Every finding on record at Bethany Home Sioux Falls

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety for one of one discharged sampled resident (57) who eloped (left the facility without staff knowledge) from the front door of the facility on 8/29/25 and was reported to the facility by a community member. The facility's front door was not alarmed or monitored at that time of the resident's elopement. Findings include:1. Review of the provider's 9/2/25 SD DOH FRI involving resident 57 revealed:*On 8/29/25 at approximately 5:10 p.m., a community member called the facility to tell staff that the resident was at their home, a block away from the facility.*The staff had last seen the resident at approximately 4:00 p.m.*According to the provider's investigation, the resident left the facility at approximately 4:06 p.m. and walked to the community member's home. She had knocked on the community member's door, and they sat with her until a facility staff member arrived.*Resident 57's goal was to go to her cousin's home, which was in that neighborhood, but she was unsure exactly where that was. She walked independently with a front-wheeled walker.*She willingly returned to the facility with the staff member.*The resident and her family had a care conference earlier that day, and the resident's sons expressed concern about the resident returning to her home independently due to her impaired cognition (mental status).*The conference earlier that day had upset resident 57, and she had expressed that to the staff member when she was picked up from the community member's home.*The resident returned to the facility at approximately 5:20 p.m. and was assisted back to her room.*The resident's son, her primary care physician, the administrator, and the director of nursing (DON) were notified of the resident's elopement.*Resident 57's vital signs after she returned to the facility on 8/29/25 were: blood pressure 128/69, pulse 80, temperature 98.0, respirations 18, oxygen saturation 95%. Her skin assessment was completed and was normal.*She was placed on 15-minute checks by staff to ensure she was in the facility and safe. 2. Review of resident 57's closed electronic medical record revealed:*She was admitted to the facility on [DATE] to the rehabilitation (rehab) unit on [NAME] Boulevard Hall following a hospitalization for a syncope incident (fainting) with collapse.*Her discharge plan was to go to an assisted living facility after completion of skilled therapies.*Her BIMS (brief interview for Mental status) score was seven, which indicated her cognition was severely impaired.*One of her sons was her responsible party and assisted her with health decisions.*She worked with therapy services five times per week.*Her diagnoses were syncope and collapse, and Hypotension (low blood pressure).*She was discharged from the facility to her home on 9/3/25 AMA (against medical advice) with her son, who was responsible for her. 3. Interview on 12/17/25 at 2:30 p.m. with CNA (certified nurse assistant) C revealed:*He vaguely remembered an elopement incident on 8/29/25 for resident 57.*He did not think that resident 57 wandered and would exit seek. *He did rounds on residents to check on them every two hours or less.*Exit doors would be locked in the back of the building, and he did not remember responding to a door alarm that day (8/29/25).*He found out there was a resident elopement when the DON had called over the radio that she was going to pick up a resident outside of the facility. 4. Interview on 12/17/25 at 2:36 p.m. with DON B revealed:*Resident 57 had a wander assessment on admission 8/5/25 and scored a 5, which indicated moderate risk for elopement, due to mobility, and she had not verbalized a desire to leave.*She had reviewed the camera footage for 8/29/25 when the resident eloped. She indicated resident 57, who used a wheeled walker independently, had left the facility going out the front door around 4:15 p.m. that day.*The front door that the resident had exited out of should have been locked and alarmed automatically at 4:30 p.m. that day. Prior to that time the front door should have been monitored by staff when it was not alarmed, but the administrative assistant (AA) D located at the front desk had stepped away to make copies in the administrative hall, and that door was not monitored or locked at the time the resident exited the facility. The AA D had not alarmed the door or notified staff to monitor the door while she stepped away. *She stated the front door should have been monitored by staff on [NAME] Boulevard Hall by camera. She could not confirm the cameras would be monitored by staff if that staff person was distracted by talking with someone or not watching the camera at all times, and she agreed that was a concern.*She stated on 8/29/25, the day of resident 57's elopement incident, a care conference with the resident and her two sons was held earlier. She stated that one of the resident's sons (responsible party) was okay for her to return to her own home alone, and the other son was not okay because she lacked awareness of her dementia (a group of symptoms affecting memory, thinking, and social abilities) and he was concerned about her safety. 5. Observation and interview on 12/18/25 at 10:30 a.m. with DON B revealed that the camera screen on [NAME] Boulevard Hall had been taken down earlier that day, 12/18/25, and was not working. She stated that the AA D had been informed to notify staff if she had to step away from monitoring the front door while it was out of order. 6. Interview on 12/17/25 at 3:35 p.m. with AA D revealed:*She had worked the day (8/29/25), when resident 57 left the building unnoticed.*She agreed she had stepped away from the desk that was located near the front door to make photocopies in the administrative hall and had left the front door unmonitored and unalarmed during that time.*She stated she should have told someone she had left that area so that the front door would have been monitored.*Since the resident's elopement, she had been reeducated to inform staff from the administrative hall or staff from the [NAME] Boulevard Hall so someone could have monitored the front door in her absence. 7. Review of the provider's undated elopement procedure for missing resident revealed:* To make certain that all residents are accounted for and their whereabouts always known, day and night.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) G followed facility policy, practiced within his scope of practice, and sought direction from a registered nurse (RN) or physician for one of one sampled resident (1) related to the family's concerns of the resident having a low hemoglobin blood level (protein in the red blood cells that carries oxygen). Findings include: 1. Review of the provider's 6/28/25 FRI submitted by the provider to the SD DOH regarding resident 1 revealed on 6/28/25 at around 7:40 p.m. LPN G documented a nursing progress note that stated Resident's daughter is concerned of possible gastrointestinal bleed (GI) due to stool being black and past like. I informed daughter its likely due to new medications but will update chart to bring light to the subject. There was no documentation to support that LPN G had assessed resident 1, called the resident's physician, or called the on-call leadership staff who was available 24 hours a day if needed. On 6/29/25 LPN G who was the night nurse the evening of 6/28/25 and reported to the oncoming day nurse, LPN D, that resident 1's daughter was concerned that she had a GI bleed. On 6/29/25 LPN D faxed resident 1's primary care physician and notified her of the daughter's concern of a GI bleed. Orders were received on 7/1/25 for a complete blood count (CBC), basic metabolic panel (BMP), and to check stool for blood. Additional orders were received for staff to monitor the resident's respiratory status and for lung sound changes. The physician was to be notified if the resident required an increase in oxygen. On 7/1/25 resident 1's daughter again expressed concerns of how the hemoglobin had dropped from when the resident was in the hospital. On 7/1/25 resident 1's primary physician ordered a stool specimen to be collected and sent for testing. The specimen was collected from the resident and sent to [NAME] Hospital lab. The specimen was not accepted due to being placed in the wrong specimen container. On 7/2/25 the correct specimen container to be placed in the stool to check for blood was ordered from [NAME] Hospital lab. On 7/3/25, the resident had been admitted to the hospital due to her having a critically low hemoglobin of 6.5 grams per deciliter (g/dl) (normal is 12.0-15.5 g/dl). There had been no time for the stool specimen to be collected prior to her hospitalization. 2. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. She had multiple co-morbidities that included: Osteomyelitis (infection of the bone) of the right ankle and foot. The resident had a diagnosis of long-term use of anticoagulants (thins the blood), type two diabetes mellitus with diabetic polyneuropathy (condition that affects many peripheral nerves, causing numbness, tingling, pain and weakness), insulin dependent, peripheral vascular disease (decreased blood flow to the legs), congestive heart failure, hypertension, atrial fibrillation irregular heartbeat). Continued review of resident 1's EMR at the time of admission on [DATE] revealed she was alert, orientated, and vital signs were stable. She was receiving antibiotics through a midline intravenous catheter placed in her left upper arm. Lab orders for a CBC and BMP were received from the hospital's infectious disease physician at the time of her admission to the facility on 6/26/25. The results from the 6/30/25 lab draw revealed her hemoglobin was 9 g/dl. That had been a 3.6 drop in the level since her last hemoglobin check during her hospitalization on 6/21/25. On 7/3/25 LPN D had received orders from the physician to recheck her hemoglobin again on 7/3/25. On 6/28/25 around 7:40 p.m. LPN G documented a nursing progress note that stated Resident daughter is concerned of possible gastrointestinal bleed (GI) due to stool being black and paste like. I informed daughter its likely due to new medications but will update chart to bring light to the subject. There was no documentation to support that LPN G had assessed resident 1, called the resident's physician, or called the on-call leadership staff who was available 24 hours a day if needed. Review of resident 1's care plan revealed her stay at the nursing home was to receive physical and occupational therapy and then return to her own home. 3. Interview on 10/28/25 at 1:36 p. m. with LPN D revealed when concerns are voiced by family members of a resident, the resident first needs to be assessed by the nurse. She indicated if further evaluation is needed after the initial assessment they are to reach out to E-Care (in the event of needing additional care that cannot be obtained at the facility), reach out to the on-call leadership staff and notify the physician. She stated that she assessed resident 1 on 6/29/25 and the resident's vitals were within normal limits and no other concerns were noted. She had indicated there was no documentation in the resident's EMR of black, tarry bowel movements from the time of admit on 6/26/25. She stated the resident was completely dependent on staff for toileting. She indicated that she notified resident 1's primary physician of the concerns voiced by the family on 6/29/25. Orders were received from the physician and followed. She stated that there had been no reports or documentation to support that the resident had been having black, tarry stools. 4. Interview on 10/28/25 at 2:00 p.m. with LPN E revealed she provided care to resident 1 while she was at the facility. She stated she was not aware of the resident having black, tarry stools or that the resident's daughter had informed her of the resident having black, tarry stools. She indicated any concerns brought forward to her as an LPN, she would first assess the resident and then continue to follow the policy and notify the physician, complete an E-care or reach out to leadership staff who are on call if needed. 5. Interview on 10/28/25 at 3:20 p.m. with director of nursing (DON) revealed her expectation of nursing staff would be to first assess a patient when a family member brings concerns forward. Staff should follow the protocol for notification of a physician or reach out to the on-call leadership staff that are available 24 hours a day. 6. Administrator A was not available for interview during the survey. 7. Review of the provider's [NAME] Home Sioux Falls/[NAME] Protocol for Notification of a Physician dated 8/2025 revealed: For the purpose of this procedure immediate notification means the physician should be informed at the time the event occurs directly via telephone system. Non-immediate notification means the attending physician should be informed of the event during normal office hours via fax or telephone system and generally no later than the next regular office day. For the condition of bleeding of blooding stools not due to hemorrhoids, indicates this is an immediate notification to the physician. 8. Review of the provider's undated position description revealed: The LPN is responsible for both direct and indirect nursing care to residents, under the supervision or direction of a registered nurse (RN) or physician. The care given must be of the quality and quantity as given by the average LPN in a similar position in the community at that time. This is appropriate individuals and performing basic preventative, therapeutic and rehabilitative procedures.-Qualifications of an LPN: Function within his/her scope of practice and to seek direction from a RN or physician as the situation indicates. 9. The provider's 6/28/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/29/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding resident assessments and appropriate documentation of findings, occult blood collection steps, interviews revealed staff understood the education provided regarding those topics, and record review of nursing progress notes, and a review of the provider's follow-up audits revealed substantial compliance. Based on the above information, noncompliance at F684 occurred on 6/28/25. Based on the provider's implemented corrective action for the deficient practice confirmed on 10/29/25, the noncompliance is considered past noncompliance.

Based on observation, interview, and document review, the facility failed to maintain cleanliness in one of one steamer and one of one convection oven in the kitchen. Findings include: 1. Observation during the initial kitchen tour on 11/5/24 from 11:43 a.m. to 12:19 p.m. revealed: *The interior of the Vulcan brand convection oven was heavily coated in baked-on grease and food particles. *The interior of the Cleveland brand SteamChef steamer had an excessive buildup of limescale and scum, and there were food particles at the bottom of the basin sitting in standing water. 2. Interview on 11/7/24 at 10:45 a.m. with cook L about cleaning the large kitchen equipment revealed: *She claimed that she cleaned the steamer and oven every day, and deep-cleaned them weekly. *That equipment had not been deep-cleaned in about a month. *She did not know the proper steps to clean the steamer. 3. Interview on 11/7/24 at 1:34 p.m. with dietary manager G about the oven and steamer revealed: *There was a cleaning schedule for the kitchen equipment. *She performed monthly audits for kitchen cleanliness. *She was unaware that the oven and steamer were that dirty. *She did not know the proper steps to clean the steamer. 4. Review of the provider's monthly kitchen cleanliness audits revealed: *The audits were completed on 8/26/24, 9/30/24, and 10/25/24. *There was a line item under the Maintenance section that read Ovens and Steamer clean and in good repair. -There was a checkmark Yes next to that line item on the above-listed audit sheets. 5. Review of the manufacturer's cleaning guidelines for the Cleveland SteamChef revealed they recommended descaling daily to prevent the buildup of minerals and limescale. *When done daily this will help prevent the buildup of calcium and other mineral deposits left over from the boiling of water, and prevent scale buildup in the steamer, helping prevent more costly maintenance and service on the steamer. 51370

Based on menu review, observation, and interview, the provider failed to ensure adequate portions were served according to the menu for one of one observed meal. This had the potential to affect all residents receiving the main menu in the facility. Findings include: 1. Review of the provider's menu for lunch on 11/7/24 revealed the following main menu items: *Beef & broccoli, #8 dip x2, which was eight ounces (oz.) total. *Diced carrots, four oz. spoodle. -A spoodle is a slotted scoop to drain the liquid. 2. Observation on 11/7/24 at 11:11 a.m. in the kitchen during lunch service revealed: *Cook L was plating the residents' lunch meal food items. *She served a three oz. scoop of the beef & broccoli. -The printed menu indicated the serving size for the regular diet as #8 dip x 2. *Cook L served a heaping two oz. spoodle of diced carrots. -The printed menu indicated the serving size as 4 oz. *Observation of the utensil drawer confirmed that a 4 oz. spoodle and a 4 oz. serving spoon were available. 3. Interview on 11/7/24 at 1:29 p.m. with cook L revealed she: *Was aware of the serving sizes on the printed menu. *Chose not to use the correct serving sizes; she did not provide a reason. 4. Interview on 11/7/24 at 1:34 p.m. with dietary manager G about the above observations revealed she: *Was not aware that dietary staff served the wrong portion sizes for lunch that day. *Was aware of the need to meet the dietary requirements of the residents by following the approved menu, including portion sizes.

Based on record review and policy review, the provider failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for one of three (247) sampled residents. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: Review of provider's documentation regarding advanced beneficiary notices (ABN) revealed on 10/11/24, the provider identified previous social worker (SW) O had not been completing SNF ABNs or NOMNCs for residents who received Medicare Part A skilled services. *Administrator A interviewed (SW) O and SW P on 10/16/24. -SW O had reported he was not trained upon his hiring on how to complete the ABNs by SW P. -SW P had reported she had trained SW O upon his hiring on how to complete the ABNs. Record review on 11/6/24 of the provider's SNF Beneficiary Notification Review Form CMS-20052 revealed: *Three randomly selected residents were given to the provider for review of SNF ABN. *Resident 247's Medicare A skilled services ended on 9/23/24, Resdient 247 was not given the SNF ABN form CMS-10055 or NOMNC form CMS-10123 by the provider prior to the end of his Medicare skilled services. *Explanation on form CMS-20052 for why the above notifications were not given to resident 247 indicated, in plan of correction. The provider implemented actions to ensure the deficient practice does not reoccur. Plan of correction included SW P provided education to nurse manager D, DON B, and administrator A on SNF ABN and NOMNC completion. Beginning 10/25/24, administrator A or designee will audit each resident discharged to ensure SNF ABNs and NONMCs were completed timely. Findings from these audits will be reported to QAPI Committee. It was confirmed on 11/5/24 after record review revealed the facility developed a plan of correction and education was provided to those involved in SNF ABN and NOMNC issuance. Based on the above information, non-compliance at F582 occurred on 10/11/2024, and based on the provider's implemented corrective action for the deficient practice confirmed on 11/5/2024, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident ( FRI), record review, interview, and policy review the provider failed to ensure 25 of 25 sampled residents on Promise Lane (1,2,3,5,6,7,8, 9, 10, 11,12, 13, 14, 20, 21, 22, 23, 25, 26, 27, 28, 36, 38, 39, and 40) had their blood sugar checked and received treatment and medications as ordered by one of one registered nurse (RN) F during a twelve-hour shift. Findings include: 1. Review of SD DOH FRI submitted on 10/9/24 revealed: *On 10/6/24 RN F had left her unit from 9:00 a.m. until 11:00 a.m. and staff were unable to locate her during this time. *Certified nursing assistant (CNA)/medication aide N had to remind RN F multiple times to give morning narcotics for three residents, but she never saw RN F go in or out of those rooms to give those medications, but they were signed off. 2. Review of the provider's investigation documentation indicated the 10/6/24 video camera footage was reviewed and revealed RN F: *RN [NAME] the unit at 6:27 a.m. Her shift began at 6:00 a.m. Then she: -Counted the narcotics with off-going nurse at 6:42 a.m. -Left the unit at 8:17 a.m. and returned at 9:47 a.m. -Entered the narcotic medication drawer and retrieved all the narcotic blister packs from that drawer, and did something with them on the treatment cart, retrieved the narcotic sign out binder and was signing it. -Administered a medication at 4:56 p.m. to resident 36. --Only had been visualized via video camera administering medication to one resident throughout her shift. -Retrieved a medication at 4:58 p.m. from the top drawer of the medication and took it. -Gave report at 6:11 p.m. to on-coming nurse. -Counted the narcotics at 6:20 p.m. with the on-coming nurse. -The count was correct. 3. Review of the provider's 10/11/24 resident chart audit for the resident's RN F had been responsible for during her 10/6/24 shift revealed: *Resident 1 should have had a lidocaine 4% patch (for pain) applied to both of her shoulders. *Resident 2 should have had an Aspercreme 4% patch (for pain) applied to her lower back and Voltaren gel (for pain) to her hands at 8:00 a.m. and 12:00 p.m. *Resident 3 should have had the dressing changed to her right leg incision and Oxycodone 2.5 milligrams (mg) (for pain) given at 8:00 a.m. and 12:00 p.m. *Resident 5 should have had her blood sugar checked at 7:00 a.m. RN F had documented the resident's blood sugar result 103 mg/deciliter (dL). *Resident 6 should have had applied Triad paste (for wound healing) applied to her bottom, received Tresiba insulin 35 units subcutaneously, and had her blood sugar checked three times and had insulin administered to her based on her sliding scale subcutaneously as needed. RN F had documented the resident's blood sugar results as: -At 8:00 a.m. 201 mg/dL and had administered six units of sliding scale insulin. -At 11:00 a.m. 201 mg/dL and had administered six units of sliding scale insulin. -At 5:00 p.m. 203 mg/dL and had administered six units of sliding scale insulin. --At 9:00 p.m. 600 mg/dL. Avel e-health had been notified and orders received for extra insulin. *Resident 7 should have had been given a Brovana 15 micrograms (mcg) nebulizer (for breathing problems) at 8:00 a.m. and a budesonide 0.5 mg nebulizer (for breathing problems) at 8:30 a.m. and 3:30 p.m. *Resident 8 should have had a Lidocaine 4% patch (for pain) applied to his back in the morning. *Resident 9 should have had Vaseline applied to her lips. *Resident 10 should have been given a Duoneb unit dose nebulizer (for breathing problems) at 7:00 a.m., 11:00 a.m., and 5:00 p.m., Humulin 14 units subcutaneously at 8:00 a.m. and six units subcutaneously at 6:00 p.m. -RN F had documented the resident's blood sugar results as: --At 7:00 a.m. 103 mg/dL. --At 11:00 a.m. 103 mg/dL. --At 5:00 p.m. 103 mg/dL. *Resident 11 should have been given a Biscodyl suppository (for constipation). *Resident 12 should have had Triad paste (for wound healing) applied to her bottom. *Resident 13 should have been Lantus insulin 48 units subcutaneously at 7:00 a.m. and 5:00 p.m., blood sugar checks three times, Aspercreme 4% (for pain) ointment to her hands, and Lidocaine 4% patch (for pain) to both the resident's knees. RN F documented the resident's blood sugar result and sliding scale Novolog insulin administered as: -At 7:00 a.m. 243 mg/dL and administered four units of insulin subcutaneously. -At 11:00 a.m. 243 mg/dL and administered four units of insulin subcutaneously. -At 5:00 p.m. 133 mg/dL with no sliding scale insulin administered. *Resident 14 should have had a Lidocaine 4% patch (for pain) applied to her lower back and Oxycodone 2.5 mg orally at 8:00 a.m. *Resident 20 should have had his scalp cleansed and had a dressing applied. *Resident 21 should have had barrier cream applied to her coccyx. *Resident 22 should have had Calmoseptine cream (a skin protectant) applied to her buttock. *Resident 23 should have had her blood checked at 7:00 a.m. -RN F had documented a blood sugar result of 199 mg/dL. *Resident 25 should have had a dressing changed to his feet, Mupirocin cream (antibiotic) applied to his first and second toes, Ketoconazole 2% (antifungal) cream applied to his face, and Ketoconazole 2% shampoo to his scalp. *Resident 26 should have had Triad paste (for wound healing) applied to her buttock, a Duoneb unit dose nebulizer (for breathing problems), and a Pulmicort 0.5 mg nebulizer (for breathing problems) at 10:00 a.m. and 6:00 p.m. *Resident 27 should have had Lantus insulin 42 units subcutaneously, her blood sugar checked at 7:00 a.m. and 5:00 p.m. RN F had documented the following blood sugar results as: -At 7:00 a.m. 199 mg/dL. -At 5:00 p.m. 103 mg/dL. *Resident 28 should have had Levemir 25 units of insulin subcutaneously, zinc oxide ointment to her buttock, and a blood sugar check. RN F had documented a blood sugar result of 102 mg/dL. *Resident 36 should have her blood sugar checked three times with sliding scale Humalog insulin administered as needed with blood sugar checks. RN F had documented resident's blood sugars results as: -At 7:00 a.m. 101 mg/dL with no sliding scale insulin administered. -At 11:00 a.m. 101 mg/dL with no sliding scale insulin administered. -At 5:00 p.m. 133 mg/dL with no sliding scale insulin administered. *Resident 38 should have had Biofreeze (for pain) applied to both of his knees, Lidocaine 4% gel (for pain) applied to the lower back, and Oxycodone 5 mg orally at 8:00 a.m. and 12:00 p.m. *Resident 39 should have had Benadryl cream (for pain and itching) applied to both arms and legs. *Resident 40 should have had a blood sugar checked. RN F had documented a result of 103 mg/dL. 4. Interview on 11/7/24 at 2:40 p.m. with director of nursing (DON) B regarding the investigation regarding RN F's care of residents on 10/6/24 revealed: *DON B had reviewed the video footage for 10/6/24 involving RN F. *DON B had been able to verify RN F had not entered the above listed residents' rooms during her shift to provide the documented cares and medications. *She had interviewed other staff that had provided care for residents on the unit RN F had been assigned to on 10/6/24. -Those interviews had verified RN F had not been seen entering the above resident's rooms. *Education would be provided to all CNA's on 11/14/24 regarding the investigation results from this incident. *Education would be provided to all nurses on 11/21/24 regarding the investigation results from this incident. Review of the provider's November 2023 Prevention of Resident Abuse, Neglect, and Misappropriation of Resident Policy revealed: *Each resident living at [NAME] has the right to be free from abuse, neglect, and misappropriation of their property. [NAME] will enforce policies and procedures that protect each resident from abuse, neglect, and misappropriation of property by [NAME] employees, other residents, consultants, volunteers, employees of other agencies serving the resident, family members and legal guardians, friends or other individuals. *[NAME] will not tolerate the abuse, neglect, or misappropriation of property of any resident by any employee, a consultant, or others working under the direction of [NAME]. The video surveillance for 10/6/24 was not made available for survey review during the survey.

Based on record review, interview, and policy review, the provider failed to ensure the care plan for two of two sampled residents (11and 25) had been updated to reflect their current condition. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *On 8/6/24 she had received a diagnosis for dementia and other diseases classified elsewhere. *On 8/15/24 an order had been received to start Seroquel 100 milligram (mg) by mouth one time a day related to Major Depressive Disorder. 2. Review of resident 11's care plan revealed: *On 8/20/24 the care plan had been updated and indicated the use of scheduled psychotropic medications related to pain management and depression. No focus area on resident's diagnosis of dementia was noted in the care plan. 3. Review of resident 25' s EMR revealed: *On 8/23/24 an order had been received to start Apixaban 2.5 mg (blood thinner) for Atrial fibrillation by mouth two times per day for blood clot prevention. 4. Review of resident 25's care plan revealed: *On 10/29/24 the care plan had been updated but did not indicate that the resident was started on Apixaban 2.5 mg, for the prevention of blood clots. 5. Interview on 11/7/24 at 2:15 p.m. with director of nursing B, nurse manager D, and administrator A revealed: *The manager of each unit is responsible for updating the residents' care plans. * Any staff member who processes an order, is also responsible for updating the care plan. * During the interview, administrator A, DON B, and nurse manager D agreed that residents 11 and 25's care plans had not been updated to reflect their care needs. Review of the provider's October 2024 Care Plan policy revealed: * Care Plans will be updated by staff on an ongoing basis. This includes care plans being reviewed and updated with appropriate significant changes as well as quarterly. Significant changes could include recent hospital stays, new admissions to hospice, new acute diagnosis, and other traits that reflect a decline is physical and emotional status. * The nurse manager will complete a daily process such as daily walking event rounds, daily review of all new orders, daily review of 24-hour sheets, daily review of progress notes and/or daily review at IDT huddle in order to keep the care plan current. The nurse manager will utilize the plan of care to create CNA's daily/weekly care flowsheets.

Based on interview and record review, the provider failed to provide a written bed-hold notice to the resident or their representative when transferred to the emergency department for one of two sampled residents reviewed (45). This citation is considered past non-compliance based on review of the corrective actions the provider implemented after discovering the lack of documentation. Findings include: 1. Interview and record review on 11/5/24 at 11:51 a.m. with administrator A revealed: *Administrator A provided the survey team with a copy of their investigation timeline and plan of correction (POC) documentation. *They discovered a lack of documentation for a variety of required notices on 10/11/24. *The management team completed an investigation to determine the extent of the issue. *The previous social worker was responsible for providing required notices to residents. That former employee was not providing the required written notices, including bed hold notices. *The nurse managers were educated on the required written notices on 10/16/24. *Chart reviews were conducted, and corrections were completed. 2. Review of resident 45's electronic medical record revealed: *She admitted to the facility on [DATE]. *She transferred to the local emergency department on 8/12/24. *The social worker spoke with the resident's representative about the bed hold policy on 8/12/24. Written notice was not documented. *The resident's representative verbally declined to hold the bed and gathered resident 45's belongings from the facility on 8/12/24. 3. Interview on 11/7/24 at 8:40 a.m. with nurse manager D about bed hold notices revealed: *The written bed hold notices were unlikely to have been done due to a situation with the former social worker. *The resident had not requested to return to the facility as she was admitted to hospice services. 4. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/5/24 after record review revealed the facility had followed their quality assurance process, education was provided to the nurse managers about required notices, interviews revealed staff understood the education provided regarding those topics, and a review of recently discharged residents revealed notices were provided as required. Based on the above information, non-compliance at F625 was discovered on 10/11/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 11/5/24, the non-compliance is considered past non-compliance. 51370

Based on interview and record review, the provider failed to provide a written notice of transfer or discharge and to notify the ombudsman of that transfer or discharge, for two of two sampled residents reviewed (31 and 45). This citation is considered past non-compliance based on review of the corrective actions the provider implemented after discovering the lack of documentation. Findings include: 1. Interview and record review on 11/5/24 at 11:51 a.m. with administrator A revealed: *Administrator A provided the survey team with a copy of their investigation timeline and their plan of correction (POC) documentation. *They discovered a lack of documentation for a variety of required notices on 10/11/24. *The management team completed an investigation to determine the extent of the issue. *The previous social worker was responsible for providing required notices to residents or their representatives. That former employee was not providing the required written notices, including transfer or discharge notices. *The nurse managers were educated on the required written notices on 10/16/24. *Chart reviews were conducted, and corrections were completed. 2. Review of resident 31's electronic medical record (EMR) revealed: *She was transferred to the local emergency department on 5/24/24, and again on 9/1/24. *There was no documentation found about a notice of transfer or discharge, or that the ombudsman was notified for either date. 3. Review of resident 45's electronic medical record revealed: *She transferred to the local emergency department on 8/12/24. *There was no documentation found about a notice of transfer or discharge, or that the ombudsman was notified. 4. Interview on 11/7/24 at 8:40 a.m. with nurse manager D about the required notices revealed that she was not sure if the notices were completed correctly due to an issue with the previous social worker. 5. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/5/24 after record review revealed the facility had followed their quality assurance process, education was provided to the nurse managers about required notices, interviews revealed staff understood the education provided regarding those topics, and a review of recently transferred or discharged residents revealed notices were provided as required. Based on the above information, non-compliance at F623 was discovered on 10/11/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 11/5/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Ensuring one of one resident (304) had performed hand hygiene after he had touched his blood from a wound on his arm prior to having the resident sign his name in the narcotics binder. *Establishing a water management program that addressed the prevention of Legionella. Findings include: 1. Observation and interview on 7/20/23 at 8:42 a.m. with licensed practical nurse (LPN) E during medication administration revealed: *She had prepared medications for resident 304. *She donned clean gloves. *She grabbed the narcotics binder from the locked narcotics drawer in the medication cart. -There were several different types of narcotics that were prescribed for different residents. -The binder sat on top of the medications. *Upon entering the resident's room, the resident was found to have been bleeding from his right upper arm. -With his left hand, he pressed a piece of tissue paper to the small bleeding wound. -His left hand had blood on it. *LPN E said to the resident, I will help you with that after we take your meds. *One of the resident's medications was methadone. -The resident was required to sign his name in the narcotics binder after he had taken the methadone. *Without prompting or assisting the resident to perform hand hygiene, LPN E handed the narcotics binder to the resident. *Resident 304 grabbed the binder with his left hand, which had blood on it, and signed his name on the designated sheet. *After administering all of the resident's medications, LPN E brought the narcotics binder back to the medication cart. *When questioned about the interaction, LPN E had not realized that resident 304's hand had blood on it. *She proceeded to disinfect the binder before placing it back in the locked narcotics drawer in the medication cart. Interview on 7/20/23 at 9:12 a.m. with director of nursing (DON) B about the above observation revealed: *She expected staff to assist residents whom had noticeable blood on their body from a wound. *Staff were to use soap and water to cleanse the skin, not just hand sanitizer. *She confirmed: -It was her expectation for staff to address a bleeding wound prior to administering their medications. -The nurse should not have handed the narcotics binder to the resident due to the blood on his hand. Review of the provider's February 2021 Bloodborne Pathogen Policy - Exposure Control Plan policy revealed there were no policy statements regarding when or how to help a resident with a bleeding wound. Review of the provider's June 2023 Medication Administration policy revealed: *19. Staff shall follow established facility infection control procedures (e.g. [for example], handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 2. Interview on 7/20/23 at 3:48 p.m. with maintenance manager F about the provider's Legionella prevention plan revealed: *They were just getting the water management plan up and running. *The topic of water management and Legionella came up at their quality assurance meeting in June. *He had not tested the level of sanitizer in the water. *He would pour water down the floor drains, but not on a scheduled basis. *When one of the units was closed for renovations, he would flush the toilets and turn the sinks on once a week to flush the pipes. *They were waiting on a contracted water management company to contact them about establishing their program. -He was not sure if there was a set date when the company would visit the facility. -His lact contact with the company was about three months ago. Interview on 7/20/23 at 4:45 p.m. with DON B and infection preventionist/neighborhood leader (IP) D about the provider's Legionella prevention plan revealed: *They went through the Legionella policy the previous month in their quality assurance meeting. *The members of the water management committee included the medical director, the administrator, the maintenance manager, the DON, and the IP. *They confirmed the following: -They had no established or defined measures, such as levels of disinfectants in the water or a target water temperature, used to control the introduction or spread of Legionella. -If a resident were to show signs or symptoms of pneumonia, then they would check the measures in the water. -They were waiting on the water management company to contact them about setting up a water management program. Interview on 7/20/23 at 6:43 p.m. with administrator A about their water management program revealed they had been: *Aware that it was a requirement to establish a water management program that addressed Legionella control and prevention. *Attempting to contract with a water management company since they had no knowledge on how to manage a Legionella program. *Having difficulties with staying in contact with their chosen water management company. *Hindered by the pandemic to establish a plan. Review of the provider's communication e-mails with a local water management company revealed: *The local water management company reached out to the provider on 2/22/19. -They wanted to follow up and see if you guys had made a decision on pursuing the water safety plans or if you are still visiting on the subject? *The provider responded on 2/25/19 stating, We are still considering proposals. We will notify you as soon as we make our final decision. *A different water management company had provided them with an appraisal on 3/4/19. -The provider had not proceeded with that proposal. *The provider again reached out to the initial water management company on 6/16/23. -By the time of the survey, the provider was waiting for them to follow up with the site visit. Review of the provider's September 2022 Legionella Surveillance and Detection policy revealed: *3. As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents [greater than] 48 hours after admission are investigated for possible Legionnaire's disease per CDC [Centers for Disease Control and Prevention] guidance. *7. Residents who have signs and symptoms of pneumonia may be placed on transmission-based (droplet) precautions, although person-to-person transmission is rare. *10. If Legionella is detected in one or more residents, the infection preventionist will: -a. initiate active surveillance for Legionnaire's diseases; -b. notify the water management team; -c. notify the local health department; and -d. notify the administrator and the director of nursing services. Review of the provider's September 2022 Legionella Water Management Program policy revealed: *1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. *3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. *5. The water management program includes the following elements: -e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); --The policy had not defined or established which measures were to be taken. -f. The control limits or parameters that are acceptable and that are monitored; --The policy had not defined acceptable parameters for the control limits. -g. A diagram of where control measures are applied; --There was a diagram of the water system in the facility, however, the diagram had not included where control measures were applied. -h. A system to monitor control limits and the effectiveness of control measures; --The policy had not included a description of a system to monitor control limits. -i. A plan for when control limits are not met and/or control measures are not effective. --The policy had not defined a plan when control limits were not met.

Based on observation, interview, record review, and policy review, the provider failed to ensure medication prescription labels were accurate with the most recent physician's orders for two of twenty-eight medication labels reviewed. Findings include: 1. Observation and interview on 7/20/23 at 8:03 a.m. with licensed practical nurse (LPN) E during medication administration revealed: *She was preparing medications for resident 27. *She grabbed the resident's bottle of MiraLAX. -The prescription label had the following directions: MiraLAX 17g [grams] in liquid by mouth every day as needed. *When she checked the physician's order for resident 27's MiraLAX, she found that there were two different orders for MiraLAX. -One order read, MiraLax Oral Packet (Polyethylene Glycol 3350) Give 8.5 gram by mouth one time a day for constipation. --LPN E confirmed there were only bulk bottles of resident 27's powdered MiraLAX, and there were no oral packets as the physician's order called for. -The other order read, MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth every 24 hours as needed for Constipation. *She confirmed the bottle of MiraLAX only had one prescription label on it. *She decided to wait on administering the resident's MiraLAX until she had a chance to contact the pharmacy. 2. Continued observation and interview on 7/20/23 at 8:25 a.m. with LPN E during medication administration revealed: *She was preparing medications for resident 304. *She grabbed the resident's bottle of lactulose. -She explained that resident 304 usually refused the lactulose, but she would offer it to him anyway. *The prescription label on the bottle of lactulose read, Lactulose 10g/15mL [milliliter] solution. Give 20g (30mL) by mouth three times per day. *She poured 15mL of lactulose into a liquid measuring cup. *When she checked the physician's order for resident 304's lactulose, she found that it was different than what the prescription label on the bottle had read. -The physician's order read, Lactulose Oral Solution 10 GM/15M (Lactulose) Give 10 gram by mouth three times a day for liver disease. *LPN E decided to wait on administering the lactulose to resident 304 until she clarified the physician's order with the pharmacy. Interview on 7/20/23 at 9:05 a.m. with director of nursing (DON) B about medication prescription labels revealed: *Resident 304's label on the bottle of lactulose was from his admission. *The physician had since changed the order. *The current order was for 10g of lactulose, not 20g. *To change the prescription label on a resident's medication, they would have to call the pharmacy to request a new label with the correct dosing. -Until they received the new label, she expected a nurse to place a sticker that read see new directions, or see new orders onto the prescription label. *She confirmed that: -Resident 304's lactulose order had changed on 7/15/23. -A nurse should have put a sticker on the lactulose prescription label to prompt staff to verify the updated physician's order. -Staff should have continued to call the pharmacy to request a new label. -Resident 27 had two separate physician's orders for MiraLAX. --One order was for 17g as needed. --The other order was scheduled for 8.5g daily. -They used the same bottle for both orders. -There was only one prescription label on resident 27's bottle of MiraLAX. *She said, Medication orders change all the time. It's hard to keep up with the bulk medication labeling. *When a resident's physician changed a medication order, nurses would send the new physician's order to the pharmacy. *They had to hound the pharmacy to get new labels, especially for the bulk medications in bottles. *The nurse working the floor was responsible for contacting the pharmacy to request new labels. Interview on 7/20/23 at 9:45 a.m. with registered nurse neighborhood leader D about resident medication prescription labels revealed: *She had called the pharmacy about requesting updated labels for resident 27's MiraLAX and resident 304's lactulose. *The pharmacist stated that they did not send new labels. -They indicated that it was acceptable for the facility nurses to place the above-mentioned stickers on the label. *The nursing staff should have put the stickers on the labels. -She confirmed there were no stickers available on the unit where LPN E was working. -She retrieved the labels from a different unit and verified that each unit had the labels available. 3. Review of the provider's June 2023 Medication Administration policy revealed: *7. The individual administering the medication much [must] check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. *8. If the dosage on a medication has been changed there must be a label placed on the container that states 'directions changed refer to chart.' The individual administering this medication should refer to chart for the correct dosage according to the most recent orders. Nurse should call pharmacy to get new medication container or label as needed.

Based on record review, interview and policy review the provider failed to ensure Minimum Data Set (MDS) discharge assessments were completed in a timely manner for two of two sampled residents (4 and 36). Findings include: 1. Review of the MDS transmission results summary report on 7/20/2023 provided by MDS coordinator C who was also the assistant director of nursing (ADON) revealed no discharge assessments had been submitted for residents 4 who had been discharged home on 1/28/23 and resident 36 who had been discharged home on 2/10/23. Review of the Resident Assessment Instrument (RAI) manual revealed discharge assessments when a resident's return was not anticipated were to have been submitted no later than fourteen days after a resident discharged . Review of the providers 7/2017 MDS Completion and Submission Timeframes policy revealed: *Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. -1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. -2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Interview on 7/20/23 at 5:45 p.m. with ADON/MDS coordinator C regarding discharge assessments for residents 4, and 36 revealed: *Completed MDS assessments were transmitted via the Internet Quality Improvement and Evaluation System. *She realized she missed completing the MDS assessment for resident 36 but thought she had completed the MDS assessment for resident 4. *She tracked the MDS assessments that would need to have been completed by utilizing the dashboard alerts in the PointClickCare system and through the morning huddle meeting. -The PointClickCare dashboard alerts were in place in the system for seven days then would fall off the list. -There was no report to print once the dashboard alerts were gone. *She had been gone when the MDS discharge assessments were due for residents 4 and 36. *Director of nursing (DON) B was her back up to complete the MDS assessments when she was gone. *She believed the system in place to identify MDS assessments due for completion were effective. *She agreed the MDS discharge assessments for residents 4 and 36 were overdue and should have been completed.

Based on observation, interview, and policy review, the provider failed to ensure infection control practices were followed for: *One of one licensed practical nurse (LPN) F using gloves that had been stored in her shirt pocket during medication pass. *One of one certified nursing assistant (CNA) G using gloves that had been stored in her pocket. *Cleaning of a mechanical lift after use for two of two observations by CNA H. Findings include: 1. Observation on 4/27/22 from 7:17 a.m. through 7:45 a.m. of LPN F while passing medications revealed she had put on gloves that had been in her shirt pocket three times. Interview on 4/27/22 at 7:45 a.m. with LPN F revealed: *Her pockets were not clean. *She should not keep clean gloves in her pockets. Interview on 4/27/22 at 7:55 a.m. with LPN nurse manager/environmental services E revealed: *Staff should not have stored gloves in their pockets. *Staff had been educated that once gloves were in their pockets they were contaminated. Interview on 4/27/22 at 8:10 a.m. with director of nursing (DON) C revealed: *Pockets were not clean, and gloves should not be stored in them. *She expected staff to perform hand hygiene when changing their gloves. Review of the providers September 2012 Infection Control Guidelines for All Nursing Procedures policy did not include proper storage of gloves. 2. Observation on 4/26/22 at 9:50 a.m. of CNAs G and H while performing personal cares for resident 10 revealed: *CNAs G and H had used a mechanical sit-to-stand lift to transfer a resident to the toilet. *Once the resident had been seated on the toilet, CNA H removed her gloves, washed her hands and left the room to obtain incontinent supplies for the resident. *CNA G had stayed with the resident and with her gloved hands she had touched her uniform, the mechanical lift, and her face multiple times. *CNA H returned to the room, and without performing hand hygiene, had put on a clean pair of gloves. *After she performed perineal care, and without removing the soiled gloves, she applied a clean incontinence brief, and pulled up the resident's clothing. *CNA G had used the same pair of gloves throughout the entire process. -She was in charge of moving the resident in the mechanical lift. *CNA H had moved the mechanical lift from the resident's room to the hallway and had not disinfected it before placing it in the hall. -She washed her hands after moving the mechanical lift to the hallway. 3. Observation on 4/26/22 at 10:20 a.m. of CNAs G and H revealed: *CNA H brought the mechanical lift into resident 14's room. *CNAs G and H assisted resident 14 to roll on her side to tuck the lift sling under her. *She had had a bowel movement, so CNA G had used peri-wipes to perform peri-care. -Resident 14's buttocks was very red, so CNA G applied a thick layer of protective ointment. -CNA G changed gloves midway through applying the cream and had removed those gloves from her uniform pocket. -She had not performed hand hygiene prior to putting on new gloves. *They transferred resident 14 to her wheelchair, using the mechanical lift, and CNA H then moved the lift into the hallway. *The lift had not been disinfected prior to removal from the room. Continued observation in the same hallway revealed the lift had not been cleaned prior to CNAs G and H taking it to another resident's room a few minutes after exiting resident 14's room. Interview on 4/26/22 at 9:50 a.m. with CNA H revealed: *She agreed she had forgotten to wash her hands when she had came back into resident 10's room. *She agreed she had not put clean gloves on prior to pulling up resident 10's clothing. *She agreed she had not cleaned the lift prior to taking it from resident 10's room and taking it into resident's 14's room. Neither of us (CNAs G and H) had cleaned the lift prior to taking it from the hall into another unidentified resident's room. Interview on 4/26/22 at 10:10 a.m. with CNA G revealed: *She agreed after she had started putting cream on resident 14's bottom, she had not changed her gloves. *She agreed she had removed those gloves and had taken a new pair from her uniform pocket. -When asked if keeping gloves in her pocket was her usual practice, she said, Yes, because I have to have a special kind of glove. *She agreed her pocket would be considered 'dirty', so the gloves would be contaminated. Interview on 04/27/22 at 9:50 a.m. with DON C regarding glove use by CNA G and lift cleaning after describing the above observations, she responded Definitely not! They [staff] have all been trained on proper hand hygiene and that pockets are considered dirty. The lifts are to be cleaned after each use.

Based on observation, interview, and record review, the provider failed to ensure care plans were revised and updated to reflect the resident's current needs for 4 of 12 sampled residents (6, 14, 27, and 28). Findings include: 1. Record review for resident 14 revealed: *She had been admitted to the hospital on 4/2/22 for pneumonia. -She had received intravenous antibiotics in the hospital and had three days of oral antibiotics upon her return to the nursing home. *The pneumonia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *No other interventions related to pneumonia had been documented on her care plan. Interview on 4/27/22 at 9:50 a.m. with director of nursing (DON) C and licensed practical nurse (LPN), manager/environmental services E, revealed: *It was their expectation that resident 14's care plan would have been updated upon her return from the hospital to reflect her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of resident 27's weight record revealed: *On 3/23/22, she had weighed 112.2 pounds (lbs). *On 4/22/22, the resident weighed 123.4 lbs, which had been a 9.98 percent gain. Review of registered dietician J's 4/23/22 progress note indicated weight gain is desirable for this resident. -Resident 27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] *Review of resident 27's medical record and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Unspecified dementia with behavioral disturbance, dementia in diseases classified elsewhere, Alzheimer's disease, and chronic kidney disease, stage 3. *She had been admitted from a local hospital on 3/23/22, taking [MEDICATION(S)] 12.5 mg in the evening. *The [MEDICATION(S)] dosage had been increased twice since her admission, on 3/25/22 and 4/14/22. Review of resident 27's care plan revealed: *It had not included a nutrition plan/goals/interventions. *It had not mentioned the use of antipsychotic medications or monitoring for side effects related to antipsychotics. Interview on 4/27/22 at 4:05 p.m. with DON C regarding resident 27's care plan for nutrition and antipsychotic use and side effect monitoring revealed: *Her expectations would be that her nutrition plan/goals/interventions and the use of antipsychotic medication and side effect monitoring would have been included on her care plan. *Further discussion and record review with DON C revealed that resident 27 had been on [MEDICATION(S)] 12.5 mg daily prior to her hospitalization . 3. Interview on 4/25/22 at 4:41 p.m. with resident 28 in his room, when he had been lying on his bed revealed he said he had a fall a couple weeks ago, I didn't get hurt. I've had a few falls. Record review from 3/1/22 to 4/25/22 for resident 28 revealed: * He has had two falls in the past two months, on 3/14/22 and 4/18/22. *He had not received any injuries from either fall. *Both falls had been related to self-transferring in his room. *His care plan interventions had not been updated following the falls on 3/14/22 and 4/18/22. *The only thing that had been added to his care plan was the date of the fall, where he had been found, and that he had received no injuries. Review of the provider's Checklist for Falls or Incidents form revealed comments on the report that could have been added to resident 28's care plan, included: *Res [resident] reminded to call for help when needed. *Staff make sure wheelchair is close enough to bed. *Spoke with resident about using call light. *Staff aware to make sure w/c [wheelchair] is close to bed. Resident does self-transfer from bed to w/c independently at baseline. Interview on 4/27/22 at 4:40 p.m. with DON C revealed: *IDT [inter-disciplinary team] huddles are completed at time of fall with staff on the unit. *If new interventions are identified such as a fall mat, low bed, positioning devices; they are put in place at that time. *Resident's primary care provider and family are notified of fall and new interventions if needed. 4. Observation of resident 6 on 4/26/22 at 10:10 a.m. revealed the resident was awake in her room sitting in her recliner. The resident did not respond when this writer knocked on the room door and greeted her, but she did move her gaze towards the room door. Interview on 4/26/22 at 10:18 a.m. with certified nursing assistant (CNA) I regarding resident 6 revealed: *The resident was not able to walk or talk. *Staff tried to toilet the resident, and she wore an incontinent brief. *She was not sure if resident 6 was on hospice care. -During the conversation, CNA I walked down the hallway to ask another unidentified staff member if the resident was on hospice and returned to confirm she was on hospice care. Review of resident 6's medical record revealed: *She was admitted on [DATE] on hospice care. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident 6's 11/9/21 Initial Plan of Care revealed she: *Was non-ambulatory, used a mechanical stand lift with the assistance of two staff and a wheelchair. *Needed assistance with all of her activities of daily livings (ADLs). Review of resident 6's 11/16/21 admission Minimum Data Set (MDS) assessment revealed she: *Required staff assistance with all ADLs. *Was always incontinent and required extensive assistance with using the toilet. *Was on hospice care. Review of resident 6's current care plan, printed on 4/26/22, revealed it did not address: *Her needed assistance with ADLs which included the level of assistance needed and what interventions were to be used. *Her need for extensive assistance with toileting and what interventions were to be used. *Her hospice care, including what services the hospice agency would provide. Interview on 4/27/22 at 1:49 p.m. with DON C regarding the hospice plan of care revealed: *She expected the hospice plan of care should be available. *The hospice agency provided a green sheet detailing how often the hospice nurse and CNAs would come to the provider and what services they would provide. *She could not find either the hospice plan of care or the green sheet. Interview on 4/27/22 at 3:12 p.m. with MDS coordinator/infection control D regarding hospice care services revealed she: *Stated hospice care was hard to care plan as it changed frequently. *Stated for resident 6, the hospice agency provided the following: -A hospice nurse once a week. -A hospice CNA three times a week. -Other services included a chaplain and a bereavement coordinator. *Confirmed resident 6's care plan had not included the hospice services provided by the hospice agency's nurse, CNA, chaplain, and bereavement coordinator. Review of the provider's 3/15/22 Hospice Plan of Care policy revealed: *The provider will ensure that each Hospice patient's written Plan of Care includes both the most recent hospice plan of care which will reflect: -Hospice patient and family goals and interventions based on the problems identified by the Hospice patient assessments. -Participation and services provided by hospice . *Specifically, the Hospice Plan of Care includes: -Identification of Hospice services . -Detailed statement of the scope and frequency of Hospice services. *Hospice and [provider name] will jointly develop and agree upon a coordinated Plan of Care . *The Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care.

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions, assessments, physician notification and proper documentation were completed for four of four sampled residents (2, 23, 27, and 235) who had developed facility acquired pressure ulcers. Findings include: 1. Review of resident 235's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Acute kidney injury with [MEDICAL CONDITION]. -Renal artery stenosis. -Type two diabetes. Interview and observation on 6/13/19 at 11:01 a.m. with resident 235 revealed. *He was moving a lot in his chair. -He was frequently off-loading himself and switching from side-to-side in the chair. *He reported his bottom hurt. *It had started to hurt since he had been admitted . Review of resident 235's skin assessment's revealed: *On 5/30/19 he had a red coccyx. *No other skin assessments were completed since 5/30/19. Review of resident 235's undated fourty eight hour admission care plan revealed: *His coccyx was red. *No interventions were noted to maintain skin integrity. Review of resident 235's physician's office fax forms revealed: *On 6/6/19 the physician was notified of the resident's red buttocks. *It was also excoriated at that time. *The physician ordered on [DATE]: -For it to be cleansed daily with soap and water. -For a moisturizing cream to be applied, and it to be covered until healed. Review of all resident 235's progress notes from admission through 6/12/19 revealed: *On 6/6/19 was the first mention of his buttock being red, and excoriated. *On 6/8/19 He had a red coccyx and was encouraged to reposition and use protective cream. Surveyor: Interview on 6/13/19 at 11:35 a.m. with registered nurse (RN) D about resident 235's red coccyx revealed: *She was not aware he had a red coccyx. *She reviewed the 5/30/19 initial nursing assessment and agreed there was not documentation other than the statement of red coccyx. *There was no description or measurements in that initial assessment. *She agreed the documentation on 6/8/19 in the nurses notes was missing that same information. Observation on 6/13/19 at 12:40 p.m. of resident 235 with RN D revealed: *A small eraser size opening at the top of his coccyx and a quarter size superficial skin loss on his right inner buttock. *The skin from the coccyx to his scrotum was noted to be bright red from the inner to outer buttock. Surveyor 2. Review of resident 27's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Generalized muscle weakness. -Acute kidney failure. -Hypertension. -Pain unspecified. -[MEDICAL CONDITION]. -[MEDICAL CONDITION] with acute exacerbation. Review of resident 27's 10/29/18 Minimum Data Set (MDS) assessment revealed: *His Brief Interview for Mental Status score assessment was fifteen indicating his cognition was intact. *He required the extensive assistance of two staff members for: -Bed mobility. -Transfer. -Dressing. -Toilet Use. *He required the extensive assistance of one staff person for locomotion on and off the unit. *He required the limited assistance of one staff member for personal hygiene. *He was at risk for developing pressure ulcers. *He had no pressure ulcers at that time. Review of resident 27's 4/30/19 MDS assessment revealed: *His BIMS score was fifteen indicating he was cognitively intact. *He needed the extensive assistance of two staff for: -Bed mobility. -Transfers. -Toilet use. *He required the limited assistance of one staff person for personal hygiene. *He was independent with locomotion. *He was at risk for developing pressure ulcers. *He had one stage three pressure ulcer. -He was readmitted with that pressure ulcer. Review of resident 27's medical record revealed he had been hosptalized on [DATE] and returned to the facility on [DATE]. Floating heel boots had been implemented upon readmission. Interview and observation on 6/10/19 at 4:12 p.m. with resident 27 and his representative revealed: *He was sitting in his wheelchair with tennis shoes and [NAME] hose on. *He used the stand-lift for transfers. *He was able to propel himself in his wheelchair. *He had one sore on his right heal. *It was his understanding that it started as a bed sore due to him moving his feet too much at night. *The nurses did a dressing change each morning after he woke up. *It remained covered after the dressing change until the following day. Review of resident 27's 2/13/19 care plan revealed: *Focus area: I have a pressure injury to my right heel. -Initiated on 2/12/19. *Goal: My pressure injury will heal through my review date. -Initiated on 2/12/19. *Intervention: I need assistance to turn/reposition at least every two hours, more often as needed or requested. I require a pressure relieving/reducing mattress on my bed/chair. Administer treatments as ordered and monitor for effectiveness. Assess/monitor/record wound healing each shift. Measure length, width and depth weekly and PRN (as needed). Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to MD. Educate me/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols or the prevention/treatment of [REDACTED]. -Initiated on 2/12/19. -Revised on 2/12/19. *The wound was not being assessed each shift per the care plan. *There were only seven of thirty-four weekly skin assessments completed. Review of resident 27's skin assessments from admission through 6/11/19 revealed: *On 10/22/18 he had bruising on his left trunk and right arm. -They were suspected to be deep tissue injuries. *On 11/7/18 he had an other injury on his right heel. measuring 2.2 centimeters (cm) by 2.2 cm. -Resident has [MEDICAL CONDITION]; may have injured his foot when transferring, etc. MD notified for treatment. *On 11/13/18 he had a: -5.0 cm by 2.7 cm by 0.1 cm shearing to his coccyx. -2.2 cm by 2.2 cm right heel other injury. -3.0 cm by 2.5 cm vascular injury. -Resident has [MEDICAL CONDITION] and does not feel his feet. Seen by CNP (certified nurse practitioner) on 11/12. Both heels have eschear present. Wears foam boots at all time. [NAME] hose dc'd (discontinued). Has [MEDICAL CONDITION] in feet. Coccyx reddened w/ (with) shearing. *On 11/18/18 he had a: -5.0 cm by 2.7 cm by 0.1 cm shearing on his coccyx. -2.2 cm by 2.2 cm right heel other injury. -3.0 cm by 2.5 cm vascular injury. -Resident has [MEDICAL CONDITION] and does not feel his feet. Seen by CNP on 11/12. Both heels have eschear present. Wears foam boots at all time. [NAME] hose dc'd. Has [MEDICAL CONDITION] in feet. Coccyx reddened w/ shearing. *On 11/28/18 he had a: -.5 cm by .8 cm shearing to his coccyx. -3.5 cm by 2.1 cm other injury to his right heel. -1 cm by 1 cm vascular injury to his left heel. -.5 cm by .8 cm vascular injury to his right toes. -Has new dark spot on R (right) great toe above nail. No s/sx (signs/symptoms) of infection. L (left) heel is pint w/ no s/sx of breakdown. R buttock has a long oval shaped area w/ white/yellow bed. *On 1/23/19 he had a: -2 cm by 2.5 cm by .5 cm vascular injury on his left heel. -Open area has macerated edges all around it d/t (due to) moist dressing. drsg (dressing) changed. Bed has 100% granulation tissue present w/ no s/sx of infection or undermining. *On 2/28/19 he had a: -1.5 cm by 3.0 cm by .5 cm stage three pressure ulcer on his right heal. *No weekly assessment was completed for 10/28/18 through 11/3/18. *From 11/23/19 through 1/23/19 there were two of nine weekly skin assessments completed. *From 1/23/19 through 2/28/19 two of six weekly skin assessments were completed. *From 2/28/19 through 6/11/19 one of sixteen weekly assessments were completed. Interview on 6/12/19 at 5:30 p.m. with the DON (director of nursing) regarding resident 27's wounds revealed: *She was not sure how it was determined if the wound was a pressure ulcer or a vascular ulcer. *She agreed a nurse could not diagnose a vascular ulcer. *She indicated the nurse who had done the skin assessments had attended training for pressure ulcers. *She then stated all nurses were able to do skin assessments. *There was not a standard process for completing skin assessments. -She allowed the nurses to complete skin assessments either in progress notes or on the skin assessment form. Interview and observation on 6/13/19 at 10:52 a.m. with resident 27 regarding his pressure injury revealed: *He used to wear heel protector boots, but he believed that is what had caused the sore. *Licensed practical nurse (LPN) A verified his restless leg syndrome created the boots to slide around on his feet and might have attributed to the pressure injury. *The pressure injury was a small circle about the size of a dime. It was crusty looking, had a dark brown center, and some brown around the edges. *LPN A indicated the dark brown was from the [MEDICATION NAME] she had put on the wound earlier in the day. On 6/13/19 at 1:52 p.m. a voicemail was left at resident 27's attending physician's clinic and the call had not been returned by the end of the survey on 6/13/19. 3. Observation on 6/10/19 at 3:59 p.m. revealed resident 23 in bed positioned slightly on her left side. No pressure reducing device was noted on her bed. There was an air filled waffle cushion in her recliner. Interview and observation on 6/11/19 at 1:41 p.m. with resident 23 revealed:*She was seated in her recliner with her feet elevated. *There was a cushion in her recliner. *Her pressure ulcer had started after she had been admitted . *She was unsure of how large the pressure ulcer was. She went to wound care, and they did the dressing changes. *She did not have her recliner when she had been admitted , so sat in her wheelchair without any cushion. *The provider had told her it was not their policy to use any type of specialty mattresses, and the mattress she had was good enough. *She ate all her meals in her room. *The only time she left her room was for a shower, physician's appointments, and wound care appointments. Review of resident 23's Braden scale for predicting pressure sore risk revealed: *On 11/26/18 and 2/20/19 her score was seventeen. *On 5/30/19 her score was fifteen. *Those scores placed her at a mild risk of developing a pressure sore. Review of the provider's weekly pressure injury monitoring sheets for resident 23 revealed: *The initial measurement had been completed on 3/15/19. It had been documented on that sheet on 3/21/19. It listed the pressure injury as acquired, was on the sacrum, and measured: length 2.5 cm, width 1.5 cm, and depth 2.0 cm opened area. It had not been staged. No nursing measures had been noted. *3/28/19 revealed the same documentation as above. *4/4/19 was considered improved, a stage 3, and measurements of length 3.5 cm, width 1.5 cm, and depth 0.1 cm with undermining at 6 to 9 o'clock position of a clock. *4/11/19, 4/18/19, and 4/25/19 revealed the same documentation from 4/4/19. *5/30/19 was considered the same, a stage 3, and measurements of length 4.0 cm, width 1.5 cm, and depth 1.75 cm with clean red bed and intact periwound. *Wound clinic measurement and description documentation was requested from the director of nursing (DON) but was not received by the time of exit on 6/13/19. Review of resident 23's current care plan as of 6/11/19 revealed the following areas: *12/7/18 interventions initiated under pain focus: -I lie on a pressure reducing mattress and need extensive assistance with repositioning at regular intervals. -I also use a pressure reducing cushion in my chair. Remind me to adjust my weight at 15 minute intervals. *Handwritten information: -3/15/19 OK for wound clinic to eval (evaluate) and tx (treat). For stage 3 pressure ulcer sacrum. -3/20/19 - To wound clinic (sacral ulcer). -4/10/19 - To wound clinic. -Reposition q (every) 2 hours. *There was no focus, goals, and interventions related to her pressure ulcer. Review of resident 23's medical record revealed: *She had been admitted from another nursing facility on 11/26/18. *Had [DIAGNOSES REDACTED]. *She did not have any open skin areas when she had been admitted . *3/15/19 10:23 a.m. nurses note: -Type of Skin Condition: open area on sacrum, area bleeding, 100 percent (%) red bed, no tunneling noted, peri wound skin intact. Edges intact. -Description (Measurements, Color, etc.): 2.5 x 1.5 x 2.0 cm (centimeters). -Treatments and Orders: Called to Dr. to get order for wound clinic. -Response to Treatment: Will send to wound clinic to get tx (treatment). -Pain: 6/10. -Physician/Family Notification: Dr. (name)/family. -Additional Notes: Resident would not let us lay her down to be able to assess area, she finally let nurse after many attempts to look at bottom and make measurements after she got off commode. *3/19/19 10:55 a.m. nurses note: Apt. (appointment) received from wound clinic for Wednesday 3/21/19, son and resident aware of apt. Staff continue to encourage resident to reposition every 2 hours from recliner to bed. *Review of the 3/20/19 wound clinic orders included: -Assess area (sacrum) daily! -Specialty Bed, Air Bed, Nursing Home to provide. Waffle cushion when in chair. -Try slide sheets when in chair do micro shifts/in chair 30 min (minutes) @ (at) time. *3/22/19 9:32 a.m. nurses note: Resident received new orders from Wound Clinic on 03/20/19 late evening, called W.C. (wound clinic) on 03/21/19 to get clarification regarding new orders, spoke to nurse and she was going to talk with Dr. and call back. Called back this a.m. and let them know we didn't get a call back yesterday, message left and nurse to returned call. Spoke to day staff and report was given that resident refused to get out of recliner all night, night staff tried multiple times without success. Talk to resident regarding the pros and cons of re-positioning. *3/22/19 1:53 p.m. nurses note: -Wound nurse returned called and she will talk to Dr. regarding resident request to change 30 minutes in chair only to 1.5 to 2 hours. Nurse will fax new orders. *3/22/19 2:21 p.m. nurses note: -RN (registered nurse) returned call from wound clinic, continue with current tx. orders from 03/20/19, office will continue to get pre-op (authorization) for Vac., resident is to be encourage to only be in chair for 30 (minutes). *4/4/19 8:45 a.m. physician's visit note: -Was seen to assess her sacral ulcer and answer questions. She is quite frustrated as she's not had problems with this in the past. She had blamed it on having to sit in the wheelchair the first few weeks she was at [NAME]any, did not have recliner available for daytime. However, it sounds like she was actually sleeping in the bed at that time and once she got the recliner she has basically been in the recliner most of the time and does not lay in bed because the mattress makes her arthritis worse. Since being diagnosed with [REDACTED]. She says that they threatened to take orally (away) may (my) recliner unless she does sleep in the bed so she agrees to go to the bed now couple of times during the day and at night as well. She feels she was doing better with the [MEDICATION NAME] but not at the doing aqua cells feels like it does not cover the ulcer well. -Physical Examination: Skin exam done with nursing assistance, she does have a very deep sacral ulcer but it is clean and dray internally, the dressing had slid off of that and she is fairly wet under her brief. -Plan I recommend to the nursing staff that they try to do something different for the covering over the aqua cell to keep it dry and clean. Hopefully she will be able to tolerate wound VAC as this is a pretty deep ulcer and will take some time to heal. *4/10/19 3:00 p.m. nurses note: -Back from wound clinic. Received order for wound vac and new orders for wound treatment. Supervisor notified. Return to wound clinic in 1 month. *4/11/19 9:23 p.m. nurses note: Resident stated she does not want wound vac. Writer told nursing supervisor and she stated she would tell social services. *4/12/19 3:04 p.m. nurses note: -Writer escorted resident to apt. with Sanford Wound Clinic, resident refused to have Wound Vac. applied to open area stated it was her choice and that she was aware of the pro/con's of refusing and asked them to go with plan B. Teaching was done by nurses at wound clinic regarding the benefits of having the wound vac. and resident refused. New orders for wound dressing ordered. *5/9/19 8:00 a.m physician's visit note: -She is quite unhappy today. She did not end up getting the wound vac. sounds like she just was not happy with the explanations and was concerned about the potential pain that may be involved. She's very unhappy with the Dakin's solution and how much that burns. She is concerned that the BID (two times a day) sitz baths are going to mess up her schedule, that she will not be able to watch her shows, they're all I have to live for. -Plan: Discussed her meds (medications) and therapies with nursing staff. They are going to work with her to try to get her on the best schedule they can to make her life as consistent as possible. *5/25/19 2:08 p.m. nurses note: -Dressing changed to coccyx wound. Skin on buttocks is bright red, [MEDICATION NAME] cream applied. Resident weepy through the change of dressing. 5/30/19 4:45 p.m. social services note: -SS (social services) spoke with (name), POA-Financial, about concerns resident had brought to her attention. These concerns consisted of loss of clothes, resident feeling like staff are telling her she cannot sit in her chair, that she is lazy and that she has to stay in bed. SS spoke with Neighborhood Leader, (name), who clarified items. Shared with (POA financial name) that Neighborhood Leader (name), will follow up with staff about the statements and retrain to get everyone on the same page. Also shared that resident has been refusing to walk to meals or leave her room. Staff are trying to encourage her to walk to one meal a day to increase her mobility. Also shared that resident has been refusing sit baths and yelling at staff. (POA financial name) stated that resident does not like the sit (sitz) bath as it is not comfortable for her to sit. Also shared that staff are encouraging resident to not sit in the chair as much due to the sore and to be in different positions. SS shared that (neighborhood leader name), has updated resident's son, (name), who is POA-medical about these issues as well. (POA financial name) stated she would update resident's daughters and also talk with resident this weekend. *6/1/19 10:00 p.m. nurses note: *Late Entry: Note Text: Res. is alert et oriented x 3 with some confusion noted at times. Speech is clear et (and) she is able to make her needs known verbally. Remains extremely sedentary. Often chooses not to attend meals in DR (dining room) or activities that are provided by this facility. Staff strongly encourage her to make better decisions to aid in the healing of her coccyx ulcer et skin issues, but she easily takes offense to this at times. Has many reddened/inflamed areas t/o (through out) her skin/body, but states the pruritus has diminished some with the recent change in abx. (antibiotic) tx. Continues receiving sitz baths et wound dressings/cares for her coccyx ulcer, per WC's orders. Res. often chooses not to take the sitz baths as well. Ulcer has a clean wound bed et appears to be free of infection. Did sit up in her recliner this evening for supper meal, per her choice. Was in good spirits, as she had family visits this afternoon. Will continue to monitor et encourage. Interview on 6/13/19 at 10:55 a.m. with licensed practical nurse (LPN)/Promise Lane neighborhood leader [NAME] revealed: *A weekly safety meeting was held every Tuesday. *Therapy, dietary, registered dietician (RD), activities, nurse managers, DON, neighborhood leaders, and SS would attend. *Residents were reviewed that had the following : -Been receiving services under Medicare part A. -Recent falls. -Any type of wounds. -Changes in their condition. *When a resident with any type of skin issue was discovered the following were notified: physician, family, resident, staff, RD, and DON. *Therapy was not involved for seating or positioning when a resident had a pressure ulcer. *Braden assessments had no process of what to initiate according to the score. *Agreed skin assessments and measurements were not done in the medical record. *No specialty mattresses were used as the provider's mattresses were already pressure relieving. *She was not aware of the difference between a pressure relieving and pressure reducing mattress. Interview on 6/13/19 at 11:07 a.m. with LPN J revealed if any type of skin issue was found she would have charted what it looked like, and when it was discovered. She would have sent a facsimile to the physician with the measurements. Interview on 6/13/19 at 11:20 a.m. CNA K revealed she would have reported any changes to the nurse. She found out information about the residents during shift reports and staff huddles. Interview on 6/13/18 at 12:05 p.m. with physical therapist I regarding what therapies involvement for residents with wounds/skin issues included. She stated they did not do any screenings for residents with wounds or skin issues. They would if asked to. She agreed they were aware of wounds during the weekly safety meeting. 4. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Essential hypertension. -Muscle weakness. -Mixed incontinence. -Paranoid [MEDICAL CONDITION]. -Unspecified dementia without behavioral disturbance. *She was being treated at the wound clinic for a wound that had started on 7/26/18. Review of resident 2's 3/12/19 MDS assessment revealed: *Her BIMS score was fourteen indicating her cognition was intact. *She required extensive assistance of two staff members for bed mobility. *She required extensive assistance of one staff member for transferring, dressing, and toilet use. Interview on 6/11/19 at 8:43 a.m. and again at 11:14 a.m. with LPN/neighborhood leader [NAME] regarding resident 2 revealed: *She had a wound on her bottom, but the MDS assessment nurse who did weekly skin checks was not calling it a pressure ulcer. *It had been found because the resident had asked LPN/neighborhood leader [NAME] to look at her bottom, because it hurt. *She stated it started as a boil, but then stated there were two areas. *The one area was tunneling. *The opened area was first documented on 7/31/18. *They debrided it, and then it became one area. *She went to the wound clinic approximately every three to four weeks. Surveyor: Observation and interview on 6/11/19 from 10:40 a.m. through 11:15 a.m. of resident 2's wound with LPN G revealed: *An approximately quarter size opened area on the inside of a previous large opened area. *The rest of the large opened area was healed. *The edges of the opened area were like loose skin that had not grown back together. *LPN G stated it had previously been a very large wound. There had been two opened areas, and the wound clinic had removed the top layer of skin between the two opened areas that had created the large wound. *She stated those two opened areas had connected under the skin. *She thought it had been a pressure ulcer, and then also had a boil. Surveyor: Review of resident 2's nursing progress notes from 7/1/18 through 12/23/18 revealed: *7/29/18: -Temp (temperature) rechecked at this time et (and) was noted to be 99.2 temp. -Will continue to monitor. -Res. (resident) also noted to have a superficial open area to her coccyx. -Was bleeding at bedtime. -Area cleansed well et barrier cream applied. -Other shifts have been applying tx. as well. -Writer encouraged res. to sit up more often, but she chooses to only stay up for meals. *7/31/18: -1) Noted on 7/31/18 on Sacrum open unstageable area with slough, noted on 7/26/18 as a small superficial open area. -2) Boil like on L) (left) gluteal fold. -Measurements: --1) L (length) = 1 cm (centimeter) W (width) = 1.5 cm D (depth) = 0.7 cm. --2) L = 3 cm W = 3 cm area hard around it and draining copious serous drainage. -Treatment: Faxed DR (doctor) to request to send to Wound Clinic to Eval (evaluate) and tx (treat). *8/1/18: -Care conference held in resident room with friend present and RCC team. -Resident voiced concerns regarding open area on bottom and increased pain, informed resident (certified nurse practitioner (CNP) name) will be coming in today to look at it and orders will be given. -Encourage resident to continue with walking to meals and can asked to be be walked in the afternoon also. -No other concerns voiced. *8/4/18: -Assessed residents bottom. -Two open areas present above rectum: distal open area dime-sized, tunneling (undetermined depth); proximal open area quarter-sized, tunneling (undetermined depth). -Small amt (amount) green drainage, scant amt brown/bloody drainage. -Cleansed area well, dried. -Had resident lie on her R (right) side, completely off her bottom. -Resident currently has appt (appointment) w/ (with) wound clinic 8/10/18. Will attempt to call wound clinic Monday 8/6/18 ASAP (as soon as possible). *8/5/18: -Removed dressing to wounds. Scant amt green/brown drainage noted. Cleansed area, dried. Left OTA (open to air). *8/10/18: -Res. out to wound clinic for an appt. this afternoon. Tx. orders rec'd et noted. F/U (follow-up) in one month. *There had been no documentation prior to 7/29/18 regarding when the actual skin issue had started, notification to the physician, or physician's orders [REDACTED]. *There had not been weekly skin assessment notes. Review of resident 2's 7/31/18 fax communication to the physician revealed the following request: *May we have (an) order to send (the) resident to wound clinic to eval et tx. *Resident has the following: -1) On sacrum unstageable open area w/ slough, started on 7/26/18 as a sm. (small) open area superficial, noted today L = 1 cm W = 1.5 cm D = 0.7 cm slight odor noted - Pain level 8/10. -2) Boil like on L) gluteal fold just below the 1st - raised with area around it hard, draining copious ****drainage - pain 8/10. *The certified nurse practitioner (CNP) responded on 8/1/18 with the following: -Consult wound care clinic. -In bed on side 30 (minutes) - 1 hr (hour) after each meal. -Air overlay mattress for bed. -Reposition (every) 2 (hours) while in bed - keep off back. Review of resident 2's 8/1/18 CNP progress note revealed: *She was seen due to a nursing request for the opened area on her buttocks. *The CNP identified the wound as a pressure ulcer. Review of resident 2's skin assessments in her medical record from 7/26/18 through 6/10/19 revealed: *There had been no initial skin assessment for the wound on 7/26/18 or prior to that date. *There had been one completed on 8/10/18, 9/13/18, 10/11/18, 11/1/18, 12/7/18, and 1/4/19. *There had been no other skin assessments completed after 1/4/19. Review of the MDS assessment nurse's weekly skin monitoring documentation for resident 2 revealed: *All weekly skin monitoring sheets since 7/26/18 had been requested, but this surveyor was only provided with 11/1/18 through 5/30/19. *There were six weeks during that timeframe she did not have documentation. *The date noted for when the wound started was 8/10/18. *From 11/8/18 through 12/13/18 the measurements were 4.5 x 0.5 x 1.0 cm s/p (status [REDACTED]. -Progress was Improved. *From 1/10/19 through 3/7/19 the measurements were 3.5 x 0.2 x 2.0 cm 100% granular/sm amt Serosanguineous drainage. -Progress was Improved. *From 3/21/19 through 5/30/19 the measurements were 2.3 x 1.5 x 2.0 cm 100% granular/sm amt Serosanguineous drainage. -Progress was Improved. *The above information had not been documented in the resident's medical record. *The above measurements did not match-up with the wound clinic documentation below. *The MDS nurse was not available to be interviewed as she was on vacation. Review of resident 2's wound clinic documentation from 11/16/18 through 5/1/19 revealed: *The reason for referral was sacrum pressure wound. *11/16/18: Measurements were 3.6 cm x 1.2 cm x 2.3 cm. -There was an order for [REDACTED]. --That order was still in place on 5/1/19. *12/7/18: 3.4 cm x 0.2 cm x 0.6 cm. *1/4/19: 3.5 cm x 0.2 cm x 2.0 cm. *2/4/19: 2.2 cm x 0.2 cm x 1.5 cm. *3/4/19: 2.0 cm x 0.2 cm x 0.2 cm. *4/1/19: 2.5 cm x 0.2 cm x 0.2 cm. -The assessment and plan was Resolving stage 3 sacral pressure ulcer. *5/1/19: 2.8 cm x 0.1 cm x 1.0 cm Observation and interview on 6/13/19 at 10:54 a.m. with resident 2 sitting in her wheelchair in her room revealed: *She had a pressure relieving cushion in her wheelchair. *There was no pillow under either thigh. *She had a blue and gray mattress on her bed. -She did not have an air overlay mattress on the bed. *She stated The mattress could be better as it is hard sometimes. Interview on 6/13/19 at 11:09 a.m. with CNA F regarding resident 2 revealed: *She required help getting up in the morning and going to bed at night. *She needed help with perineal-care and repositioning. -She was not able to move on her own in bed. *She was not aware of using a pillow under her thigh while up in the wheelchair. Interview on 6/13/19 at 11:22 a.m. with LPN/neighborhood leader [NAME] regarding resident 2 revealed there was no air mattress on her bed. They had not looked into it prior to now but stated she would. On 6/13/19 at 12:15 p.m. a call was placed to the wound clinic, but there was no answer. At 12:33 p.m. this surveyor left a message at the wound clinic. They had not returned the phone call by the end of the survey on 6/13/19. 5. Review of the provider's (MONTH) (YEAR) Prevention and treatment of [REDACTED]. *To identify residents at risk for skin breakdown in order to successfully prevent such an occurrence. *To aggressively treat and heal skin issues by use of effective interventions. *A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage to underlying tissue. *These [MEDICAL CONDITION] are defined in stages. *Complete Braden Scale Assessment on admission, annually and with significant change in status. *Establish care plan based on assessment. *Dietary will assess nutritional status to assure food and fluid needs are met. *Establish a repositioning and turning program using turning sheets or devices. *Establish a bladder program. *Monitor skin da

Based on observation, interview, record review, and job description review, the provider failed to ensure appropriate social services involvement for one of one sampled resident (23) who had mental health concerns to potentially maintain psychosocial well-being. Findings include: 1. Interview and observation on 6/11/19 at 1:41 p.m. with resident 23 revealed: *She was seated in her recliner with her feet elevated. *There was a cushion in her recliner. *She had a pressure ulcer on her bottom that she had acquired after she had been admitted . *She was unsure of how large the pressure ulcer was. She went to wound care, and they did the dressing changes. *She did not have her recliner when she had been admitted , so she had sat in her wheelchair without any cushion instead. *The provider had told her it was not their policy to use any type of specialty mattresses and the mattress she had was good enough. *She had a history of [REDACTED]. *She ate all her meals in her room. *She did not attend any activities out of her. She only liked to watch her television programs. *They only time she left her room was for a shower, physician's appointments, and wound care appointments. *She avoided eye contact during the conversation. *Was very distracted by her skin being very itchy. *She stated she would feel a lot better if her skin quit itching. Interview on 6/11/19 at 9:00 a.m. with licensed practical nurse (LPN) [NAME] revealed resident 23: *Had a large pressure ulcer on her coccyx. *Refused to reposition. *Refused to sleep in her bed most of time. *Mostly sat in her recliner. *Did not want to be disturbed when she was watching television. *Rarely came out of her room anymore. *Used to come out to meals when she first was admitted . *Could be very rude to staff when they were helping her. Review of resident 23's physician's orders [REDACTED].>*1/3/19 to decrease her [MEDICATION NAME] to 5 milligram (mg) daily for ten days then discontinue. Also decrease [MEDICATION NAME] to 15 mg every bedtime for ten days then discontinue. *6/13/19 [MEDICATION NAME] DC'd (discontinued) in 1/2019 at (resident) request as she felt she was doing well. She has had multiple med (medical) problems since then and having more depression/anger/anxiety. If patient (resident) willing, please restart [MEDICATION NAME] 10 mg daily. If no improvement in 3 weeks, let me know and we may restart [MEDICATION NAME] as well. Review of the SS (social service) director's documentation for resident 23 included: *12/7/18 at 10:39 a.m. MDS (Minimum Data Set) SS Admission, lookback 11/26-12/02/2018: (resident) is alert and oriented x3 with times of forgetfulness and confusion. She is able to make her needs known at times; staff anticipates her needs and offers cuing as needed. She can make day to day decisions, but likes to include her family in larger decisions. She was pleasant and cooperative during the assessment. She scored a 15/15 on the BIMS (Brief Interview for Mental Status) and a 00/27 on the PHQ9; (patient health questionnaire) stating no mood concerns. *2/15/19 at 10:27 a.m. MDS SS Quarterly, lookback 2/6 to 2/12: (Resident) is alert and oriented x3. She is able to make her needs known and can participate in establishing goals. She is able to make daily decisions on her own, but does like to have family involved in larger decisions. Communication is clear. She is pleasant and cooperative. No s/s of [MEDICAL CONDITION] present. (Resident) scored a 15/15 on the BIMS. She scored a 00/27 on the PHQ9; no concerns reported. No behaviors noted during look back period. *5/7/19 at 8:18 a.m. MDS SS Quarterly, lookback 5/1 to 5/7: (Resident) is alert and oriented x3. She is able to make her needs known and can participate in establishing goals. She is able to make daily decisions on her own, but does like to have family involved in larger decisions. Communication is clear. She is pleasant and cooperative. No s/s of [MEDICAL CONDITION] present. No memory concerns noted. (Resident) scored a 15/15 on the BIMS. She scored a 9/27 on the PHQ9. She reports trouble sleeping and poor appetite every day. No behaviors noted during look back period. She prefers not to be asked about returning to the community on all assessments. She denies any current suicidal ideation. Information taken from resident interview, staff observation and report, and chart review. *5/30/19 at 4:45 p.m. SS spoke with (name), POA-Financial, about concerns resident had brought to her attention. These concerns consisted of loss of clothes, resident feeling like staff are telling her she cannot sit in her chair, that she is lazy and that she has to stay in bed. SS spoke with Neighborhood Leader, (name), who clarified items. Shared with (POA financial name) that Neighborhood Leader (name), will follow up with staff about the statements and retrain to get everyone on the same page. Also shared that resident has been refusing to walk to meals or leave her room. Staff are trying to encourage her to walk to one meal a day to increase her mobility. Also shared that resident has been refusing sit baths and yelling at staff. (POA financial name) stated that resident does not like the sit (sitz) bath as it is not comfortable for her to sit. Also shared that staff are encouraging resident to not sit in the chair as much due to the sore and to be in different positions. SS shared that (neighborhood leader name), has updated resident's son, (name), who is POA-medical about these issues as well. (POA financial name) stated she would update resident's daughters and also talk with resident this weekend. Interview on 6/11/19 at 3:30 p.m. with the SS director revealed she: *Confirmed resident 23's PHQ-9 score had changed from 2/15/19 of a 0 out of 27 to 5/7/19 of a 9 out of 27. *Had not investigated the reason for that change. *Was not really aware of the physician's orders [REDACTED]. *Had offered that counseling services was available for her to visit with. She was not sure when she had offered those services. *Had not asked her if there was any other resources she could have contacted. *Agreed resident 23 had been displaying signs and symptoms (S/S) of depression. Review of resident 23's [DIAGNOSES REDACTED]. She had been admitted on [DATE] with that diagnosis. Review of resident 23's PHQ-9 assessment revealed a score between 5 and 14 suggested mild major [MEDICAL CONDITION]. Provider uses clinical judgement about treatment based on patient's (resident) duration of symptoms and functional impairment. Review of resident 23's physician's orders [REDACTED].? Answer with Yes (Y) or No(N). If yes document in progress notes. Review of resident 23's certified nursing assistant (CNA) behavior documentation from 5/15/19 through 6/12/19 revealed: *One episode of wandering. *Eight episodes of rejection of care. Interview on 6/12/19 at 1:54 p.m. with LPN [NAME] confirmed: *The 11/26/18 physician's orders [REDACTED]. *She was not sure why that order had not transferred onto the treatment administration record. *No communication with SS for monitoring behaviors had been done. *No follow-up had been completed after her anti-depressants had been discontinued. Interview on 6/13/19 at 11:07 a.m. with LPN J revealed she had noticed more S/S of depression since (MONTH) 2019. Resident 23 would not follow prompts to turn and reposition. She was very short with staff and was very angry. Did not come out to eat in the dining room anymore. Interview on 6/13/19 at 11:20 a.m. with CNA K revealed when resident 23 had been admitted she was very nice and easy to get along with. She now was very crabby and angry. She would yell at staff just for coming in her room. She stated that had started a few months ago. Review of the provider's reviewed 4/8/16 Social Services Director (SSD) position job description revealed: *The SSD was generally responsible for overseeing the identification of the social, psychological, emotional strengths, needs of the residents on an individual basis, the provision of services to meet such needs, and fulfill such strengths. *The SSD would actively participate in the development, implementation, and evaluation of resident care planning. *Would assess and develop a plan of care that met resident's needs. *Accommodate resident's needs through responding appropriately to resident's verbal and non-verbal expressions of needs. *Receive and share information. Observed and report resident's conditions to the appropriate staff. *Communicate with staff on issues related to resident care, rights, and behaviors.

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions were implemented and care planned for two of three sampled residents (19 and 22) who had falls with injury. Findings include: 1. Review of resident 22's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Hypertension. -[MEDICAL CONDITION]. -Type two diabetes. -Unspecified dementia without behavioral disturbance. Review of resident 22's 12/27/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was nine indicating her cognition was moderately impaired. *She required extensive assistance of one staff member for: -Bed mobility. -Dressing. *She required extensive assistance of two or more staff members for: -Transfer. -Toilet use. *She was not steady and was only able to stabilize with assistance for: -Moving from a seated position to standing. -Moving on and off the toilet. -Transferring from one surface to another. *She did not ambulate in her room or the corridor. Review of resident 22's 5/7/19 MDS assessment revealed: *Her BIMS score was nine indicating her cognition was moderately impaired. *She required the total assistance of two or more staff for: -Bed Mobility. -Toileting. -Dressing. -Transfers. *She was totally dependent on one staff member for locomotion on and off the unit. *She was not steady and was only able to stabilize with assistance for: -Moving from a seated position to standing. -Moving on and off the toilet. -Transferring from one surface to another. *She did not ambulate in her room or the corridor. Random observations on 6/11/19 from 8:00 a.m. through 5:00 p.m. and on 6/12/19 from 8:00 a.m. through 5:00 p.m. revealed: *She was in her recliner, wheelchair, or bed. *She was not observed to ambulate. Review of resident 22's fall risk assessments revealed: *On 12/21/18 she scored a twenty-one indicating she was at high risk for falls. *On 2/4/19 she scored a nineteen indicating she was at high risk for falls. *On 5/13/19 she scored a sixteen indicating she was at high risk for falls. *On 6/3/19 she scored a fifteen indicating she was at moderate risk for falls. Review of resident 22's fall reports revealed: *On 2/2/19 she was found laying on the floor in her bathroom at 4:15 p.m. -She reported to staff she had hit her head, and it was hurting. -She was assisted off the floor with a total body lift. -She was not taken to the hospital. -She was ambulatory without assistance. *On 6/3/19 her roommate came to the nurses station reporting that resident 22 needed help. -She was found on the floor of her bathroom at 11:30 a.m. -She was assisted off the floor and back into her wheelchair. -She was not taken to the hospital. -Her level of mobility was wheelchair bound. Review of the investigation into resident 22's fall on 2/2/19 revealed: *She was taken to the emergency room . *She sustained a Jefferson fracture, C1 cervical fracture, and scalp hematoma. *She remained at the hospital from 2/2/19 through 2/5/19. *Discussion had been taking place if there was a need for a sign to be in her room to remind her to call for help. *Action taken by the provider was reviewing or revising her care plan. Review of resident 22's 1/19/19 care plan revealed: *Focus area: I am alert and oriented x1-2 (times one to two). I can be pretty forgetful at times; my memory just isn't what is used to be. I can make my needs known most of the time but I may need occasional reminders. -Initiated on 1/3/19 by social worker. *Goal: High risk for falls. -Handwritten. -No date or staff identification. *Interventions: -2/2/19 fall (send to ER) C1 Jefferson Fx (fracture). -Returned with cervical collar at all times. -5/15/19 order to discontinue cervical collar. --Handwritten no staff identified. *There were no interventions prior to 2/2/19 related to her being at high risk for falls. Interview on 6/12/19 at 5:17 p.m. with the director of nursing (DON) and licensed practical nurse (LPN)/neighborhood leader [NAME] regarding care plans revealed care plans were updated during care conferences by the neighborhood leaders. 2. Review of resident 19's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Mixed [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Unspecified dementia with behavioral disturbance. -Essential (primary) hypertension. -[MEDICAL CONDITION]. -[DIAGNOSES REDACTED] of intestine. Review of resident 19's 3/12/19 MDS assessment revealed: *His BIMS score was five indicating his cognition was severely impaired. *He required supervision of one staff person for walking. *He had two or more falls since admission/entry, or reentry, or prior assessment. Review of resident 19's fall risk assessments from 12/21/18 through 6/4/19 revealed: *His score on his admission assessment on 12/21/18 was seventeen indicating he was at high risk for falls. *On 1/8/19 they completed an assessment due to recent falls. -His score was twenty-three indicating he was at high risk for falls. *On 1/18/19 they completed an assessment due to recent falls. -His score was nineteen indicating he was at high risk for falls. *On 2/6/19 they completed an assessment due to recent falls. -His score was twenty-one indicating he was at high risk for falls. *On 3/15/19, 4/3/19, and 6/4/19 they completed assessments due to other. -His score was twenty-one indicating he was at high risk for falls. Interview and record review on 6/11/19 at 8:56 a.m. with LPN/neighborhood leader [NAME] regarding resident 19 revealed he had fallen on 1/18/19, 2/8/19, 2/28/19, 4/28/19 where he hit his head, and on 5/8/19. Review of resident 19's fall incident reports revealed: *12/30/18: He was found sitting on the floor between two recliners. -He had a rectangular shaped abrasion to his left lower back measuring 7 centimeters (cm) by 3.5 cm. *1/4/19: He was found in between the recliner and the end table with no injuries noted. *1/8/19: He was found sitting on the floor between the recliners in his room. The recliner was noted to be in the highest position. There were no noted injuries. He did complain of some back pain. *1/13/19: Resident scooted on bottom out to doorway of his room. Stated he was in bathroom, and when he went to sit down in his recliner he fell . *1/18/19: Resident was found sitting on the floor with no apparent injury. *2/5/19: He was found sitting on the floor between the two recliners in his room with no apparent injury. *2/28/19: Staff entered rooms to do rounds and found the resident sitting on the floor in front of his recliner. The recliner was partially elevated. There were no apparent injuries. *4/2/19: Resident was found sitting on the floor in front of the table and chair. Stated he hit his back on the edge of the table. Denies hitting head. Noted to have a red scrape on left shoulder blade area. The person filling out the form later stated there were no observed injuries. *4/19/19: Found resident on the floor next to his recliner. *4/28/19: Resident was lying in the doorway of his room with his walker sitting in front of him with no apparent injury. That contradicted what LPN/neighborhood leader [NAME] had said above. *5/8/19: The resident was lying on his left side on the floor in his room with his walker tipped over. *There was no documentation they reviewed the care plan or attempted any interventions. Observation on 6/11/19 at 5:51 p.m. of resident 19 revealed he was walking out of the Promise Lane dining room with a front wheeled walker. His shoe lace was untied. He walked past two certified nursing assistants (CNA) who spoke with him but had not noticed or addressed the shoe lace being untied. This surveyor stated to the resident his shoe was untied. A different CNA heard and came to assist him. The staff did not walk down the hall with the resident. Review of resident 19's 6/11/19 care plan revealed falls had not been addressed. There were no interventions on the care plan. Interview and record review on 6/12/19 at 10:38 a.m. with LPN/neighborhood leader [NAME] regarding resident 19 revealed: *The care plan did not have falls or fall interventions listed, but it should have due to him having falls. *She looked at resolved interventions, but there were no resolved or canceled interventions for falls. *She stated they had changed the room around thinking that might help reduce his falls, but they did not have it care planned or documented. 3. Review of the provider's 4/19/12 Accidents and Supervision, Fall Risk Management and Fall Prevention policy revealed: *Resident's would be assessed on admission, quarterly, annually, and whenever a significant change occurs for risk factors that may place them at risk for falls. Residents will also be assessed after a fall to determine what risk factors if any, contributed to the fall. *Fall risk assessment will be done on admission and appropriate interventions placed to prevent falls if resident is deemed at risk. *Risk is identified by a score of ten or greater. *Certified nursing assistants (CNA) will check that shoes/slippers are non-skid and are fitting and feeling comfortable. *CNAs will check that pants/skirts or bath robe are not dragging on the floor when they ambulate. *If a resident is considered to be a high risk for falls, every staff member is responsible to ensure that resident safety. Each staff member should look into the resident's room each time they walk by. If the resident is attempting to transfer staff should stay with the resident and assist as they are able.

Based on observation, interview, record review, and policy review, the provider failed to ensure professional standards: *Had been used during medication administration for one of ten sampled residents (8). *For the prevention, assessment, and documentation of pressure ulcers for four of five sampled residents (2, 23, 27, and 235) with facility acquired pressure ulcers. Findings include: 1. Observation on 6/11/19 at 10:00 a.m. revealed licensed practical nurse (LPN) student H and LPN G were setting up resident 8's morning medications. As she checked the medication blister pack labels to the electronic medication administration record (eMAR)LPN student H noted they did not match. The medication blister pack label was for [MEDICATION NAME] and the eMAR label was for [MEDICATION NAME]. LPN G did determine the physician order [REDACTED]. LPN G agreed that medication had a start date of 2/25/19 and had most likely not matched since then. She confirmed the medication right of verifying the right medication had not been followed. Interview on 6/12/19 at 5:20 p.m. with LPN/Promise Lane Neighborhood leader [NAME] confirmed the eMAR and medication label did not match. It had not been discovered until LPN student H noted it on 6/11/19. 2. During observation, resident medical chart review, interview, and policy reviews it was found there was a lack of nursing documentation and assessments on the status of residents 2, 23, 27, and 235's pressure ulcers. Refer to F686.

Based on observation, record review, interview, and policy review, the provider failed to have comprehensive care plans that reflected the residents current needs for 6 of 16 sampled residents (10, 14, 19, 22, 23, and 27). Findings include: 1. Review of resident 23's current care plan as of 6/11/19 revealed the following areas: *12/7/18 interventions initiated under pain focus: -I lie on a pressure reducing mattress and need extensive assistance with repositioning at regular intervals. -I also use a pressure reducing cushion in my chair. Remind me to adjust my weight at 15 minute intervals. *Handwritten information at the bottom of the care plan was: -3/15/19 OK for wound clinic to eval (evaluate) and tx (treat). For stage 3 pressure ulcer sacrum. -3/20/19 - To wound clinic (sacral ulcer). -4/10/19 - To wound clinic. -Reposition q (every) 2 hours. *There was no focus, goals, and interventions related to her stage 3 pressure ulcer. Refer to F686, finding 3. Continued review of resident 23's current care plan as of 6/11/19 revealed: *A focus area initiated on 12/7/18 with no revisions: -I use antidepressant medication r/t (related to) Depression. *A goal initiated on 12/7/18 with no revisions and a target date of 2/25/19: -I will be/remain free from discomfort or adverse reactions related to antidepressant therapy and will show decreased episodes of s/sx (signs and symptoms) of depression through the review date. *Interventions initiated on 12/7/18 with no revisions included: -Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. -Monitor/document/report to MD (medical doctor) prn (as needed) ongoing s/sx of depression unaltered by antidepressant meds (medication). Interview on 6/13/19 at 10:55 a.m. with licensed practical nurse (LPN) [NAME] confirmed resident 23's care plan did not contain a focus, goal, or interventions regarding her stage 3 pressure ulcer. She also stated resident 23 no longer took anti-depressant medications. 2. Observation of resident 14 revealed: *On 6/10/19 at 6:39 p.m.: She was seated in a tilt-in-space wheelchair. She had a seat belt on when she was seated in the wheelchair. It was not released she was assisted with her evening meal. *06/11/19 at 6:30 p.m.: Seat belt not released during her evening meal. Review of resident 14's revised 5/11/15 care plan with a focus area for her activities of daily living self-care performance deficit revealed an 11/26/18 intervention of: (Resident) has poor trunk control and requires a tilt & space wheel chair to maintain balance and safety. Use seatbelt when unattended. There was no separate care plan regarding the use of the wheelchair seatbelt. 3. Review of resident 10's medical record revealed she did not have a complete and comprehensive care plan. They had identified ending her nursing restorative program although it was still on her care plan. Refer to F676, finding 1. 4. Review of resident 22's medical record revealed she did not have a complete and comprehensive care plan. She had a fall that resulted in a C1 fracture and hospitalization . Fall prevention was not addressed on her care plan. Refer to F689, finding 1. She had a significant weight loss over six months, that was not reflected on her care plan. Refer to F692, finding 2. She was receiving two anti-depressants and depression was not reflected on her care plan. Refer to F758, finding 1. 5. Review of resident 27's medical record revealed he did not have a complete and comprehensive care plan. He had multiple pressure ulcers develope since admission, there were no preventative measures were on the care plan until (MONTH) 2019. Refer to F686, finding 2. 6. Review of resident 19's medical record revealed he had eleven falls since his admission on 12/21/18. Review of his 6/11/19 care plan revealed falls had not been addressed. Refer to F689, finding 2. 7. Review of resident 19's medical record revealed he had obvious cavities and broken natural teeth. Review of his 6/11/19 care plan revealed his dental needs had not been addressed on the care plan. Refer to F790, finding 1. 8. Review of the provider's (MONTH) (YEAR) Plan of Care policy revealed: *An interdisciplinary plan of care is developed within seven (7) days after completion of the comprehensive MDS assessment and is based upon the identification of the resident's condition and needs. *The plan of care identifies problems, approaches, goals, and the services necessary to assist the resident in attaining the highest practicable level of functioning. *Care plans will be updated by a nurse on an ongoing basis. This includes care plans being reviewed and updated with appropriate significant changes as well as quarterly.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all forty-two residents in the facility. Findings include: 1. Interviews, observations, record reviews, and policy reviews conducted throughout the course of the survey from 6/10/19 through 6/13/19 revealed the administrator and the director of nursing had not been an effective leadership team to ensure the safe management and overall well-being of the residents. Interview on 6/13/19 at 12:45 p.m. with the director of nursing (DON) regarding the skin monitoring documentation revealed: *She stated the date on the form was when the nurse typed up the information. *She stated the nurse typed up the information on Thursdays, but that was not the day she did the measurements. *She stated they meet on Tuesdays, and she did the measurements before that either Tuesday morning or Monday. *So the date documented was not the date she completed the measurements. Interview on 6/13/19 at 1:00 p.m. with licensed practical nurse(LPN)/neighborhood leader [NAME] revealed: *The above system the DON described for skin monitoring documentation was inaccurate. *She stated the date on the sheet was the date the nurse took the measurements. *She took the measurements on Thursday, and then they discussed them the following Tuesday. -That was five days before they met to discuss the pressure ulcers. *They met every Tuesday to discuss weight loss, falls, and pressure ulcers. *The DON was not at those weekly meetings, because she was attending stand-up at the other facility. Interview on 6/13/19 at 1:25 p.m. with the medical director revealed: *He attended the quarterly quality assurance meetings. *They discussed pressure ulcers and other issues at those meetings. *He thought those issues were under control. *He was not made aware of all the concerns and the seriousness of the current survey findings. Review of the provider's 4/6/16 DON job description revealed: *The Director of Nursing is responsible for the operation of the total nursing department which includes restorative nursing staff. *Her supervisor was the administrator. *The DON is responsible for the quality of care delivered to the residents. *Assures that all aspects of the MDS process are completed accurately and in a timely manner. *Assures through audits that care plans address problems areas as indicated on the RAP Summary. *Is knowledgeable of Federal and State regulations and implements changes in policy and procedures as regulations require. *Works closely with the Administrator and communicates concerns and problems promptly. Review of the provider's 10/26/18 CEO/administrator job description revealed: *The CEO/Administrator is directly responsible to the Board of Directors. *The CEO/Administrator is responsible for corporate oversight of [NAME]any Home Sioux Falls. *Approves all policies of the Home. *Interprets policies of the Home. *Oversees development and enforcement of the policies and procedures approved by the Board of Directors with the Home. Refer to F609, F656, F658, F676, F686, F689, F692, F698, F745, F758, F761, F790, F842, F867, and F880.