Every finding on record at Belleville Healthcare and Rehabilitation Center

Based on record review, observation, and interview, the facility failed to identify, assess, and implement pressure injury prevention interventions for Resident (R) 1, who developed a painful wound to her buttock, in which the hospital identified as an unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer. Staff also failed to assess and document evidence of monitoring the wound once it developed. Findings included:- R1's Electronic Medical Record (EMR) documented R1 admitted on [DATE]. R1's EMR revealed diagnoses of weakness, abnormalities of gait and mobility, repeated falls, chronic pain, and unspecified abdominal pain. R1's admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required moderate to substantial staff assistance with most of her activities of daily living (ADL) except eating. The MDS documented R1 was at risk for sustaining pressure ulcers. R1 admitted to the facility without any pressure ulcers or skin issues, and no pressure-relieving devices for her chair or bed were initiated. The MDS noted a turning and repositioning program had not been initiated. The Functional Abilities Care Area Assessment (CAA), dated 04/31/2026, documented R1 was cognitively alert but physically frail and required varying levels of assistance for all daily tasks due to chronic conditions. The CAA documented R1's functional mobility would be addressed in her care plan, and staff were to assist R1 with ADL care as needed, anticipate her needs so her care needs were adequately met, and provide therapy services to help increase her functional mobility. The Incontinence CAA, dated 04/31/2026, documented R1 was continent of bowel but incontinent of bladder at times. The CAA documented staff should consider prompted toileting or a toileting program. The CAA directed staff to monitor R1's output, monitor R1 for signs and symptoms of a urinary tract infection, and protect R1's skin. The Pressure Ulcer/Injury CAA, dated 04/31/2026, documented R1 was at risk for pressure ulcers and skin breakdown. The CAA documented R1's skin was free from pressure ulcers, but she had a small red spot on her left gluteal (pertaining to the buttocks or buttocks muscles) fold, along with a larger open lesion that had a depth of 0.5 centimeters (cm) just above the small red spot. The area was reported to be painful to R1 and treated with protective cream. The CAA directed staff to assist with repositioning R1 per protocol and as needed to help maintain skin integrity. Licensed Nursing (LN) staff were to monitor R1's skin weekly to monitor skin issues. The CAA documented pressure redistributing surfaces should be in place on R1's bed and wheelchair to help maintain R1's skin integrity. R1's Care Plan, initiated 04/24/2026, documented R1 was at risk for skin breakdown based on the Braden Scale (a clinical tool used to predict a resident's risk of developing pressure injuries but did not list interventions to prevent pressure injuries until 05/05/2026. Interventions dated 05/05/2026 (after the development of the pressure injury) directed the following:R1 would receive preventative measures to keep skin intact.Staff were to ensure R1 had adequate protein, implement a turning schedule, provide pressure redistributing devices for R1's bed and chair, increase caloric intake, maintain good hydration, refer to the dietician for all skin concerns, and supplement R1 with vitamins as needed.R1's Care Plan documented an intervention dated 05/07/2026 that directed staff to provide R1 with a low air loss mattress.R1's required assistance for bed mobility was not addressed in the care plan. The Clinical admission Note, dated 04/24/2026, documented R1 had no skin issues identified. The Braden Scale, dated 04/24/2026, documented a score of 19, which indicated a low risk for pressure ulcers. The Nurse's Note, dated 04/28/2026, documented R1's responsible party was concerned R1 seemed off. Upon assessment, R1 was warm to the touch and temperature was consistently 101 degrees Fahrenheit (F). R1's blood pressure had a low diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of blood pressure reading) and R1 was lethargic. Staff notified R1's primary care physician, who ordered fluids intravenously (IV-administered directly into the bloodstream via a vein). The late entry Multidisciplinary Care Conference Note, dated 04/26/2026, documented R1 had an average meal intake of 50%. The note documented R1 received intravenous fluids for dehydration on 04/28/2026, and R1's skin was intact. The Nutritional Assessment Note, dated 04/30/2026, documented R1 weighed 150.6 pounds, and her body mass index (BMI) was 25.8, within normal limits. R1's average meal intake was 50%, and R1 was at risk for malnutrition. The dietitian recommended fortified food with all meals and Ensure, eight ounces every day to optimize nutrition. The note documented R1's skin was intact. The Skin Check Note, dated 05/01/2026, documented R1 had a new skin issue. R1 had an open lesion to her left gluteal fold, which the note documented as being present on admission. The wound was continuously painful to R1. The note documented staff would implement an intervention to reposition R1. The wound measured 2 cm by 2 cm by 0.5 cm. The Braden Scale Evaluation Note, dated 05/01/2026, documented R1 had a score of 16, which indicated R1 was at mild risk for pressure ulcers. R1's EMR lacked any documentation of treatment to the wound area (first identified in the CAA dated 04/31/2026 and again on 05/01/2026) or of physician notification until 05/04/2026. The Nurse's Note, dated 05/04/2026, documented R1 had a small red spot on her left gluteal fold with a larger area with some depth above it. Protective cream was applied to the areas. The staff notified the wound nurse of the area, and notified R1's primary care physician, who wanted more documentation. The Skin and Wound Tab, dated 05/05/2026, showed a picture of R1's wound to her buttock. Observation revealed there was a smaller circular area on the left side of the buttock which had 80% slough (dead tissue, usually cream or yellow in color), and the edges were red. In the middle of R1's buttock cleft was a larger open wound with 90% slough to the wound bed. The peri-wound (skin surrounding the wound) was dark purple/red in color. Administrative Nurse E documented the wound was Moisture-Associated Skin Damage (MASD) and documented the wound was present on admission. The wound measured 2.41 cm by 5.08 cm by 0.1 cm. The Skin Issues Note, dated 05/05/2026, documented R1's coccyx (tailbone area) had MASD, and the wound was present on admission, and it was unknown how long the wound had been present. The wound measured 2.41 cm by 5.08 cm by 0.1 cm. The note documented the wound as having 70% granulation tissue (new tissue formed during wound healing), 10% slough, and 20 % eschar (dead tissue). The wound had light serous (thin, clear) exudate (a fluid that leaks out of body vessels and tissues), and the peri-wound was normal in color. Interventions included a pressure-reducing device for R1's chair, moisture control, dietary supplementation, a mattress with a pump, and repositioning. R1's Treatment Administration Record (TAR), dated May 2026, documented a treatment for R1's pressure wound, initiated on 05/07/2026. The TAR directed nursing staff to cleanse the area with soap and water, allow it to dry, apply a sacral Mepilex (a self-adherent, five-layer silicone foam dressing specifically shaped to fit the tailbone and lower back area) to the wound, change it every three days and as needed for soiling. The TAR documented the wound as MASD. The Braden Scale, dated 05/08/2026, documented R1 had a Braden score of 14, which indicated moderate risk for pressure ulcers. On 05/11/2026, R1's EMR lacked notes related to R1 going to the hospital, at her representative's request, where she admitted to the hospital and never returned to the facility. R1's EMR lacked evidence of physician assessment of the wound from admission on [DATE] through discharge on [DATE]. The Hospital Health and Physical (H&P), dated 05/11/2026, documented R1 presented to the emergency room (ER) with decreased intake, concerns for a urinary tract infection (UTI), and a low-grade temperature over the last couple of days with concern for sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The Consult Note, from the acute hospital dated 05/11/2026, documented R1 had an unstageable pressure ulcer to her coccyx that butterflied to each buttock. The edges were well-defined. The area was wet and drained serous fluid. The wound was covered with a thick adherent slough. The peri-wound was purple and fanned out to a deep red color. R1 also had a smaller Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure injury to her right buttock. The note documented a new order for Santyl (prescription ointment is used to remove damaged tissue from skin ulcers) twice a day to break down the fibrous slough and plan for surgical debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) later in the week. On 07/28/2026 at 01:30 PM, Administrative Nurse D stated she had only done one admission since starting her job as the administrative nurse at the facility and was unsure what the process was for implementing pressure ulcer preventative interventions. On 07/28/2026 at 03:25 PM, Administrative Staff A asked if she could present more documentation regarding R1's pressure ulcer. On 07/28/2026 at 07:30 PM, LN G stated R1 admitted to the facility and did not have a pressure ulcer to her coccyx. LN G verified R1 did not have any turning/repositioning interventions or pressure-relieving devices put in place until after the pressure ulcer appeared and worsened. On 07/28/2026 at 08:00 PM, Certified Nurse Aide (CNA) M stated R1 had not had a turning/repositioning task until after she had the pressure ulcer. CNA M stated R1 had not been on a check and change program. On 07/28/2026 at 08:36 PM, the facility presented a form via e-mail, signed by the Medical Director of the facility, which documented R1's pressure ulcer was unavoidable and documented it as a Kennedy terminal ulcer (KTU- a pressure-based injury that can develop quickly and is often a sign of terminal illness or impending death). The facility's undated Pressure Injury Prevention and Management Policy documented the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal pressure ulcers, prevent infection, and prevent the development of additional pressure ulcers. Licensed nurses will conduct a pressure injury risk assessment on all residents on admission, weekly for four weeks, then quarterly, or whenever the resident's condition changes. The facility would use a systematic approach for pressure injury prevention and management: including prompt assessment and treatment, intervening to stabilize, reduce, or remove underlying risk factors, monitoring the impact of interventions, and modifying interventions as appropriate.

Based on record review, observations, and interviews, the facility failed to immediately implement dietician recommendations to promote nutritional status during an identified gradual weight loss after admission for Resident (R) 1, who also had wounds. (Refer to F686). Findings included:- R1's Electronic Medical Record (EMR) documented R1 admitted on [DATE]. R1's EMR revealed diagnoses of weakness, abnormalities of gait and mobility, repeated falls, chronic pain, and unspecified abdominal pain. R1's admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required moderate to substantial staff assistance with most of her activities of daily living (ADL) except eating. The MDS documented R1 was at risk for sustaining pressure ulcers. R1 admitted to the facility without any pressure ulcers or skin issues, and no pressure-relieving devices for her chair or bed were initiated. The MDS noted a turning and repositioning program had not been initiated. The Functional Abilities Care Area Assessment (CAA), dated 04/31/2026, documented R1 was cognitively alert but physically frail and required varying levels of assistance for all daily tasks due to chronic conditions. The CAA documented R1's functional mobility would be addressed in her care plan, and staff were to assist R1 with ADL care as needed, anticipating her needs so her care needs were adequately met, and provide therapy services to help increase her functional mobility. The Incontinence CAA, dated 04/31/2026, documented R1 was continent of bowel but incontinent of bladder at times. The CAA documented staff should consider prompted toileting or a toileting program. The CAA directed staff to monitor R1's output, monitor R1 for signs and symptoms of a urinary tract infection, and protect R1's skin. The Pressure Ulcer/Injury CAA, dated 04/31/2026, documented R1 was at risk for pressure ulcers and skin breakdown. The CAA documented R1's skin was free from pressure ulcers, but she had a small red spot on her left gluteal (pertaining to the buttocks or buttocks muscles) fold, along with a larger open lesion that had a depth of 0.5 centimeters (cm) just above the small red spot. The area was reported to be painful to R1 and treated with protective cream. The CAA directed staff to assist with repositioning R1 per protocol and as needed to help maintain skin integrity. Licensed Nursing (LN) staff were to monitor R1's skin weekly to monitor skin issues. The CAA documented pressure redistributing surfaces should be in place on R1's bed and wheelchair to help maintain R1's skin integrity. R1's Care Plan, initiated 04/24/2026, documented R1 was at risk for skin breakdown based on the Braden Scale (a clinical tool used to predict a resident's risk of developing pressure injuries) Interventions dated 05/05/2026 (after the development of the pressure injury) directed the following:Staff were to ensure R1 had adequate protein, increase caloric intake, maintain good hydration, and refer to the dietician for all skin concerns, and supplement R1 with vitamins as needed. R1's EMR documented R1 had an admission weight of 150.6 pounds on 04/24/2026. R1's EMR documented R1 had a weight of 144.8 pounds on 04/26/2026. The Nurse's Note, dated 04/28/2026, documented R1's responsible party was concerned R1 seemed off. Upon assessment, R1 was warm to the touch and temperature was consistently 101 degrees Fahrenheit (F). R1's blood pressure had a low diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of blood pressure reading) and R1 was lethargic. Staff notified R1's primary care physician, who ordered fluids intravenously (IV-administered directly into the bloodstream via a vein). The late entry Multidisciplinary Care Conference Note, dated 04/26/2026, documented R1 had an average meal intake of 50%. The note documented R1 received intravenous fluids for dehydration on 04/28/2026, and R1's skin was intact. The Nutritional Assessment Note, dated 04/30/2026, documented R1 weighed 150.6 pounds, and her body mass index (BMI) was 25.8, within normal limits. R1's average meal intake was 50%, and R1 was at risk for malnutrition. The dietitian recommended fortified food with all meals and Ensure, eight ounces every day to optimize nutrition. R1's EMR documented R1 had a weight of 148.2 pounds on 05/01/2026; a weight of 140.3 pounds on 05/02/2026; a weight of 137.6 pounds on 05/03/2026; a weight of 136.2 pounds on 05/05/2026. The Dietary Note, dated 05/05/2026, documented R1 triggered for a significant weight loss of 13 pounds since admission on [DATE] or an 8.6% weight loss since admission. The note documented the dietitian thought some of the weights were erroneous and directed nursing to strike out erroneous weights as appropriate and recommended to reweigh R1 daily for three days to obtain an accurate baseline and to continue the previous order of fortified foods and Ensure eight ounces daily. R1's EMR documented R1 had a weight of 135.0 pounds on 05/07/2026 R1's Medicine Administration Record (MAR), dated May 2026, documented Ensure eight ounces daily was not initiated until 05/08/2026 R1's Order Summary Report, dated May 2026, documented fortified foods were not started until 05/08/2026. On 07/28/26 at 01:30 PM, Administrative Nurse D stated she was unsure of the process of completing the dietitian's dietary recommendations for residents. Administrative Nurse D stated she did not know R1's plan of care very well because she never had to take care of her. The facility's undated Weight Monitoring Policy documented based on the resident's comprehensive assessment, the facility would ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Interventions will be identified, implemented, monitored and modified, consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for restorative nursing services. Based on observation, interview, and record review, the facility failed to provide restorative nursing services to prevent further decrease in range of motion (ROM) for Resident (R) 40's left hand, which had limited mobility. This deficient practice resulted in actual harm when R40 had a significant decrease in ROM to the left hand, could not mobilize her wheelchair without staff assistance, voiced concern that an orthopedic (pertaining to bones) surgeon would have to rebreak her hand to repair it, and voiced pain in her left hand at all times.Findings included:- R40's Electronic Medical Record (EMR) documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and traumatic subdural hematoma (SDH- a serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R40 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R40 required partial to moderate assistance with showering. The MDS documented R40 did not have any range of motion services with restorative nursing therapy during the look-back period. The MDS noted no functional limitation in ROM.The Functional Abilities Care Area Assessment (CAA), dated 11/18/24, documented the facility would address functional mobility in R40's care plan. The CAA documented staff were to assist R40 with her activities of daily living (ADL) as needed, anticipate R40's cares so her needs were met effectively. The CAA documented therapy services were to be used as needed to increase functional mobility.R40's Care Plan directed staff to know R40 was at risk for alteration in comfort due to decreased mobility, assess R40 for pain each shift, and report pain in a timely manner (11/13/24). The care plan documented R40 received restorative care for walking (08/12/25). The care plan lacked any other restorative discipline. The care plan documented R40 had an alteration in musculoskeletal status related to fractures (broken bones) at the base of the proximal phalanx (the bone in a finger closest the hand) of the fifth digit of the left hand, an acute displaced fracture of the hamate (a small triangular shaped bone in the wrist) of the left hand, and an acute fracture of the lateral radial styloid (the palpable bony projection on the outer side of the distal radius bone) of the left hand from a fall on 01/31/25. The goal in the care plan was for R40's fracture to heal and progress without any complications, and R40 would return to her prior level of function after the fractures healed. The care plan directed staff R40 wear a brace on her left arm until after the orthopedic follow-up (02/04/25).The Incident Note, dated 01/31/25 at 11:15 PM, documented staff assisted R40 outside in her wheelchair. While outside, R40 leaned forward and rolled out of her wheelchair onto the ground. Staff brought R40 back inside and noted a scrape on R40's left cheek and chin. R40 complained of left wrist pain and held her left wrist. Staff asked the resident to grip the nurse's hands and she could not do so with her left hand. Staff notified the local hospital of R40's pending transfer. The General Note, dated 02/01/25 at 11:39 AM, documented R40 returned from the local hospital and noted she sustained a fracture of her left wrist and pinky finger. The note stated R40 was to wear a brace at all times until seen by the orthopedic doctor. R40 received new orders for Norco (pain medication) and Metoprolol (blood pressure medication).The February 2025 Treatment Administration Record (TAR) documented R40 wore a brace at all times until the orthopedic surgeon could see her, with no refusals documented. This order discontinued on 02/24/25. The TAR documented a new order for a specialized brace to the resident's left wrist, which could be removed for ROM and hygiene, started 02/24/25 with no refusals documented.The Appointment Note, dated 02/18/25, documented due to sickness in the building and weather, R40's appointment with the orthopedic surgeon was moved to 02/24/25 at 10:45 AM.The Nurse's Note, dated 02/24/25, documented the resident returned from the orthopedic surgeon appointment with diagnoses of left distal radius (wrist) fracture and left small finger proximal phalanx (finger) fracture. Staff would apply a specialized brace to the resident's wrist and remove for ROM and hygiene. The resident required occupational therapy for gentle finger ROM for the next three weeks, and then could add gentle wrist ROM. Occupational therapy (OT) received a copy of the orders.The Occupational Therapy Evaluation and Plan of Treatment, dated 02/26/25, documented OT would see R40 one to five times a week for four weeks. The goals for R40 would be to increase the flexion (bending of a limb or joint) of her left wrist to 45 degrees to improve functional grasp/release skills. R40's prior level of flexion of her left wrist was 70 degrees, and the current level of flexion was 10 degrees. R40 would increase her left thumb flexion to 30 degrees to improve functional grasp/release skills. R40's prior level of function in her left thumb was 45 degrees, and her current level of function was 0 degrees. R40 would increase her left ring finger flexion to 75 degrees to improve functional grasp/release skills. R40's prior level of flexion to the left ring finger was 90 degrees, and her current level of flexion was 0 degrees. R40 would increase her pinky finger flexion to 75 degrees to improve her functional grasp/release skills. R40's prior level of function in her pinky finger was 90 degrees, and her current level of function was 0 degrees. The evaluation noted R40 presented with impairments in dexterity, fine motor coordination, mobility, and strength. The March 2025 TAR documented R40 wore her specialized brace daily, with no refusals. The order was discontinued on 03/24/25.The Therapy Screen Note, dated 04/21/25, documented R40 had a fall on 04/14/25. R40 continued to receive occupational therapy for strengthening and ROM on the left hand following a fracture.The Occupational Therapy Discharge Summary, dated 04/30/25, documented R40 was discontinued from therapy due to R40 having exhausted/used all of her benefits. R40's left wrist flexion prior to her wrist fracture was 70 degrees, and her level of function at the time of discharge was 45 degrees. R40's left thumb flexion prior to her injury was 45 degrees, and her current level of function was 35 degrees. The left ring finger's prior level of flexion was 90 degrees, with a current level of flexion at 70 degrees. The left pinky finger's prior level of function was 90 degrees, and her current level of flexion was 70 degrees. Occupational therapy recommended R40 for a restorative ROM program.The Range of Motion Task for May 2025 documented the resident would receive gentle assisted active ROM four to seven times a week to her left wrist and fingers. Documentation revealed staff performed gentle assisted ROM 13 days out of 31 days for fifteen minutes each.The Range of Motion Task for June 2025 documented the resident would receive gentle assisted active ROM four to seven times a week to her left wrist and fingers. Documentation revealed staff performed gentle assisted ROM 11 days out of 30 days for fifteen to 30 minutes each.The Range of Motion Task for July 2025 documented the resident would receive gentle assisted active ROM four to seven times a week to her left wrist and fingers. Documentation revealed staff performed gentle assisted ROM two days out of 31 days for thirty minutes each.The EMR lacked documentation staff performed ROM on R40 in August 2025, and the restorative aide discontinued the task on 08/05/25.On 09/14/25 at 10:30 AM, R40 sat in her wheelchair in her room. R40's left hand was contracted. R40 rubbed her left hand with her right hand as she was spoke. R40 stated she fell out of her wheelchair when she was outside smoking and broke her left hand. R40 stated her hand was frozen and she could not move her fingers. R40 stated she thought the doctor was going to have to re-break her hand and fingers to get her hand back to normal. R40 stated her left hand hurt all the time.On 09/15/25 at 01:30 PM, R40 sat in the living area putting a puzzle together. R40 had her left hand wrapped up in a blanket. R40 stated she could not do much with her left hand, it was cold, hurt all of the time, and that is why she kept that hand covered up with her blanket. On 09/16/25 at 11:00 AM, R40 stated she could not use her hands to self-propel in her wheelchair because her left hand would not work moving the wheel. R40 again stated the doctor was going to have to re-break her hand to get it back to normal.On 09/15/25 at 02:30 PM, Director of Therapy GG stated she discontinued R40 from therapy because her left hand was functional. She placed R40 on a restorative range of motion program for her left hand. Director of Therapy GG stated she was unaware R40 was no longer on a restorative program for ROM.On 09/15/25 at 03:30 PM, Administrative Nurse D stated the reason R40 had the contracture of her left hand was because she refused to wear her arm braces the way she was supposed to. Administrative Nurse D verified the months and days restorative therapy were and were not provided to R40. Administrative Nurse D did not know why restorative ROM activities were discontinued for R40.The facility's undated Restorative Nursing Programs Policy documented the policy of the facility is to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Physical functioning of all residents will be assessed in accordance with the facility's assessment protocols. The interdisciplinary team, with the support and guidance from the physician, will ensure the ongoing review, evaluation, and decision-making regarding the services needed to maintain or improve residents' abilities in accordance with the residents' comprehensive assessment, goals, and preferences. Nursing personnel are trained on basic, or maintenance, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. All residents would receive maintenance restorative nursing services as needed by certified nursing assistants.

The facility identified a census of 48 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during the day-to-day operations and emergencies. Findings included:- On 09/15/25, Administrative Nurse D provided a Facility Assessment updated 04/28/25. A review of the assessment revealed the following:The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shift for the weekends.The assessment failed to identify the resident's acuity for care needs.The assessment failed to provide a detailed emergency staffing plan in the event of emergent situations.On 09/15/25 at 03:00 PM, Consultant HH stated the facility assessment that had previously been given to the survey team was not the correct facility assessment. Consultant HH gave a new facility assessment, stating, This is the actual facility assessment. Consultant HH stated Administrative Nurse D filled out the facility assessment, and everything she typed in the assessment would be in bold black print.On 09/15/25 at 03:15 PM, Administrative Nurse D stated she did not feel the facility had low weekend staffing, and the facility assessment had daily nursing hours that included the increased staff presence during the weekdays.On 09/16/25 at 10:00 AM, Administrative Staff A verified the facility assessment did not have a detailed emergency staffing plan.The facility's undated Facility Assessment and Procedure Policy documented it was the facility's policy to conduct and document a facility-wide assessment to determine the resources necessary to care for its residents during the day-to-day operations (including nights and weekends) and during emergencies. The facility would review and/or revise the assessment as necessary and as required by law.

The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. Findings included:- On 09/15/25 at 11:00 AM, a review of the noon meal consisted of chicken breast with seasoned tomatoes, squash, fortified mashed potatoes, buttered noodles, and cake.On 09/15/25 at 11:30 AM, observation revealed Dietary Staff (DS) BB in the kitchen preparing the noon meal. On 09/15/25 at 10:50 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled and started the dietary certification classes.On 09/16/25 at 10:07 AM, Administrative Nurse D verified DS BB had no dietary manager certification but had enrolled and started the dietary certification classes. The facility's Dining Services Manager Roles and Responsibilities Policy, undated, documented the following qualifications of the dining services manager: should be considered: Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) credential, or Certified Food Service Manager; or National certification for food service management and safety from a national certifying body; or Associate's or higher degree in food service management or hospitality from an accredited institution of higher learning. The policy documented that the facility would provide orientation, training, supervision, and evaluation of all dining services staff.

The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide an adequate number of dietary staff to serve the residents, who received their meals in the dining room.Findings included:- On 09/15/25 at 11:45 AM, observation in the kitchen revealed Dietary Manager (DM) BB had tempered the food items on the steam table and was ready to serve the residents' food. Observation revealed several residents sat at dining room tables waiting for their noon meal.On 09/15/25 at 12:15 PM, staff came to the serving window and notified DM BB that they were ready to serve residents' food. Observation revealed DM BB completed serving at 01:00 PM.On 09/15/25 at 11:45 AM, DM BB stated the scheduled time for the noon meal was 11:30 AM. DM BB stated she could not start serving residents in the dining room their noon meal until staff were available in the dining room to serve food. DM BB stated she only had one dietary aide who was responsible for placing drinks on trays and other items needed that were not on the steam table. DM BB stated the dietary aide was also responsible for dishwashing.On 09/16/25 at 12:55 PM, observation revealed Resident (R) 31 and R17 had not received their noon room meal trays.On 09/16/25 at 01:00 PM, Administrative Nurse D stated the noon meal should be served in a timely manner, and she was unaware the dietary department was short-staffed. Administrative Nurse D stated DM BB was in charge of hiring her staff. Administrative Nurse D stated that Administrative Staff A and she would be helping DM BB in the future to hire staff.Upon request, the facility failed to provide a policy regarding dietary staff serving time.

The facility had a census of 48 residents. Based on observation, interview, and record review, the facility failed to cover clean linen and clothing when transporting through the facility to prevent potential contamination, which could lead to infection. Findings included: - On 09/14/25 at 12:30 PM, Housekeeping Staff U took an uncovered laundry cart with clean resident clothing hanging up and linens on the shelf through the facility to the southeast hall.On 09/15/25 at 11:55 AM, Housekeeping Staff V verified staff were to cover residents' personal clothing when transporting it to their room. On 09/15/25 at 01:00 PM, Administrative Nurse D staff should cover the residents' clothing when taking through the hall to their room. The facility's Handling Clean Linen policy, dated 06/2025, stated linen could become contaminated from environmental contaminants. The policy stated clean linens should be delivered to resident care units on covered carts with the covers down.

The facility identified a census of 48 residents. The sample included 12 residents, with five residents reviewed for falls, supervision, and safety. Based on record review, observation, and interview, the facility failed to provide a safe environment with appropriate supervision to prevent falls for Resident (R) 46 and R5.Findings included:- R46's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility, and a chronic non-pressure wound to the right foot. The Quarterly Minimum Data Set (MDS), dated 07/29/25, documented R46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R46 required partial to moderate assistance for donning and doffing footwear, lower body dressing, bathing, and toileting. R46 required supervision/touching assistance for shower transfer. The MDS documented R46 had one fall with minor injury during the lookback period. The Functional Abilities Care Area Assessment (CAA), dated 04/28/25, documented staff were to assist R46 with activities of daily living (ADL) cares as needed, anticipating cares to that her care needs were met effectively. The Falls CAA, dated 04/28/25, documented staff were to anticipate and meet R46's care needs so that R46 did not attempt to unsafely perform ADL cares without staff assistance. R46's Care Plan documented R46 was at risk for falls due to impaired mobility and muscle weakness (10/25/24). The care plan documented R46 was to be non-weight bearing to her right foot due to a chronic ulcer on the bottom of her foot. The care plan documented staff were directed to use extra safety measures when the shower floor was wet (07/29/25). The care plan documented R46 required assistance with transferring due to being non-weight-bearing to her right lower extremity (04/24/25). The care plan directed staff R46 required one staff assist for bathing. The care plan lacked any interventions related to R46 refusing help from staff with transfers or help in the shower. The Incident Note, dated 07/29/25, documented the Certified Nurse's Aide (CNA) called the nurse to the west shower. On entering the shower house, observed R46 lying on the floor in front of her wheelchair. R46 had been standing in front of the shower chair for a bit and then transferred herself to the wheelchair and when R46 moved her left foot slid out from underneath her on the wet floor, and she fell forward. R46 fell to her knees and then went forward and caught herself on the wheelchair with the inner sides of her elbows. R46's head was lying on the seat of her wheelchair. An assessment was done, R46 had bruising on her bilateral inner elbows and abrasions on her bilateral knees. The floor was dried up, and then multiple staff members assisted R46 up from the floor and into her wheelchair. The Fall Investigation, dated 07/29/25, documented the reason for the fall was the exhaust fan was off, so the humidity was seen on the floor, possibly causing a slick surface. The intervention for the fall was for staff to use extra safety measures when the floor is wet/humid. On 07/14/25 at 11:30 AM, observation revealed R46 sat in her electric recliner watching out the window.R46 stated that a couple of months ago, she had fallen in the shower because the staff would not help her transfer. R46 stated she is non-weight-bearing on her right foot because of an ulcer, and it is difficult for her to transfer by herself in the shower. R46 stated she knew what her care plan said about transfer and showering. R46 stated she never received any help from staff in the shower area. R46 stated she feels like the lack of staff support caused her to fall. On 09/16/25 at 01:30 PM, CNA O stated she had just gotten done giving R46 a shower. CNA O stated she only observed R46 showering and did not help her with anything in the shower. CNA O stated she did not know if R46 had ever refused help transferring or not. On 09/15/25 at 03:30 PM, Administrative Nurse D stated R46 refused all staff assistance with transferring or bathing. Administrative Nurse D stated the only thing R46 might ask for help with was toileting hygiene. Administrative Nurse D stated the facility could not help that R46 refused help. The facility's Accident and Supervision Policy, dated 02/01/2020, documented the resident environment would remain as free from accident hazards as possible and each resident would receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazards and risks, evaluating and analyzing hazards and risks, interventions to reduce hazards and risks, and monitoring for effectiveness - R5's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, and confusion), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R5's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R5 was dependent on staff for activities of daily living, including mobility, and had no falls since admission. R5's Fall Care Area Assessment (CAA), dated 06/06/25, stated R5 was at risk for falls and staff were to anticipate and meet the resident's care needs so that the resident does not attempt to unsafely perform activities of daily living (ADL) cares without staff assistance. The CAA documented therapy services were to be available to help increase functional mobility and reduce fall risk. R5's Care Plan, dated 06/03/25, documented fall prevention interventions were to educate the resident on how the call light works, date initiated 05/31/25. The care plan documented to offer the resident to lie down following meals, date initiated 06/01/25. The care plan directed R5's bed to be repositioned with the right side against the wall per the resident and family request to aid in positioning safety, date initiated 06/05/25. The care plan directed staff to increase monitoring during periods of increased confusion, date initiated 07/11/25. The care plan directed staff to place his water cup within reach, date initiated 08/07/25. The care plan documented Dycem (non-slip material) to be placed in his chair, date initiated 08/11/25. The care plan documented R5 to have labs to evaluate for acute infection, date initiated 08/31/25. The Fall Risk Assessment, dated 05/30/25, documented R5 was at high risk for falling, had a history of falls, and was forgetful of his own safety limits. The Fall Note, dated 05/31/25 at 12:51 PM, documented staff found R5 on the floor by his bed. He stated he was looking for his call light, which was lying across his chest. The Fall Note, dated 06/01/25 at 02:15 PM, documented R5 was in his wheelchair in the lobby area, and the nurse was looking around the lobby to check on the residents who were sitting in there. R5 leaned forward in his wheelchair, fell face forward, and had no injuries at this time. The Fall Note, dated 06/05/25 at 08:51 PM, staff found R5 lying on the right side of his bed on the floor. The bed was in the lowest position, and no injuries were seen at this time. His bed was repositioned so that the right side of it was placed next to the wall, and it was in the lowest position. Staff were educated about the bed placement and that it needed to be in the lowest position when he was in bed. The Fall Note, dated 06/06/25 at 12:02 AM, documented R5 pulled the call light cord out of the wall, stating, It gets the staff in faster. Upon entering the room, staff noted that R5 had just sat on the floor and told the nurse that he was trying to get up to get something to eat. While staff attempted to help R5 back into his bed, he laid down on the floor and told staff that he fell out of his bed. Three staff members were in his room when he did this. The Fall Note, dated 07/11/25 at 03:43 PM, documented at 10:15 AM R5 was observed lying on the floor next to his bed face down. The fall reopened a skin tear on his left forearm, which was cleaned, and a bandage was applied. The resident said that he was Getting his car keys and going to his car and leaving. The note documented visual monitoring provided throughout the day. The Fall Note, dated 07/14/25 at 09:18 AM, documented R5 was in the dining room and sliding out of his chair. Staff had to assist him multiple times to sit up in his wheelchair. R5 then slid onto the floor under the dining room table, with no injuries. No intervention to prevent further falls was documented after the fall. The Fall Note, dated 08/07/25 at 08:01 PM, documented R5's roommate informed the nurse and another staff member that R5 was sitting on the floor beside his bed, with his left hand on the mobility bar. R5 said that he was trying to pick up his water cup as it had fallen to the floor. His bed was in the low position, and his call light had been pulled out of the wall. Prior to this, he had been lying in bed with it in the low position and his call light in reach. No injuries seen at this time. Staff placed a fall mat by his bed for the intervention. (after three prior falls from the bed). The Fall Note, dated 08/10/25 at 04:26 PM, documented another resident had notified the nurse that R5 had slid out of his chair. Staff found R5 lying in front of his wheelchair with skin tears to his right upper arm. Staff turned R5's wheelchair to face the staff in the lounge. The 08/11/25 intervention was to add a non-slip material to his wheelchair seat. (after the second fall where R5 slid out of his wheelchair). The Fall Note, dated 08/23/25 at 02:42 AM, staff found R5 in the lounge, lying on his back on the floor. Staff applied Band-Aids to his elbows. R5 stated he wanted to go to bed. No new intervention noted. The Fall Note, dated 08/30/25 at 06:15 PM, documented staff found R5 lying on the floor in front of his wheelchair. R5 stated he slipped out and was going to crawl to his room. R5 had a skin tear on his right elbow. On 08/31/25, the intervention was to obtain lab work. The 09/14/25 Therapy Screen stated R5 had a fall on 08/30/25. R5 had been discharged from therapy due to decreased participation and refusals. The screen stated R5 was noncompliant with interventions and had decreased safety awareness. Therapy requested the physician's orders for therapy. On 09/15/25 at 07:40 AM, R5 sat in his wheelchair in the facility's living room with his eyes closed. Staff were within sight and assisting other residents to the dining room. On 09/15/25 at 07:53 AM, Licensed Nurse (LN) H stated R5 was trying to get out of bed earlier this morning, so staff assisted him up at that time. She stated he had not had breakfast yet. On 09/16/25 at 08:09 AM, Administrative Nurse D verified that obtaining lab work was not an immediate fall prevention intervention. She verified the interventions should be directed toward preventing further falls. The facility's Accidents and Supervision policy, dated 02/01/20, stated both facility-centered and resident-directed approaches include evaluating hazard and accident risk, including prior accidents, analyzing potential causes, and identifying or developing interventions. The policy stated supervision was an intervention of mitigating accident risk, and the facility would provide adequate supervision to prevent accidents.

The facility had a census of 48 residents. The sample included 12 residents, with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice, as required, to Resident (R) 4 or their representative upon discharge from the facility. Findings included:- R4's Electronic Medical Record documented diagnoses of sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), seizures (violent involuntary series of contractions of a group of muscles), and a history of sudden cardiac arrest.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R4 was dependent on staff for all activities of daily living. R4's medical record documented she had been discharged to a hospital on the following dates:On 03/22/25 and readmitted to the facility on [DATE]. On 04/02/25 and readmitted to the facility on [DATE].The facility lacked evidence R4 or her representative was provided a bed hold notice at the time of each discharge. On 09/15/25 at 07:47 AM, R4 laid in bed with the head of the bed elevated. She had a gastric tube feeding running at 35 milliliters per hour. On 09/16/25 at 08:25 AM, Consultant HH verified the facility had not provided the bed hold notices for two of R4's hospital stays. The facility's Transfer and Discharge policy, dated 02/01/20, stated staff were to provide a notice of the resident's bed hold policy to the resident and their representative within 24 hours of the transfer.

The facility had a census of 48 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to review or revise Resident (R) 5's care plan with new effective interventions after each fall.Findings included: - R5's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, and confusion), and cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R5's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R5 was dependent on staff for activities of daily living, including mobility, and had no falls since admission.R5's Fall Care Area Assessment (CAA), dated 06/06/25, stated R5 was at risk for falls and staff were to anticipate and meet the resident's care needs so that the resident did not attempt to unsafely perform activities of daily living (ADL) cares without staff assistance. The CAA documented therapy services were to be available to help increase functional mobility and reduce fall risk.R5's Care Plan, documented fall prevention interventions were to educate the resident on how the call light works, date initiated 05/31/25. The care plan directed staff to offer the resident to lie down following meals, date initiated 06/01/25. The care plan directed R5's bed to be repositioned with the right side against the wall per the resident and family request to aid in positioning safety, date initiated 06/05/25. The care plan directed staff to increase monitoring during periods of increased confusion, date initiated 07/11/25. The care plan directed staff to place his water cup within reach, date initiated 08/07/25. The care plan directed that Dycem (non-slip material) be placed in his chair, date initiated 08/11/25. The care plan documented R5 would have labs to evaluate for acute infection, date initiated 08/31/25.The Fall Risk Assessment, dated 05/30/25, documented R5 was at high risk for falling, had a history of falls and was forgetful of own safety limits.The Fall Note, dated 05/31/25 at 12:51 PM, documented staff found R5 on the floor by his bed. He stated he was looking for his call light, which was lying across his chest. The Fall Note, dated 06/01/25 at 02:15 PM, documented R5 was in his wheelchair in the lobby area, and the nurse was looking around the lobby to check on the residents who were sitting in there. R5 leaned forward in his wheelchair, fell face forward, and had no injuries at this time. The Fall Note, dated 06/05/25 at 08:51 PM, staff found R5 lying on the right side of his bed on the floor. The bed was in the lowest position, and no injuries seen at this time. His bed was repositioned so that the right side of it was placed next to the wall, and it was in the lowest position. Staff were educated about the bed placement and that it needed to be in the lowest position when he was in bed. The Fall Note, dated 06/06/25 at 12:02 AM, documented R5 pulled the call light cord out of the wall, stating, It gets the staff in faster. Upon entering the room, staff noted that R5 had just sat on the floor and told the nurse that he was trying to get up to get something to eat. While staff attempted to help R5 back into his bed, he laid down on the floor and told staff that he fell out of his bed. Three staff members were in his room when he did this.The Fall Note, dated 07/11/25 at 03:43 PM, documented at 10:15 AM R5 was observed lying on the floor next to his bed face down. The fall reopened a skin tear on his left forearm, which was cleaned, and a bandage was applied. R5 said that he was Getting his car keys and going to his car and leaving. The note documented visual monitoring provided throughout the day. The Fall Note, dated 07/14/25 at 09:18 AM, documented R5 was in the dining room and sliding out of his chair. Staff had to assist him multiple times to sit up in his wheelchair. R5 then slid onto the floor under the dining room table, with no injuries. No intervention to prevent further falls was documented after the fall. The Fall Note, dated 08/07/25 at 08:01 PM, documented R5's roommate informed the nurse and another staff member that R5 sat on the floor beside his bed, with his left hand on the mobility bar. R5 said that he was trying to pick up his water cup as it had fallen to the floor. His bed was in the low position, and his call light had been pulled out of the wall. Prior to this, he had been lying in bed with it in the low position and his call light in reach. No injuries seen at this time. Staff placed a fall mat by his bed for the intervention. (after three prior falls from the bed).The Fall Note, dated 08/10/25 at 04:26 PM, documented another resident had notified the nurse that R5 had slid out of his chair. Staff found R5 lying in front of his wheelchair with skin tears to his right upper arm. Staff turned R5's wheelchair to face the staff in the lounge. The 08/11/25 intervention was to add a non-slip material to his wheelchair seat. (after the second fall, where R5 slid out of his wheelchair).The Fall Note, dated 08/23/25 at 02:42 AM, staff found R5 in the lounge, lying on his back on the floor. Staff applied Band-Aids to his elbows. R5 stated he wanted to go to bed. No new intervention noted. The Fall Note, dated 08/30/25 at 06:15 PM, documented staff found R5 lying on the floor in front of his wheelchair. R5 stated he slipped out and was going to crawl to his room. R5 had a skin tear on his right elbow. On 08/31/25, the intervention was to obtain lab work. The 09/14/25 Therapy Screen stated R5 had a fall on 08/30/25. R5 had been discharged from therapy due to decreased participation and refusals. The screen stated R5 was noncompliant with interventions and had decreased safety awareness. Therapy requested the physician's orders for therapy. On 09/15/25 at 07:40 AM, R5 sat in his wheelchair in the facility's living room with his eyes closed. Staff were within sight and assisting other residents to the dining room. On 09/15/25 at 07:53 AM, Licensed Nurse (LN) H stated R5 was trying to get out of bed earlier this morning, so staff assisted him up at that time. She stated he had not had breakfast yet. On 09/16/25 at 08:09 AM, Administrative Nurse D verified that obtaining lab work was not an immediate fall prevention intervention. She verified the interventions should be directed toward preventing further falls. The facility's Care Plan Revisions Upon Status Change policy, dated 02/01/20, stated the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change.

The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 31 was showered/bathed according to her preference, twice a week. Findings included:- R31's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria) of the lower extremities, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), polyneuropathy (a general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), and hypertension (high blood pressure).The admission Minimum Data Set (MDS), dated 09/09/25, documented R31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R31 required supervision/touching or set-up help for all ADLs. The MDS documented R31 used a walker for locomotion. The MDS documented R31 received scheduled pain medication, as needed pain medication. R31 frequently had pain, which occasionally affected her sleep and occasionally affected her day-to-day activities. R31 rated her pain at a seven on a pain scale of zero to 10.The Functional Abilities Care Area Assessment (CAA), dated 09/09/25, documented R31 required supervision or light touch for ADLs. The CAA documented R31 used a walker, had weakness, and polyneuropathy, which could impair sensation and balance. The CAA documented R31 had chronic pain with complaints of pain daily. The CAA documented R31 took medications that could lead to dizziness and increase her risk for falls.The Pain CAA, dated 09/09/25, documented R31 routinely reported symptoms of pain and had several diagnoses that could cause pain. Frequent and daily pain should be care planned for R31 and should focus on prevention as well as symptom management.R31's Care Plan, dated 09/04/25, documented R31 required moderate/partial assistance with toileting hygiene and bathing. The care plan documented for all other ADLs, R31 required supervision or was independent (09/04/25). The care plan documented R31 was incontinent of urine and occasionally incontinent of bowel (09/04/25). The care plan directed staff to assess R31 for pain each shift and treat reported pain in a timely manner (09/04/25). The care plan documented R31 was at risk for falls and directed staff to anticipate and meet R31's needs, be sure R31's call light was in reach, and respond promptly to all requests (09/04/25).The EMR documented R31 had one shower in the twelve days she had been in the facility.On 09/14/25 at 09:30 AM, observation revealed R31 had unclean, unkempt hair. R31 had a distinct odor of urine about her. R31 stated she had not had but one shower since she had been in the facility, and she felt dirty, unclean, and felt like she smelled.On 09/15/25 at 010:00 AM, Licensed Nurse (LN) H stated she expected the residents to receive their showers per their preference.On 09/15/25 at 03:30 PM, Administrative Nurse D stated she expected staff to shower residents more than once every twelve days. The facility's Activity of Daily Living Policy, dated 08/01/19, documented the facility would ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility would maintain the individual objectives of the care plan.

The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for accommodation of needs. Based on record review, observation, and interview, the facility failed to accommodate Resident (R) 31's needs when they failed to ensure R31's walker could safely fit into the bathroom after her admission to the facility. This deficient practice placed R31 at risk for falls as she would leave her walker outside the bathroom door and furniture walk (using the sink for support) in the bathroom to use the toilet and wash her hands.Findings included:- R31's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria) of the lower extremities, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), polyneuropathy (a general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), and hypertension (high blood pressure).The admission Minimum Data Set, dated 09/09/25, documented R31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R31 required supervision/touching or set-up help for all activities of daily living (ADL). The MDS documented R31 used a walker for locomotion. The MDS documented R31 received scheduled pain medication, as-needed (PRN) pain medication. R31 frequently had pain, which occasionally affected her sleep and occasionally affected her day-to-day activities. R31 rated her pain at seven on a pain scale of zero to 10.The Functional Abilities Care Area Assessment (CAA), dated 09/09/25, documented R31 required supervision or light touch for ADLs. The CAA documented R31 used a walker, had weakness, and polyneuropathy, which could impair sensation and balance. The CAA documented R31 had chronic pain with complaints of pain daily. The CAA documented R31 took medications that could lead to dizziness and increase her risk for falls.The Pain CAA, dated 09/09/25, documented R31 routinely reported symptoms of pain and had several diagnoses that could cause pain. Frequent and daily pain should be care planned for R31 and should focus on prevention, as well as symptom management.R31's Care Plan, dated 09/04/25, documented R31 required moderate/partial assistance with toileting hygiene and bathing. The care plan documented for all other ADLs, R31 required supervision or was independent (09/04/25). The care plan documented R31 was incontinent of urine and occasionally incontinent of bowel (09/04/25). The care plan directed staff to assess R31 for pain each shift and treat reported pain in a timely manner (09/04/25). The care plan documented R31 was at risk for falls and directed staff to anticipate and meet R31's needs, be sure R31's call light was in reach, and respond promptly to all requests (09/04/25).The EMR lacked nursing notes regarding the accommodation of needs or pain.On 09/14/25 at 09:30 AM, R31 stated she had been in the facility for almost two weeks, and she was very disappointed in the care she had received so far. R31 stated she did not feel safe going to the bathroom because her walker would not fit into the bathroom, and she had to leave her walker by the door and use the sink and the door frame to get into the bathroom to get to the toilet to urinate.On 09/14/25 at 09:45 AM, observation revealed R31 used her walker to walk to the bathroom and then tried to get her walker into the bathroom, but the walker would not fit into the bathroom.On 09/15/25 at 09:30 AM, observation revealed R31 had been moved into a different room up the hall from her previous room. R31's walker was observed not to fit into the bathroom. R31 stated she had been moved to the new room last night so the floor in her room could be redone. R31 stated the new bathroom was even worse than the first bathroom, and she had an even harder time getting into the new bathroom. R31 stated her roommate could not get into the bathroom safely.On 09/16/25 at 01:00 PM, observation revealed R31 in a different room on a different hall. R31 stated her new bathroom was much bigger, her walker fit into it, and she felt safe going to the bathroom.On 09/15/25 at 03:00 PM, Administrative Staff A went to R31's room and was shown how R31's walker would not fit into the old room's bathroom, as well as the new room's bathroom. R31 stated she did not feel safe going to the bathroom. Administrative Staff A verified that neither bathroom was safe for R31 to use. Administrative Staff A stated he would figure something out.The facility's undated Accommodation of Needs Policy documented the facility would treat each resident with dignity and respect and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident except when the health and safety of the individual or other residents would be endangered. The facility will make reasonable accommodations to individualize the resident's physical environment, including their personal bathroom, bedroom, and common living areas within the facility.

The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 16 with dignity at the dining table when Certified Nurse Aide (CNA) P stated, Here is your bib, and placed a clothing protector on R16. Findings included:- On 09/14/25 at 11:32 AM, during the noon meal, R16 sat at the dining room table. CNA P brought a clothing protector to her table, stated, Here is your bib, and placed the clothing protector on R16.On 09/16/25 at 11:18 AM, Administrative Nurse D stated she would expect staff to offer a resident a clothing protector at meals, and staff should not call it a bib.The facility's Promoting/Maintaining Resident Dignity Policy, revised 01/01/20, documented that it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality.

The facility identified a census of 34 residents with three residents reviewed for unintended weight loss. Based on record review, observation, and interview, the facility failed to obtain consistent weights to establish a baseline, failed to identify and respond to progressive weight loss with intervention and increased assistance, and failed to follow the Registered Dietician (RD) recommendations to provide nutritional support for Resident (R)1. Subsequently, R1 had a significant unintended weight loss. This deficient practice also placed R1 at risk for decreased nourishment and delayed wound healing. Findings included: - R1's Electronic Medical Record (EMR) documented 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), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings of sadness), hyponatremia (lower than normal concentration of sodium in the blood), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R1 had an impaired range of motion in both of her upper extremities and both of her lower extremities. R1 required moderate assistance from staff with eating. R1's admission weight was 191 pounds (lbs.). R1 was on a mechanically altered and therapeutic diet and had no natural teeth or tooth fragments. The MDS documented R1 was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. The Nutritional Status Care Area Assessment (CAA), dated 09/16/24, documented R1's nutritional status would be addressed in her care plan. The CAA directed staff to monitor R1's body weight every week to help monitor trends in body weight. The CAA directed staff to monitor intrinsic factors, such as pain or functional mobility, that could affect her food and fluid intake. The CAA documented the registered dietitian was to meet with R1 regularly to help ensure R1's nutritional needs were met. The Pressure Ulcer/Injury CAA, dated 09/16/24, documented 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) would be addressed on R1's Care Plan. The CAA directed staff to help maintain R1's skin integrity with repositioning per protocol and as needed. The CAA directed licensed nursing staff to monitor R1's skin integrity weekly and monitor for any skin issues. The Functional Abilities CAA, dated 09/16/24, directed staff to assist with activities of daily living (ADLs) and anticipate care, as needed, so that R1's care needs were effectively met. R1's Care Plan documented R1 used specialty devices of a wheelchair and a Hoyer lift (total body mechanical lift) (09/16/24). The care plan documented R1 as at risk for skin breakdown based on risk scale assessment and had a coccyx (area at the base of the spine) pressure wound present on admission and a pressure injury to her right buttock area, facility acquired on 11/17/24. The care plan documented R1 was to use an air mattress to assist with wound healing and prevention measures for future skin breakdown (09/17/24). The care plan documented R1 would use a Broda chair (specialized wheelchair with the ability to tilt and recline) (12/10/24). Encourage good nutrition and hydration to promote healthier skin (12/10/24). The care plan directed staff to get R1 up right before meals and lay down as soon as possible after eating to aid in wound healing (12/10/24). The care plan directed staff to ensure R1 had adequate protein intake, supplement R1 with vitamins when indicated, and refer to the RD with skin concerns (09/16/24). The care plan directed staff R1 required setup or clean-up assistance for eating (10/01/24). The care plan documented R1 was dependent on staff for oral hygiene, toileting, bathing, dressing, transfers, and bed mobility (10/01/24). The care plan documented R1 was on Enhanced Barrier Precautions (EBP) due to a wound and directed staff to don personal protective equipment while providing care to the affected area (10/17/24). The care plan documented R1 had multiple significant Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) wounds that required increased nutrient needs for wound healing demands, notify RD and nursing if there was a change in baseline for intake of food or beverages, and provide nutrition and supplements, as ordered (12/10/24). The Hospital Health and Physical (H&P) dated, 09/09/24, documented R1's weight was 188.5 lbs. The H&P documented R1 was bed-bound at her baseline, required a mechanical lift for transfers, and required maximum to moderate assistance by therapies for ADLs. R1 required total assistance for mobility with contractures (abnormal fixation of a muscle or joint) noted. Speech therapy recommended a mechanically altered diet with nectar thick liquids, as R1 was noted to pocket foods and was on aspiration precautions. Dietary was consulted due to moderate protein-calorie malnutrition. R1's Dismissal Instructions, dated 09/13/24, documented the transfer to the nursing facility and directed R1 resume her home diet, resume activity as tolerated, and included a treatment plan for R1's closed Stage 4 pressure injury as follows: cleanse wound with gentle flush and pat dry, apply moisture barrier cream to peri-wound, apply Sorbact (wound dressing) to the wound and cover with a foam dressing, change two times weekly on Monday and Thursday; float heels with pillows lengthwise or utilize Prevalon boots (specialized pressure reliving boots) at all times, even when sitting in a chair; monitor bilateral heels to ensure closed pressure injuries remain intact; air mattress with turning regimen of at least every two hours at 30-degree intervals; when sitting up in chair limit to one-hour intervals, and ensure a chair cushion was in place. The Admission Assessment, dated 09/13/24 documented R1 arrived at the facility via wheelchair. The reason for R1's admission was weakness and wound care. R1's weight was 191.2 pounds. R1 was oriented to the call light and bed controls. R1's skin was normal for ethnicity. R1 had full upper and lower dentures. R1 was alert and oriented to person, place, and time. The Admission Summary Note, dated 09/13/24, documented the facility received the report from the hospital nurse. The note documented R1 had been on aspiration precautions and had admitted to the hospital on 09/04/24 for sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and failure to thrive. R1 was on a mechanically altered diet with honey thick liquids. R1 had a Stage 4 closed pressure wound on her coccyx with dressing changes every 72 hours. Staff would float heels and turn every two hours. R1 was bedridden and needed Prevalon boots on. The Multidisciplinary Care Conference Note, dated 09/13/24, documented R1 needed extensive assistance with ADLs, used a Broda chair for mobility propelled by staff, and a full body lift for transfers. For the dietary section, R1 weighed 191 lbs., had bilateral lower extremity edema, received Lasix (a diuretic used to promote urine excretion and reduce swelling), and had a body mass index (BMI) of 32.8 which indicated obesity. R1 was on a controlled carbohydrate and mechanical soft diet, with nectar-thickened liquids, due to DM and dysphagia (difficulty swallowing). R1 had a fair appetite with variable intakes. The note documented R1 did not eat meat per her preference, and she was able to feed herself after set-up and assist as needed. The note documented staff would anticipate weight fluctuations due to fluid shifts and noted a gradual weight loss was desirable given R1's obesity. The Weights and Vitals Tab, dated 09/13/24, documented R1's weight was 191.2 pounds. This value was crossed out as disputed by licensed nursing staff on 10/21/24. The initial Nutritional Assessment Note, dated 09/19/24, documented R1 admitted post sepsis with an admission height of 64 inches and a weight of 191 pounds. R1 had bilateral lower extremity edema (swelling) with a diagnosis of CHF and received Lasix. R1's body mass index was 32.8 which indicated obesity. R1 had weekly weights in place. R1 tolerated the current diet, she had a fair appetite with variable meal intakes, and she did not eat meat per her preference. R1 was able to feed herself after set-up; staff would assist as needed. R1 had skin concerns on her coccyx and a scab on her second toe. R1 was at nutritional risk due to infection, obesity, the potential for weight fluctuations due to fluid shifts, DM, and the need for a therapeutic diet. Other risks included dysphagia, variable intakes, and skin concerns. The RD indicated staff would continue to monitor R1's weekly weights and would anticipate weight fluctuations due to fluid shifts. A gradual weight loss was desirable given R1's obesity. Staff were to follow speech therapy recommendations, continue to encourage intake, and follow her food preferences. The RD recommended encouraging protein for wound healing, strengthening, and blood sugar control. The Weights and Vitals Tab, dated 09/26/24, documented R1's weight was 190.4 pounds. This value was crossed out as disputed by licensed nursing staff on 10/21/24. The Weights and Vitals Tab, dated 10/13/24 (2.5 weeks after the last weight), documented R1's weight was 161.2 pounds. The Weights and Vitals Tab, dated 10/20/24, documented R1's weight was 160.7 pounds. This value was crossed out as disputed by licensed nursing staff on 10/21/24. The Weights and Vitals Tab, dated 10/21/24, documented R1's weight was 160.7 pounds. The Weights and Vitals Tab, dated 10/27/24, documented R1's weight was 165 pounds. R1's meal intake monitoring was requested from the facility. The facility provided part of November 2024, from 11/17/24 through 11/26/24. The documentation had three meals with no percentages documented, four days where R1 ate 26-50% of her meals, fourteen days she ate 51-75% of her meals, and eight days she ate 76-100% of her meals. The facility was unable to provide any other meal intake records for October or November. The Weights and Vitals Tab, dated 11/12/24, documented R1's weight was 152 lbs. This value was crossed out as disputed by licensed nursing staff on 12/15/24. The Nutrition/Dietary Note, dated 11/15/24, documented a nutrition review was completed related to R1's wound. R1 had a Stage 4 pressure ulcer to her coccyx and required increased nutrient needs for healing. R1 was eating 50-100% of her meals on a mechanical soft consistent carbohydrate diet with honey-thickened liquids. The RD recommended ordering 30 milliliters (ml) of liquid protein to provide R1 with 200 kilocalories and 30 grams of protein for wound healing demands. The note recorded the RD would monitor and follow up as needed. R1's Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) lacked any orders for 30 ml of liquid protein for wound healing demands. The Weights and Vitals Tab, dated 11/16/24, documented R1's weight was 152.8 pounds. This value was crossed out as disputed by licensed nursing staff on 12/15/24. The Weights and Vitals Tab, dated 11/23/24, documented R1's weight was 162.4 pounds. Meal Percentages for December 2024 from 12/07/24 through 12/16/24 documented R1 had two meals where no percentages were documented, three meals she ate 0-25% of her meal, five meals she ate 26-50% of her meal, seven meals she ate 51-75% of her meals, and ten meals she ate 76-100% of her meals. The Nutritional Assessment Note, dated 12/10/24, documented R1 had significant deterioration of wounds with infection present, was on antibiotics, and had multiple Stage 4 pressure ulcers. R1 required increased protein/kilocalorie needs as her intake at meals were inadequate to meet her increased needs. Recommendations included modifying R1's diet to regular/mechanical soft with honey-thickened fluids, ordering 60 ml of liquid protein twice a day, ordering fortified foods with meals, and monitoring intakes, labs, wound status, and follow-up as needed. On 12/11/24, R1's December 2024 MAR documented an order for a Prenatal Vitamin, one tab daily, for wound healing per the facility's request. On 12/12/24, R1's MAR documented Prostat (liquid protein) 60 ml twice a day was ordered for wound healing. Upon the surveyor's request, the facility weighed R1 on 12/17/24. R1's weight was 154 pounds. On 12/17/24 at 09:30 AM, observation revealed R1 laid in bed on her left side with covers over her. R1's water pitcher was back on a bedside table, unreachable for R1. On 12/17/24 at 10:30 AM, observation revealed a dressing change performed to R1's right Stage 4 pressure ulcer. The removed dressing was saturated with serosanguineous (semi-thick blood-tinged drainage) drainage. The pressure area had a large amount of gray eschar (dead tissue) and a moderate amount of cream-colored slough (dead tissue, usually cream or yellow in color). Licensed Nurse (LN) G and Certified Nurse Aide (CNA) M donned gloves but no gowns and CNA M held R1 over to her left side while LN G cleansed the wound, cut the dressing to fit the wound, and then covered the wound with a bordered dressing. R1 did complain of pain during the dressing change. The staff did not measure R1's wound. On 12/17/24 at 11:40 AM, R1 stated she could not feed herself all the time because she got so tired. She also stated staff did not help her eat or drink at mealtime. R1 stated she was not always offered water to drink with care and when she asked for water staff did not hear her. On 12/17/24 at 09:35 AM, Certified Medication Aide (CMA) R stated R1 came to the facility with pressure ulcers. CMA R stated R1 required turning and repositioning and required assistance with eating her food at mealtimes. On 12/17/24 at 11:30 AM, CNA M stated R1 required assistance with eating sometimes, but generally was able to eat by herself after the meals were set-up. CNA M stated there was no turning schedule for R1 and charting on turning was only every shift. CNA M stated the aides just kept R1's turning schedule in their heads and turned her when it was time. On 12/17/24 at 01:00 PM, RD GG stated it was not unusual for the first weight after admission to a facility to be wrong. RD GG stated she saw the first several weights were struck out by the nursing staff. RD GG stated she had not requested new weights to be obtained. RD GG stated baseline weights on new admissions should be obtained weekly for the first four weeks. RD GG verified baseline weights on R1 were not obtained by the facility. RD GG stated she did not realized that her first recommendation for additional protein had not been ordered for R1 until she reviewed R1's weights and wounds in December and made additional recommendations. On 12/17/24 at 01:30 PM, Administrative Nurse D stated it was the facility's policy to obtain weights on new admissions for the first four weeks after a resident was admitted to the facility, to obtain a baseline. Administrative D stated residents on skilled care were weighed weekly and verified R1 had been on skilled care for strengthening and therapy. Administrative Nurse D stated all of the weights were reviewed weekly and she did not know why R1's weights were not obtained but it probably had to do with agency staff not charting the weights. Administrative Nurse D stated nursing staff did not see RD GG's order in November for liquid protein to be added to R1's MAR and verified R1 did not start receiving liquid protein for increased protein intake and wound healing until 12/12/24. Administrative Nurse D also verified a multivitamin had not been ordered for wound healing until 12/11/24. Administrative Nurse D stated R1's plan of care did state R1 did not eat meat per her choice, but she had talked to dietary staff, and they stated R1 did eat meat. The facility's Weight Monitoring Policy, dated 10/30/24, documented based on the resident's comprehensive assessment, the facility will ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this is not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight (gradual unintended weight loss over a period) may indicate a nutritional problem. The facility will utilize a systemic approach to a resident's nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors, evaluating, and analyzing the assessment information, developing, and consistently implementing pertinent approaches, monitoring the effectiveness of interventions, and revising when necessary. Implementation gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's nutritional concerns and preferences. Interventions will be identified, implemented, monitored, and modified consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. The newly admitted resident's weight will be monitored weekly for four weeks. Residents with weight loss weights will be monitored weekly. If clinically indicated monitor weight daily. All others monitor weight monthly. The newly recorded resident weight should be compared to the previously recorded weight. A significant change in weight is defined as: a 5% change in weight in 1 month, a 7.5% change in weight in three months, and a 10% change in weight in six months. The physician should be informed of a significant change in weight and may order nutritional interventions. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary team as needed. If the interdisciplinary team desires to explore specific meal consumption information for a resident the RD or Dietary Manager, or the nursing department may initiate this process. The RD or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition process notes. Observations pertinent to the resident's weight status should be recorded in the medical record. The interdisciplinary team communicated care instructions to staff. The facility failed to obtain consistent weight to establish a baseline, failed to identify and respond to progressive weight loss with interventions and increased assistance, and failed to follow the RD's recommendations to provide nutritional support for R1. Subsequently, R1 had a 19.5 % significant weight loss in ninety-five days from her admission on 09/13/24. This deficient practice also placed R1 at risk for decreased nourishment and delayed wound healing.

The facility identified a census of 34 residents. The facility identified 11 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observation, and interview, the facility failed to ensure staff implemented targeted gown and glove use during the high-contact care of a resident with a wound infection during a dressing change. This deficient practice placed the resident at risk for infectious diseases. Findings included: - On 12/17/24 at 10:30 AM, Licensed Nurse (LN) G and Certified Nurse's Aide (CNA) M entered R1's room to perform a dressing change to the resident's buttocks. LN G and CNA M did not don a gown for the dressing change. LN G and CNA M entered R1's room, donned gloves only, and performed the dressing change. CNA M held R1 over to her left side while LN G cleansed the wound, cut the dressing to fit the wound, and then covered the wound with a bordered dressing. R1 did complain of pain during the dressing change. No measurements were taken of R1's wound. On 12/17/24 at 10:45 AM, LN G stated she had forgotten the resident was on EBP and verified she had not donned a gown prior to performing the resident's dressing change. On 12/17/24 at 11:30 AM, CNA M verified she had not donned a gown prior to assisting LN G with the resident's dressing change. On 12/17/24 at 01:30 PM Administrative Nurse D stated LN G had come to her after the dressing change and told her she had forgotten to don a gown prior to performing the dressing change. Administrative Nurse D verified R1 was on EBP for the wound on R1's buttocks. Administrative Nurse D stated there were a total of 11 residents on EBP. Administrative Nurse D stated the staff should have donned gowns and gloves prior to completing the resident's wound care. The facility's Enhanced Barrier Precautions Policy, dated 04/01/24, documented it is the policy of this facility to implement EBP for the prevention of transmission of multi-drug resistant organisms. All staff will receive training upon hire and at least annually and are expected to comply with all designated precautions. The facility will make gowns and gloves available immediately near or outside of the resident's room. Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside the room). Position trash can inside the resident room or near the exit for discarding PPE after removal prior to exit of the room or before providing care for another resident in the same room. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. The facility failed to ensure staff wore a gown during the high-contact care of a resident with a wound infection during a dressing change. This deficient practice placed the resident at risk for infectious diseases.

The facility had a census of 58 residents. The sample included three residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from misappropriation of her property. This placed the resident at risk for ongoing misappropriation and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), pain, hypertension (high blood pressure), and weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented a resident interview where R2 indicated choosing her own clothes, and taking care of her personal belongings or things was very important to her. The Quarterly MDS dated [DATE] documented R2 had moderately impaired cognition. R2 required supervision with upper body dressing and personal hygiene. R2 required partial assistance with toileting, mobility, lower body dressing, and transfers. R2 did not ambulate. R2's Care Plan, dated 08/16/24 and initiated on 11/29/23, documented R2 had impaired cognition and directed staff to cue, reorient, and supervise as needed. The plan directed staff to administer medications as needed, engage in simple, structured activities that avoid overly demanding tasks, and monitor for any changes in R2's cognition. R2's Inventory Sheet, dated 12/11/23 documented R2 had a gold diamond ring. The facility Investigation Report, dated 10/29/24, documented that staff reported to Administrative Nurse D that R2's wedding ring was missing from her finger. R2's knuckle on the ring finger was very large and the ring would not have been able to fall off. R2 reported to staff that someone sprayed something on her finger, and took the ring, and her finger had hurt for a few days. R2 could not remember who or when this occurred. Administrative Nurse D searched R2's room, interviewed and obtained witness statements of all staff who had worked that day and the previous night. The facility was searched by leadership staff and the ring was not located. The facility contacted local Law Enforcement (LE) and statements were given. The facility conducted a staff in-service for Abuse Neglect and Exploitation. On 11/13/24 at 08:30 AM, observation revealed that R2 sat in her recliner and received a breathing treatment. On 11/13/24 at 09:00 AM, Social Service X stated she received a call to see if she had locked up R2's wedding ring as it was missing from R2's finger. Social Service X stated she had not locked up the ring and could not remember when she had last seen the ring. Social Service X stated she, Administrative Nurse D, and Administrative Staff A searched R2's room, her roommate's belongings, and the laundry but they were unable to locate the ring. Social Service X stated that when R2 was first admitted to the facility, she asked R2's family to take the ring home but several family members could not get the ring off her finger, so they left it on her finger. Social Service X stated that during the recent care plan meeting R2, who was cognitively impaired, told them again that someone had taken the ring but could not pinpoint when it happened. Social Service X stated when residents were admitted to the facility with anything of value like expensive jewelry, she asked the family to take it home or keep it in the facility lockbox. On 11/13/24 at 9:19 AM, Administrative Nurse D stated she had been notified by a staff member that they could not locate R2's wedding ring and she had thought it was in the facility lock box because someone had found a ring, but it was not R2's wedding ring. Administrative Nurse D interviewed staff and searched R2's room, and the recliner in the living room area she always sat in. Administrative Nurse D said staff took apart the plumbing to the sink but were still unable to locate the ring. Staff filled out witness statements, and agency staff were notified that a statement would need to be filled out as soon as possible. Administrative Nurse D stated the two agency staff members who had worked at the facility declined to come in and write statements and then canceled all their upcoming shifts. LE was notified and a report with all the information as well as the two agency staff members was provided to the police. A picture of the ring was also provided to the police department. On 11/13/24 at 9:30 AM, Administrative Staff A stated he searched the resident's room as well as the roommates' possessions, and recliners, and took apart the washing machine and sink plumbing in the hope that the ring was there. Administrative Staff A stated they interviewed staff and contacted the police to start an investigation. Administrative Staff A stated the facility would rather the family take valuables with them or keep them in their lockbox, just so they are not faced with this kind of situation. On 11/13/24 at 2:30 PM, Certified Nurse Aide (CNA) M stated she had only worked at the facility for a few days and was unaware of the missing ring. On 11/13/24 at 02:45 PM Licensed Nurse H stated she had seen R2's wedding ring when she would do her assessments but could not remember when the ring was last on her finger and did not know what happened to it. The facility's Personal Property undated policy, documented, that this facility understands the value and importance of everyone's personal property. The loss of valuable personal property is an unfortunate event and a very difficult task to manage in a long-term care facility where many diverse residents reside and employees work, there are many valuables to control including the presence of confused and/or ambulatory residents, multiple occupancy rooms, visitation by friends and relatives, and residents who frequently leave the facility. By defining an approach to investigate complaints of theft or misplaced personal property, the administration wishes not only to discover lost items but also to gather information and determine potential patterns that may lead to the reduction and eventual prevention of lost items or theft. The facility's The Resident's Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, undated, documented the residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the company. The facility failed to protect R2 from misappropriation of resident property after staff failed to safeguard R2's wedding ring, which had to be physically removed, went missing. This placed the resident at risk for further loss of property and psychosocial decline.

The facility had a census of 58 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures for Resident (R) 1 during wound care, when staff did not change her gloves after she cleansed the wound. This placed the resident at risk for continued wound infection and complications. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), open lesion (wound or injury), and cellulitis of the foot (skin infection caused by bacteria). The Quarterly/Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented that R1 had intact cognition. R1 required set-up assistance with eating, bathing, personal hygiene, and transfers. The MDS documented R1 was at risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), had an infection of the foot, and had application of ointment and dressings to the feet. R1's Care Plan, dated 08/15/24 and initiated on 07/28/21, directed staff to observe and assess her skin weekly, refer to the dietician with skin concerns and supplement with vitamins as indicated. The update, dated 10/25/24, directed staff to promote good nutrition and hydration, document weekly treatments including measurements of each area of skin breakdown, and follow facility protocols for treatment of injury. R1's Physician's Order, dated 10/28/24, directed staff to cleanse the open lesion to the bottom of her right foot with Hibiclens (antiseptic skin cleanser used to prevent skin infections) and water, apply Triple Antibiotic Ointment (TAO-a antibiotic ointment used to prevent and treat minor skin infections) to the open area, apply an ABD pad (large pad to absorb drainage), and wrap with Kling (a sterile, flexible, rolled gauze bandage used to secure gauze pads or nonstick dressings), every day shift for the right foot wound. On 11/13/24 at 3:03 PM, observation revealed R1, in her recliner, with her feet elevated. Licensed Nurse (LN) G sanitized her hands, donned a clean gown and gloves, placed a barrier under R1's right foot, and removed the soiled dressing. The dressing had brown drainage visible which had soaked through the dressing and LN G placed it in a red bag. LN G then removed her soiled gloves, performed hand hygiene, and donned clean gloves. LN G used her tablet to take pictures of the wound and also took R1's phone to take pictures of the wound for the resident. Wearing the same gloves, LN G cleansed the wound with wound cleanser. LN G applied a small amount of TAO directly onto R1's wound wearing the same soiled gloves and then placed a fresh ABD pad on it and wrapped R1's foot with the Kling. On 11/13/24 at 3:10 PM, LN G stated she measured the wound weekly and the dressing was changed daily. LN G stated she should have changed her gloves after she cleansed the wound. On 11/13/24 at 03:30 PM, Administrative Nurse D stated LN G should have changed her gloves after she cleansed the wound. The facility's Infection Control Preventing Spread of Infection undated policy, documented the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility administration and medical director should ensure that current standards of practice based on recognized guidelines are incorporated into the resident care policies and procedures. These practices must include hand hygiene before and after changing a dressing. The facility failed to ensure adequate infection control measures during wound care for R1, who had a recent infection in her right foot wound, This placed the resident at risk for continued infection and complications.

The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the refrigerator seals were intact and ailed to use sanitation strips for the three-compartment sink. This placed the residents at risk for foodborne illness. Findings included: - On [DATE] at 08:30 AM, observation of the kitchen revealed a #1 two-door refrigerator with door seals peeling off. Further observation revealed #2 two-door refrigerator with door seals peeling off both doors. On [DATE] at 08:45 AM, observation revealed a three-compartment sink with water in the sink. Further observation revealed a cork bulletin board hanging above the sink with large pieces of the cork board falling into the sink. On [DATE] at 08:50 AM, observation revealed a plastic baggie hanging on the cork bulletin board above the three-compartment sink which contained sanitation strips with an expiration date of [DATE]. On [DATE] at 08:50 AM, Dietary Staff (DS) BB verified refrigerators #1 and # 2 with door seals peeling off. DS BB verified sanitation strips for checking the three-compartment sink had expired. On [DATE] at 09:50 AM, Maintenance Staff (MS) verified refrigerators #1 and #2 needed repair of the door seals. The facility's undated Food-Supply Storage-Food and Nutrition Services Policy documented to ensure food is stored properly The dishwashing areas and sink sanitation are to be tested daily and recorded. The facility failed to ensure the refrigerator seals were intact and failed to use sanitation strips for the three-compartment sink. This placed the residents at risk for foodborne illness.

The facility had a census of 47 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required infection preventionist attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 02/05/24 at 10:45 AM, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence the infection preventionist attended the June 2023, September 2023, and December 2023 meetings. On 02/05/24 at 12:33 PM, Administrative Nurse D verified the lack of an infection preventionist signature on the quarterly meetings sign-in sheets and stated the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI) documented the purpose of the QAPI was to provide excellent quality care and services to the residents. The QAPI committee would meet monthly to report and discuss identified trends or concerns from internal monitoring and auditing. The administrator would be responsible for documenting and maintain QAPI meeting minutes. The facility failed to retain evidence of the required QAA and QAPI member, the infection preventionist, attended meetings at least quarterly. This placed residents at risk of unidentified quality care services.

The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 47 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for impaired nutrition. Findings included: - On 01/30/24 at 08:30 AM, observation revealed Dietary Staff BB was in the kitchen and oversaw the preparation of the breakfast meal. On 01/30/24 at 08:35 AM, Dietary Staff BB verified she was not a certified dietary manager. On 01/30/24 at 09:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Director of Food and Nutrition Services policy, dated 2021, stated the director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, cost management, and meeting nutritional needs of the residents. The director of food services is to be a certified dietary manager. The facility failed to employ a full-time certified dietary manager for 47 residents who resided in the facility. This placed the residents at risk for inadequate nutrition.

The facility identified a census of 40 residents. The sample included four residents. Based on observations, record review, and interviews, the facility failed to ensure staff implemented care and treatment consistent with standards of care, and physician orders, when staff failed to follow physician orders, and failed to update the physician when the resident did not receive medications and failure to follow physician orders. On 04/04/23 Resident (R)1's urinalysis (examination of urine) revealed a urinary tract infection (UTI) and R1's physician ordered Bactrim DS (antibiotic- medication used to treat infection) twice daily for five days, to start on 04/05/23. On 04/05/23, the Bactrim DS was not administered for both morning and evening doses and was marked as not available. On 04/06/23, the morning dose of Bactrim DS was not administered due to lack of availability. R1's medical record lacked evidence the physician was notified. On 04/06/23 R1's physician reviewed R1's complete metabolic panel (CMP- laboratory test used to examine the function of several organs in the body) results, drawn on 04/04/23, and faxed an order to the facility which directed staff to administer one liter of normal saline (saline water solution) intravenously (IV- infusion administration of fluids into a vein by means of a steel needle or plastic catheter). Facility staff did not administer the IV fluids to R1 due to the lack of availability. R1's medical record lacked evidence the physician was notified. On 04/08/23, R1's family was in the facility and expressed concerns regarding the fact that R1 had not received the IV fluids as ordered by the physician and insisted the resident receive the fluids that evening. Staff then notified R1's physician and received an order to send R1 to the hospital for hydration. R1 went to the hospital and was admitted with UTI, sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock), and acute kidney injury (AKI- sudden decrease in kidney function). The facility's failure to ensure staff provided adequate care and treatment for R1 placed R1 in Immediate Jeopardy. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 04/08/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dehydration, volume depletion (state of abnormally low extracellular [fluid found outside of cells] fluid in the body), and chronic kidney disease stage four (CKD- gradual loss of kidney function). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. R1 required extensive assistance with two staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. R1 received antibiotic medications two days in the seven-day lookback period. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 01/19/23, documented R1 had a BIMS score of seven and had short-term and long-term memory loss. The Care Plan dated 03/21/23, documented R1 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and directed staff performed catheter care every shift and as needed. The Care Plan did not address R1's antibiotic usage or UTI. The Orders tab of R1's EMR documented an order dated 04/04/23 for Bactrim DS 800-160 milligrams (mg) two times a day for UTI for five days. Review of R1's Medication Administration Record (MAR) for April 2023 documented Bactrim DS was to be administered starting the morning of 04/05/23. The MAR revealed Bactrim DS was not administered for the scheduled doses on 04/05/23 morning dose, 04/05/23 evening dose, and 04/06/23 morning dose. The Notes tab of R1's EMR revealed the following: An Orders- Administration Note on 04/05/23 at 08:46 AM documented Bactrim DS was not administered with a reason as not applicable. An Orders- Administration Note on 04/05/23 at 05:38 PM documented Bactrim DS was not administered with a reason as not delivered. An Orders- Administration Note on 04/06/23 at 09:09 AM documented Bactrim DS was not administered with a reason as waiting for delivery. The Miscellaneous (Misc.) tab of R1's EMR revealed a Physician Order/Communication Sheet for Laboratory Results that documented a fax was sent on 04/04/23 to Consultant GG regarding CMP laboratory results. On 04/06/23, Consultant GG wrote an order to give one liter of NS via IV for R1 and was faxed back to the facility on [DATE]. The Orders tab of R1's EMR lacked evidence of the order for NS. The Notes tab of R1's EMR revealed the following: A Nurse's Note on 04/06/23 at 01:11 PM documented staff left a message with R1's family member regarding orders from Consultant GG. An Infection Note on 04/06/23 at 08:41 PM documented an infection control assessment was completed that shift for R1 due to a catheter associated UTI. The Note recorded the physician reviewed R1 for signs/symptoms of infection telephonically. R1's medical record lacked evidence the physician was notified of the missed Bactrim DS doses on 04/05/23 and 04/06/23 or the lack of IV fluid administration as ordered. A General Note on 04/09/23 at 03:53 AM documented at around 08:30 PM, R1's family was at the facility verbalizing a concern that she had not received the ordered IV fluids. The facility was still waiting for delivery of IV fluids from pharmacy. R1's family insisted she received fluids that night and an order was received from Consultant GG to send R1 to the hospital for hydration. R1 left the facility around 09:00 PM. The Misc tab of R1's EMR revealed a History and Physical Reports from the hospital on 04/09/23. The History and Physical documented R1 was found to have a UTI last week and was started on Bactrim. She was also noted to have an AKI and struggled to maintain adequate oral liquid intake so was to get IV fluids but was unable to receive them. R1 was admitted to the hospital with diagnoses of UTI with sepsis. On 04/19/23 at 11:58 AM, Administrative Nurse D stated R1 had missed antibiotics and fluids. The physician had ordered Bactrim and the pharmacy said they did not receive the order until 4/6/23, but staff stated they called it in on 4/4/23. She stated staff should have used the emergency medication kit (eKit) for the Bactrim but the eKit did not have IV fluids. On 04/19/23 at 01:54 PM, Certified Medication Aide (CMA) R stated if a medication was unavailable, she notified the nurse and called the pharmacy to see if they received the order. If the pharmacy had not received the order, she let the nurse know. She stated she checked the eKit. for the medication and there was a paper that listed what medications were available. CMA R stated she always ensured or tried to do everything she could to make sure the medication was given. On 04/19/23 at 2:00 PM, Licensed Nurse (LN) G stated when new orders were received, they were placed in the computer by the nurse assigned to the resident for the order. She stated the facility communicated with the physician via fax for something vague or called their office for something needed right away. LN G stated after an order was placed in the computer, it was faxed to the pharmacy which usually delivered within one day. She stated if the medication was in the eKit, she pulled it out of there and there was a list of the medications available in the kit, Bactrim was in the eKit. LN G stated if a resident missed a dose, the physician was notified. If an order for IV fluids was received, the pharmacy was notified. The physician was notified if the fluids were not going to be delivered until later. LN G stated the person who received the order, put the order in the computer. If she knew about a situation, she followed up the next day if an order had not been received. On 04/19/23 at 02:16 PM, Administrative Nurse D stated the nurse on the floor received new orders and were expected to place them in the computer and notify the pharmacy and family of changes. She stated if a medication was unavailable, staff were expected to check to see if the medication was brought in and if they did not find it, they were to check the eKit, especially if it was an antibiotic. Administrative Nurse D stated residents should not have missed any doses of medications and the physician was notified if one dose was missed then documented in the nurse's notes. She stated the IV fluid order was received via fax and should have been placed in the computer then sent to the pharmacy. The nurse should have followed up on the IV fluids the next day. Administrative Nurse D stated she completed an audit and realized the antibiotics and fluids were missed so it was reported to state. On 04/20/23 at 10:53 AM, Consultant GG stated he was not notified R1 had missed antibiotic doses and had not received the IV fluids until her family was in the facility and wanted her sent to the hospital for fluids. He stated he was not sure if the delay in treatment contributed to her hospitalization because she was on the incorrect antibiotic for her UTI which they discovered in the hospital. Consultant GG stated R1's care was delayed, and he expected to be notified if an antibiotic was missed. The facility's Notification of Changes policy, not dated, directed the facility consulted the resident's physician when there was a change requiring such notification which included circumstances that required a need to alter treatment. The facility's Consulting Physician/Practitioner Orders policy, dated 01/01/20, directed for orders received in writing or via fax, the nurse in a timely manner: called the physician to verify the order; documented the verification order; and followed facility procedures for verbal and telephone orders which included noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. The facility failed to implement orders for Bactrim and IV fluids in a timely manner for R1 and failed to notify Consultant GG of the missed doses of Bactrim and IV fluids. R1 was sent to the hospital for IV fluids and was admitted for UTI with sepsis and AKI. The facility's failure placed R1 in immediate jeopardy. The facility completed the following corrections by 04/17/23: All relevant staff received education for administration of medications, removal of needed medications from the emergency kit when needed, following up with the pharmacy to ensure medications delivered and physician notification. Daily medication audits started on 04/14/23 by Administrative Nurse D An eKit for IV fluids was obtained from the pharmacy. The corrections were completed prior to the start of the survey therefore the deficient practice was cited at past non-compliance.

The facility identified a census of 40 residents. The sample included three residents with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from accidents and hazards when Certified Nurse's Aide (CNA) M prepared a hot pack and placed it to R1's left hip without consulting the nurse on duty and without assessing the actual temperature of the hot pack. As a result, R1 sustained two second degree [CONDITION(S)] (burn which affects the first and second layers of skin and can cause severe pain) to his left hip. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscular weakness of one half of the body) following cerebral infarction (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) affecting the left non-dominant side, convulsions (involuntary series of contractions of a group of muscles), and cognitive communications deficit (difficulty with thinking and how someone uses language). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1's Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS further documented R1 required total dependence of two staff for transfers, locomotion, and bathing and extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. The Activity of Daily Living Care Area Assessment (CAA) dated 04/03/21 documented R1 required assistance with activities of daily living and directed staff to anticipate R1's needs to make ensure his care needs were effectively met. The Pain Care Plan, revised on 07/14/21, directed staff to administer analgesia as ordered, observe and report changes in usual routine, sleep patterns, and abilities, and to encourage R1 to try different pain relieving methods like positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, and muscle stimulation. The Nurses Note, dated 02/21/22, documented R1's primary care physician was at the facility on rounds and wrote a new order to apply heat to left hip for pain. The EMR's Electronic Treatment Administration Record (ETAR), dated 02/21/22, recorded a physician's order which directed staff to apply a warm compress to the left hip for pain. The order further directed the nurse to monitor the temperature of the warm pack, for 15 minutes or less at a time and to assess the skin after each application. The order directed nursing to dampen a washcloth with warm water, place in a plastic zip bag, seal, and wrap the plastic bag with a towel before placing on R1. The Facility Investigation documented a timeline of events which started on 03/12/22, when Licensed Nurse (LN) H alerted Administrative Nurse D that R1 had blisters to the left thigh. On 03/12/22 R1 stated in an interview with facility staff that he asked for a warm pack for his hip due to pain. R1 told facility the night shift girl gave him a warm pack which was hot. R1 reported he did not alert any other staff about the warm pack and reported when the staff member came back to retrieve the warm pack, he did not have pain from the wound. The timeline recorded LN I was on duty at the time of the incident. LN I reported she was unaware R1 received a warm pack for his pain. The timeline further recorded on 03/14/22 CNA M reported she placed a warm pack on R1's thigh per his request. CNA M stated the temperature of the pack was warm, but not hot and was on the resident for 10-15 minutes. CNA M reported to Administrative D she was unaware warm packs were considered medical treatments and required a nurse to administer. The Nurses Note, dated 03/13/22, documented R1 had two open areas to his upper left hip and both measured 4 centimeters (cm) by 3 cm. The Skin/Wound Note, dated 03/14/22 documented a burn to R1's left hip measuring 4.6 cm by 3.3 cm. R1 told staff the burn was from a hot pack. Granulation (tissue formed during wound healing) to 100 percent (%) of the wound bed with light serous (clear) drainage. The surrounding skin was normal in color. Peri-wound (skin around the wound) was warm to the touch. Staff cleansed the wound, applied xeroform (a primary dressing used to maintain a moist wound environment) to the wound bed and covered the wound with an abdominal dressing. The note continued to document a second burn to R1's left hip measuring 5.4 cm by 2.5 cm which R1 reported to staff was also from a hot pack. The wound had granulation to 100% of the wound bed with light serous sanguineous (semi-thick reddish) drainage. The surrounding skin was normal in color. The peri-wound temperature was warm to the touch. Staff cleansed the wound, applied xeroform applied and covered the wound with an abdominal dressing. The Skin/Wound Note, dated 03/23/22, documented the first burn to R1's left thigh measured 5.1 cm by 2.6 cm. Slough (dead tissue, usually cream or yellow in color) covered 70% of the wound bed and 30% of the wound bed was granulation tissue with no drainage noted. The surrounding tissue was normal in color. The Skin/Wound Note, continued to document the second burn to R1's left thigh measured 4.7 cm x 4.1 cm. Slough covered 80% of the wound bed and 20% of the wound bed had granulation. Staff cleansed the wounds, applied xeroform and covered the wound with an abdominal pad. The Nurses Note, dated 03/25/22, documented a new order to change the dressing to the wounds on R1's left hip to [MEDICATION(S)] (a [MEDICATION(S)] burn ointment) 1% ointment to be applied to the [CONDITION(S)] on the left hip daily and covered with a gauze dressing. The order directed to follow up with R1's primary care physician in one week. On 03/29/22 at 12:45 PM, LN G changed the dressing to R1'sleft hip. Observation revealed two wounds on the left hip. The first wound measured 4.82 cm by 2.53 cm. The wound bed had 100% granulation. The second wound measured 3.93 cm by 2.68 cm with 100% granulation to the wound bed. On 03/29/22 at 11:30 AM, LN G stated that she never applied a warm most pack on a resident while working at the facility. On 03/29/22 at 11:40 AM, LN H stated she never used warm moist packs while working at the facility and never had a resident ask for a warm moist pack. On 03/29/22 at 12:00 PM, CNA N stated she never placed warm moist packs on any resident while working at the facility. CNA N stated a warm moist pack would have to be applied by the nurse on duty, not the CNA. On 03/29/22 at 12:50 PM R1 stated he requested the warm moist pack from CNA M. R1 said when CNA M brought it to him it felt good at first and then it got too .hot. R1 stated he moved the warm pack further down on his left hip. He stated he did not let anyone know the warm moist pack was too hot. R1 stated he received the warm moist packs on previous occasions. R1 stated the [CONDITION(S)] on his left hip hurt all the time, but especially at night when he got tremors in his legs. On 03/29/22 at 12:55 PM, Administrative Staff A stated the incident should not have happened because CNA M should have known not to place a warm moist pack onto R1's left hip. Administrative Staff A stated she educated CNA M regarding treatments which were only to be performed by nurses on duty. Administrative Staff A stated CNA M should have reported R1's pain to the nurse on shift. On 03/29/22 at 01:10 PM, Administrative Nurse D stated she expected all CNAs to notify the nurse if any resident had pain. Administrative Nurse D stated CNAs should not perform a treatment for the resident that may harm the resident or place the resident at risk for injury. The facility's undated Accidents and Supervision policy documented the resident environment will remain as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to ensure R1 was free from accidents or hazards when CNA M prepared a hot pack and placed it to R1's left hip without consulting the nurse on duty and without assessing the actual temperature of the hot pack. As a result, R1 sustained two second degree [CONDITION(S)] to his left hip. This deficient practice placed R1 at risk for impaired healing and infection. On 03/15/22 the facility completed the following corrections: Education to all staff stating reiterating that all medical interventions must be physician ordered and administered under the supervision of a licensed nurse or physician. Education was provided to nursing staff on the safe use of warm compresses. CNA M was suspended during the investigation and educated on 03/15/22. The deficient practice was cited as past non-compliance.

The facility had a census of 34 residents. The sample included six residents. Based on observation, record review, and interview, the facility failed to properly isolate two cognitively impaired residents who freely ambulated throughout facility without masks, Resident (R) 1 whose Durable Power of Attorney (DPOA) refused COVID-19 (a mild to severe respiratory illness caused by a new strain of coronavirus, characterized by fever, cough, shortness of breath) testing and R5, a new admission. The facility failed to ensure five isolated resident room doors remained closed (R1, R2, R4, R5, R6) and failed to properly complete Coronavirus Risk Questionnaires since 03/15/20, placing all residents in the facility in immediate jeopardy. Findings included: - On 06/16/20 at 08:30 AM, upon entrance into the facility, Administrative Staff A and Administrative Nurse D reported no residents in isolation. Initial tour revealed no Personal Protective Equipment (PPE) containers noted in hallways and no isolation signs obvious on resident doors. On 06/16/20 at 09:00 AM, observation revealed R1 and R5 ambulated in the North and South hallways without masks. Further observation revealed R2, R4 and R6 seated in their rooms with doors open and no visible signs on doors referring to precautions about isolation. On 06/16/20 at 10:44 AM, observation revealed R4's room door lacked a yellow sign that noted Attention visitors please check with nurse prior to entering room and upon further observation, Administrative Nurse D located the sign on a table inside the resident's room, not visible before entering the room. On 06/16/20 at 10:30 AM, Administrative Nurse D verified the facility had five residents on isolation precautions, and the facility allowed these doors to be open. On 06/16/20 at 11:13 AM, Administrative Nurse D and Administrative Staff A verified R1 on isolation, wandered the entire building, refused to wear a mask, and family refused to have the resident COVID-19 tested . The facility placed a yellow sign on the R1's room door which stated Attention visitors please check with nurse prior to entering room, the sign was difficult to see when the door was open, and the PPE was inside the isolation rooms as R1 would contaminate the PPE when it was in the hallway. Administrative Nurse D and Administrative Staff A verified R1, R2, R4, R5 and R6 were on isolation. On 06/16/20 at 11:52 AM, Administrative Nurse D stated isolation residents should be on the COVID-19 isolation wing, but the facility did not want to utilize (PRN) as needed and agency staff. Administrative Nurse D stated the residents on isolation had their doors open so staff could monitor the residents for falls and corporate staff informed her today that the isolation room doors should remain closed and residents remain in their rooms. On 06/16/20 at 03:32 PM, Licensed Nurse (LN) G verified the isolation room doors should be closed and had found them open. LN G verified R1 and R4 were on isolation, often came out of their rooms, and if a resident was on isolation, the resident should not be out of their room. LN G stated R2 and R4 were new admissions and any new admissions or returns from the hospital were placed on isolation precautions for 14 days. On 06/16/20 at 03:46 PM, Certified Nurse Aide (CNA) M verified R2, R4, R5 and R6 were on isolation because all new admissions and return from hospitals were on 14 day isolation, and R1 came out of isolation today. CNA M stated that R1 and R5 were difficult to keep in their rooms and ambulated in both the North and South halls. CNA M verified the isolation room doors should be closed and were often left open. On 06/17/20 at 02:18 PM, Administrative Staff A stated the facility had an all staff in-service on 03/30/20 and educated all staff on how to complete the Coronavirus Risk Questionnaire upon entrance to the facility, staff were instructed to complete the questionnaire for any non-employees and check the non-employees' temperature. Administrative Staff A verified if an employee entered the building, whomever let the employee into the building needed to verify the Coronavirus Risk Questionnaire was thoroughly completed and a temperature obtained. Administrative Staff A stated she reviewed the temperature logs, but did not review the Coronavirus Risk Questionnaire for completion. A random review of the Coronavirus Risk Questionnaires for four days between the dates of 03/15 and 06/16/20 revealed 30 forms not fully completed. The facility's COVID 19 Testing policy, dated 05/04/20, documented current in-house residents would be tested via a nasopharyngeal (back of the nasal cavity) swab. Residents that refused testing would be moved to isolation unit. All new admissions and readmissions without a negative swab in the 24 hours prior to discharge to the facility would be placed in the isolation unit (private room preferred, if available) and tested via a nasopharyngeal swab. The resident would be monitored for COVID-19 via facility protocol. The facility's Isolation - Categories of Transmission Based Precautions policy, dated August 2012, documented the facility would implement a system to alert staff and visitors to the type of precaution the resident required. The facility would ensure that the resident's care plan and care specialist communication system indicated the type of precautions implemented for the resident. Staff would apply a mask when entering the room or cubicle. For contact precautions the staff wear disposable gown upon entering the contact precaution room. The facility failed to properly isolate two cognitively impaired residents, R1 and R5, who freely ambulated throughout facility without masks, failed to ensure five isolated residents room doors (R1, R2, R4, R5, R6) remained closed, and failed to properly complete Coronavirus Risk Questionnaires since 03/15/20. This deficient practice placed the 34 residents in the facility in immediate jeopardy. The facility presented an acceptable plan for removal of the immediate jeopardy on 06/17/20 at 09:08 PM, which included an in-service on 06/17/20 with staff on isolation precautions and keeping isolation room doors closed. R5 placed on 1:1 observation to ensure she stayed in her room. R1 removed from isolation precautions. On 06/18/20 education completed with designated screeners and staff on completing the COVID-19 Risk Questionnaire in its entirety and no person allowed in the facility if the questionnaire not fully completed. The deficient practice remained at a scope and severity of F.

The facility had a census of 54 residents. The sample included 3 residents. Based on record review and interview the facility failed to provide adequate supervision to prevent 1 of 3 residents left the building without staff supervision and was found approximately 2 and 1/2 blocks away from the facility. (1) This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 7/10/18, documented the resident had a (BIMS) Brief Interview for Mental Status score of 9, which indicated moderately impaired cognition. The MDS documented the resident had wandering behavior that occurred 1 to 3 days of the 7 day look back period, required staff supervision with (ADLs) Activities of Daily Living, balance steady at all times, and used no mobility devices. The 7/10/18 cognitive loss/dementia (CAA) Care Area Assessment documented the resident confused and was unaware of current situation, was able to follow conversation if directed by another person and wandered through the facility. The 7/3/18 initial care plan documented the resident was a risk for elopement, instructed staff to redirect the resident, encourage structured schedule, including activities and to place a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) bracelet on the resident. The 7/10/18 ADL CAA documented the resident required staff supervision with all ADLs due to his/her cognitive status. The CAA documented the resident able to ambulate with steady gait and no assistive devices. The 7/3/18 physician order [REDACTED]. The 7/19/18 at 1:33 AM nurse's note documented the resident was agitated at beginning of shift, wandered throughout facility asking staff members and residents how he/she could leave the facility. The note documented the resident complained of pan to the left ankle where wander guard device was placed, the nurse noted 1+ [MEDICAL CONDITION] to left lowered extremity, removed the wander guard and placed a new one on the residents right wrist. The note documented the nurse would continue to monitor the resident for exit seeking behaviors. The 7/20/18 at 2:05 AM nurse's note documented the resident very agitated at the beginning of shift, had removed his/her wander guard device from his/her wrist. The note documented the resident requested to go hunt for his/her cat, staff explained to the resident he/she could not allow the resident to leave without permission and attempted to walk out the front door. The note indicated staff intervened, replaced the resident's wander guard device on his/her ankle, and staff walked him/her back to the west wing. The facility's incident report documented on 7/20/18 at approximately 2:30 PM the resident was found 2 blocks away from facility by kitchen staff and was returned to facility via private vehicle at approximately 2:35 PM. The report documented the resident stated he/she was going to the store to get some thing, and when the resident returned to the building, through the front door, his/her wander guard device did set off the door alarm. The report documented upon investigation the alarm to the front door was sounding as Nurse Aide M and N were coming out of an elder's room on the North wing, Nurse Aide M shut both alarms off, and did not look outside for any elders, while the other went to help another elder. The report documented the nursed performed a head to toe assessment of the resident had there was no physical harm. The report documented the resident was last seen by staff at approximately 2:15 PM by the nurse's station, and when staff asked the resident how he/she had gotten outside, the resident pointed to the front door and said that door right there. The report documented staff checked all door alarms and were working appropriately, all residents' wanderguards were checked and were working appropriately, and the facility initiated in-service on elopement and alarm protocol. The report documented the resident had been transferred to another facility where there was a secured unit. The notarized statement from Nurse Aide M documented on 7/20/18 he/she was in a resident's room transferring a resident with Nurse Aide N, during this time he/she heard the alarms go off . When he/she finished in the room and came out , no one was around but the alarms were going off. He /she figured some one had left the doors open to long as the alarms go off frequently every day. The statement documented he/she shut one alarm off then asked for the code on the second, and shut it off. The statement documented Nurse Aide M did not think to go outside and look for anyone , when he/she had earlier started in a resident's room before the alarms went off and the nurse on duty was at the desk, so he/she assumed the nurse may had been helping someone or a resident through the doorway. The statement documented Nurse Aide M had no knowledge, until this occurred, that the resident was at risk of trying to leave the facility on his/her own or that the resident had been trying to take off his/her alarm bracelet for several days, and at least once succeeded. The statement documented Nurse Aide M have never nor would knowingly ever let a resident leave or be at risk, he/she was not updated on this new resident and as far ever as he/she knew the resident was still on the west side of the facility, where the his/her room was. The statement documented Nurse Aide M did hot see the resident before he/she entered the other resident's room nor after. The notarized statement from Dietary Aide BB documented he/she was leaving work on 7/20/18 at approximately 2:30 PM, when he/she was at the intersection of L street, looked down the block and thought he/she saw one of the facility's residents walking down the block. The statement documented Dietary Aide BB turned around and found the resident walking near L street and 27th street, and was able to get the resident to come back to the facility with him/her in his/her car. The statement documented the resident told Dietary Aide BB he/she was just going to go to the grocery store to pick up a few odds and ends. Review of the resident's 15 minute checks revealed documentation they were initiated on 7/20/18 at 3:15 PM, and were completed every 15 minutes until the resident was discharged on [DATE] at 1:00 PM. On 7/23/18 at 3:59 PM, Administrative Staff A stated the facility's front door will alarm when anyone goes out the door without punching in the code on the keypad. If a resident with a wanderguard bracelet goes out it makes both alarms go off, one for wanderguard device and one for main door key pad code device. He/She stated the facility has elopement risk assessments as a method for identifying resident's at risk for elopement, staff are trained on elopement upon hire and annually in-services with skills. Administrative Staff A stated if the door was alarming, he/she would expect staff to go outside and look to make sure there were no residents. The facility's 2001 elopement policy documented the director of nursing or designee organizes and institutes an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where the resident was last seen, and entire unit where the patient/resident resides or was last seen. The facility failed to ensure Resident #1 received adequate supervision, when he/she left the building unattended by staff, and was found 2 and 1/2 blocks away from the facility, placing the resident, placing the resident in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility immediately suspended Nurse Aide M, started in-service training on elopement on 7/20/18, placed the resident on 15 minute visual checks until he/she was discharged to another facility with a locked unit on 7/21/18 at 1:00 PM.

The facility had a census of 60 residents. The sample included 19 residents. Based on observation, record review and interview, the facility failed to provide the necessary care and services for 2 sampled residents. Resident #75 who had pain during a dressing change and staff had not administered pain medication prior to the dressing change or later after the resident complained of pain. Resident #18, when his/her feet were were not placed on foot pedals and his/her feet slid on the floor. Findings included: - Resident #75's medical record revealed the facility admitted the resident to skilled nursing on 2/27/15 and admitted the resident to Hospice (end of life care) services on 4/23/15. The (POS) physician's orders [REDACTED]. skin sensation), muscle weakness (lack of muscle strength), depression (a persistent feeling of sadness and loss of interest), and shortness of breath (a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity). The significant change (MDS) Minimum Data Set assessment, dated 5/1/15, 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 members for bed mobility, transfers, toileting, and dressing. The assessment further revealed the resident had non verbal signs of pain, vocal complaint of pain, and facial expressions of pain daily, and received scheduled and as needed pain medication. The 5/1/15 (CAA) Care Area Assessment summary for pain stated the resident had vocal complaints of pain daily during the review period, was on scheduled [MEDICATION NAME] (a narcotic [MEDICATION NAME] medication used to treat moderate to severe pain) and [MEDICATION NAME] (a medication for neuropathic pain (chronic pain state that usually is accompanied by tissue injury). The CAA further stated the resident had pressure ulcers (an area of skin that breaks down with constant pressure), arthritis (inflammation of one or more joints) and recently admitted to hospice care, who would work in conjunction with the facility to manage the resident's pain. The 5/11/15 updated care plan directed the staff to administer pain medication, to the resident as ordered, anticipate the resident's need for pain relief and immediately respond to his/her needs. The care plan directed staff to monitor the resident and record pain characteristics using a pain scale of 1-10, and report non-verbal signs and symptoms of pain. The 3/12/15 initial pain assessment indicated the resident had frequent, severe pain which limited his/her daily activity and sleeping. The 2/27/15 physician's orders [REDACTED]. [MEDICATION NAME], 2 mg, by mouth, 4 times daily, for chronic pain and document pain level upon administration. Review of the (MAR) Medication Administration Record [REDACTED] April-13 times May-19 times The 4/24/15 physician's orders [REDACTED]. Review of the 2015 MARs revealed staff administered the [MEDICATION NAME] medication as follows for pain: March-12 times April-16 times May-17 times June-23 times The 6/9/15 nursing progress note stated the resident had pain in his/her buttocks and legs and the resident received [MEDICATION NAME] 2-3 times daily, and continued to experience pain. The 6/21/15 physician's telephone order directed the staff to administer [MEDICATION NAME], 7.5 mg, by mouth, every 4 hours as needed for pain. The 6/21/15 at 6:19 PM, nurse's note stated the resident received the as needed [MEDICATION NAME] pain medication at 10:30 AM due to his/her yelling. The note further stated, when asked, the resident verified he/she was hurting and did not ask for pain medication, stating, I forgot. On 6/23/15 at 12:00 PM, observation revealed Nurse F removed the coban (a self adherent dressing that sticks to itself) from the resident's left arm. Further observation revealed the abd pad (a pad for the absorption of drainage from wounds) on the resident's elbow had dried, with brown colored drainage on the outside of the pad, which was stuck to the pressure ulcer on the resident's elbow. While Nurse F proceeded to remove the dressing from the resident's elbow, the resident hollered OUCH several times. Nurse F took a saline bullet (a small vial of sterile saline) and wet the inside of the dressing, then without letting it soak into the dry dressing to remove it easier, he/she pulled the dressing off the resident's elbow causing new skin to be pulled off. The resident's elbow began to bleed and the resident stated, that burns, ouch! The resident cursed several times stating, that hurt and the nurse stated, the dressing needed changed, with no response to the resident's complaints of pain. Nurse F placed a new abd dressing with hydrogel (an absorbent gel for wounds) and rewrapped the resident's arm with coban. Continued observation revealed Nurse F removed the coban dressing from the resident's right arm and the resident yelled,ouch, that hurts. Nurse F stated, in a harsh tone, he/she was just taking off the coban. Further observation revealed the abd dressing on the resident's right elbow also had the dried, brown colored drainage on the outside of the dressing. Licensed Nurse F used another saline bullet and wet the inside of the dressing and pulled down on the dressing. The resident yelled, ouch and the dressing came off. Licensed Nurse F replaced the old dressing with a new abd pad and hydrogel and rewrapped the elbow with coban. On 6/25/15 at 8:30 AM, observation revealed the resident at the dining room with his/her head down. Dietary Staff G asked the resident how he/she was doing. Observation further revealed the resident shook his/her head. Dietary Staff G asked the resident what was wrong, the resident stated, I hurt all over. Observation revealed Dietary Staff G stated, I hope your day gets better, but did not alert the nursing staff the resident was in pain. On 6/23/15 at 12:30 PM, Nurse F stated he/she always changed the resident's dressing that way and that the resident had received a pain pill earlier that morning. (Review of the MAR indicated [REDACTED]. Licensed Nurse F stated the resident always hollered out with pain. On 6/23/15 at 1:30 PM, Administrative Nurse A stated the resident always hollered in pain, even if staff just touched his/her arm. Administrative Nurse A stated the current dressing may not be appropriate for the resident's wounds. On 6/24/15 at 8:09 AM, Administrative Nurse B stated the nursing staff are instructed to administer pain medication to the resident at least an hour prior to dressing changes. Administrative Nurse B further stated the nursing staff are shown any new treatments for the resident's pressure ulcers but he/she does not observe to see if the nurse does the treatments correctly. On 6/24/15 at 4:00 PM, Nurse M stated the resident complained of pain a lot in the evening and the staff administer as needed [MEDICATION NAME]. On 6/25/15 at 11:01 AM, Nurse F stated the resident was on hospice care and the staff are encouraged to administer [MEDICATION NAME] to the resident for pain. Nurse F further stated the resident often complained of pain when sitting up at meals, with a majority of his/her pain a level 5, but Nurse F stated he/she did not feel the resident understood the pain scale. On 6/25/15 at 2:30 PM, Hospice Nurse O stated he/she had encouraged the staff to administer the resident's as needed pain medication more often, especially prior to wound care. Hospice Nurse O further stated, at times the resident had only been given the as needed pain medication once a day and at this time he/she was unable to get the resident more scheduled pain medication due to the lack of use of the as needed pain medication. Hospice Nurse O stated he/she has requested nursing staff administer pain medication to the resident when he/she provides wound care. The facility's 6/25/15 As Need Medication Policy stated resident's that receive as needed medication will have follow-up assessment documented on the medication/treatment record within 1-2 hours of administration. The policy further stated the Director of Nursing and Assistant Director of Nursing will follow up periodically to ensure compliance. The facility failed to administer appropriately timed pain medication to Resident #75 prior to wound care, assess the resident's pain during wound care, and acknowledge the resident's physical and verbal indications of severe pain. - Resident #18's 05/18/15 physician's orders [REDACTED]. enough insulin made or the body can't respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), [MEDICAL CONDITION] (a condition when the heart output is low and the body becomes congested with fluid), hypertension (elevated blood pressure) and [MEDICAL CONDITION] (any abnormal condition affecting the blood vessels). The quarterly (MDS) Minimum Data Set assessment, dated 05/01/15, indicated the resident had severely impaired cognition with poor memory and inattention. The MDS also indicated the resident required total assistance with all (ADLs) Activities of Daily Living including transfers and positioning, had impaired balance that required human assistance to stabilize, and used a wheelchair for mobility. The 05/11/15 care plan directed 1 or 2 staff to provide the resident with extensive assistance for all ADLs and 2 staff to transfer the resident with a total sling lift. The care plan also directed staff to place the resident in a Broda chair (specialized wheelchair with the ability to tilt and recline) for positioning and mobility, and directed staff to propel the resident's Broda chair. The care plan further directed staff to position the resident for comfort and assess the resident for skin problems and foot care needs. The 05/05/15 fall risk assessment indicated the resident a moderate risk for falls. The 05/05/15 Braden Scale assessment indicated the resident a moderate risk to develop pressure ulcers. On 06/23/15 at 12:09 PM, observation revealed the resident, seated in a Broda chair, with gripper socks on his/her feet, and bilateral legs and feet dependent, resting on the floor. Continued observation revealed the resident's Broda chair had no padded footrest to support or position the resident's lower legs and feet. Continued observation revealed staff propelled the resident's Broda chair with his/her feet sliding on the carpeted floor in the living room and over the transition strip to the laminate floor in the dining room. On 06/23/15 at 4:14 PM, observation revealed staff propelled the resident, seated in a Broda chair, with his/her feet sliding on the tile floor, from the resident's room (approximately 150 feet) to the carpeted floor in the living room. On 06/23/15 at 3:34 PM, Nurse J stated the resident was very confused, difficult to communicate with and required total assistance with all ADLs. Nurse J stated the resident's Broda chair had no footrest to support the resident's lower extremities and staff could not reposition the resident for comfort or pressure relief. Nurse J stated staff assessed the resident as a fall risk and should not transport the resident with his/her feet sliding on the floor. Nurse J further stated the resident was diabetic with a history of foot and/or toe problems and at risk for injuries when staff transported the resident with his/her feet sliding on the floor. On 06/24/15 at 7:47 AM, Therapy Staff E stated therapy had not assessed the resident's Broda Chair positioning for several years. Therapy Staff E stated the resident's Broda chair had no footrest to elevate and support the resident's lower extremities because the resident had been able to self propel the Broda chair many months ago. Therapy Staff E further stated the resident was at risk for injury and/or falls when staff propelled the resident with his/her feet sliding on the floor. On 06/24/15 at 2:08 PM, Nurse Aide C stated the resident had severely impaired cognition and required total assistance with all ADLs. Nurse Aide C also stated the resident's Broda chair had no footrest to support the resident's lower legs or feet and the resident's feet were always dependent. Nurse Aide C further stated staff propelled the resident in the Broda chair with the resident's feet sliding on the floor and the resident was at risk for foot injuries or falls. On 06/24/15 at 3:34 PM, Nurse Aide D stated the resident's Broda chair had no footrest to support the resident's lower extremities and the resident had severely impaired cognition and could not understand or respond to staff's directions to lift his/her feet during transport. Nurse Aide D also stated the resident's feet were always dependent and staff could not reposition the resident for pressure relief or comfort. Nurse Aide D further stated staff placed the resident at risk for injuries or falls when staff transported the resident with his/her feet sliding on the floor. On 06/24/15 at 4:05 PM, Nurse A stated the resident had severely impaired cognition and required total assistance with ADLs. Nurse A also stated the resident's Broda chair had no footrest to support his/her lower extremities and the resident was unable to lift his/her feet while staff transported the resident in his/her Broda chair. Nurse A further stated the facility had not provided a timely and accurate assessment for the resident's safe and comfortable use of his/her Broda chair. The facility failed to provide a timely and accurate Broda chair assessment for the safety and comfort of Resident #18.

The facility had a census of 60 residents. The sample included 19 residents of which 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to implement effective interventions to prevent the development, and promote healing of pressure ulcers for 2 of 3 sampled residents who developed facility acquired pressure ulcers. (#8, #75) Findings included: - Resident #75's (POS) physician's orders [REDACTED].), pneumonia (lung inflammation caused by bacterial or [MEDICAL CONDITION] infection), and muscle weakness (lack of muscle strength). The admission (MDS) Minimum Data Set assessment, dated 3/6/15, 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 1 staff member for bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and set-up and supervision with eating. The assessment further revealed the resident at risk for skin breakdown, no current breakdown and had pressure relieving devices for his/her bed and chair. The significant change MDS, dated [DATE], indicated the resident had a (BIMS) score of 3 which indicated severely impaired cognition, and now required extensive assistance of 2 staff members for bed mobility and 1 staff member for transfers, ambulation, dressing, toileting and personal hygiene. The assessment further revealed the resident and had 2 stage 2 (a loss of partial thickness of the outer layer of skin and present as an intact fluid filled blister) pressure ulcers, had pressure relieving devices for the bed and chair, on a turning and repositioning program, received nutrition and hydration interventions, and pressure ulcer care. The 3/6/15 (CAA) Care Area Assessment summary for pressure ulcers indicated the resident had intact skin which staff monitored with cares. The assessment further stated the resident required assistance with repositioning. The 3/9/15 care plan stated the resident had a potential for pressure ulcer development, required pressure relieving devices on the bed and chair, and required extensive assistance with turning. The 4/3/15 care plan update directed the staff to assess wound healing weekly, and avoid positioning the resident on his/her back. The 4/13/15 care plan update directed the staff to place elbow protectors on the resident at all times, and encourage and assist him/her with putting them on. The 4/23/15 care plan update stated the resident required supplemental protein, amino acids, vitamins, and minerals, as ordered, to promote wound healing. The 3/6/15 admission Braden Scale assessment for skin breakdown indicated the resident had a low risk for developing pressure ulcer. The 3/18/15 physician's orders [REDACTED]. The 3/26/15 at 8:48 AM, nurse's note stated the resident had (MASD) moisture-associated skin damage to his/her buttocks which was caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection and would be monitored with cares. The 4/1/15 physician's orders [REDACTED]. The 4/3/15 at 12:59 PM, nurse's note stated the resident had a 0.5 (cm) centimeter x 0.5 cm open area on his/her left buttock. The 4/6/15 physician's orders [REDACTED]. The 4/10/15 at 1:54 PM, nurse's note stated the resident had a 1 cm x 0.5 cm open area on his/her left buttocks. The 4/13/15 at 8:25 AM, nurse's note stated the resident had a quarter sized open area on his/her right elbow. The 4/13/15 blood laboratory report revealed a protein level of 6.3 (6.4 -8.2 normal) and an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) level of 3.2 (3.3-4.5 normal) The 4/13/15 physician's orders [REDACTED]. Zinc, (a mineral to help wound healing) 50 mg, by mouth, daily Vitamin C, 500 mg, by mouth, daily [MEDICATION NAME], (a nutritional supplement) by mouth, 2 times daily, until wounds heal,then discontinue. The 4/14/15 physician's orders [REDACTED]. The 4/16/15 (RD) registered dietician's nutritional assessment revealed the resident received Med Pass three times a day with meals, and a multivitamin with minerals to promote wound healing. Review of the medical record revealed no dietician review of the resident's nutritional status from 3/5/15 until 4/16/15 after the resident developed 2 pressure ulcers. The 4/23/15 physician's orders [REDACTED]. Review of the nurse's notes revealed the following: 4/17/15 at 1:40 PM, a 2.7 cm x 2.5 cm open area on the resident's right buttocks with MASD to the surrounding tissue. The staff encouraged the resident (who had severely impaired cognition) to off load his/her weight several times during the shift. 4/21/15 at 2:44 PM, a 2 cm x 2 cm open area on his/her left elbow and an order for [REDACTED]. 4/23/15 untimed, open area on the resident's left buttock measured 2.7 cm x 2 cm with eschar (dead tissue) that covered 3 cm x 2 cm, an open area on his/her right buttock that measured 3 cm x 1.5 cm, and the resident's right elbow measured 2.7 cm x 2.1 cm. 5/1/15 at 1:02 PM, open area on the resident's right elbow, measured 2.7 cm x 2.1 cm, his/her left buttock measured 2.7 cm x 2 cm, right buttock measured 3 cm x 1.5 cm and duoderm was applied. 5/22/15 at 3:17 PM, an open area on the resident's left elbow measured 4 cm x 3 cm, right elbow open area measured 2.5 cm x 3 cm, the buttocks measured 5 cm x 4 cm with a 1.2 cm x 1.5 cm x 1.3 cm grayish area that surrounded the wound. 6/5/15 at 2:30 PM, a 5 cm x 2 cm x 1 cm open area on the left buttock, the right elbow open area measured 1 cm x 1 cm, the left elbow open area measured 4 cm x 3.8 cm with serosanguious drainage (consisting of both blood and fluid) 6/16/15 at 2:30 PM, the resident's left elbow open area measured 3 cm x 2 cm, the right elbow open area measured 2.7 cm x 2 cm with greenish colored substance, the buttocks measured 4 cm x 5 cm x 2 cm with a moderate amount of serosanguious (bloody) drainage. The 5/15/15 at 1:28 PM, physician's orders [REDACTED].), secure with a foam dressing and tape, and change 2 times daily. The physician's orders [REDACTED]. The medical record revealed on 5/17/15, a culture of the elbow (did not specify which elbow) revealed [MEDICAL CONDITION] (a strain of staph bacteria that's become resistant to the antibiotics) and the physician ordered [MEDICATION NAME], (an antibiotic medication) 100 (mg) milligrams, by mouth, twice daily, for 7 days. Further review of the medical record revealed on 6/10/15 staff obtained another wound culture which revealed the right elbow had staphylococcus auricularis (a gram positive bacteria) and the left elbow had staphylococcus epidermidis (a bacteria). Review of the medical record lacked documentation of any follow up with the physician to obtain further antibiotic treatment for [REDACTED]. The 5/30/15 physician's note stated the resident had open areas to the resident's elbows due to chronic pressure and poor nutritional status. The 6/2/15 physician's note stated the resident does not appear terminal at this time. The 6/22/15 physician's orders [REDACTED]. The physician's orders [REDACTED]. On 6/23/15 at 12:00 PM, observation revealed Licensed Nurse F donned clean gloves, opened a package of abd pads (a pad for the absorption of drainage from wounds), laid the abd pad partially on the opened package, part of it hung over onto the resident's night stand without a protective barrier. Licensed Nurse F removed the coban (a self-adherent dressing that sticks to itself) from the resident's left arm. Further observation revealed the abd pad on the resident's elbow had dried, with brown colored drainage on the outside of the pad, which was stuck to the pressure ulcer on the resident's elbow. While Licensed Nurse F proceeded to remove the dressing from the resident's elbow, the resident hollered OUCH several times, Licensed Nurse F took a saline bullet (a small vial of sterile saline) and wet the inside of the dressing, then without letting it soak into the dry dressing, to remove it easier, he/she pulled the dressing off the resident's elbow causing new skin to be pulled off. The resident's elbow began to bleed and the resident stated, that burns, ouch! The resident cursed several times stating that hurt and the nurse stated, he/she needed to change the dressing and made no response to the resident's complaints of pain. Licensed Nurse F placed a new abd dressing with hydrogel (an absorbent gel for wounds) and rewrapped the resident's arm with coban. Licensed Nurse F did not don clean gloves prior to putting on the new dressing. Licensed Nurse F removed his/her soiled gloves and put on clean gloves. Continued observation revealed Licensed Nurse F removed the coban dressing from the resident's right arm and the resident yelled,ouch, that hurts. Licensed Nurse F stated, in a harsh tone, he/she was just taking off the coban. Further observation revealed the abd dressing on the resident's right elbow also had the dried, brown colored drainage on the outside of the dressing. Licensed Nurse F took another saline bullet and wet the inside of the dressing and pulled down. The resident yelled, OUCH, and the dressing came off. Licensed Nurse F, with same soiled gloves on, took scissors out of the night stand drawer to cut the abd pad in half for each elbow, and did not wipe the scissors off before or after use and replaced them in the drawer. Licensed Nurse F replaced the old dressing with a new abd pad and hydrogel and rewrapped the elbow with coban. Licensed Nurse F did not don clean gloves prior to putting on the new dressing. Licensed Nurse F and a nurse aide walked the resident into the bathroom, put on clean gloves, and turned off the resident's pressure pad alarm. Licensed Nurse F pulled the resident's pants down, and touched the resident's buttocks. Without changing gloves, Licensed Nurse F opened the resident's night stand and pulled out a package of abd pads. The package fell on the floor and Licensed Nurse F picked it up, then opened it and laid it on the night stand. Licensed Nurse F opened a package of skin prep (a procedure for cleansing the skin with an antiseptic) and laid it and a q-tip on the night stand. The resident stated, I'm tired, I want to sit down. Licensed Nurse F stated he/she had to finish the dressing change before the resident could sit down. Further observation revealed Licensed Nurse F, with the same soiled gloves, opened the package of calcium alginate, pulled out a piece of it and used the q-tip to put it in the resident's wound. Licensed Nurse F applied a new abd pad to the residents coccyx wound and pulled up the resident's pants. Licensed Nurse F coughed multiple times during the wound care and did not wear a mask to protect the resident. On 6/24/15 at 8:09 AM, Administrative Nurse B stated the resident acquired the pressure ulcers on his/her elbows in the facility but thought the resident already had the open area on his/her buttocks, although the staff had not documented that he/she had one on admission. Administrative Nurse B further stated the dressing changes are done daily and he/she measured the wounds weekly. On 6/25/15 at 3:26 PM, Nurse Aide P stated the resident would refuse to get up and out of his/her recliner which caused the breakdown on the resident's elbows. Nurse Aide P further stated, there were not any interventions in place to prevent the breakdown until after the resident's skin broke down. Nurse Aide P stated the resident was on a supplement and would drink 100% because he/she liked them. On 6/25/15 at 3:52 PM, Licensed Nurse M stated the resident received arginade and med pass supplement at meals and drinks well. Licensed Nurse M stated the resident did not have any interventions in place prior to the skin breakdown but does have protective cushions in place now. Licensed Nurse M stated the resident's open areas on his/her elbows are slow to heal because of the skin grafts he/she had in the past. On 6/25/15 at 3:30 PM, Dietician Staff U stated the resident did not have skin breakdown when he/she completed the initial review of the resident on 3/5/15. Dietician Staff U further stated the resident had skin breakdown when he/she was asked to review the resident on 4/16/15 and the resident was placed on [MEDICATION NAME] and med pass, due to his/her decline. The 3/5/04 facility's Preventative Skin Care Protocol directed the staff to identify at risk individuals who need interventions and specific factors that place the resident at risk. The policy further directed the staff to initiate a Braden scale assessment on admission and update quarterly on all residents, and to care plan any risk assessments for immobility, nutritional factors, incontinence, decreased sensory perception, history and physical, and diagnoses. The facility failed to implement effective interventions to prevent the development of pressure ulcers for Resident #75, who acquired skin breakdown on his/her buttocks and elbows. - Resident #8's significant change (MDS) Minimum Data Set assessment, dated 05/15/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 5 (severe cognitive impairment). The MDS also indicated the resident required extensive staff assistance with bed mobility, transfers, walking, dressing and personal hygiene. The MDS further indicated the resident was at risk to develop pressure ulcers, no current pressure ulcer, and had pressure relieving devices on his/her bed and chair. The 05/26/15 care plan directed staff to provide extensive assistance with (ADLs) Activities of Daily Living. The care plan also directed the staff to monitor the resident's skin during bathing and daily cares. The care plan revealed no preventive measures to prevent the development of pressure ulcers. The 03/13/15 Braden Scale assessment indicated the resident had a moderate risk to develop a pressure ulcer. The 05/07/15 physician's progress note indicated the resident had bilateral lower extremity [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in body tissues). The 06/05/15 at 2:49 PM, nurse's note indicated the resident had significant [MEDICAL CONDITION] in his/her bilateral lower extremities. The 06/08/15 at 1:16 PM, nurse's note indicated the resident had significant [MEDICAL CONDITION] in his/her bilateral lower extremities. The 06/09/15 at 1:51 AM, nurse's note indicated the resident's bilateral lower legs were [MEDICAL CONDITION]. The 06/09/15 at 11:08 AM, nurse's note indicated the nurse noted a dark soft area on the resident's left heel while measuring for tubular stockings (specialized compression stockings designed to help manage excess fluid in the feet/legs). The nurse's note indicated the nurse notified the facility's wound nurse, obtained foam boots for the resident to wear while in bed, and removed the resident's black tennis shoes from his/her room. Review of the medical record revealed no documentation of preventative measures or physician contact due to the [MEDICAL CONDITION] in the resident's bilateral lower extremities, after 5/7/15. The 06/09/15 at 8:51 PM, nurse's note indicated the staff found discolored skin on both of the resident's heels, sensitive to touch, with soft and warm tissue noted to the areas. The resident's discolored, tender skin areas measured 4.0 (cm) centimeters by 2.5 centimeters on the left heel and 3.0 cm by 1.3 cm on the right heel. The June 2015 (TAR) Treatment Administration Record indicated staff initiated the following nursing ordered treatments on 06/09/15: skin prep to bilateral heels every day until healed foam boots while in bed tubular stockings to bilateral legs, on in the AM and off in the PM The resident's medical record revealed no documentation staff notified the physician and/or received orders to evaluate and treat the resident's pressure ulcers on his/her bilateral heels. The resident's medical record revealed no documentation staff notified the Registered Dietician concerning the resident's pressure ulcers on his/her bilateral heels. The 06/16/15 at 1:41 PM, nurse's note indicated the resident had an intact 4.0 cm by 3.3 cm dark brown area on his/her left heel. On 06/24/15 at 11:24 AM, observation revealed the resident, seated in a wheel chair, with tubular stockings and gripper socks on his/her bilateral lower extremities that hung down in a dependent position. Continued observation revealed Nurse B and Nurse F removed the resident's tubular stockings and revealed [MEDICAL CONDITION] in both the resident's lower legs and feet, with indentions/imprints noted from the tubular stockings. Continued observation of the resident's bilateral heels revealed a 2.0 cm by 1.0 cm light brown intact area, surrounded by dry, peeling skin, on the resident's right heel and a 4.0 cm by 2.5 cm dark purple and black area with hard, intact skin on the resident's left outer heel. Continued observation revealed Nurse B cleansed the pressure areas with normal saline and applied skin prep. On 06/24/15 at 11:33 AM, Nurse B stated staff had assessed the resident's shoes as too tight after the pressure areas were found on the resident's bilateral heels. Nurse B also stated the staff noted the pressure areas on the resident's heels, on 06/09/15 (15 days ago) and had not notified the physician to receive treatment orders or specific interventions/instructions. Nurse B further stated the resident's current pressure ulcer treatment were nursing interventions only. On 06/24/15 at 1:27 PM, Nurse A stated the staff should immediately notify the physician of the resident's development of pressure ulcers on his/her heels. Nurse A also stated the staff should provide interventions and treatments as ordered by the physician. The facility's 03/05/04 Pressure Ulcer Policy directed staff to identify at-risk residents who require preventive interventions due to specific factors that place the resident at risk to develop pressure ulcers. The policy also directed staff to provide pressure ulcer treatments and specific interventions/instructions as ordered by the physician. The facility failed to initiate preventive interventions concerning bilateral lower extremity [MEDICAL CONDITION] and seek physician involvement to provide treatments and/or specific interventions for Resident #8's facility acquired pressure ulcers on his/her bilateral heels.