three stage 3 pressure ulcers after admission to the facility. On 5/2/18 at 12:00, Physician's Nurse GG stated if the resident would have had the appropriate bariatric bed and received the appropriate care, the pressure ulcers could have been avoided. The 7/2017 facility policy for pressure ulcers documented a resident has an increased risk to develop a pressure ulcer if the resident has decreased mobility, decreased functional ability, and/or exposure of skin to urine incontinence. The facility needs to have preventative measures in place to prevent the development of pressure ulcers including specialized beds and cushions for wheelchairs. The facility is to select specialized support surfaces for residents at risk for pressure ulcer development. The facility failed to provide appropriate interventions to prevent pressure ulcers for Resident #46, who developed three Stage 3 pressure ulcers after admission to the facility, placing the resident at risk for infection and further skin breakdown.

The facility had a census of 61 residents. The sample included 5 residents, who were reviewed for pressure ulcers. Based on observation, record review and interview the facility failed to provide necessary services and treatment to promote healing, prevent infection and prevent new pressure ulcers from developing for 3 of 5 sampled residents. Resident #1 admitted to the facility with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) on his/her left hip, that worsened to a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) with an infection, which required a prolonged hospitalization , placing Resident #1 in immediate jeopardy. Resident #2 developed a facility acquired Stage IV pressure ulcer with an infection, which required a prolonged hospitalization , placing Resident #2 in immediate jeopardy. Resident #3 admitted to the facility with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible). Findings Included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 09/29/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 11 (moderately impaired cognition). The MDS also indicated the resident required limited assistance with bed mobility, extensive assistance with transfers and toileting, and was incontinent of bowel and bladder. The MDS further indicated the resident had an unstageable pressure ulcer (wound bed covered by scab/hardened skin) and received nutritional interventions and wound dressings. The 09/22/16 admission care plan directed staff to provide the resident's wound care as ordered by the physician, and report skin issues to the charge nurse immediately. The care plan lacked documentation of the type of wound, stage of wound, location of the wound or any interventions to promote healing of the wound. The 09/29/16 (CAA) Care Area Assessment for pressure ulcers indicated the resident admitted to the facility after his/her left hip pressure ulcer was debrided (removal of dead tissue and foreign material from a wound) and received wound care at the hospital. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/06/16 care plan revealed the resident was admitted with a left hip pressure ulcer and was at risk for further skin alterations. The care plan directed staff to provide the resident's wound cares as ordered by the physician. The care plan lacked documentation of the stage of the wound or any care interventions to promote healing of the wound. The 09/22/16 physician's discharge orders indicated the resident had a resolved Stage IV pressure ulcer on his/her left hip and directed staff to take the resident to the wound clinic every week for wound therapy. The physician's orders [REDACTED]. The 09/22/16 wound clinic discharge orders indicated the resident had a superficial wound, with 100% healthy tissue, on his/her left hip and directed staff to provide wound care as ordered by the physician and take the resident to the wound clinic every week for wound therapy. review of the resident's medical record revealed [REDACTED]. The 09/22/16 at 7:01 PM, admission nurse's note indicated staff would complete a skin assessment for the resident later in the evening. review of the resident's medical record revealed [REDACTED]. The 09/27/16 at 9:38 AM, nurse's notes indicated the the resident's left hip pressure ulcer had no dressing, measured 1.2 (cm) centimeters by 0.8 cm by 0.3 cm deep, and a small amount of serosanguineous (bloody) drainage. The nurse's note indicated the facility currently did not have the correct dressing supplies (polymen silver dressing change daily) for the resident's pressure ulcer and the dressing supplies would be delivered today (5 days after admission). The wound assessment lacked a description of the wound bed and/or the condition of the surrounding tissue. The 10/02/16 at 2:30 AM, nurse's note indicated the resident's left hip pressure ulcer had a white wound bed with serosanguineous drainage, raised soft spots under the skin and dark redness around the wound. The 10/03/16 at 2:25 AM, nurse's note indicated the resident's left hip pressure ulcer had serosanguineous and purulent (yellow/white liquid produced with certain infections) drainage. The nurse's note also indicated the resident's pressure ulcer was tunneling (wound expansion under the skin/tissue) approximately 4 cm towards the knee. Review of the note revealed no documentation indicating staff notified the physician of signs of infection (purulent drainage and tunneling). The 10/06/16 at 8:00 PM, nurse's note indicated the resident's pressure ulcer measured 1.1 cm by 0.6 cm, redness surrounding the wound and purulent drainage. The nurse's note indicated staff notified the physician concerning the possible infection in the resident's pressure ulcer (3 days after noting purulent drainage from the wound). The 10/06/16 physician's orders [REDACTED]. The 10/07/16 wound culture indicated the resident's left hip pressure ulcer was positive for (MRSA) [MEDICAL CONDITION]-resistant Staphylococcus aureus (antibiotic resistant infection). The 10/07/16 physician's orders [REDACTED]. The 10/16/16 at 1:09 PM, nurse's note indicated the resident continued on antibiotic medication and the resident's pressure ulcer measured 0.6 cm by 0.4 cm by 0.2 cm deep, with unmeasureable tunneling present. The 10/21/16 at 5:10 PM, nurse's note indicated the resident's left hip pressure ulcer had purulent drainage with redness noted around the wound. Continued review of the resident's medical record revealed [REDACTED]. The 10/26/16 at 7:10 AM, nurse's note indicated the resident's pressure ulcer continued with purulent drainage and tunneling. Continued review of the resident's medical record revealed [REDACTED]. The 11/03/16 at 3:10 PM, nurse's note indicated the (PA) Physician Assistant O assessed the resident's pressure ulcer and ordered a wound care consult at the hospital. The 11/07/16 wound clinic progress note indicated the resident presented for evaluation and treatment for [REDACTED]. The note indicated the wound had no dressing and the resident's pants were saturated with drainage on the area near the wound site. The note indicated the resident had a blister above an open area, that consistently drained purulent drainage and when staff put pressure on the blister the purulent drainage increased from the open area, indicating the wound and blister were connected by a tunnel. The note indicated the open area measured 0.1 cm in diameter, the blister was fluid filled and the entire surrounding area was dark red, felt mushy/boggy (soft or spongy) and measured 9 cm by 6 cm. The note indicated staff cultured the resident's left hip pressure ulcer due to an apparent infection. The note further indicated the resident had a physician's orders [REDACTED]. The 11/07/16 nurse's note indicated the wound clinic directed staff to cover the resident's wound with polymen silver dressing and an ABD pad (thick dressing for moisture absorbency) and change the ABD pad every day or as needed. The 11/10/16 wound clinic progress note indicated the resident presented with an ABD pad saturated with purulent drainage and the blister area increased in size. The note indicated staff notified the resident's physician of possible need for I&D (incision and drainage). The note indicated the surgeon made an incision in the wound and found a mixture of sanguineous and purulent drainage deep inside the wound. The note indicated the wound measured 5.0 cm by 2.0 cm and a depth of 3.0 cm, and the wound was packed with medicated dressing and covered with an ABD pad. The note further indicated the wound culture was positive for a large amount [MEDICAL CONDITION] and the resident would be admitted to hospital for (IV) intravenous antibiotic therapy and placement of a wound vac (device used to create a sealed system to remove wound fluids and promote healing). The 11/11/16 physician progress notes [REDACTED]. The progress note indicated the facility notified the physician last week the resident's left hip pressure ulcer had returned. The progress note indicated the wound required an I&D, measured 6.0 cm by 1.7 cm by 3.0 cm deep and the culture report [MEDICAL CONDITION]. The progress note further indicated the resident admitted to the hospital for IV antibiotic therapy and wound care. On 11/30/16 at 11:19 AM, observation revealed the resident walked independently with a wheeled walker to the dining room and sat at the table. Continued observation revealed the wound vac tubing visible from the top of the resident's pants to the wound vac placed in the wire basket on the resident's walker. On 11/17/16 at 2:18 PM, Nurse D stated the nursing staff should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated the resident admitted with the left hip pressure ulcer and the wound worsened with infection and large amounts of drainage. On 11/17/16 at 4:44 PM, Wound Clinic Staff E stated the wound clinic previously treated the resident's left hip pressure ulcer and when the resident discharged back to the facility, on 09/22/16, the wound was superficial with 100% healthy tissue. Wound Clinic Staff E stated the facility had physician's orders [REDACTED]. Wound Clinic Staff E further stated the wound clinic would have monitored and directed the resident's wound care to prevent the development of an infected Stage IV pressure ulcer. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident admitted from the hospital with a pressure ulcer and had physician's orders [REDACTED]. Administrative Nurse B stated the facility had not implemented the physician's orders [REDACTED]. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/28/16 at 4:41 PM, Nurse Aide C stated the resident was independent with positioning, but staff assisted the resident with toileting and incontinent cares. Nurse Aide C stated the resident had a pressure ulcer on his/her left hip with increased drainage that saturated his/her dressings. On 11/29/16 at 9:14 AM, Physician G stated the resident discharged from the hospital with an almost healed pressure ulcer and the facility had not notified him/her in a timely manner regarding the worsening of the resident's pressure ulcer. Physician G further stated the facility had not followed his/her order for weekly wound therapy at the wound clinic and the wound clinic would have monitored and directed wound care to prevent the worsening of the resident's pressure ulcer. On 11/30/16 at 11:16 AM, Resident #1 stated his/her pressure ulcer drainage increased, would often get his/her clothing and bedding wet, and frequently would saturate the dressing, causing it to fall off. Resident #1 stated staff often changed his/her dressing in the middle of the night and did not turn on the room light, using only the light from the hallway. The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment to Resident #1 who admitted to the facility with a Stage II pressure ulcer on his/her left hip, that worsened to a Stage IV pressure ulcer with an infection, which required a prolonged hospitalization for wound care and placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a G. - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 11/02/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 12 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, total assistance with transfers, toileting, and always incontinent of bowel and urine.The MDS further indicated the resident had open [MEDICAL CONDITION] and (MASD) Moisture Associated Skin Damage. The 08/07/16 care plan indicated the resident had a history of [REDACTED]. The 10/28/16 care plan revision indicated the resident had denuded (skin loss) and excoriated (abraded, rubbed, chafed) areas on his/her buttocks and directed staff to provide incontinence care every hour at night. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 08/03/16 Braden Scale assessment score was 16, which indicated the resident was at risk to develop pressure ulcers. The 10/20/16 physician progress notes [REDACTED]. The 10/21/16 weekly skin assessment indicated the resident had no skin issues. The 10/26/16 at 3:00 AM, nurse's note indicated the resident had the following four areas of excoriated skin: 3.8 (cm) centimeters by 2.0 cm on upper left buttock, 2.0 cm x 1.2 cm on upper right buttock, 2.0 cm by 1.0 cm on left lower buttock and 2.2 cm by 1.1 cm on lower right buttock. The nurse's note indicated staff cleansed the areas, applied a dressing and notified the physician. The 11/02/16 physician fax indicated the resident's buttock wounds improved and staff would continue to provide check and change program (scheduled incontinent cares) and barrier cream after each incontinent episode. Review of the resident's medical record from 11/02/16 to 11/08/16 (6 days) revealed no documentation the staff had assessed the resident's wounds. The 11/08/16 physician fax indicated the resident spent most of his/her time on his/her right side due to left leg spasms and the skin breakdown on the resident's right buttock had worsened. The facility requested physical therapy to evaluate and treat the skin breakdown. The physician ordered physical therapy to evaluate and treat the resident's wound and body positioning. The physician also ordered the nursing staff to verify staff repositioned the resident every 2 hours for pressure relief. review of the resident's medical record revealed [REDACTED]. The 11/09/16 (PT) Physical Therapy Note indicated the resident's lower right buttock wound measured 2.0 cm by 1.3 cm with tunneling (wound expansion under the skin/tissue) noted. The 11/11/16 physician fax indicated PT reported a foul odor from the resident's lower right buttock wound and requested a wound culture. The 11/14/16 wound culture indicated the wound was positive for viridans streptococci, bacteria species with the potential to cause endocarditis (inflammation of heart valve) and streptococcus, bacteria species with the potential to cause meningitis (inflammation of protective membranes on the brain or spinal cord) and pneumonia (inflammation of the lungs). The 11/14/16 physician's orders [REDACTED]. The 11/14/16 at 2:51 PM, PT note indicated the resident's right lower buttock pressure ulcer measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/15/16 physician fax from the PT indicated the resident's lower right buttock pressure ulcer had increased slough (dead tissue, usually cream or yellow in color) and now measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/16/16 physician's orders [REDACTED]. The 11/17/16 at 3:20 PM, PT note indicated the resident's pressure ulcer continued to have slough and when staff applied pressure to the tunneling area odorous, purulent (yellow/white liquid produced with certain infections) drainage came from the wound. The 11/18/16 physician progress notes [REDACTED]. The progress note indicated the plan of treatment for [REDACTED]. The 11/18/16 surgical nurse's note indicated the resident had a Stage IV pressure ulcer on his/her right buttock with odorous, purulent drainage. The nurse's note indicated the resident's wound was surrounded by dark red skin and had necrotic tissue (localized dead tissue related to disease or injury). The 11/20/16 hospital nurse's note indicated the resident received scheduled (IV) intravenous antibiotic therapy for an infected pressure ulcer. The 11/21/16 surgical wound report indicated the physician completed an (I&D) incision and drainage, on the resident's right lower buttock Stage IV pressure ulcer. The wound report indicated the resident's pressure ulcer measured 4 cm in diameter and 3 cm deep with bloody drainage. The 11/22/16 at 10:00 PM, hospital nurse's note indicated staff notified the physician, that the resident's pressure ulcer, with the I&D, continued with large amounts of bleeding. The 11/25/16 at 9:52 AM, hospital nurse's note indicated the resident would be discharged to another hospital, with a wound clinic, for continued wound care and antibiotic therapy. On 11/17/16 at 9:16 AM, observation revealed 2 staff transferred the resident with a mechanical lift from his/her wheelchair to bed. Continued observation revealed Nurse Aide C and Nurse J provided extensive assistance to move the resident's legs and torso, to position the resident in bed. Continued observation revealed the resident had a duoderm (non-breathable adherent wound dressing) on his/her right lower buttock and left coccyx area, with reddened skin surrounding both dressing sites. On 11/17/16 at 11:16 AM, Physical Therapy Staff H stated the resident developed pressure ulcers on both buttocks several weeks ago, that had worsened with tunneling and odorous drainage. Physical Therapy Staff H stated the resident had an appointment with the surgeon tomorrow (11/18/16) for an evaluation and treatment. On 11/17/16 at 2:18 PM, Nurse D stated the nurse should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated staff assessed the resident with several excoriated areas on his/her buttocks several weeks ago, and the wounds have developed into pressure ulcers with odorous drainage. On 11/22/16 at 2:01 PM, Administrative Nurse B stated staff noted excoriation/skin issues on the resident's buttocks, on 10/26/16, and the resident admitted to the hospital with [REDACTED]. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify that staff repositioned the resident for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/29/16 at 10:27 AM, Nurse J stated the resident required total assistance with repositioning, transfers and toileting and he/she was not aware the physician had ordered a repositioning/turning program, to ensure pressure relief for the resident's wounds. Nurse J stated the resident refused to be repositioned at times and staff had not implemented new pressure relief devices or educated the resident of the consequences of not being repositioned. On 11/29/16 at 4:24 PM, Nurse Aide K stated the resident required total assistance with repositioning, transfers and toileting and was always incontinent of bowel and urine. Nurse Aide K stated he/she was not aware of a turning/repositioning schedule for the resident and staff repositioned the resident as he/she allowed. On 12/01/16 at 9:55 AM, Physician L stated the resident's wounds developed and deteriorated rapidly and the facility had not kept him/her adequately informed to direct the resident's wound care, before it became necessary for surgical treatment and hospitalization . The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment for [REDACTED].#2 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a G. - Resident #3's admission (MDS) Minimum Data Set assessment, dated 10/10/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 14 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, transfers and toileting, and was occasionally incontinent of urine. The MDS further stated the resident had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) with granulation (moist red or pink tissue) in the wound bed. The 10/03/16 admission care plan indicated the resident had a Stage II pressure ulcer on his/her coccyx (small triangular bone at the base of the spine). The care plan directed staff to provide wound treatment as physician ordered and report changes of skin issues to the charge nurse immediately. The 10/12/16 (CAA) Care Area Assessment indicated the resident admitted with a Stage II pressure ulcer on his/her coccyx. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/26/16 care plan indicated the resident admitted with a Stage II pressure ulcer and directed staff to provide wound treatment as ordered by the physician. The care plan directed (PT) Physical Therapy staff to provide a wound evaluation and treatment on 11/01/16 and indicated the resident had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible) on 11/02/16. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 10/06/16 Wound/Skin Healing Report indicated the resident admitted to the facility with a Stage II pressure ulcer on his/her coccyx that measured 1.6 (cm) centimeters by 1.0 cm by 0.1 cm deep and the wound bed with granulation tissue. The 10/12/16 nurse's note indicated staff noted the resident's pressure ulcer wound bed was covered with slough (dead tissue, usually cream or yellow in color). The 10/14/16 at 9:09 AM, nurse's note indicated the resident's wound had no dressing, was 90% full of slough and measured 2 cm by 3 cm. review of the resident's medical record revealed [REDACTED]. The 10/16/16 at 12:00 AM, nurse's note indicated the resident's pressure ulcer wound bed continued covered with slough. The 10/20/16 Wound/Skin Report indicated the resident's Stage II pressure ulcer measured 0.9 cm by 0.6 cm by 0.1 cm deep with slough and a small amount of serosanguineous fluid (wound drainage of semi-thick reddish fluid). The 11/01/16 at 1:00 PM, nurse's note indicated the physician ordered PT to evaluate and treat the resident's pressure ulcer on the coccyx. The 11/02/16 at 6:45, nurse's note indicated the resident's pressure ulcer measured 2.0 cm by 1.2 cm by 0.9 cm deep and the wound bed covered with slough. The 11/10/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 0.8 cm by 1.2 cm deep with slough and a small amount of serosanguineous drainage. The 11/11/16 at 2:30 PM, nurse's note indicated the physician ordered nursing staff to verify staff repositioned the resident every 2 hours and directed staff to consult the surgeon to evaluate the resident's pressure ulcer. review of the resident's medical record revealed [REDACTED]. The 11/18/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 1.0 cm by 1.2 cm deep with granulation and a small amount of serosanguineous drainage. The report indicated PT provided wound care and the resident had a consult with the surgeon on 11/30/16. The 11/23/16 Wound/Skin Report indicated the resident's Stage III pressure ulcer measured 2.0 cm by 0.8 cm by 1.0 cm deep with granulation and a small amount of serosanguineous drainage. The 11/30/16 physician's wound consult orders directed staff to change the resident's wound treatment to daily, provide aggressive rehabilitation to get the resident out of his/her wheelchair, continue to measure and monitor the wound, and follow-up appointment in 1 month. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident was admitted to the facility with a Stage II pressure ulcer on his/her coccyx that had worsened to a Stage III pressure ulcer. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify the resident was repositioned for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, pain. The facility failed to develop and implement interventions for Resident #3, who admitted with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer.

The facility had a census of 61 residents. The sample included 24 residents of which 11 were reviewed for (ADLs) Activities of Daily Living. Based on observation, record review and interview the facility failed to provide the necessary care and services to maintain personal hygiene and bathing for 9 of 11 residents reviewed for activities of daily living. (#49, #71 #79, #84, #47, #78, #70, #46, and #31) The facility placed Resident #49 in immediate jeopardy when they failed to provide timely personal hygiene care. Findings included: - Resident #49's quarterly (MDS) Minimum Data Set assessment, dated 5/27/2016, indicated the resident had a (BIMS) Brief Interview for Mental status score of 10 which indicated moderately impaired cognition, and required extensive assistance of two plus staff with dressing, personal hygiene, and bed mobility and was totally dependent with two plus staff for transfers, toilet use, and bathing, and frequently incontinent. The MDS indicated the resident was at risk for developing pressure ulcers, and had a pressure reducing device for bed and chair. The 12/09/2015 (CAA) Care Area Assessment for (ADLs) Activities of Daily Living indicated the resident required extensive assistance and two staff for bed mobility, dressing, toilet use, personal hygiene and bathing. The 6/08/2016 care plan stated the resident required 2 assistance of staff for personal hygiene, assistance of 1 staff for bed bath, for oral hygiene, and bathing, and nail care weekly by the nurse. The care plan directed the staff to monitor the resident's skin folds daily for redness or discoloration, assist with turning and repositioning every two hours and as needed, apply moisturizing lotion to all extremities with morning and evening cares. The care plan directed the nurse to complete a weekly skin assessment. Review of the bath/shower book through 8/31/2016 revealed the staff assisted the resident with a bath on Monday PM and Friday PM. Continued review revealed the following days the resident received a bed bath: August 1, 2 ,4, 9,and 11, 2016. The documentation revealed no documentation the staff washed the residents hair in August. Review of the (MAR) Medication Administration Record [REDACTED]. Review of the weekly skin assessment revealed: 6/04/2016, redness to all folds and creases, antifungal cream applied to areas. 6/11/2016, skin slight redness noted to the folds and creases. 6/18/2016, redness to all creases and folds. No skin breakdown noted to the red areas, antifungal cream ( a medicated cream use to treat fungal infections of the skin, scalp and nails) applied to areas after cleaning. 6/25/2016, slight redness to the folds of left inner elbow. 7/02/2016 slight redness noted to underarms. 7/10/2016, no skin issues documented. 7/16/2016, no skin issues documented. 7/30/2016, light redness noted to both knees. 8/13/2016 slight redness noted to folds. The 8/15/2016 emergency room report stated the resident transferred from the facility to the emergency room by ambulance for altered level of consciousness, and lower right abdominal pain. The physical examination revealed he/she had bilateral diminished lung sounds, appeared to have mold between the two skin folds in the armpit area and indicated all of the resident's skin folds were (gaulded) rubbed to the point of rawness and almost to the point of bleeding. The resident's toenails were thick, long and not clipped. The documentation stated the condition of the resident's nails put him/her at risk for skin abrasions and lacerations. The residents feet were not clean with thick skin and appeared to have not been washed in a long time. The notes indicated the resident's hair needs to be washed. The emergency room report assessment indicated the medical provider diagnosed the resident with: right lower lobe pneumonia, possible aspiration, cardiomegaly (an enlarged heart) and neglect (a form of abuse where the perpetrator is responsible for caring for someone who is unable to care for him/herself but fails to do so). The 8/16/2016 physician progress notes [REDACTED]. The physician noted the state of the patient's arrival from the nursing home facility was poor to say the least, and stated he/she had mold within his/her skin folds, teeth had not been cleaned for some time, and the nails were extremely long. The 8/15/2016 at 3:00 AM, nurse's notes indicated the resident complained of abdominal pain and the nurse was unable to determine the pain origin. The nurse aide stated the resident had a medium bowel movement, soft and formed. Nurse P instructed the staff to turn the resident to his/her left side. The 8/15/2016 at 5:00 AM, nurse's notes indicated the resident had no relief and he/she administered two Tylenol. Further assessment of the resident vital signs blood pressure 110/78, pulse 76, respirations 18 and temperature 98.5, blood sugar 130, and oxygen saturation at 94% at 2 liters per nasal cannula. The resident complained of tenderness on the right lower abdomen. The nurse's notes indicated the resident was difficult to arouse, and very slow to respond to verbal command. No complaints of nausea, and bowel sounds active. (no documentation of a reassessment from 3:00 AM to 5:00 AM) The 8/15/2016 at 5:30 AM, Nurse P notified the hospital of the resident's sign and symptoms and he/she indicated they would notify the residents primary care physician. The 8/15/2016 at 5:47 AM, nurse's notes orders to transfer the resident to the hospital emergency room . The 8/15/2016 at 6:15 AM, nurse's notes stated the emergency medical service arrived to transport the resident to the hospital. The 8/15/2016 at 6:45 AM, nurse's notes indicated the resident left the facility to go to the hospital. The 8/15/2016 emergency room Report stated the resident arrived at the hospital with an altered level of consciousness, and had right lower quadrant abdominal pain, difficult to arouse and had pain. The physical examination revealed the resident had what appeared to be mold between his/her two skin folds on her right lateral midaxillary line distal from that. The examination revealed all of his/her skin folds were gaulded, and the axilla bilaterally were gaulded almost to the point of bleeding. The examination revealed his/her feet were not clean and appear to have not been scrubbed for a long time, toenails were not clipped, thick, long and that put the resident at risk for skin abrasions and lacerations, his/her hair needed to be washed. The 8/15/2016 hospital microbiology results indicated the resident had Pseudomonas aeruginosa (a bacteria that causes infections) and Gram negative bacillius (bacteria that cause pneumonia, blood stream infections, wound or surgical sit infections, and meningitis in healthcare settings) cultured from the right side skin fold. On 8/18/2016 at 5:05 PM, observation revealed the resident, seated on a reclining chair, in a hospital room with hospital Registered Nurse L in attendance. Further observation revealed the following: flaking and peeling skin on the soles of his/her left foot and ankle area, and the right great toenail was very thick, yellow, had grown past the tip of the toe approximately 1/2 inch, and was very brittle. The other 4 toes had jagged toenails that curled over the ends of the toes. Observation of the resident's right foot revealed the same observation as the left foot except the great toenail had grown past the tip of the toe approximately 1/4 inch, and was very brittle. The other 4 toes had jagged toenails that curled over the ends of the toes. right and left armpit had red, gaulded area approximately 2 x 3. right and left upper arm skin folds red and gaulded 2 neck folds red and gaulded along the crease abdominal skin fold red and gaulded along the crease right and left thigh skin folds red and gaulded The resident was unable to roll on his/her side to visualize the rolls of skin on his/her back. On 8/18/2016 at 9:30 AM, hospital Nurse M verified the resident arrived in the emergency roiagnom on [DATE] due to pain in his/her right lower abdomen. Nurse M described the following condition of the resident upon transfer; very dirty, gaulded abdominal folds with areas on the verge of bleeding, an area approximately 3 () inch x 3 area that was green and fuzzy, and look like mold. Nurse N stated the resident's feet had layers of old skin and appeared to have not been scrubbed for awhile, his/her hair was very dirty and appeared to have cradle cap (yellowish, patchy, grease, scaly and crusty) on his/her head. Nurse M stated when the resident arrived at the emergency room he/she could only state his/her name, and after the resident received fluids, the resident told hospital staff he/she could not remember when he/she last had a bath. On 8/18/2016 at 10:30 AM, Medical Provider AA verified he/she saw the resident in the emergency roiagnom on [DATE] and verified the resident's skin folds were gaulded almost to the point of bleeding. The resident had an area on the right mid axillary line that was green- and the culture grew pseudomonis. The toenails were thick and and had not been trimmed. Throughout the exam the resident had cried and Medical Provider AA stated he/she felt it was neglect. On 8/18/2016 at 5:15 PM, hospital Nurse L verified the resident presented to the hospital with gaulded abdominal skin folds, neck skin folds, and back skin folds. Hospital Nurse L verified the resident was very dirty, had dried skin pealing/flaking off his/her feet and ankles, with untrimmed toenails and the big toenails were very thick and over grown. On 8/24/2016 at 2:20 PM, Nurse Aide R stated he/she was the facility bath aide and gave the resident a bath at least once a week. Nurse Aide R stated he/she provided the resident a bed bath because the resident refused to go to the shower because the shower chair was uncomfortable and hurt his/her legs. Nurse Aide R stated the resident's bath were documented in the bath book. On 8/24/2016 at 5:30 PM, Nurse O stated he/she assessed the resident on 8/13/2016 prior to transferring him/her to the hospital. The skin report indicated the resident had redness and dry powder in his/her skin folds so he/she wiped down the resident's skin folds along the abdomen, back, legs and upper back areas as much as he/she could and stated that caused the resident some discomfort. Nurse O stated after the areas were wiped off he/she applied new powder to the reddened areas. Nurse O verified the resident's toenails were thick and when he/she trimmed the nail the resident started to say, oh, oh my feet hurt. Nurse O stated his/her pain was from arthritis in his/her feet and legs. On 8/24/2016 at 6:10 PM, Nurse P stated on 8/15/2016 at 3:00 AM a nurse aide alerted the nurse the resident complained of pain. Nurse P assessed the resident and determined he/she had pain across his/ her abdomen. The nurse instructed the nurse aides to turn the resident to his/her left side to relieve his/her gas, and he/she administered two Tylenol 325 (mg) milligrams to him/her to help with pain relief. Nurse P stated the resident had no relief during the assessment and a second nurse assisted him/her to assess the resident, and both nurses determined the resident had pain in his/her right lower abdominal quadrant. Nurse P stated the resident had been difficult to arouse and slow to respond during the assessment but was able to rate his/her pain at a 10, on a 1-10 scale and 10 being the worst and stated it was the worst pain he/she had ever had. Nurse P reported he/she contacted the hospital at 5:30 AM to report the resident's signs and symptoms and at 5:47 AM the emergency room nurse returned a call and gave the order to transport the resident to the emergency room for further evaluation. At 6:15 AM, the ambulance arrived and at 6:45 AM transported the resident to the hospital. Nurse P stated during all of his/her assessments of the resident he/she had not noted the any yeast odor or had any reports from aides of any odor that would alert the nurse to assess the resident's abdominal folds. On 8/29/2016 at 10:25 AM, Nurse N verified the nurses were to trim the resident's toenails on the evening and/or night shift weekly. Nurse N stated he/she had never noted the resident had an odor or was unkempt. On 8/24/2016 at 11:25 AM, Administrative Nurse A verified the staff are to assess the resident's skin daily and report any concerns to the charge nurse, and assist the resident with bathing. Administrative Nurse A verified if the resident was diabetic the treatment nurses were to trim and/or provide weekly nail care. Administrative Nurse A stated he/she was not aware of the resident's odor, skin condition and long toenails. Administrative Nurse A stated the staff are to provide these services to the resident as ordered. Administrative Nurse A stated he/she was unaware the hospital had assessed the resident with neglect and/or the culture results obtained from the resident's skin folds. The facility's 10/2010 Bath and Shower policy stated the facility would provide each resident a bath or shower to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The staff would observe the resident's skin for any redness, rashes, broken skin, tender areas, irritation, reddish or blue-gray area of skin over a pressure point, blister, or skin breakdown. The policy stated to notify the supervisor if the resident refuses the shower/tub bath, and notify the physician of any skin areas that may need to be treated. The facility failed to provide Resident #49 with assistance for grooming and bathing needs which placed the resident in immediate jeopardy for possible infection. The facility abated the immediate jeopardy on 9/26/16 when they educated all nursing staff on the facility's policies for grooming, bathing, nail care, head to toe skin assessments and skin care, the definition of neglect, the facility policy regarding the prevention of neglect and the procedure for using the red alert binder for newly identified skin concerns. This deficient practice remains at a scope and severity of G. - Resident #31's (POS) physician's orders [REDACTED]. Resident #31's quarterly (MDS) Minimum Data Set assessment, dated 5/18/2016, indicated the resident required had short and long term memory loss and moderately impaired cognition. The assessment further indicated the required extensive assistance of 2 staff for bed mobility, dressing, and total dependence of two staff for transfers, toilet use, and total dependence of 1 staff for eating, personal hygiene, and bathing. The assessment indicated the resident was frequently incontinent of urine. The 11/30/2015 (ADLs) Activities of Daily Living (CAA) Care Area Assessment indicated the resident required assistance with all ADLs and is incontinent. The 6/01/2016 care plan directed two staff to address the resident by name and to be with the resident at all times, and assist with all ADL cares, personal hygiene, bathing assist with one, oral hygiene assist with oral care twice a day, and as needed. Review of the bath/shower book revealed the staff assisted the resident with a shower on Tuesday and Friday AM. Continued review revealed the following days the resident received a shower through 8/23/16. August 2,5,10,12, and 17. Review of the (MAR) Medication Administration Record [REDACTED]. Review of the weekly skin assessment revealed: 8/05/2016, No skin issues noted. Dependent [MEDICAL CONDITION] noted to bilateral lower extremities 8/12/2016, No skin issues noted. On 8/17/2016 at 4:00 PM, observation revealed the resident seated in a wheelchair in his/her room dressed in street clothes with shoes and socks on. Administrative Nurse A removed the resident's socks and shoes, revealing the following: The left great toenail was very thick, yellow, had grown past the tip of the toe approximately 1/4 inch, and was very brittle. The 2nd toenail was curled over the end of the toe and some of the nail not attached, the other 3 toes were ok. Observation of the resident's left foot revealed the same observation as the left foot except the great toenail had grown past the tip of the toe approximately 1/8 inch, and was very brittle. The other 4 toenails were cut straight across and the sides were very pointed. On 8/29/2016 at 10:25 AM, Administrative Nurse A verified the staff are to assess the resident's skin daily, report any concerns to the charge nurse, and assist the resident with bathing. Administrative Nurse A verified if the resident was diabetic the treatment nurse were to trim and/or provide weekly skin care. Administrative Nurse A stated the staff are to provide theses services to the resident as ordered. Administrative Nurse A stated he/she was unaware the resident toenails were not trimmed and his/her feet unkempt. The facility's 10/2010 Bath and Shower policy stated the facility would provide each resident a bath or shower to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The staff would observe the resident's skin for any redness, rashes, broken skin, tender areas, irritation, reddish or blue-gray area of skin over a pressure point, blister, or skin breakdown. The policy stated to notify the supervisor if the resident refuses the shower/tub bath, and notify the physician of any skin areas that may need to be treated. The facility failed to provide Resident #31 with assistance for grooming, and bathing, placing the resident at risk for infection and odor. - Resident # 46's (POS) physician's orders [REDACTED]. Resident #46's annual (MDS) Minimum Data Set assessment, dated 5/1/2016, indicated the resident had a (BIMS) Brief Interview for Mental Score of 10, (moderate cognitive impairment) and required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment further revealed the resident at risk for developing pressure ulcers, was on a turning and repositioning program and always incontinent of bowel and bladder. The assessment indicated the resident had pressure reducing devices for bed and chair and did not have any skin issues or pressure ulcers. The 5/21/2016 care plan directed the staff to monitor the resident's skin for redness or discoloration especially over bony prominence's, and notify the charge nurse if indicated. The care plan directed two staff to assist the resident to turn/reposition at least every two hours and as needed, and use a pressure reducing mattress on the bed and pressure reducing cushion in the wheelchair. The care plan directed the staff to assist the resident with all ADL cares, personal hygiene, bathing assistance with two, oral hygiene assist with oral care twice a day and as needed. Review of the bath/shower book revealed the staff assisted the resident with a shower on Tuesday and Friday AM. Continued review revealed the following days the resident received a shower through 8/23/1. August 2, 5,10,12, and 17. Review of the (MAR) Medication Administration Record [REDACTED]. Review of the weekly skin assessment revealed: 8/09/2016, Dressings to the coccyx and right ischium pressure ulcers, No skin issues noted. Dependent [MEDICAL CONDITION] noted to bilateral lower extremities 8/14/2016, Dressings to the coccyx and right ischium pressure ulcers, dependent [MEDICAL CONDITION] noted. No redness noted. On 8/17/2016 at 4:00 PM, observation revealed the resident lying in bed in his/her room, dressed in street clothes, and pressure relieving boots on both feet/heels. Administrative Nurse A removed the resident's pressure boots, revealing the following: right great toenail was very thick, yellow, had grown past the tip of the toe approximately 1/4 inch, and was very brittle. The 2nd- 5th toenail were jagged. Observation of the resident's left foot revealed the same observation as the right foot. Continued observation revealed the resident's abdominal skin fold red, gaulded and moist with a pungent foul yeast smell. On 8/29/2016 at 10:25 AM, Administrative Nurse A verified the staffs are to assess the resident's skin daily and report any concerns to the charge nurse, and assist the resident with bathing. Administrative Nurse A verified if the resident was diabetic the treatment nurse were to trim and/or provide weekly skin care. Administrative Nurse A stated the staff are to provide these services to the resident as ordered. Administrative Nurse A stated he/she was unaware the resident toenails were not trimmed and his/her feet unkempt. The facility's 10/2010 Bath and Shower policy stated the facility would provide each resident a bath or shower to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The staff would observe the resident's skin for any redness, rashes, broken skin, tender areas, irritation, reddish or blue-gray area of skin over a pressure point, blister, or skin breakdown. The policy stated to notify the supervisor if the resident refuses the shower/tub bath, and notify the physician of any skin areas that may need to be treated. The facility failed to provide Resident #46 with assistance for grooming, and bathing, placing the resident at risk for infection and odor. - Resident #78's quarterly (MDS) Minimum Data Set assessment, dated 8/2/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 14, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The 8/3/16 care plan indicated the resident required 1 staff assistance with personal hygiene and bathing. Review of the bathing record revealed documentation the resident did not receive baths on the following days: 5/11- 5/16/16 (6 days) 5/24- 5/31/16 (8 days) 6/22- 6/31/16 (10 days) 7/2- 7/7/16 (6 days) 7/9- 7/14/16 (6 days) The bathing record revealed the resident refused a shower on 6/7 and 7/5 but lacked follow-up documentation that staff offered an alternative day or time for a shower. Review of the facility skin assessment documentation revealed the following: 5/1/16- redness under the abdominal folds 5/29/16- redness to groin area 6/5/16- slight redness to abdominal folds 7/10/16- open area under abdominal fold 7/16/16- no breakdown 8/3/16- slight redness to abdominal folds The 6/30/16 fax communication to the physician stated the resident had an open area with redness to his/her abdominal fold and requested [MEDICATION NAME] powder (medication used to treat fungal infections) The 6/30/16 physician's orders [REDACTED]. On 8/17/16 at 3:00 PM, observation revealed the resident had an approximately 4 (in) inch by 3 in bright red area under his/her abdominal fold, which had a foul, moist, yeasty odor, and the resident stated was tender to the touch. Further observation revealed the resident's toenails were approximately 1/8 in past the end of the toes and the skin from the ankle to approximately 5 inches up the leg, flaky (breaking or separating easily into small thin pieces) and peeling (lose parts of its outer layer). On 8/17/16 at 4:20 PM, Administrative Nurse A verified the resident's skin was red under his/her abdominal fold, toenails too long, and stated the resident's legs looked very dry and needed lotion. On 8/18/16 at 9:00 AM, Resident #78 stated he/she was supposed to get 2 showers a week but that did not always happen. The resident further stated he/she received a shower last night which made him/her feel better and now he/she can wear shoes again after staff trimmed his/her toenails. On 8/18/16 at 3:45 PM, Nurse Aide H stated the resident received showers 2 times a week, and the nurse provided nailcare for the resident because he/she had diabetes. On 8/29/16 at 2:54 PM, Licensed Nurse F stated the resident received 2 showers a week and the shower aides provide nailcare. On 8/30/16 at 10:45 AM, Administrative Nurse A stated the resident should receive showers twice a week and nail care. Administrative Nurse A further stated if the resident refused, the shower aide should document the reason for the refusal and provide an alternative day and time for a shower. The October 2010 facility Shower and Tub Bath Policy directed staff to notify the supervisor if the resident refused showers, to document the reasons why, and interventions taken. The October 2010 facility Finger and Toenail Policy stated nailcare included daily cleaning and regular trimming. The policy further stated unless permitted, do not trim the nails of diabetic residents and to report to the nurse if there was evidence of ingrown nails (a condition in which the corner or side of a toenail grows into the soft flesh), infections, pain, or if nails are too hard or too thick to cut with ease. The policy stated to notify the supervisor if the resident refused nail care and report any other infections in accordance with facility policy and professional standards of practice. The facility failed to provide the necessary care and services to maintain good grooming and personal hygiene for Resident #78 which placed the resident at risk for poor hygiene and infection. - Resident #79's quarterly (MDS) Minimum Data Set assessment, dated 5/11/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. The assessment revealed the resident, independent with bed mobility, transfers, dressing, toileting and personal hygiene. The assessment further revealed the resident required assistance of 1 staff for bathing. The 5/11/16 care plan indicated the resident was independent with personal hygiene and required assistance of 1 staff for bathing. Review of the bathing record documentation revealed the resident did not receive baths on the following days from: 5/4- 5/9/16 (6 days) 6/15- 6/20/16 (6 days) 6/22- 6/27/16 (6 days) 7/16- 7/25/16 (10 days) 7/27- 8/8/16 (13 days) 8/10- 8/16/16 (7 days) 8/18- 8/25/16 (8 days) The above bathing record had no documentation of refusals from the resident for showers. On 8/24/17 at 10:22 AM, observation revealed the resident's left big toenail, brown and cracked and approximately 1/8 inch over the top of the toe. Further observation revealed the resident's right big toenail approximately 1/8 inch over the top of the toe. On 8/24/16 at 10:25 AM, Resident #79 stated he/she has had ingrown toenails in the past and has not had his/her toenails trimmed in a long time. On 8/24/16 at 11:00 AM, Administrative Nurse A verified the resident's toenails were very long and stated nursing staff should cut the resident's toenails. On 8/28/16 at 2:54 PM, Licensed Nurse F stated the resident often refused showers and stated the resident's nail care was done during showers. On 8/30/16 at 10:45 AM, Administrative Nurse A stated the resident should have received showers twice a week and nail care. Administrative Nurse A verified no documentation of shower refusals and stated, the shower aide should document the reason for the refusal and provide an alternative day and time for a shower. The October 2010 facility Shower and Tub Bath Policy directed staff to notify the supervisor if the resident refused showers and to document the reasons why and interventions taken. The October 2010 facility Finger and Toenail Policy stated nail care included daily cleaning and regular trimming. The policy further stated unless permitted, do not trim the nails of diabetic residents and to report to the nurse if there was evidence of ingrown nails (a condition in which the corner or side of a toenail grows into the soft flesh), infections, pain, or if nails are too hard or too thick to cut with ease. The policy stated to notify the supervisor if the resident refused nail care and report any other infections in accordance with facility policy and professional standards of practice. The facility failed to provide the necessary care and services to maintain good grooming and personal hygiene for Resident #79 which placed the resident at risk for poor hygiene, infections, and social isolation. - Resident #47's quarterly (MDS) Minimum Data Set assessment, dated 5/18/16, indicated the resident had long and short term memory problems with moderately impaired decision making skills. The assessment further revealed the resident required extensive assistance of 1 staff for dressing and personal hygiene. The assessment also revealed the resident required 1 staff assistance with bathing. The 5/25/16 care plan indicated the resident required assistance of 1 staff for personal hygiene and bathing. Review of the bathing record revealed documentation the resident did not receive baths on the following days from: 5/4- 5/9/16 (6 days) 5/28- 6/6/16 (10 days) 7/27- 8/1/16 (6 days) The above bathing record had no documentation of refusals from the resident for showers. On 8/24/16 at 10:04 AM, Nurse Aide B stated the resident received 2 showers a week and received nail care with showers. Nurse Aide B further stated there are times the resident fights the staff during nail care. On 8/24/16 at 11:30 AM, observation revealed the resident's left foot had toenails approximately 1/8 inch over the end of the resident's toe. Further observation revealed the right foot toenails were neatly trimmed. On 8/29/16 at 2:54 PM, Licensed Nurse F stated the resident received 2 showers per week and the resident received nail care during his/her shower. On 8/30/16 at 10:45 AM, Administrative Nurse A stated the resident should have received showers twice a week and nail care and verified the documentation of no showers. Administrative Nurse A further stated if the resident refused, the shower aide should document the reason for the refusal and provide an alternative day and time for a shower. The October 2010 facility Shower and Tub Bath Policy directed staff to notify the supervisor if the resident refused showers, to document the reasons why, and interventions taken. The October 2010 facility Finger and Toenail Policy stated nail care included daily cleaning and regular trimming. The policy further stated unless permitted, do not trim the nails of diabetic residents and to report to the nurse if there was evidence of ingrown nails (a condition in which the corner or side of a toenail grows into the soft flesh), infections, pain, or if nails are too hard or too thick to cut with ease. The policy stated to notify the supervisor if the resident refused nail care and report any other infections in accordance with facility policy and professional standards of practice. The facility failed to provide the necessary care and services to maintain good grooming and personal hygiene for Resident #47 which placed the resident at risk for poor hygiene and infection. - Resident #71's annual (MD) Minimum Data Set assessment, dated 4/19/16, indicated 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 2 staff for bed mobili

The facility had a census of 61 residents. The sample included 5 residents, who were reviewed for pressure ulcers. Based on observation, record review and interview the facility failed to provide necessary services and treatment to promote healing, prevent infection and prevent new pressure ulcers from developing for 3 of 5 sampled residents. Resident #1 admitted to the facility with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) on his/her left hip, that worsened to a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) with an infection, which required a prolonged hospitalization , placing Resident #1 in immediate jeopardy. Resident #2 developed a facility acquired Stage IV pressure ulcer with an infection, which required a prolonged hospitalization , placing Resident #2 in immediate jeopardy. Resident #3 admitted to the facility with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible). Findings Included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 09/29/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 11 (moderately impaired cognition). The MDS also indicated the resident required limited assistance with bed mobility, extensive assistance with transfers and toileting, and was incontinent of bowel and bladder. The MDS further indicated the resident had an unstageable pressure ulcer (wound bed covered by scab/hardened skin) and received nutritional interventions and wound dressings. The 09/22/16 admission care plan directed staff to provide the resident's wound care as ordered by the physician, and report skin issues to the charge nurse immediately. The care plan lacked documentation of the type of wound, stage of wound, location of the wound or any interventions to promote healing of the wound. The 09/29/16 (CAA) Care Area Assessment for pressure ulcers indicated the resident admitted to the facility after his/her left hip pressure ulcer was debrided (removal of dead tissue and foreign material from a wound) and received wound care at the hospital. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/06/16 care plan revealed the resident was admitted with a left hip pressure ulcer and was at risk for further skin alterations. The care plan directed staff to provide the resident's wound cares as ordered by the physician. The care plan lacked documentation of the stage of the wound or any care interventions to promote healing of the wound. The 09/22/16 physician's discharge orders indicated the resident had a resolved Stage IV pressure ulcer on his/her left hip and directed staff to take the resident to the wound clinic every week for wound therapy. The physician's orders [REDACTED]. The 09/22/16 wound clinic discharge orders indicated the resident had a superficial wound, with 100% healthy tissue, on his/her left hip and directed staff to provide wound care as ordered by the physician and take the resident to the wound clinic every week for wound therapy. review of the resident's medical record revealed [REDACTED]. The 09/22/16 at 7:01 PM, admission nurse's note indicated staff would complete a skin assessment for the resident later in the evening. review of the resident's medical record revealed [REDACTED]. The 09/27/16 at 9:38 AM, nurse's notes indicated the the resident's left hip pressure ulcer had no dressing, measured 1.2 (cm) centimeters by 0.8 cm by 0.3 cm deep, and a small amount of serosanguineous (bloody) drainage. The nurse's note indicated the facility currently did not have the correct dressing supplies (polymen silver dressing change daily) for the resident's pressure ulcer and the dressing supplies would be delivered today (5 days after admission). The wound assessment lacked a description of the wound bed and/or the condition of the surrounding tissue. The 10/02/16 at 2:30 AM, nurse's note indicated the resident's left hip pressure ulcer had a white wound bed with serosanguineous drainage, raised soft spots under the skin and dark redness around the wound. The 10/03/16 at 2:25 AM, nurse's note indicated the resident's left hip pressure ulcer had serosanguineous and purulent (yellow/white liquid produced with certain infections) drainage. The nurse's note also indicated the resident's pressure ulcer was tunneling (wound expansion under the skin/tissue) approximately 4 cm towards the knee. Review of the note revealed no documentation indicating staff notified the physician of signs of infection (purulent drainage and tunneling). The 10/06/16 at 8:00 PM, nurse's note indicated the resident's pressure ulcer measured 1.1 cm by 0.6 cm, redness surrounding the wound and purulent drainage. The nurse's note indicated staff notified the physician concerning the possible infection in the resident's pressure ulcer (3 days after noting purulent drainage from the wound). The 10/06/16 physician's orders [REDACTED]. The 10/07/16 wound culture indicated the resident's left hip pressure ulcer was positive for (MRSA) [MEDICAL CONDITION]-resistant Staphylococcus aureus (antibiotic resistant infection). The 10/07/16 physician's orders [REDACTED]. The 10/16/16 at 1:09 PM, nurse's note indicated the resident continued on antibiotic medication and the resident's pressure ulcer measured 0.6 cm by 0.4 cm by 0.2 cm deep, with unmeasureable tunneling present. The 10/21/16 at 5:10 PM, nurse's note indicated the resident's left hip pressure ulcer had purulent drainage with redness noted around the wound. Continued review of the resident's medical record revealed [REDACTED]. The 10/26/16 at 7:10 AM, nurse's note indicated the resident's pressure ulcer continued with purulent drainage and tunneling. Continued review of the resident's medical record revealed [REDACTED]. The 11/03/16 at 3:10 PM, nurse's note indicated the (PA) Physician Assistant O assessed the resident's pressure ulcer and ordered a wound care consult at the hospital. The 11/07/16 wound clinic progress note indicated the resident presented for evaluation and treatment for [REDACTED]. The note indicated the wound had no dressing and the resident's pants were saturated with drainage on the area near the wound site. The note indicated the resident had a blister above an open area, that consistently drained purulent drainage and when staff put pressure on the blister the purulent drainage increased from the open area, indicating the wound and blister were connected by a tunnel. The note indicated the open area measured 0.1 cm in diameter, the blister was fluid filled and the entire surrounding area was dark red, felt mushy/boggy (soft or spongy) and measured 9 cm by 6 cm. The note indicated staff cultured the resident's left hip pressure ulcer due to an apparent infection. The note further indicated the resident had a physician's orders [REDACTED]. The 11/07/16 nurse's note indicated the wound clinic directed staff to cover the resident's wound with polymen silver dressing and an ABD pad (thick dressing for moisture absorbency) and change the ABD pad every day or as needed. The 11/10/16 wound clinic progress note indicated the resident presented with an ABD pad saturated with purulent drainage and the blister area increased in size. The note indicated staff notified the resident's physician of possible need for I&D (incision and drainage). The note indicated the surgeon made an incision in the wound and found a mixture of sanguineous and purulent drainage deep inside the wound. The note indicated the wound measured 5.0 cm by 2.0 cm and a depth of 3.0 cm, and the wound was packed with medicated dressing and covered with an ABD pad. The note further indicated the wound culture was positive for a large amount [MEDICAL CONDITION] and the resident would be admitted to hospital for (IV) intravenous antibiotic therapy and placement of a wound vac (device used to create a sealed system to remove wound fluids and promote healing). The 11/11/16 physician progress notes [REDACTED]. The progress note indicated the facility notified the physician last week the resident's left hip pressure ulcer had returned. The progress note indicated the wound required an I&D, measured 6.0 cm by 1.7 cm by 3.0 cm deep and the culture report [MEDICAL CONDITION]. The progress note further indicated the resident admitted to the hospital for IV antibiotic therapy and wound care. On 11/30/16 at 11:19 AM, observation revealed the resident walked independently with a wheeled walker to the dining room and sat at the table. Continued observation revealed the wound vac tubing visible from the top of the resident's pants to the wound vac placed in the wire basket on the resident's walker. On 11/17/16 at 2:18 PM, Nurse D stated the nursing staff should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated the resident admitted with the left hip pressure ulcer and the wound worsened with infection and large amounts of drainage. On 11/17/16 at 4:44 PM, Wound Clinic Staff [NAME] stated the wound clinic previously treated the resident's left hip pressure ulcer and when the resident discharged back to the facility, on 09/22/16, the wound was superficial with 100% healthy tissue. Wound Clinic Staff [NAME] stated the facility had physician's orders [REDACTED]. Wound Clinic Staff [NAME] further stated the wound clinic would have monitored and directed the resident's wound care to prevent the development of an infected Stage IV pressure ulcer. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident admitted from the hospital with a pressure ulcer and had physician's orders [REDACTED]. Administrative Nurse B stated the facility had not implemented the physician's orders [REDACTED]. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/28/16 at 4:41 PM, Nurse Aide C stated the resident was independent with positioning, but staff assisted the resident with toileting and incontinent cares. Nurse Aide C stated the resident had a pressure ulcer on his/her left hip with increased drainage that saturated his/her dressings. On 11/29/16 at 9:14 AM, Physician G stated the resident discharged from the hospital with an almost healed pressure ulcer and the facility had not notified him/her in a timely manner regarding the worsening of the resident's pressure ulcer. Physician G further stated the facility had not followed his/her order for weekly wound therapy at the wound clinic and the wound clinic would have monitored and directed wound care to prevent the worsening of the resident's pressure ulcer. On 11/30/16 at 11:16 AM, Resident #1 stated his/her pressure ulcer drainage increased, would often get his/her clothing and bedding wet, and frequently would saturate the dressing, causing it to fall off. Resident #1 stated staff often changed his/her dressing in the middle of the night and did not turn on the room light, using only the light from the hallway. The facility's (MONTH) 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment to Resident #1 who admitted to the facility with a Stage II pressure ulcer on his/her left hip, that worsened to a Stage IV pressure ulcer with an infection, which required a prolonged hospitalization for wound care and placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a [NAME] - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 11/02/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 12 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, total assistance with transfers, toileting, and always incontinent of bowel and urine.The MDS further indicated the resident had open [MEDICAL CONDITION] and (MASD) Moisture Associated Skin Damage. The 08/07/16 care plan indicated the resident had a history of [REDACTED]. The 10/28/16 care plan revision indicated the resident had denuded (skin loss) and excoriated (abraded, rubbed, chafed) areas on his/her buttocks and directed staff to provide incontinence care every hour at night. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 08/03/16 Braden Scale assessment score was 16, which indicated the resident was at risk to develop pressure ulcers. The 10/20/16 physician progress notes [REDACTED]. The 10/21/16 weekly skin assessment indicated the resident had no skin issues. The 10/26/16 at 3:00 AM, nurse's note indicated the resident had the following four areas of excoriated skin: 3.8 (cm) centimeters by 2.0 cm on upper left buttock, 2.0 cm x 1.2 cm on upper right buttock, 2.0 cm by 1.0 cm on left lower buttock and 2.2 cm by 1.1 cm on lower right buttock. The nurse's note indicated staff cleansed the areas, applied a dressing and notified the physician. The 11/02/16 physician fax indicated the resident's buttock wounds improved and staff would continue to provide check and change program (scheduled incontinent cares) and barrier cream after each incontinent episode. Review of the resident's medical record from 11/02/16 to 11/08/16 (6 days) revealed no documentation the staff had assessed the resident's wounds. The 11/08/16 physician fax indicated the resident spent most of his/her time on his/her right side due to left leg spasms and the skin breakdown on the resident's right buttock had worsened. The facility requested physical therapy to evaluate and treat the skin breakdown. The physician ordered physical therapy to evaluate and treat the resident's wound and body positioning. The physician also ordered the nursing staff to verify staff repositioned the resident every 2 hours for pressure relief. review of the resident's medical record revealed [REDACTED]. The 11/09/16 (PT) Physical Therapy Note indicated the resident's lower right buttock wound measured 2.0 cm by 1.3 cm with tunneling (wound expansion under the skin/tissue) noted. The 11/11/16 physician fax indicated PT reported a foul odor from the resident's lower right buttock wound and requested a wound culture. The 11/14/16 wound culture indicated the wound was positive for viridans streptococci, bacteria species with the potential to cause endocarditis (inflammation of heart valve) and streptococcus, bacteria species with the potential to cause meningitis (inflammation of protective membranes on the brain or spinal cord) and pneumonia (inflammation of the lungs). The 11/14/16 physician's orders [REDACTED]. The 11/14/16 at 2:51 PM, PT note indicated the resident's right lower buttock pressure ulcer measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/15/16 physician fax from the PT indicated the resident's lower right buttock pressure ulcer had increased slough (dead tissue, usually cream or yellow in color) and now measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/16/16 physician's orders [REDACTED]. The 11/17/16 at 3:20 PM, PT note indicated the resident's pressure ulcer continued to have slough and when staff applied pressure to the tunneling area odorous, purulent (yellow/white liquid produced with certain infections) drainage came from the wound. The 11/18/16 physician progress notes [REDACTED]. The progress note indicated the plan of treatment for [REDACTED]. The 11/18/16 surgical nurse's note indicated the resident had a Stage IV pressure ulcer on his/her right buttock with odorous, purulent drainage. The nurse's note indicated the resident's wound was surrounded by dark red skin and had necrotic tissue (localized dead tissue related to disease or injury). The 11/20/16 hospital nurse's note indicated the resident received scheduled (IV) intravenous antibiotic therapy for an infected pressure ulcer. The 11/21/16 surgical wound report indicated the physician completed an (I&D) incision and drainage, on the resident's right lower buttock Stage IV pressure ulcer. The wound report indicated the resident's pressure ulcer measured 4 cm in diameter and 3 cm deep with bloody drainage. The 11/22/16 at 10:00 PM, hospital nurse's note indicated staff notified the physician, that the resident's pressure ulcer, with the I&D, continued with large amounts of bleeding. The 11/25/16 at 9:52 AM, hospital nurse's note indicated the resident would be discharged to another hospital, with a wound clinic, for continued wound care and antibiotic therapy. On 11/17/16 at 9:16 AM, observation revealed 2 staff transferred the resident with a mechanical lift from his/her wheelchair to bed. Continued observation revealed Nurse Aide C and Nurse J provided extensive assistance to move the resident's legs and torso, to position the resident in bed. Continued observation revealed the resident had a duoderm (non-breathable adherent wound dressing) on his/her right lower buttock and left coccyx area, with reddened skin surrounding both dressing sites. On 11/17/16 at 11:16 AM, Physical Therapy Staff H stated the resident developed pressure ulcers on both buttocks several weeks ago, that had worsened with tunneling and odorous drainage. Physical Therapy Staff H stated the resident had an appointment with the surgeon tomorrow (11/18/16) for an evaluation and treatment. On 11/17/16 at 2:18 PM, Nurse D stated the nurse should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated staff assessed the resident with several excoriated areas on his/her buttocks several weeks ago, and the wounds have developed into pressure ulcers with odorous drainage. On 11/22/16 at 2:01 PM, Administrative Nurse B stated staff noted excoriation/skin issues on the resident's buttocks, on 10/26/16, and the resident admitted to the hospital with [REDACTED]. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify that staff repositioned the resident for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/29/16 at 10:27 AM, Nurse J stated the resident required total assistance with repositioning, transfers and toileting and he/she was not aware the physician had ordered a repositioning/turning program, to ensure pressure relief for the resident's wounds. Nurse J stated the resident refused to be repositioned at times and staff had not implemented new pressure relief devices or educated the resident of the consequences of not being repositioned. On 11/29/16 at 4:24 PM, Nurse Aide K stated the resident required total assistance with repositioning, transfers and toileting and was always incontinent of bowel and urine. Nurse Aide K stated he/she was not aware of a turning/repositioning schedule for the resident and staff repositioned the resident as he/she allowed. On 12/01/16 at 9:55 AM, Physician L stated the resident's wounds developed and deteriorated rapidly and the facility had not kept him/her adequately informed to direct the resident's wound care, before it became necessary for surgical treatment and hospitalization . The facility's (MONTH) 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment for [REDACTED].#2 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a [NAME] - Resident #3's admission (MDS) Minimum Data Set assessment, dated 10/10/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 14 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, transfers and toileting, and was occasionally incontinent of urine. The MDS further stated the resident had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) with granulation (moist red or pink tissue) in the wound bed. The 10/03/16 admission care plan indicated the resident had a Stage II pressure ulcer on his/her coccyx (small triangular bone at the base of the spine). The care plan directed staff to provide wound treatment as physician ordered and report changes of skin issues to the charge nurse immediately. The 10/12/16 (CAA) Care Area Assessment indicated the resident admitted with a Stage II pressure ulcer on his/her coccyx. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/26/16 care plan indicated the resident admitted with a Stage II pressure ulcer and directed staff to provide wound treatment as ordered by the physician. The care plan directed (PT) Physical Therapy staff to provide a wound evaluation and treatment on 11/01/16 and indicated the resident had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible) on 11/02/16. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 10/06/16 Wound/Skin Healing Report indicated the resident admitted to the facility with a Stage II pressure ulcer on his/her coccyx that measured 1.6 (cm) centimeters by 1.0 cm by 0.1 cm deep and the wound bed with granulation tissue. The 10/12/16 nurse's note indicated staff noted the resident's pressure ulcer wound bed was covered with slough (dead tissue, usually cream or yellow in color). The 10/14/16 at 9:09 AM, nurse's note indicated the resident's wound had no dressing, was 90% full of slough and measured 2 cm by 3 cm. review of the resident's medical record revealed [REDACTED]. The 10/16/16 at 12:00 AM, nurse's note indicated the resident's pressure ulcer wound bed continued covered with slough. The 10/20/16 Wound/Skin Report indicated the resident's Stage II pressure ulcer measured 0.9 cm by 0.6 cm by 0.1 cm deep with slough and a small amount of serosanguineous fluid (wound drainage of semi-thick reddish fluid). The 11/01/16 at 1:00 PM, nurse's note indicated the physician ordered PT to evaluate and treat the resident's pressure ulcer on the coccyx. The 11/02/16 at 6:45, nurse's note indicated the resident's pressure ulcer measured 2.0 cm by 1.2 cm by 0.9 cm deep and the wound bed covered with slough. The 11/10/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 0.8 cm by 1.2 cm deep with slough and a small amount of serosanguineous drainage. The 11/11/16 at 2:30 PM, nurse's note indicated the physician ordered nursing staff to verify staff repositioned the resident every 2 hours and directed staff to consult the surgeon to evaluate the resident's pressure ulcer. review of the resident's medical record revealed [REDACTED]. The 11/18/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 1.0 cm by 1.2 cm deep with granulation and a small amount of serosanguineous drainage. The report indicated PT provided wound care and the resident had a consult with the surgeon on 11/30/16. The 11/23/16 Wound/Skin Report indicated the resident's Stage III pressure ulcer measured 2.0 cm by 0.8 cm by 1.0 cm deep with granulation and a small amount of serosanguineous drainage. The 11/30/16 physician's wound consult orders directed staff to change the resident's wound treatment to daily, provide aggressive rehabilitation to get the resident out of his/her wheelchair, continue to measure and monitor the wound, and follow-up appointment in 1 month. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident was admitted to the facility with a Stage II pressure ulcer on his/her coccyx that had worsened to a Stage III pressure ulcer. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify the resident was repositioned for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. The facility's (MONTH) 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, pain. The facility failed to develop and implement interventions for Resident #3, who admitted with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer.

The facility had a census of 61 residents. The sample included 5 residents, who were reviewed for pressure ulcers. Based on observation, record review and interview the facility failed to provide necessary services and treatment to promote healing, prevent infection and prevent new pressure ulcers from developing for 3 of 5 sampled residents. Resident #1 admitted to the facility with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) on his/her left hip, that worsened to a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) with an infection, which required a prolonged hospitalization , placing Resident #1 in immediate jeopardy. Resident #2 developed a facility acquired Stage IV pressure ulcer with an infection, which required a prolonged hospitalization , placing Resident #2 in immediate jeopardy. Resident #3 admitted to the facility with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible). Findings Included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 09/29/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 11 (moderately impaired cognition). The MDS also indicated the resident required limited assistance with bed mobility, extensive assistance with transfers and toileting, and was incontinent of bowel and bladder. The MDS further indicated the resident had an unstageable pressure ulcer (wound bed covered by scab/hardened skin) and received nutritional interventions and wound dressings. The 09/22/16 admission care plan directed staff to provide the resident's wound care as ordered by the physician, and report skin issues to the charge nurse immediately. The care plan lacked documentation of the type of wound, stage of wound, location of the wound or any interventions to promote healing of the wound. The 09/29/16 (CAA) Care Area Assessment for pressure ulcers indicated the resident admitted to the facility after his/her left hip pressure ulcer was debrided (removal of dead tissue and foreign material from a wound) and received wound care at the hospital. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/06/16 care plan revealed the resident was admitted with a left hip pressure ulcer and was at risk for further skin alterations. The care plan directed staff to provide the resident's wound cares as ordered by the physician. The care plan lacked documentation of the stage of the wound or any care interventions to promote healing of the wound. The 09/22/16 physician's discharge orders indicated the resident had a resolved Stage IV pressure ulcer on his/her left hip and directed staff to take the resident to the wound clinic every week for wound therapy. The physician's orders [REDACTED]. The 09/22/16 wound clinic discharge orders indicated the resident had a superficial wound, with 100% healthy tissue, on his/her left hip and directed staff to provide wound care as ordered by the physician and take the resident to the wound clinic every week for wound therapy. review of the resident's medical record revealed [REDACTED]. The 09/22/16 at 7:01 PM, admission nurse's note indicated staff would complete a skin assessment for the resident later in the evening. review of the resident's medical record revealed [REDACTED]. The 09/27/16 at 9:38 AM, nurse's notes indicated the the resident's left hip pressure ulcer had no dressing, measured 1.2 (cm) centimeters by 0.8 cm by 0.3 cm deep, and a small amount of serosanguineous (bloody) drainage. The nurse's note indicated the facility currently did not have the correct dressing supplies (polymen silver dressing change daily) for the resident's pressure ulcer and the dressing supplies would be delivered today (5 days after admission). The wound assessment lacked a description of the wound bed and/or the condition of the surrounding tissue. The 10/02/16 at 2:30 AM, nurse's note indicated the resident's left hip pressure ulcer had a white wound bed with serosanguineous drainage, raised soft spots under the skin and dark redness around the wound. The 10/03/16 at 2:25 AM, nurse's note indicated the resident's left hip pressure ulcer had serosanguineous and purulent (yellow/white liquid produced with certain infections) drainage. The nurse's note also indicated the resident's pressure ulcer was tunneling (wound expansion under the skin/tissue) approximately 4 cm towards the knee. Review of the note revealed no documentation indicating staff notified the physician of signs of infection (purulent drainage and tunneling). The 10/06/16 at 8:00 PM, nurse's note indicated the resident's pressure ulcer measured 1.1 cm by 0.6 cm, redness surrounding the wound and purulent drainage. The nurse's note indicated staff notified the physician concerning the possible infection in the resident's pressure ulcer (3 days after noting purulent drainage from the wound). The 10/06/16 physician's orders [REDACTED]. The 10/07/16 wound culture indicated the resident's left hip pressure ulcer was positive for (MRSA) [MEDICAL CONDITION]-resistant Staphylococcus aureus (antibiotic resistant infection). The 10/07/16 physician's orders [REDACTED]. The 10/16/16 at 1:09 PM, nurse's note indicated the resident continued on antibiotic medication and the resident's pressure ulcer measured 0.6 cm by 0.4 cm by 0.2 cm deep, with unmeasureable tunneling present. The 10/21/16 at 5:10 PM, nurse's note indicated the resident's left hip pressure ulcer had purulent drainage with redness noted around the wound. Continued review of the resident's medical record revealed [REDACTED]. The 10/26/16 at 7:10 AM, nurse's note indicated the resident's pressure ulcer continued with purulent drainage and tunneling. Continued review of the resident's medical record revealed [REDACTED]. The 11/03/16 at 3:10 PM, nurse's note indicated the (PA) Physician Assistant O assessed the resident's pressure ulcer and ordered a wound care consult at the hospital. The 11/07/16 wound clinic progress note indicated the resident presented for evaluation and treatment for [REDACTED]. The note indicated the wound had no dressing and the resident's pants were saturated with drainage on the area near the wound site. The note indicated the resident had a blister above an open area, that consistently drained purulent drainage and when staff put pressure on the blister the purulent drainage increased from the open area, indicating the wound and blister were connected by a tunnel. The note indicated the open area measured 0.1 cm in diameter, the blister was fluid filled and the entire surrounding area was dark red, felt mushy/boggy (soft or spongy) and measured 9 cm by 6 cm. The note indicated staff cultured the resident's left hip pressure ulcer due to an apparent infection. The note further indicated the resident had a physician's orders [REDACTED]. The 11/07/16 nurse's note indicated the wound clinic directed staff to cover the resident's wound with polymen silver dressing and an ABD pad (thick dressing for moisture absorbency) and change the ABD pad every day or as needed. The 11/10/16 wound clinic progress note indicated the resident presented with an ABD pad saturated with purulent drainage and the blister area increased in size. The note indicated staff notified the resident's physician of possible need for I&D (incision and drainage). The note indicated the surgeon made an incision in the wound and found a mixture of sanguineous and purulent drainage deep inside the wound. The note indicated the wound measured 5.0 cm by 2.0 cm and a depth of 3.0 cm, and the wound was packed with medicated dressing and covered with an ABD pad. The note further indicated the wound culture was positive for a large amount [MEDICAL CONDITION] and the resident would be admitted to hospital for (IV) intravenous antibiotic therapy and placement of a wound vac (device used to create a sealed system to remove wound fluids and promote healing). The 11/11/16 physician progress notes [REDACTED]. The progress note indicated the facility notified the physician last week the resident's left hip pressure ulcer had returned. The progress note indicated the wound required an I&D, measured 6.0 cm by 1.7 cm by 3.0 cm deep and the culture report [MEDICAL CONDITION]. The progress note further indicated the resident admitted to the hospital for IV antibiotic therapy and wound care. On 11/30/16 at 11:19 AM, observation revealed the resident walked independently with a wheeled walker to the dining room and sat at the table. Continued observation revealed the wound vac tubing visible from the top of the resident's pants to the wound vac placed in the wire basket on the resident's walker. On 11/17/16 at 2:18 PM, Nurse D stated the nursing staff should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated the resident admitted with the left hip pressure ulcer and the wound worsened with infection and large amounts of drainage. On 11/17/16 at 4:44 PM, Wound Clinic Staff E stated the wound clinic previously treated the resident's left hip pressure ulcer and when the resident discharged back to the facility, on 09/22/16, the wound was superficial with 100% healthy tissue. Wound Clinic Staff E stated the facility had physician's orders [REDACTED]. Wound Clinic Staff E further stated the wound clinic would have monitored and directed the resident's wound care to prevent the development of an infected Stage IV pressure ulcer. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident admitted from the hospital with a pressure ulcer and had physician's orders [REDACTED]. Administrative Nurse B stated the facility had not implemented the physician's orders [REDACTED]. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/28/16 at 4:41 PM, Nurse Aide C stated the resident was independent with positioning, but staff assisted the resident with toileting and incontinent cares. Nurse Aide C stated the resident had a pressure ulcer on his/her left hip with increased drainage that saturated his/her dressings. On 11/29/16 at 9:14 AM, Physician G stated the resident discharged from the hospital with an almost healed pressure ulcer and the facility had not notified him/her in a timely manner regarding the worsening of the resident's pressure ulcer. Physician G further stated the facility had not followed his/her order for weekly wound therapy at the wound clinic and the wound clinic would have monitored and directed wound care to prevent the worsening of the resident's pressure ulcer. On 11/30/16 at 11:16 AM, Resident #1 stated his/her pressure ulcer drainage increased, would often get his/her clothing and bedding wet, and frequently would saturate the dressing, causing it to fall off. Resident #1 stated staff often changed his/her dressing in the middle of the night and did not turn on the room light, using only the light from the hallway. The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment to Resident #1 who admitted to the facility with a Stage II pressure ulcer on his/her left hip, that worsened to a Stage IV pressure ulcer with an infection, which required a prolonged hospitalization for wound care and placed Resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a G. - Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 11/02/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 12 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, total assistance with transfers, toileting, and always incontinent of bowel and urine.The MDS further indicated the resident had open [MEDICAL CONDITION] and (MASD) Moisture Associated Skin Damage. The 08/07/16 care plan indicated the resident had a history of [REDACTED]. The 10/28/16 care plan revision indicated the resident had denuded (skin loss) and excoriated (abraded, rubbed, chafed) areas on his/her buttocks and directed staff to provide incontinence care every hour at night. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 08/03/16 Braden Scale assessment score was 16, which indicated the resident was at risk to develop pressure ulcers. The 10/20/16 physician progress notes [REDACTED]. The 10/21/16 weekly skin assessment indicated the resident had no skin issues. The 10/26/16 at 3:00 AM, nurse's note indicated the resident had the following four areas of excoriated skin: 3.8 (cm) centimeters by 2.0 cm on upper left buttock, 2.0 cm x 1.2 cm on upper right buttock, 2.0 cm by 1.0 cm on left lower buttock and 2.2 cm by 1.1 cm on lower right buttock. The nurse's note indicated staff cleansed the areas, applied a dressing and notified the physician. The 11/02/16 physician fax indicated the resident's buttock wounds improved and staff would continue to provide check and change program (scheduled incontinent cares) and barrier cream after each incontinent episode. Review of the resident's medical record from 11/02/16 to 11/08/16 (6 days) revealed no documentation the staff had assessed the resident's wounds. The 11/08/16 physician fax indicated the resident spent most of his/her time on his/her right side due to left leg spasms and the skin breakdown on the resident's right buttock had worsened. The facility requested physical therapy to evaluate and treat the skin breakdown. The physician ordered physical therapy to evaluate and treat the resident's wound and body positioning. The physician also ordered the nursing staff to verify staff repositioned the resident every 2 hours for pressure relief. review of the resident's medical record revealed [REDACTED]. The 11/09/16 (PT) Physical Therapy Note indicated the resident's lower right buttock wound measured 2.0 cm by 1.3 cm with tunneling (wound expansion under the skin/tissue) noted. The 11/11/16 physician fax indicated PT reported a foul odor from the resident's lower right buttock wound and requested a wound culture. The 11/14/16 wound culture indicated the wound was positive for viridans streptococci, bacteria species with the potential to cause endocarditis (inflammation of heart valve) and streptococcus, bacteria species with the potential to cause meningitis (inflammation of protective membranes on the brain or spinal cord) and pneumonia (inflammation of the lungs). The 11/14/16 physician's orders [REDACTED]. The 11/14/16 at 2:51 PM, PT note indicated the resident's right lower buttock pressure ulcer measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/15/16 physician fax from the PT indicated the resident's lower right buttock pressure ulcer had increased slough (dead tissue, usually cream or yellow in color) and now measured 2.5 cm by 2.0 cm by 0.5 cm deep with tunneling. The 11/16/16 physician's orders [REDACTED]. The 11/17/16 at 3:20 PM, PT note indicated the resident's pressure ulcer continued to have slough and when staff applied pressure to the tunneling area odorous, purulent (yellow/white liquid produced with certain infections) drainage came from the wound. The 11/18/16 physician progress notes [REDACTED]. The progress note indicated the plan of treatment for [REDACTED]. The 11/18/16 surgical nurse's note indicated the resident had a Stage IV pressure ulcer on his/her right buttock with odorous, purulent drainage. The nurse's note indicated the resident's wound was surrounded by dark red skin and had necrotic tissue (localized dead tissue related to disease or injury). The 11/20/16 hospital nurse's note indicated the resident received scheduled (IV) intravenous antibiotic therapy for an infected pressure ulcer. The 11/21/16 surgical wound report indicated the physician completed an (I&D) incision and drainage, on the resident's right lower buttock Stage IV pressure ulcer. The wound report indicated the resident's pressure ulcer measured 4 cm in diameter and 3 cm deep with bloody drainage. The 11/22/16 at 10:00 PM, hospital nurse's note indicated staff notified the physician, that the resident's pressure ulcer, with the I&D, continued with large amounts of bleeding. The 11/25/16 at 9:52 AM, hospital nurse's note indicated the resident would be discharged to another hospital, with a wound clinic, for continued wound care and antibiotic therapy. On 11/17/16 at 9:16 AM, observation revealed 2 staff transferred the resident with a mechanical lift from his/her wheelchair to bed. Continued observation revealed Nurse Aide C and Nurse J provided extensive assistance to move the resident's legs and torso, to position the resident in bed. Continued observation revealed the resident had a duoderm (non-breathable adherent wound dressing) on his/her right lower buttock and left coccyx area, with reddened skin surrounding both dressing sites. On 11/17/16 at 11:16 AM, Physical Therapy Staff H stated the resident developed pressure ulcers on both buttocks several weeks ago, that had worsened with tunneling and odorous drainage. Physical Therapy Staff H stated the resident had an appointment with the surgeon tomorrow (11/18/16) for an evaluation and treatment. On 11/17/16 at 2:18 PM, Nurse D stated the nurse should assess skin issues each shift and document wound assessments in the nurse's notes. Nurse D stated staff should notify the physician immediately if skin issues developed or worsened and he/she was not aware who monitored the residents' skin/wound assessments. Nurse D stated staff assessed the resident with several excoriated areas on his/her buttocks several weeks ago, and the wounds have developed into pressure ulcers with odorous drainage. On 11/22/16 at 2:01 PM, Administrative Nurse B stated staff noted excoriation/skin issues on the resident's buttocks, on 10/26/16, and the resident admitted to the hospital with [REDACTED]. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify that staff repositioned the resident for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. Administrative Nurse B stated the facility had not implemented isolation precautions for the resident's infected pressure ulcer with drainage. On 11/29/16 at 10:27 AM, Nurse J stated the resident required total assistance with repositioning, transfers and toileting and he/she was not aware the physician had ordered a repositioning/turning program, to ensure pressure relief for the resident's wounds. Nurse J stated the resident refused to be repositioned at times and staff had not implemented new pressure relief devices or educated the resident of the consequences of not being repositioned. On 11/29/16 at 4:24 PM, Nurse Aide K stated the resident required total assistance with repositioning, transfers and toileting and was always incontinent of bowel and urine. Nurse Aide K stated he/she was not aware of a turning/repositioning schedule for the resident and staff repositioned the resident as he/she allowed. On 12/01/16 at 9:55 AM, Physician L stated the resident's wounds developed and deteriorated rapidly and the facility had not kept him/her adequately informed to direct the resident's wound care, before it became necessary for surgical treatment and hospitalization . The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, and pain. The facility failed to provide necessary care and treatment for [REDACTED].#2 in immediate jeopardy. The facility abated the immediate jeopardy on 12/01/16 at 5:00 PM, after the completion of training all staff regarding assessment for the risk of skin breakdown, reporting new or worsened skin issues, and providing appropriate interventions for the prevention of skin breakdown: turning/repositioning programs, incontinent cares, pressure relief devices, and dressing changes. The training also included the importance of following the wound/skin care policy and following physician's orders [REDACTED]. This deficient practice remained at a scope and severity of a G. - Resident #3's admission (MDS) Minimum Data Set assessment, dated 10/10/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 14 (cognitively intact). The MDS also indicated the resident required extensive assistance with bed mobility, transfers and toileting, and was occasionally incontinent of urine. The MDS further stated the resident had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow wound) with granulation (moist red or pink tissue) in the wound bed. The 10/03/16 admission care plan indicated the resident had a Stage II pressure ulcer on his/her coccyx (small triangular bone at the base of the spine). The care plan directed staff to provide wound treatment as physician ordered and report changes of skin issues to the charge nurse immediately. The 10/12/16 (CAA) Care Area Assessment indicated the resident admitted with a Stage II pressure ulcer on his/her coccyx. The CAA indicated the facility would provide wound care as ordered by the physician. The 10/26/16 care plan indicated the resident admitted with a Stage II pressure ulcer and directed staff to provide wound treatment as ordered by the physician. The care plan directed (PT) Physical Therapy staff to provide a wound evaluation and treatment on 11/01/16 and indicated the resident had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible) on 11/02/16. The care plan lacked the type of mattress used or any other care interventions to promote healing of the pressure ulcer. The 10/06/16 Wound/Skin Healing Report indicated the resident admitted to the facility with a Stage II pressure ulcer on his/her coccyx that measured 1.6 (cm) centimeters by 1.0 cm by 0.1 cm deep and the wound bed with granulation tissue. The 10/12/16 nurse's note indicated staff noted the resident's pressure ulcer wound bed was covered with slough (dead tissue, usually cream or yellow in color). The 10/14/16 at 9:09 AM, nurse's note indicated the resident's wound had no dressing, was 90% full of slough and measured 2 cm by 3 cm. review of the resident's medical record revealed [REDACTED]. The 10/16/16 at 12:00 AM, nurse's note indicated the resident's pressure ulcer wound bed continued covered with slough. The 10/20/16 Wound/Skin Report indicated the resident's Stage II pressure ulcer measured 0.9 cm by 0.6 cm by 0.1 cm deep with slough and a small amount of serosanguineous fluid (wound drainage of semi-thick reddish fluid). The 11/01/16 at 1:00 PM, nurse's note indicated the physician ordered PT to evaluate and treat the resident's pressure ulcer on the coccyx. The 11/02/16 at 6:45, nurse's note indicated the resident's pressure ulcer measured 2.0 cm by 1.2 cm by 0.9 cm deep and the wound bed covered with slough. The 11/10/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 0.8 cm by 1.2 cm deep with slough and a small amount of serosanguineous drainage. The 11/11/16 at 2:30 PM, nurse's note indicated the physician ordered nursing staff to verify staff repositioned the resident every 2 hours and directed staff to consult the surgeon to evaluate the resident's pressure ulcer. review of the resident's medical record revealed [REDACTED]. The 11/18/16 Wound/Skin Report indicated the resident's pressure ulcer deteriorated to a Stage III and measured 2.0 cm by 1.0 cm by 1.2 cm deep with granulation and a small amount of serosanguineous drainage. The report indicated PT provided wound care and the resident had a consult with the surgeon on 11/30/16. The 11/23/16 Wound/Skin Report indicated the resident's Stage III pressure ulcer measured 2.0 cm by 0.8 cm by 1.0 cm deep with granulation and a small amount of serosanguineous drainage. The 11/30/16 physician's wound consult orders directed staff to change the resident's wound treatment to daily, provide aggressive rehabilitation to get the resident out of his/her wheelchair, continue to measure and monitor the wound, and follow-up appointment in 1 month. On 11/22/16 at 2:01 PM, Administrative Nurse B stated the resident was admitted to the facility with a Stage II pressure ulcer on his/her coccyx that had worsened to a Stage III pressure ulcer. Administrative Nurse B stated he/she was not aware the physician ordered the nursing staff to verify the resident was repositioned for pressure relief. Administrative Nurse B stated the facility did not have a system in place to accurately assess and monitor skin issues. The facility's March 2014 Pressure Ulcer Policy directed staff to follow physician's orders [REDACTED]. The policy directed staff to provide timely and accurate wound assessments and report new or worsening skin issues to the physician immediately. The policy directed staff to develop specific care plan interventions for special needs such as: immobility, incontinence, infection, pain. The facility failed to develop and implement interventions for Resident #3, who admitted with a Stage II pressure ulcer on his/her coccyx, which worsened to a Stage III pressure ulcer.

The facility had a census of 61 residents. The sample included 24 residents of which 11 were reviewed for (ADLs) Activities of Daily Living. Based on observation, record review and interview the facility failed to ensure 1 of 11 residents free of neglect for lack of adequate personal hygiene and bathing. (#49) Findings included: - Resident #49's quarterly (MDS) Minimum Data Set assessment, dated 5/27/2016, indicated the resident had a (BIMS) Brief Interview for Mental status score of 10 which indicated moderately impaired cognition, and required extensive assistance of two plus staff with dressing, personal hygiene, and bed mobility and was totally dependent with two plus staff for transfers, toilet use, and bathing, and frequently incontinent. The MDS indicated the resident was at risk for developing pressure ulcers, and had a pressure reducing device for bed and chair. The 12/09/2015 (CAA) Care Area Assessment for (ADLs) Activities of Daily Living indicated the resident required extensive assistance and two staff for bed mobility, dressing, toilet use, personal hygiene and bathing. The 6/08/2016 care plan stated the resident required 2 assistance of staff for personal hygiene, assistance of 1 staff for bed bath, for oral hygiene, and bathing, and nail care weekly by the nurse. The care plan directed the staff to monitor the resident's skin folds daily for redness or discoloration, assist with turning and repositioning every two hours and as needed, apply moisturizing lotion to all extremities with morning and evening cares. The care plan directed the nurse to complete a weekly skin assessment. Review of the bath/shower book through 8/31/2016 revealed the staff assisted the resident with a bath on Monday PM and Friday PM. Continued review revealed the following days the resident received a bed bath: August 1, 2 ,4, 9,and 11, 2016. The documentation revealed no documentation the staff washed the residents hair in August. Review of the (MAR) Medication Administration Record [REDACTED]. Review of the weekly skin assessment revealed: 6/04/2016, redness to all folds and creases, antifungal cream applied to areas. 6/11/2016, skin slight redness noted to the folds and creases. 6/18/2016, redness to all creases and folds. No skin breakdown noted to the red areas, antifungal cream ( a medicated cream use to treat fungal infections of the skin, scalp and nails) applied to areas after cleaning. 6/25/2016, slight redness to the folds of left inner elbow. 7/02/2016 slight redness noted to underarms. 7/10/2016, no skin issues documented. 7/16/2016, no skin issues documented. 7/30/2016, light redness noted to both knees. 8/13/2016 slight redness noted to folds. The 8/15/2016 emergency room report stated the resident transferred from the facility to the emergency room by ambulance for altered level of consciousness, and lower right abdominal pain. The physical examination revealed he/she had bilateral diminished lung sounds, appeared to have mold between the two skin folds in the armpit area and indicated all of the resident's skin folds were (gaulded) rubbed to the point of rawness and almost to the point of bleeding. The resident's toenails were thick, long and not clipped. The documentation stated the condition of the resident's nails put him/her at risk for skin abrasions and lacerations. The residents feet were not clean with thick skin and appeared to have not been washed in a long time. The notes indicated the resident's hair needs to be washed. The emergency room report assessment indicated the medical provider diagnosed the resident with: right lower lobe pneumonia, possible aspiration, cardiomegaly (an enlarged heart) and neglect (a form of abuse where the perpetrator is responsible for caring for someone who is unable to care for him/herself but fails to do so). The 8/16/2016 physician progress notes [REDACTED]. The physician noted the state of the patient's arrival from the nursing home facility was poor to say the least, and stated he/she had mold within his/her skin folds, teeth had not been cleaned for some time, and the nails were extremely long. The 8/15/2016 at 3:00 AM, nurse's notes indicated the resident complained of abdominal pain and the nurse was unable to determine the pain origin. The nurse aide stated the resident had a medium bowel movement, soft and formed. Nurse P instructed the staff to turn the resident to his/her left side. The 8/15/2016 at 5:00 AM, nurse's notes indicated the resident had no relief and he/she administered two Tylenol. Further assessment of the resident vital signs blood pressure 110/78, pulse 76, respirations 18 and temperature 98.5, blood sugar 130, and oxygen saturation at 94% at 2 liters per nasal cannula. The resident complained of tenderness on the right lower abdomen. The nurse's notes indicated the resident was difficult to arouse, and very slow to respond to verbal command. No complaints of nausea, and bowel sounds active. (no documentation of a reassessment from 3:00 AM to 5:00 AM) The 8/15/2016 at 5:30 AM, Nurse P notified the hospital of the resident's sign and symptoms and he/she indicated they would notify the residents primary care physician. The 8/15/2016 at 5:47 AM, nurse's notes orders to transfer the resident to the hospital emergency room . The 8/15/2016 at 6:15 AM, nurse's notes stated the emergency medical service arrived to transport the resident to the hospital. The 8/15/2016 at 6:45 AM, nurse's notes indicated the resident left the facility to go to the hospital. The 8/15/2016 emergency room Report stated the resident arrived at the hospital with an altered level of consciousness, and had right lower quadrant abdominal pain, difficult to arouse and had pain. The physical examination revealed the resident had what appeared to be mold between his/her two skin folds on her right lateral midaxillary line distal from that. The examination revealed all of his/her skin folds were gaulded, and the axilla bilaterally were gaulded almost to the point of bleeding. The examination revealed his/her feet were not clean and appear to have not been scrubbed for a long time, toenails were not clipped, thick, long and that put the resident at risk for skin abrasions and lacerations, his/her hair needed to be washed. The 8/15/2016 hospital microbiology results indicated the resident had Pseudomonas aeruginosa (a bacteria that causes infections) and Gram negative bacillius (bacteria that cause pneumonia, blood stream infections, wound or surgical site infections, and meningitis in healthcare settings) cultured from the right side skin fold. On 8/18/2016 at 5:05 PM, observation revealed the resident, seated on a reclining chair, in a hospital room with hospital Registered Nurse L in attendance. Further observation revealed the following: flaking and peeling skin on the soles of his/her left foot and ankle area, and the right great toenail was very thick, yellow, had grown past the tip of the toe approximately 1/2 inch, and was very brittle. The other 4 toes had jagged toenails that curled over the ends of the toes. Observation of the resident's right foot revealed the same observation as the left foot except the great toenail had grown past the tip of the toe approximately 1/4 inch, and was very brittle. The other 4 toes had jagged toenails that curled over the ends of the toes. right and left armpit had red, gaulded area approximately 2 x 3. right and left upper arm skin folds red and gaulded 2 neck folds red and gaulded along the crease abdominal skin fold red and gaulded along the crease right and left thigh skin folds red and gaulded The resident was unable to roll on his/her side to visualize the rolls of skin on his/her back. On 8/18/2016 at 9:30 AM, hospital Nurse M verified the resident arrived in the emergency roiagnom on [DATE] due to pain in his/her right lower abdomen. Nurse M described the following condition of the resident upon transfer; very dirty, gaulded abdominal folds with areas on the verge of bleeding, an area approximately 3 () inch x 3 area that was green and fuzzy, and look like mold. Nurse N stated the resident's feet had layers of old skin and appeared to have not been scrubbed for awhile, his/her hair was very dirty and appeared to have cradle cap (yellowish, patchy, grease, scaly and crusty) on his/her head. Nurse M stated when the resident arrived at the emergency room he/she could only state his/her name, and after the resident received fluids, the resident told hospital staff he/she could not remember when he/she last had a bath. On 8/18/2016 at 10:30 AM, Medical Provider AA verified he/she saw the resident in the emergency roiagnom on [DATE] and verified the resident's skin folds were gaulded almost to the point of bleeding. The resident had an area on the right mid axillary line that was green- and the culture grew pseudomonis. The toenails were thick and and had not been trimmed. Throughout the exam the resident had cried and Medical Provider AA stated he/she felt it was neglect. On 8/18/2016 at 5:15 PM, hospital Nurse L verified the resident presented to the hospital with gaulded abdominal skin folds, neck skin folds, and back skin folds. Hospital Nurse L verified the resident was very dirty, had dried skin pealing/flaking off his/her feet and ankles, with untrimmed toenails and the big toenails were very thick and over grown. On 8/24/2016 at 2:20 PM, Nurse Aide R stated he/she was the facility bath aide and gave the resident a bath at least once a week. Nurse Aide R stated he/she provided the resident a bed bath because the resident refused to go to the shower because the shower chair was uncomfortable and hurt his/her legs. Nurse Aide R stated the resident's bath were documented in the bath book. On 8/24/2016 at 5:30 PM, Nurse O stated he/she assessed the resident on 8/13/2016 prior to transferring him/her to the hospital. The skin report indicated the resident had redness and dry powder in his/her skin folds so he/she wiped down the resident's skin folds along the abdomen, back, legs and upper back areas as much as he/she could and stated that caused the resident some discomfort. Nurse O stated after the areas were wiped off he/she applied new powder to the reddened areas. Nurse O verified the resident's toenails were thick and when he/she trimmed the nail the resident started to say, oh, oh my feet hurt. Nurse O stated his/her pain was from arthritis in his/her feet and legs. On 8/24/2016 at 6:10 PM, Nurse P stated on 8/15/2016 at 3:00 AM a nurse aide alerted the nurse the resident complained of pain. Nurse P assessed the resident and determined he/she had pain across his/ her abdomen. The nurse instructed the nurse aides to turn the resident to his/her left side to relieve his/her gas, and he/she administered two Tylenol 325 (mg) milligrams to him/her to help with pain relief. Nurse P stated the resident had no relief during the assessment and a second nurse assisted him/her to assess the resident, and both nurses determined the resident had pain in his/her right lower abdominal quadrant. Nurse P stated the resident had been difficult to arouse and slow to respond during the assessment but was able to rate his/her pain at a 10, on a 1-10 scale and 10 being the worst and stated it was the worst pain he/she had ever had. Nurse P reported he/she contacted the hospital at 5:30 AM to report the resident's signs and symptoms and at 5:47 AM the emergency room nurse returned a call and gave the order to transport the resident to the emergency room for further evaluation. At 6:15 AM, the ambulance arrived and at 6:45 AM transported the resident to the hospital. Nurse P stated during all of his/her assessments of the resident he/she had not noted the any yeast odor or had any reports from aides of any odor that would alert the nurse to assess the resident's abdominal folds. On 8/29/2016 at 10:25 AM, Nurse N verified the nurses were to trim the resident's toenails on the evening and/or night shift weekly. Nurse N stated he/she had never noted the resident had an odor or was unkempt. On 8/24/2016 at 11:25 AM, Administrative Nurse A verified the staff are to assess the resident's skin daily and report any concerns to the charge nurse, and assist the resident with bathing. Administrative Nurse A verified if the resident was diabetic the treatment nurses were to trim and/or provide weekly nail care. Administrative Nurse A stated he/she was not aware of the resident's odor, skin condition and long toenails. Administrative Nurse A stated the staff are to provide these services to the resident as ordered. Administrative Nurse A stated he/she was unaware the hospital had assessed the resident with neglect and/or the culture results obtained from the resident's skin folds. The Abuse, Neglect, and Exploitation policy, dated 8/1999, stated Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fail to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents. Neglect occurs when a facility fails to provide necessary care for residents, such as situations in which residents are left to lie in urine and feces. The facility failed to provide Resident #49 with assistance for grooming and bathing needs resulting in neglect and placing the resident at risk for infections, odor and self - worth decline.

The facility had a census of 61 residents. The sample included 18 residents, of which 6 were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents or ensure the resident environment remained as free of accident hazards as possible for 4 of the 6 residents reviewed for accidents. Resident #24 had a fall out of a recliner with injury, Resident #70, who had a resident to resident altercation and wandered into an unlocked shower room, then locked the door without staff knowledge, Resident #36 had a shoulder fracture and required more assistance to prevent further falls, and Resident #27 who sustained skin tears with transfers. Findings included: - Resident #24's annual (MDS) Minimum Data Set assessment, dated 9/02/2016, indicated the resident had short and long term memory loss. The assessment revealed the resident totally dependent on staff for locomotion on and off the unit, extensive assistance for transfers, dressing and toilet use, and limited assistance for walking in the room and corridor. The assessment further revealed the resident had unsteady balance with moving from a seated to a standing position and walking, but able to stabilize with assistance. The resident received antidepressant medication, which increased his/her fall risk. The 9/02/2016 fall (CAA) Care Area Assessment summary stated the resident had an unsteady gait, and could stabilize without assistance, but occasionally required staff to assist him/her. The CAA further stated the resident had a history of [REDACTED]. The 9/07/2016 care plan directed the staff to assist the resident for long distances, indicated he/she resided on a secured unit due to wandering, and the level of assistance he/she needed may vary throughout the day, generally requiring more assistance at night. The care plan directed staff to have the resident stand for a few minutes before ambulating, place a motion sensor (a device that detects physical movement and alerts staff of movement) on the bed and the personal alarm. Past update on 6/25/2015 (approximately 1 year and 4 months ago) intervention indicated that no recliners were to be on the special care unit. Continued care plan review revealed the resident had a fall on 5/24/2016, and on 7/09/2016 with no new interventions. Record review revealed the resident had falls on 5/24/2016 and 7/09/2016 with no new interventions on the care plan and the facility failed to complete a root cause analysis for the falls. The 8/24/2016 fall risk assessment revealed a score of 21 with a score of 10 or higher represents a high risk for falls. Review of the 10/01/2016 physician orders [REDACTED]. The medication side effects include dizziness, drowsiness, and hypotension (low blood pressure that results in dizziness, fainting). The 10/12/2016 at 12:10 PM, nurse's notes documented the staff found the resident lying on his/her left side on the floor in his/her room with alarms sounding. The nurse contacted the emergency medical service for transport to the local hospital (nurse's notes lacked any other description of the event). The 10/12/2016 facility investigation report indicated the staff found the resident on the floor and prior to the fall, staff took the resident from the dining room to his/her room and assisted him/her to a recliner. The report stated the resident's left shoulder was deformed at the collar bone. The report further indicated the steps the facility took to prevent recurrences were 15 minute checks, a sling, and a shoulder immobilizer placed on the resident. The 10/12/2016 Emergency Department Record transition summary and discharge instructions indicated the resident had a fall and sustained a fractured left clavicle. The patient's discharge instructions indicated the resident would wear a sling, apply ice, and take Tylenol for discomfort. The 10/12/2016 radiology report impression, comminuted (producing multiple bone splinters) left mid shaft clavicular (the long bone that serves as a strut between the shoulder blade and the breastbone) fracture with overriding and displacement. On 10/12/2016 at 10:30 AM, observation revealed the resident in his/her room in the recliner, with feet elevated and the personal alarm on the resident. On 10/12/2016 at 11:30 AM, observation revealed EMS wheeled the resident out of the special care unit on a gurney (a wheeled stretcher used to transport hospital patients). Continued observation revealed the resident had his/her left arm folded across his/her chest and he/she rubbed the arm with his/her right hand with a grimacing expression on his/her face. On 10/13/2016 at 9:10 AM, Nurse Aide F stated staff assisted the resident to his/her recliner after breakfast, placed a pressure alarm on, elevated the foot rest on the recliner, and covered the resident with a blanket. On 10/13/2016 at 12:00 PM, Nurse Aide G stated some days the resident would walk and other days, he/she required a wheelchair for mobility. Nurse Aide G stated when the resident was in his/her room, he/she was positioned in the recliner with a pressure alarm on. On 10/12/2016 at 5:50 PM, Nurse H stated the resident had been in the recliner, apparently attempted to get out, he/she went forward and the recliner tipped forward resulting in the resident falling on the floor. The alarm sounded and staff found him/her face down on the floor with an obvious deformity to his/her left shoulder. Nurse H stated the resident returned to the facility with a sling on his/her left arm, which the resident would remove and it did not stabilize the arm enough, so he/she returned to the hospital and the emergency room staff placed an immobilizer on the resident for the fractured clavicle. On 10/13/2016 at 11:30, Administrative Nurse E stated the resident had an unwitnessed fall from the manual recliner that resulted in a fractured clavicle. Administrative Nurse E verified the care plan documented on 6/25/2015 that no recliners were to be on the unit. The 12/07 facility Fall Managing Policy stated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling reoccurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant if underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment. The staff will monitor and document each resident's response to interventions intend to reduce falling or the risks of falling. If the interventions have been successful in preventing falling, staff will continue interventions or reconsider whether these measures are still needed if a problem that required the intervention has been resolved. If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions as needed. The attending physician will help the staff reconsider possible causes that may not have previously been identified. The staff and/or physician will document the basis for conclusions that specified irreversible risk factors exist that continue to present a risk for falling and no injury due to falls. The facility failed to ensure the resident's environment remained free of accident hazards when staff placed Resident #24 in a recliner, with the footrest elevated, and he/she fell and sustained a fractured clavicle. - Resident #70's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 9/09/2016, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 4, indicating severely impaired cognition. The assessment revealed the resident independent with bed mobility, required supervision for ambulation and locomotion on/off the unit and limited assistance with transfers. The assessment further revealed the resident had wandering behavior 4-6 days of the 7 day look back period with delirium (serious disturbance in mental abilities that result in confused thinking and reduced awareness of surroundings) and delusions (a false belief held despite strong evidence that is not true) present. The 9/14/2016 dementia care plan directed staff to assess the resident for possible reasons for wandering such as, the need to use the toilet, or restlessness from inactivity, to redirect the resident to keep him/her from entering areas that do not pertain to him/her, and place a stop sign in areas warranted to divert the resident from entering. The care plan documented the staff would ensure that all areas of concern that can be locked are locked when unoccupied. The undated, handwritten update indicated the facility was looking for more suitable placement for the resident and the staff educated not to leave the shower room unlocked. Further care plan review for behavioral symptoms directed the staff to observe the resident for exit seeking, ensure the resident is safe, redirect his/her attention and/or take to another location, administer medications that promote decreased anxiety and monitor for effectiveness, and consult the local center for counseling. The 10/05/2016, accident/incident/investigation report stated on 10/03/2016, Administrative Nurse E had reviewed skin assessments and noticed Resident #37 had a 6 (cm) centimeter by 8 cm bruise on his/her left arm. Administrative Nurse E requested the nurse who completed the skin assessment to investigate the cause of the bruise. The investigation revealed on 9/29/2016 at 7:00 PM, Resident #70 entered Resident #37's room and grabbed his/her left arm, causing a 6 cm by 8 cm bruise. The report indicated Resident #37 did not have any pain. The 10/06/2016, accident/incident/investigation report stated, on 9/30/2016 at 2:00 PM, staff found the resident in the shower room on the special care unit, with the door shut and a wheelchair up against the door on the inside. The report stated at 1:50 PM staff redirected the resident and found the resident locked in the shower room at 2:00 PM. On 10/10/2016 at 7:49 AM, observation revealed the resident, walking independently up and down the hall, then stopped at the exit door looking out the window in the door, then staff redirected the resident away from the door. On 10/13/2016 at 9:53 until 10:04 AM, observation revealed the resident pushing another resident in a wheelchair, from the dining room to the end of the hall, then proceeded to push him/her back down the hall and back into the dining room. Ongoing observation revealed one staff attempted to redirect the resident, however the resident proceeded to push the other resident in the wheelchair until 10:04 AM. On 10/13/2016 at 11:02 AM, observation revealed the resident took an unoccupied wheelchair, in the hall way, push it through the dining room, turned around, pushed it into another resident's room, left the wheelchair in the room and walked into the dining room. On 10/10/2016 at 2:20 PM, Nurse R stated he/she had completed a skin assessment on 9/29/2016 and documented Resident #37's skin bruise and stated he/she had concurred the bruise was from the resident's blood thinner medication. On 10/12/2016 at 9:10 AM, Nurse Aide A stated the resident is very active, ambulates independently, and staff redirect him/her as needed. Nurse Aide A further stated, the resident will go in and out of other resident rooms and the staff constantly watches him/her. Nurse Aide A staff verified staff is to keep the shower room door locked at all times if staff are not in attendance. On 10/12/2016 at 9:40 AM, Nurse Aide B verified the shower room door is to be kept locked at all times, unless staff are in the room assisting the residents with showers. Nurse Aide B stated the resident is always on the go wandering up and down the halls, staff assist him/her with diversional activities, and provide snacks for him/her. On 10/12/2016 at 9:45 AM, Maintenance Staff C verified he/she found the resident in the special care unit shower room, with the door locked on 9/30/2016 at 2:00 PM. Maintenance Staff C stated the resident had placed a wheelchair and a straight back chair behind the wheelchair. Maintenance Staff C indicated he/she had planned on working on the shower floor and replace the caulking at 2:00 PM that day and incidentally found the resident in the locked shower room. On 10/12/2016 at 4:10 PM, Resident #37 stated the resident is constantly walking around and wandering day and night. Resident #37 requested his/her physician place him/her on another hall and not in the special care unit due to Resident #70's constant disruptions. Resident #37 stated he/she had previously voiced the concerns regarding Resident #70's wandering to the nurses and social service designee and nothing had been done. On 10/11/2016 at 3:00 PM, Administrative Nurse E stated staff found the resident in the locked shower room on the special care unit on 9/30/2016 at 2:00 PM when maintenance went to do some already scheduled maintenance on the shower room floor. Administrative Nurse E verified after the facility investigation, it was determined the resident grabbed Resident #37's left arm and incurred the bruise on his/her left arm. Administrative Nurse E did not know of the incident until he/she reviewed the weekly skin assessment sheets and then started the investigation. (4 days between the incident and the investigation) The 8/2014 Wandering/Unsafe Resident policy, indicated the staff would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident at risk for safety issues, and provide interventions to try and maintain safety. The facility failed to ensure the resident environment remained as safe/free of accident hazards as possible, and complete root cause analysis after the incidents in order to implement further preventive measures to prevent Resident #70 from wandering into unsafe area/rooms, such as inside a locked shower room and other residents' rooms, which placed the resident at risk for injury. - Resident #36's annual (MDS) Minimum Data Set assessment, dated 8/18/16, indicated the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15. The assessment revealed the resident independent with all (ADLs) activities of daily living, able to re-balance self without assistance, had no range of motion impairment, and used a walker. The assessment revealed the resident always continent of urine, had no falls, and received antidepressant and diuretic (medication to promote the formation and excretion of urine) medications. The 8/18/16 (CAA) Care Area Assessment summary for falls revealed the resident independent with ambulation with a walker, able to make his/her needs known and will request help when needed. The 8/17/16 care plan for falls directed staff to perform a fall risk assessment per protocol, provide properly fitting shoes, and non-skid strips by his/her recliner. The care plan stated the resident was independent with bed mobility, transfers, and ambulation with a walker. The 10/2/16 update directed staff to provide a night light and personal alarm. The 10/7/16 update directed staff to perform 30 minute checks of the resident. The 10/7/16 temporary care plan for ADLs directed staff to consult therapy as needed, provide assistance of one with bathing, hygiene, and assistance of 2 with dressing/grooming, toileting, and ambulation/transfers. The care plan for the left shoulder fracture directed staff to not remove the shoulder immobilizer, allow the resident to flex his/her elbow/wrist, but no motion to the left shoulder, and administer pain medication as ordered. The 10/2/15 therapy communication to nursing revealed the resident was upgraded to independent with ambulation in room/halls. The 10/2/16 fall risk score of 7 indicated the resident not at high risk for falls. (10 or above indicates high risk). The 10/2/16 at 5:30 AM, nurse's note revealed staff found the resident on the floor in his/her room, on his/her left side, in front of the bathroom door. The note stated the resident was at the foot of his/her bed, which was moved away from the wall. The resident was able to tell the nurse that he/she got up to go to the bathroom, but when he/she reached for his/her walker it was not in reach and he/she wobbled and fell . The resident reported very low light in the room and his/her walker was behind him/her. The note further stated the resident reported extreme pain in his/her left shoulder and staff called the resident's physician, (EMS) Emergency Medical Service and family. At 5:50 AM, EMS arrived and transported the resident to the hospital. The 10/2/16 at 11:01 AM, nurse's note revealed hospital staff admitted the resident due to the dislocation of his/her left shoulder with a fracture of 3 bones, requiring surgery. The 10/3/16 hospital documentation stated the resident fell at his/her nursing home and injured his/her left shoulder. The resident reported he/she had gotten up to go to the bathroom and the furniture had been re-arranged in his/her room. When the resident reached for his/her walker, which was partly away from his/her bed, he/she fell , and sustained an acute dislocation of the left shoulder and fracture of the humerus (the bone of the upper arm). On 10/10/16 at 1:17 PM, observation revealed the resident had his/her left arm in a sling under his/her clothing. The resident stated he/she got out of bed independently and reached for his/her walker, but it was not there and he/she fell . The resident stated he/she used the call light at times prior to the fall, but usually got up and around on his/her own. Continued observation revealed Nurse Aides B, J, and K left the room without placing the resident's call light in reach, and the family moved the call light within the resident's reach. On 10/12/16 at 12:49 PM, observation revealed the resident self-propelled his/her wheelchair from the hall into his/her room. Further observation revealed the resident's left arm in a sling under his/her shirt, glasses on and rubber soled slippers on. The resident stated the cleaning staff moved his/her bed when he/she was at a birthday party on Saturday, October 1st. The resident stated he/she had not asked staff to re-arrange his/her furniture. The resident stated staff moved the bed from beside the wall to the center of the room and when he/she got up to go to the bathroom, his/her walker was on the other side of the bed. On 10/12/16 at 6:57 AM, observation revealed the resident's call light sounding. At 6:59 AM, Nurse H answered the light. Further observation revealed the resident was on the toilet, Nurse H assisted the resident to stand, without a gait belt, and the resident took steps to turn to the wheelchair and Nurse Aide F was there to assist the resident to sit in his/her wheelchair. Continued observation revealed Nurse Aide F used a gait belt to transfer the resident to his/her recliner and gave him/her the call light. Continued observation revealed the resident did not have shoes or gripper socks on his/her feet (he/she was barefoot) Nurse Aide F placed socks on the resident after the surveyor asked if the resident should have something on his/her feet. On 10/12/16 at 2:50 PM, Nurse L stated on 10/1/16 the resident had complained about his/her bed and staff replaced the bed. The new bed would not allow the door to be closed when placed where the other bed had been. Nurse L stated the resident was out of the building with family at the time. Nurse L stated on 10/2/16, right after the resident fell , while waiting for the ambulance, Nurse L asked him/her what happened and the resident stated he/she had moved the bed so he/she could shut the door. On 10/12/16 at 4:08 PM, Environmental Services Staff C stated he/she had changed out the resident's bed on 10/1/16, and placed the bed where the old bed was, but the door could not be closed. He/she stated he/she locked the bed brakes at that time. Observation at 4:18 PM, revealed the resident's bed brake at the foot of his/her bed was not locked. The observation was verified by environmental services Staff C. On 10/12/16 at 5:00 PM, Nurse H verified he/she should have used a gait belt when he/she transferred the resident from the toilet to his/her wheelchair. On 10/12/16 at 1:04 PM, Environmental Services Staff M stated he/she changed the resident's bed prior to the fall. He/she stated he/she left the bed against the south wall, but it was just a bit too long to shut the door and the resident stated that was okay for now. Environmental Services Staff M stated when he/she left for the day, the resident's bed was against the south wall, by the door. On 10/13/16 at 7:28 AM, Nurse N stated he/she found the resident on the floor on 10/2/16, after he/she heard a loud noise in the resident's room. He/she stated the resident was lying on his/her left side, with his/her head towards the bathroom. Nurse N stated the foot of the bed was angled away from the hall door, with the head of the bed still in the corner. The walker was behind the resident. Nurse N stated the resident was able to tell staff what happened. Nurse N stated he/she did not know if the resident moved the bed, but it had not been moved out before 8:30 PM when he/she administered medication to the resident. Nurse N stated the resident had a nightlight prior to his/her fall, but a chair was in front of it. He/she stated the night light did provide some light in the room, but it was not bright. Nurse N stated staff were going to re-arrange the resident's room in the morning, because the resident was ready for bed when they discovered his/her door could not be shut. On 10/13/16 at 1:42 PM, Administrative Nurse E stated staff are to ensure the call light within reach, use a gait belt with transfers, and should make sure the resident is wearing non-skid socks or shoes during transfers. Administrative Nurse E stated the resident told staff he/she had moved his/her bed during the night prior to his/her fall. The facility's 12/2007 Fall and Fall Risk Managing policy stated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will identify environmental factors that may contribute to falling, such as lighting and room layout and address modifiable fall risk factors. The facility failed to ensure an accident free environment as possible, when moving a new bed into the room which did not allow the room door to close as the resident preferred and Resident #36 rearranged the room, fell , and sustained a dislocated shoulder and fractured humerus, when unable to reach his/her walker. The facility failed to provide interventions to prevent further falls such as: ensure the call light within reach, use a gait belt with transfers, and ensure the resident is wearing non-skid socks or shoes during transfers for Resident #36. - Resident #27's quarterly (MDS) Minimum Data Set assessment, dated 8/18/16, indicated the resident's vision adequate with glasses, and the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15. The assessment revealed the resident independent with eating, required limited assistance with hygiene, extensive assistance with walking, dressing, toilet use, bed mobility, transfers and total assistance with locomotion. The resident able to balance with assistance, had no range of motion impairment and used a walker and a wheelchair. The assessment revealed no falls, no skin issues, applications of dressings/ointments, and the resident received anticoagulant (blood thinning) medication. The 8/4/16 care plan for skin directed nursing staff to perform a weekly skin assessment, nurse aides to monitor skin daily and notify the nurse as warranted, provide wound treatment as ordered. The 9/17/17 update directed wound care to the resident's left elbow skin tear, offer the resident a bigger room, therapy to screen for lift safety and resident education. The care plan directed staff competency checks for lift use. The 9/20/16 update revealed a skin tear to the resident's right elbow. The care plan directed staff to use a sit to stand lift with 2 staff, and to use a commode for toileting the resident. Further review of the care plan revealed no revision regarding geri sleeves (to protect the upper extremities from abrasions, bruises, snags and tears), as recommended in the undated therapy evaluation after the resident received skin tears on 2 separate occasions. The 9/16/16 investigation of a skin tear, at 8:50 PM, revealed staff transferred the resident with the sit to stand lift. The resident's left elbow was inside the sling and when staff attempted to move the arm out of the sling, the resident sustained [REDACTED]. The investigation indicated staff notified the physician and family the next day, updated the care plan with wound care, and therapy demonstrated proper lift use for the aide involved. The 9/21/16 incident investigation revealed staff found a skin tear on the resident's right forearm, no measurements listed, and the resident reported he/she hit it on the doorframe when staff helped him/her to the bathroom. The facility notified the physician and family, offered the resident a different room with a wider bathroom door, but the resident refused. The investigation indicated therapy staff were to educate the resident on lift safety and the care plan update revealed therapy was to screen the resident for lift safety and provide resident education. The undated therapy referral form revealed the resident would benefit from padded sleeves to protect from bumping walls and etc., and would benefit for using the commode instead of the bathroom. The form revealed the resident stated I am not using that, I want to go in the bathroom. The resident's family member agreed with him/her, and staff provided lift safety and resident education. Review of the nurse's notes revealed no further education provided to the resident or his/her family member regarding the use of the commode and other safety measures. On 10/11/16 at 3:21 PM, observation revealed the resident sat in his/her wheelchair in his/her room, with the call light in his/her lap. The resident wore thick geri sleeves and stated he/she also wore the sleeves at night. The resident stated he/she hit his/her arm on the bathroom door frame and sustained a big skin tear. He/She stated staff were coming to get him/her for a shower. On 10/11/16 at 4:27 PM, observation revealed the resident's family member activated the call light because the resident wanted to use the bathroom and staff answered within a minute, but told him/her he/she had to find another staff to assist. Continued observation revealed the resident sat in his/her wheelchair with a short sleeved blouse on and no geri sleeves. Nurse Aides J and AA used the sit to stand lift, lifted the resident's feet and placed them on the stand, placed the lift belt, and the resident gripped the handles of the lift. Further observation revealed staff instructed the resident to pull in his/her elbows, but the resident did not move them and the staff failed to notice the resident was not wearing the geri sleeves. When going through the bathroom door, the resident's right elbow hit the door frame and left a blood smear. Staff immediately activated the call light for the nurse to come. At 4:37 PM, Nurse BB responded and noted the resident's right elbow had 2 skin tears, approximately 2 (cm) centimeters by 2 cm, and 1 cm by 1.5 cm. Nurse BB stated the resident received Coumadin (a blood thinner) daily. Nurse BB cleansed the wound with wound cleanser, applied steri strips (Skin closure secures, closes and supports small cuts and wounds), and asked the resident's pain level. The resident stated it did not hurt anymore, but was level 5 when it happened. On 10/12/16 at 5:40 AM, observation revealed the resident in a recliner watching TV. The resident stated he/she had pushed the call light but no staff had come yet. Observation revealed the call light was not on at this time, so he/she pushed it and the light came on. At 6:02 AM, Nurse Aides F and CC answered the resident's call light and used the sit to stand lift to transfer him/her to the toilet in the bathroom. The resident wore a thick geri sleeve on his/her left arm, but none on his/her right arm. He/she wore a short sleeved shirt. The aides provided cares and when asked why the resident only had one sleeve on, the aides said the other one got soiled. When surveyor pointed to the sleeve on the bedside table, they said oh and put it on the resident. On 10/6/16 at 1:12 PM, Nurse Aide DD stated the resident required 2 staff with a sit to stand lift for transfers and had sustained a skin tear while being transferred with the lift. He/she stated the aides need more training on the lift and to slow down and be careful. On 10/12/16 at 113 PM, Physician EE stated the resident had fragile skin and if staff ensured he/she wore geri sleeves, that would help protect his/her skin. On 10/12/16 at 2:20 PM, Administrative Nurse E stated the resident had refused to use the bedside commode or to wear the geri sleeve last night due to not wanting to get it bloody. Administrative Staff E verified staff should offer to put the sleeve on the resident before transfers and stated he/she changed the care plan yesterday (10/11/16) to read: sit to stand lift with 2 staff, the resident refused to use the commode. On 10/13/16 at 7:28 AM, Nurse N stated the geri sleeves were a nursing intervention staff started and nurses are supposed to update the care plan when they start new interventions. Nurse N stated staff are to ensure the sleeves are on at all times, and if soiled, staff should get new ones from the storeroom. On 10/13/16 at 1:42 PM, Administrative Nurse E stated staff and new hires are oriented to use the lifts, but the resident and his/her family member refused to use the equipment suggested for the resident's safety. Administrative Nurse E verified the facility did not document the education given the resident regarding safety. The facility's 9/2013 policy for skin tears instructed staff to assess the wound and surrounding skin, clean and dress the wound, and complete an investigation of the cause. The policy further directed staff to document any complications (bleeding, redness, drainage, swelling or pain), interventions implemented or modified to prevent additional abrasions, and to complete a Report of Incident/Accident. The facility failed to ensure staff used available interventions to prevent further skin tears to Resident #27's arms during transfers. This deficient practice placed the resident at risk to sustain further skin tears.

The facility had a census of 70 residents. The sample included 3 residents reviewed for elopement. Based on observation, interview and record review, the facility failed to ensure appropriate monitoring and supervision for 1 of 3 residents at risk for falls, who was found by staff outside, alone, and disoriented. Staff lowered the resident to the ground. Resident #1 had an acute physical status change, was left unsupervised by staff, and left the facility without the staff's knowledge which placed the resident in immediate jeopardy. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 3/15/16, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status of 11. The assessment indicated the resident had adequate vision with glasses, no behaviors or wandering, and required extensive staff assistance with transfers and walking, had unsteady balance, only able to re-balance with assistance, and had no (ROM) Range of Motion impairment. The assessment revealed the resident used a walker, had a history of [REDACTED]. The 3/8/16 care plan for falls indicated the resident had a history of [REDACTED]. The 3/18/16 care plan update directed staff to provide a personal alarm or pressure pad alarm, and perform 15 minute visual checks on the resident. The 3/18/16 care plan update for elopement risk directed staff to complete a wandering/elopement risk assessment per facility protocol, monitor the resident's location closely, and provide verbal cues and redirection as needed. The care plan further directed staff to review the resident's medication as needed, and report to the charge nurse any combative behavior or disorientation. The 3/18/16 care plan update indicated risk for elopement increases with low blood sugar, personal or pressure alarms at all times, and 15 minute visual checks. The 3/18/16 at 6:00 PM, nurse's note indicated the resident's blood sugar at 6:00 PM was 36 and the nurse provided a health shake and administered a glucose tablet. The note indicated the resident was alert and anxious at this time. The note indicated the nurse contacted the physician at 6:02 PM. The physician directed the nurse to re-check the blood sugar in 30 minutes. The note indicated the blood sugar at 6:25 PM was still 36 and the nurse administered an instant glucose gel to the resident. The note stated, at this time, the resident had a decreased level of consciousness and was combative with staff. The nurse notified the physician, at 6:27 PM, of the blood sugar of 36 and the physician directed staff to test the blood sugar testing device on him/herself. The note indicated the nurse's blood sugar was 76 and the physician directed the nurse to re-check the resident's blood sugar in 45 minutes. The note stated, at 6:50 PM, the nurse aide notified the nurse he/she was unable to locate the resident. The door alarm on the southeast/north hall exit was sounding and the nurse sent the nurse aide outside to look for the resident. The nurse went to the south hall to notify the other staff about the missing resident and saw the resident standing outside on the sidewalk. A nurse aide was the first to reach the resident and lowered him/her to the ground when the resident started to fall. The note stated the resident had no injury from the fall, but continued to be combative and disoriented. Staff assisted the resident into a wheelchair, then transferred him/her to the ground as he/she continued to be combative and increasingly aggressive. At 7:23 PM, staff contacted (EMS) Emergency Medical Services and the physician, who directed the nurse to administer glucagon (a peptide hormone that works to raise the concentration of glucose in the bloodstream.) (IM) intramuscular injection. At 7:27 PM, EMS arrived and obtained a blood sugar of 56, from the resident. The resident's family arrived at 7:50 PM. The re-check of the resident's blood sugar at 7:55 PM was 85, and the nurse notified the physician the resident was having dry heaves (repetitive involuntary throwing up that is not accompanied by vomit). The physician ordered Zofran (anti-nausea medication) 4 (mg) milligram, and to call him/her if that did not help. The note indicated the resident was still disoriented but less combative. The nurse notified the physician the Zofran was ineffective and he/she ordered Phenergan (anti-nausea medication), 25 mg, rectally. The 3/30/16 notarized statement by Nurse Aide C revealed the following: Nurse Aide C reported the resident had increased confusion and he/she notified the nurse and served the resident a glass of orange juice after the nurse told him/her the resident's blood sugar was low. The statement indicated the nurse told Nurse Aide C to check the resident every 15 minutes. He/she assisted the resident to bed while the nurse called the physician. Nurse Aide C stated the nurse administered 2 glucose tabs and then went to the main dining room. The statement indicated Nurse Aide C assisted another resident on the same hall and when he/she went back to check on Resident #1, he/she was gone. Nurse Aide C notified the nurse and they did a room to room search. The statement indicated a visitor saw the resident outside and informed staff. Nurse Aide C reported when he/she approached the resident, he/she became combative, so he/she grabbed the resident to prevent him/her from falling. The statement indicated the resident lost his/her balance and fell , landing on the staff, then continued to be combative so the aide went inside the facility to get a wheelchair and more help. Nurse Aide C reported the resident was so combative, staff lowered him/her to the ground again and staff brought blankets to cover the resident. The historic weather data, from the wunderground website, indicated on 3/18/16 the weather at 6:35 PM, was 42.8 degrees, wind chill of 36.6, wind speed of 11.5 (mph) miles per hour, with a clear sky. At 7:35 PM, the temperature was 39.2, wind chill was 33, wind speed 9.2 mph, and the sky partly cloudy. The EMS report and the fall documentation lacked information regarding resident's body temperature after potentially being outside for 30 minutes. On 3/30/16 at 8:50 AM, observation revealed the resident seated in the north dining/living area with gripper socks, well-fitting clothing, and eyeglasses on. Further observation revealed Nurse Aide C assisted the resident to ambulate, with a gait belt, and walker, to his/her room. Nurse Aide C placed the pressure pad alarm on the bed and had the resident sit on it. Nurse Aide C also activated a motion sensor on the floor. On 3/30/16 at 8:50 AM, the resident stated the staff wanted to know if he/she was up walking around, and stated the alarms were used prior to his/her elopement and fall incident. The resident stated his/her falls are due to being in a hurry. On 3/30/16 at 1:06 PM, Nurse Aide C stated the resident used a walker to ambulate and is steady except when he/she first stood up. Nurse Aide C stated he/she assisted another resident to bed and had not observed the resident for 15 minutes. The nurse directed him/her to check the resident every 15 minutes, but did not tell him/her to stay with the resident. Nurse Aide C stated he/she noted the northeast exit door light was blinking so he/she checked the exit door and no one was out there. Nurse Aide C stated Nurse D assisted to check all the rooms for the resident, and when they did not find the resident, they checked the other halls. At that time, about 15 minutes after they started looking for the resident, a family member notified staff a resident was outside on the south sidewalk. Nurse Aide C stated he/she saw the resident outside on the side walk, caught up to the resident and the resident started swinging at him/her. Nurse Aide C stated the resident was unsteady, had no walker or cane, was standing on the edge of a slope, then he/she lost his/her balance, and the staff fell with him/her. Nurse Aide C stated the resident continued to fight, kicking the 4 staff assisting at that time. On 3/30/16 at 1:26 PM, Nurse Aide C demonstrated where the resident was found outside and where he/she went from there. Observation revealed the staff found the resident on a sidewalk on the south side of the building that goes west from the front exit, toward highway 96 (speed limit 40 mph). According to Nurse Aide C, the resident ambulated to the southwest corner of the building and left the sidewalk when he/she saw the staff. Nurse Aide C stated the resident was standing on the edge of a slope of the highway ditch, approximately 50 feet from the highway, when staff reached him/her and assisted him/her to the ground. On 3/31/16 at 5:05 PM, Medication Aide G stated he/she was administering medications on the west hall when the staff where looking for the resident. Medication Aide G stated a visitor informed staff the resident was outside, in front of the building. On 3/31/16 at 8:05 AM, Nurse D stated at 6:00 PM, he/she gave the resident a house shake and glucose tab for a blood sugar of 36. Nurse D stated he/she told the aide to check the resident every 15 minutes, and then he/she called the physician. Nurse D stated he/she was in and out of other residents' rooms on the same hall and at 6:30 PM, he/she re-checked the resident's blood sugar, which was still 36, and observed the resident to be slightly diaphoretic (sweaty) and lethargic (drowsy). Nurse D stated, at 6:50 PM, the aide notified him/her the resident was missing and they looked inside the facility for him/her. Nurse D stated the alarm for the east door sounded and the aide went out to look for the resident. Nurse D stated he/she notified other staff and then saw the resident outside, walking west on the sidewalk, toward the highway. The resident walked at a moderate pace, without his/her walker, stepped off the side walk and lost his/her balance. Nurse D stated staff assisted the resident to the ground. Nurse D stated the weather was fairly cold and the resident still combative, so staff called 911 for more assistance. Nurse D stated another nurse stayed outside with the resident while he/she notified the physician and obtained an order for [REDACTED]. Nurse D verified the resident required a walker and was a fall risk due to falls at home. On 3/31/16 at 8:44 AM, Nurse E stated the resident a fall risk, but was not considered an elopement risk prior to 3/18/16. On 3/31/16 at 4:00 PM, Administrative Nurse A verified the nurse should have continued close observation of the resident, who continued to have a very low blood sugar and was displaying a decreased level of consciousness. Administrative Nurse A verified the staff last observed the resident at 6:30 PM, and did not find him/her until 6:57 PM, outside. (27 minutes later) Review of the facility's exit monitoring checks revealed the facility had not documented if all 12 of the exit doors to the outside were checked to ensure the alarms worked. The Door Alarm Maintenance checklist included only the following 6 doors: unit/north, north, front, southwest, and southeast. On 4/12/16 at 8:05 PM, an unannounced visit to the facility revealed all exit door alarms working and staff answered the alarms in a timely manner. On 4/12/16 at 8:30 PM, Administrative Nurse A verified staff did not document each exit check individually. The facility's 9/21/02 wandering and Elopement policy stated all personnel are to report any resident suspected of being missing to the charge nurse as soon as possible. Staff should determine if the resident is out on leave, direct a search of the building and premises, including all areas of the building if the resident is not located, the charge nurse will direct a search of the facility grounds, take a head count and notify the administrator and director of nursing. The facility failed to provide adequate supervision for Resident #1, who was confused, experiencing acute medical problems, left the facility without staff knowledge, and fell outside on a cold evening, which placed the resident in immediate jeopardy. This deficiency is determined to be past non-compliance when the facility in-serviced the staff, on 3/22/16, regarding dementia, types, causes and behavioral symptoms, wandering behaviors including identification of resident specific triggers for wandering and elopement, elopement risk factors and developing and implementing an effective interdisciplinary plan of care for the resident at risk for wandering / elopement.

The facility had a census of 74 residents. The sample included 10 residents. Based on observation, interview and record review the facility failed to provide care and treatment to prevent the development of pressure ulcers and to promote healing, for 4 of 5 residents reviewed for facility acquired pressure ulcers. (#4, #1, #6, #2) Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/30/14, indicated the resident had severe cognitive impairment with short and long term memory problems and moderately impaired cognitive skills for decision making with inattention. The MDS indicated the resident required total assistance from 2 staff for bed mobility, transfers, dressing, toileting, and bathing, and always had bowel and bladder incontinence. The MDS indicated the resident had a feeding tube and had 1 stage 2 (partial thickness skin loss involving dermis presenting as a shallow open ulcer with a red/pink wound bed) pressure ulcer, and a healed stage 4 (full thickness loss, with exposed bones) pressure ulcer, and moisture related skin damage. The MDS indicated the resident had a pressure reducing device for the chair and bed, on a repositioning program, nutrition or hydration interventions and pressure ulcer care. The 10/27/13 pressure ulcer (CAA) Care Area Assessment indicated the resident had 2 pressure ulcers with signs of healing, used a pressure reducing mattress, was dependent on the staff for mobility, and the staff checked the resident for incontinence every 2 hours. The 7/30/14 care plan indicated the resident was dependent on the staff for all (ADLs) Activities of Daily Living, and instructed the staff to provide assistance of 2 staff for toileting every 2 hours, and to reposition him/her every 2 hours. The care plan further indicated the resident used a pressure reducing mattress and cushion in his/her wheelchair, used heel protectors, and directed staff to place a pillow in between the resident's knees. The care plan indicated the resident had a re-opened wound, and the staff planned to change and reposition the resident more frequently. The 6/27/14 physician's orders [REDACTED]. The 7/16/14 Braden skin assessment tool, indicated the resident scored a 14, which indicated the resident was high risk for pressure ulcer development. The 7/16/14 physician's orders [REDACTED]. The 7/28/14 fax communication to the physician indicated the facility notified the physician the resident's right hip had a scant (very small) amount of drainage and his/her skin was red around the wound and sore. The staff informed the physician the wound was cleansed with wound cleanser and an allevyn dressing applied, and changed every 7 days. On 7/29/14 the physician agreed to the treatment with the additional order to update in 1 week or sooner if his/her condition worsened. The August 2014 weekly skin assessments revealed the following: 8/5/14, no new areas of redness or skin breakdown noted at this time, previous wounds. 8/12/14, continues to have wounds on bilateral hips and a scratch over his/her left eye. 8/19/14, open area to bilateral hips, bruises to his/her knees, and a scratch noted to the resident's bottom. The assessment indicated there are no new skin issues. 8/26/14, the assessment indicated the resident had open areas to his/her bilateral hips, and the staff changed the dressing, and the resident continued to have an abrasion on his/her bottom, with the dressing intact. The wound healing records revealed the following: Right buttocks: 6/26/14 - 2 (cm) centimeters by 3 cm, with no odor or drainage. 7/1/14 - 2.9 cm by 2 cm, with no odor or drainage. 7/10/14 - 1 cm by 0.5 cm, with no odor or drainage. 7/16/14 - 1.5 cm by 1.6 cm, and depth of 0.7 cm, with no odor and a moderate amount of serous-sanguineous (semi-thick reddish drainage) drainage. 7/23/14 - 1.8 cm by 1.7 cm, and depth of 0.7 cm, with no odor and a moderate amount of serous (clear) drainage. 7/30/14 - 2.5 cm by 1.5 cm, and depth of 0.7 cm, with no odor and a small amount of serous drainage. 8/6/14 - 1.5 cm by 1.5 cm, and depth of 0.7 cm, with no odor and a scant amount of serous drainage. 8/13/14 - 1.0 cm by 1.0 cm, and depth of 0.5 cm, with no odor and a small amount of serous drainage. 8/20/14 - 1.3 cm by 0.7 cm, and depth of 0.5 cm, with no odor and serous drainage. 8/27/14 - 1.0 cm by 0.5 cm, and depth of 0.25 cm, with no odor and serous drainage. 9/3/14 - 1.0 cm by 0.5 cm, and depth of 1.0 cm, with no odor and serous drainage. The wound was staged at a stage 2, with response to treatment deteriorated. Left hip: 7/28/14 the wound measurements were not documented, with no odor and serous drainage. The wound was staged a stage 2. 7/30/14 - 0.5 cm by 0.1 cm, with no odor and a scant amount of serous drainage. The wound was stage at a stage 2, with response to treatment deteriorated. 8/6/14 - 0.5 cm by 0.1 cm, with no odor and serous drainage. The wound was staged at a stage 2. 8/13/14 - 0.5 cm by 0.1 cm, with no odor and serous drainage. The wound was staged at a stage 2. 8/28/14 - 0.7 cm by 0.3 cm, with no odor and moderate amount of serous drainage. The wound was staged at a stage 2, with response to treatment deteriorated. 9/3/14 - 1.8 cm by 0.2 cm, with 0.5 cm in depth, with no odor and scant amount of serous drainage. The wound was staged at a stage 2, with response to treatment deteriorated. The 9/6/14 hospital (H&P) history and physical indicated the resident had a large deep decubitus that did not have exudate (drainage), [DIAGNOSES REDACTED] (redness) surrounding it, and did not appear infected. The H&P further indicated the resident had a small stage 1 decubitus developed at the base of his/her sacrum and skin breakdown on the right side as well between the 2 areas. The 9/7/14 hospital operative report indicated the resident had a debridement (removal of dead tissue) of the coccyx (bottom) and left hip decubitus(pressure) ulcers. The report indicated the resident received 24 hours of antibiotics before going to the operating room to have a limited debridement of his/her ulcers and to define if the resident had underlying osteo[DIAGNOSES REDACTED] (local or generalized infection of the bone and bone marrow) in his/her wounds. The operative procedure performed was a limited debridement and both ulcers were found to be down to the level of the bone consistent with osteo[DIAGNOSES REDACTED]. On 9/16/14 at 10:15 AM, Physician N stated the resident had 2 pressure ulcers which were related to positioning and suspected the staff had not repositioned the resident in a timely manner. Physician N verified the pressure ulcers were down to the bone, and verified the staff had failed to provide optimal wound care. Physician N stated he/she removed some gauze from the resident's wound, which was hard, so he/she was unsure as to how often the staff had changed the resident's dressing. On 9/17/14 at 5:50 PM, Nurse M stated about a week before the resident went to the hospital, he/she had redressed the resident's wounds. Nurse M stated the wound on the resident's bottom looked "pretty bad", and verified he/she had not documented the assessment anywhere in the medical record. On 9/22/14 at 4:02 PM, Administrative Nurse A stated he/she had seen the resident's wounds a week prior to his/her hospital admission and had felt they looked good and had nice pink tissue. Administrative Nurse A stated the right buttocks wound was a re-opened stage 4, which had only been open for a couple of months. Administrative Nurse A verified if staff identified the wounds had deteriorated he/she expected for the staff to document the assessment and notify the physician. Administrative Nurse A further verified wounds can change in a week. On 9/29/14 at 4:05 PM, Physician Office Nurse O verified the facility had not notified the physician of the changes of the resident's wound he/she had presented to the hospital with, and would had been expected to had been notified so treatment could had been changed. The facility's 4/2008 Skin and Wound Care Program policy indicated a skin assessment the staff complete immediately before the resident is transferred to another facility, at the time of death, or upon discharge home. The facility failed to provide treatment to prevent Resident #1's pressure ulcers from opening and healing. - Resident #4's annual (MDS) Minimum Data Set assessment, dated 7/3/14, indicated the resident had severe cognitive impairment with short and long term memory problems with moderately impaired decision making skills. The MDS indicated the resident required total assistance from 2 staff for bed mobility, transfers, toilet use, bathing, and required total assistance from 1 staff for eating and personal hygiene. The MDS further indicated the resident had frequent bowel and bladder incontinence, had 1 stage 2 (superficial open sore in the upper layer of skin) pressure ulcer with granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) tissue, used a pressure reducing device for the chair and bed, and received pressure ulcer care. The 7/3/14 pressure ulcer (CAA) Care Area Assessment indicated the resident had a stage 2 pressure ulcer on his/her right foot and was dependent on the staff with bed mobility and transfers. The CAA further indicated the resident was at risk for further pressure ulcers due to incontinence and mobility dependence. The 7/2/14 care plan instructed the staff to perform a weekly skin assessment by a licensed nurse, reposition the resident every 2 hours, provide moon boots (pressure reducing boots) to his/her feet at all times, and to be mindful of extremity placement during cares and transfers. The care plan directed the staff to place a pillow between the resident's legs when he/she was in bed, provide treatment as ordered by the physician, and to notify the resident's physician if no improvement was noted in a 2 week period or if the wound had declined. The 7/2/14 Braden skin assessment revealed a score of 14, which indicated the resident had a moderate risk for pressure ulcer development. The 7/8/14 at 11:00 AM, nurse's note indicated the resident's wound to his/her right great toe had reopened and measured 2 (cm) centimeters by 2 cm. The note indicated the staff cleansed the area the wound cleanser and applied an adhesive allevyn (layer of soft foam) dressing. The 7/11/14 physician's orders [REDACTED]. The physician directed the staff to notify him/her of any increased sore or worsening of signs and symptoms, and to change the resident's position frequently. The 7/11/14 physician progress notes [REDACTED]. The note indicated the resident was severely contracted (abnormal permanent fixation of a joint), unable to vocalize his/her complaints or feelings, used a wheelchair, and relied on the staff for total care. The physician noted upon assessment, the resident's right great toe had a small open area that measured over 1.0 cm and was less than 0.5 cm deep. The note indicated the area had no drainage, had no eschar (dead tissue) and the physician ordered treatment of [REDACTED]. The 7/25/14 physician's orders [REDACTED]. The 7/28/14 physician progress notes [REDACTED]. On 9/16/14 at 2:52 PM, observation revealed the resident lying in bed with his/her eyes closed with moon boots on his/her feet and no pillow placed in between his/her legs as directed by the plan of care. On 9/17/14 at 11:15 AM, observation revealed the resident seated in his/her recliner and Administrative Staff A in the room to provide a dressing change. Observation revealed Administrative Staff A removed the resident's boot, sock and old dressing from his/her right foot. Administrative Staff A cleansed the resident's wound with wound cleanser, which removed dry, flakey skin from the resident's wound, and revealed a small area, which appeared as a hole in the resident's toe. The area was not discolored and measured 0.2 cm by 0.2 cm. Continued observation of the resident's toe revealed a small crack to the right of the pressure ulcer which had a small amount of sanguineous (bloody) drainage filling the crack. Administrative Staff A verified the cracked draining area was new, and applied gauze to the resident's entire foot, and replaced his/her sock and moon boot. Administrative Staff A obtained no measurement of the newly acquired area. On 9/17/14 at 1:00 PM, observation revealed the resident seated in his/her wheelchair, propelled by a family member. Continued observation revealed the resident's feet had moon boots to his/her right foot, no foot pedals applied to the wheelchair, and his/her feet drug along the floor. On 9/17/14 at 1:55 PM, observation revealed the resident lying in bed on his/her left side. Continued observation revealed no moon boots on the resident's feet, or a pillow in between his/her legs as directed by the plan of care, and his/her feet covered in socks and his/her right toe rested directly on the bed. Continuous observation revealed the resident remained in the same position until 4:22 PM. (2 hours and 27 minutes) At 4:22 PM, observation revealed Nurse Aide B and Nurse Aide C entered the resident's room with a mechanical lift. Continued observation revealed Nurse Aide C checked the resident's brief which revealed the resident had bowel and bladder incontinence soaked through to his/her bed pad. The resident's left side was pink and had a small red area on his/her left ankle. On 9/18/14 at 8:09 AM, observation revealed the resident seated in his/her wheelchair, with moon boots applied to both of his/her feet and his/her legs crossed at the ankle. Continued observation revealed Nurse D entered the resident's room to do a dressing change. Observation revealed Nurse D removed the resident's dressing and touched the open area on the resident's right toe without gloves on. Nurse D did not uncross the resident's legs, or visually assess the area of the maceration (open area). Observation revealed, upon the surveyor's request, Nurse D assessed the resident's newly aquired area observed the previous day just to the right of the other pressure ulcer. Observation revealed the area was purple with no drainage and Nurse D verified he/she had not seen the area previously. On 9/17/14 at 4:30 PM, Nurse Aide B stated the resident use to have his/her moon boots on all the time, but the staff changed his/her plan of care. Nurse Aide B further stated the previous shift did not notify him/her of how long the resident had been lying in the current position and the resident was to be repositioned every 2 hours. On 9/17/14 at 4:36 PM, Nurse E verified the staff are to place moon boots on the resident's feet at all times. Nurse E stated without the boots on the resident's toe rested on the bed and created pressure. On 9/22/14 at 4:02 PM, Administrative Nurse A verified the staff should put the resident's moon boots on the resident's feet at all times and he/she expected the staff to reposition the resident at least every 2 hours. Administrative Nurse A further verified the resident had acquired the new area and the medical record had no documentation of the new area observed on 9/17/14, four days ago, and further verified no documentation staff notified the physician as directed in his/her order. Administrative Nurse A verified the resident's pressure area closed and reopened several times over the past year, and the staff planned to monitor the area. The facility's 8/2009 Dressing, Dry/ Clean policy instructed the staff to position the resident and adjust his/her clothing to provide access to the affected area during a dressing change, and to assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage. The facility's 4/2008 Skin and Wound Care Program policy instructed the staff that for a resident who was at risk for skin breakdown, then staff implemented a turning and repositioning program and repositioned the at risk resident at least every 2 hours or per his/her individual needs. The facility failed to follow Resident #4's care plan to prevent his/her pressure ulcer from re opening or to prevent the development of a new area, failed to provide timely repositioning and to notify the physician as outlined in his/her order. - Resident #2's significant change (MDS) Minimum Data Set assessment, dated 8/7/14, indicated the resident had severe cognitive impairment moderately impaired decision making skills with inattention, and exhibited disorganized thinking behaviors. The MDS indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, toilet use and bathing and required extensive assistance from 1 staff for personal hygiene, eating, and dressing. The MDS further indicated the resident had a less than 6 month life expectancy, received hospice services, was at risk for pressure ulcers, had no skin problems, on a reposition program, and used pressure reducing devices for the chair and bed. The 8/7/14 pressure ulcer (CAA) Care Area Assessment indicated the resident had a pressure reducing wheelchair cushion and mattress, staff repositioned the resident every 2 hours and as needed, and the resident was at risk for pressure ulcers due to incontinence and assistance needed with mobility. The 8/7/14 care plan instructed the staff to complete a Braden skin assessment per protocol on the resident, for a licensed nurse to perform a weekly skin assessment, and directed the staff to reposition the resident every 2 hours. The 8/13/14 care plan update instructed the staff to apply pressure reducing boots to the resident's feet at all times. The 8/14/14 care plan update instructed the staff to frequently change the resident's position, and use decubitus (pressure ulcer) precautions. The 9/16/14 care plan update instructed the staff to place a pillow in between the resident's knees. The 7/2/14 Braden skin assessment indicated a score of 14 which placed the resident at moderate risk for the development of a pressure sore. The 8/14/14 fax communication to the physician revealed the staff notified the physician the resident had developed a stage 2 (partial thickness skin loss involving dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough) pressure ulcer on his/her left malleolus (part of the ankle) that measured 1.0 (cm) centimeters by 0.5 cm, less than 0.1 cm in depth with a pink base, no drainage and had pink surrounding tissue. The facility requested an order to cleanse the area with wound cleanser, apply an allevyn (layer of soft foam) dressing every 7 days or until healed, and apply boots to the resident's feet at all times. On 8/14/14, the physician approved the facility's request and added to frequently change the resident's position and to provide decubitus precautions. The 8/25/14 fax communication to the physician revealed the staff noted an abrasion to the left side of the resident's mid back which measured 3 cm by 2 cm. The fax communication further revealed the staff informed the physician they had cleansed the abrasion and covered the area with an allevyn dressing and planned to change the dressing every 7 days and as needed. On 8/25/14, the physician approved the treatment and further directed the staff to monitor the area for signs of infection. The 9/4/14 (RD) Registered Dietician note indicated the RD recommended the resident receive 60 (ml) milliliters of Med Pass (a high protein supplement) 4 times a day, until the wound healed. (The medical record revealed no documentation the staff notified the physician of the RD's recommendation) The 9/10/14 fax communication to the physician revealed the staff notified the physician the resident had a non blanching (areas of damaged tissue that do not lose color or fade when pressed) on his/her left hip, and the skin was intact. The fax indicated the staff applied an allevyn dressing for skin protection, requested to change the dressing every 7 days or as needed, until the area healed. On 9/10/14, the physician noted and approved the facility's request. The 9/11/14 fax communication to the physician revealed the staff notified the physician the wound on the left side of the resident's mid back measured 6.0 cm by 4.0 cm with unknown depth. The staff noted the abrasion was now red, swollen and had necrotic (dead) tissue. The staff requested to change the resident's treatment and to cleanse the abrasion with wound cleanser, apply a thin layer of Santyl (ointment used to remove dead tissue) ointment, cover with gauze and apply a cover site (padded dressing) daily and as needed until debrided (dead tissue removed). On 9/11/14, the physician approved the facility's request. The 9/16/14 at 5:00 AM, nurse's note indicated the staff reported the resident had an open area on his/her left inner knee which measured 2 cm by 1 cm, and an open area on his/her right inner knee which measured 3 cm by 2 cm. The note indicated the staff cleansed the open areas with wound cleanser, patted dry, and applied an allevyn dressing and planned to change every 7 days until healed. The note continued to indicate the staff notified the physician by fax implemented a new intervention to keep a pillow in between the resident's knees to reduce pressure. Review of the pressure ulcer healing record documentation revealed the following measurements on the resident's left malleolus (ankle): 8/13/14 - 1.0 cm by 0.5 cm, no odor or drainage and staged at a stage 2. 8/20/14 - 1.0 cm by 1.0 cm, no odor with serous (clear) drainage and staged at a stage 2. 8/27/14 - 1.5 cm by 1.5 cm, no odor with serous drainage, slough (dead tissue, usually cream or yellow in color) in the wound bed, and staged at a stage 2. 9/3/14 - 1.0 cm by 1.0 cm, no odor with serous drainage, slough in the wound bed, and staged at a stage 2. 9/10/14 - 2.0 cm by 2.0 cm, no odor with serous-sanguineous (semi-thick reddish drainage) drainage, 100% slough in the wound bed, and documented as un-stageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue)). Review of the pressure ulcer healing record documentation revealed the following measurements on of the resident's abrasion on the left side of his/her mid back: 8/25/14 - 3.0 cm by 2.0 cm, no odor or drainage. 8/27/14 - 4.0 cm by 2.0 cm, no odor or drainage, and had black/brown eschar (dead tissue) present. 9/3/14 - 2.0 by 2.0, no odor or drainage, and had slough present. 9/10/14 - 4.0 cm by 4.0 cm, had a slight odor and moderate serous-sanguineous drainage, with slough and black/brown eschar present in the wound bed. Review of the pressure ulcer healing record documentation revealed the following measurement on the resident's left hip: 9/10/14 - 1.5 cm by 1.5 cm, with no odor or drainage, and staged at a stage 2. Review of the pressure ulcer healing record documentation revealed the following measurement on the resident's left inner knee: 9/16/14 - 2.0 cm by 1.0 cm, with no odor or drainage and staged at a stage 2. Review of the pressure ulcer healing record documentation revealed the following measurement on the resident's right inner knee: 9/16/14 - 3.0 by 2.0, with no odor or drainage and staged at a stage 2. On 9/16/14 at 8:32 AM, observation revealed the resident, seated in his/her wheelchair, in his/her room with his/her eyes closed. Continued observation revealed a tray on the bedside table in front of him/her with cream of wheat and a banana. Continuous observation revealed at 8:38 AM, Nurse Aide F entered the resident's room and assisted the resident to take a few bites of his/her morning meal. At 8:45 AM, observation revealed Nurse Aide F on his/her cell phone in the dining room. At 8:49 AM, observation revealed the resident's meal tray on the soiled utility cart, with only a few bites taken, ready to be returned to the kitchen. Frequent observation of the resident's morning meal revealed no encouragement, education or offer for substitution by staff. On 9/16/14 at 11:00 AM, observation revealed the resident lying in bed on his/her right side. Continued observation revealed Nurse G at the resident's bedside to perform a dressing change to his/her left mid back. Continued observation revealed Nurse G washed his/her hands, applied gloves, and removed the old dressing, that revealed an area with yellow slough surrounding the wound bed, and the wound bed had brown/ black eschar. Continued observation revealed Nurse G changed his/her gloves, cleansed the area with wound cleanser, applied santyl ointment to his/her gloved finger, applied the ointment to resident's wound, and applied an allevyn dressing. On 9/17/14 at 8:37 AM, observation revealed the resident lying on his/her left side in bed and Administrative Nurse A at the resident's bedside to do dressing changes to the resident's pressure areas. Continued observation revealed Administrative Nurse A washed his/her hands, applied gloves, removed the dressing to the resident's left malleolus, which revealed a foul smelling area with red bloody drainage, yellow slough in the wound bed, and the skin surrounding the wound was bright red. Observation revealed Administrative Nurse A cleansed the wound with wound cleanser, and measured the wound at 1.8 cm by 2.0 cm. Nurse A verified the wound had no odor or drainage the previous week. Administrative Nurse A changed his/her gloves, and placed an allevyn dressing over the wound. Continued observation revealed Administrative Nurse A removed a dressing over the resident's right hip, which revealed 2 light tan open areas that measured 1.5 cm by 2.0 cm (an increase in size since 9/10/14). Observation revealed Administrative Nurse A cleansed the area with wound cleanser and placed an allevyn dressing over the wound. Continued observation revealed Administrative Nurse A removed the dressing from the resident's left mid back, and the old dressing had visible reddish drainage on it. Administrative Nurse A cleansed the area with wound cleanser and measured the wound at 5.5 cm by 3.0 cm (an increase in size since 9/10/14). The resident's wound had yellow slough surrounding the wound bed which had brown/ black eschar surrounded by red with purple discolored tissue. Continued observation revealed Administrative Nurse A changed his/her gloves, applied santyl ointment to the wound bed, with a cotton swab, then covered the area with a padded dressing. Continued observation revealed Administrative Nurse A removed a dressing from the inside of the resident's right knee, which revealed a bright red area, with serous drainage, and slough formation in the wound bed which measured 3.0 cm by 2.2 cm (a slight increase from 9/16/14 measurements). Observation revealed Administrative Nurse A changed his/her gloves, cleansed the area with wound cleanser, and applied an allevyn dressing over the wound. Continued observation revealed Administrative Nurse A removed a dressing from the inside of the resident's left knee which revealed a red area, with the top layer of skin removed, with serous drainage, and white slough at the outer edges, that measured 2 cm by 3.0 cm. Observation revealed Administrative Nurse A changed his/her gloves, cleansed the wound with wound cleanser, and placed an allevyn dressing over the wound. On 9/17/14 at 1:55 PM, observation revealed the resident with his/her eyes closed, lying in bed in his/her room, tilted slightly to the right with a pillow tucked under his/her left side, a pillow in between his/her legs, which are bent at the knee, and his/her right pinky toe rested on the bed hanging out of the moon boots on his/her feet. Continuous observation remained at 2:10 PM, 2:25 PM, 2:40 PM, 2:55 PM, 3:10 PM, 3:25 PM, 3:40 PM, 3:55 PM, 4:10 PM, and 4:25 PM, and at 4:46 PM, observation revealed Nurse Aide B and Nurse Aide C at the resident's bedside, to reposition him/her, per the surveyor's request, for a skin check. Nurse Aide B verified the resident had not been repositioned in 3 hours. Observation of the resident's skin revealed his/her right side to be pink and multiple impressions in his/her skin from wrinkles in the bedding. On 9/17/14 at 6:00 PM, observation revealed the resident seated in his/her wheelchair in his/her room. Continued observation revealed the resident's toes were hanging out of the moon boots on the right side with his/her great toe resting on the floor. Continued observation revealed at 6:15 PM Nurse Aide H delivered the resident's evening meal tray to his/her room, removed the lid from the plate, and covers from his/her beverages, then he/she left the room. Continuous observation from 6:15 PM, revealed the resident's meal remained untouched, his/her eyes stayed closed, and no staff observed in the room to offer him/her encouragement or assistance. At 6:59 PM, Nurse Aide H entered the resident's room, asked if he/she was finished eating and removed the resident's untouched meal tray from his/her room, without offering assistance, an alternate, and/or encouragement to the resident. On 9/18/14 at 12:38 PM, observation revealed the resident lying in bed with his/her eyes closed, and Nurse Aide I entered the room to deliver the resident's noon meal. Continuous observation revealed no staff entered the resident's room to offer encouragement or assistance to the resident with his/her noon meal. Continued observation from 12:38 PM, 12:53 PM, and 1:08 PM, revealed at 1:12 PM (34 minutes later), Nurse Aide I entered the resident's room and began to assist the resident with his/her meal. Continued observation revealed dietary staff in the resident ' s room to take food temperatures, per the surveyor's request, which revealed the pureed meat was 94.8 degrees and the mashed potatoes and gravy was 103 degrees. On 9/16/14 at 11:09 AM, Nurse Aide F stated he/she did not continue to assist the resident his/her morning meal because the resident stated he/she was done. Nurse Aide F further stated lately the staff had to assist the resident with his/her meals and offer encouragement to eat. On 9/17/14 at 7:03 PM, Nurse E verified the staff should offer the resident assistance and encouragement with his/her meal. On 9/18/14 at 8:18 AM, Nurse D stated lately the resident has not wanted to get up and has required assistance to eat in his/her room. Nurse D stated the resident disliked eating in the dining room, in the past, so the staff assisted him/her, with meals, in his/her room. On 9/18/14 at 1:25 PM, Nurse Aide I verified the resident's noon meal had been on his/her bedside table for 40 minutes before he/she could return to assist the resident to eat. Nurse Aide I stated it was okay to serve the resident the food after it had been sitting for over 40 minutes. On 9/18/14 at 10:35 AM, Registered Dietician J verified he/she had recommended Med Pass for the resident to assist with wound healing, and the facility had not notified the resident's physician. Registered Dietician J further verified the resident required extensive assistance with meals and if he/she did not receive assistance and encouragement with his/her meals, it could compromise his/her wound healing and the development of more wounds. On 9/18/14 at 1:35 PM, Registered Dietician J stated 20 minutes after food leaves the kitchen, it is no longer acceptable and should be replaced by staff if a resident had not eaten the food. On 9/22/14 at 4:02 PM, Administrative Nurse A verified the resident's

The facility had a census of 74 residents. The sample included 10 residents. Based on observation, interview, and record review the facility failed to provide appropriate care and services and provide assessment and reassessment for 2 of 4 residents reviewed who required hospitalization for treatment. (#1, #2) Findings included: - Resident #2's annual (MDS) Minimum Data Set assessment, dated 4/15/14, indicated the resident had severe cognitive impairment with long and short term memory problems, moderately impaired decision making skills, inattention, rejection of care and other behaviors not directed toward others. The MDS indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, toilet use, and bathing with frequent bladder incontinence. The 4/15/14 care plan instructed staff to administer oxygen as ordered by the physician, to assess for anxiety, restlessness, shortness of breath, cyanosis (bluish discoloration of the skin), rapid or shallow respirations and to notify the physician if needed. The 6/4/14 physician order [REDACTED]. (normal percentage of oxygen in blood was 90-100%) The 6/26/14 physician's orders [REDACTED]. The 6/27/14 at 1:20 PM, nurse's note indicated the facility received a fax from the physician which stated the resident no longer had a [MEDICAL CONDITION] urinary tract infection, and no longer needed an antibiotic. The physician ordered Methamine (an antibiotic), 1 (gm) gram, twice daily, for UTI [MEDICATION NAME] (prevention). The 6/28/14 at 7:30 AM, nurse's note indicated the resident received a skin tear to his/her left upper calf when 2 (CNA) certified nurse aides transferred him/her from the bed to his/her wheelchair. The CNAs reported the resident did not act like him/herself, and he/she did not talk or move as much. The note indicated the resident seemed very sleepy, and did not eat any breakfast. The note further indicated the resident's vital signs included the following: Blood pressure - 130/66 (optimal 120/80) Pulse - 94 (optimal 60-100) Respirations - 14 (optimal 12-15) Oxygen saturation - 98% Temperature - 99 (baseline 98.3) The medical record lacked documentation the staff completed any further physical assessment or reassessment of the resident's change in condition. The 6/28/14 at 2:00 PM nurse's note indicated the resident was in a deep sleep and his/her respirations at 12 per minute, and he/she did not wake up to eat lunch. The note further indicated the nurse had another nurse check on the resident although the documentation revealed no assessment of the resident at this time. The medical record lacked documentation the staff completed a physical assessment or reassessment of the resident's status, from 7:30 AM to 2:00 PM (6 ? hours later). The 6/28/14 3:10 PM nurse's note indicated the resident was mouth breathing and unable to arouse, warm and clammy to touch, and his/her lung sounds were coarse with rhonchi (coarse rattling respiratory sound somewhat like snoring). The note further indicated the resident's vital signs were the following: Blood pressure - 89/52 Pulse 110 - Respirations - 9 Temperature - 97.1 Oxygen saturation - 44% The note indicated the staff applied oxygen at 2 liters by nasal cannula and the resident's oxygen saturations increased to 91%. The note further indicated the staff called the physician and received an order to send the resident to the emergency room for evaluation and treatment. The 6/28/14 at 5:50 PM, nurse's note indicated the staff called the hospital to inquire about the resident's status. The hospital indicated the resident admitted with [DIAGNOSES REDACTED]. The 7/11/14 physician's progress note indicated the resident was recently admitted into the hospital related [MEDICAL CONDITION] (systemic infection of the blood), which was related to pneumonia. The 7/11/14 physician's orders [REDACTED]. On 9/16/14 at 7:31 AM, observation revealed the resident seated in his/her wheelchair with his/her oxygen concentrator running, and his/her oxygen cannula in his/her lap. Continued observation revealed the resident had his/her eyes closed. On 9/23/14 at 4:02 PM, Administrative Nurse A verified he/she expected staff to perform a head to toe assessment and reassessment when a resident showed a decline and change of status. Administrative Nurse A stated the facility had identified the concern, and the nurse on that day was a new nurse, and he/she had expected the charge nurse to go down and assess the resident as well. On 9/29/14 at 4:52 PM, Physician P verified he/she changed the resident's pain medication 2 days prior to his/her hospital admission. Physician P stated he/she informed the facility to keep a close eye on him/her and notify him/her with any respiratory depression, so the pain medication could be discontinued. Physician P further stated he/she expected the staff to notify him/her of the changes the resident experienced so he/she could direct the staff to administer [MEDICATION NAME] to reverse the pain medication and the respiratory depression. The facility's 2/2014 Resident Examination and Assessment policy informed the staff the purpose of the assessment was to examine and assess the resident for any abnormalities in health status, which provided a basis for the care plan. The policy instructed the staff to examine and note all of the resident's body systems for abnormalities. The facility failed to assess and reassess Resident #2 after a change in status, which resulted in a hospital admission. - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/30/14, indicated the resident had severe cognitive impairment, moderately impaired decision making skills, and displayed inattention behaviors. The MDS further indicated the resident required total assistance from 2 staff for bed mobility, transfers, dressing, toilet use and bathing, had a feeding tube and received insulin injections. The 10/27/13 Cognitive Loss dementia (CAA) Care Area Assessment indicated the resident was verbally unable to express him/herself and the staff would develop a care plan to make sure staff anticipated his/her needs. The 7/30/14 care plan instructed staff to assess the resident for anxiety, restlessness, shortness of breath, cyanosis (bluish discoloration of the skin), rapid or shallow respirations and to notify the physician if needed. Review of the Respiratory Flow Sheet indicated the resident's breath sounds were clear on 9/3/14 at 5:00 AM. Continued review of the medical record lacked any further documentation of the resident's lung sounds. The 9/6/14 at 4:30 AM, nurse's note indicated the staff called the on call physician to report the resident had a temperature of 102.8 after Tylenol administration at 12:30 AM for a temperature of 101.3. The note indicated the physician ordered, [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 600 (mg) milligrams, to bring down the resident's fever. Review of the medical record revealed no further documentation of an assessment or reassessment of the resident's status. The 9/6/14 at 6:00 AM, nurse's note indicated the staff called the resident's (DPOA) Durable Power of Attorney (written document executed by a competent adult authorizing another person or a corporation to act on her behalf) and notified him/her the resident was going to the emergency room . Review of the medical record revealed no further documentation of an assessment or reassessment of the resident's status since the documentation at 4:30 AM of the resident's elevated temperature. The 9/6/14 hospital history and physical indicated the resident arrived in the emergency department and his/her eyes were sunken in and his/her mouth was dry. The resident's initial blood pressure was 66/42, heart rate 103 and a low grade temperature. The oxygen saturation reported by the nursing facility was 70% and his/her lungs were coarse with rhonchi. The note indicated the resident presented with dehydration, [MEDICAL CONDITION] (the body or a region of the body is deprived of adequate oxygen supply), and acute [MEDICAL CONDITION] associated with dehydration. The 9/7/14 operative report indicated the resident had constipation, aspiration pneumonia,[MEDICAL CONDITION] (infection in the blood stream), and a defective feeding tube. The report indicated the resident was found to have a mega-rectum and 15 pounds of stool was manually dis-impacted from the resident's colon. On 9/16/14 at 10:15 AM, Physician N stated the resident's feeding tube was coiled, and it was hard to tell how long it had been that way. Physician N stated the resident had acquired aspiration pneumonia, his/her mouth care was atrocious and contributed to the aspiration, his/her teeth were black, and he/she did not eat. Physician N stated it was apparent the resident had not received oral care, and frequent oral care would have helped prevent frequent aspiration. Physician N stated upon physical examination the resident had 3 discreet masses and anyone who had felt the resident's abdomen would have known it was there. On 9/22/14 at 4:02 PM, Administrative Nurse A stated the resident periodically had emesis and the staff documented when it occurred, and if there were problems the staff notified the physician. Administrative Nurse A further verified the staff had assessed the resident's abdomen frequently when checking for placement of the resident's feeding tube, before administration of medications and feedings. Administrative Nurse A stated the resident did have almost daily bowel movements, but staff monitored for emesis (vomiting), that occurred frequently and documented in the medical record for the physician to review. The facility's 2/2014 Resident Examination and Assessment policy informed the staff the purpose of the assessment was to examine and assess the resident for any abnormalities in health status, which provided the basis for the care plan. The policy instructed the staff to examine and note all of the resident's body systems for abnormalities. The facility failed to assess and reassess Resident #1 after a change in status, which resulted in a hospital admission.

The facility had a census of 66 residents. The sample included 4 residents. Based on observation, record review and interview the facility failed to provide necessary care and services, including a thorough assessment and reassessment, after an accident/injury for 1 of the 5 residents reviewed for accidents. (#8) Findings included: - Resident #8's medical record included physician's order [REDACTED]. blood pressure) , diabetes mellitus II (abnormally high levels of blood sugar levels in the blood), and fatigue (weariness, sleepiness drowsiness or exhaustion). The quarterly (MDS) Minimum Data Set assessment, dated 10/06/2014, indicated the resident had severe cognitive impairment with short and long term memory impairment and severely impaired decision making skills. The MDS further indicted the resident required total assistance from two staff for transfers, dressing, toilet use, and had upper extremity range of motion impairment on one side. The MDS indicated the resident had a history of [REDACTED]. The 5/06/2014 fall (CAA) Care Area Assessment indicated the resident was at risk for falls due to his/her, impaired cognition, [MEDICAL CONDITION] drug use and the need for assistance. The 8/06/2014 care plan indicated the resident was dependent on staff for (ADLs) Activities of Daily Living, required extensive assistance of two staff for bed mobility, check and change, and bathing. The care plan further instructed the staff to complete a fall risk assessment, keep the environment free of clutter and safety hazards, place frequently used items within reach, and follow the toileting plan. The 8/30/2014 care plan revision stated the resident would not be left up in the wheelchair in his/her room unattended by the staff. The 9/23/2014 care plan revision indicated the staff would not leave the resident alone in the dining room. The care plan indicated the resident had ineffective breathing and the staff would assess for anxiety, restlessness, shortness of breath, rapid or shallow respirations and notify the physician if warranted. The care plan further directed the staff to administer oxygen and nebulizer treatments to the resident as ordered by the physician. The care plan update 11/05/2014, indicated the staff discontinued the 8/30/2014 intervention due to the resident receiving a new wheelchair. The 8/20/2014 fall risk assessment indicated a score of 12, and a score of 10 or higher represented a high fall risk. The 9/23/2014 at 9:40 PM, nurse's notes indicated at 6:30 PM the resident was at the dining room table and slid out of his/her wheelchair onto the foot pedals and the floor. Two nurse aides picked the resident up off the floor with assistance of a gait belt. The staff did not know if he/she hit his/her head, neuro checks were started and vital signs obtained. The physician and the (DPOA) durable power of attorney were notified. The 11/16/2014 at 9:30 AM, nurse's notes indicated at 7:20 AM the staff heard the resident' s personal alarm sounding and the aide found the resident lying on the floor face down. The nurse's notes indicated the staff called (EMS) emergency medical services who transported the resident to the hospital. Continued review of the nurse's notes verified no vital signs, blood sugar or neuro checks were obtained by the staff after the resident fell in his/her room. The facility's 11/16/2014 investigation form revealed the following: Nurse Aide J documented the resident rocked back and forth when in the wheelchair and the reason for the fall was the resident leaned too far forward. Nurse I documented the reason for the fall was the resident was in the room in a wheelchair with no staff in the room. The facility indicated the root cause of the fall was the resident was unaware of safety issues due to his/her dementia and would rock too far forward in the wheelchair or reach for something that was not within his/her reach. The EMS documentation revealed the following: The resident had been seated in a wheelchair alone in his/her room, when the staff heard a personal alarm sounding, walked into the resident's room and observed him/her lying face down. The staff indicated it was not witnessed the staff and had moved him/her from a prone to supine position. Staff noted the resident had a laceration to his/her forehead, 1 inch long to ? inch wide, and when the emergency response staff arrived they placed a cervical (neck) collar on the resident and obtained his/her vitals. The resident was then placed on a scoop board, moved to a cot and the board was removed, and the response staff secured him/her to the cot. EMS then transported the resident to the hospital. The 11/19/2014 discharge hospital notes stated the hospital admitted the resident for an un-witness fall with trauma. The notes indicated the resident had a laceration on his/her forehead, a [MEDICAL CONDITION] spine(neck) at cervical vertebra 1 (a bony or cartilaginous segments that make up the spinal column), and a non-displaced, mildly comminuted ( a fracture in which the bone is splintered or crushed into numerous pieces) [MEDICAL CONDITION] cervical vertebra. Upon admission the hospital placed the resident in a cervical collar on admission and then in a fitted collar on 11/18/2014. The discharge notes indicated the resident would continue his/her pre admission medications, diet and activity, continue to wear the cervical collar as instructed, and directed the facility staff to contact the physician's office in the morning in regards to follow up. On 11/19/2014 at 8:55 AM, Nurse E stated the resident had 2 previous falls, and was a two person total body lift, and dependent on staff for positioning and transfers. On 11/18/2014 at 3:40 PM, Nurse I stated he/she had applied a nebulizer mask on the resident on the morning of 11/16/2014 and left the resident sitting in his/her wheelchair alone in his/her room. Nurse I left the room to attend to another resident and heard the resident ' s personal alarm sounding. Nurse I stated Nurse Aide J responded to the resident first then he/she responded. Nurse I stated he/she observed the resident lying face down on the floor, the nursing staff moved the resident, observed blood under his/her head, a laceration to his/her forehead and notified Nurse K to call for an ambulance. Continued interview with Nurse I verified he/she had not obtained vital signs after the fall but documented the vital signs and blood sugar readings he/she had obtained prior to the fall. Nurse I verified the fall was unwitnessed by staff on the accident/incident report. On 11/18/2014 at 3:40 PM, Nurse Aide J stated he/she heard the resident ' s alarm sounding and observed the resident lying face down on the floor and notified the nurse of the fall. Nurse Aide J stated he/she then left the room to attend to another resident who had a sounding personal alarm. On 11/18/2014 at 2:12 PM, Administrative Nurse D verified the resident had a fall in August and at that time the care plan had been updated to state " do not leave the resident in wheelchair unattended " Administrative Nurse D stated on 9/03/2014 the staff updated the care plan and discontinued the August intervention due to the resident now used a new pediatric wheelchair. Continued interview revealed he/she was not aware the resident did not have an evaluation or assessment for the pediatric wheelchair. On 11/19/2014 at 10:45 AM, Therapy Staff L stated the resident did not have an evaluation or assessment after the 8/26/2014 fall and the former (DON) director of nursing directed him/her to get a pediatric wheelchair for the resident. Therapy Staff L verified the therapy staff had not assessed the resident ' s safety, for the safe use of the pediatric wheelchair after the facility ' s restorative manager obtained the pediatric wheelchair. The record lacked evidence the new wheelchair was evaluated for being safe and appropriate for this resident. On 12/01/2014 at 11:15 AM, Physician O stated the facility should of contacted him/her to get a Physical Therapy assessment and evaluation prior to the use of the pediatric wheelchair and verified the facility should not of used the wheelchair without an assessment with the physician order, and was unsure of the reason the used the pediatric wheelchair. The facility ' s 4/2013 fall policy indicated the facility would, as part of the initial assessment, identify residents with a history of falls and risk factors for subsequent falls. The fall policy stated the staff would evaluate and document falls that occur in the facility, such as when and where they happened and any observation of the event. The policy stated the staff and physician would re-evaluate the situation and consider other possible reasons for the resident ' s falls (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. The facility failed to ensure the staff completed a thorough assessment of Resident #8, after the resident had an unwitnessed fall, and upon return from the hospital to the facility and was diagnosed with [REDACTED].

The facility had a census of 74 residents. The sample included 10 residents. Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards for 2 of 4 residents sampled for accidents, by failure to follow the 2 dependent residents care plans and both fell out of bed. (#1, #2) Findings included: - Resident #1's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/30/14, indicated the resident had severe cognitive impairment with short and long term memory impairment and moderately impaired decision making skills with inattention. The MDS further indicated the resident required total assistance from 2 staff for bed mobility, transfers, dressing, toilet use, and bathing, and had an upper and lower range of motion impairment on both sides. The MDS indicated the resident had a history of [REDACTED]. The 10/27/13 fall (CAA) Care Area Assessment indicated the resident was at risk for falls due to his/her dependence on the staff for mobility and incontinence. The 7/30/14 care plan indicated the resident was dependent on the staff for (ADLs) Activities of Daily Living, required the assistance of 2 staff for toileting and to check and change the resident every 2 hours. The care plan further instructed the staff to complete a fall risk assessment, keep the environment free of clutter and safety hazards, place frequently used items within his/her easy reach, and to make sure the resident had properly fitting shoes. The 8/7/14 care plan update instructed the staff to place pillows on either side of the resident. The 7/16/14 fall risk assessment indicated a score of 14, which indicated the resident a high fall risk. The 8/7/14 at 4:15 AM, nurse's note indicated staff heard a noise and found the resident lying on the floor beside the bed and dresser on his/her left side. The note further indicated the resident had a 2 (cm) centimeter laceration on the left outer eye area. On 9/18/14 at 7:59 AM, Nurse K stated the resident was completely dependent on the staff for bed mobility, and staff positioned him/her in bed for safety. On 9/22/14 at 4:02 PM, Administrative Nurse A verified he/she expected the staff to position the resident safely to prevent an accident. The staff has access to the care plan to know specific care the resident required, and staff are expected to review it. Administrative Nurse A further stated the staff member who had positioned the resident the evening of the fall was not aware he/she required pillows placed on both sides while in bed. The facility failed to provide an environment free of accident hazards for Resident #1 by not providing proper positioning, as outlined in the plan of care, which resulted in a fall out of his/her bed and he/she sustained a head laceration. - Resident #2's significant change (MDS) Minimum Data Set assessment, dated 8/7/14, indicated the resident had severe cognitive impairment with short and long term memory impairment, moderately impaired decision making skills, with inattention and disorganized thinking behaviors. The MDS further indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, toilet use, and bathing, with frequent bowel and bladder incontinence. The MDS indicated the resident received hospice services and had no history of falls. The 8/7/14 fall (CAAs) Care Area Assessment indicated the resident at risk for falls due to assistance needed with mobility and incontinence. The 8/7/14 care plan instructed the staff to complete a fall risk assessment, keep the environment free of clutter, place frequently used items within reach, place a personal alarm on the resident at all times and provide a motion sensor alarm. The 8/31/14 care plan update instructed the staff to remove the side rails from the bed and to provide a scoop mattress. The 7/2/14 side rail assessment screen indicated the resident at risk for injury with the use of side rails. The 7/2/14 fall risk assessment indicated a score of 14 which indicated a high risk for falls. The 8/31/14 untimed nurse's note indicated at approximately 3:50 PM the resident's alarm sounded and upon arrival to the resident's room, the staff found the resident seated on the floor beside the bed with his/her right arm wrapped around the bedrail, holding on and his/her head and neck between the rail and the mattress. The note indicated upon assessment the resident had no apparent injuries, denied pain, and the staff put the side rails down and replaced the alarm. The note further indicated earlier in the shift the staff positioned the resident due to restlessness and he/she almost rolled out of bed. The 9/3/14 at 9:00 AM nurse's note indicated the staff spoke to hospice in regards to removing the side rails from the resident's bed and applying a scoop mattress to prevent falls from rolling out of bed. (3 days later) On 9/15/14 at 10:15 AM, observation revealed the resident lying in bed on his/her right with his/her eyes closed. Observation further revealed the resident had a scoop mattress applied on the bed and a floor alarm in place. On 9/16/14 at 11:30 AM, Nurse Aide I stated the staff use a bed alarm to assist in preventing the resident from having a fall. Nurse Aide I stated the staff keep the bed in the lowest position and a fall mat is not required for him/her. On 9/22/14 at 4:02 PM, Administrative Nurse A verified the resident had not had side rails in the past. Administrative Nurse A stated when the resident was transferred to a hospice bed, the bed had side rails on it, a staff member had put the side rails up, and he/she was unsure of which staff member did it. Administrative nurse A further verified the resident had been restless that day and had not received an antianxiety medication for his/her restlessness. The facility failed to provide an environment free of accident hazards for Resident #2 by not ensuring side rails were removed from his/her bed.

The facility had a census of 76 residents. The sample included 14 residents of which 7 residents were reviewed for accidents. Based on observation, record review and interview the facility failed to provide appropriate supervision and assistive devices to prevent falls/accidents for 3 of 7 sampled residents, (#17, #70, #39) and for the 17 independently mobile, cognitively impaired residents in the main facility and the 14 independently mobile, cognitively impaired residents of the secured unit. Findings included: - Resident #39's annual (MDS) Minimum Data Set 3.0 assessment, dated 2/12/2014, indicated the resident had severely impaired cognition. The MDS indicated the resident required extensive assistance of two staff for bed mobility, transfers, dressing and locomotion on and off the unit. The MDS indicated the resident was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position and had 2 falls since admission to the facility. The 2/12/2014 (CAAs) Care Area Assessment for falls, stated the resident received valproic acid (an anti seizure medication) and his/her incontinence of urine placed the resident at greater risk for falls. The 3/27/2014 and 5/14/2014 care plan instructed the staff to provide assistance to the resident with transferring and toileting, and to use two staff members for all transfers. Staff initiated the intervention for the use of two staff members on 1/28/14. The care plan directed the staff to keep the environment free of clutter and safety hazards. The care plan instructed the staff to place a personal alarm on the resident at all times, and a motion sensor alarm when in bed. Review of the record revealed the resident had falls on the following: On 1/28/14 at 7:10 PM an aide and the resident's family member assisted the resident and the resident lost his/her balance and staff lowered him/her to the floor. On 2/10/14 at 6:45 AM an aide transferred the resident and the resident had to be lowered to the floor. On 3/27/14 at 7:40 AM an aide transferred the resident and the resident had to be lowered to the floor. Review of the medical record revealed the staff continued to transfer the resident with one staff assistance after the 1/28/14 care plan intervention to transfer the resident with two staff. The staff lowered the resident to the floor on 2/10/14 and 3/27/14 when transferred using only one staff. The 5/18/2014 at 8:45 AM, nurse's notes revealed the resident had a fall in his/her room while ambulating with a nurse aide, walker and had a gait belt around his/her waist. The resident began leaning forward and fell to the ground. The nurse's notes revealed the resident had a laceration above his/her left eyebrow. Staff notified the physician on call who instructed the staff to perform neurological checks, monitor for a change in condition, and arrange for the resident to see the physician in the morning. The 5/19/2014 at 9:50 AM, nurse's notes revealed the resident complained of right arm pain and staff administered Tylenol (pain medication). The 5/19/14, no time, nurse's notes revealed the resident had a large purple bruise noted to his/her left rib cage area, from the fall. The 5/19/14 at 9:50 AM, nurse's notes indicated the resident saw the physician who determined the resident had bruising to his/her left rib cage area. The resident's family asked for x-rays to be taken but they were not obtained at that time. The 5/21/2014 hospital chest X-ray report indicated the findings of acute (sudden) minimally displaced (removed from the usual or normal position)fractures of the 4th thru the 10th ribs. The report also revealed the resident had multiple left rib fracture deformities, which were new since 11/30/13. On 6/10/2014 at 7:55 AM, observation revealed Nurse Aide Q and Nurse Aide R assisted the resident from his/her bed to the wheelchair using a gait belt. Continued observation revealed the resident received oxygen by nasal cannula and was able to stand and pivot with staff assistance to his/her wheelchair. On 6/09/2014 at 2:05 PM, Nurse I verified the resident had a fall in his/her room when one staff assisted him/her to the toilet. Nurse I verified the resident was a two person assist at the time of the fall. On 6/10/2014 at 2:39 PM, Nurse S stated the resident had a fall on 5/18/2014 which resulted in a laceration above his/her left eyebrow. Staff assessed the resident, notified the physician, who instructed the staff to monitor the resident, obtain neurological checks and the resident was to see the physician in the morning. On 6/10/2014 at 3:00 PM, Nurse Aide K verified the resident was a two person transfer and the day of the fall he/she worked the North side and assisted the resident to the toilet by him/herself. The 9/15/2003 facility fall policy, indicated the facility would identify residents at risk for falls, develop care plans that address the risk and implement procedures to assist in preventing falls. The faculty will provide training to staff regarding the Fall Prevention Program and encourage responsible party participation in assisting to develop interventions to reduce the risk of falls. The facility failed to provide adequate staff assistance for cognitively impaired Resident #39, who had a history of [REDACTED]. The fall resulted in a laceration above his/her left eye and fractured ribs. - Resident # 17's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 1/1/14, indicated the resident had adequate vision with glasses, short/long term memory problems and moderately impaired decision making skill. The MDS indicated the resident wandered daily, was independent with bed mobility, transfers, walking, eating and required limited staff assistance with dressing, toileting and hygiene. The MDS indicated the resident had unsteady balance, but able to stabilize him/herself, and used a walker or wheelchair for mobility. The MDS indicated the resident had no (ROM) Range of Movement impairment, no falls, and received anticoagulant (blood thinning) medication 7 days of the look back period. The annual MDS, dated [DATE], indicated the same. The 6/3/14 significant change MDS indicated a (BIMS) Brief Interview for Mental Status score of 3 (severely impaired cognition), the resident required supervision with eating and extensive assistance of 1-2 staff with all other (ADLs) Activities of Daily Living. The MDS indicated the resident's balance unsteady and he/she now required assistance to stabilize, had 1 minor injury and 1 major injury fall since the prior MDS. The 6/3/14 (CAAs) Care Area Assessment summary for falls indicated the resident sustained [REDACTED]. The 4/23/14 fall care plan, reviewed 6/3/14, directed the staff to perform a fall risk assessment of the resident per facility protocol, place frequently used items within his/her reach, a night light in the room, ensure proper fitting shoes and assistance of 1 staff for bed mobility, transfers, ambulation, dressing, hygiene and toileting. The care plan indicated the resident wore glasses and directed the staff to assist with cleaning and application. The care plan updates included: 5/11/14 personal alarm at all times. 5/14/14 resident moved back to the secured unit. 5/15/14 motion sensor alarm on when in bed. The 5/11/14 at 6:05 AM, nurse's note indicated staff found the resident on his/her bathroom floor. The note indicated the resident stated he/she was walking back to bed from the bathroom when his/her right knee gave out. The note stated the resident complained of pain in the right ankle below the knee and above the ankle, had no redness or bruising and no complaints with range of motion. The note indicated the resident had tenderness when putting weight on his/her right leg. The note indicated at 7:15 AM, the resident had no complaints of pain and at 8:45 AM, the staff notified the physician of the incident and assessment. The physician ordered the staff to send the resident to the emergency room for evaluation. The 5/11/14 Radiology report stated the resident had a distal fibula (a bone in the lower leg) fracture of the right leg. The 5/14/14 at 4:30 PM, nurse's note indicated the staff found the resident lying on his/her right side, on the floor, in the front lobby with no apparent injury. The note indicated the staff received a physician's orders [REDACTED]. At 8:45 PM, staff transferred the resident to the secured unit and placed a bedside commode in his/her room and a personal alarm on the resident. The note indicated the resident was upset that staff assisted him/her with toileting since he/she was independent prior to the ankle fracture. The 5/20/14 at 5:00 AM, nurse's note indicated the resident would forget about his/her ankle fracture and became agitated when staff help him/her with toileting and placed alarms on him/her. The 5/20/14 at 12:50 PM, nurse's note indicated the resident went to a physician appointment and returned with orders to be (NWB) non-weight bearing to the right lower extremity, keep the cast clean and follow up in 4 weeks. The 5/22/14 at 2:00 PM, nurse's note indicated the resident's cast clean and dry, his/her toes pink and warm, able to wiggle toes and reported no pain. Review of the nurse's notes 5/22/14 through 5/26/14 revealed the same and no indication of problems with the cast such as rough edges or fit. The 5/26/14 at 7:15 PM, nurse's note indicated 2 staff transferred the resident from his/her bed to the wheelchair after the resident set off the motion alarm. The note indicated that, during the transfer, the resident complained of pain in his/her leg and blood was noted on the resident's right lower pant leg. The note stated assessment revealed a 3 by 2.5 inch skin tear, staff applied pressure, cleansed the area, applied steri-strips and covered with Alevyn, then notified the physician and family. The 5/26/14 investigation of the skin tear on the resident's right lower leg indicated, based on the location of the skin tear (right above the top of the cast), it appeared the skin tear was caused by the cast during the transfer. The investigation stated the plan was for the staff to be more cautious during transfers. On 6/5/14 at 2:07 PM, observation revealed the resident lying in bed, eyes closed, the call light within reach, and a motion monitor on the floor in front of the bed. Further observation revealed the resident had a cast on his/her right foot/ankle area. Observation revealed a sign on the room door that indicated (NWB) non-weight bearing to the (LLE) left lower extremity. At the time of the observation, Nurse J verified the sign was incorrect and should say (RLE) Right Lower Extremity. On 6/10/14 at 7:45 AM, observation revealed the resident's motion sensor was on the night stand by the door, turned off. Further observation revealed at 8:45 AM, Nurse L went into the resident's room, no alarms sounded and the personal alarm was not attached to the resident's clothing. Nurse L verified the motion alarm was not on and the personal alarm not attached to the resident at the time of the observation and stated staff are to ensure the motion alarm and personal alarm are on when the resident is in bed. On 6/10/14 at 2:35 PM, observation revealed the resident in bed with a motion sensor on the floor in front of the bed. Certified Medication Aide (CMA) M verified the sensor was not turned on at this time. On 6/10/14 at 11:50 AM, Nurse I verified staff are to ensure the resident's motion sensor on when in the resident is in bed. The facility failed to ensure the motion sensor alarm and personal alarm were activated while the resident was in bed as care planned. - Resident #70's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 1/8/14, indicated the resident had short/long term memory problems, moderately impaired decision making skill, and adequate vision with glasses. The MDS indicated the resident required extensive staff assistance with bed mobility, dressing, toileting and hygiene and total staff assistance with transfers. The MDS indicated the resident had an unsteady balance, no (ROM) Range of Motion limitations, 1 minor injury fall and received restorative nursing for transfer training 5 days of the look back period. The quarterly MDS, dated [DATE], indicated the same except severely impaired decision making and the resident had 2 or more minor injury falls. The 4/22/14 care plan directed the staff to provide extensive assistance of 2 staff with transfers, use a wheelchair with anti tip bars and automatic lock brakes for the resident, and a lap buddy while the resident was up in his/her wheelchair. The care plan further directed the staff to toilet the resident immediately after meals and complete 30 minute visual checks on the resident. The Fall Risk assessments on 3/20/14 and 4/9/14 indicated the resident at high risk with scores of 14-16. (10 or above indicated high risk) The 2/27/14 physician order [REDACTED]. The 5/2/14 at 3:20 PM, facility note to the physician stated the resident fell in the lobby, the nurse and other staff heard his/her personal alarm sounding, and found the resident on the floor on his/her left side with his/her left arm behind him/her. The note indicated blood dripped at a steady rate from the left side of the resident's face, but the staff were unable to determine the exact location due to the resident's position. The note stated the resident able to lift his/her head so pressure could be applied and a pad placed. The resident stated his/her head and his/her right pinky finger hurt. The note indicated the staff immediately contacted emergency services. The 5/2/14 at 6:30 PM, nurse's note indicated the resident returned to the facility with sutures over his/her left eye with the dressing intact. The note stated the physician had ordered the following: (1) keep sutures clean and dry, removal in 5-7 days (2) monitor for infection, (3) use an ice pack to the laceration - 20 minutes every 2 hours for 24 hours. The medical record revealed no documentation the staff completed the 30 minute visual checks on 5/2/14 from 1:00 PM through 3:00 PM, prior to finding the resident on the floor with a laceration above his/her left eye. On 6/4/14 at 3:09 PM, observation revealed the resident stood up in his/her wheelchair, but was unable to stand completely upright as he/she had a lap buddy on the wheelchair. The resident was confused, but stated he/she did not want to fall. Continued observation revealed nursing staff responded as the resident stood up 3 times and the tabs alarm sounded each time. Nurse N sat with the resident for a one to one visit for a few minutes, but when Nurse N started to leave the resident's side at 3:07 PM, the resident again attempted to stand and the alarm sounded. Further observation revealed Nurse N wheeled the resident up to the nurse's station and talked more with him/her until the resident started talking to another resident and then self-propelled his/her wheelchair in the hall. On 6/10/14 at 12:00 PM, Nurse I stated the resident was able to remove the lap buddy himself/herself. On 6/10/14 at 2:00 PM, Nurse N verified the lack of documentation of the 30 minute visual checks, of the resident, on 5/2/14 and stated the aides are to document the 30 minute checks and where the resident is at that time. On 6/10/14 at 2:10 PM, (CMA) Certified Medication Aide M stated the aides are responsible for documenting the 30 minute visual checks. On 6/10/14 at 2:23 PM, Nurse L stated staff are to ensure the lap buddy is on when the resident is in the wheelchair and stated he/she had observed the resident take off the lap buddy. On 6/12/14 at 11:45 AM, Physician V stated he/she expected the facility staff to perform 30 minute visual checks on the resident to ensure the resident's safety because at times the resident was more active. He/She stated the facility had not made him/her aware the resident removed his/her lap buddy restraint at times. On 6/16/14 at 11:35 AM, Administrative Nurse I stated the staff had not re-assessed the resident for the use of the lap buddy after the 3/20/14 fall. The facility failed to provide adequate supervision for Resident #70, who was known to remove his/her lap buddy, to prevent a second fall, with injury, out of his/her wheelchair. - On 6/3/14 at 12:52 PM, observation on the facility's southeast hall, near the chapel, revealed the exit doors to the lobby between the southeast hall and the chapel, unlocked, and no alarm sounded when the surveyor opened the doors to the outside. As the surveyor waited for staff to come by, a resident came to get a cup of water in that lobby, and at 12:58 PM, Office Staff P verified the exit doors should alarm when opened without putting in the code. Continued observation revealed the exit doors did not alarm when opened at this time and Office Staff P immediately called for maintenance. On 6/3/14 at 1:10 PM, Maintenance Staff D stated the alarm was turned off with a key and he/she was unsure who else had a key, or why and when the alarm was turned off. Maintenance Staff D stated he/she performed a weekly check of all the exits and the last check was done on 5/30/14. On 6/10/14 at 12:15 PM, Administrative Nurse I reported 17 residents in the main building were independently mobile, cognitively impaired and staff are to ensure the exits are alarmed at all times. Review of the facility's exit alarm documentation indicated the staff checked the southeast exit between the southeast hall and the chapel on 5/30/14. The facility's 5/2010 policy for Wandering and Elopement stated the facility will ensure any monitoring devices such as door alarms are operational 24 hours a day. The policy stated a nurse/designee will check each door alarm every shift and record on the Door Alarm Maintenance Checklist. The facility failed to ensure the exit alarms of the facility were working properly. - On 6/3/14 at 1:30 PM, observation on the secured unit of the facility revealed the following hazardous chemicals in an unlocked storage room and accessible to residents: (1) Lysol disinfectant spray, 19 ounces, with a label warning to Keep out of Reach of Children and flammable. (2) Horizon Flo Plus surfactant detergent, 2 gallons, with the warning label to Keep out of Reach of Children, do not get in eyes, on skin or take internally. (3) Sure Flo high strength alkali builder, with the warning label may cause burns to skin, eyes or mucous membranes. On 6/3/14 at 1:30 PM,Nurse L, verified the above observations and the staff should keep the door locked at all times. On 6/10/14 at 12:15 PM, Administrative Nurse I reported 14 residents in the secured unit were independently mobile and cognitively impaired. The facility failed to ensure a safe environment for the 14 residents of the secured unit.

The facility had a census of 75 residents. The sample included 7 residents. Based on interview and record review the facility failed to provide the scheduled showers and necessary oral care to maintain good nutrition and personal and oral hygiene for 1 of 3 sampled residents reviewed for personal and oral hygiene. Resident #1 had a recent significant decline in (ADL) activities of daily living and mental function and required extensive assistance with personal and oral hygiene. Findings Included: - Resident #1 ' s admission (MDS) Minimum Data Set 3.0 assessment, dated 11/20/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS indicated the resident was independent with transfers, ambulation, toilet use and eating/drinking. The MDS indicated the resident had no swallowing problems and received a therapeutic diet. Resident #1 ' s significant change (MDS) Minimum Data Set 3.0 assessment, dated 02/12/14, indicated the resident had short and long term memory problems and severely impaired decision making skills with inattention and disorganized thinking. The MDS also indicated the resident required extensive assistance with all ADLs including eating. The MDS further indicated the resident had bowel and bladder incontinence. The 11/21/13 (CAA) Care Area Assessment for ADL function indicated the resident received physical and occupational therapy and his/her ADL function had improved. The CAA indicated the resident required assistance with showers and maintained independence with all other activities of daily living. The 02/12/14 revised care plan directed 2 staff to provide extensive assistance with dressing, personal hygiene and toileting and the assistance of 1 staff for eating/drinking. The care plan also directed the staff to provide the resident with 2 showers a week and oral care every day. Review of the January and February 2014 Bath Aide Shower Flowsheet revealed no documentation the resident had a shower from 01/31/14 to 02/11/14 (10 days). Continued review of the flowsheet revealed the resident had one shower from 01/21/14 to 02/11/14 (20 days). The facility ' s 02/11/14 Physician Fax Communication form indicated a family member wanted the resident evaluated for swallowing problems. The note further indicated the family member expressed concern the resident may be dehydrated due to his/her swallowing problems. The 02/11/14 physician's order [REDACTED]. The 02/17/14 Swallow Evaluation/Speech Therapy Notes indicated the resident was nonverbal and unable to participate in a swallow study. The notes indicated the resident had extremely poor oral hygiene with food collected throughout the resident ' s oral cavity and stuck to the resident ' s upper dentures. The note indicated the resident should be NPO (nothing by mouth) at this time, secondary to his/her inability to manage food or liquid orally. The note indicated the resident ' s swallowing problems put him/her at a significant risk for aspiration (breath food/fluids into the respiratory tract). The note indicated the resident must receive oral hygiene on a regular basis to decrease the risk for pneumonia. On 02/26/14 at 3:11 PM, Nurse G stated the Speech Therapist reported to him/her, on 02/17/14 at 4:15 PM, the resident had poor oral care with a large amount of food pocketed in the oral cavity. Nurse G stated the staff should provide oral care to the resident 2 times a day and if the staff had problems with oral care, they should report to charge nurse. On 02/27/14 at 7:43 AM, Nurse Aide D stated the resident had a recent decline in ADL function with increased swallowing problems such as: choking, coughing and pocketing foods. and required extensive assistance with eating/drinking and oral care. Nurse Aide G stated the resident required extensive assistance with bathing and was scheduled for 2 showers a week. Nurse Aide G stated, when a resident refused a shower, staff should document the refusal and report it to the nurse. On 02/27/14 at 8:01 AM, Nurse O stated the resident had a recent decline in mental and ADL function and required extensive assistance with eating/drinking and oral care. Nurse O stated the resident had swallowing problems, such as coughing, choking and pocketing food and was only able to take a few small bites or sips. Nurse O stated the staff should provide oral cares and showers for the resident, as care planned, and report to the charge nurse, if there were problems. On 02/27/14 at 8:16 AM, Nurse Aide B stated the resident had required extensive assistance with eating/drinking and oral care, in the last several weeks, before his/her discharge. Nurse Aide B stated the resident had difficulty swallowing and was only able to tolerate small bites and sips. Nurse Aide B stated the staff provided oral care twice daily and showers 2 times a week and if the staff had problems with either, they should notify the nurse. On 02/27/14 at 10:49 AM, Nurse G stated all residents were scheduled for 2 showers a week which should be documented on the shower flowsheet. Nurse G stated the staff should report problems with showers to the charge nurse to ensure the residents were well groomed. On 02/27/14 at 4:52 PM, Speech Therapist P stated he/she attempted to provide a swallow evaluation for the resident, who had a recent health decline and required extensive assistance with eating/drinking. Speech Therapist P stated the facility had provided extremely poor oral hygiene to the resident, who had food debris collected/adhered throughout his/her oral cavity. Speech Therapist P stated he/she used at least a dozen toothette swabs to remove the large amounts of food debris, that had collected in the resident ' s oral cavity. Speech Therapist P also stated most of the food debris had been in the resident ' s oral cavity for several days, because it had dried and stuck to the oral tissue and had a foul odor when he/she removed it. Speech Therapist P further stated the oral cavity tissue was very dry, the resident had signs and symptoms of dehydration and this contributed to the resident ' s swallowing problems. The facility ' s revised October 2010, Shower/Bath Policy directed the staff to record the date and time of the resident ' s shower and the name of the staff, who provided the shower. The policy also directed the staff to document a resident ' s shower refusal, the interventions taken to provide the shower, and report to the nurse. The facility ' s, revised October 2010, Oral Care Policy indicated the purpose of oral care was to clean and freshen the resident ' s mouth, prevent infections and maintain the health of teeth and gums. The policy directed the staff to assess the resident ' s oral care needs, assemble the necessary equipment and assist as needed with the resident ' s oral care. The facility failed to provide the scheduled showers and necessary oral care to maintain good nutrition and personal and oral hygiene for Resident #1, who had a recent significant decline in (ADL) activities of daily living and mental function and required extensive assistance with personal and oral hygiene. - Resident #4 ' s annual (MDS) Minimum Data Set 3.0 assessment, dated 10/22/13, indicated the resident had short and long term memory problems and moderately impaired decision making skills. The MDS indicated the resident required the extensive assistance of 1-2 staff for all (ADLs) Activities of Daily Living, including bathing, used a wheelchair, and had (ROM) Range of Motion impairment in both extremities on one side. The 1/8/14 quarterly MDS indicated the same. The 10/22/13 ADL (CAAs) Care Area Assessment summary indicated the resident had paralysis of his/her dominant side. The summary indicated the resident required extensive assistance with all ADLs. The 1/22/14 care plan directed the staff to provide extensive assistance of 1 staff with toileting, eating, oral hygiene, personal hygiene, dressing and bathing. The December 2013 bathing flow sheet revealed no documentation the resident received a shower or bath from 12/21/13 through 12/30/13 (10 consecutive days). The flow sheet lacked indication the resident refused any baths. The February 2014 bathing flow sheet revealed no documentation the resident received a shower from 2/8/14 through 2/13/14 (6 consecutive days). The flow sheet lacked indication the resident refused any baths. On 2/26/14 at 9:15 AM, Nurse K verified the medical record included no documentation indicating the staff bathed the resident for 10 consecutive days in December and 6 days in February. Nurse K stated he/she was unaware if the bath aide was on vacation or if the staff failed to document the baths. He/She stated if showers or baths were not documented they were not done. On 2/26/14 at 10:49 AM, Administrative Nurse G stated all residents are to receive a shower or bath twice per week and ensure the resident is clean and well groomed. He/She stated the staff are to document on the flow sheet after the shower or bath is completed. Administrative Nurse G stated if showers or baths were not documented they were not done. On 2/25/14 at 12:05 PM, observation revealed Resident #4, seated in a high backed wheelchair at the dining table, well groomed and appropriately dressed. The facility ' s 2010 Shower/Tub Bath policy stated the staff are to record the time and date the shower/bath was provided to a resident. The policy stated if a resident refused the shower/bath, the reason why and the intervention taken should be documented. Staff are to notify the supervisor if the resident refuses a shower/bath. The facility failed to provide routine, timely bathing for Resident #4 who required extensive staff assistance with ADLs, including bathing.

The facility had a census of 75 residents. The sample included 7 residents. Based on record review and interview the facility failed to provide sufficient fluid intake to maintain proper health and hydration for 1 of 3 sampled residents reviewed for hydration. Resident # 1 had a recent health and mental decline, required extensive assistance with eating and drinking and required a hospitalization for dehydration. Findings included: - Resident #1 ' s admission (MDS) Minimum Data Set 3.0 assessment, dated 11/20/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS indicated the resident was independent with transfers, ambulation, toilet use and eating/drinking. The MDS indicated the resident had no swallowing problems and received a therapeutic diet. Resident #1 ' s significant change (MDS) Minimum Data Set 3.0 assessment, dated 02/14/14, indicated the resident had short and long term memory problems and severely impaired cognition with inattention and disorganized thinking. The MDS also indicated the resident required extensive assistance with all (ADLs) activities of daily living including eating/drinking. The MDS further indicated the resident incontinent of bowel and urine and received a diuretic (increase secretion and flow of urine medication) 7 days a week. The revised 02/12/14 care plan, directed the staff to assist the resident with eating/drinking, offer choice of beverages at meals and offer fluids between meals, during activities and with medications. The care plan directed the staff to report abnormal laboratory test results to the physician and monitor the resident for signs and symptoms of dehydration. The 02/12/14 acute care plan, developed due to the resident ' s [MEDICAL CONDITION] Urinary Tract Infection, directed the staff to offer cranberry juice and extra fluids to the resident and encourage the resident to consume increased fluid intake. The 02/06/14 Dehydration Risk assessment indicated the resident had a total score of 4 which indicated high risk related to recent weight loss and fluid intake less than 1499 (ml) milliliters/day. The 02/06/14 Consultant Registered Dietician ' s Nutrition Risk assessment indicated the resident ' s estimated fluid needs were 2190-2670 ml per day. The February 2014 Daily Diet Monitoring Record and February 2014 Daily Diet/Hydration Monitoring Record indicated the following daily fluid totals (ml/day) for all meals, snacks and medication pass. 02/01/14 - 720 ml/day 02/02/14 - 890 ml/day 02/03/14 - 1330 ml/day 02/04/14 - 1200 ml/day 02/05/14 - 240 ml/day 02/06/14 - 680 ml/day 02/07/14 - 240 ml/day 02/08/14 - 1080 ml/day 02/09/14 - 1200 ml/day 02/10/14 - 790 ml/day 02/11/14 - 620 ml/day 02/13/14 - 820 ml/day 02/14/14 - 1680 ml/day 02/15/14 - 1060 ml/day 02/16/14 - 690 ml/day 02/17/14 - 1200 ml/day The above totals were all below the resident ' s estimated fluid needs (2190 - 2670 ml/day) established by the Registered Dietician on 02/06/14. Further review of the resident ' s daily fluid intake totals revealed 13 out of 17 days the resident consumed less than 1200 ml of fluid in a day. Review of the resident ' s medical record revealed, on 02/10/14, the facility transferred the resident to the hospital (ER) emergency room for leaning to the left with left side facial drooping and a decline in mental status. Review of the 02/10/14 ER record revealed the (CMP) Complete Metabolic Panel blood laboratory test indicated the resident had a sodium level of 138 (reference range 135-145). The 02/10/14 Urinalysis laboratory test indicated the resident was positive for bacteria in the urine and the physician ordered antibiotic treatment on 02/11/14. The facility ' s 02/11/14 Physician Fax Communication form indicated a family member requested the resident be evaluated for swallowing problems. The note further indicated the family member expressed concern the resident may be dehydrated due to his/her swallowing problems. The 02/11/14 physician's order [REDACTED]. The 02/17/14 Swallow Evaluation/Speech Therapy Notes indicated the resident was nonverbal and unable to participate in a swallow study. The notes indicated the resident had extremely poor oral hygiene with food collected throughout the resident ' s oral cavity and stuck to the resident ' s upper dentures. The note indicated the resident should be NPO (nothing by mouth) at this time, secondary to his/her inability to manage food or liquid orally The note indicated the resident ' s swallowing problems put him/her at a significant risk for aspiration (breath food/fluids into the respiratory tract). The note indicated the resident must receive oral hygiene on a regular basis to decrease the risk for pneumonia. The 02/17/14 at 7:20 PM, nurse ' s notes indicated the resident was discharged from the facility to the hospital ER per family request. The 02/17/14 Hospital Emergency Physician Record indicated the resident was lethargic and had dry mucous membranes (lining of nasal and oral cavities). The record indicated the resident had a sodium level of 158 (normal levels 135 - 145) which indicated [MEDICAL CONDITION] (elevated sodium level which can be caused by dehydration (lack of fluids) with clinical symptoms: lethargy, weakness, irritability, [MEDICAL CONDITION], and coma may occur). The record indicated the resident was admitted to the hospital with [REDACTED]. On 02/27/14 at 7:43 AM, Nurse Aide D stated the resident had a recent decline in ADL function with increased swallowing problems, choking, coughing and pocketing foods and required extensive assistance with eating and drinking. Nurse Aide D stated staff offered the resident fluids between meals and the resident was only able to take small sips. Nurse Aide D stated the (CNAs) Certified Nurse Aides documented the fluids and he/she was not aware who monitored the resident ' s fluid intake . On 02/27/14 at 8:01 AM, Nurse O stated the resident had a recent decline in mental and ADL function and required extensive assistance with eating/drinking. Nurse O stated the resident had swallowing problems such as coughing, choking and pocketing food and was only able to take a few small bites or sips. Nurse O stated the CNAs document fluid intakes and were also to monitor the amount of the resident ' s fluid intake. On 02/27/14 at 8:16 AM, Nurse Aide B stated the resident had required extensive assistance with eating/drinking, in the last several weeks before his/her discharge. Nurse Aide B stated the resident had difficulty swallowing and was only able to tolerate small bites and sips with long intervals between. Nurse Aide B stated the CNAs documented the resident ' s intake and he/she was not aware who monitored the overall fluid intake of the resident. On 02/27/14 at 9:50 AM, Nurse K stated the resident had an UTI and received antibiotic therapy. Nurse K stated the resident had a recent health decline, required extensive assist with eating/drinking and had swallowing problems. Nurse K stated the CNAs documented and monitored the resident ' s fluid intake and he/she was not aware of a system, regarding who was responsible to ensure the resident received increased fluids for his/her UTI. On 02/27/14 at 10:49 AM, Nurse G stated the resident had a rapid health decline, required extensive assistance with eating and drinking and had swallowing difficulties such as choking, coughing and pocketing foods and fluids. Nurse G stated the CNAs documented and monitored the resident ' s fluid intake and the facility had no system in place, regarding the fluid intake, to ensure the resident received increased/extra fluids. On 02/27/14 at 4:52 PM, Speech Therapist P stated he/she attempted to provide a swallow evaluation for Resident #1, who had a recent health decline and required extensive assistance with eating/drinking. Speech Therapist P stated the facility had provided extremely poor oral hygiene to the resident, who had food debris collected/adhered throughout his/her oral cavity. Speech Therapist P stated he/she used at least a dozen toothette swabs to remove the large amounts of food debris, that had collected in the resident ' s oral cavity. Speech Therapist P also stated most of the food debris had been in the resident ' s oral cavity for several days, because it had dried and stuck to the oral tissue and had a foul odor when he/she removed it. Speech Therapist P further stated the oral cavity tissue was very dry, the resident had signs and symptoms of dehydration and this contributed to the resident ' s swallowing problems. The facility ' s revised December 2011 Hydration/Prevention of Dehydration Policy, directed the Registered Dietician to calculate the resident ' s fluid needs and assess for hydration adequacy at least quarterly. The policy directed the CNAs to document the resident ' s fluid intake in the medical record and report fluid intake of less than 1200 ml/day to the nurse. The policy directed the nurses to assess the residents for signs and symptoms of dehydration with daily cares. The facility failed to provide sufficient fluid intake to maintain hydration for Resident # 1, who was admitted to the hospital for dehydration.

The facility had a census of 80 residents. The sample included 4 residents. Based on observation, record review and interview, the facility failed to thoroughly assess 1 of 4 residents who demonstrated a change of status. Resident #4 returned to the facility from a hospital stay with a significant change of status, had a fall, displayed changes including, abnormal facial twitching and abnormal arm movements, then had a second fall and experienced another change of status which resulted in hospitalization . (#4) The facility failed to provide effective pain management for 1 of 3 residents reviewed for pain. (#2) Findings included: - Resident #4's admission 5 day (MDS) Minimum Data Set 3.0 assessment, dated 8/16/13, indicated the resident had cognitive impairment with long and short term memory problems and moderately impaired decision making. The assessment revealed the resident required no assistance for bed mobility, transfers, walk in room, walk in corridor and required limited assistance with one staff member for dressing, toileting, and personal hygiene. The assessment further revealed the resident's balance was steady at all times. Resident #4's significant change MDS, dated [DATE], indicated the resident had cognitive impairment with long and short term memory problems with moderately impaired decision making. The assessment revealed the resident required extensive assistance with two plus staff members for bed mobility, transfers, walk in room, toileting and required extensive assistance of one staff person for dressing, eating, and personal hygiene. The assessment further revealed the resident was not steady and was only able to stabilize with staff assistance. The Pressure Ulcer Care Area Assessment, dated 9/10/13, indicated the resident required assistance of 2 staff for ambulation. The 8/2/13 care plan stated the resident was independent with bed mobility, transfers, ambulation, and required assist of two staff for toileting, dressing, and personal hygiene. The 8/2/13 at 6:00 PM, nurse's note indicated the staff transferred the resident to the facility's special care unit and the resident independently ambulated without problems. The Fall Risk Assessment Evaluation dated 8/2/13, indicated the resident a high risk for falls. The 8/9/13 at 2:45 PM, nurse's note indicated the facility sent the resident to an inpatient behavioral unit as he/she had been physically and verbally aggressive towards staff and wandered in and out of other residents' rooms. The 8/30/13 at 4:45 PM, nurse's note indicated the resident returned to the facility. The note indicated 2 staff members unsuccessfully attempted to assist the resident to the bathroom, but the resident was unable to stand. The resident was unable to sit on the toilet and staff had to hold him/her on the toilet so he/she would not hit his/her head. The resident required 4 staff members to assist with his/her care and then the staff transferred him/her to a wheelchair. The note further indicated the staff placed a pillow in the wheelchair to prop the resident up . The note did not indicate the staff notified the physician of the resident's arrival and his/her physical condition. The Abnormal Involuntary Movement Scale, dated 8/31/13, had a score of 0 which indicated the resident at low risk of a movement disorder. The 9/1/13 at 10:30 AM, nurse's note indicated the resident required extensive assistance of 2 staff members for ambulation. The 9/3/13 at 2:00 PM, nurse's note indicated the resident continued to require 2 staff members for cares and ambulation. The 9/4/13 at 5:45 PM, nurse's note indicated 1 nurse aide ambulated with the resident to the dining room table. The nurse aide briefly turned his/her back, and the resident fell . The resident hit the back of his/her head on the corner of the dining room table and the nurse ' s note further indicated the staff contacted the primary care physician who stated he/she was unaware the resident had returned from the inpatient behavioral unit. The physician directed the staff to send the resident to the emergency room . The 9/4/13 at 7:20 PM, nurse's note indicated the resident returned to the facility and had received staples to the laceration at the back of his/her head. The 9/4/13 emergency room physician orders [REDACTED]. 1. Remove the staples from the resident ' s head in 7-8 days 2. Provide Tylenol for pain 3. Ensure the resident used a wheelchair for the next 2 days 4. Limit walking attempts by the resident unless two assisted as the resident may be unsteady 5. If up to two weeks from this date the resident develops a headache, nausea/vomiting or unusual gait instability that is new, contact the physician to arrange a CT (computerized tomography) scan (test that uses x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels). The 9/4/13 care plan directed staff to have two staff members to assist with transfers and ambulation. The care plan directed staff to have a personal alarm on the resident at all times. The 9/5/13 at 3:15 AM, nurse's note indicated the resident received pain medication earlier in the evening due to the resident clinching his/her teeth and moaning. The note further stated the resident no longer clinched his/her teeth but the resident's face had been involuntarily twitching. This had lessened but had not stopped when the resident fell asleep. The note stated while awake, the resident's right arm would move in a seemingly purposeless manner which this behavior had not been witnessed before. The nurse's note stated the physician would be contacted in the morning if the movements continued. Review of the medical record revealed no documentation the staff notified the physician of the resident's abnormal movement. The 9/5/13 at 2:00 PM, nurse's note indicated the resident received Tylenol (an over the counter pain medication) for a headache. The 9/7/13 at 3:05 PM, nurse's note revealed the alarm sounded in the resident's room, and the staff found the resident lying on the floor. The note further indicated the resident had no injury as the resident had not hit his/her head, although the staff had not witnessed the fall of the cognitively impaired resident. Staff assisted the resident to the bathroom and assisted him/her back into bed. The staff notified the family and the physician of the incident. Review of the medical record revealed the alarm sounded and the staff found the resident lying on the floor in his/her room. The clinical record lacked evidence the facility completed neurological checks for the second fall for this cognitively impaired resident who experienced an unwitnessed fall. The 9/8/13 at 3:20 AM, nurse's note indicated the resident was grimacing and moaning. No intervention charted (approximately 12 hours after the fall). The 9/9/13 physician orders [REDACTED]. The 9/10/13 at 2:00 PM, nurse's note indicated the staff requested a lap buddy for the resident (a device that keeps the person properly positioned in a wheelchair) and the resident ' s physician provided the physical restraint order. The nurse's note further indicated the resident had not urinated the entire shift. The clinical record lacked evidence the facility notified the physician. The 9/10/13 at 9:00 PM, nurse's note indicated the resident remained on bed rest and had not urinated the entire shift. The clinical record lacked evidence the facility notified the physician. The 9/11/13 at 2:00 PM, nurse's note indicated the staff administered pain medication to the resident and the reason for the pain medication was not documented by the staff. The 9/12/13 at 2:00 PM, nurse's notes indicated the staff planned to obtain a physician order [REDACTED]. The 9/13/13 at 3:15 PM, nurse's note indicated the physician started the resident [MEDICATION NAME](an antibiotic), 250 mg, twice a day, for 7 days for a Urinary Tract Infection. The 9/29/13 at 5:00 PM, nurse's note indicated the staff rechecked the resident's urinalysis. The 10/8/13 at 2:30 PM, nurse's note indicated the physician had decreased the resident's Trazadone ( an antidepressant) medication from 100 mg at bedtime to 50 mg at bedtime and the physician ordered [MEDICATION NAME], (an antibiotic) 100 mg, twice a day, for 10 days, for a Urinary Tract Infection. The Physician order, dated 10/8/13, directed the staff to decrease the resident's Trazadone 100 milligrams at bedtime to 50 milligrams at bedtime. The 10/9/13 at 1:50 PM, nurse's note indicated the staff assessed the resident as lethargic (unresponsive) and unable to keep his/her eyes open, and not easily aroused. The staff did not notify the physician. The 10/10/13 at 1:40 PM, nurse's note indicated the physician ordered [MEDICATION NAME] (an antibiotic), 1 gram, every 24 hours for 7 days at the Infusion Clinic due to a Urinary Tract Infection. The 10/13/13 at 9:30 AM, nurse's note indicated the resident had been hyperextending his/her neck and having difficulty swallowing. The note further stated the resident would start to cough after swallowing and the staff had to hold his/her head up so he/she could swallow. The staff notified the physician. The 10/14/13 at 9:35 AM, nurse's note indicated the resident was weak, limp, lethargic unable to stand and did not stay awake. The staff transferred the resident to his/her wheelchair and took the resident to the dining room. The resident could not hold up his/her head and would not respond to verbal or painful stimuli. The staff gave the resident liquid, but it would run out of his/her mouth. The staff notified the physician and received an order to send the resident to the emergency room . The 10/15/13 at 11:45 AM, nurse's note indicated the facility readmitted the resident with the [DIAGNOSES REDACTED]. The 10/15/13 signed progress note from the physician stated the resident had a [DIAGNOSES REDACTED]. On 10/15/13 at 8:00 PM, observation revealed the resident lying on his/her back with eyes closed. The resident had pillows under his/her legs and both arms. Nurse aide H and I repositioned the resident in bed. The resident did open his/her eyes as nurse aide H raised the head of the bed. Observation revealed a personal alarm attached to the resident's right shoulder and the motion alarm placed on the floor. On 10/16/13 at 3:35 PM, Nurse E stated prior to the resident going to the behavior unit, he/she walked independently but when he/she came back, the resident hardly talked and required two staff when walking and with all cares. On 10/17/13 at 1:04 PM, Nurse Aide F stated the resident required two person assistance after the fall for transfers and ambulation. Nurse Aide F further stated the resident would stiffen up and at times be resistive with cares. On 10/17/13 at 4:00 PM, Administrative Nurse C stated he/she would expect the staff to have called the physician with updates on the resident's condition upon his/her return from the inpatient behavioral unit. Administrative Nurse C also would have expected the staff to use two people and a gait belt when ambulating the resident after the change in condition. Administrative Nurse C stated the nurse should have contacted the physician when the resident had facial twitching and abnormal arm movements as there was obviously something going on in the resident's brain. Administrative Nurse C verified with any changes with the resident, the physician should have been contacted. On 10/18/13 at 1:58 PM, Physician G stated he/she would have expected the facility to have notified him/her upon the return from the inpatient behavioral unit as well as the resident's change of condition. Physician G stated he/she would have expected the staff to have contacted him/her regarding the involuntary twitching in the residents face and abnormal arm movements. He/she would have expected to be notified of the resident having headaches as well as being lethargic. Physician G verified the falls on 9/4/13 and 9/7/13 could have contributed to the subdural hematoma. The facility failed to provide adequate and timely assessments for this cognitively impaired, dependent Resident #4, who sustained 2 falls and had a significant change in condition, which resulted in hospitalization . - Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 10/15/13, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 12 which indicated a moderate cognitive impairment. The assessment revealed the resident required extensive assistance of one staff member for bed mobility, dressing, personal hygiene and required extensive assistance of 2 staff members for transfers and toileting. The assessment further indicated the resident had frequent and moderate pain. The 7/12/13 (most current) care plan directed staff to complete a pain assessment per facility protocol which included: assessment location, frequency, and the intensity of the pain, then document the assessment and to notify the physician of any increased pain. The care plan further directed the staff to administer pain medication to the resident as ordered by the physician, monitor for side effects, document and notify the physician of inadequate pain relief. The 9/7/13 at 9:00 PM, nurse's note indicated the resident bumped his/her right stump between the staff's legs. The staff administered [MEDICATION NAME] (a medication used to treat moderate to severe pain), 50 (mg) milligrams, at bedtime and Tylenol (an [MEDICATION NAME] for mild pain), 325 mg, 2 tablets for pain. The 9/7/13 at 10:10 PM, nurse's note indicated the resident reported no relief from the pain medication. The staff attempted to contact the physician at the emergency room but the emergency room staff reported the physician was unavailable at the time. (1 hour 10 minutes after the incident) The 9/7/13 at 10:50 PM, nurse's note indicated the staff administered [MEDICATION NAME], 5/500 mg, (an [MEDICATION NAME] for mild to moderate pain) and [MEDICATION NAME] (used for muscle spasms and acute injury) 10 mg, to the resident for pain. ( 1 hour 50 minutes after the incident). The 9/8/13 at 12:30 AM, nurse's note indicated the resident still awake and in severe pain. The resident described the pain as shooting in intensity. Nurse ' s note further indicated the staff repositioned the resident which helped to decrease the pain. The staff attempted to call the emergency room again, but the physician was still unavailable. The resident refused any other interventions to aide in relieving the pain. (3 hours 30 minutes after the incident) The 9/8/13 at 4:00 AM, nurse's note indicated the resident awake and in severe pain. The staff offered the resident another [MEDICATION NAME] but the resident refused and stated he/she did not feel the medication would alleviate the pain. (7 hours after the incident) The 9/8/13 at 6:30 AM, nurse's note indicated the resident awake and in severe pain, sobbing and holding his/her right stump. The staff assessed the resident who rated the pain as a 10 (1 being the lowest and 10 being the highest pain level). The note further indicated the resident requested to be taken to the emergency room . The staff administered, [MEDICATION NAME] 100 mg and informed the resident the staff would contact the physician. (9 hours 30 minutes after the incident) The 9/8/13 at 6:40 AM, nurse ' s note indicated the emergency room staff directed the facility to contact the physician by calling his/her cell phone for direction. The 9/8/13 at 6:50 AM, nurse ' s note indicated the physician ordered the resident to be sent to the emergency room . (9 hours and 50 minutes after the incident) The 9/8/13 at 7:25 AM, nurse ' s note indicated the resident went to the emergency room by ambulance. The 9/8/13 at 12:25 PM, nurse ' s note indicated the resident returned to the facility with a [DIAGNOSES REDACTED]. The 9/8/13 X-ray report of the resident's right hip revealed a normal appearance, no fracture or dislocation, and an abnormal appearance of the proximal and mid femur. The 9/9/13 at 11:10 AM, nurse ' s note indicated the staff obtained a new order from the physician for [MEDICATION NAME] 5/500 mg, 1 tablet every four hours as needed for pain for the resident. The 9/10/13 at 10:05 AM, nurse's note indicated the resident continued to experience severe pain to his/her right stump and hip. The note further indicated the resident requested an appointment with his/her physician. The 9/12/13 at 1:00 PM, nurse's note indicated the resident returned from an appointment with his/her physician with orders. The physician instructed the staff to place ice to the resident's right stump, for 20 minutes, 4 times a day. The 9/16/13 at 8:30 AM, nurse's note indicated the resident continued to experience extreme pain, and ranked the pain level at 10. The note further indicated the staff assessed the resident then sent him/her to the emergency room for lab and a CT scan. The 9/16/13 at 12:50 PM, nurse's note indicated the resident returned to the facility, and the staff were directed by the physician to administer medication already prescribed and to add [MEDICATION NAME] (medication used to control neurological pain), 300 mg, 1 tablet a day, for 2 days then 1 tablet 3 times a day. The 9/23/13 at 5:00 PM, nurse ' s note indicated the staff found the resident on the floor in his/her room. The resident ' s wheelchair pad was not fastened to the back of his/her wheelchair. The note further stated the resident had bumped his/her head on the floor. The staff assessed the resident and assisted him/her up into his/her wheelchair. Staff administered prn (as needed) [MEDICATION NAME] for stump pain. The 9/24/13 at 4:00 AM, nurse ' s note indicated the resident ' s neurological assessment completed and remained within normal limits. The note further indicated the resident continued to experience right stump and hip pain that has been ongoing prior to fall. The 9/25/13 at 2:00 AM, nurse's note indicated the staff administered prn [MEDICATION NAME] to the resident for pain and discomfort. The 9/26/13 at 1:40 AM, nurse's note indicated the staff administered prn [MEDICATION NAME] to the resident for complaint of pain and discomfort. The 9/26/13 at 9:50 PM, nurse's note indicated the resident complained of stump pain. The staff administered prn [MEDICATION NAME]. The 10/1/13 at 1:30 PM, nurse's note indicated the resident returned from a doctor appointment with the resident ' s orthopedic physician, for his/her previous scheduled follow-up appointment The orthopedic physician provided new orders for [MEDICATION NAME] 7.5/325mg, 1 or 2 tablets every 4 hours as needed for pain. The 10/1/13 physician note indicated the resident's x-rays showed a right fracture to his/her femur with progression of [MEDICAL CONDITION] in the bone. The September Pain flow sheets indicated the resident 's pain level was no higher than a 10 and after 1 hour of taking as needed pain medication, the resident's pain level was no lower than 2. The October Pain flow sheets indicated the resident's pain level was no higher than 9 and after 1 hour of taking as needed pain medication, the resident ' s pain level was no lower than 2. Review of the resident's medication record revealed the resident received 65 doses of as needed [MEDICATION NAME] pain medication in September and he/she received 55 doses in October. On 10/15/13 at 7:03 PM, observation revealed the resident transferred by two staff members from his/her wheelchair to the bed. Observation further revealed the resident grimaced in pain as the staff rolled the resident from his/her back to his/her left side and back to his/her right side. The staff rolled the resident to his/her back which caused the resident to moan. On 10/16/13 at 9:10 AM, observation revealed the resident in bed. Two staff members are in the room to assist the resident to get dressed to go to a doctor appointment. The resident cried in pain as the staff rolled him/her onto his/her left side. The staff then rolled the resident onto his/her back and the resident cried in pain. The resident continued to cry as the staff put pants onto the resident. The aides put a gait belt on the resident and stood him/her up, and transferred the resident to his/her wheelchair. The resident ' s pants were put on crooked and the open zipper was on the left side instead of positioned in front. The staff told the resident they would need to stand him/her up again to fix the pants. The staff stood the resident, fixed the pants and sat him/her down again. The resident continued to grimace in pain. The staff told the resident that the pants did not have a button or a properly working zipper. The resident told the nurse aides to fasten the pants with a safety pin but the staff are unable to find one. The resident stated that he/she wished they would have noticed this before they put on the pants. The nurse aides told the resident the pants would need to be changed and they would need to stand the resident up again. The staff got another pair of pants out and put the gait belt back on the resident, and stood him/her up. The resident continued to holler in pain as the staff changed his/her pants and then sat him/her back into the wheelchair. On 10/17/13 at 1:10 PM, Resident #2 stated the [MEDICATION NAME] does not help his/her pain. On 10/16/13 at 9:24 AM, Nurse Aide J stated he/she is unsure why the resident continues to have the pain in his/her leg. On 10/16/13 at 3:35 PM, Nurse E stated the resident has had a lot of leg pain but doesn ' t usually complain. Nurse E further stated the resident takes a lot of pain pills. On 10/17/13 at 1:00 PM, Nurse L stated the resident continues to have pain in his/her leg and the staff has called the doctor to try to get the resident different pain medication as the [MEDICATION NAME] isn't working for the resident. On 10/17/13 at 4:00 PM, Administrative Nurse C stated he/she expected the staff to provide care to the resident in a manner that does not cause the resident pain and to monitor the effectiveness of the pain management program with physician notification as needed. The undated facility Pain Management Policy stated the facility will provide skilled assessment and appropriate treatment of [REDACTED]. The facility failed to provide effective pain management including the provision of care in a manner that limits pain for Resident #2.

The facility had a census of 80 residents. The sample included 4 residents. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents who had a significant change in status and required increased staff assistance. Resident #4 sustained a laceration to the back of his/her head from a fall which resulted in staples to the back of the resident's head. Findings included: - Resident #4's admission 5 day (MDS) Minimum Data Set 3.0, dated 8/16/13, indicated the resident had cognitive impairment with long and short term memory problems and moderately impaired decision making. The assessment revealed the resident required no assistance for bed mobility, transfers, walk in room, walk in corridor and required limited assistance with one staff member for dressing, toileting, and personal hygiene. The assessment further revealed the resident was frequently incontinent of bladder and bowel and the resident ' s balance was steady at all times. Resident #4's significant change MDS, dated [DATE], indicated the resident had cognitive impairment with long and short term memory problems with moderately impaired decision making. The assessment revealed the resident required extensive assistance with two plus staff members for bed mobility, transfers, walk in room, toileting and required extensive assistance of one staff person for dressing, eating, and personal hygiene. The assessment further revealed the resident was not steady and was only able to stabilize with staff assistance. The Pressure Ulcer Care Area Assessment, dated 9/10/13, indicated the resident required assistance of 2 staff for ambulation The 8/2/13 care plan stated the resident independent with bed mobility, transfers, ambulation, and required assist of two staff for toileting, dressing, and personal hygiene. The 8/2/13 Fall Risk Assessment Evaluation indicated the resident a high risk for falls. The 8/2/13 at 6:00 PM, nurse's note indicated staff transferred the resident to the special care unit within the facility and the resident independently ambulated without problems. The 8/9/13 at 2:45 PM, nurse's note indicated the facility sent the resident to a hospital based inpatient behavioral unit as he/she had been physically and verbally aggressive towards staff and wandered in and out of other residents ' rooms. The 8/30/13 at 4:45 PM, nurse's note indicated the resident returned to the facility. The note indicated 2 staff members unsuccessfully attempted to assist the resident to the bathroom, but the resident was unable to stand. The resident was unable to sit unassisted on the toilet, and staff had to hold him/her on the toilet so he/she would not hit his/her head. The resident required 4 staff members to assist with his/her care and then the staff transferred him/her to a wheelchair. The note further indicated the staff placed a pillow in the wheelchair to prop the resident up . The 9/1/13 at 10:30 AM, nurse's note indicated the resident required extensive assistance of 2 staff members for ambulation. The 9/3/13 at 2:00 PM, nurse's note indicated the resident continued to require 2 staff members for cares and ambulation. The 9/4/13 at 5:45 PM, nurse's note indicated 1 nurse aide ambulated with the resident to the dining room table. The nurse aide briefly turned his/her back, and the resident fell . The resident hit the back of his/her head on the corner of the dining room table and the nurse's note further indicated the staff contacted the primary care physician who directed the staff to send the resident to the emergency room . The 9/4/13 at 7:20 PM, nurse's note indicated the resident returned to the facility and had received staples to the laceration at the back of his/her head. The 9/4/13 revision to the care plan directed the staff to use two staff members to assist the resident with transfers and ambulation. The care plan directed staff to have a personal alarm on the resident at all times. On 10/15/13 at 8:00 PM, observation revealed the resident lying on his/her back with his/her eyes closed. The resident had pillows under his/her legs and both arms. Nurse Aides H and I repositioned the resident in bed. The resident did open his/her eyes as Nurse Aide H raised the head of the bed. Observation revealed a personal alarm attached to the resident's right shoulder and the motion alarm placed on the floor. On 10/16/13 at 3:35 PM, Nurse E stated prior to the resident going to the behavior unit, he/she walked independently but when he/she came back, the resident hardly talked and required two staff when walking and with all cares. Nurse E verified the resident was ambulating with one nurse aide at the time of the fall on 9/4/13. On 10/17/13 at 1:04 PM, Nurse Aide F stated the resident required two person assistance, after the fal,l for transfers and ambulation. Nurse Aide F further stated the resident would stiffen up and at times be resistive with cares. On 10/17/13 at 2:45 PM, Nurse D stated the shift was hectic the day of the resident ' s fall. The nurse only had one aide until the second aide came in at 5:45 PM. The nurse aide on duty was walking with the resident in the dining room and could not get the resident to sit down at the table for supper. Nurse D stated he/she told the aide that they did not have time to coax the resident to sit down nor explain to the resident that it was time to eat. Nurse D went into the medication room and heard a crash. When he/she went back into the dining room, the resident was on the floor. The back of the resident ' s head was bleeding. Nurse D verified two staff were to walk with the resident and the resident did not have a gait belt on when he/she fell . On 10/17/13 at Administrative Nurse C stated he/she would have expected the staff to use two people and a gait belt when ambulating the resident after the change in his/her condition. The undated Fall Prevention Protocol Overview stated a complete plan will be in place for each resident who exhibits risk issues and will be reviewed at least quarterly or with in the resident's condition. The facility failed to provide adequate supervision and assistance, including the implementation of new interventions to prevent accidents for Resident #4, who had a change in his/her condition, fell and sustained severe injury.

The facility had a census of 87 residents. The sample included 19 residents of which 4 were reviewed for accidents. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent accidents for 1 of the 4 sampled residents who sustained a second degree burn while eating, and failed to provide an environment free of accident hazards from a water leak after recognized by the staff. (#31) Findings included: - Resident #31's quarterly (MDS) Minimum Data Set 3.0 assessments, dated 1/23/13 and 4/24/13, indicated the resident had a short term and long term memory problem with severely impaired decision making skills. The MDS further indicated the resident required assistance from 2 staff for bed mobility, transfers, toilet use, and assistance from 1 staff for personal hygiene and eating. The MDS indicated the resident's balance was not steady and he/she only able to stabilize with staff assistance. The 8/14/12 (CAAs) Care Area Assessment, stated the resident required extensive assist with (ADLs) Activities of Daily Living from the staff and was at risk for falls and injuries due to cognitive impairment, medication and incontinence. The CAAs further stated the resident was on a pureed diet and able to eat independent at times. The 2/7/13 care plan instructed the staff to provide the resident with assistance as needed with eating. The 2/28/13 care plan update instructed the staff to keep hot food in cups, out of reach of the resident, and to not provide hot food to the resident. Review of the nurse's notes revealed the following: On 2/28/13 at 7:10 PM, the staff documented the resident spilled a cup of hot fluid on his/her left thigh which caused a large red area with blistering noted. The area measured 9.0 (cm) centimeters x 19.0 cm with a 8 cm x 9 cm blister in the center. A Lortab (an analgesic) was administered due to the resident stating " ouchy, ouchy " . The staff did not see him/her spill the cup and the food was cold on his/her lap when it was noticed by the staff. (approximately 1 1/2 hours after the start of meal service) On 3/1/13 at 1:30 PM, the staff documented a blister to the resident ' s left thigh with redness surrounding the burn and a cool wash cloth was applied to the area. Review of the medical record revealed the following fax communications with the physician: 3/1/13 at 4:53 AM, notification of the resident's burn and treatment that was done by the staff. (7 hours after the burn occured) The facility notified the physician of using triple antibiotic ointment to the burn and asked if a different treatment needed to be ordered. The physician replied to the fax at 1:46 PM and directed the staff to wash the burn with soap and water and pat dry. 3/10/13 at 12:52 PM, notification of the size and appearance of the resident's burn. The burn measured 3.0 cm x 6.0 cm with purple marbeling of the wound and the wound bed was black dry eschar (dead tissue) with red swollen surrounding tissue. Review of the physician ' s notes revealed the following: On 3/8/13 the physician documented the resident had sustained a burn the previous week when hot chili fell on his/her thigh. The exam of his/her left thigh revealed the blister had opened and had an open area fragile at the time of examination. On 4/26/13 the physician documented the resident had a history of [REDACTED]. The resident had followed up with another physician for debridement (the removal of dead, damaged or infected tissue to improve the healing potential of the remaining healthy tissue) and it is now almost completely healed. On 6/24/13 at 12:07 PM, observation revealed the resident independently drinking his/her meal from coffee cups, without a lid, after the staff provided set up assistance. Further observation revealed the resident spilling liquid on his/her lap. On 6/26/13 at 10:05 AM, observation revealed the staff assisted the resident with a shower. Observation further revealed approximately a 3 inch purple scar on his/her left thigh, and staff verified the scar was from his/her burn sustained in February. On 6/26/13 at 12:23 PM, observation revealed the resident independently drinking water. The resident spilled the water and the staff intervened to help him/her from spilling it more. On 6/27/13 at 9:00 AM, Nurse Aide T stated the resident's burn was the worse he/she had ever seen and it had turned green and infected. Nurse Aide T further stated Nurse Aide students were seated with the resident at the time of the incident. On 6/27/13 at 12:49 PM, Nurse A verified the staff should assist the resident with meals. On 6/27/13 at 4:00 PM, Dietary Staff V stated the resident received his/her meals in cups and the staff now pour cold milk in his/her food. On 7/2/13 at 4:12 PM, Nurse A verified the staff had not notified the physician of the resident's burn until 3/1/13 at 4:53 AM, by fax. Nurse A further verified he/she would have notified the physician after the incident by phone with the seriousness of the accident and follow up with a fax. The facility failed to ensure adequate supervision to prevent accidents for Resident #31 by failing to provide adequate supervision and assistance to prevent injury when this cognitively impaired resident received a second degree burn when feeding his/herself hot food. - On 6/26/13 at 2:25 PM, observation revealed a large puddle of water on the floor outside the staff breakroom door, approximately 2 foot x 2 foot and 2 inches deep, which was unattended by the staff. Further observation revealed Nurse Aide U walking up the hallway with blankets and a wet floor sign. On 6/26/13 at 2:25 PM, Dietary Staff V verified Nurse Aide U left the area unattended, without notifying other staff members, while he/she went to get supplies to clean up the water. On 6/26/13 at 2:33 PM, Administrative Staff W verified leaving the puddle of water unattended is a safety hazard. The facility failed to provide an environment free of accident hazards in 1 of 3 hallways.

The facility had a census of 81 residents. The sample included 8 resident of which 4 were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide supervision and assistive devices for accidents for 2 of 4 residents and to ensure an environment free from accident hazards as possible for the 19 cognitively impaired ambulatory residents The facility failed to ensure the environment remained free from accident hazards as possible for the residents who reside in the facility due to an unmarked syringe with clear liquid left unattended on the medication cart. (#82, #31) Findings included: - Resident # 82's annual (MDS) Minimum Data Set 3.0 assessment, dated 6/19/13, indicated the resident had long and short term memory loss, and severely impaired cognition. The assessment revealed the resident required extensive assistance with two staff members for toileting, transfers, walk in room, walk in corridor, locomotion on and off the unit, and limited assistance with one staff member for bed mobility and has had two falls since prior assessment. Further review revealed the resident was at significant risk for injury due to the resident's behaviors and the resident rejected care 4 to 6 days a week. The 7/31/13 care plan directed staff to have a personal alarm on the resident at all times, placed where the resident cannot remove it, a pressure pad on his/her bed and/or chair, a motion sensor alarm in his/her room, and redirect the resident at a later time if he/she was agitated. The care plan further directed staff to assist the resident with ambulation. Review of the resident's record revealed multiple Fall risk assessments in which the resident scored over 10, indicating the resident was a high risk for falls. -6/19/13, the resident scored a 19 -6/27/13, the resident scored a 19 -6/29/13, the resident scored a 19 -7/25/13, the resident scored a 21 -7/26/13, the resident scored a 21 -7/31/13, the resident scored a 21 The 5/4/13 at 9:45 AM, nurse's note stated the resident was sitting on the floor in his/her room in front of his/her recliner. The nurse's note revealed the staff would contact the resident's son in the morning and stated the resident needed supervision while ambulating. The 6/13/13 at 4:00 AM, nurse's note stated the resident was standing in a puddle of urine in his/her bathroom. The nurse aide went to steady the resident and the resident lost his/her balance, falling backwards and hitting his/her head. The note stated the resident had bleeding from the back of his/her head, a pressure dressing was applied and the resident was transferred by ambulance to the hospital and was kept for observation. The nurse's note further stated the legal representative and physician were notified after the incident. The 6/13/13 at 10:30 AM, nurse's note stated the resident returned to the facility with two staples to the back of his/her head. The 6/25/13 at 10:15 AM, nurse's note stated the nurse aide was assisting the resident to sit in his/her recliner and as the resident started to sit down the nurse aide moved the recliner so it would be behind the resident. The note stated the resident lost his/her balance, bumped his/her head on the foot of the bed. The resident acquired a 1 (cm) centimeter abrasion to his/her left forehead and the resident's vital signs were taken. The note stated the resident's legal representative and physician were notified. The 6/26/13 at 4:10 PM, nurse's note stated the resident was lying on the dining room floor. The resident was assessed with [REDACTED].(6 days later) The 6/26/13 at 10:00 AM, nurse's note stated the resident fell on his/her bathroom floor, acquired no injuries and staff notified the resident's son. The 7/25/13 at 7:20 PM, nurse's note stated the resident was on the dining room floor and a dining room chair was tipped over. The note stated the staff assessed the resident with no injury noted and staff notified the family of the incident. The 7/26/13 at 8:40 PM, nurse's note stated the resident attempted to go into another resident's room, staff intervened attempting to redirect the resident. The nurse aid attempted to assist the resident to persuade the resident to go to the dining room table for a snack. The resident began to get upset and yell at the nurse aide. The nurse aide let go of the resident's hands and the resident stumbled a few steps and fell to his/her knees and hands. The nurse aide had attempted to "catch" the resident but was unsuccessful. The resident turned him/herself over and sat on his/her buttocks. An assessment with vital signs were obtained after the nurse gently spoke to the resident. The resident denied pain and staff notified the family of the incident. The 7/31/13 at 2:15 PM, nurse's note stated the resident was hanging onto another resident's wheelchair. The resident in the wheelchair began to move which caused the resident to stumble and the resident was able to lower him/herself to the ground. The 8/2/13 at 2:00 PM, nurse's note stated the resident slipped in urine in his/her bathroom and the nurse aide was able to lower him/her to the floor without injury. The resident was assessed, vital signs were obtained. On 8/27/13 at 1:13 PM, observation revealed the resident seated at a table, in the dining, room without a personal alarm. On 8/27/13 at 2:00 PM, observation revealed the resident independently ambulating to his/her room with an unsteady gait. On 8/28/13 at 9:34 AM, observation revealed the resident seated in his/her room in a recliner, with his/her eyes closed. Observation further revealed no pressure alarm under the resident in the recliner nor a personal alarm placed on the resident. On 8/28/13 at 10:05 AM, observation revealed the resident seated in his/her room in a recliner, with his/her eyes closed. Observation further revealed no pressure alarm under the resident in the recliner nor a personal alarm placed on the resident. The motion sensor alarm was placed on his/her dresser pointed away from the resident and did not sound when walking by. On 8/28/13 at 2:20 PM, observation revealed the resident seated at a table in the dining room being assisted by one staff person with his/her meal. Further observation noted the resident did not have a personal alarm attached. On 8/28/13 at 7:15 AM, Nurse K stated the staff assist the resident with all cares. He/she further stated the resident ambulated independently throughout the special care unit and the resident had a pressure alarm for his bed. On 8/28/13 at 10:05 AM, Nurse Aide M stated the resident has a floor alarm which is placed on his/her dresser because he/she had a roommate, and the resident has a bed alarm but Nurse Aide M was unsure if the resident had a personal alarm. On 8/28/13 at 1:34 PM, Nurse A verified the staff should be following the care plan and Resident #82's need for assistance with ambulation varies throughout the day. On 8/28/13 at 2:30 PM, Nurse H stated the resident is to have a sensor alarm for his/her floor and is to have a pressure alarm pad on his/her bed also. Nurse H further stated that all of the nurses are able to update the resident care plan if needed. The April 2010 facility policy for Care Plans stated the care plan is maintained for each resident that identifies the highest level of functioning the resident may be expected to attain. The policy further states the care plan is to aid in preventing or reducing declines in the resident's functional status and/or functional level. The facility failed to ensure the resident's environment remained as free of accident hazards as possible by not following the care plan regarding fall prevention for Resident #82, who had a history of [REDACTED]. - On 8/28/13 at 7:59 AM, observation revealed on the northwest hall outside of Room #61, 15 vials of insulin sitting on top of a medication cart, unattended. Further observation revealed a capped insulin syringe, filled to the 15 units mark with a clear liquid. At 8:05 AM, Nurse J emerged from room #63 and returned to the medication cart for approximately 2 minutes, then left the medication cart unattended and walked into room #61 and closed the door. Several residents were observed independently walking past the unattended medication cart. At 8:11 AM, Nurse J returned to the cart and pushed it toward the south hall. On 8/28/13 at 8:11 AM, Nurse J verified the insulin vials should be locked up in the medication cart or in the medication room refrigerator at all times and the syringes should always be labeled and not left on top of the medication cart. On 2/28/13 at 1:04 PM, Nurse A verified that insulin vials should not be left on top of the medication cart unattended and all syringes should be labeled and not left on top of the medication cart. The facility identified 38 residents who were cognitively impaired, independently mobile residents. The 8/28/13 facility Storage of Medications policy stated only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. It also stated the medication rooms, carts and medication supplies are to be locked or attended by persons with authorized access. The facility failed to ensure an environment free of accident hazards for the cognitively impaired, independent mobile residents, who reside in the facility - Resident #31's annual (MDS) Minimum Data Set 3.0 assessment, dated 7/24/13, indicated the resident had unclear speech, rarely understood or rarely understands, and had short and long term memory problems. The MDS also indicated the resident had severely impaired decision making skills and required extensive assistance of 2 staff for bed mobility, transfers and toileting. The MDS further indicated the resident had no falls for the past 3 months. The 8/7/13 care plan, instructed the staff to use 2 staff when transferring and toileting the resident. The care plan also directed staff to assist the resident with positioning every 2 hours. The facility policy for Safe Lifting and Movement of Residents stated nursing staff in conjunction with the rehabilitation staff, shall assess individual residents needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. The assessment shall include the resident's mobility (degree of dependency, weight bearing ability and cognitive status. The policy further stated staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. On 8/28/13 at 11:07 AM, observation revealed the resident being transferred from the recliner to the wheelchair. (CNA) Certified Nurse Aide B and CNA C, moved Resident #31 to the edge of the recliner, grabbed under his/her arms, held on to the back of his/her pants, picked him/her up, and swung him/her to his/her wheelchair. Once seated in the wheelchair, Resident #31 moaned. CNA C asked Resident #31 "Are you alright?". Resident #31 just looked up at him/her. No gait belt was used during the transfer. On 8/28/13 at 11:10 AM, CNA B stated that he/she was new and was not sure if they use a gait belt when they transfer people. CNA D stated we are always to use a gait belt when we transfer someone. CNA B verified he/she and CNA C didn't use a gait belt when transferring Resident #31. On 8/28/13 at 11:13 AM CNA C stated staff are to use a gait belt when transferring the residents. On 8/28/13 at 9:57 AM, Physical Therapy Staff E stated Resident #31 is receiving physical therapy 3 times per week for spinal stenosis and muscle weakness. On 8/28/13 at 11:33 AM, Physical Therapy Staff F stated Resident #31 is unable to stand on his/her own, is non-weight bearing, and can not straighten out his/her legs. Physical Therapy Staff F further stated he/she would not recommend transferring the resident without the assistance of two staff and a gait belt. On 8/28/13 at 1:04 PM, Nurse A verified Resident #31 should always be transferred with a gait belt and the assistance of 2 staff. The facility failed to ensure staff used assistive devices to transfer Resident #31, who required extensive staff assistance.