Every finding on record at Bethesda Home

The facility reported a census of 28. The sample included three residents. Based on interview and record review the facility failed to follow physicians' orders for the care of a surgical wound for Resident (R)1. This placed R1 at risk for wound complications and infection. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of a fracture (a broken bone) of the right lower leg and a fracture of the right shoulder R1's admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. R1 required staff assistance with dressing, grooming, toileting, and showering. The MDS noted R1 had a surgical wound. R1's Care Plan dated 06/05/25 documented R1 had Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) due to a surgical dressing. The plan directed staff to use gloves and gowns prior to high-contact care activity. R1's Physician Orders dated 06/04/25 ordered to keep the surgical dressing in place: keep the dressing clean and dry until post operative appointment; Call the physician for concerns or questions on surgical site or incision. A Nurses Notes dated 06/01/25 at 03:09 PM documented the dressing on R1's right leg fixator (a device used to stabilize broken bones, particularly in cases of severe fracture) was wet with serous (thin, clear) drainage; the gauze dressing was replaced with clean gauze. R1's EMR lacked evidence staff notified the surgeon of the drainage and dressing change. R1's Nurses Notes dated 06/02/25 04:27 PM documented R1 continued on skilled services for physical therapy and occupational therapy for fracture of the upper right humerus (arm bone) and an external fixator to the right leg. A Nurses Note dated 06/05/25 at 09:05 PM documented R1 continued skilled services for physical therapy, R1 had a fixator on her right leg. The note documented R1 was alert and required assistance with activities of daily living (ADL). R1 was non weight bearing on her right arm and right leg. R1 was transferred with a full lift. A Nurses Note dated 06/06/25 at 08:20 AM documented that staff observed a maggot (fly larvae) at the end of the gauze dressing on R1's right leg. The gauze dressing was dry to damp with yellow tinged drainage on it. Licensed Nurse (LN) G documented she removed around three dozen maggots from around the bottom of the distal fixator rod and out of the wound bed. A Nurses Note dated 06/06/25 at 09:09 AM documented LN G received orders to send R1 to the emergency room for an evaluation. On 06/23/25 at 01:25 PM LN G stated she assessed R1's surgical site on 06/01/25 and noted the dressing was saturated with drainage. LN G said R1's orders directed to keep the dressing clean and dry, so she removed the dressing and replaced the gauze. LN G stated she returned to work on 06/06/25 and when she assessed R1's surgical site, she observed maggots towards the end of the gauze. LN G said she was uncertain how the maggots ended up in R1's surgical site. On 06/23/25 at 01:35 PM Administrative Nurse D and Administrative Nurse E said R1's orders from the physicians directed staff to keep the surgical dressing placed by the surgeon in place until the follow up appointment with the physician which was in one to two weeks. On 06/23/25 at 01:50 PM, R1's Durable Power of Attorney (DPOA) indicated she felt the staff should have called the surgeon regarding the oozing from the site before changing the dressing because the physician made a comment that he packed the surgical site with antibiotic ointment. On 06/23/25 at 02:50 PM Medical Assistant (GG) stated the surgeon said there was no negative outcome from the maggots in R1's surgical wound. The facility did not provide a policy on following physicians' orders for surgical wound care as requested on 06/24/25.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 2 who had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed the resident at risk for possible exposure of infection. Findings included: - On 03/11/25 at 11:30 AM observation revealed License Nurse (LN) G and Administrative Nurse E entered the room of R2, who was sitting in a recliner in her room with both feet elevated. Observation revealed LN G removed the resident's Ankle-foot orthosis (AFO - an external device fitted to the body, used to: improve or prevent physical deformity. Stabilizes a joint or joints, reduces pain, and improves mobility and performance) splint from her right lower leg. Observation revealed Administrative Nurse E washed her hands and removed R2's sock and the resident had a dressing on her right heel and, a pressure ulcer. Continued observation revealed Administrative Nurse E washed her hands then donned gloves but no gown, removed the border foam dressing from the right heel, and a collagen packing on the heel wound area. Continued observation revealed the resident's right heel area was covered with pink skin and no open areas or drainage were noted at this time. LN G instructed Administrative Nurse E to change the treatment plan and use skin prep on the wound area then cover the wound with border foam dressing. Administrative Nurse E proceeded with the new treatment order and then put the resident's sock and AFO splint on R2's right leg. On 03/11/25 at 03:00 PM, Administrative Nurse D verified the staff should wear PPE for EBP when providing care for R2. They verified they lacked PPE equipment or a sign on the door that indicated the staff should wear PPE when providing R2's wound care. Administrivia Staff D stated this slipped through the cracks. Administrative Nurse D verified she would post the necessary signage on the resident's door regarding the use of PPE for a resident on TBP. The facility's Enhanced Barrier Precautions policy, dated January 2025, documented the facility would follow recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). Multidrug-resistant organisms (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and increased healthcare costs. On the recommendation and approval of the facility Infection Preventionist in collaboration with the facility's Medical Director, EBP were implemented as one intervention the facility uses to reduce transmission of resistant organisms that employ targeted PPE use during high-contact resident care activities. Standard Precautions continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. EBP is used in conjunction with standard precautions and expanded the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. ENBP expands PPE use beyond standard precautions when there is anticipated exposure to bold or body fluid. Gown and gloves are used during high-contact activities with increased risk for MDRO transmission to staff clothing and hands including but not limited to dressings, bathing/showering, transferring, providing hygiene, and changing linens. Changing briefs or assisting with toileting, device care, or use including central lines catheters, feeding tubes, tracheostomy/ventilators, wound care, and skin opening requiring a dressing. The facility failed to adhere to infection control standards and policies for R2 who required TBP. This placed the resident at risk for possible exposure to illness.

The facility reported a census of 29 residents, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from accident hazards, when on 04/23/22, Certified Nurse Aide (CNA) M failed to safely secure R1 in a whirlpool chair with the safety belt or safety bar, and failed to lower the resident's whirlpool chair to the lowest position before the CNA retrieved the resident's wheelchair, which was approximately two feet from the whirlpool chair, to transfer R1. CNA M left the resident suspended with the resident's feet dangling in the air and with no safety belt to secure him in the whirlpool chair while she went to retrieve the wheelchair. At that time, the resident fell forward out of the whirlpool chair, to the floor and onto his left side, where he sustained multiple injuries, that included a left hand skin avulsion (a wound that happens when skin is torn from the body during an accident or other injury) that measured 10 centimeters (cm) by 7 cm, which exposed tendons and veins in his left hand, and a purple left shoulder bruise that measured 22 cm by 19 cm with two skin tears on the bruise that measured 12 cm by 4.5 cm and 6 cm by 1 cm, requiring a trip to the emergency room for treatment. Findings included: - The Physician Order Sheet (POS), dated 06/16/22, documented R1 with diagnoses of cognitive communication deficit (difficulty with thinking and how someone uses language) and cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain [stroke]). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 9, or moderately impaired cognition. The resident required limited assistance of one staff member with toileting, transfers, and bathing. The resident used a wheelchair for mobility. The Activities of Daily Living (ADLs) Functional/ Rehabilitation Potential Care Area Assessment (CAA), dated 11/30/21, advised staff that the resident needed limited to extensive assistance of one staff member with his ADLs. The Cognitive Loss/Dementia CAA, dated 11/30/21, advised staff that R1 had moderate cognitive impairment, confusion, and forgetfulness. The staff were to provide R1 with reminders, cues, and orientation as needed. The Falls CAA, dated 11/30/21, advised staff that R1 had a potential for increased risk for falling due to chronic health conditions, weakness, unsteadiness, and history of falls. The Quarterly MDS, dated [DATE], documented the resident with a BIMS score of 9, or moderately impaired cognition. The resident required limited assistance of one staff member with toileting, transfers, and bathing. The resident used a wheelchair for mobility. The Falls Care Plan, updated 05/12/22, advised staff that the resident was at risk for falling related to a history of falls, poor balance, and [CONDITION(S)] (low blood pressure). The staff received education on 04/23/22 to use the safety belt on the whirlpool chair during the resident's bath, after the fall. The ADLs Care Plan, updated 05/12/22, advised staff that the resident required limited to extensive assistance with bathing and transfers. A Nursing Note, dated 04/23/22 at 10:57 AM, by Licensed Nurse (LN) G revealed she heard a scream from the spa room and opened the door to find R1 lying on his left side on the floor with his head against the shower stall. R1 received a whirlpool bath with assistance from CNA M. CNA M turned around to grab the wheelchair while the resident was still in the whirlpool chair and the resident fell out of the whirlpool chair onto the floor. The resident had skin trauma to the left occiput (back of head) that measured 2 centimeters (cm) by 2cm, with a L-shaped skin tear with edges approximated (to bring together) and the bleeding controlled. The area was edematous (swollen). The resident had a purple left shoulder bruise that measured 22 cm by 19 cm with two skin tears on the bruise that measured 12 cm by 4.5 cm and 6 cm by 1 cm. Two left elbow skin tears measured 14.5 cm by 9 cm and 4 cm by 9 cm assessed. He also sustained a left-hand skin avulsion with tendons and veins exposed that measured 10 cm by 7 cm and a left little finger skin tear that measured 2 cm by 2.5 cm. Staff noted multiple small bruises on the resident's arms. LN G notified Administrative Nurse D and the resident's durable power of attorney. The resident transferred to the hospital emergency room by Emergency Medical Services (EMS). A Nursing Note, dated 04/23/22 at 4:02 PM, by LN H revealed a phone report received from the hospital. The elder had skin tears on left hand, elbow, and shoulder from the fall. Treatment included wet to dry dressings on each skin tear secured with paper tape and [MEDICATION(S)] (wrap) for wound care. A Witness Statement, dated 04/23/22, by CNA M revealed she finished bathing R1and had the bottom half of the resident dressed while in the whirlpool chair. The safety bar was up and to the side of the resident. She turned away from the resident to move the resident's wheelchair and when she turned back around, the resident was on the floor. Observation, on 06/21/22 at 10:05 AM, Certified Medication Aide (CMA) R and Administrative Nurse E demonstrated use of the whirlpool chair. Administrative Nurse E sat in the chair equipped with a safety belt and a safety bar that can be moved up and down in front of a resident sitting in the chair. CMA R secured Administrative Nurse E in the chair by placing the safety belt around her waist and securing it and then lowering the safety bar in front of Nurse E. Staff lifted the chair approximately a foot up in the air so her feet would clear the edge of the whirlpool tub. During the demonstration, CMA R stated after assisting a resident out of the whirlpool bath, the resident should be taken over by the wall to use the grab bar while the aide lowered the chair to the floor. The resident should never be up in the air during drying or dressing them after a bath. The safety belt should remain on the resident and the safety bar down until the resident's feet were safely on the floor. Interview, on 06/21/22 at 10:10 AM, Administrative Nurse E stated the facility's investigation revealed CNA M assisted R1 out of the whirlpool tub with no safety belt around his waist and the safety bar in the up position. Instead of lowering R1 safely to the floor before getting the wheelchair, CNA M turned her back while he was still up in the air and he tumbled forward, out of the chair and landed on his left side. The staff were to always use the safety belt and bar regardless of the resident's mobility status or cognition during whirlpool baths. Interview, on 06/21/22 at 10:21 AM, CNA N revealed she was walking by the spa room and heard someone scream. CNA N found R1 lying on the floor and all he said was I want to go back to my room. CNA N noticed the whirlpool chair was Too high up in the air. She saw R1 had injuries and his head was laying against the wall. LPN G heard the screaming too and immediately came to the spa room and did an assessment. LN G called the Director of Nursing (DON) and the DON instructed LN G to call EMS. The facility policy Bathing in Whirlpool, revised 01/16/20, documented .Whirlpool Tub Bath .Assist resident to transfer into the whirlpool lift chair. Ensure the seatbelt strap is over the waist of the resident and fastened securely . The facility failed to safely secure R1 in a whirlpool chair with the safety belt and safety bar, and failed to lower the resident to the floor before retrieving his wheelchair, which was approximately two feet from the whirlpool chair, to transfer R1. CNA M left the resident suspended with his feet dangling in the air and with no safety belt or safety bar to secure him in the whirlpool chair while she went to retrieve the wheelchair. At that time, the resident fell forward out of the chair to the floor and onto his left side where he sustained multiple injuries, including a left hand skin avulsion that measured 10 centimeters (cm) by 7 cm, which exposed tendons and veins in his hand, and a purple left shoulder bruise that measured 22 cm by 19 cm with two skin tears on the bruise that measured 12 cm by 4.5 cm and 6 cm by 1 cm, requiring a trip to the emergency room for treatment. This citation was considered to be past non-compliance, when the facility corrected the deficient practice, with implementation and then completion of the following items, on 04/30/22 at 02:26 PM. 1. On 04/23/22, after the resident's fall, education on use of the safety belt/position bar in the whirlpool tub began at 12:30 PM. Facility education was completed by 19 of the facility staff members on 04/30/22 at 02:26 PM.

The facility reported a census of 27 residents. Based on interview and record review, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship proactively to ensure antibiotic use in a safe and effective manner to prevent unnecessary side effects of antibiotics and development of antibiotic resistance in the residents of the facility. Findings included: - Review of the Antibiotic Stewardship Log, revealed the facility lacked the use of an assessment tool (for antibiotic appropriateness) at the initiation of antibiotic therapy. The facility reviewed antibiotic appropriateness at the completion of the antibiotic. Furthermore, the facility lacked periodic review of antibiotic use by physician and compilation of organisms/resistive organisms in the facility. Review of the Antibiotic Stewardship Log, for September 2021, revealed an entry for resident (R)10 with a urinary tract infection due to benign prostate [CONDITION(S)] (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with a culture result of E coli (a type of bacteria) and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Antibiotic Stewardship Log, for October 2021, revealed R10 developed burning discomfort and cloudy, odorous urine had a culture result of E coli, and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . With the indication the resident had the same infection from September 2021 with continuation of symptoms. Review of the Antibiotic Stewardship Log, for November 2021, revealed an entry for resident R10, with a urinary tract infection with a culture result of E-coli (a type of bacteria) and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, on 12/07/21, at 11:00 AM, with Administrative Nurse D, revealed the facility lacked an assessment tool, for nursing staff to utilize at the initiation of the antibiotics, at this time but would initiate the McGeer's Criteria (a systematic guide for antibiotic use based on criteria for specific infections included [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D stated the facility did not compile a separate report of the number of antibiotics used for prophylaxis. Interview, on 12/08/21 at 10:43 AM, with Licensed Nurse (LN) G, revealed she lacked training in use of criteria/guides for antibiotic initiation, but followed the prompts in the electronic medical record for infection documentation. Interview, on 12/08/21 at 11:15 AM with LN H, revealed she was not familiar with a tool for use prior to initiation of an antibiotic. Interview, on 12/14/21 at 11:00 AM with Administrative Nurse D revealed the pharmacist identified the R10's prophylactic (for prevention) use of antibiotic in November 2021, and the physician wrote a benefit statement that included prostatic hypertrophy and urinary retention but failed to identify the risks of antibiotic use. The facility policy Antibiotic Stewardship Program reviewed 4/2021, instructed staff to promote the appropriate use of antibiotics while optimizing the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy instructed the Administrative Nurse to monitor antibiotic usage patterns and report the number of antibiotics prescribed and provide a separate report for antibiotics that did not meet criteria for active infection. The facility failed to proactively monitor initiation of antibiotics and failed to monitor antibiotic use patterns by prescribers to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance.

The facility reported a census of 27 residents. Based on observation, interview, and record review, the facility failed to ensure staff provided environmental cleaning in a sanitary manner to prevent the spread of infection, failed to ensure pet vaccinations remained up to date for resident's cat, failed to ensure the water temperature in the laundry remained at least 160 degrees Fahrenheit to ensure sanitary laundering of resident linen. Findings included: - Observation, on 12/08/21 at 08:28 AM, revealed housekeeping staff VV and WW changing resident bed linen. Staff VV with gloves on changed the bed linen in a resident room, came out of the room, with the same gloves on, went into another resident room and changed the bed linen, and with the same gloves on wheeled the dirty linen cart into the resident room, placed the dirty linen in the cart, removed her gloves, performed hand hygiene and wheeled the cart out of the room. Interview, on 12/08/21 at 11:00 AM, with Administrative Nurse D, revealed she would expect staff to change gloves and perform hand hygiene upon exit of each resident room when changing bed linen. The facility failed to provide a policy related to this issue. The facility failed to ensure staff provided changing of resident bed linen cleaning in a sanitary manner to prevent the spread of infection. - Observation, on 12/09/21 at 07:53 AM, revealed Housekeeping staff V cleaning a resident room. Staff V donned gloves and obtained a sanitary wipe and proceeded to wipe the toilet flush handle, then wearing the same gloves and with the same wipe, Staff V started to wipe the resident's shelf containing the resident's [NAME] knacks. Surveyor GG questioned staff V if the toilet flusher was a dirty surface and the shelf a clean surface, and staff V concluded she should change her gloves and provide hand hygiene and changed her gloves and obtained a new wipe. Staff V continued with cleaning surfaces in the resident's room. Observation revealed staff V obtained the toilet bowl cleaning products, lifted the toilet seat lid, and squirted the cleaning agents, in the bowl, returned the cleaning product to her cart, then with the same gloves, obtained a scrubber for the resident's sink and proceeded to clean the resident's sink. Surveyor GG advised staff V that her gloves were considered contaminated from the contact with the toilet bowl. Staff V agreed and doffed these gloves, performed hand hygiene and then donned gloves and threw the sink scrubber away. Observation continued as staff V cleaned the toilet seat lid and surface, and with the same gloved hands and same sanitizing wipe, then cleaned the toilet riser's hand rails. Interview, on 12/08/21 at 11:00 AM, with Administrative Nurse D, revealed she would expect staff to change gloves and perform hand hygiene when in contact with a dirty surface, before contact with a clean surface. The facility policy Donning and Doffing Disposable Gloves, revised 08/2020, instructed staff to change gloves and perform hand hygiene when moving from soiled contaminated area of care to clean areas of care. The facility failed to provide housekeeping services to a resident room in a sanitary manner to prevent the spread of infection. - Observation, on 12/09/21 at 10:01 AM, revealed a temperature log in the laundry room with temperatures logged as 162 degrees Fahrenheit, the log lacked temperature documentation from 12/06/21, 12/07/21, 12/08/21 and 12/09/21. Interview at that time with Laundry staff W, revealed laundry staff obtained the water temperature from the gauge on the water line going to the noncommercial washing machine. Laundry staff W stated the washing machines used hot water for sanitizing laundry and the bags used for isolation laundry dissolved in water at a temperature of 160 degrees Fahrenheit. Staff W stated laundry staff use a graph to determine what setting to use for various types of laundry and the detergent, softener and bleach were dispensed automatically, and whites were sanitized at 160 degrees temperatures. Staff W stated maintenance checked the water temperature in the hand washing sink. Interview with Maintenance staff UU, revealed he did not check the water temperature in the washing machines. Observation, on 12/09/21 at 10:30 AM, revealed maintenance staff U, obtained a water temperature from the hot water line leading to the commercial washing machines as 147.5 degrees Fahrenheit. Staff W stated the water temperature should be above 160 degrees. Interview, on 12/09/21 at 11:00 AM, with Maintenance staff U, revealed the hot water tank temperature had been inadvertently turned down to below 160 degrees. Maintenance staff U did not know how long the water temperature's thermostat was in this position. The facility policy Laundry Protocol, undated, instructed staff to prevent the spread of infections by hot water washing included water temperatures exceeding 160 degrees for 24 minutes. The maintenance/environmental service department instructed to routinely inspect maintain and document hot water temperatures on the washers at 160 degrees. The facility failed to ensure adequate hot water sanitation of resident laundry to prevent the spread of infections. - Observation on 12/07/21 at 08:30 AM, revealed resident (R)10 personal cat lived in his room and facility staff provided a litter box and feeding to the pet. Review of the pet's vaccination records revealed the last date of vaccinations as November 2, 2018, November 16, 2018, November 24, 2018 and November 24, 2018. Interview, on 12/09/21 at 11:00AM, with Administrative staff A, confirmed the vaccines were not renewed since 2018. The facility Pet Policy, dated January 2019, instructed staff that all animals must be examined by the veterinarian and certified as healthy with all recommended immunizations. The facility failed to ensure one resident's cat had current vaccinations to prevent the spread of infection.

The facility reported a census of 27 residents. Based on record review and interview, the facility failed to display the actual hours worked on the daily nursing staffing sheets on a daily basis, for the 27 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, for the past 90 days, revealed the section for the actual nursing hours worked, lacked completion. On 12/9/21 at 02:00 PM, Administrative Nurse D stated, the facility staff failed to complete the nursing staff sheets with the actual nursing hours worked, as they should have been. The facility policy for Posting Daily Nurse Staffing Form dated 2018, included: The total number of hours of each position is posted at the entrance to the health center and will be kept current during each day by revising the form as staffing and census change. The facility failed to properly complete the daily nursing staffing sheets to include the actual hours the nursing staff worked, for the residents of the facility.

The facility reported a census of 43 residents with 15 residents sampled, including 6 residents sampled for accidents. Based on observation, record review and interview, the facility failed to provide appropriate interventions for 4 of the 6 (#13, #26, #34 and #36) sampled residents, to prevent further falls. Findings included: - The POS (Physician order [REDACTED].#13 had a [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 5-14-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. The resident required extensive assistance of 2 for transfers, required human assistance for stabilization and had no impairment in functional ROM (Range of Motion). He/she had 2 or more non-injury falls since admission and used a bed/chair alarm daily. The CAA (Care Area Assessment) for cognition, dated 5-17-18, documented the resident believed he/she could get up and walk on his/her own and required continued reminders, cueing and education to utilize the call light. Staff considered him/her a high fall risk. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 7, indicating severe cognitive impairment. The resident required extensive assistance of 2 for transfers, required human assistance for stabilization, and had no impairment in functional ROM. He/she had 2 or more injury (except major) falls since the prior assessment and continued to utilize a bed/chair alarm daily. The care plan for falls, dated 11-08-18, instructed staff the resident required assistance of 2 when getting out of the whirlpool, slipper socks at night, encouragement to use the call light, to be toileted around 5:00 p.m., the door to his/her room left open for monitoring, reminded to lock the brakes on his/her wheelchair, a scoop mattress, and to keep the resident's items within easy reach of him/her. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. The intervention for the fall at 6:30 p.m., also included a medication review. Neither fall included an immediate intervention to prevent further falls. On 1-16-19 at 2:42 p.m., the resident propelled him/herself in their wheelchair in the hall. The resident wore appropriate footwear. On 1-16-19 at 1:49 p.m., direct care staff N stated staff attempt to educate the resident to use the call light, however, he/she is confused. On 1-17-19 at 1:31 p.m., licensed staff C stated, staff should initiate a new intervention following each fall. 1-18-19 8:25 a.m., administrative staff A, stated each fall should have a new intervention. The two falls on 10-04-18 have the same intervention and neither one of them was immediate. The facility's policy for Falls, updated 9-03-18, included: The resident's care plan will be reviewed, and interventions added to help reduce the risk of and/or eliminate future falls. The facility failed to determine the root cause and initiate immediate and appropriate interventions following two falls, on the same day, for this resident at a high risk for falls. - The POS (Physician order [REDACTED].#36, documented the resident had a [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set), dated 10-10-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating he/she had intact cognition. The resident required extensive assistance of 2 for bed mobility and transfers, required human assistance for stabilization and no impairment in functional ROM (Range of Motion). He/she had no falls since the prior assessment. The CAA (Care Area Assessment) for falls, dated 10-12-18, documented the resident was at risk for falls due to weakness and problems with balance. The admission MDS, dated [DATE], documented the resident had a BIMS score of 13, indicating he/she had intact cognition. The resident required extensive assistance of 2 for bed mobility and transfers. He/she had no falls since admission. The care plan, dated 1-03-19, instructed staff the resident was at risk for falls due to impaired balance and use of antianxiety medication. Staff needed to keep the resident's bed in the lowest position at all times. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 12-17-18, documented the resident fell from bed while in his/her room. The resident stated he/she had rolled out of bed. The staff intervention following the fall was to keep the resident's bed in the lowest position at all times and to position the resident in the middle of the bed when he/she was on his/her side. On 1-15-19 at 2:34 p.m., the resident rested in his/her bed which was in the high position. On 1-17-19 at 1:32 p.m., the resident rested in his/her bed which was in the high position. On 1-17-19 at 10:16 a.m., direct care staff R stated having the resident's bed in the lowest position was not a fall intervention for the resident. On 1-17-19 at 1:38 p.m., licensed staff M confirmed the resident's bed was in the high position. Staff M also stated the resident's bed should be in the lowest position at all times. On 1-17-19 at 3:51 p.m., licensed staff J stated the resident's bed was to be in the lowest position at all times. On 1-18-19 at 8:25 a.m., administrative staff A stated the intervention for the resident following the fall on 12-17-18, was to have his/her bed in the lowest position. Staff A would expect the staff to keep the bed in the lowest position, as care planned. The facility's policy for Falls, updated 9-03-18, included: The resident's care plan will be reviewed, and interventions added to help reduce the risk of and/or eliminate future falls. The facility failed to provide planned interventions including keeping the resident's bed in the lowest position, to prevent further falls for this resident at a high risk for falls. - Review of resident #26 physician order [REDACTED]. The admission MDS (minimum data set), dated 10/30/18, assessed the resident with a BIMS (brief interview for mental status) score of 13, indicating intact cognition, needed extensive assist of one for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident required limited assist of one for walking in room and corridor and for locomotion on/off unit, balance not steady, but able to stabilize without human assist when moving from seated to standing position, moving on/off the toilet, surface to surface transfer, and only able to stabilize with human assistance for walking, and turning around and facing the other direction while walking, and no impairment to upper or lower extremities. The resident was continent of bowel and bladder and not on a toileting program, had a fall in the last month and last 2-6 months prior to admission. The SCSA (significant change in status assessment) MDS, dated [DATE], assessed the resident with a BIMS score of 13, indicating intact cognition, needed extensive assist of 2 for bed mobility, transfers, toileting, dressing, and hygiene; ambulation did not occur, lower extremity impairment both sides, impaired balance for moving from seated to standing, on/off toilet, and surface to surface transfer. The resident was frequently incontinent of bladder, occasionally incontinent of bowel, no toileting program in place, and one fall with major injury since prior assessment, no restraints or alarms used. The CAA for falls, dated 11/5/18, indicated the resident has slowly been declining while living over in Assisted Living, he/she has had some falls, his/her balance is poor and takes an antidepressant. He/she will be working with PT (physical therapy) & OT (occupational therapy) to regain some strength and balance as well as develop restorative programs to maintain, and is at risk for falls. The CAA for ADLs (activities of daily living), dated 11/5/18, indicted that the resident needed limited to extensive assist of 1 - 2 nursing staff for his/her ADL's. The CAA for falls, dated 12/4/18, indicated the resident has slowly been declining while living over in Assisted Living, he/she has had some falls, his/her balance is poor and he/she takes an antidepressant, he/she had a fall resulting in pelvic fractures on 11/18/18 and the goal was for him/her to heal without complications and have no other injurious falls. The CAA for ADL's, dated 12/3/18, chose to care plan for ADLs as he/she had been declining and needing more nursing assist so was moved from assisted living recently and had a fall resulting in some fractures. The CAA for urinary, dated 12/4/18, chose to care plan for area because he/she was frequently incontinent of bladder and needs nursing assist to safely get to the bathroom, and that she did have a 3 day bowel and bladder assessment done upon admission, and that he/she will call for staff assist. The baseline care plan, dated 10/24/18, revealed these interventions: wears glasses, history of falls marked with intervention added on 10/31/18 for request for PT/OT, restorative program marked but no program listed, assist of one for bed mobility, transfer, walking, toileting, locomotion, grooming/hygiene, is continent of bowel and bladder and does not need a toileting program, and uses a four wheeled walker for short distances and a wheelchair for longer distances. On 10/29/18 an intervention was added of a riser with hand rails applied to the toilet. The comprehensive care plan, last reviewed 12/6/18, advised staff to provide an environment free of clutter, provide proper well-maintained footwear, leave night light on in room, keep personal items and frequently used items within reach, keep call light in reach at all times, keep bed in lowest position and locked, encourage he/she to use environmental devices such as hand grips and hand rails and etc., assure the floor is free of glare/liquids/foreign objects, assure that resident is wearing eyeglasses, assure eyeglasses are clean and in good repair. I need limited to extensive assist of 2 staff for pivot transfers, bed mobility, dressing/undressing, at this time I am in a w/c for all mobility staff propelled. I am working with PT/OT to return to my prior level of function with ambulation. On 11/12/18 an intervention added that resident was continent of both bowel and bladder. I will call for assist when I need to use the bathroom. On 11/18/18 an intervention added to educate me to use my call light for assistance with cares. On 11/30/18 an intervention was added that resident will be working with PT&OT for strengthening. On 1/7/19 an intervention was added to have a pad chair alarm on the resident's bed, chair, and recliner and take with resident when transferred. On 1/12/19 an intervention added to educate the staff to ensure that he/she was wearing non-skid socks while in bed. The fall risk assessment, dated 10/24/18, indicated the resident was a high risk for falls. The fall risk assessment, dated 11/23/18, indicated the resident was a high risk for falls, with action to continue current plan of care. The resident's medical record showed on 11/18/18 at 04:15 a.m., the resident fell ambulating independently to her bathroom. He/she was found on his/her bathroom floor which resulted in a skin tear to his/her left elbow and a pelvic fracture. The intervention for the fall was to educate resident to use call light for assistance with cares. The resident's medical record showed on 1/1/19 at 3:20 p.m., the resident was found sitting on the floor beside her bed, call light was on reach but not turned on, glasses were on and clean, nylon stockings were found on his/ her feet, environment was free of clutter. The intervention was alarm pad placed in wheelchair and on resident's bed. The resident's medical record showed on 1/12/19 at 04:45 a.m., the fall alarm went off and the resident was found sitting on the floor beside the bed. Resident had said that he/she got up to use the bathroom. Resident was alert with confusion per his/her norm. Resident was toileted at 03:00 a.m. Intervention in the nurses note dated 1/12/19 at 05:37 a.m. was to remind the resident to use the call light every time he/she gets up. The intervention added to the care plan on 1/12/19 was to educate staff to ensure that the resident is wearing non-skid socks while in bed. Observation, on 01/16/19 at 11:58 a.m., revealed the resident was sitting in a wheelchair at the dining room table, the pressure pad alarm was in the seat of the wheelchair, but it was not connected to an alarm box. The resident had non-skid footwear in place. Direct care staff K left the dining area and returned with an alarm box and attached the pressure pad cord to it. Observation, on 01/17/19 at 09:12 a.m., revealed the resident was resting in bed with his/her eyes closed, pressure pad alarm in place to bed and connected to alarm box, wheelchair at bedside and locked. The overbed table that had a water glass on it, eyeglasses, snacks, was across the room out of the resident's reach, the call light was in reach of the resident. Observation, on 01/17/19 at 10:11 a.m., revealed that direct care staff K assisted the resident to sit up on the side of the bed, nylon stockings in place to his/her feet. After placing on her shoes, the direct care staff member assisted the resident to/the wheelchair and on/off the toilet to the wheelchair, and back to bed with nylon stockings on his/her feet. Pressure pad to bed connected to alarm box. Direct care staff K left the room and failed to provide appropriate footwear for the resident. Interview, on 01/17/19 at 10:31 a.m. with direct care staff K confirmed that the resident sometimes calls for assistance to the bathroom and that he/she is on a scheduled toileting program. Interview, on 1/17/19 with direct care staff L, confirmed that the resident is a fall risk and that interventions in place to prevent falls was the use of the pad alarm and a sticker on the call light box in the bathroom that indicates not to leave the resident unattended on the toilet. Direct care staff L also confirmed that the resident does not always use the call light for assistance to the bathroom, and the later it is in the shift, the less often he/she uses the call light. The direct care staff L reported that he/she toilets the resident every two hours if the resident is restless and might sit her in the recliner in the living room. The direct care staff L confirmed that staff check care plan for any new fall interventions or the nurse might tell them in report. Interview, on 01/17/19 at 3:14 p.m., with resident #26, revealed that resident was unable to answer what he/she would do if she needed to get up during the night to use the bathroom and that he/she would just get up and go. Interview, on 01/17/19 at 3:29 p.m., with licensed nursing staff H, confirmed that new fall interventions are passed on in report, it's on their care plan, and it is on a fall sheet in the red communication book. Interview, on 01/17/19 at 4:18 p.m., with licensed nursing staff J, revealed the resident tends to get very confused and doesn't know the time of day, the staff will bring the resident out to the living room area if he/she doesn't want to sleep. Also confirmed some nights he/she is alert and cognitive intact and uses light all night, and other nights he/she does not, and that he/she does visual checks at night because he/she is a fall risk and at times he/she has bladder incontinence. Nursing staff J included that fall interventions are in the red CNA book and staff are to check at the beginning of the shift and pass on in report. Interview, on 01/17/19 @ 12:57 p.m., with administrative nursing staff A, revealed that nursing staff are made aware of fall interventions via the communication book and a message is sent to Care Tracker. Staff are to check the communication book at the beginning of the shift and check Care Tracker messages. The specific fall intervention would be in the Care Tracker message. The facility fall policy, dated 9/3/18, included: Factors which may have contributed to the fall will be evaluated and eliminated if possible at the time of the fall and individualized interventions will be put in place as indicated in the care plan to promote safety. The resident's care plan will also be reviewed, and interventions added to help reduce the risk of and/or eliminate future falls. The facility failed to ensure planned interventions were in place to prevent further falls for resident #26 that was assessed to be at high risk for falls. On 1/16/98 at 11:58 a.m., staff failed to connect alarm box to pressure pad cord. On 1/17/19 at 9:12 a.m., staff failed to ensure frequently used items were within the resident's reach and on 1/17/19 at 10:11 a.m. resident was in bed without the appropriate footwear, was transferred out of bed to wheelchair without the appropriate footwear, and was transferred back to bed, and left in bed, without the appropriate footwear. - Review of resident #34's physician order [REDACTED]. The quarterly MDS (minimum data set) dated 9-14-18, assessed the resident with a BIMS (brief interview for mental status) score of 4 indicating severely impaired cognitive status, wandering 4-6 days of the 7 day look back period, required limited assistance of 1 person for bed mobility, dressing, independent with ambulation in the room, required supervision for ambulation in corridor, required supervision for toileting, no impairment in range of motion of upper or lower extremities and 1 non injury fall. The annual MDS, dated [DATE] assessed the resident with a BIMS score of 3, limited assistance of 1 person for bed mobility and transfer, supervision of 1 person for ambulation in room corridor, extensive assistance of 1 person for dressing, toilet use, and personal hygiene, no impairment of upper or lower extremities, and 2 noninjury falls since prior assessment. The CAA (care area assessment) for falls, dated 1-14-19, assessed the resident experience several falls during the assessment period with many contributing factors including cognitive status and poor safety awareness. The CAA for activities, dated 1-14-19, assessed the resident as spending time in the common living area so nursing staff can easily observe the resident. The care plan, last reviewed, 12-23-18, advised staff of the following interventions: An intervention, dated 5-16-18, advised staff to place gripper socks on the resident at night. An intervention, dated 9-27-18, advised staff to ensure appropriate footwear on to safely ambulate. An intervention, dated 11-1-18, advised staff to place gripper socks on the resident at night, as they provide more stability when ambulating. (per nurses' note dated 11-1-18, documented the resident sustained [REDACTED]. An intervention, dated 12-21-18, advised staff to place the resident in an area of high visibility while awake for monitoring related to confusion weakness and increased falls. An intervention, dated 12-23-18, advised staff to place a motion sensor by his/her bed or chair so staff can be alerted when the resident tries to get up without assistance. The fall log, dated (MONTH) and December, (YEAR), revealed the resident sustained [REDACTED]. Observation, on 1-17-19 at 9:49 am, revealed the resident seated in the recliner in the common living area. Licensed nursing staff D, about to leave the area, with no other staff around the resident. Interview, on 1-17-19 at 9:49 am, with staff D, revealed the resident at risk for falls and required staff observation. Staff D stated the motion sensor should be on when staff leave the area, and staff D checked the motion detector and found that it was in the off position. Observation, on 1-18-19 at 1:30 pm, revealed the resident seated in his/her wheelchair with gait belt around his/her waist, at the dining room table, with no nursing staff in the area. The motion sensor was in the common living area. The resident was alert to name and asked what he/she should do now. Interview, on 1-18-19 at 1:30 pm, with dietary staff T, revealed he/she did not know the resident was still seated in the dining room, but would notify nursing staff. Interview, on 1-18-19 at 1:30 pm, with licensed nursing staff E, revealed he/she did not think the resident would try to get up from his/her wheelchair when at the dining table. Staff E stated the gait belt was on the resident at all times in case the resident got up quickly so staff could securely assist the resident. Staff E then transferred the resident with direct care staff O to the recliner in the common living area. The facility policy for falls, dated 9-3-18, advised staff to develop precautions and interventions and add these to the care plan to help reduce the risk of and or eliminate future falls. The facility failed to ensure staff provided planned interventions, including use of the motion sensor, gripper socks and keeping the resident within staff visibility, placing the resident at risk for further falls.

The facility reported a census of 43 residents with 15 residents sampled, including 1 resident sampled for Advanced Directives. Based on record review and interview, the facility failed to have a physician signed DNR (Do Not Resuscitate) for 1 (#35) sampled resident. Findings included: - The POS (Physician order [REDACTED].#35, dated 1-15-19, documented the resident had a [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 12-14-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident had severe cognitive impairment. The CAA (Care Area Assessment) for cognition, dated 12-19-18, documented the resident had a [DIAGNOSES REDACTED]. The care plan for cognition, dated 12-27-18, instructed staff to monitor and assist the resident with appropriate decision making. The admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. The document lacked a physician's signature. A nurse's note, dated 12-11-18, documented staff faxed the DNR to the physician for his/her signature. On 1-16-19 at 1:40 p.m., licensed staff F stated a physician would need to sign the DNR for the document to be valid. On 1-16-18 at 1:45 p.m., social service staff S stated, staff faxed the DNR to the resident's physician on 12-10-18, however staff lacked follow-up to ensure the physician returned the signed paper. On 1-18-19 at 8:25 a.m., administrative staff A stated, the physician should sign any advanced directives, including the DNR, within 24 hours of the resident's admission. The facility's policy for Advanced Directives, dated (MONTH) (YEAR), included: The facility acts under the direction of a licensed physician and each advanced directive, including DNR, will occur under the direct order of a physician's orders [REDACTED].>The facility failed to have a physician's signed DNR for this dependent resident to ensure the resident received care in accordance with his/her choices.

The facility reported a census of 43 residents, with 15 residents sampled. Based on observation, interview and record review, the facility failed to review and revise the care plans for 2 of the 15 sampled residents, (#13, and #34) related to falls. Findings included: - The POS (Physician order [REDACTED].#13 had a [DIAGNOSES REDACTED]. The care plan for falls, dated 11-08-18, instructed staff the resident required assistance of 2 when getting out of the whirlpool, slipper socks at night, encouragement to use the call light, to be toileted around 5:00 p.m., the door to his/her room left open for monitoring, reminded to lock the brakes on his/her wheelchair, a scoop mattress, and to keep the resident's items within easy reach of him/her. The plan of care lacked revision following the resident's 2 falls on 10-04-18. review of the resident's medical record revealed [REDACTED]. The intervention for the fall at 6:30 p.m., also included a medication review. Neither fall included an immediate intervention to prevent further falls. On 1-16-19 at 2:42 p.m., the resident propelled him/herself in their wheelchair in the hall. The resident wore appropriate footwear. On 1-17-19 at 1:31 p.m., licensed staff C stated, staff should initiate a new intervention following each fall and revise the plan of care. 1-18-19 8:25 a.m., administrative staff A, stated each fall should have a new intervention with the care plan updated at the time of the fall. The facility's policy for Falls, updated 9-03-18, included: Interventions will be individualized for each resident and noted in the resident's plan of care. The facility failed to review and revise the care plans for this resident with falls. - Review of resident #34's physician order [REDACTED]. The quarterly MDS (minimum data set) dated 9-14-18, assessed the resident with a BIMS (brief interview for mental status) score of 4 indicating severely impaired cognitive status, wandering 4-6 days of the 7 day look back period, required limited assistance of 1 person for bed mobility, dressing, independent with ambulation in the room, required supervision for ambulation in corridor, required supervision for toileting, no impairment in range of motion of upper or lower extremities and 1 non injury fall. The annual MDS, dated [DATE] assessed the resident with a BIMS score of 3, limited assistance of 1 person for bed mobility and transfer, supervision of 1 person for ambulation in room corridor, extensive assistance of 1 person for dressing, toilet use, and personal hygiene, no impairment of upper or lower extremities, and 2 noninjury falls since prior assessment. The CAA (care area assessment) for falls, dated 1-14-19, assessed the resident experience several falls during the assessment period with many contributing factors including cognitive status and poor safety awareness. The CAA for activities, dated 1-14-19, assessed the resident as spending time in the common living area so nursing staff can easily observe the resident. The care plan, last reviewed, 12-23-18, advised staff of the following interventions: An intervention, dated 5-16-18, advised staff to place gripper socks on the resident at night. An intervention, dated 9-27-18, advised staff to ensure appropriate footwear on to safely ambulate. An intervention, dated 11-1-18, advised staff to place gripper socks on the resident at night, as they provide more stability when ambulating. (per nurses' note dated 11-1-18, documented the resident sustained [REDACTED]. The fall log, dated (MONTH) and (MONTH) (YEAR), revealed the resident sustained [REDACTED]. Observation, on 1-17-19 at 9:49 am, revealed the resident seated in the recliner in the common living area. Licensed nursing staff D, about to leave the area, with no other staff around the resident. Interview, on 1-17-19 at 9:49 am, with staff D, revealed the resident at risk for falls and required staff observation. Staff D stated the motion sensor should be on when staff leave the area, and staff D checked the motion detector and found that it was in the off position. Interview, on 1-18-19 at 10:30 am, with administrative nursing staff A, revealed the fall committee reviews falls, and it is the expectation for the charge nurse, fall committee or MDS (minimum data set) nurse to review and revise the care plan. Staff A confirmed a repeat of the fall intervention on 5-16-18 for the resident to wear gripper socks at night, and again as an intervention, on 11-1-18, after a fall at night with the resident wearing regular socks. The facility policy for reviewing and revising the care plan, dated 10/18, advised staff to review the resident's care plan and add interventions to reduce the risk of falls. The facility failed to review and revise the care plans for this resident with falls.

The facility identified a census of 43 residents with 15 selected for review. The sample included 5 residents reviewed for unnecessary medications. Based on record review and interview, the facility administered medication to resident #42 without a physician order. Findings included: - The POS (physician order [REDACTED].#42, dated 01/02/19, documented a [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 11/16/18, documented the resident had a BIMS (brief interview of mental status) of 7, indicating the resident was moderately cognitively impaired. The MDS further indicated that the resident received a diuretic (a medication to promote fluid loss) 7 out of 7 days. The care plan, revised on 11/29/18, indicated that the resident receives [MEDICATION NAME], and identified it as a black box warning medication. It also identified the resident as having polypharmacy that put the resident at risk for medication interactions and side effects. The care plan also included that the resident's weight fluctuated and he/she had lower extremity swelling and takes a diuretic which may cause his/her weight to fluctuate. The medical record revealed the resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. The medical record revealed the physician signed Patient Summary Discharge Instructions, Orders, and Medication sheet, dated 12/31/18, from the hospital, which instructed the staff to discontinue the [MEDICATION NAME] 40mg every day. The POS, signed on 1/2/19, instructed staff to administer [MEDICATION NAME] 40mg daily. Interview, on 1/18/19 at 10:05am, with administrative nursing staff A, confirmed the resident received [MEDICATION NAME] on 12/31/18 and 1/1/19 without an order. The facility failed to follow the physician orders [REDACTED].

The facility reported a census of 42 residents with 6 selected for sample review. Based on observation, interview, and record review the facility failed to provide timely assessment and treatment for one resident (#1) of 3 reviewed for pressure ulcers. The hospice provider assessed the resident with skin breakdown on 8/2/18, delivered an air mattress for the resident's bed on 8/3/18, and licensed facility staff failed to identify, measure and evaluate the area for treatment until 8/14/18 (12 days after the breakdown occurred). Findings included: - Resident #1's [DIAGNOSES REDACTED]. A significant change MDS (minimum data set), dated 6/13/18, identified the resident as moderately impaired of cognition with long and short-term memory loss, required extensive assistance of staff for ADLs and without pressure ulcers. The CAA (care area assessment) for cognition, dated 6/19/18, included the resident had a [DIAGNOSES REDACTED]. The CAA for pressure ulcers, dated 6/20/18, identified the resident at risk for pressure ulcer development due to mobility limitations and nutritional status. The resident had an indwelling urinary catheter which could help with reducing the risk of skin breakdown, but he/she experienced bowel incontinence and needed to be kept as clean and dry as possible. The staff needed to continue to provide assistance with bed mobility and repositioning routinely. The Braden Pressure Ulcer Risk assessment, identified the resident at high risk, as follows: 2/5/18 - scored 18. 3/30/18 - scored 17. 6/7/18 - scored 17. Interpretation of Scores: 19 or Higher - NOT AT RISK - No interventions necessary; 15-18 - AT RISK - If other major risk factors are present (e.g., advanced age, fever, poor dietary intake of protein, Diastolic BP < 60, hemodynamic instability) advance to next level of risk; 13-14 - MODERATE RISK - If other major risk factors are present advance to next level of risk. 10-12 - HIGH RISK; 9 or Less - VERY HIGH RISK. The resident's care plan, dated 6/22/18, included Assist into wheelchair when restless in bed. Double cushions to wheelchair for prevention of skin breakdown. Change position every 2 hours. Hospice provided low air loss air mattress. Added 8/3/18. Skin excoriation to buttocks. Added 8/13/18. Continue to encourage position changes and when combative leave and re-approach. Added 8/13/18. The care plan failed to instruct the staff in changing the pressure relieving cushion from the wheelchair to the recliner. Review of nursing notes, dated 8/3/18 at 9:27 AM, a late entry recorded on 8/17/18, identified the facility received a low air loss mattress from hospice for the resident. A nursing note on 8/6/18 at 3:28 AM, a late entry on 8/6/18 at 3:34 AM, documented the resident awakened and presented with restlessness and grimacing. A PRN (as needed) pain medication was administered for buttock pain. Nursing notes on 8/14/18 at 11:42 AM, identified a skin assessment completed and assessed excoriation to the buttocks (no specific area identified), red in color and dry. Noted a chair cushion and barrier cream in use. Review of hospice notes included: 8/2/18 Hospice Nurse log documented the resident was restless at night, was not sleeping, and noted breakdown to his/her buttock area. Intervention included a low air loss mattress ordered and to continue with the current plan of care. An additional hospice report, dated 8/2/18 at 4:01 PM, a nursing visit record included that the facility reported the resident was not sleeping and sat up in his/her wheelchair all night. Breakdown to the buttocks crease formed despite gel cushion. RN (registered nurse) encouraged to place gel cushion in the recliner during use and transfer back and forth from the wheelchair to the recliner. A reddened area, non-blanchable, to the buttock crease, measured approximately 0.3 cm long. Resident currently receiving barrier cream and offloading, at that time. On 10/3/18 at 11:59 AM, direct care staff G reported the resident needed extensive assistance for all cares, except sometimes could feed him/her self. The resident had a catheter but was occasionally incontinent of bowel and reported the resident often refused care, especially in the evenings. The staff did not recall the resident having any pressure ulcers or special treatments. On 10/3/18 at 4:45 PM, administrative nursing staff C reported believing the resident's overall decline in dementia/behaviors, intake and the dying process contributed to the wound the resident developed. On 10/4/18 at 5:00 AM, licensed nursing staff D reported that the resident was frequently awake during the night. Often, he/she would follow staff in his/her wheelchair, sometimes could be distracted with another activity, and slept in the recliner in the lobby area a lot, due to getting out of bed frequently and being a high fall risk. The staff did not recall the resident had a pressure ulcer. On 10/8/18 at 10:30 AM, administrative nursing staff B reported being unaware why the licensed staff did not assess the resident's bottom after the hospice reported breakdown. Staff B later reported the normal wound care nurse was on vacation and another nurse completed the treatments and measurements that week and should have assessed the wound, which hospice services had identified, on 8/2/18. On 10/8/18 at 10:36 AM, licensed nursing staff E recalled the noted breakdown to the resident's bottom was related to shearing, and was not a pressure ulcer on 8/2/18 when observed. A low air loss mattress, application of [MEDICATION NAME] and a gel cushion for use in the recliner were provided to ensure the resident remained free of further breakdown. The staff later reviewed other documentation and verified the development of a non-blanchable 0.3 cm breakdown in the crease of the resident's buttock area. The facility policy, dated 5/18, included: all residents developing or admitted with pressure ulcers shall receive appropriate monitoring and treatment to promote healing. The facility failed to assess, monitor and provide care and treatment in a timely manner to promote healing of a pressure ulcer which developed. The facility failed to assess and treat the resident, assessed by a hospice nurse on 8/2/18, and found to have developed a pressure ulcer to the buttock crease, until 8/14/18, 12 days later.

The facility reported a census of 42 residents with 6 selected for sample review. Based on observation, interview, and record review the facility failed to ensure 1 resident (#1) of 3 reviewed for accidents, remained free of falls, when the staff failed to ensure the personal safety alarm, care planned for the resident, was turned on after the provision of cares. The resident subsequently arose from the bed, fell to the floor, hitting his/her head and received skin tears to his/her arm. Findings included: - Resident #1's [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 11/17/17, identified the resident unable to complete the BIMS (brief interview of mental status) and staff identified the resident with long and short-term memory impairment, required assistance of staff for ADLs (activities of daily living), and indicated the resident without falls since admission. A significant change MDS, dated [DATE], identified the resident as severely impaired of cognition with long and short-term memory loss, needed assistance with ADLs, including mobility and had 1 fall since the prior assessment. A significant change MDS, dated [DATE], identified the resident as moderately impaired of cognition with long and short-term memory impairment, and with 2 falls since the prior assessment. The CAA (care area assessment) for cognition, dated 6/19/18, included the resident had a [DIAGNOSES REDACTED]. Additionally, the resident experienced reduced ADL ability, however, believes that he/she can stand, walk and care for him/herself due to dementia and confusion. The resident required monitoring for safety awareness and the risk of falling. The CAA for falls, dated 6/20/18, identified the resident at increased risk for falls due to cognitive deficits, poor safety awareness, poor decision-making abilities, potential for pain, potential side effects of medications, and mobility limitations. The resident experienced actual falls on 4/13/18 & 5/1/18. Review of the residents Fall Risk Assessments, included: 2/5/18 - scored 18. 3/30/18 - scored 15. 6/7/18 -- scored 25. The legend identified the Fall Risk Scores of 10 or higher represented a high risk for falls. The resident's care plan, dated 6/22/18, included the following fall interventions: 1. Sit with resident at the bar or at a table in the dining room when anxious. 2. Close supervision during meals. 3. Staff supervise when awake on 3rd shift. 4. Assist into wheelchair, when restless, in bed. 5. When assigned 1:1 stay with the resident. 6. Thirty-minute checks at nighttime, when in room, or provide activity in the common area. 7. Pressure sensitive alarm to bed/chair when in bed/chair. 8. Keep call light within reach. 9. One to two staff extensive assistance with transfers. 10. Ensure alarm is plugged in before leaving the room. 11. If not sleeping, call spouse; don't take resident to another unit for monitoring. 12. Provide structured activity when awake and getting restless prior to supper time. 5/1/18 13. Call hospice when having behaviors and when up at night with behaviors. 7/3/18 14. Educate staff to double check alarm is connected before leaving the room. 7/24/18 15. Two staff assist for transfers. 7/26/18 Nursing notes dated 6/22/18 at 12:03 AM, identified the staff assisted the resident to bed at approximately 2100 (9PM) and was up again by 2230 (10:30 PM). The resident's alarm sounded when he/she attempted to get out of bed. Staff took the resident to a commons area and assisted him/her into the recliner with the chair alarm in place and working properly. Nursing notes on 7/25/18 at 12:38 AM, identified staff notified the physician at approximately 10:57 PM, on 7/24/18, of a fall with the resident hitting his/her head. The staff assessed a small bump with a pinpoint red center, without bleeding present with skin tears to the left upper arm, measuring 2.50 cm (centimeter) by 1 cm and 5.50 cm by 1 cm. The resident appeared to have gotten him/her self out of bed and ambulated to the hallway where he/she fell . The resident's wheelchair and walker were both noted in his/her room and the resident was barefoot. The resident's bed pressure sensitive alarm failed to sound. Staff implemented an intervention educating staff to double check that alarms are connected before leaving the resident's room. A review of the facility fall investigation identified the staff members last caring for the resident failed to turn the pressure sensitive alarm on after providing the cares. On 10/8/18 at 10:56 AM, administrative nursing staff B reported that the fall committee reviewed the resident's fall and identified that the staff failed to turn on the alarm, with the resident subsequently falling. At the time of the review, all staff received re-education regarding ensuring the residents with alarms are in proper operation before staff exit the resident's room. The staff verified the staff on duty at the time of the fall were included in the re-education. The facility policy, dated 9/3/18, included the management committee would help determine a pattern/cause for the fall and review and implement individualized interventions to help reduce the risk of and/or eliminate future falls. The facility failed to provide assistive devices and or supervision to prevent the resident from falling, as planned, when staff failed to turn on a pressure sensitive alarm, used for detection of the resident getting up unassisted, with the resident falling and receiving a bump on the head and a skin tear on his/her arm.

The facility had a census of 42 residents and the sample included 3 residents, reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure residents were free from staff to resident verbal abuse when a staff member observed another staff member verbally abusing Resident #1, and then failed to immediately report the incident to the facility administration. The facility failed to immediately protect the all residents and allowed the staff member to work during the investigation. This deficient practice placed Resident #1 in immediate jeopardy. (#1) Findings included: - The 8/25/16 physician order [REDACTED]. or more and experiencing obesity-related health conditions, such as high blood pressure or diabetes), eating disorder, anxiety (uneasy feelings), [MEDICAL CONDITION] (an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions sufficiently severe to cause marked distress, consume considerable time or significantly interfere with the patient's occupational, social or interpersonal functioning), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 9/2/16, revealed the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, behaviors, independent with all (ADLs) activities of daily living except toileting and hygiene, weighed 370#, received a therapeutic diet, and antianxiety medication. The 6/23/16 care plan directed staff to provide weekly portions of fresh fruit and unsalted peanuts for snacks, and to have access to $1.00 a day for vending machine snacks. The care plan stated the resident to work on food seeking behaviors, health and bariatric concerns, but did not include specific interventions. The care plan directed staff to provide a structured daily schedule and routine. The care plan directed staff to accompany the resident, if he/she leaves his/her room during the late evening or night, to redirect any intent to go through the kitchenettes for food. The care plan instructed staff to redirect the resident immediately, in a firm but appropriate manner, when inappropriate behavior is noted. Review of the nurse's notes revealed: 8/1/16 at 7:17 PM, the facility's social worker talked with the resident about his/her eating behaviors. The resident acknowledged that he/she liked to eat and did not care how he/she attained the food - from the trash can, the fridge, other people's plates, etc. The document stated the social worker discussed concerns of the resident's increasing weight and encouraged him/her to lose weight. The 8/20/16 at 9:49 PM, email from direct care staff D to Administrative Nurse A, Administration Staff I, and Social Services Staff E, revealed the resident had eaten another resident's bierocks. Nurse Aide B walked up and started yelling at the resident. Nurse Aide B yelled at the resident for roughly 30 minutes and was so loud staff heard him/her down that neighborhood and on another neighborhood. Nurse Aide B made comments of can you not read?, Are you that stupid?, I never save anything in this refrigerator for you and you should know this by now. Nurse Aide B told the resident he/she should be worried about his/her weight. Nurse Aide B kept going on about the bierocks did not belong to the resident. Nurse Aide B also stated he/she was going to make sure the resident would not get his/her weekly allowance and that it would go to paying for the bierocks. The email stated Nurse Aide B forcefully made the resident write an apology note. Nurse Aide B stated he/she did this because the resident needed to have consequences for his/her actions. The e-mail stated the reporter thought the situation should have been handled differently and he/she felt like Nurse Aide B had belittled the resident about his/her poor choices. The reporter stated the resident was upset afterward, even though he/she denied it, and his/her eyes were red and he/she was shaking. Review of the medical record revealed the facility lacked documentation regarding the staff member's verbal abuse of the resident on 8/20/16. The 8/21/16 Report of Concern from Nurse G, revealed the resident stated he/she felt like he/she was a little child being yelled at by his/her parent and was just waiting for Nurse Aide B to take a fly swatter and give him/her a couple of whacks. The resident said Nurse Aide B said he/she would charge him/her $5 for 2 bierocks when the kitchen only charges $1.50 each. When asked how he/she felt when he/she was asked to write a letter of apology, the resident stated I felt like a bad boy/girl. The resident stated Nurse Aide B told him/her that he/she would take away his/her allowance when he/she received it next week. The resident stated, at breakfast this morning, Nurse Aide B took away a partial cup of coffee before he/she was finished and said after last night, you are done with your coffee. The 8/23/16 investigation note (3 days after the incident) revealed, during interview with the resident, he/she stated Nurse Aide B saw him/her eating 2 bierocks and got mad at him/her. The resident reported Nurse Aide B stated didn't you see the note, those bierocks were someone else's and you can't take other people's food. Nurse Aide B told the resident he/she needed to apologize and told the resident he/she should write a note of apology. When asked if Nurse Aide B was cranky with him/her, the resident said Nurse Aide B took my coffee the next morning when he/she was cleaning up before I was done. Review of Nurse Aide B's facility time sheet revealed he/she worked the day after the incident, 8/21/16, and 8/23/16. On 9/26/16 at 8:15 AM, observation revealed the resident independently ate breakfast in the dining room. On 9/26/16 at 8:30 AM, Administration Staff C stated the facility had investigated a recent report of a staff to resident verbal altercation. He/she stated the nursing staff who witnessed the altercation should have intervened and stopped the altercation, then reported it to administration. On 9/26/16 at 9:55 AM, Nurse Aide H stated the day after the incident the resident told him/her what happened and how it made him/her feel. Nurse Aide H stated the resident reported it was like he/she was a child and his/her parent was screaming at him/her. Nurse Aide H stated the resident stated he/she thought Nurse Aide B might hit him/her, but he/she did not. The resident stated Nurse Aide B called him/her stupid. On 9/26/16 at 10:56 AM, Social Services Staff E stated Nurse Aide B reported the incident to him/her the next day, 8/21/16, and he/she reported it to the administrative staff during a morning meeting, and then followed up on it with interviews. Social Services Staff E stated the resident had a history of [REDACTED]. The social worker stated the resident was worried Nurse Aide B might hit him/her since that was what his/her parent used to do. Social Services Staff E stated administrative staff C interviewed Nurse Aide B and the facility suspended him/her on 8/23/16, for 3 days. He/she stated Nurse Aide B now works on other halls but not the same hall Resident #1 lives on. On 9/26/16 at 11:40 AM, Nurse Aide B stated on 8/20/16, he/she lost it and yelled at the resident because he/she felt personally responsible for those bierocks. Nurse Aide B stated he/she had marked the bierocks for another resident. Nurse Aide B verified he/she told the resident the least he/she could do was write an apology to the other resident, got the paper and pen for him/her, and waited while he/she wrote the note. Nurse Aide B verified he/she told the resident he/she would have to pay for the bierocks and stated he/she was upset and cannot remember how he/she spoke to the resident. Nurse Aide B stated the charge nurse did not send him/her home. Nurse Aide B stated he/she does not remember any interaction with the resident the next morning. On 9/26/16 at 3:48 PM, Administrative Staff C verified Nurse Aide B clocked out at 9:00 PM on 8/20/16. He/she stated administrative staff normally do not review their email on the weekends and did not review the 8/20/16 email regarding the staff to resident abuse until Monday 8/22/16. Administrative Staff C verified staff did not immediately report the verbal abuse incident to the director of nursing or administrative staff via phone. Administrative Staff C reported Nurse Aide B was not working on Monday 8/22/16, so administration waited until Tuesday 8/23/16 to suspend him/her. Administrative Staff C verified Nurse Aide B worked Sunday, 8/21/16, and the morning of 8/23/16 and the administration received more information so they suspended Nurse Aide B in the afternoon. He/she verified facility policy was to immediately suspend the alleged perpetrator, report to the state agency, and investigate. On 9/26/16 at 2:30 PM, direct care staff D stated he/she witnessed Nurse Aide B yelling at Resident #1 in the evening of 8/20/16. Direct care staff D stated he/she told Nurse Aide B to stop but he/she did not. He/she stated Nurse Aide B got the resident paper and pen and stood over him/her while he/she wrote a note. Direct care staff D stated he/she notified the charge nurse who asked Nurse Aide B to stop. On 9/26/16 at 4:45 PM, Nurse G stated he/she was on another neighborhood working and heard a loud voice. Nurse G stated during investigation, he/she interviewed the resident and he/she stated it felt unpleasant to him/her. Nurse G stated he/she did not think about sending Nurse Aide B home, as this was the first time abuse occurred on his/her shift and he/she was unsure what to do. Nurse G stated he/she notified an administrative nurse on Sunday, 8/21/16. On 9/26/16 at 8:50 PM, Nurse Aide F stated he/she heard the altercation from inside a resident's room, approximately 150 feet from the dining area where the shouting occurred. Nurse Aide F stated he/she recognized Nurse Aide B's voice yelling about consequences of behavior, should have to pay it back and should not get allowance for the week. Nurse Aide F stated he/she could not leave the resident he/she was with and stated the charge nurse came to him/her to see what he/she heard. Nurse Aide F stated he/she reported the concern to an administrative nurse via paper, but was aware the administrative nurse would not see it until Monday (2 days later). On 9/27/16 at 10:30 AM, Administrative Staff I stated he/she was on vacation on Monday 8/22/16, and was unsure if he/she received a direct email or a forwarded one. He/she stated administration was still investigating the incident Tuesday, 8/23/16, before they suspended Nurse Aide B. At 10:48 AM, Administrative Staff C verified the facility allowed Nurse Aide B to work Tuesday, 8/23/16, as he/she would have been in a supervised area in the kitchen and dining room and would not be alone with the resident. Administrative Staff C stated if the facility suspended Nurse Aide B immediately, they may not have had enough staff to provide all care for residents. On 9/27/16 at 3:05 PM, Nurse A stated staff texted, by phone, him/her on Sunday, 8/21/16, about the Saturday night, 8/20/16, incident. Nurse A stated the staff who reported it to him/her had not even worked that night and had heard it from someone. Nurse A stated he/she treated it as hearsay (gossip) and instructed the staff person to write a Concerns Report and he/she would notify Nurse Aide B's supervisor. Nurse A stated management discussed the incident at 8:15 AM, Monday, 8/22/16. He/she stated if staff actually witnessed abuse, they are to call him/her immediately and then he/she immediately calls administrative staff immediately. Nurse A stated the facility has a no tolerance abuse policy. The facility's 2/2011 policy of Resident/Abuse/Neglect and Exploitation Investigation stated all allegations of resident mistreatment were taken seriously and investigated promptly. The policy stated, in the event of any evidence or cause to believe that a resident had suffered any abuse, the person (s) observing such incident are requested to report all allegations, suspicions, or incidents to the charge nurse or administrator of the facility, or to state officials, as posted in the facility. Upon report of any allegation or violations the administrator or his/her designated representative will thoroughly investigate the situation. Any individual suspected of abuse or neglect will be removed from direct care of or contact with the resident while the investigation was in progress. At the time that an incident was identified, the person who initially observed the incident would complete a Report of Concern and give it to the charge nurse. The charge nurse would immediately begin the investigation or refer the incident to the director of nursing and/or the administrator. The result of all investigations were reported to the administrator or his/her representative. The administrator was responsible for reporting all incidents to the state agency or local law enforcement in accordance with state law. If an instance of abuse, neglect or exploitation occurs, the facility staff will review our policies and procedures to determine if any changes are needed. If the alleged violation is verified, appropriate corrective action is taken. The facility failed to protect Resident #1 from verbal abuse when a staff member witnessed another staff member verbally abusing Resident #1. Staff did not intervene, did not immediately report the verbal abuse to facility administration, and protect the resident from potential abuse. The facility's administration failed to immediately suspend the alleged abuser, and allowed him/her to continue working, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 9/29/16 at 11:00 AM, when they terminated nurse aide B and completed face to face training for all staff regarding the facility's Abuse, Neglect and Exploitation policy, revision of the Abuse, Neglect and Exploitation policy to include the immediate reporting of any allegations and continued abuse prevention education. This deficient practice remained at a scope of G.

The facility had a census of 42 residents, and the sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility staff failed to immediately report, to administration, an incident regarding abuse when a staff member observed another staff member verbally abuse of Resident #1, and when administration became aware of the incident, they failed to report the verbal abuse to the appropriate state agency. Findings included: - The 8/25/16 physician order [REDACTED]. or more and experiencing obesity-related health conditions, such as high blood pressure or diabetes), eating disorder, anxiety (uneasy feelings), [MEDICAL CONDITION] (an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions sufficiently severe to cause marked distress, consume considerable time or significantly interfere with the patient's occupational, social or interpersonal functioning), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 9/2/16, revealed the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, behaviors, independent with all (ADLs) activities of daily living except toileting and hygiene, weighed 370#, received a therapeutic diet, and antianxiety medication. The 6/23/16 care plan directed staff to provide weekly portions of fresh fruit and unsalted peanuts for snacks, and to have access to $1.00 a day for vending machine snacks. The care plan stated the resident to work on food seeking behaviors, health and bariatric concerns, but did not include specific interventions. The care plan directed staff to provide a structured daily schedule and routine. The care plan directed staff to accompany the resident, if he/she leaves his/her room during the late evening or night, to redirect any intent to go through the kitchenettes for food. The care plan instructed staff to redirect the resident immediately, in a firm but appropriate manner, when inappropriate behavior is noted. Review of the nurse's notes revealed: 8/1/16 at 7:17 PM, the facility's social worker talked with the resident about his/her eating behaviors. The resident acknowledged that he/she liked to eat and did not care how he/she attained the food - from the trash can, the fridge, other people's plates, etc. The document stated the social worker discussed concerns of the resident's increasing weight and encouraged him/her to lose weight. The 8/20/16 at 9:49 PM, email from direct care staff D to Administrative Nurse A, Administration Staff I, and Social Services Staff E, revealed the resident had eaten another resident's bierocks. Nurse Aide B walked up and started yelling at the resident. Nurse Aide B yelled at the resident for roughly 30 minutes and was so loud staff heard him/her down that neighborhood and on another neighborhood. Nurse Aide B made comments of can you not read?, Are you that stupid?, I never save anything in this refrigerator for you and you should know this by now. Nurse Aide B told the resident he/she should be worried about his/her weight. Nurse Aide B kept going on about the bierocks did not belong to the resident. Nurse Aide B also stated he/she was going to make sure the resident would not get his/her weekly allowance and that it would go to paying for the bierocks. The email stated Nurse Aide B forcefully made the resident write an apology note. Nurse Aide B stated he/she did this because the resident needed to have consequences for his/her actions. The e-mail stated the reporter thought the situation should have been handled differently and he/she felt like Nurse Aide B had belittled the resident about his/her poor choices. The reporter stated the resident was upset afterward, even though he/she denied it, and his/her eyes were red and he/she was shaking. Review of the medical record revealed the facility lacked documentation regarding the staff member's verbal abuse of the resident on 8/20/16. The 8/21/16 Report of Concern from Nurse G, revealed the resident stated he/she felt like he/she was a little child being yelled at by his/her parent and was just waiting for Nurse Aide B to take a fly swatter and give him/her a couple of whacks. The resident said Nurse Aide B said he/she would charge him/her $5 for 2 bierocks when the kitchen only charges $1.50 each. When asked how he/she felt when he/she was asked to write a letter of apology, the resident stated I felt like a bad boy/girl. The resident stated Nurse Aide B told him/her that he/she would take away his/her allowance when he/she received it next week. The resident stated, at breakfast this morning, Nurse Aide B took away a partial cup of coffee before he/she was finished and said after last night, you are done with your coffee. The 8/23/16 investigation note (3 days after the incident) revealed, during interview with the resident, he/she stated Nurse Aide B saw him/her eating 2 bierocks and got mad at him/her. The resident reported Nurse Aide B stated didn't you see the note, those bierocks were someone else's and you can't take other people's food. Nurse Aide B told the resident he/she needed to apologize and told the resident he/she should write a note of apology. When asked if Nurse Aide B was cranky with him/her, the resident said Nurse Aide B took my coffee the next morning when he/she was cleaning up before I was done . Review of Nurse Aide B's facility time sheet revealed he/she worked the day after the incident, 8/21/16, and 8/23/16. On 9/26/16 at 8:15 AM, observation revealed the resident independently ate breakfast in the dining room. On 9/26/16 at 8:30 AM, Administration Staff C stated the facility had investigated a recent report of a staff to resident verbal altercation. He/she stated the nursing staff who witnessed the altercation should have intervened and stopped the altercation, then reported it to administration. On 9/26/16 at 9:55 AM, Nurse Aide H stated the day after the incident the resident told him/her what happened and how it made him/her feel. Nurse Aide H stated the resident reported it was like he/she was a child and his/her parent was screaming at him/her. Nurse Aide H stated the resident stated he/she thought Nurse Aide B might hit him/her, but he/she did not. The resident stated Nurse Aide B called him/her stupid. On 9/26/16 at 10:56 AM, Social Services Staff E stated Nurse Aide B reported the incident to him/her the next day, 8/21/16, and he/she reported it to the administrative staff during a morning meeting, and then followed up on it with interviews. Social Services Staff E stated the resident had a history of [REDACTED]. The social worker stated the resident was worried Nurse Aide B might hit him/her since that was what his/her parent used to do. Social Services Staff E stated administrative staff C interviewed Nurse Aide B and the facility suspended him/her on 8/23/16, for 3 days. He/she stated Nurse Aide B now works on other halls but not the same hall Resident #1 lives on. On 9/26/16 at 11:40 AM, Nurse Aide B stated on 8/20/16, he/she lost it and yelled at the resident because he/she felt personally responsible for those bierocks. Nurse Aide B stated he/she had marked the bierocks for another resident. Nurse Aide B verified he/she told the resident the least he/she could do was write an apology to the other resident, got the paper and pen for him/her, and waited while he/she wrote the note. Nurse Aide B verified he/she told the resident he/she would have to pay for the bierocks and stated he/she was upset and cannot remember how he/she spoke to the resident. Nurse Aide B stated the charge nurse did not send him/her home. Nurse Aide B stated he/she does not remember any interaction with the resident the next morning. On 9/26/16 at 3:48 PM, Administrative Staff C verified Nurse Aide B clocked out at 9:00 PM on 8/20/16. He/she stated administrative staff normally do not review their email on the weekends and did not review the 8/20/16 email regarding the staff to resident abuse until Monday 8/22/16. Administrative Staff C verified staff did not immediately report the verbal abuse incident to the director of nursing or administrative staff via phone. Administrative Staff C reported Nurse Aide B was not working on Monday 8/22/16, so administration waited until Tuesday 8/23/16 to suspend him/her. Administrative Staff C verified Nurse Aide B worked Sunday, 8/21/16, and the morning of 8/23/16 and the administration received more information so they suspended Nurse Aide B in the afternoon. He/she verified facility policy was to immediately suspend the alleged perpetrator, report to the state agency, and investigate. On 9/26/16 at 2:30 PM, direct care staff D stated he/she witnessed Nurse Aide B yelling at Resident #1 in the evening of 8/20/16. Direct care staff D stated he/she told Nurse Aide B to stop but he/she did not. He/she stated Nurse Aide B got the resident paper and pen and stood over him/her while he/she wrote a note. Direct care staff D stated he/she notified the charge nurse who asked Nurse Aide B to stop. On 9/26/16 at 4:45 PM, Nurse G stated he/she was on another neighborhood working and heard a loud voice. Nurse G stated during investigation, he/she interviewed the resident and he/she stated it felt unpleasant to him/her. Nurse G stated he/she did not think about sending Nurse Aide B home, as this was the first time abuse occurred on his/her shift and he/she was unsure what to do. Nurse G stated he/she notified an administrative nurse on Sunday, 8/21/16. On 9/26/16 at 8:50 PM, Nurse Aide F stated he/she heard the altercation from inside a resident's room, approximately 150 feet from the dining area where the shouting occurred. Nurse Aide F stated he/she recognized Nurse Aide B's voice yelling about consequences of behavior, should have to pay it back and should not get allowance for the week. Nurse Aide F stated he/she could not leave the resident he/she was with and stated the charge nurse came to him/her to see what he/she heard. Nurse Aide F stated he/she reported the concern to an administrative nurse via paper, but was aware the administrative nurse would not see it until Monday (2 days later). On 9/27/16 at 1030 AM, Administrative Staff I stated he/she was on vacation on Monday 8/22/16, and was unsure if he/she received a direct email or a forwarded one. He/she stated administration was still investigating the incident Tuesday, 8/23/16, before they suspended Nurse Aide B. At 10:48 AM, Administrative Staff C verified the facility allowed Nurse Aide B to work Tuesday, 8/23/16, as he/she would have been in a supervised area in the kitchen and dining room and would not be alone with the resident. Administrative Staff C stated if the facility suspended Nurse Aide B immediately, they may not have had enough staff to provide all care for residents. On 9/27/16 at 3:05 PM, Nurse A stated staff texted, by phone, him/her on Sunday, 8/21/16, about the Saturday night, 8/20/16, incident. Nurse A stated the staff who reported it to him/her had not even worked that night and had heard it from someone. Nurse A stated he/she treated it as hearsay (gossip) and instructed the staff person to write a Concerns Report and he/she would notify Nurse Aide B's supervisor. Nurse A stated management discussed the incident at 8:15 AM, Monday, 8/22/16. He/she stated if staff actually witnessed abuse, they are to call him/her immediately and then he/she immediately calls administrative staff immediately. Nurse A stated the facility has a no tolerance abuse policy. The facility's 2/2011 policy of Resident/Abuse/Neglect and Exploitation Investigation stated all allegations of resident mistreatment were taken seriously and investigated promptly. The policy stated, in the event of any evidence or cause to believe that a resident had suffered any abuse, the person (s) observing such incident are requested to report all allegations, suspicions, or incidents to the charge nurse or administrator of the facility, or to state officials, as posted in the facility. Upon report of any allegation or violations the administrator or his/her designated representative will thoroughly investigate the situation. Any individual suspected of abuse or neglect will be removed from direct care of or contact with the resident while the investigation was in progress. At the time that an incident was identified, the person who initially observed the incident would complete a Report of Concern and give it to the charge nurse. The charge nurse would immediately begin the investigation or refer the incident to the director of nursing and/or the administrator. The result of all investigations were reported to the administrator or his/her representative. The administrator was responsible for reporting all incidents to the state agency or local law enforcement in accordance with state law. If an instance of abuse, neglect or exploitation occurs, the facility staff will review our policies and procedures to determine if any changes are needed. If the alleged violation is verified, appropriate corrective action is taken. The facility failed to protect Resident #1 from verbal abuse when a staff member witnessed another staff member verbally abusing Resident #1. Staff did not immediately report the verbal abuse to facility administration, the facility's administration failed to immediately suspend the alleged abuser, and allowed him/her to continue working, which placed the residents of the facility at risk for verbal abuse.

The facility had a census of 42 residents. The sample included 14 residents of which 1 was reviewed for pressure ulcers. Based on observations, record review and interview, the facility failed to provide care and services to prevent worsening of a perisacral (above the gluteal fold) pressure ulcer to a stage 3 (full thickness tissue loss), and the development of a stage 4 (reaching into the muscle and bone causing extensive damage to the tendons and joints) pressure ulcer to the resident's heel, and a stage 3 pressure ulcer to the resident's left lateral calf. (#9) Findings included: - Resident #9's admission (MDS) Minimum Data Set assessment, dated 12/29/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 11, indicating moderately impaired cognition, and required extensive assist of 2 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further indicated the resident had impaired limitation in range of motion to both lower extremities and had a history of [REDACTED]. The MDS indicated the resident admitted to the facility with pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shearing); 1 stage 2 pressure ulcer (partial thickness loss of dermis (the thick layer of tissue below the top layer of skin) presenting as a shallow open ulcer with a red pink wound bed and 2 stage 1 pressure ulcers (intact skin with non-blanchable (reddened area that remains red when light pressure is applied to the area) redness of a localized area). The MDS indicated the resident had a pressure reducing device to his/her bed and chair, a turning and repositioning program, nutritional interventions, pressure ulcer care, applications of non-surgical dressings and applications of ointments and/or medications other than to his/her feet. The significant change MDS, dated [DATE], indicated the resident had a BIMS score of 11, required extensive assistance of 2 staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene; and total assistance of 2 staff for bathing. The MDS further indicated the resident had 1 stage 3 pressure ulcer and 2 unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow devitalized tissue that can be stringy or thick and adherent on the tissue bed) and/or eschar (dead tissue) in the wound bed). The MDS indicated the resident had a pressure reducing device for his/her bed and chair, a turning/repositioning program, nutritional interventions in place to manage skin problems, pressure ulcer care, surgical wound care, application of non-surgical dressings and applications of ointments and/or medications other than to his/her feet. The 1/29/16 CAA for pressure ulcers indicated the pressure areas the resident admitted with had merged to develop a stage 3 pressure ulcer to the peri-sacral (above the gluteal fold)area. The CAA further stated the resident had developed a stage 4 pressure ulcer to his/her left heel and a stage 3 pressure ulcer to the left lateral (outer side) calf, above the malleolus (bony prominence on both sides of the ankle). The CAA indicated the wound clinic routinely treated the resident, a routine toileting program was unsuccessful, and the resident had an indwelling catheter to prevent urine contamination to the wounds. The 12/23/15 care plan indicated the resident had limited mobility due to a recent left femoral (thigh) fracture and surgical repair and he/she admitted to the facility with skin breakdown to the buttock area and was at risk for additional skin breakdown. The care plan directed staff to assess the current pressure areas to the buttocks and provide treatment as the physician indicated. The care plan further directed staff to provide pressure relieving devices and off-loading (non-weight bearing to the area) techniques and indicated staff placed a pressure-relieving cushion in the resident's recliner and wheelchair. The care plan further directed staff to maintain the resident's immobilizer to his/her left lower extremity, monitor for impaired circulation to both lower extremities, and the resident was on non-weight bearing status. The 12/24/15, care plan update instructed staff to provide a nutritional intervention program of providing protein powder in juice at two meals per day. The 1/7/16 care plan indicated the resident admitted to the facility with one stage 2 pressure ulcer to the midline of his/her right buttock and 2 stage 1 ulcers to the midline of his/her left buttock. The care plan further indicated the resident had a stage 2 pressure ulcer to his/her left Achilles (tendon connecting calf muscles to the heel) tendon area and was at increased risk for additional skin breakdown. The care plan directed staff to maintain pressure relieving boots to the resident's feet to prevent pressure to the Achilles tendon area related to the resident's leg brace. The care plan indicated the rehabilitation department would obtain a circulating air mattress for the resident's bed for pressure relief and directed staff to provide a routine repositioning program to reposition the resident every two hours or more often, if needed. The 12/22/15 at 3:22 PM, physician's orders [REDACTED]. The 12/22/15 at 5:06 PM, admission nursing note indicated the resident arrived at the facility to receive therapy services following surgery to repair a fractured femur and the resident had an immobilizer to his/her right leg from the thigh to the ankle. The 12/23/15 at 2:36 AM, nursing note indicated the resident had a brace on his/her left leg. The note further indicated the resident admitted from the hospital with an open area to his/her right buttock that measured 3.5 (cm) centimeters length x 3 cm width had fresh red blood drainage. Staff cleansed the open area with soap and water, patted the area dry, and applied a dry dressing. The nursing note indicated the resident had an area on the left buttock that appeared like the skin was blistered, but the skin remained intact and staff turned the resident side to side while in bed to prevent pressure to his/her buttocks. The 12/23/15 at 2:44 PM, nursing note indicated the surgical incision to the left leg was well approximated (close together) without drainage. Staff covered the area with an (ABD) Abdominal dressings secured with ACE wrap and the resident's knee immobilizer was in place. The nursing note lacked documentation of a complete assessment of the resident's left leg, which was in the immobilizer. The 12/23/15 at 2:59 PM, nursing note indicated staff measured and assessed the areas on the resident's buttocks. The open area to the right midline buttock measured 5 cm length x 4 cm width with a light amount of drainage observed. There were 2 areas to the left midline buttock that were not open, but were red and measured 0.7 cm length x 0.8 cm width and 1.0 cm length x 0.8 cm width. Staff faxed the resident's primary physician to request treatment orders. The 12/23/15 at 3:07 PM, nursing note indicated staff positioned the resident on either side while in bed due to the pressure areas to his/her buttocks. The 12/31/15 at 10:11 PM, nursing skin assessment note indicated the resident had a stage 2 pressure ulcer to the right of the midline buttock that measured 5 cm length x 4 cm width, the area was deep red with an open area to the center, 2 areas left of the midline buttock were not open, but red and measured 0.7 cm length x 0.8 cm width and 1.0 cm length x 0.8 cm width. The nursing note lacked documentation of a complete assessment of the resident's left leg, which was covered with the immobilizer. The 1/4/16 at 4:47 PM, nursing note indicated the resident returned from a physician visit with new orders for ACE wraps as needed to both legs, the splint to the left leg continued to be in place. The 1/5/16 at 5:50 PM, nursing note indicated the resident had a 3 cm length x 5 cm width open area observed to the posterior (back) left ankle, staff to monitor pressure area to posterior left ankle related to brace, and to keep pressure off the area to promote healing. The note further indicated staff notified the resident's primary physician of the new pressure area and requested new treatment orders. The 1/5/16 at 10:21 PM, nursing note indicated staff turned the resident side to side while in bed and the splint to the left leg had padding on the edge to prevent rubbing the heel ulcer. The 1/6/16 at 3:04 PM, nursing note indicated staff turned the resident noting a deep, dark red pressure area to his/her buttocks as well as an open pressure ulcer to his/her right buttock that was bordering on a stage 3. The note stated the staff's attempts to keep the resident on either side was met with some resistance, staff provided education to the resident about staying off of his/her back and staff provided a positioning wedge. Staff assessed the immobilizer at that time and observed to be in the correct position. The 1/7/16 at 8:36 PM, nursing note of the resident's skin assessment indicated the resident had a 6 cm length x 5 cm width stage 2 pressure ulcer to the right midline buttock with a light amount of drainage observed, the 2 stage 1 pressure areas left of the midline buttock were resolved, and a 3 cm length x 5 cm width pressure ulcer to the posterior left ankle. The 1/12/16 at 9:56 AM, physician's orders [REDACTED]. The 1/14/16 at 8:44 PM, nursing note indicated the resident's buttock wound had moderate odor observed. The 1/14/16 at 10:09 PM, nursing skin assessment indicated the resident had a stage 2 pressure ulcer to the right midline buttock, with a light amount of drainage, deep red with an open area to the center, measured 6 cm length x 5 cm width and the resident was referred to the wound clinic 1/15/16. The two areas to the left of the midline buttock were resolved. The groin area and buttocks were red in color. The posterior left ankle had an open area to that measured 3 cm length x 4.5 cm width and the resident had a red, open area to the right iliac crest (upper buttock, near the hip) that measured 3 cm length x 1.3 cm width. The 1/15/16 at 1:09 PM, nursing note indicated the resident returned from the wound clinic with new orders: -an arterial duplex (ultrasound testing to determine blood flow) to the left leg -discontinue the leg brace/immobilizer -discontinue compression (ace wraps) to the left lower leg -paint the left heel with [MEDICATION NAME] (topical anti-infective medication) daily -every 3 days, remove the dressing from the right iliac crest region, wash with wound cleanser, place [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) on the ulcer bed and cover with [MEDICATION NAME] (soft, [MEDICATION NAME] dressing designed to maintain a moist wound bed and absorb and retain drainage). -every 3 days, remove dressing from the peri-sacral region ulcer, wash with wound cleanser, apply Iodosorb (powder that cleans wounds by absorbing fluids, removing pus and debris, and forming a gel over the wound surface) to a 2 x 2 gauze, place it on the ulcer bed, and cover with [MEDICATION NAME]. May change dressing as needed. -right lower limb [MEDICAL CONDITION]: every morning wrap 3 ACE bandage from base of toes to just above the ankle. Use a 6 ace bandage from just above the ankle to just below the knee and remove daily at bedtime. -keep dressings and ulcers dry when bathing. -return for follow up appointment on 1/26/16 -Roho cushion (specialized cushion designed to reduce pressure), please obtain. (27 days after admission) On 1/18/16 at 8:24 AM, nursing notes indicated the resident's physician ordered a ROHO cushion. The 1/19/16 at 11:28 AM, nursing skin assessment indicated the following: -pressure ulcer observed to the left heel, unstageable per wound clinic documentation. The wound measured 4.9 cm length x 2.2 cm width x 0.1 cm depth with no drainage observed and necrotic (dead tissue) eschar observed to the wound. -stage 3 pressure ulcer observed to the right iliac crest, no drainage observed, and area measured 1.5 cm length x 1.3 cm width x 0.1 cm depth. -stage 3 pressure ulcer observed to the peri-sacral region with serosanguineous drainage (yellowish blood serum with small amounts of blood) observed, measured 4 cm length x 2.5 cm width x 0.1 cm depth. The 1/19/16 at 6:58 PM, nursing note indicated staff notified the orthopedic (bone) physician via fax the resident's dressing to the peri-sacral region became soiled several times a day, which required the dressing to be changed several times daily. The 1/20/16 at 2:11 PM, dietician note indicated the resident's meal intake averages for 2 weeks was breakfast 100% for 9 days and refused on one day, dinner 100%, supper 88% with protein powder placed in juice and offered at least 2 meals per day. The resident's FBS was high at 135. The 1/24/16 at 8:41 PM, nursing note indicated the resident rested in bed with an air mattress inflated and positioned with a pillow to minimize pressure to the buttocks. The note further indicated staff used pillows for positioning and the staff repositioned the resident frequently. Staff observed a small amount of dark brown drainage on the pillow that was under the necrotic areas to the left heel. The 1/26/16 physician's orders [REDACTED]. - Ulcer left heel, measures 4.8 cm length x 2.9 cm width x 0.3 cm depth, remove old dressing, cleanse with wound cleanser. Cleanse peri-ulcer with wound cleanser, cleanse with normal saline, use Iodosorb as the primary dressing. Use 2 x 2 gauze and [MEDICATION NAME] as the secondary dressing two times per week for one week. -Ulcer peri-sacral region, measures 3.4 cm length x 2.9 cm width x 0.2 cm depth, remove old dressing, cleanse with wound cleanser. Cleanse peri-ulcer with wound cleanser, cleanse with normal saline, use [MEDICATION NAME] Ag as primary dressing, use [MEDICATION NAME] and [MEDICATION NAME] (transparent dressing used to cover and protect) as the secondary dressing. Cover the dressing with [MEDICATION NAME] to try to keep the dressing clean. May use skin prep (liquid used to form a protective layer to prevent friction, is sticky or tacky) to help the dressing stick two times per week for one week and as needed. -[MEDICAL CONDITION] left lower leg, measures 29 cm at the calf, 23.4 cm at the ankle, and 26.2 cm around the foot. Remove old dressing, cleanse with wound cleanser and normal saline. Elevate lower extremity whenever able. Please apply foam boot to left foot/heel to help with offloading. -[MEDICAL CONDITION] right lower leg, measures 30 cm at the calf, 20.5 cm at the ankle, and 23.2 cm around the foot. Remove old dressing, cleanse with wound cleanser and normal saline. Wrap with ace wrap and elevate lower extremity when able. -Ulcer left lateral calf, superior malleolus measures 2.8 cm length x 1.5 cm width x 0.1 cm depth. Remove old dressing, cleanse with wound cleanser, cleanse the peri-ulcer with wound cleanser and normal saline. Use [MEDICATION NAME] Ag as the primary dressing and [MEDICATION NAME] as the secondary dressing two times per week for one week. The 2/1/16 physician's orders [REDACTED]. The 2/1/16 physician's orders [REDACTED]. - Ulcer left heel, measures 4.4 cm length x 2.9 cm width x 0.3 cm depth, remove old dressing, cleanse with wound cleanser. Cleanse peri-ulcer with wound cleanser, cleanse with normal saline, use Iodosorb to ulcer bed and [MEDICATION NAME] to peri-ulcer as the primary dressing. Use 2 x 2 gauze and Exudry (one piece dressing designed to absorb drainage and reduce friction and shearing) as the secondary dressing two times per week for one week. -Ulcer peri-sacral region, measures 3.0 cm length x 2.9 cm width x 0.2 cm depth, remove old dressing, cleanse with wound cleanser. Cleanse peri-ulcer with wound cleanser, cleanse with normal saline, use [MEDICATION NAME] Ag to the wound bed and clamoseptine (multipurpose moisture barrier) to the peri-ulcer as primary dressing, use [MEDICATION NAME] and [MEDICATION NAME] as the secondary dressing. Cover the dressing with [MEDICATION NAME] to try to keep the dressing clean. May use skin prep to help the dressing stick. This order is to be carried out two times per week for one week and as needed. -[MEDICAL CONDITION] left lower leg, measures 28.4 cm at the calf, 23.8 cm at the ankle, and 24.9 cm around the foot. Remove old dressing, cleanse with wound cleanser and normal saline. Elevate lower extremity whenever able. -[MEDICAL CONDITION] right lower leg, measures 30.3 cm at the calf, 22.2 cm at the ankle, and 23.5 cm around the foot. Remove old dressing, cleanse with wound cleanser and normal saline. Wrap with ace wrap and elevate lower extremity when able. Use a 3 ACE wrap from the base of the toes to the ankle, 6 ACE wrap from the ankle to below the knee. -Ulcer left lateral calf, superior malleolus measures 2.5 cm length x 1 cm width x 0.1 cm depth. Remove old dressing, cleanse with wound cleanser, cleanse the peri-ulcer with wound cleanser and normal saline. Use [MEDICATION NAME] Ag to the wound bed and [MEDICATION NAME] to the peri-wound as the primary dressing and [MEDICATION NAME] as the secondary dressing two times per week for one week. On 2/4/16 nursing staff faxed communication to the primary physician from nursing staff that stated the resident had an order for [REDACTED]. On 2/5/16, the primary physician responded to the faxed communication yes the resident could have a whirlpool/shower 2 times per week. The 2/10/16 at 9:45 AM, wound clinic physician's orders [REDACTED]. The orders directed staff to change the dressings every 3 days and as needed, cleanse with wound cleanser, apply [MEDICATION NAME] to peri-ulcers, apply medi-honey to the left lateral malleolus, apply iodosorb to gauze and place to left heel. Apply [MEDICATION NAME] Ag to the ulcer bed of the sacral area and cover all ulcers with [MEDICATION NAME] dressings. Continue to off load heel with pillow boot and sacral area with Roho cushion and apply a tensoshape (compression bandage) to the right lower leg, on in the morning and off at bedtime. The 2/16/16 at 11:27 AM, nursing notes indicated the wound to the left lateral malleolus was noticeably worse, measured 4.4 cm length x 4 cm width x 0.8 cm depth, stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle)with the Achilles tendon showing the entire length of the wound. The nurse attempted to call the wound clinic multiple times and received a busy signal. The 2/16/16 at 12:32 PM, nursing notes indicated the nurse was able to reach the wound clinic and report the pressure area changes. The response from the wound clinic indicated the clinic thought the wound sounded the same as it was at the prior visit and more red from the medicine doing it's job. The resident's next appointment with the wound clinic was scheduled for 2/22/16 and at the appointment they would talk about maybe applying a wound vac (negative pressure wound therapy uses a vacuum dressing to promote wound healing) to help heal the wound. The 2/20/16 at 9:31 PM, nursing note indicated the left heel dressing had a moderate amount of odorous, bloody drainage soaked through the dressing and onto the heel protector. Staff changed the heel dressing and the sacral dressing. The 2/22/16 physician's orders [REDACTED]. Orders further directed staff the ulcer to the peri-sacral region measured 2.6 cm length x 2.7 cm width x 0.4 cm depth, to apply [MEDICATION NAME] to the peri-ulcer, [MEDICATION NAME] Ag to the ulcer bed, cover with an Allevyn dressing and change every 2 days and as needed. The ulcer to the left heel measured 4.4 cm length x 2.7 cm width x 0 cm depth, apply [MEDICATION NAME] to the peri-ulcer, medi-honey to the ulcer bed, cover with [MEDICATION NAME] and change the dressing every 2 days and as needed. The ulcer to the left lateral calf, superior to malleolus measured 2.4 cm length x 0.9 cm width x 0 cm depth, apply [MEDICATION NAME] to the peri-ulcer, medi-honey to the ulcer bed, cover with [MEDICATION NAME], and change the dressing every 2 days and as needed. The orders further instructed staff to continue offloading boots to both feet when the resident is in a chair and when he/she is not working with therapy, to continue utilizing the Roho cushion and wound cultures were obtained to the left heel. The 2/24/16 at 9:37 AM, nursing notes indicated staff changed the dressings to the left heel and left lateral calf areas. Staff observed the left lateral calf with a small amount of drainage and yellowish-green exudate to the wound bed. The left heel was observed to be malodorous (unpleasant smelling) with a moderate amount of drainage dark in color, yellowish-white exudate (fluid with a high content of protein and cellular debris) over the tendon and darker to the outer edges. The staff changed the dressings per the physician's orders [REDACTED]. The 3/1/16 at 2:30 PM, nursing skin assessment indicated the following description of the resident's wounds: -Peri-sacral wound bed measured 1.5 cm length x 1.8 cm width x 0.3 cm depth with the peri-wound measured at 2.3 cm length x 3.3 cm width. The ulcer had minimal drainage observed with beefy red granulation (new connective tissue) tissue observed to the wound bed. -Left lateral calf wound superior to the malleolus wound bed measured 2.5 cm length x 0.5 cm width with the peri-wound measured at 4.8 cm length x 2.5 cm width. Staff observed a moderate amount of serosanguinous drainage, beefy red granualation tissue to the wound bed and [DIAGNOSES REDACTED] (redness). -The left heel ulcer wound bed measured 2.5 cm length x 0.5 cm width, the peri-wound measured 4.8 cm length x 3.5 cm width x 0.6 cm depth. Staff observed a moderate amount of serosanguinous drainage and the wound was malodorous. The 3/2/16 at 8:53 PM, nursing notes indicated the dressing to the resident's left heel was changed due to a large amount of brown drainage seeping through the dressing. The Achilles tendon visible, with the surrounding skin pink and irritated-looking. The 3/5/16 at 10:00 AM, nursing notes indicated the resident's left lateral calf wound dressing was changed. A moderate amount of serosanguinous drainage was observed and the wound was noted to be malodorous with [DIAGNOSES REDACTED] present. The left heel dressing changed, with the wound noted to be malodorous. The dressings were changed per the physician's orders [REDACTED]. The 3/6/16 at 8:37 PM, nursing notes indicated the resident's left lateral leg and heel dressings came off while he/she was being repositioned in bed. The left lateral leg dressing had brownish-green drainage, with the wound bed observed to have a moderate amount of brownish-green drainage. The left heel wound skin edges were gray in color with greenish-dark, red-brownish, drainage observed. Staff noted odors from both wounds during the dressing change. Staff placed heel protectors back on the resident after the dressing change. The 3/9/16 at 9:23 AM, nursing skin assessment notes indicated staff assessed the resident's wounds and changed dressings were to the following areas: -Peri-sacral wound stage 3, healed as of 3/9/16, wound bed measures 0.1 cm length x 0.2 cm width x 0.1 cm depth, with no exudate observed, beefy red granulation tissue observed, and excoriated area surrounding the wound measuring 9 cm length x 11 cm width. -Left lateral calf wound superior to the malleolus-stage 3, wound bed measured 2.2 cm length x 1.3 cm width x 0.3 cm depth. The peri-wound measured 4.3 cm length x 3.1 cm depth, and staff noted a moderate amount of serous exudate from the wound with beefy red granulation tissue observed. The wound also had slough present and covered with [MEDICATION NAME] (elastic, insoluble, whitish protein), the pressure ulcer bed as exposed subcutaneous tissue and the surrounding skin macerated (softening and breaking down of skin due to prolonged exposure to moisture). -Left posterior heel ulcer, stage 4, wound bed measured 5.8 cm length x 3.9 cm width x 0.3 cm depth with the peri-wound measured at 7.3 cm length x 4.7 cm width and observed to be indurated. The wound had large amounts of serous (clear, thin, watery) and serosanguinous exudate and malodorous. The tendon continued to be exposed, and the pressure ulcer base was noted to have beefy red granulation with slough and covered with [MEDICATION NAME]. The nursing note indicated the resident had new treatment orders to the left heel pressure ulcer of Restore Silver (non-adherent wound dressing for moderate to low drainage) over the tendon covered with [MEDICATION NAME] Ag and [MEDICATION NAME]. The resident had a new [DIAGNOSES REDACTED]. The 3/11/16 at 9:23 AM, nursing note indicated the peri-sacral wound had re-opened due to prolonged sitting in his/her wheelchair while he/she received IV antibiotics at an outpatient clinic. The wound measured 4.3 cm length x 3 cm width, with a minimal amount of serous drainage observed. The wound was dressed per orders and staff were instructed to continue offloading pressure and to keep the resident in bed as much as possible. The 3/9/16 at 5:05 PM, nursing note indicated the resident had a (PICC) peripherally inserted central catheter line (a form of intravenous access that can be used for a prolonged period of time) inserted on an outpatient basis and would receive IV antibiotic via the line. On 5/5/16 at 1:50 PM, (CNA) Certified Nurse Aid C stated the resident was repositioned every two hours and was placed side to side while in bed. CNA C further stated the resident wore pressure relieving boots and had a special cushion to sit on while he/she was sitting in the wheelchair or recliner. CNA C could not recall if the resident had an air mattress on his/her bed, but stated he/she thought the resident did have one. On 5/4/16 at 2:45 PM, Administrative Nurse A verified the resident came to the facility with a wound to his/her buttocks at a stage 2 and it progressed to a stage 3 pressure ulcer. He/she verified the pressure ulcer to the resident's left lateral leg, above the malleolus and the left heel were caused by pressure from the resident's leg immobilizer that he/she came to the facility with. He/she further stated the facility struggled with the resident's wounds and did not feel the resident's doctors and wound clinic were doing much to take care of the wounds. On 5/9/16 at 10:52 AM, Administrative Nurse A verified the resident's alternating air mattress was placed on his/her bed on 1/7/16 (16 days after the resident was admitted with a stage 2 pressure ulcer to right buttock and 2 stage 1 pressure ulcers to left buttock and 2 days after pressure ulcer to left heel was observed by the facility). He/she verified the resident's pressure ulcers that he/she was admitted with did get worse and that he/she developed additional pressure ulcers while in the facility that developed into a stage 3 and stage 4 wounds. On 5/9/16 at 3:37 PM, Physician J stated there could have been more done by the facility to prevent the resident's wounds from getting larger. He/she stated the wounds were nasty. Physician J stated orders were continually written to keep the resident's legs wrapped with compression and to float his/her heel and the resident would come to the wound clinic without the the compression devices and without the heel protector on. The facility's Skin Care Prevention, Intervention, Monitoring, Treatment policy, revised March 2015, stated it is the policy of the facility to prevent and manage pressure ulcers to preserve or attain the highest practical level skin integrity for all residents. The policy further instructed staff to off load hourly residents that are sitting, in bed, or in a recliner with the head elevated above 30 degrees. The facility failed to prevent the worsening of pressure ulcers that were present upon admission and to prevent new pressure areas from developing for Resident #9.

The facility had a census of 42 residents. The sample included 14 residents of which 2 were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents for 1 sampled resident, #30 who received second degree burns after eating mashed potatoes with his/her hands without staff assistance. Findings included: - Resident #30's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had long term and short term memory problems and moderately impaired cognition. The assessment revealed the resident required extensive assistance of 1 staff member for all activities of daily living. The assessment further revealed the resident wandered, did not have any behaviors during the lookback period and received antipsychotic and antidepressant medication. The 5/29/15 (CAA) Care Area Assessment for cognition stated the resident's cognitive decline contributes to his/her behavior and he/she would not yell out or steal food from other residents if he/she was able to communicate. The staff should provide appropriate monitoring of his/her decision making skills as he/she may not be able to do this independently. The 2/18/16 care plan directed staff to establish a daily routine that was comfortable for him/her and help him/her to feel safe and cared for. The care plan stated the resident was not allowed to eat alone and a staff member should always be present. The 5/8/16 untimed, nurse's note stated the resident stuck his/her hand into his/her mashed potatoes and started eating. The note stated by the afternoon the resident had fluid filled blisters on his/her right thumb and middle finger. The note further stated the thumb had 2 blisters measuring 3.5 (cm) centimeters by 1.5 cm and 1/8 cm by 1.0 cm. The middle finger blister measured 3.5 cm by 2.0 cm and 1.0 cm by 1.0 cm. The 5/9/16 untimed, nurse's note stated the staff assessed the burns to the right hand and the top of the right thumb had a large fluid filled blister measuring 1.5 cm by 2.1 cm, the bottom of the right thumb wrapping to the sides measuring 2.5 cm by 3.5 cm, a large ruptured blister to the bottom of the 3rd finger measured 3.3 cm by 2.8 cm with a ruptured hole in the middle measured 0.2 cm by 0.2 cm. The note further stated there was a small blister to the middle of the 3rd finger measured 1.0 cm by 0.9 cm. The note stated the lateral right ring finger had a bright red area measured 1.4 cm by 1.3 cm and a bright red area to the top of the right ring finger measured 0.6 cm by 0.8 cm. The 5/9/16 physician order [REDACTED]. On 5/3/16 at 11:52 AM, observation revealed the resident seated at the table with a specialized plate with a lip and defined edges that suction to the table top. Further observation revealed the staff handed him/her a spoon, he/she sat it down and started to eat with his/her right hand fingers. Continued observation revealed staff check on him/her periodically and the resident was served one food item at a time. Observation revealed the resident used the plate and it's edges to scoop food out of it and into her mouth, using her hands and would alternate between using a spoon and his/her fingers. On 5/9/16 at 2:57 PM, Administrative Nurse A stated the nurse faxed the physician regarding the resident's burned hand and did not feel the staff should have called the resident because he/she did not display any signs and symptoms of pain. Administrative Nurse A stated the temperature of the potatoes should have been 135 degrees but when staff placed the potatoes on the cart, the temperature was 150 degrees. Administrative Nurse stated the staff in the kitchen took the temperature of the potatoes prior to serving but failed to write it down and did not remember what it was. On 5/10/16 at 9:55 AM, Physician I stated the staff should have contacted him/her by telephone regarding the burns, instead of by fax machine so the resident could get treatment started. Upon request a policy for accident hazard was not provided from the facility. The facility failed to ensure the resident's environment remained free of accident hazards for Resident #30, who received multiple burns after sticking his/her hands in mashed potatoes without staff assist.

The facility had a census of 42 residents. The sample included 14 residents of which 4 residents were reviewed for nutrition. Based on record review and interview the facility failed to implement new interventions to prevent further weight loss for 1 of 4 sampled residents. (#9) Findings included: - Resident #9's medical record revealed the facility admitted the resident on 12/22/15. The medical record revealed the following [DIAGNOSES REDACTED]. Nutritional [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), fracture of lower end of the left femur (thigh bone) (leg immobilizer in place). The admission 5 day (MDS) Minimum Data Set assessment, dated 12/29/15, indicated the resident scored 11, on the (BIMS) Brief Interview for Mental Status, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting and eating. The MDS indicated the resident weighted 158 (#) pounds, with no height listed, had no swallowing disorders, and received a therapeutic diet. The significant change MDS, dated [DATE], was unchanged except the resident required supervision with set up help only for eating, the resident was 65 inches tall, and weighed 168#. The admission nutritional status (CAA) Care Area Assessment, dated 12/29/15, indicated the resident received a therapeutic diet, (NSA) No Salt Added, and (NCS) No Concentrated Sweets) related to higher blood sugars during his/her hospital stay. The significant change nutritional status CAA, dated 1/29/16, indicated the resident's weight on 12/22/15 158# and on 1/5/16 168#. The CAA indicated the facility initiated a nutrition intervention program of protein powder in juice twice a day. The 12/24/15 care plan instructed the staff to provide a nutrition intervention program of protein powder in juice twice a day. The 12/22/15, no time documented, nurse's notes indicated when the resident left the hospital he/she had high blood sugar levels and the staff would monitor the resident's blood sugars, but the resident does not have a [DIAGNOSES REDACTED]. The 12/23/15 at 1:01 PM, nurse's notes indicated the resident had been eating his/her meals in his/her room. The 12/27/15 at 10:58 PM, nurse's notes indicated the resident had 3+ [MEDICAL CONDITION] (score of 3 is deeper yet (6mm) millimeter, and can last longer than a minute; in stage 3 [MEDICAL CONDITION] the extremity also looks grossly swollen) in both lower legs, with weeping noted from the inside of the resident's right leg. The 2/11/16 at 9:56 AM, nurse's notes indicated the resident had pain and poor coordination of his/her hands/arms and therapy progress was slowing down. The 2/18/16 at 9:29 PM, nurse's notes indicated the resident needed staff assistance this shift for eating and drinking. The 2/21/16 at 12:56 PM, nurse's note indicated the staff tried to get the resident up for lunch but he/she would not wake up or acknowledge the staff was present. The 1/7/16 at 1:39 PM, dietician note indicated the resident's recent meal intake averages were 98% for breakfast, dinner and 90% for supper. The note indicated the resident's weight was 168# on 1/5/16 and a 10 pound weight gain since admission on 12/22/15. The note indicated some of the weight gain may be related to fluid retention. The note indicated the resident's (FBS) fasting blood sugar was 135 on 12/29/15. The 1/20/16 at 2:11 PM, dietician note indicated the resident's meal intake averages for 2 weeks was breakfast 100% for 9 days and refused on one day, dinner 100%, supper 88% with protein powder placed in juice and offered at least 2 meals per day. The resident's FBS was high at 135. The 2/1/16 at 11:44 AM, dietician note indicated the resident's meal intake average for 2 weeks-breakfast 100% on 12 days, refused on 1 day, dinner 93% and supper 88%. The note indicated (OT) Occupational Therapy had been working with the resident, and started using a special divided plate and sippy cups for beverages on 1/26/16. On 1/27/16 a special curved spoon with built up handle was started. The 2/11/16 at 12:22 PM, dietician note indicated the resident enjoyed eating a few Hershey Kisses each day that he/she kept in his/her room. The note indicated the staff offered house supplements to the resident for help with his/her protein level. The note indicated the resident had a 32.8# weight loss since 1/5/16 although the accuracy of the January weight is now questioned. The 2/22/16 at 12:25 PM, the dietician note indicated the resident's meal intake averages for 2 weeks was 94% for breakfast, 92% for dinner for 12 days and refused on 1 day with 92% for supper. The weight record revealed the following: 12/22/15-158# (admission weight) 12/31/15-162# 1/5/16-168# 2/11/16-135.2# (19.5% weight loss in 38 days) (Review of the medical record revealed the staff did not re-weigh the resident per facility protocol) 3/1/16-141.6# On 3/4/16, CBC (Complete Blood Count) indicated the resident's (RBC) Red Blood Cells count -3.91 which was low, (normal 4.0-5.2). Further review of the resident's medical record revealed [REDACTED]. On 5/5/16 at 1:50 PM, Medication Aide C stated the resident didn't eat well, depending on what the meal provided consisted of. Medication Aide C stated the resident would sometimes eat 75 % of his/her meal at first ate independently, then he/she started to decline and the staff started to assist him/her to eat. On 5/5/16 at 3:26 PM, Nurse E stated he/she didn't remember specific dietary interventions but remembered the staff tried several. Nurse E stated he/she remembered the resident wouldn't eat, no matter what the staff brought him/her and no matter what the staff tried, he/she just wouldn't eat. Nurse E stated the resident's son visited frequently, was very helpful in the resident's care and supportive with his/her care. Nurse E stated the resident would refuse to cooperate with staff and very adamant about not assisting the staff at all with his/her cares and the staff had to strongly encourage the resident. On 5/4/16 at 2:45 PM, Administrative Nurse A stated the resident's leg brace which was a metal brace with sheepskin padding, full length, was discontinued on 2/11/16 and the resident's [MEDICAL CONDITION] improved. Administrative Nurse A verified on 2/17/16, the resident triggered 7.5% weight loss in the last 3 months. Administrative Nurse A stated the staff would re-weigh a resident who had a 5 pound weight change, and the staff was to do an automatic re-weigh and put both weights in the kiosk. Administrative Nurse A verified if a resident had a significant weight loss then the facility would weigh the resident weekly. The medical record revealed no documentation staff weighed the resident before and after removal of the brace to determine the actual weight of the brace. On 5/5/16 at 2:42 PM, Dietary Staff D stated the resident's weight loss was from his/her [MEDICAL CONDITION] and fluid retention and the lack of the brace. Dietary Staff D stated the staff had to weigh the resident with the brace due to it not being able to remove the brace and when the brace was discontinued is when the resident's weight showed a weight loss. Dietary Staff D stated he/she could not confirm if the staff did a reweigh, but from what is on the kiosk, there is only one weight listed. Dietary Staff D stated it was our policy to do a reweigh immediately with a 5 pound weight loss or gain and he/she would like for the staff to put both weights in so he/she could see the staff had reweighed the resident. Dietary Staff D stated he/she did not have a paper copy of the residents' weights so he/she could not say for sure if it was completed. Dietary Staff D stated it would be our policy when a resident has a significant weight loss to have the staff weigh the resident weekly. Dietary Staff D verified the staff had not added additional interventions or supplements to the resident ' s diet. Dietary Staff D stated the resident was on a NCS diet and the facility did not carry sugar-free shakes. Dietary Staff D stated OT had worked with the resident and implemented a specialized plate, cup and curved spoon, which would help the resident feed him/herself easier or at least increase the chances of it making it easier to feed him/herself. The 6/24/10 facility's weight loss protocol indicated on a weekly basis, the resident weight would be evaluated for significant weight loss (5% in one month, 7.5% in three months or 10% in six months.) The policy stated the staff would do a minimum of weekly weights until the resident was no longer identified on the internal significant weight loss list, at that time, the need for weekly weights would be evaluated. The facility failed to implement additional nutritional interventions or do weekly weights as directed by the facility weight loss policy after a significant weight loss. The facility failed to weigh the resident prior to or after removing the leg brace to determine the actual weight of the brace and whether Resident #9 had a true significant weight loss.

The facility had a census of 42 residents. The sample included 14 residents of which 2 were reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure Resident #30 receives care and services regarding improved verbal communication and inability to control his/her behaviors towards other residents on his/her neighborhood. Findings included: - Resident #30's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had long term and short term memory problems and moderately impaired cognition. The assessment revealed the resident required extensive assistance of 1 staff member for all activities of daily living. The assessment further revealed the resident wandered, did not have any behaviors during the lookback period and received antipsychotic and antidepressant medication. The 5/29/15 (CAA) Care Area Assessment for behavioral symptoms stated the resident had dementia and many mental health diagnoses' that contribute to his/her behaviors. The CAA further stated the resident was nonverbal and used behaviors to attempt to communicate to staff. The CAA for cognition stated the resident's cognitive decline contributed to his/her behavior and he/she would not yell out or steal food from other residents if he/she was able to communicate. The CAA further stated the staff needed to monitor behaviors and not interfere unless it affected the resident or other's safety. The staff should provide appropriate monitoring of his/her decision making skills as he/she may not be able to do this independently. The 2/18/16 care plan indicated the resident often wandered from his/her room and took food from other residents. The care plan directed staff to be aware that the resident may display behaviors in an effort to try and communicate or have a need met and directed staff to assess what that need may be. The care plan directed staff to establish a daily routine that was comfortable for him/her and help him/her to feel safe and cared for. The care plan lacked direction to staff as to what interventions were put into place when the resident had behaviors. The Behavior Interventions Analysis Reports from 4/5/16 to 5/5/16 revealed the following: 4/10/16 at 4:30 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/20/16 at 3:45 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/21/16 at 2:00 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/21/16 at 4:00 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/25/16 at 2:30 PM-the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/25/16 at 3:00 PM-the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. The 3/8/16 at 7:39 PM, nurse's note stated the resident went into another resident's room and grabbed the resident's arms. The note further stated the family was present, witnessed the event and escorted the resident out of the room. The 3/15/16 at 9:32 PM, nurse's note stated the resident grabbed another resident's arm causing him/her to yell out and stated his/her arm hurt. The 4/4/16 at 7:48 PM, nurse's note stated the resident grabbed another resident and tried to pull him/her out of the wheelchair. The note further stated, the other resident was observed crying and yelling help very loudly. The note stated the other resident's arm was assessed and the resident continued to cry and yelled that his/her arm burned and an ice pack was provided. The 4/8/16 at 10:38 AM, nurse's note state the resident grabbed several residents' arms during breakfast. The note further stated the resident was pushing his/her dining room chair down the middle of the hallway. The 4/13/16 at 8:28 PM, nurse's note stated the resident grabbed multiple residents and staff by the arm and hand with a very rough and strong grasp. The note further stated the resident took another resident's food off the plate and ate it and was difficult to redirect. The 4/14/16 at 3:07 AM, nurse's note stated the doors to the resident's neighborhood were open and the resident walked out the open doors and went into another residents room that was on Hospice services and laid done in the bed with him/her which caused the other resident to yell for assistance. The 4/15/16 at 3:46 PM, nurse's note stated the resident grabbed a visitor and caused a small skin tear to his/her forearm. The 4/29/16 at 3:09 PM, nurse's note stated the resident grabbed Administrative Staff H, had a very tight grasp and would not let go, pulling the Administrative Staff H to his/her room. The note further stated the resident then pulled Administrative Staff H to the dining room. The note stated the resident grabbed an assisted living resident causing the other resident's drink to spill onto the floor. The note stated staff tried to redirect the resident, but it was difficulty. The note stated Administrative Staff H went to assist another resident and within 2 minutes heard another resident screaming from the hallway. The note stated the resident grabbed another resident's arm and staff intervened. On 4/30/16 at 6:42 PM, nurse's note stated the resident was very restless and would grab any residents or staff member on the hallway or dining room. The note stated he/she would follow resident's into their rooms and at times would push a chair down the hallway. The note stated the resident was toileted multiple times, and offered a snack. On 5/4/16 at 8:08 AM, observation revealed the resident walked to a dining room table and grabbed another resident's right forearm with both of his/her hands, causing the other resident to yell. Further observation revealed the staff redirected the resident to his/her room. Continued observation revealed the resident came out of his/her room and attempted to walk into the kitchenette causing multiple residents to yell for assistance. On 5/4/16 at 3:45 PM, observation revealed the resident grabbed another resident by the wrist and attempted to take the resident's food and spoon. Further observation revealed staff intervened but did not assess the resident's arm. On 5/4/16 at 3:46 PM, Nurse Aide B stated the resident has a behavior of grabbing and at times staff cannot redirect him/her. Nurse Aide B further stated other residents scream when he/she was coming near them. Nurse Aide B stated a lot of the other residents requested to keep their doors closed so he/she did not wander into their rooms. On 5/5/16 at 11:02 AM, Licensed Nurse D stated staff monitored the camera and listened for the door if the resident was in the hallway and if he/she is getting up and going, staff had to intervene. Licensed Nurse D further stated another resident on the hall will scream out when he/she saw the resident because he/she was afraid of what's coming . On 5/5/16 at 2:00 PM, Nurse Aide C stated other residents do not like it when he/she grabbed them and stated staff were usually in the commons area to make sure he/she was not grabbing other residents and visitors. On 5/9/16 at 2:57 PM, Administrative Nurse A stated the resident grabbed resident and staff as a way of communication. Upon request a policy for behavior was not provided. The facility failed to ensure Resident #30 recieves care and services regarding improved verbal communication and inability to control his/her behaviors towards other residents on his/her neighborhood.

The facility had a census of 42 residents. The sample included 14 residents of which 5 were reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to adequately monitor the bowel management program and need for interventions for 1 of 5 sampled residents. (#33) Findings included: - Resident #33's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/15/16, indicated the resident had short term and long term memory problems with moderately impaired cognition. The assessment revealed the resident was independent with toileting but required limited assistance of 1 staff member for personal hygiene. The assessment further revealed the resident was always continent of bowel. The 4/19/16 care plan directed the staff to provide supervision, cueing, reminders, and/or assistance with toileting if and when needed. The care plan revealed the resident received [MEDICATION NAME] (an antipsychotic medication) and directed the staff to monitor for constipation. The 3/23/16 POS directed the staff to administer Milk of Magnesium, (a laxative) 15-30 (ml) milliliters, as needed, daily for constipation. Review of the April 2016 facility bowel movement record revealed no documentation the resident had a bowel movement from 4/11/16 through 4/16/16, (6 consecutive days) and from 4/20/16 through 5/9/16. (20 consecutive days). Review of the (MAR) Medication Administration Record [REDACTED]. On 5/3/16 at 10:07 AM, observation revealed the resident sitting at a dining room table eating breakfast. On 5/4/16 at 3:46 PM, Nurse Aide B stated the staff doesn't know when he/she has bowel movements, they go by if the resident's stomach is distended. On 5/6/16 at 10:00 AM, Licensed Nurse G stated if it is the third day, they watch, then give Milk of Magnesium and chart it in the MAR. Licensed Nurse G further stated the resident is independent with toileting and the staff try to catch him/her but they don ' t always. Licensed Nurse G stated the resident will rub his/her stomach if it has been a few days since he/she has had a bowel movement. Licensed Nurse G stated dragon fruit (a fruit used as a dietary supplement containing fiber) is given to the resident to help with his/her bowel movements but is not charted in the MAR. On 5/9/16 at 10:18 AM, Administrative Nurse A stated the resident has regular bowel movements and if he/she does not, his/her stomach becomes distended and he/she will ask for something for his/her stomach. Administrative Nurse A further stated when he/she deviates from his/her normal routine and not acting right, they give him/her something. The March 2015 facility' s Bowel Monitoring Policy directed staff to document resident bowel movements on Caretracker and/or a neighborhood bowel movement spreadsheet. The policy further states each shift, the charge nurse and/or the medication aide will review the neighborhood bowel movement spreadsheet to determine a pattern and if the constipation protocol shall be implemented. The constipation prevention protocol will be implemented if the resident has not had a vowel movement for 48 hours. The facility failed to adequately monitor and provide interventions for bowel management for Resident #33, who lacked documentation of a bowel movement for 6 and 20 consecutive days.

The facility had a census of 42 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to review and revise the care plan for 2 of the 14 sampled residents. Resident #33 for bowel monitoring and Resident #30 for the behaviors toward other residents. Findings included: - Resident #33's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/15/16, indicated the resident had short term and long term memory problems with moderately impaired cognition. The assessment revealed the resident was independent with toileting but required limited assistance of 1 staff member for personal hygiene. The assessment further revealed the resident was always continent of bowel. The 4/19/16 care plan directed the staff to provide supervision, cueing, reminders, and/or assistance with toileting if and when needed. The care plan revealed the resident received [MEDICATION NAME] (an antipsychotic medication) and directed the staff to monitor for constipation. The care plan lacked directed to the staff on interventions for bowel monitoring for the resident. The 3/23/16 POS directed the staff to administer Milk of Magnesium, (a laxative) 15-30 (ml) milliliters, as needed, daily for constipation. Review of the April 2016 facility bowel movement record revealed no documentation the resident had a bowel movement from 4/11/16 through 4/16/16, (6 consecutive days) and from 4/20/16 through 5/9/16. (20 consecutive days). Review of the (MAR) Medication Administration Record [REDACTED]. On 5/3/16 at 10:07 AM, observation revealed the resident sitting at a dining room table eating breakfast. On 5/4/16 at 3:46 PM, Nurse Aide B stated the staff doesn't know when he/she has bowel movements, they go by if the resident's stomach is distended. On 5/6/16 at 10:00 AM, Licensed Nurse G stated if it is the third day, they watch, then give Milk of Magnesium and chart it in the MAR. Licensed Nurse G further stated the resident is independent with toileting and the staff try to catch him/her but they don't always. Licensed Nurse G stated the resident will rub his/her stomach if it has been a few days since he/she has had a bowel movement. Licensed Nurse G stated dragon fruit (a fruit used as a dietary supplement containing fiber) is given to the resident to help with his/her bowel movements but is not charted in the MAR. On 5/9/16 at 10:18 AM, Administrative Nurse A stated the resident has regular bowel movements and if he/she does not, his/her stomach becomes distended and he/she will ask for something for his/her stomach. Administrative Nurse A further stated when he/she deviates from his/her normal routine and not acting right, they give him/her something. Administrative Nurse A verified the care plan should direct the staff on interventions to assist with bowel monitoring. The January 2016 Resident Assessment MDS Policy stated care plans will be revised not more than 14 days after completion of the quarterly assessment. The facility failed to review and revise the care plan for Resident #9 to include interventions for bowel monitoring. - Resident #30's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/5/16, indicated the resident had long term and short term memory problems and moderately impaired cognition. The assessment revealed the resident required extensive assistance of 1 staff member for all activities of daily living. The assessment further revealed the resident wandered, did not have any behaviors during the lookback period and received antipsychotic and antidepressant medication. The 5/29/15 (CAA) Care Area Assessment for behavioral symptoms stated the resident had dementia and many mental health diagnoses' that contribute to his/her behaviors. The CAA further stated the resident was nonverbal and used behaviors to attempt to communicate to staff. The CAA for cognition stated the resident's cognitive decline contributed to his/her behavior and he/she would not yell out or steal food from other residents if he/she was able to communicate. The CAA further stated the staff needed to monitor behaviors and not interfere unless it affected the resident or other's safety. The staff should provide appropriate monitoring of his/her decision making skills as he/she may not be able to do this independently. The 2/18/16 care plan indicated the resident often wandered from his/her room and took food from other residents. The care plan directed staff to be aware that the resident may display behaviors in an effort to try and communicate or have a need met and directed staff to assess what that need may be. The care plan directed staff to establish a daily routine that was comfortable for him/her and help him/her to feel safe and cared for. The care plan lacked direction to staff as to what interventions were put into place when the resident had behaviors. The Behavior Interventions Analysis Reports from 4/5/16 to 5/5/16 revealed the following: 4/10/16 at 4:30 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/20/16 at 3:45 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/21/16 at 2:00 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/21/16 at 4:00 PM- the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/25/16 at 2:30 PM-the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. 4/25/16 at 3:00 PM-the resident was physically abusive, staff tried 1:1, diversional activities, and toileting. The report stated the interventions were ineffective. The 3/8/16 at 7:39 PM, nurse's note stated the resident went into another resident's room and grabbed the resident's arms. The note further stated the family was present, witnessed the event and escorted the resident out of the room. The 3/15/16 at 9:32 PM, nurse's note stated the resident grabbed another resident's arm causing him/her to yell out and stated his/her arm hurt. The 4/4/16 at 7:48 PM, nurse's note stated the resident grabbed another resident and tried to pull him/her out of the wheelchair. The note further stated, the other resident was observed crying and yelling help very loudly. The note stated the other resident's arm was assessed and the resident continued to cry and yelled that his/her arm burned and an ice pack was provided. The 4/8/16 at 10:38 AM, nurse's note state the resident grabbed several residents' arms during breakfast. The note further stated the resident was pushing his/her dining room chair down the middle of the hallway. The 4/13/16 at 8:28 PM, nurse's note stated the resident grabbed multiple residents and staff by the arm and hand with a very rough and strong grasp. The note further stated the resident took another resident's food off the plate and ate it and was difficult to redirect. The 4/14/16 at 3:07 AM, nurse's note stated the doors to the resident's neighborhood were open and the resident walked out the open doors and went into another residents room that was on Hospice services and laid done in the bed with him/her which caused the other resident to yell for assistance. The 4/15/16 at 3:46 PM, nurse's note stated the resident grabbed a visitor and caused a small skin tear to his/her forearm. The 4/29/16 at 3:09 PM, nurse's note stated the resident grabbed Administrative Staff H, had a very tight grasp and would not let go, pulling the Administrative Staff H to his/her room. The note further stated the resident then pulled Administrative Staff H to the dining room. The note stated the resident grabbed an assisted living resident causing the other resident's drink to spill onto the floor. The note stated staff tried to redirect the resident, but it was difficult. The note stated Administrative Staff H went to assist another resident and within 2 minutes heard another resident screaming from the hallway. The note stated the resident grabbed another resident's arm and staff intervened. On 4/30/16 at 6:42 PM, nurse's note stated the resident was very restless and would grab any residents or staff member on the hallway or dining room. The note stated he/she would follow residents into their rooms and at times would push a chair down the hallway. The note stated the resident was toileted multiple times, and offered a snack. On 5/4/16 at 8:08 AM, observation revealed the resident walked to a dining room table and grabbed another resident's right forearm with both of his/her hands, causing the other resident to yell. Further observation revealed the staff redirected the resident to his/her room. Continued observation revealed the resident came out of his/her room and attempted to walk into the kitchenette causing multiple residents to yell for assistance. On 5/4/16 at 3:45 PM, observation revealed the resident grabbed another resident by the wrist and attempted to take the resident's food and spoon. Further observation revealed staff intervened but did not assess the resident's arm. On 5/4/16 at 3:46 PM, Nurse Aide B stated the resident has a behavior of grabbing and at times staff cannot redirect him/her. Nurse Aide B further stated other residents scream when he/she was coming near them. Nurse Aide B stated a lot of the other residents requested to keep their doors closed so he/she did not wander into their rooms. On 5/5/16 at 11:02 AM, Licensed Nurse D stated staff monitored the camera and listened for the door if the resident was in the hallway and if he/she is getting up and going, staff had to intervene. Licensed Nurse D further stated another resident on the hall will scream out when he/she saw the resident because he/she was afraid of what's coming . On 5/5/16 at 2:00 PM, Nurse Aide C stated other residents do not like it when he/she grabbed them and stated staff were usually in the commons area to make sure he/she was not grabbing other residents and visitors. On 5/9/16 at 2:57 PM, Administrative Nurse A stated the resident grabbed residents and staff as a way of communication. The facility failed to review and revise Resident #30's care plan for interventions regarding the resident's behavior toward others.

The facility had a census of 51 residents. The sample included 4 residents, who were reviewed for accidents. Based on observation, record review and interview, the facility failed to appropriately secure and safely transport sampled Resident #1, who had a fall with a subdural hematoma (collection of blood on the surface of the brain). This deficient practice place Resident #1 in immediate jeopardy and the resident died . Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS also indicated the resident required extensive assistance with transfers, had impaired balance that required human assistance to stabilize and had range of motion impairment of both upper extremities and one side of the lower extremities. The MDS further indicated the resident used a wheelchair for mobility. The [DATE] care plan directed the staff to transfer the resident with a sit to stand lift or 2 staff with the use a gait belt to transfer the resident. The care plan indicated the resident used an electric wheelchair for mobility. The [DATE] care plan revision (after the resident's fall in the facility van) directed staff to ensure the resident appropriately secured with a seatbelt during transport in the facility van. The [DATE] at 10:15 AM, nurse's note indicated, per the transport driver report, the resident slid out of his/her wheelchair and hit his/her head, when the driver braked the facility van for a yellow light. The nurse's note indicated a prn (as needed) nurse from the facility in the vicinity and a passerby (a nurse from the hospital) assisted the driver to transfer the resident back into his/her electric wheelchair and then transported the resident to the emergency room . The [DATE] at 11:11 AM, nurse's note indicated the hospital admitted the resident with a Diagnosis: [REDACTED]. The [DATE] Initial Fall report indicated the resident slid out of his/her electric wheelchair, when the driver braked the facility van. The report indicated the resident had head and neck injuries with mild pain. The report indicated the care plan intervention directed the staff to ensure the resident appropriately secured with a seatbelt during transport in the facility van. The [DATE] emergency room Physician Report indicated the facility transported the resident unrestrained in his/her electric wheelchair and the resident slid out of his/her electric wheelchair, when the driver had to suddenly stop the facility van. The report indicated the resident struck the back of his/her head and received head and neck injuries. The [DATE] Diagnostic Imaging Report indicated the resident had an acute (a disease or injury characterized by a sudden onset of symptoms that are usually severe) subdural hematoma. The [DATE] Physician's Progress note indicated the resident had significant worsening in the right-sided subdural hematoma with evidence of ongoing bleeding and new significant mass. The progress note also indicated the resident's neurologic examination (systematic examination of the nervous system to assess mental status and sensory and neuromuscular function) was consistent with imminent death. On [DATE] at 2:24 PM, Nurse C stated the resident had impaired balance, limited range of motion in his/her extremities, required a sit to stand lift for transfers and used an electric wheelchair for mobility. Nurse C also stated the charge nurse checked the transport log every morning and directed staff to have the resident ready for appointments. Nurse C further stated the transport staff picked the resident up in his/her room or on the unit and took the resident to the facility van for transport. On [DATE] at 2:55 PM, Nurse Aide A stated the resident required extensive assistance with transfers and used a motorized wheelchair for mobility. Nurse Aide A also stated staff ensured the resident ready for his/her appointments and transport staff picked-up the resident on the unit and took the resident out to the facility van. On [DATE] at 3:48 PM, Maintenance Staff B stated the facility trained the transport staff how to use the van safety equipment to secure the resident and his/her wheelchair. Maintenance Staff B also stated the facility policy and the law directed staff to safely secure all residents during transport in the facility van. On [DATE] at 8:34 AM, Administrative Nurse D stated nursing staff ensured the resident was ready for his/her appointment and transport staff picked-up the resident in his/her room and took to the facility van. Administrative Staff D stated the resident had impaired balance, limited range of motion, used an electric wheelchair for mobility and should be safely secured for transport in the facility van. On [DATE] at 7:50 AM, Nurse E stated he/she observed the facility van stopped at the curb with flashing warning lights on and the driver outside the van. Nurse E stated he/she immediately responded to the scene and observed the driver and a passer-by (nurse from the hospital) assisted the resident to transfer to his/her wheelchair. Nurse E stated he/she assessed the resident found no apparent injuries and no complaints of pain or distress, but the resident stated he/she had hit his/her head. Nurse E stated the resident had not been secured with a seatbelt prior to the accident. Nurse E further stated he/she accompanied the resident in the facility van to the emergency room for evaluation of a possible head injury. On [DATE] at 9:15 AM, Transport Staff F stated, on the morning of [DATE], it was very hectic due to recent changes made to the transport schedule and he/she was several minutes behind schedule and felt hurried. Transport Staff F stated he/she had not secured the resident in his/her motorized wheelchair with a seatbelt and the resident slid out of the wheelchair, when he/she had to stop suddenly at a yellow light. Transport Staff F stated no other staff had assisted to load the resident in the facility van, he/she had not requested assistance, despite being behind schedule and feeling hurried. Transport Staff F further stated he/she had not rechecked the resident's safety/security, when he/she dropped another resident from the facility off at an appointment prior to the accident. The facility's undated Transportation Policy directed the driver to offer assistance to all residents using wheelchairs or scooter as they enter and exit the van. The policy directed the driver to restrain all wheelchairs/scooters and the residents in place using the facility's van restraint system and safety equipment. The facility failed to appropriately secure and safely transport Resident #1, who had a fall with a subdural hematoma. This deficient practice place this resident in immediate jeopardy. The facility abated the Immediate Jeopardy on [DATE] when it provided an all staff inservice regarding proper use of wheelchair securement and occupant restraint systems and a transportation compentency checklist for proper transportation of residents in the facility's van. This deficient practice remains at a scope and severity of a G.

The facility had a census of 53 residents. The sample included 5 residents. Based on observation, record review and interview the facility failed to check the physician's orders and/or care plan, provide adequate assessments and inappropriately applied, on two separate occasions, a hot moist pack (padded device, with filler to maintain the temperature, heated to 160 degrees in a hot water bath) to Resident #1's right shoulder, causing burns and multiple blisters. This failure placed the resident in jeopardy. Findings Included: - Resident #1's quarterly (MDS) Minimum Data Set, dated dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 9 (moderately impaired). The MDS also indicated the resident required extensive assistance with bed mobility, transfers and dressing. The MDS further indicated the resident received scheduled and (prn) as needed pain medications. The 12/13/12 care plan directed the staff to assess the resident's pain and monitor the effectiveness of his/her pain medications. The care plan also directed the staff to reposition the resident every 2 hours to provide comfort and pressure relief. Continued review of the care plan revealed no documentation to direct the staff to apply a (HMP) hot moist pack on the resident. The 12/03/12 Physician's Standing Orders directed the staff to place a warm moist pack (not a hot moist pack) for 20 minute as needed for sore joints/muscles. review of the resident's medical record revealed [REDACTED]. The undated 8 inch by 11 inch sign, posted above the hydroculator (device used to heat and maintain water temperature at 160 degrees to prepare a HNP), alerted the staff "CAUTION - Check resident skin before and after application of HNP !!!" The undated guidelines, posted above the hydroculator, directed the staff to provide the following cares and precautions while applying a HMP on a resident: 1) Never leave the HMP on longer than 30 minutes. 2) Always place at least 8 or more layers between the HMP and the resident's skin. "It should be the constant thought in the mind of the caregiver, that it is easier to remove layers of toweling, than to treat skin burns." 3) Use care and judgment when applying HMP to the elderly. Constantly check the temperature of the HMP. 4) Exercise extreme caution when applying HMP to the resident with fragile skin or "bony areas'. Assess and monitor the resident's skin before, during and after the HMP application. The 12/31/12 at 10:30 AM, nurse's note indicated the resident had a 1.5 (cm) centimeter by 0.7 cm fluid filled blister on his/her right shoulder. The nurse's note also indicated the resident had a 2 cm by 3 cm reddened area around the blister. The nurse's note further indicated there was no evidence the staff had applied a HMP to the resident's shoulder. review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. The 01/01/13 at 7:00 AM, nurse's note indicated the staff found several more blisters on the resident's right shoulder. The nurse's note also indicated the staff had placed a HMP on the resident at 3:20 AM and removed the HMP during 4:00 AM rounds (not the definite and safe time period of 30 minutes as directed by the HMP guidelines). Review of the 01/07/13 facility investigation revealed on 12/31/12 at 1:50 AM, Aide A offered the resident a HMP for his/her shoulder pain. The investigation indicated Aide A informed Nurse B of the resident's request for a HMP and applied the HMP to the resident's right shoulder. The investigation indicated Aide A removed the HMP from the resident's right shoulder at 3:35 AM (1 hour and 15 minutes longer than the 30 minutes directed in the HMP guidelines). The investigation indicated the staff had not assessed the resident's skin during or after the HMP application. The investigation indicated, on the morning of 12/31/12, Nurse D assessed a 1.5 cm by .75 cm fluid filled blister surrounded by a 2 cm by 3 cm reddened area on the resident's right shoulder. The investigation indicated the staff had not investigated the resident's injury of unknown origin. The investigation indicated, on 01/01/13 at 3:20 AM, Nurse E applied a HMP to the resident's right shoulder. The investigation indicated Nurse E noted the blister on the top of the resident's right shoulder and placed the HMP next to and behind the resident's blister and reddened area. The investigation indicated the staff removed the HMP after approximately 40 minutes (again not applied safely for 30 minutes as directed in the guidelines) and the staff again, had not assessed and/or monitored the resident's skin during the HMP application. The investigation indicated, on 01/01/13 at 7:00 AM, the staff noted a 18 cm by 10 cm reddened area with several new blisters. On 01/10/13 at 12:51 PM, observation revealed the resident had a ABD pad (4 inch by 6 inch padded dressing) on his/her right shoulder. Continued observation revealed a 2 cm by 3 cm dark brown blister on the top of the resident's right shoulder and three 1 cm light brown blisters on the upper back of the resident's shoulder. On 01/10/13 at 3:28 PM, Aide A stated he/she was not aware of a policy to direct the application of a HMP on a resident and he/she had not been trained/educated to apply a HMP. Aide A stated he/she informed the charge nurse before preparing and applying the HMP on the resident on 12/31/12 at 1:50 AM. Aide A stated he/she was not aware if the nurse had assessed the resident's skin before, during or after the application of the HMP. On 01/10/13 at 1:04 PM and 2:37 PM, Nurse G stated the resident had no physician's order or care plan to direct the staff to apply a HMP on the resident's right shoulder. Nurse G stated the facility had no policy/procedure to direct the application and monitoring of a HMP on the residents and/or no system in place to appropriately train/educate the staff on the application of a HMP. Nurse G stated the nurses should assess the resident's skin before, during and after the application of a HMP and the time should be monitored to keep the HMP application within the 30 minute safety guidelines. Nurse G further stated the facility should have investigated the resident's burn/blister on 12/31/12 as an injury of unknown origin. The facility failed to check the physician's orders and/or care plan, provide adequate assessments and inappropriately applied, on two separate occasions, a hot moist pack to Resident #1's right shoulder, causing burns and multiple blisters. The facility failed to develop and implement a policy for application of HMP and further failed to train staff on the safe application of HMPs. The facility abated the Immediate Jeopardy, on 01/10/13 at 4:14 PM, when it discontinued the use of the hydrocolator and hot moist packs and established a policy/procedure to train and direct the licensed nursing staff to use warm rice packs as physician ordered and care planned. The facility's Rice Bag Policy directed the nursing staff to obtain a physician's order before applying a warm rice bag on a resident. The policy directed a Licensed Nurse to record the time of the rice bag placement and removal (no longer than 20 minutes) on the treatment record. The policy directed a Licensed Nurse to assess the resident's skin before, during and after the warm rice bag application and document the skin assessment in the nurse's notes. The facility in-serviced their staff on 01/11/13, regarding the policy/procedure for the use of warm rice packs. The facility provided verbal instruction and a written policy and the licensed staff signed off on the in-service form, they understood the process. The deficient practice remains at a scope and severity of a G.