Every finding on record at Bonner Springs Nursing & Rehab Center

Based on observation, interviews, and record review, the facility failed to provide a clean, home-like environment for the residents who resided in the facility. Findings included:- On 06/16/2026 at 08:00 AM, during the facility walk through revealed Resident (R) 3's and R4's rooms had brown sticky stains on the floors. The [NAME] Hall smelled strongly of urine. with a stronger odor next to R2's room, which spread down the hallway. A Personal Protective Equipment (PPE) cart was placed in a cubby hole in the [NAME] Hall; the cart had a blue foam positioner on top of the cart, and on the floor beside the cart. The dining room had dried spilled stains throughout the dining room area. On the East Hall, R5's sink had dark brown rings on the outside of the sink. A hopper on the East Hall had brown standing water inside the hopper with brown substances floating in the water.The Grievance Log dated 02/21/2026 and 02/22/2026 documented multiple families complained that the floors were dirty and the facility had a smell.On 06/16/2026 at 02:10 PM, Administrative Nurse D stated she did not have family members complain about the smell of the facility or the cleanliness of the facility. She stated she did have an outside provider come to her about the smell and the cleanliness of a resident's room. She stated the specific rooms were deep cleaned. She stated the facility's expectations were the sinks, floors and rooms would be clean and the facility would not smell of urine.On 06/16/2026 at 03:00 PM, Administrative Staff A stated the facility had specific rooms on the [NAME] Hall that were known to have odors. She stated the expectation that all residents' rooms would be clean and without a urine smell. The facility's Quality of Life-Home Like Environment policy dated 10/21 documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interviews, observation, and record review, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Residents (R) 1, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. Findings included:- R1 was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) dated 05/12/2026 triggered the CAA for functional abilities (self-care mobility), urinary incontinence, indwelling catheter, pressure ulcer, pain, falls, communication, and psychotropic drug use. All triggered CAA had been completed on 06/05/2026, which was 24 days past due. On 06/16/2026 at 02:10 PM, Administrative Nurse D stated the CAA should be completed within the allotted timetable. Administrative Nurse D stated R1's CAA should have directed the person-centered care plan.The facility's Comprehensive Assessments and the Care Delivery Process policy last revised 12/2016 documented comprehensive assessments would be conducted to assist in the development of the person-centered care plans. Comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on interviews, observation, and record review, the facility failed to develop a person-centered baseline care plan for Resident (R) 1, which included pain management. Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of nerve pain and herpes zoster (shingles- infection characterized by painful skin eruptions following the route of a nerve).The admission Minimum Data Set (MDS) dated 05/12/2026 documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had received opioid medication during the observation period. The MDS documented R1 received pain medication and had not received non-medication interventions during the observation period. The MDS documented R1 had reported frequent pain, occasionally had difficulty sleeping, and limited her day-to-day activities during the observation period related to pain. The MDS lacked a numerical rating for pain intensity for R1.R1's Pain Care Area Assessment (CAA), dated 06/05/2026 documented she triggered for frequent pain.Review of R1's EMR under the Assessment tab lacked a Baseline Care Plan.The facility was unable to provide a Baseline Care Plan for R1 on 06/16/2026 as requested. (R1 was admitted to the facility on [DATE]).Review of R1's EMR under the Care Plan tab revealed a care plan that only addressed R1's code status as Full Code, dated 04/29/2026.R1's EMR under the Orders tab revealed the following physician orders:Oxycodone (opioid) hci oral tablet five milligrams (mg) give one tablet by mouth every six hours as needed for pain dated 04/29/2026.Tramadol (opioid) hcl oral tablet 50 mg give one tablet by mouth every six hours as needed for pain. Do not exceed 400mg daily, dated 04/29/2026.Tylenol (pain reliever) oral tablet 325 mg give two tablets by mouth every six hours as needed for pain, dated 05/02/2026.On 06/16/26 at 09:30 AM, R1 lay on her bed in the lowest position. R1 was covered with a blanket to her chest area as she watched TV. R1 stated she had not received her opioid pain medication a few weeks back. R1 stated the facility was unable to administer her pain medication that relieved the shingles pain in her right ear. R1 stated she had been in pain for two days, waiting for her pain medication.On 06/16/26 at 02:10 PM, Administrative Nurse D stated the baseline care plans should be completed after the resident's admission under the Assessment tab. Administrative Nurse D stated she was unable to locate R1's baseline care plan under the assessment tab.The facility's Baseline Care Plan policy last revised 12/2016 documented a baseline plan of care to meet the resident's immediate needs would be developed for each resident within forty-eight (48) hours of admission.

Based on interviews, observation, and record review, the facility failed to develop a person-centered comprehensive care plan for Resident (R) 1, which included pain management. Findings included:- R1 was admitted on [DATE].R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of nerve pain and herpes zoster (shingles- infection characterized by painful skin eruptions following the route of a nerve).The admission Minimum Data Set (MDS) dated 05/12/2026 documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had received opioid medication during the observation period. The MDS documented R1 received pain medication and did not receive non-medication interventions during the observation period. The MDS documented R1 had reported frequent pain, occasionally had difficulty sleeping, and limited her day-to-day activities during the observation period related to pain. The MDS lacked a numerical rating for pain intensity for R1. R1's Pain Care Area Assessment (CAA), dated 06/05/2026 documented she triggered for frequent pain.R1' Comprehensive Care Plan, documented the following interventions:04/29/2026- Code status: Full code.The comprehensive care plan lacked any direction to nursing staff for pain management for R1. R1 was admitted to the facility for 47 days.R1's EMR under the Orders tab revealed the following physician orders:Oxycodone (opioid) hci oral tablet five milligrams (mg) give one tablet by mouth every six hours as needed for pain dated 04/29/2026.Tramadol (opioid) hcl oral tablet 50 mg give one tablet by mouth every six hours as needed for pain. Do not exceed 400mg daily, dated 04/29/2026.Tylenol (pain reliever) oral tablet 325mg (Acetaminophen) give two tablets by mouth every six hours as needed for pain dated 05/02/2026.On 06/16/2026 at 09:30 AM, R1 laid on her bed in the lowest position. R1 was covered with a blanket to her chest area as she watched TV. R1 stated she had not received her opioid pain medication a few weeks back. R1 stated the facility was unable to administer her pain medication that relieved the shingles pain in her right ear. R1 stated she had been in pain for two days, waiting for her pain medication.On 06/16/2026 at 02:10 PM, Administrative Nurse D stated the comprehensive care plans should be completed after the resident's admission and the completion of the MDS.The facility's Comprehensive Assessments and the Care Delivery Process policy, last revised 12/2016 documented comprehensive assessments would be conducted to assist in the development of the person-centered care plans. Comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on interviews, observation, and record review, the facility failed to ensure staff provided effective pain management as ordered for Resident (R) 1, who received a as needed opioid (a class of medication used to treat pain). Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of nerve pain and herpes zoster (shingles- infection characterized by painful skin eruptions following the route of a nerve).The admission Minimum Data Set (MDS) dated 05/12/2026 documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had received opioid medication during the observation period. The MDS documented R1 received pain medication and had not received non-medication interventions during the observation period. The MDS documented R1 had reported frequent pain, occasionally had difficulty sleeping, and limited her day-to-day activities during the observation period related to pain. The MDS lacked a numerical rating for pain intensity for R1. R1's Pain Care Area Assessment (CAA), dated 06/05/2026 documented she triggered for frequent pain.R1's Care Plan, documented the following interventions:04/29/2026- Code status: Full code.R1's Care Plan lacked any interventions for pain management. R1's EMR under the Orders tab revealed the following physician orders:Oxycodone (opioid) hci oral tablet five milligrams (mg) give one tablet by mouth every six hours as needed for pain dated 04/29/26.Tramadol (opioid) hcl oral tablet 50 mg give one tablet by mouth every six hours as needed for pain. Do not exceed 400 mg daily, dated 04/29/2026.Tylenol (pain reliever) oral tablet 325mg (Acetaminophen) give two tablets by mouth every six hours as needed for pain dated 05/02/2026.Review of R1's Medication Administration Record (MAR) and the Controlled Drug Receipt/Record/Disposition Form provided by the facility reviewed from 04/29/2026 to 06/15/2026 (47 days) revealed R1 had received at least an oxycodone daily with the exception for the following dates 06/07/2026, 06/08/2026, and 06/09/2026. The controlled drug receipt/record/disposition record form dated 05/21/2026 the last dose of oxycodone that was administered was dated 06/06/26. The next sheet dated 06/09/2026 was the date the medication was delivered from the pharmacy.On 06/16/2026 at 09:30 AM, R1 laid on her bed in the lowest position. R1 was covered with a blanket to her chest area as she watched TV. R1 stated she had not received her opioid pain medication a few weeks back. R1 stated the facility was unable to administer her pain medication that relieved the shingle pain in her right ear. R1 stated she had been in pain for the two days, waiting for her pain medication.On 06/16/2026 at 12:51 PM, Licensed Nurse (LN) G stated several residents that received controlled pain medication had been without their medication. LN G stated the medical director only provided the facility with a handwritten prescription for the recording of their controlled medication on the days he made rounds at the facility. LN G stated she was attempting to eliminate that by tracking the as needed use and when the scheduled medication needed to be reordered.On 06/16/2026 at 02:10 PM, Administrative Nurse D stated there had been a few residents that had run out of their pain medications. Administrative Nurse D stated the facility was trying to work with the medical director to shorten the time the pharmacy received the prescription from the physician reordering to being filled by the pharmacy, and the facility received the medication.The facility's Pain Assessment and Management policy last revised 03/2020 documented the purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.

Based on interviews, observation, and record review, the facility failed to ensure the accurate reconciliation of controlled drugs administered to the controlled drug receipt/record/disposition form for Resident (R) 1, who received a as needed opioid (a class of medication used to treat pain). Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of nerve pain and herpes zoster (shingles- infection characterized by painful skin eruptions following the route of a nerve).The admission Minimum Data Set (MDS) dated 05/12/2026 documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had received opioid medication during the observation period. The MDS documented R1 received pain medication and did not receive non-medication interventions during the observation period. The MDS documented R1 had reported frequent pain, occasionally had difficulty sleeping, and limited her day-to-day activities during the observation period related to pain. The MDS lacked a numerical rating for pain intensity for R1. R1's Pain Care Area Assessment (CAA) dated 06/05/2026 documented she triggered for frequent pain.R1's Care Plan documented the following interventions:04/29/2026- Code status: Full code.R1's Care Plan lacked any interventions for pain management. R1's EMR under the Orders tab revealed the following physician orders:Oxycodone (opioid) hci oral tablet five milligrams (mg) give one tablet by mouth every six hours as needed for pain dated 04/29/26.Tramadol (opioid) hcl oral tablet 50 mg give one tablet by mouth every six hours as needed for pain. Do not exceed 400 mg daily, dated 04/29/2026.Tylenol (pain reliever) oral tablet 325mg (Acetaminophen) give two tablets by mouth every six hours as needed for pain dated 05/02/2026.Review of R1's Medication Administration Record (MAR) and the Controlled Drug Receipt/Record/Disposition Form provided by the facility reviewed from 04/29/2026 to 06/15/2026 (47 days) revealed 25 times oxycodone was documented as administered to R1 on the controlled drug receipt/record/ disposition form but was not documented as administered on R1's MAR. The discrepancies were noted for the following dates: 04/29/2026, 05/01/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/12/2026, 05/18/2026, 05/20/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/24/2026 (two times), 05/26/2026, 05/30/2026, 05/31/2026 (two times) 06/01/2026 (two times), 06/04/2026, 06/05/2026, 06/09/2026, 06/13/2026 (two times), and 06/14/2026.On 06/16/2026 at 09:30 AM, R1 laid on her bed in the lowest position. R1 was covered with a blanket to her chest area as she watched TV. R1 stated she had not received her opioid pain medication a few weeks back. R1 stated the facility was unable to administer her pain medication that relieved the shingle pain in her right ear. R1 stated she had been in pain for two days, waiting for her pain medication.On 06/16/2026 at 02:10 PM, Administrative Nurse D stated there probably had been times the nurse had administered R1's oxycodone to treat her pain and forgotten to document the medication on the MAR. Administrative Nurse D stated she had not realized that it had happened as frequently. Administrative Nurse D stated her expectation was the medication was documented on the resident's MAR as it was administered.The facility's Role of the Provider Pharmacy Services policy last reviewed 10/2020 documented the facility would have a written agreement with a provider pharmacy to provide regular and reliable pharmacy services to residents, including medications, services, and related equipment and supplies.

The facility had a census of 34 residents. The sample included 12 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to act upon an identified risk for pressure ulcers and implement preventative interventions for Resident (R) 33, who had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) in her leg and required staff assistance with activities of daily living (ADL). Subsequently, R33 developed a Stage 3 (full-thickness tissue loss) pressure ulcer on her right heel. The facility then failed to involve the Registered Dietitian (RD) for nutritional recommendations to promote wound healing, and also placed the resident at risk for delayed healing or worsened wounds. Findings included: - The Electronic Medical Record (EMR) documented R33 has diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbance of language and communication, and fragmentation of thought), dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), hypertension (high blood pressure), acquired absence of toes (a condition where one or more toes are lost as a result of trauma, infection, vascular disease, tumors or diabetes), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Admission Minimum Data Set (MDS), dated [DATE], documented R33 had severely impaired cognition. R33 required substantial assistance from staff for showers, lower body dressing, personal hygiene, transfers, and partial assistance for mobility. The MDS documented R33 was at risk for pressure ulcers and had no pressure-relieving device for her bed and chair. She had functional impairment on both sides of her upper and lower extremities. The MDS recorded she was not on a turning or repositioning program and had no skin breakdown. The Pressure Ulcer Care Area Assessment (CAA), dated 01/13/25, documented R33 was at risk for skin breakdown due to incontinence episodes and bed mobility, and directed staff to observe and report any skin changes. The Significant Change MDS, dated [DATE], documented R33 had severely impaired cognition. R33 was dependent upon staff for bed mobility, eating, oral hygiene, and lower body dressing. The MDS documented R33 was at risk for pressure ulcers and had no pressure-relieving device for her bed and chair. She had functional impairment on both sides of her upper and lower extremities. R33 had an unhealed Stage 3 pressure ulcer and received pressure ulcer care. The Pressure Ulcer CAA, dated 04/08/25, documented R33 had a pressure ulcer due to a history of pressure ulcers, cognitive loss, incontinence, and pain. R33's skin would be assessed each week, and the physician would be notified of any abnormal findings. The RD would monitor R33's food and fluid intake and implement dietary interventions as necessary. The caregivers would reposition R33 every two hours and as needed for comfort. The CAA further documented a care plan would be initiated to improve the actual pressure ulcer by decreasing size and condition, improving status, and functional ability, and decreasing further pressure ulcer risk. R33's Care Plan, dated 03/23/25, initiated on 01/09/25, documented R33 was assisted with all care and directed staff to assist her with activities, ensure her call light was within reach, and administer medication as ordered. The care plan lacked interventions to prevent skin breakdown. The Braden Scale Assessment (a formal assessment for predicting pressure ulcer risk) dated 01/12/25 documented R33 had a very high risk for developing pressure ulcers. The Braden Scale Assessments dated 01/22/25 and 04/10/25, documented R33 was at high risk for pressure ulcers. The Registered Dietitian Progress Note, dated 03/19/25, documented R33's weight had increased by four pounds and R33 often ate 100% at meals. R33 required meal assistance and had intact skin. The note documented staff were to refer to the RD as needed. The Skin Only Evaluation, dated 03/26/25, documented R33's skin was intact. The Nurse's Note, dated 03/27/25 at 02:31 PM, documented R33 had a fluid-filled blister on her right heel. The note documented that a low-air-loss mattress (a specialized medical mattress that maintains a constant airflow through tiny holes in the mattress surface to help with skin breakdown) was on order, and the wound clinic would evaluate and treat her heel. The note further documented that staff notified the physician and guardian, and R33 was to wear heel protectors while in bed. The Physician's Order, dated 03/27/25, directed staff to apply Skin-prep (liquid skin protectant) daily, and directed staff may place a foam dressing for extra protection to be done daily at bedtime. The order further directed staff to check R33's low-air-loss mattress every shift to ensure it was functioning properly. The order was discontinued on 03/28/28. The Wound Clinic Assessment, dated 03/28/25, documented R33 had a blood/fluid-filled blister on her right heel that was still intact. The assessment documented the blister measured the area at 11.6 centimeters (cm), with a perimeter of 12.9 cm, and was 4.6 cm long, 3.7 cm wide, with a wound volume of 1.70 cm. Staff were ordered to cleanse the wound with wound cleanser, apply Skin-prep to the stable eschar (dead skin), and apply Duoderm (wafer-type moisture-retentive wound dressing used for partial and full thickness wounds leaking fluids) at bedtime on Monday, Wednesday, Friday, and as needed. R33 had edema to her right and left legs, and staff received education on the importance of offloading (removing or keeping pressure off) the area as much as possible. The Physician's Order, dated 03/28/25, directed staff to place heel protectors on R33's feet while in bed every shift. The Skin Only Evaluation, dated 04/02/24, documented R33 had intact skin. The Wound Clinic Assessment, dated 04/04/25, documented R33 had an open wound on her right heel. The assessment documented an area measured 3 cm (length) by 3.6 cm (width) by 1.08 cm (depth). The staff were ordered to continue the current treatment. Staff were educated on the importance of offloading the area as much as possible. The Wound Clinic Assessment, dated 04/11/24, documented R33 had an open wound on her right heel. The assessment documented R33's wound measured 3.9 cm (length) by 3 cm (width) by 0.1 cm (depth), and to continue the current treatment. Staff were provided with education on how to continue to elevate R33's legs due to edema and to continue with the pressure-relieving boots. The Skin Only Evaluation, dated 04/11/24, documented R33 had a Stage 3 pressure ulcer on her right heel. The wound bed had epithelial tissue (new skin growing in a wound), no exudate (the fluid that leaks out of body vessels and tissue), and the undermining (the separation of skin and underlying tissues, creating a space or pocket around the wound edge) was mushy. The Skin Only Evaluation, dated 04/16/24, documented R33 had a Stage 3 pressure ulcer on her right heel. The evaluation noted the wound bed had epithelial tissue, had no exudate, and was mushy. The evaluation documented that protective boots were placed on R33. The EMR for R33's lacked documentation the RD was notified after R33 developed skin breakdown and R33's clinical record lacked evidence of a RD evaluation or recommendation from 03/20/25 through 04/15/25. On 04/14/25 at 02:05 PM, observation revealed R33 laid in her bed, which had a low-air-loss mattress. Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N donned gowns, gloves, and masks. LN G placed a paper towel on the nightstand and laid the Duoderm and Skin-prep on it. LN G asked R33 if she could change the dressing on her heel, and R33 consented. Continued observation revealed R33 wore regular socks and her heels were pressed against the mattress. R33 was not wearing her protective boots. On 04/15/25 at 07:45 AM, observation revealed R33 in the living room area and she did not have her protective boots on. On 04/14/25 at 02:37 PM, Administrative Nurse E stated it was a team effort to ensure interventions were on the care plan, but said it was her responsibility to make sure the care plans were completed. Administrative Nurse E verified there was not a pressure ulcer care plan in place for R33. On 04/15/25 at 09:25 AM, CNA N stated she did not know what caused R33's pressure ulcer. CNA N was unable to say what interventions were put in place before and after R33 developed the pressure ulcer. On 04/15/25 at 9:30 AM, LN G stated R33 did not move her feet, always had her heels directly on the mattress, and she had developed a pressure ulcer. LN G further stated R33 had the pressure-relieving mattress and was supposed to wear the protective boots at all times. LN G verified R33 had not had the protective boots on while in bed. On 04/15/25 at 03:10 PM, Consultant GG stated she went to the facility monthly and had originally recommended Pro-Stat (to support the dietary management of a condition requiring increased protein intake in low volume), but since R33 did not have any skin issues, it was discontinued. Consultant GG stated she expected the facility to contact her for recommendations if a resident had a change in their skin condition. On 04/16/25 at 09:06 AM, Dietary Staff BB stated she was unaware R33 had skin breakdown and verified R33 was not receiving any additional protein in her diet or any type of supplement for wound healing. On 04/16/25 at 01:00 PM, Administrative Nurse D stated they should have interventions put into place to prevent R33's pressure ulcer. Administrative Nurse D stated she would work with the RD for recommendations for healing the pressure ulcer. The facility's Pressure Injuries undated policy, documented that any area caused by unrelieved pressure resulting in damage of underlying tissue was a pressure ulcer. Pressure ulcers are usually located over bony prominences and are classified by stage to describe the degree of tissue damage. Assessment and documentation must appear in the medical record if the resident's pressure ulcer is unavoidable. Routine preventative care means proper positioning and repositioning, application of pressure reduction or relief devices, providing good skin care, and maintaining adequate nutrition and hydration.

The facility had a census of 34 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for inadequate nurse staff. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter (Q) 2 indicated no licensed nurse coverage on nine dates. The PBJ for FY 2024 Q4 recorded no licensed nurse coverage on six dates. The PBJ for FY 2025 Q1 recorded no licensed nurse coverage on eleven dates. Review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day, seven days a week. On 04/15/24 at 10:00 AM, Administrative Staff B stated she did the scheduling for the nursing staff but did not submit the information for the PBJ report. Administrative Staff B stated she always scheduled a nurse from 6:00 AM- 06:00 PM and then a nurse from 06:00 PM- 06:00 AM. She had the availability of agency staff and there has always been a nurse scheduled for each of the 12-hour shifts. On 04/15/25 at 04:45 PM, Administrative Nurse A stated the corporate team submitted the PBJ. Administrative Staff A stated there was always a nurse in the building. The facility's Report Direct-Care Staffing Information (Payroll-Based Journal) policy, dated 10/21 documented staffing and census information would be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Direct care staffing information included staff hired directly by the facility, those hired through an agency, and contract employees. The facility failed to submit complete and accurate staffing information through PBJ as required. This deficient practice placed the residents at risk for inadequate nurse staff.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that met quarterly and had the required membership in attendance. The facility failed to maintain a QA&A Committee that met quarterly and had the required membership in attendance. Findings included: - The facility provided QA&A committee attendance roster for 09/11/24 only. On 04/16/25 at 01:23 PM, Administrative Staff A provided the signature sheet for the meeting held on 09/11/24. Administrative Staff A stated that they had also had a QA&A meeting on 04/20/25 but did not have the attendance sheet available. Administrative Staff A stated they are meeting monthly, and the Medical Director would attend the meetings quarterly. Administrative Staff A stated they had started working through the areas that were lacking direction and were working hard to get the facility in good standing as they had gone through a lot of administrative staff. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy, dated 10/21, documented the committee meets monthly to review reports, evaluate data, monitor QAPI-related activities, and make adjustments to the plan. The QAPI committee oversees the implementation of the QAPI Plan, which is the written component describing the specifics of the QAPI program, how the facility would conduct its QAPI functions, and the activities of the QAPI committee.

The facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility. Findings included: - Review of the facility Infection Control Surveillance Log for tracking and trending infections from January 2024 through March 2025, lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated for February 2024, April 2024, May 2024, September 2024, November 2024, and December 2024. On 04/16/25 at 12:50 PM, Administrative Nurse D stated when she took over the infection control program, she was made aware that the previous infection preventionist had not been completing the monthly antibiotic stewardship surveillance logs. The interdisciplinary team has a Performance Improvement Project (PIP) in place for the infection control program. The Antibiotic Stewardship policy dated October 2021 documented that antibiotics would be prescribed and administered to residents and the guidance of the facility's antibiotic stewardship program. The purpose of the program was to monitor the use of antibiotics in the residents. The Surveillance for Infections policy dated October 2021 documented the purpose of the surveillance of infections was to identify both individual cases and trends of epidemiologically (in a manner relating to the branch of medical science concerned with the occurrence, transmission, and control of epidemic diseases) significant organisms and health-associated infections, to guide appropriate interventions, and to prevent future infections. Infections would be included in routine surveillance, including those with evidence of transmissibility (the ease with which a disease or other agent can be transmitted from one individual to another) in a healthcare environment; the available processes and procedures that prevent or reduce the spread of infection; clinically significant morbidity or mortality associated with infection; and pathogens (a living organism that can cause disease in another organism) associated with serious outbreaks.

- R36's Electronic Medical Record (EMR) documented diagnoses of type 2 diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and neoplasm (tumor) of the lung. R36's admission Minimum Data Set (MDS) dated 12/17/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R36 needed set-up to partial assistance from staff for his functional abilities. R36 used a walker to assist with ambulation. R36's overall goal was to discharge to the community within three months or less. R36's Discharge MDS dated 01/21/25 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R36's Entry MDS dated 01/24/25 documented a re-entry to the facility from an unlisted facility. The facility could not provide a written notification of transfer and notification to the ombudsman for this facility-initiated discharge as requested. R36's Discharge MDS dated 02/01/25 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. The facility was unable to provide a written notification of transfer and notification to the ombudsman for R36's facility-initiated discharge as requested. On 04/15/24 at 09:39 AM, Administrative Staff A and Social Services X stated that the facility had a Performance Improvement Project (PIP) in place to begin doing the bed holds, written notification, and notification to the ombudsman. Administrative Staff A stated it had been discovered that those had not been completed by previous administrative staff as required. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfer, written information would be given to the residents and the resident representative the details of the notified, per the Notice of Transfer to explain the rights and limitations of the resident. The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a written notice for a facility-initiated transfer for Resident (R) 2, R6, R21, and R36 or their representatives when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of R2, R6, R21, and R36. This placed the residents at risk for uninformed care choices and impaired rights. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension, (high blood pressure), anxiety, (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two. The admission Minimum Data Set (MDS), dated [DATE], documented R2 had moderately impaired cognition. R2 required supervision with ambulation and showers. R2 was independent with mobility, personal hygiene, and dressing. The Quarterly MDS, dated 02/26/25, documented R2 had intact cognition. R2 required supervision with mobility and ambulation. R2 was independent with toileting, personal hygiene, and dressing. R2's Care Plan, dated 03/23/25, initiated on 11/23/24, directed staff to administer medications as ordered, encourage participation in self-calming behaviors such as breathing exercises, meditation, and evaluate verbal expression of fear. R2's Progress Notes, dated 03/19/25 at 10:30 AM, documented R2 called 911 independently and stated he needed to go to the hospital. The progress note documented when the ambulance arrived R2 was having difficulty breathing and he had not told the nurse. Oxygen was placed on R2 and he was transferred to the hospital. R2's clinical record lacked evidence the resident, the resident's representative was provided a written notice, or the LTCO was notified of the hospital transfer. On 04/15/25 at 09:10 AM, observation revealed R2 came out of his room with his water pitcher and asked for more water. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R2 or his representative written notice of his transfer to the hospital and had not notified the LTCO of the hospital transfer. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had educated her staff to provide written notice of transfer to the resident or representative at the time of transfer. Administrative Nurse D further stated that if there was an emergency, staff were to contact the representative by phone and document it in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfer, written information would be given to the residents and the resident representative the details of the notified, per the Notice of Transfer to explain the rights and limitations of the resident. - The Electronic Medical Record (EMR) for R6 documented diagnoses of diastolic heart failure (occurs when the heart's left ventricle stiffens and can't fill properly), chronic kidney disorder (severe kidney damage), hypertension (high blood pressure), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type one. The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition. R6 required staff su[ervision for personal hygiene, lower body dressing, and transfers. R6 was independent with upper body dressing and mobility. R6 received insulin (a hormone produced by the pancreas that regulates blood glucose levels) daily. The Quarterly MDS, dated 03/07/25, documented R6 had intact cognition. R6 required supervision from staff with transfers, and personal hygiene, lower body dressing. R6 was independent with upper body dressing, and mobility. R6 received insulin daily. R6's Care Plan, dated 03/25/25, initiated on 11/14/19, directed staff to administer medications as ordered and monitor for any side effects and effectiveness. The update, dated 09/10/24, directed staff to impress upon R6 the importance of letting staff know when the chest pain had started and to monitor his vital signs (measurements of basic bodily functions that indicate how well a person's body is working). R6's Progress Notes, dated 02/23/25 at 09:55 PM, documented R6 was having difficulty speaking and was short of breath. Staff obtained R6's vital signs, his oxygen saturation (percentage of oxygen in the blood) was 85% (normal is 95% to 100%) and was placed on oxygen. R6 was transferred to the hospital. R6's clinical record lacked evidence the resident, the resident's representative was provided written notice, or the ombudsman was notified of the hospital transfer. R6's Progress Notes, dated 03/04/25 at 12:15 PM, documented R6 returned the hospital. R6's Progress Notes, dated 04/10/24 at 11:02 AM, documented R6 was transferred to the hospital due to low oxygen saturation and shortness of breath. R6's clinical record lacked evidence the resident, the resident's representative was provided written notice, or the ombudsman was notified of the hospital transfer. R6's Progress Notes, dated 04/13/25 at 12:29 PM, documented R6 returned from the hospital. On 04/15/25 at 08:20 AM, observation revealed R6 sat in his wheelchair and received his morning medication without difficulty. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R6 or his representative written notice of his transfer to the hospital and had not notified the LTCO of the hospital transfer. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had educated her staff to provide written notice of transfer to the resident or representative at the time of transfer. Administrative Nurse D further stated that if there was an emergency, staff were to contact the representative by phone and document it in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfer, written information would be given to the residents and the resident representative the details of the notified, per the Notice of Transfer to explain the rights and limitations of the resident. - The Electronic Medical Record (EMR) for R21 documented diagnoses of heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R21 had intact cognition. R21 was dependent upon staff for transfers and toileting and required substantial staff assistance for showers, dressing, and personal hygiene. R21 received pain medication and was on supplemental oxygen daily. The Significant Change MDS, dated 02/26/25, documented R21 had intact cognition. R21 required substantial assistance from staff for showers, lower body dressing, mobility, and personal hygiene. R21 received pain medication and was on supplemental oxygen daily. R21's Care Plan, dated 03/23/25, initiated on 09/22/22, documented R21 had chronic pain and directed staff to administer medication as ordered. Staff were directed to anticipate her need for pain relief and evaluate the effectiveness of the medication. The update, dated 02/25/25, directed staff to monitor her oxygen saturation every eight hours and maintain her oxygen saturation at or above 92%. R21's Progress Notes, dated 02/11/25 at 04:32 AM, documented R21 felt that she was filling up with fluid and requested to be transferred to the hospital. R21 was told that if she went to the hospital she would be discharged from hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. R21 stated she no longer wanted to be on hospice and wanted to go to the hospital. The family and Hospice were notified and R21 was transferred to the hospital. R21's clinical record lacked evidence the resident or representative was provided written notice or LTCO was notified of the hospital transfer. R21's Physician's Order, dated 02/25/25, directed staff to monitor her oxygen saturation every eight hours and may use one liter of oxygen via nasal cannula (a medical device used to deliver supplemental oxygen to a patient) to maintain her oxygen saturation of above 92%. On 04/15/25 at 12:15 PM, observation revealed R21 laid in bed,waiting for lunch. She wore her nasal cannula. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R21 or her representative written notice of her transfer to the hospital and had not notified the LTCO of the hospital transfer. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had now educated her staff to provide written notice of transfer to the resident or representative at the time of transfer. Administrative Nurse D further stated, if it is an emergency, staff are to contact the representative by phone and documented in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfer, written information would be given to the residents and the resident representative the details of the notified, per the Notice of Transfer to explain the rights and limitations of the resident.

The facility had a census of 34 residents. The sample included 12 residents with five reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide four residents, Resident (R) 2, R6, R21, and R36 with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two. The admission Minimum Data Set (MDS), dated [DATE], documented R2 had moderately impaired cognition. R2 required supervision with ambulation and showers. R2 was independent with mobility, personal hygiene, and dressing. The Quarterly MDS, dated 02/26/25, documented R2 had intact cognition. R2 required supervision with mobility and ambulation. R2 was independent with toileting, personal hygiene, and dressing. R2's Care Plan dated 03/23/25, initiated on 11/23/24, directed staff to administer medications as ordered, encourage participation in self-calming behaviors such as breathing exercises, meditation, and evaluate verbal expression of fear. R2's Progress Notes dated 03/19/25 at 10:30 AM documented R2 called 911 independently and stated he needed to go to the hospital. The progress note documented when the ambulance arrived R2 was having difficulty breathing and stated he had not told the nurse. Oxygen was placed on R2, and he was transferred to the hospital. R2's clinical record lacked evidence a copy of the bed hold policy was provided to the resident or representative when he was transferred to the hospital. On 04/15/25 at 09:10 AM, observation revealed R2 came out of his room with his water pitcher and asked for more water. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R2 or his representative the written bed hold notice when he went to the hospital. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had now educated her staff to provide written notice of transfer to the resident or representative at the time of transfer and the bed hold policy. Administrative Nurse D further stated, that if it is an emergency, staff were to contact the representative by phone and document in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfers and therapeutic leaves, residents or residents' representative would be informed in writing of the bed-hold and return policy. Prior to or at the time of discharge, written information would be given to the resident and the resident representative that explained in detail the rights and limitations of the resident regarding bed-holds. The details of the transfer and a copy of the bed hold agreement. - The Electronic Medical Record (EMR) for R6 documented diagnoses of diastolic heart failure (occurs when the hearts left ventricle stiffens and can't fill properly), chronic kidney disorder (severe kidney damage), hypertension (high blood pressure), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type one. The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition. R6 required supervision of staff for personal hygiene, lower body dressing, and transfers. R6 was independent with upper body dressing, and mobility. R6 received insulin (a hormone produced by the pancreas that regulates blood glucose levels) medication daily. The Quarterly MDS, dated 03/07/25, documented R6 had intact cognition. R6 required supervision from staff with transfers, and personal hygiene, lower body dressing. R6 was independent with upper body dressing, and mobility. R6 received insulin medication daily. R6's Care Plan dated 03/25/25, initiated on 11/14/19, directed staff to administer medications as ordered, and monitor for any side effects, and effectiveness. The update, dated 09/10/24, directed staff to impress upon R6 the importance of letting staff know when the chest pain has started and to monitor his vital signs (measurements of basic bodily functions that indicate how well a person's body is working). R6's Progress Notes, dated 02/23/25 at 09:55 PM, documented R6 was having difficulty speaking and was short of breath. Staff obtained his vital signs, and his oxygen saturation (percentage of oxygen in the blood) was 85% (normal is 95% to 100%), and was placed on oxygen. R6 was transferred to the hospital. R6's clinical record lacked evidence a copy of the bed hold policy was provided to the resident or representative when he was transferred to the hospital. R6's Physician's Order, dated 02/25/25, directed staff to monitor her oxygen saturation every eight hours and may use 1 Liter of oxygen via nasal cannula (a medical device used to deliver supplemental oxygen to a patient) to maintain her oxygen saturation of above 92%. R6's Progress Notes, dated 03/04/25 at 12:15 PM, documented R6 return from the hospital. R6's Progress Notes, dated 04/10/24 at 11:02 AM, documented R6 was transferred to the hospital due to low oxygen saturation and shortness of breath. R6's clinical record lacked evidence the resident or representative was provided written notice, or the ombudsman was notified of the hospital transfer. R6's Progress Notes, dated 04/13/25 at 12:29 PM, documented R6 returned from the hospital. On 04/15/25 at 08:20 AM, observation revealed R6 sat in his wheelchair and received his morning medication without difficulty. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R6 or his representative the written bed hold notice when he went to the hospital. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had now educated her staff to provide written notice of transfer to the resident or representative at the time of transfer and the bed hold policy. Administrative Nurse D further stated, that if it is an emergency, staff are to contact the representative by phone and documented in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfers and therapeutic leaves, residents or residents' representative would be informed in writing of the bed-hold and return policy. Prior to or at the time of discharge, written information would be given to the resident and the resident representative that explained in detail the rights and limitations of the resident regarding bed-holds. The details of the transfer and a copy of the bed hold agreement. - The Electronic Medical Record (EMR) for R21 documented diagnoses of heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R21 had intact cognition. R21 was dependent upon staff for transfers and toileting; and required substantial staff assistance for showers, dressing, and personal hygiene. R21 received pain medication and was on supplemental oxygen daily. The Significant Change MDS, dated 02/26/25, documented R21 had intact cognition. R21 required substantial assistance from staff for showers, lower body dressing, mobility, and personal hygiene. R21 received pain medication and was on supplemental oxygen daily. R21's Care Plan dated 03/23/25, initiated on 09/22/22, documented R21 had chronic pain and directed staff to administer medication as ordered. Staff were directed to anticipate her need for pain relief and evaluate the effectiveness of the medication. The update, dated 02/25/25, directed staff to monitor her oxygen saturation every eight hours and to maintain her oxygen saturation at above 92%. R21's Progress Notes, dated 02/11/25 at 04:32 AM, documented R21 felt that she was filling up with fluid and requested to be transferred to the hospital. R21 was told that if she went to the hospital she would be discharged from Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. R21 stated she no longer wanted to be on Hospice and wanted to go to the hospital. The family and Hospice were notified and R21 was transferred to the hospital. R21's clinical record lacked evidence a copy of the bed hold policy was provided to the resident or representative when she was transferred to the hospital. On 04/15/25 at 12:15 PM, observation revealed R21 in bed, 02 as ordered, and waiting for lunch. On 04/15/5 at 10:00 AM, Social Service X stated she had not provided R21 or her representative the written bed hold notices when she went to the hospital. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had now educated her staff to provide written notice of transfer to the resident or representative at the time of transfer and the bed hold policy. Administrative Nurse D further stated, that if it is an emergency, staff are to contact the representative by phone and documented in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfers and therapeutic leaves, residents or residents' representative would be informed in writing of the bed-hold and return policy. Prior to or at the time of discharge, written information would be given to the resident and the resident representative that explained in detail the rights and limitations of the resident regarding bed-holds. The details of the transfer and a copy of the bed hold agreement. - R36's Electronic Medical Record (EMR) documented diagnoses of Type 2 diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and neoplasm (tumor) of the lung. R36's admission Minimum Data Set (MDS) dated 12/17/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R36 needed set-up to partial assistance from staff for his functional abilities. R36 used a walker to assist with ambulation. R36's overall goal was to discharge to the community within three months or less. R36's Discharge MDS dated 01/21/25 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. R36's Entry MDS dated 01/24/25 documented a re-entry to the facility from an unlisted facility. The facility failed to provide a bed hold for this facility-initiated discharge as requested. R36's Discharge MDS dated 02/01/25 documented an unplanned discharge to an inpatient psychiatric facility with a return anticipated. The facility failed to provide a bed hold for R36's facility-initiated discharge as requested. R36's Functional Abilities Care Area Assessment (CAA) dated 01/07/24 documented he required a varied level of assistance with care needs due to respiratory failure, malignant neoplasm of lung, and DM. Therapy was involved and the resident plans to return home. R36's Care Plan, initiated on 12/30/24, directed staff that his goal was to work with physical and occupational therapy to return to independent functioning at home. On 04/15/24 at 09:39 AM, Administrative Staff A and Social Services X stated that the facility had a Performance Improvement Project (PIP) in place to begin doing the bed holds, written notification, and notification to the ombudsman. Administrative Staff A stated it had been discovered that those had not been completed by previous administrative staff as required. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she had now educated her staff to provide written notice of transfer to the resident or representative at the time of transfer and the bed hold policy. Administrative Nurse D further stated, that if it is an emergency, staff are to contact the representative by phone and documented in the medical record. The facility's Bed-Holds and Returns policy, dated 10/21, documented, prior to or at the time of transfers and therapeutic leaves, residents or residents' representative would be informed in writing of the bed-hold and return policy. Prior to or at the time of discharge, written information would be given to the resident and the resident representative that explained in detail the rights and limitations of the resident regarding bed-holds. The details of the transfer and a copy of the bed hold agreement.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions to prevent pressure ulcers for one resident, Resident (R) 33. This placed the resident at risk for unmet care needs and skin breakdown. Findings included: - The Electronic Medical Record (EMR) documented R33 has diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbance of language and communication, and fragmentation of thought), dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), hypertension (high blood pressure), acquired absence of toes (a condition where one or more toes are lost as a result of trauma, infection, vascular disease, tumors or diabetes), and peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Admission Minimum Data Set (MDS), dated [DATE], documented R33 had severely impaired cognition. R33 required substantial assistance from staff for showers, lower body dressing, personal hygiene, transfers, and partial assistance for mobility. The MDS documented R33 was at risk for pressure ulcers, had no pressure relieving device for bed and chair, upper and lower functional impairment on both sides, and no turning or repositioning program. R33 had no skin breakdown. The Pressure Ulcer Care Area Assessment (CAA), dated 01/13/25, documented R33 was at risk for skin breakdown due to incontinent episodes and bed mobility, and directed staff to observe and report any skin changes. The Significant Change MDS, dated [DATE], documented R33 had severely impaired cognition. R33 was dependent upon staff for bed mobility, eating, oral hygiene, and lower body dressing. R33 was at risk for pressure ulcers, had pressure relieving devices for her bed and chair, and had no turning or repositioning program. R33 had an unhealed Stage 3 pressure ulcer and received pressure ulcer care. The Pressure Ulcer CAA, dated 04/08/25, documented R33 had a pressure ulcer due to a history of pressure ulcers, cognitive loss, incontinence, and pain. R33's skin would be assessed each week and the physician would be notified of any abnormal findings, The RD would monitor R33's food and fluid intake and implement dietary interventions as necessary. The caregivers would reposition R33 every two hours and as needed for comfort. The CAA further documented a care plan would be initiated to improve the actual pressure ulcer by decreasing size and condition, improving current status, and functional ability, and decreasing further pressure ulcer risk. R33's Care Plan lacked a care area with interventions for skin breakdown. The Braden Scale Assessment, (formal assessment for predicting pressure ulcer risk) dated 01/12/25, documented R33 had a very high risk for developing pressure ulcers. The Braden Scale Assessments, dated 01/22/25 and 04/10/25, documented R33 was a high risk for pressure ulcers. The Skin Only Evaluation, dated 03/26/25, documented R33's skin was intact. The Nurse's Note, dated 03/27/25 at 02:31 PM, documented R33 had a fluid-filled blister on her right heel. A low air-loss mattress (a specialized mattress designed to prevent skin breakdown and pressure ulcers by continuously circulating air through the mattress surface, creating a cool and dry environment). As on order, the wound clinic would evaluate and treat her heel. The note further documented the physician and guardian had been notified and R33 was to wear heel protectors while in bed. The Physician's Order, dated 03/27/25, directed staff to apply Skin prep (liquid skin protectant) daily, and may use a foam dressing for extra protection to be done daily at bedtime. The order further directed staff to check her low air loss mattress every shift to ensure it was functioning properly. The order was discontinued on 03/28/28. The Physician's Order, dated 03/28/25, directed staff to place heel protectors on R33's feet while in bed every shift. The Wound Clinic Assessment, dated 03/28/25, documented R33 had a blood/fluid-filled blister on her right heel that was still intact. The assessment documented the blister measured the area at 11.6 centimeters (cm), perimeter 12.9 cm, 4.6 cm long, and 3.7 cm wide, with a wound volume of 1.70 cm. Staff were ordered to cleanse the wound with wound cleanser, skin prep to stable eschar (dead skin), apply duoderm (wafer-type moisture-retentive wound dressing used for partial and full thickness wounds leaking fluids) at bedtime on Monday, Wednesday, Friday, and as needed. R33 had edema to her right and left leg and educated staff on the importance of offloading (removing or keeping pressure off) the area as much as possible. The Skin Only Evaluation, dated 04/02/25 documented R33 had intact skin. The Wound Clinic Assessment, dated 04/04/25, documented R33 had an open wound on her right heel. The assessment documented area measured 3 cm x 3.6 cm x 1.08 cm. The staff were ordered to continue the current treatment. Staff were education on the importance of offloading the area as much as possible. The Wound Clinic Assessment, dated 04/11/24, documented R33 had an open wound on her right heel. The assessment documented R33's wound measured 3.9 cm x 3 cm x 0.1 cm and to continue current treatment. Staff were provided with education to continue to elevate R33's legs due to edema and to continue with the pressure-relieving boots. The Skin Only Evaluation, dated 04/11/25, documented R33 had a pressure ulcer on her right heel that was a stage 3. The wound bed had epithelial tissue (new skin growing in a wound), no exudate (the fluid that leaks out of body vessels and tissue), and the undermining (the separation of skin and underlying tissues, creating a space or pocket around the wound edge) was mushy. The Skin Only Evaluation, dated 04/16/25, documented R33 had a pressure ulcer on her right heel that was a stage 3. The wound bed had epithelial tissue and no exudate was mushy. The evaluation documented protective boots were in place. On 04/14/25 at 02:05 PM AM, observation revealed R33 in bed, she had a low air-loss mattress on her bed. Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N gowned, gloved, and masked. LN G placed a paper towel on the nightstand and laid the duoderm and skin prep on it. She asked R33 if she could change the dressing on her heel. R33 responded, Ok. LN G told R33 that this Surveyor needed to look at her heel and pulled down R33's blanket. R33 had regular socks on, and her heels pressed against the mattress, she did not have her protective boots on. R33 began to scream, NO, NO, NO loudly. LN G stated, Can we please look at your heel? R33 stated, NO! LN G stated, Do you want to hold your baby doll while we look at your heel? R33 screamed loudly. LN G pulled R33's blanket back up and stated, Her dressing is usually changed in the evening at bedtime. On 04/14/25 at 02:37 PM, Administrative Nurse E stated it was a team effort to provide interventions on the care plan but it was her responsibility to make sure the care plans were completed. Administrative Nurse E verified that there was not a pressure ulcer care plan in place. On 04/15/25 at 07:45 AM, observation revealed R33, in in the living room area, with regular socks and shoes on. On 04/15/25 at 09:25 AM, CNA N stated she did not know what had caused R33's pressure ulcer and was unable to tell me what interventions were put into place prior to and after she developed the pressure ulcer. On 04/15/25 at 9:30 AM, LN G stated R33 did not move her feet and were always planted with her heels on the mattress, and she developed the pressure ulcer. LN G further stated she has the pressure relieving mattress and was supposed to wear the protective boots at all times and verified R33 had not had them on while in bed. On 04/15/25 at 03:10 PM, Consultant GG stated she went to the facility monthly and had originally recommended Pro-Stat (to support the dietary management of a condition requiring increased protein intake in low volume) but since R33 did not have any skin issues, it was discontinued. Consultant GG stated she expected the facility to contact her for recommendations if a resident had a change in their skin condition. On 04/16/25 at 09:06 AM, Dietary BB stated she was unaware R33 had skin breakdown and verified R33 was not receiving any additional protein in her diet or any type of supplement for wound healing. On 04/16/25 at 09:45 AM, LN G stated R33 refused to have the dressing changed. On 04/16/25 at 01:00 PM, Administrative Nurse D stated that they should have interventions put into place to prevent her pressure ulcer. Administrative Nurse D stated that she would work with the RD for recommendations for healing of the pressure ulcer. The facility's Care Planning-Interdisciplinary Team policy, dated 08/11/21, documented the team was responsible for the development of an individualized comprehensive care plan for each resident. The care plan was developed within seven days of completion of the resident assessment.

The facility identified a census of 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that the physician responded to the recommendations made by the Consultant Pharmacist (CP) to ensure that Resident (R) 23's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Seroquel had an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use. These deficient practices placed R23 at risk of unnecessary medication administration and related complications. Findings included: - R23's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and symptoms involving emotional state (the feelings and mood an individual experiences, such as happiness, sadness, anger, fear, or anxiety). R23's Significant Change Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R23 was independent with his functional abilities and used a walker to assist with ambulation. R23 received an antipsychotic on a routine basis. R23's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/08/24 documented he received an antipsychotic and antianxiety (a class of medications that calm and relax people) medications to treat anxiety and mood impairment. A gradual dose reduction (GDR) had not been recommended by the physician since admission. R23's Care Plan revised on 07/25/24 directed staff to administer medications as ordered. Staff were to monitor and document side effects. Staff were directed to monitor his behaviors every shift. When R23 would become agitated, staff were directed to intervene before the agitation escalated. Staff were directed to guide the resident away from the source of distress. R23's Orders tab of the EMR documented an active order dated 09/13/24 for quetiapine (Seroquel an antipsychotic medication) 200 milligrams (mg) to be given by mouth at bedtime for mood management. A 04/24/24 Note to Attending Physician/Prescriber for R23 documented the CP's recommendation that R23 received the antipsychotic agent Seroquel but lacked an allowable diagnosis to support the use. If continued use of this medication for the indication currently listed in the chart was warranted, please provide a clinical rationale. The physician failed to respond to the CP recommendation. On 04/15/25 at 09:15 AM, R23 ambulated with his walker down the hall. On 04/16/25 at 12:50 PM, Administrative Nurse D stated administrative staff had noticed that in the past that the previous physician had not been addressing the CP recommendation as they should have been. Administrative Nurse D stated that she, along with other administrative staff were working with the physicians and pharmacy to ensure that the recommendations were being addressed promptly. The facility's Medication Regimen Reviews (MRR) policy, revised on October 2024 documented that the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involved a thorough review of the resident's medical record to prevent, identify, report, and resolve medication-related problems, medication errors, and other irregularities such as medications ordered in excessive doses or without clinical indication. Within 24 hours of the MRR, the Consultant Pharmacist provided a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. If the attending physician did not provide a timely or adequate response, or the CP identified that no action had been taken, he/she would contact the medical director or the administrator. The attending physician documented in the medical record that the irregularity had been reviewed and what action had been taken to address it. The CP provided the director of nursing services and the medical director with a written, signed, and dated copy of all medication regimen reports. Copies of MRR, including physician responses, were maintained as part of the permanent medical record.

The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for two residents, Resident (R) 8 and R21. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of pain, traumatic brain injury (TBI - an injury to the brain caused by external forces), dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and hypertension (high blood pressure). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent upon staff for all activities of daily living (ADL) and did not ambulate. R8 received diuretic (a medication to promote the formation and excretion of urine), antidepressant (a class of medication used to treat mood disorders), and insulin (a hormone produced by the pancreas that regulates blood glucose levels) medication daily. R8's Care Plan 04/11/25, initiated on 01/22/24, directed staff to administer his blood pressure medication as ordered and monitor for potential side effects. The care plan directed staff to monitor the blood pressure according to the physician's instructions, accurately record blood pressure readings, and promptly notify the physician if readings fall outside the target range or if a significant change occurs. The Physician's Order, dated 03/18/23, directed staff to administer losartan (high blood pressure medication), 100 milligrams (mg), one tablet, by mouth, daily, for hypertension. Hold the medication if the systolic blood pressure (SBP - the top number, the force your heart exerts on the walls of your arteries) was less than 110 millimeters of mercury (mmHg) or if the heart rate was less than 65 beats per minute (bpm). The Physician's Order, dated 08/22/24, directed staff to administer amlodipine (high blood pressure medication), 10 mg, one tablet, by mouth, daily for hypertension. Hold the medication if the SBP was less than 110 or his heart rate was less than 60 bmp. The Physician's Order, dated 03/04/25, directed staff to administer Coreg (high blood pressure medication), 3.125 mg, one tablet, by mouth, twice per day, for hypertension. Hold for SBP less than 110 or heart rate less than 60 bpm. R8's Medication Administration Record (MAR) for March and April 2025 documented the following days R8 received the losartan when his heart rate was under the ordered parameters: 03/14/25 - 58 bpm 03/21/25 - 56 bpm 03/22/25 - 57 bpm 04/10/25 - 58 bpm 04/15/25 - 55 bpm R8's MAR for March and April 2025 documented the following days R8 received the amlodipine when his heart rate was under the ordered parameters: 03/11/25 - 53 bpm 03/14/25 - 58 bpm 03/21/25 - 56 bpm 03/22/25 - 57 bpm 04/10/25 - 58 bpm 04/13/25 - 54 bpm 04/15/25 - 55 bpm R8's MAR for March and April 2025 documented the following days R8 received the Coreg when his heart rate was under the ordered parameters: 03/11/25 - 57 bpm 03/13/25 - 55 bpm 03/14/25 - 58 bpm 03/21/25 - 56 bpm 03/22/25 - 57 bpm 04/15/25 - 55 bpm On 04/15/25 at 09:20 AM, observation revealed Certified Medication Aide (CMA) R took R8's blood pressure and heart rate. CMA R administered all of R8's medication and stated he was to hold the blood pressure medications if the SBP was less than 110. R8's heart rate was 55 and CMA R had not realized he should have held the blood pressure medication due to R8's low heart rate. On 04/16/25 at 10:16 AM, Licensed Nurse (LN) G stated the CMAs were supposed to tell her when a resident's vital signs were out of the physician-ordered parameter because some orders directed that the physician was to be notified. LN G stated she would follow up with R8 and the physician regarding the low heart rate. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she expected staff to follow the physician's orders and hold the medication when the vital signs were out of parameters. The facility's Medication Therapy policy, dated 10/24, documented each resident's medication regimen should include only those medications necessary to treat existing conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatment. All medication orders would be supported by appropriate care processes and practices. - The Electronic Medical Record (EMR) for R21 documented diagnoses of heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and pain. The Significant Change MDS, dated [DATE], documented R21 had intact cognition. R21 required substantial assistance from staff for showers, lower body dressing, mobility, and personal hygiene. R21 received antianxiety (a class of medications that calm and relax people), antidepressant (a class of medication used to treat mood disorders), diuretic (a medication to promote the formation and secretion of urine), pain, and anticoagulant (a class of medications used to prevent the blood from clotting) daily. R21's Care Plan dated 03/23/25, initiated on 09/23/23, directed staff to administer medications as ordered and to monitor for side effects and effectiveness. The Physician's Order, dated 12/04/24, directed staff to administer, metoprolol tartrate (a medication used for high blood pressure), 25 milligrams (mg), one tablet, by mouth twice a day, for hypertension. Hold the medication if the systolic blood pressure (SBP - the top number, the force your heart exerts on the walls of your arteries less than 110 millimeters of mercury (mmHg) or if the pulse is less than 65 beats per minute (bpm). R21's Medication administration Record (MAR) for March 2025 documented the following days R21 received the metoprolol when the SBP was under the ordered parameters: 03/16/25 - 102/63 mmHg 03/17/25 - 108/64 mmHg 03/21/25 - 105/61 mmHg 03/23/25 - 107/75 mmHg 03/26/25 - 98/56 mmHg R21's Medication Administration Record (MAR) for April 2025 documented the following days R21 received the metoprolol when the SBP was under the ordered parameters: 04/02/25 - 99/56 mmHg AM dose 04/02/25 - 95/60 mmHg PM dose 04/03/25 - 92/61 mmHg PM dose 04/04/25 - 106/78 mmHg AM dose 04/11/25 - 102/64 mmHg AM dose On 04/15/25 at 12:15 PM, observation revealed R21 in bed, 02 on, and waiting for lunch. On 04/16/25 at 10:16 AM, Licensed Nurse (LN) G stated the CMAs were supposed to tell her when a resident's vital signs were out of the physician-ordered parameter because some orders directed that the physician was to be notified. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she expected staff to follow the physician's orders and hold the medication when the vital signs were out of parameters. The facility's Medication Therapy policy, dated 10/24, documented each resident's medication regimen should include only those medications necessary to treat existing conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatment. All medication orders would be supported by appropriate care processes and practices.

The facility identified a census of 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate diagnosis or a physician's statement of the risk versus benefit for the continued use of Seroquel (antipsychotic medication-a class of medications used to treat major mental conditions that cause a break from reality). These deficient practices placed R23 at risk of unnecessary medication administration and related complications. Findings included: - R23's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), encephalopathy (a broad term for any brain disease that alters brain function or structure), chronic obstruction pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), systolic heart failure, hypertension (HTN - elevated blood pressure), dysphagia (swallowing difficulty), and symptoms involving emotional state (the feelings and mood an individual experiences, such as happiness, sadness, anger, fear, or anxiety). R23's Significant Change Minimum Data Set (MDS) dated 07/25/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R23 was independent with his functional abilities and used a walker to assist with ambulation. R23 received an antipsychotic on a routine basis. R23's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/08/24 documented he received an antipsychotic and antianxiety (a class of medications that calm and relax people) medications to treat anxiety and mood impairment. A gradual dose reduction (GDR) had not been recommended by the physician since admission. R23's Care Plan revised on 07/25/24 directed staff to administer medications as ordered. Staff were to monitor and document side effects. Staff were directed to monitor his behaviors every shift. When R23 became agitated, staff were directed to intervene before the agitation escalated. Staff were directed to guide the resident away from the source of distress. R23's Orders tab of the EMR documented an active order dated 09/13/24 for quetiapine (Seroquel) 200 milligrams (mg) to be given by mouth at bedtime for mood management. On 04/15/25 at 09:15 AM, R23 ambulated with his walker down the hall. On 04/16/25 at 12:50 PM, Administrative Nurse D stated administrative staff had noticed in the past that the previous facility physician had not been addressing concerns about the inappropriate diagnosis and continued use of R23 Seroquel. Administrative Nurse D stated that the interdisciplinary team had been working with the physicians and pharmacy to ensure that any antipsychotic medication had an approved diagnosis and the risk versus benefit for use. The Antipsychotic Medication Use policy dated October 2021, documented antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and were subject to gradual dose reduction and re-review. Residents would only receive antipsychotic medication when necessary to treat specific conditions for which was indicated and effective. Antipsychotic medications shall generally be used only for the approved conditions/diagnoses consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders. Diagnoses alone do not warrant the use of antipsychotic medication. In addition, antipsychotic medications would generally only be considered if the following conditions were also met: the behavioral symptoms present a danger to the resident or others, and the symptoms were identified as being due to mania or psychosis, or behavioral interventions had been attempted and included in the plan of care, except in an emergency. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility to prevent medication administration errors for Resident (R) 8 whose heart rate was out of physician-ordered parameters and he received four blood pressure medications. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of pain, traumatic brain injury (TBI - an injury to the brain caused by external forces), dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and hypertension (high blood pressure). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had severely impaired cognition. R8 was dependent on staff for all activities of daily living (ADL) and did not ambulate. R8 received diuretic (a medication to promote the formation and excretion of urine), antidepressant (a class of medication used to treat mood disorders), and insulin (a hormone produced by the pancreas that regulates blood glucose levels) medication daily. R8's Care Plan dated 04/11/25, initiated on 01/22/24, directed staff to administer his blood pressure medication as ordered and monitor for potential side effects. The care plan directed staff to monitor the blood pressure according to the physician's instructions, accurately record blood pressure readings, and promptly notify the physician if readings fall outside the target range or if a significant change occurs. The Physician's Order, dated 03/18/23, directed staff to administer losartan (high blood pressure medication), 100 milligrams (mg), one tablet, by mouth, daily, for hypertension. Hold the medication if the systolic blood pressure (SBP - the top number, the force your heart exerts on the walls of your arteries) was less than 110 millimeters of mercury (mmHg) or if the heart rate was less than 65 beats per minute (bpm). The Physician's Order, dated 08/22/24, directed staff to administer amlodipine (high blood pressure medication), 10 mg, one tablet, by mouth, daily for hypertension. Hold the medication if the SBP was less than 110 or his heart rate was less than 60 bmp. The Physician's Order, dated 03/04/25, directed staff to administer Coreg (high blood pressure medication), 3.125 mg, one tablet, by mouth, twice per day, for hypertension. Hold for SBP less than 110 or heart rate less than 60 bpm. On 04/15/25 at 09:20 AM, observation revealed Certified Medication Aide (CMA) R took R8's blood pressure and heart rate. CMA R administered all of R8's medication and stated he was to hold the blood pressure medications if the SBP was less than 110. R8's heart rate was 55 and CMA R had not realized he should have held the blood pressure medication due to R8's low heart rate. On 04/16/25 at 10:16 AM, Licensed Nurse (LN) G stated the CMAs were supposed to tell her when a resident's vital signs were out of the physician-ordered parameter because some orders directed that the physician was to be notified. LN G stated she would follow up with R8 and the physician regarding the low heart rate. On 04/16/25 at 01:00 PM, Administrative Nurse D stated she expected staff to follow the physician's orders and hold the medication when the vital signs were out of parameters. Administrative Nurse D stated she would write up a medication error and the physician would be notified. A policy for medication errors was not provided by the facility.

The facility had a census of 34 residents. The sample included two residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R)26 and R16, which included a plan of care and a description of the services provided which included visit frequency, medications, and medical equipment. This placed the residents at risk of not receiving needed care. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), bipolar disorder (a major mental illness that causes people to have episodes of severe high and lows), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), atrial fibrillation (rapid heart rate), and morbid obesity (a disorder that involves having too much body fat which increases the risk of health problems). R26's Significant Change Minimum Data Set (MDS), dated [DATE], documentR26 had intact cognition. R26 was dependent upon staff for transfers, toileting, showers, dressing, and personal hygiene. The MDS documented R26 received hospice services. R26's Care Plan, dated 02/04/25, directed staff to document in social service notes the advanced directive review and maintain advanced directives in his file. The care plan directed staff to ensure R26's wishes were honored regarding any advanced directive or end-of-life care. The care plan documented R26 was enrolled in hospice. The care plan lacked a contact number for hospice, and what supplies, equipment, and medications hospice would provide. The care plan lacked when hospice staff would be in the building and what care they would provide. The Physician Order, dated 01/10/25, directed staff to admit R26 to hospice services. On 04/15/25 at 02:20 PM, observation revealed R26 in bed, eyes closed. On 04/16/25 at 12:6 PM, Administrative Nurse E stated she had been trying to catch up on all of the care plans and get them updated. Administrative Nurse E stated she was aware the care plan was not complete with the required information. On 04/16/25 at 01:00 PM, Administrative Nurse D stated the care plan would be updated with information related to his hospice services. The facility's Hospice Program policy, dated 10/21, documented coordinated care plans for residents receiving hospice services including the most recent hospice plan of care as well as the care and services provided by our facility to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 41713 - R17's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), trigeminal neuralgia (a condition that causes intense pain like an electric shock on one side of the face), and major depressive disorder (a serious mental illness that involves persistent feelings of sadness and loss of interest in activities). R17's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated an intact cognition. R17 required set-up assistance with eating and was dependent on staff for toileting, bathing, and dressing. R17 was on hospice services. R17's Functional Abilities Care Area Assessment (CAA) dated 03/21/24 documented she had a decline in her overall functioning. R17 required extensive to total assist with care, mobility, and transfers. R17 was alert and oriented at times and able to make her needs known. R17 required a wheelchair for mobility. R17 signed for hospice services due to breast cancer (tumor). R17's Care Plan revised on 03/30/25 directed staff that she was on hospice services. Staff was directed to honor R17's advance directives and end-of-life care. Staff were directed to provide life-sustaining treatment decisions per resident. R17's hospice care plan lacked staff direction for the services the hospice would provide (durable medical equipment, supplies, etc.). The care plan lacked staff directions on the services the facility would continue to provide. The care plan lacked a communication process, including how the communication would be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met. Provision that the LTC facility immediately notified the hospice about the following: a significant change in the resident's physical, mental, social, or emotional status; clinical complications that suggest a need to alter the plan of care; a need to transfer the resident from the facility for any condition; and the resident's death. The care plan lacked staff direction on when the hospice provider team members would visit the facility and the frequency of the visits. R17's Orders tab of the EMR documented a physician's order dated 02/17/25 to admit to hospice. On 04/15/25 at 11:47 AM, R17 was wheeled by staff to the dining room in her Broda chair (specialized wheelchair with the ability to tilt and recline). On 04/16/25 at 12:50 PM, Administrative Nurse D stated that R17's care plan should include how to contact the hospice provider and what supplies and equipment were provided by hospice. Administrative Nurse D stated the care plan should also direct staff on when to notify the hospice service and how often the hospice staff would visit the facility. The Hospice Program policy dated October 2021 documented it was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided was appropriately based on the resident's needs including 24-hour room and board care, administering prescribed therapies, notifying the hospice about significant change in the resident's status, clinical complications that suggest a need to alter the plan of care, a need to transfer the resident from the facility for any condition, and the resident's death. Coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and discipline assigned to specific tasks) to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

The facility identified a census of 29 residents. The sample included three residents reviewed for abuse. The facility failed to provide adequate supervision to ensure residents remained free from resident-to-resident abuse when Resident (R)1 threw a ceramic mug at R2 during an unsupervised altercation in the dining room. This resulted in a broken nose for R2 and placed the resident at risk for pain, impaired psychosocial well-being, and ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of alcoholic cirrhosis of the liver, dysphagia (swallowing difficulty), dementia (a progressive mental disorder characterized by failing memory and confusion), mental disorder, mood affective disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) disorder bipolar (a major mental illness that causes people to have episodes of severe high and low moods) type, adjustment disorder with mixed disturbance of emotions and conduct, restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), abnormalities of gait and mobility, a history of falling and hepatic encephalopathy (a broad term for any brain disease that alters brain function or structure). The Admission Minimum Data Set (MDS) dated [DATE] documented per staff interview, R1 had short and long-term memory problems. The MDS documented R1 was short-tempered and easily annoyed for two to six days during the observation period, with no behaviors documented. R1 required partial to moderate assistance from the staff with transfers and set-up assistance with eating. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 04/04/24 documented R1 had impaired cognition related to his diagnoses of dementia, impaired cognition, and encephalopathy. The Activities of Daily Living [ADL] CAA dated 04/04/24 documented R1 had impaired self-care and mobility. The Behavioral Symptoms CAA dated 04/04/24 documented R1 wandering due to dementia. R1's Care Plan initiated on 04/21/22 documented staff would cue, reorient, and supervise R1 as needed. The plan recorded an intervention dated 08/18/23 that directed staff to analyze the times of date, places, circumstances, triggers, and what de-escalated his behavior and document it. R1 had a personal history of trauma and team members would be mindful of trauma-informed care when assisting R1. R1's Care Plan revised on 08/19/23 documented R1 placed on one-on-one checks as directed by the administration until not seen as a threat to others. R1's Care Plan initiated on 10/07/23 documented on 09/21/23 R1 became upset when an unidentified resident entered R1's room and sat in R1's recliner. R1 reported the unidentified resident made a menacing move towards R1 so R1 started hitting the unidentified resident. The plan recorded an intervention revised on 02/22/24 that documented R1 had an altercation with another resident. R1's Care Plan initiated on 07/08/24 directed staff to give R1 as many choices as possible about care and activities. Nursing staff would provide care in pairs until R1 was clear of physical aggression. The Incident Follow-Up Note dated 02/22/24 at 06:39 PM documented R1 had an altercation with an unidentified resident. R1 was physically aggressive towards another unidentified resident. R1 was placed on one-on-one monitoring after getting separated immediately from the unidentified resident. The Incident Follow-Up Note dated 09/04/24 at 05:20 PM documented staff heard a commotion in the dining room that sounded like someone hitting the tables. Licensed Nurse (LN) G looked around the corner into the dining room and saw objects being thrown across the dining room by both R1 and R2. R2 threw a vase at R1 and R1 threw his ceramic mug at R2. Both R1 and R2 were heard yelling back and forth at each other. LN G tried to separate R1 and R2. When R1 was asked about the event, R1 stated since R2 threw something first, he had to throw something back. R1 and R2 were separated and placed under one-on-one supervision. R2 was sent out to the emergency room , and R1 continued one-on-one supervision due to aggressive, angry behaviors that continued after the incident had concluded to protect the other residents in the dining room. A review of R2's emergency department paperwork dated 09/05/24 at 06:54 AM revealed that R2 had a comminuted fracture (break or splinter of the bone into more than two fragments) of the nasal bones and nasal bridge. Certified Medication Aide (CMA) R's Notarized Witness Statement dated 09/04/24 documented CMA R stood facing the dining room in the front living area, passing medication. CMA R documented the residents at the back of the dining room were pounding on the table. CMA R documented she continued her medication pass, but upon looking up she observed R1 and R2 throwing objects at each other. CMA R hollered for help and LN G helped CMA R calm the situation down. LN G's undated Notarized Witness Statement documented LN G had taken R2's finger stick blood sugar and returned to the nurse's station when LN G heard a commotion in the dining room. LN G looked around the corner and observed R2 standing at his table yelling at R1 and R1 was yelling back at R2. LN G watched R2 throw a vase at R1's face and immediately R1 threw his ceramic mug at R2. LN G observed blood dripping down R2's face. LN G documented she was attempting to separate R1 and R2. LN G placed R1 one-on-one with staff in the dining room to keep the other residents safe. The Facility Investigation dated 09/11/24 documented at approximately 05:36 PM on 09/04/24 R1 and R2 had an unwitnessed altercation in the dining room. The altercation escalated to R1 and R2 throwing a vase and a ceramic mug at each other. The object thrown by R1 struck R2 in the face causing injury to his nose. During an observation on 09/18/24 at 11:53 AM R1 sat in his wheelchair in the dining room. R1 appeared calm and well-groomed. R1 wore a hat and self-propelled around the dining room tables. During an observation on 09/18/24 at 12:01 PM, R2 sat at a table near the living room area, while R1 sat three tables away from R2 near the back of the dining room. R2 appeared well-groomed and somber while awaiting lunch. The tables of R1 and R2 were approximately 15 feet apart. During an observation on 09/18/24 at 03:10 PM, R2 lay in his bed with his blankets pulled up over his shoulders. R2 responded to his name and stated that he had no concerns with anyone in the facility. R2 asked if there was anything else because he wanted to take a nap. During an observation on 09/18/24 at 03:12 PM, R1 lay in his bed on his back watching television and appeared relaxed. R1 did not respond to his name. During an interview on 09/18/24 at 12:41 PM, LN G stated R1 and R2 sat at the same table on 09/04/24. R2 threw a vase that was on the table as decoration at R1. R1 reported to LN G that the vase bounced off R1's hat. LN G stated R1 instantly threw the ceramic mug at R1 and broke R2's nose. LN G reported it was at the beginning of the meal and she had not heard the banging on the tables but had witnessed R1 and R2 throwing things. LN G tried to recall the delay in the meal being served and stated she felt it was a kitchen problem and one of the CNAs on shift had to help in the kitchen. LN G stated nursing staff should not be going outside during meals. LN G revealed when the residents and staff are awaiting the meals to be served the CNAs will take out their trash because the shift change occurs when the residents are in the dining room at dinner time and a late dinner puts the CNAs late on finishing their shift tasks. During an interview on 09/18/24 at 01:50 PM, CNA M stated she and CNA N took all the trash out. CNA M said when she got back into the building R2 was bloody and getting cleaned up by LN G. CNA M said LN G and CMA R told her it was not the first time R1 and R2 had gotten into it. CNA M stated she was new to the building and had not witnessed any altercations with R1 or R2, but staff had mentioned it had happened before. CNA N stated CMA R was watching the dining room. During an interview on 09/18/24 at 02:06 PM, CMA R stated she stood in the living room facing the dining room passing medication. CMA R revealed that her husband had just called, and she was on the phone when it started to get rowdy in the back of the dining room. CMA R proceeded to get off the phone and the next thing CMA R knew; things were being thrown. CMA R stated at first when the residents were pounding on the table it was playful and the residents were laughing. CMA R revealed she did not know what happened between R1 and R2, but it intensified. CMA R revealed R1 had a history of behaviors and has had multiple altercations with other residents; R2 is a little rowdy and very mouthy. CMA R further revealed that R1 is very quiet but also very crazy and would react quickly. CMA R stated staff were to have at least one staff person in the dining room watching the residents. CMA R stated that when Dietary BB worked, dinner was served a little late. During an interview on 09/18/24 at 03:10 PM, CNA N was in the kitchen getting the resident drinks ready for dinner. CNA N stated when she came out of the kitchen, she was informed that R1 was on one-on-one and R2 was being sent out because R2 was bleeding. CNA N revealed that at times she goes into the kitchen to get the drinks for the residents because the residents are not fed until 05:30 PM to 06:000 PM. CNA N stated that in the past two years, R1 had behaviors and has been sent out to geriatric psych facilities related to his behaviors. CNA N stated she had seen behaviors previously with R1. CNA N revealed that she would have not let the banging continue with the residents and would have gone to ask the residents what was going on before it got to things being thrown. During an interview on 09/18/24 at 02:26 PM Administrative Nurse D stated that R1 historically has had behaviors. Administrative Nurse D stated that both CNAs should not have been taking out the trash and that the CMA should not have taken the call while monitoring the dining room. Administrative Nurse D further stated that staff should have been alert to the banging on the table when it involved R1. Administrative Nurse D stated that Dietary BB did come in late to his shift. Administrative Nurse D stated staff should be present in the dining room to be able to be observant and make sure behaviors did not occur. Administrative Nurse D stated that she had not had the staff do abuse and neglect training after the R1 and R2 had the altercation, but training has been going on monthly since she started. Administrative Nurse D stated she did training on resident abuse, respect for residents, and inappropriate conversations monthly since April of this year. During an interview on 09/18/24 at 03:30 PM Administrative Staff A stated it was the expectation for two nursing staff to be in the dining room with the residents when the residents were in the dining room to eat. Administrative Staff A stated if a staff member needed to take a phone call, she expected the staff member to alert her fell ow staff and step off the floor to somewhere private. Administrative Staff A said she expected staff to attempt to redirect the residents before the behaviors escalated. Administrative Staff A stated she had recently received training on handling behaviors with residents in the building and it was sent out for the staff to complete. Administrative Staff A stated she had completed the training herself, so she knew what was included in the training the staff were taking. The facility's policy Resident-to-Resident Altercations revised August 2021 documented that facility staff would monitor residents for aggressive and or inappropriate behavior towards other residents, family members, visitors, or staff. The facility's policy Abuse Prevention Program revised on August 2024 documented the community had a zero-tolerance on abuse, neglect, exploitation, or misappropriation. The policy interpretation and implementation documented the facility would protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteer staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. The policy required staff training and or orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behaviors. The facility failed to ensure the residents received the needed supervision to ensure resident safety and to prevent episodes of resident-to-resident abuse when R1 threw a ceramic mug at R2 and fractured R2's nose.

The facility identified a census of 31 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure there was a director of food and nutrition services employed at the facility with the required qualifications. This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On [DATE] at 10:31 AM Social Services X worked in the kitchen. Social Services X stated the facility did not have a Certified Dietary Manager (CDM) to oversee the kitchen. Social Services X stated that she was filling in to cover the kitchen currently. She stated the facility had a full time cook, but the cook was out since [DATE] so she was covering for them until they returned. Social Services X stated she had a Dietary Aide to assist her in the kitchen. Social Services X stated she was unsure is the food temperature logs were done for breakfast that morning [DATE]. Social Services X further stated Administrative Staff B helped with the kitchen as well and may have had the missing temperature logs. Social Services X stated she had a ServSafe certification for food safety through the United States Department of Agriculture (USDA); however, she stated the certification had expired. On [DATE] at 11:17 AM Administrative Staff B stated the facility did not currently have a CDM or manager to oversee the kitchen. She stated the administrator was also helping to run it and they were working on hiring someone and had interviews lined up for this week. Administrative Staff B stated the facility had gone about a couple of months without a dietary manager. She further stated the facility had two cooks, one full time and one part time and confirmed that the full time cook was currently out for personal issues so other staff were covering until the cook returned. She stated whoever was cooking for the day was responsible for filling out the temperature logs. Administrative Staff B further stated the facility had a registered dietitian that came to the facility on ce a month and was available as needed. On [DATE] at 11:46 AM Administrative Staff A stated she had been at the facility for about two and a half weeks and has been actively looking for a CDM and had some interviews for the position lined up. Administrative Staff A stated the facility's full-time cook has had to call off for the last few days and Administrative Staff A confirmed the facility had been without a dietary manager for around two months. Administrative Staff A stated Administrative Staff B noticed there were missing entries in the temperature logs and they began providing education for staff. Administrative Staff A stated she and Administrative Staff B were splitting the role of overseeing the kitchen at the moment and that Administrative Staff B was a previous manager. She further stated the facility had a dietitian that came to the facility on ce a month unless the facility needed them more frequently. The facility provided Food and Nutrition Services policy with a revised date of [DATE], documented the food Services manager will be CDM certified or enrolled in an accredited CDM program and on pace for completion. In the absence of a Food Services Manager, the duties will be assigned to other available staff members with input and direction from the dietician. The facility failed to ensure there was a director of food and nutrition services employed at the facility with the required qualifications. This placed residents at risk for unmet dietary and nutritional needs. (Refer to F802)

The facility identified a census of 35 residents. The sample included three residents reviewed for elopement (when a cognitively impaired residents exits the facility without staff knowledge and supervision). Based on observation, record review, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent cognitively impaired Resident (R) 1, who was at high risk for elopement, from exiting the facility through the window. On 12/28/23 at 01:45 PM Certified Nurse Aid (CNA) M observed R1 pacing in his room. At 02:13 PM Dietary Staff BB returned to the facility after lunch and observed R1 walking down the street approximately 150 feet from the facility. The temperature outside was approximately 40 degrees Fahrenheit (F) at that time. Staff assessed R1, noted no injuries, returned R1 to his room and saw R1's window was open. R1 stated he jumped (out of the window) when asked how he exited. The facility failed to identify and secure likely avenues of exit for R1, who was at high risk for elopement and severely cognitively impaired. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of drug induced subacute dyskinesia (inability to execute voluntary movements), other schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R1's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R1 was independent with mobility. R1 had no behaviors nor exhibited wandering behaviors. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/27/23 documented R1 had inattention and disorganized thinking. did not always give a verbal response or an appropriate response to the questions asked. The Falls CAA dated 02/27/23 documented R1 ambulated independently without a device. R1's Quarterly MDS dated [DATE] documented a BIMS score of one, which indicated severely impaired cognition. R1 was independent with no assistance from a staff member for mobility. R1 had no documented behaviors. R1's referral packet, under the Misc tab included R1's care plan sent from his previous facility. The plan documented R1 was an elopement risk. The referral packet documented R1 was one-on-one whenever R1 left his room and was on 15-minute checks when he was in his room. The referral packet documented R1's broke a glass door and exited his previous facility. R1's Wander Risk assessment dated [DATE] documented he was at high risk to wander. A Physician Progress Note dated 02/24/23 at 09:17 PM documented R1 admitted to the facility from another long-term care facility. The note documented R1 had a history of elopement. R1's Elopement Risk/Wandering Care Plan initiated on 04/11/23 directed staff to check R1's Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) for function and check Wander Guard placement as directed. Staff were directed to assess R1 for fall risk and provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes. The Notes sections of R1's EMR documented the following: A Physician Progress Note dated 02/24/23 at 09:17 PM documented R1 admitted to the facility from another long-term care facility. The note documented R1 had a history of elopement. A Social Services Progress Note dated 04/06/23 at 11:29 AM documented R1 wandered the halls at night. A Physician Progress Note dated 11/02/23 at 03:22 PM documented R1 ambulated in the hallways as R1 frequently did. A Physician Progress Note dated 11/28/23 at 01:25 PM documented R1 was frequently seen ambulating in the hallway making uncontrollable gestures; R1 sometimes had difficulty with his mobility. The Physician Progress Note dated 12/06/23 at 11:26 AM documented R1 ambulated in the hallway as he frequently did. A late entry Nursing Progress Note dated 12/28/23 at 03:00 PM documented the notification of R1's elopement to R1's representative at 03:00 PM. R1's representative revealed R1 had a history of jumping out of windows. An Incident Follow Up Note dated 12/28/23 at 03:00 PM documented at 02:13 PM, CMA R received a call from Dietary Staff BB. Dietary Staff BB stated R1 was outside the building on the sidewalk. CMA R proceeded to go outside and redirect R1 back into the facility. When R1 arrived back to the facility staff walked R1 back to his room for a full body assessment. R1 stated he jumped out of the window when staff asked him how he got out . The facility investigation dated 01/05/24 documented staff observed R1 walking back and forth from R1's bathroom to his bed. R1 frequently paced throughout the facility and in R1's room. Staff witnessed R1 walking outside on the sidewalk. Nursing staff went to R1 who was outside on the sidewalk of the same street as the facility, on the facility side of the street. Staff redirected R1 back to the facility with no resistance or behaviors. R1 returned to the facility and was assessed with no noted injuries. R1 was placed on one-on-one monitoring. Staff checked the facility doors and noted the Wander Guard system functioned appropriately. Facility staff noted that R1's bedroom window was open, and the screen was removed from the window frame. All windows were secured in the facility and R1 was then removed from one-on-one monitoring. CNA M's undated Witness Statement documented CNA M last saw R1 a little after 01:45 PM. R1 walked back and forth from his bathroom to his bed. Dietary Staff BB's Witness Statement dated 12/28/23, documented on 12/28/23 at 02:13 PM Dietary Staff BB headed back to work from lunch. Dietary Staff BB approached the stop sign down the street, took a left turn, and saw R1 outside walking down the street with his jacket on, and a cup in his hand. Dietary Staff BB called CMA R and asked if CMA R knew that R1 was gone. CMA R stated no and went to get R1. CMA R's Witness Statement dated 12/28/23, R documented on 12/28/23 at 02:13 PM Dietary Staff BB called to see if any staff knew that R1 was out of the building walking down the street. CMA R hung up and went outside. CMA R saw R1 walking towards the building. CMA R ran and helped R1 back to the facility. CMA R recalled she last saw R1 during lunch. LN G's undated Witness Statement documented on 12/28/23 at 02:13 PM, CMA R received a call from Dietary Staff BB stating R1 was outside on the sidewalk. CMA R went outside and redirected R1 back into the facility. Once R1 returned into the facility, LN G walked with R1 back to R1's room and performed a full body assessment. R1 had no skin issues noted and reported he had no pain. On 01/23/24 at 10:53 AM R1 walked independently in the hallway with no balance issues. On 01/23/204 at 10:55 AM observations revealed the window in R1's room had a screw placed in the bottom of the window track roughly four inches away from the glass pain preventing the window from fully opening. There was a small wooden [NAME] at the top of the windowpane to prevent pulling out the glass pane. R1's window faced the front side of the building. The window was approximately two to two and one-half feet off the floor and/or ground on the inside and outside of the building. The area right under the window had loose rock landscaping. The road where R1 walked had a gradual downward slope. R1 had to cross a street that was perpendicular to the street R1 walked along which had a posted speed limit of 30 miles per hour. On 01/23/24 at 01:55 PM CMA S stated R1 had a history of trying to open doors in the past, but staff redirected him. CMA S stated that R1 was easily redirected. CMA S revealed that R1's representative had informed facility staff that R1 eloped from his previous facility and that R1 could potentially elope. CMA S stated the facility staff knew to keep eyes on R1 and watch out for him since they knew about his potential to elope. On 01/23/24 at 02:07 PM CMA R stated Dietary Staff BB called her and asked if staff knew that R1 was walking down the street. CMA R revealed R1 was walking down the side of the street that the facility was on but was one street over. CMA R she was unaware of R1's history of eloping or jumping out of windows. On 01/23/24 at 03:03 PM Administrative Nurse D stated he was unaware of R1's eloping history. Administrative Nurse D stated that R1 walked the halls and was known to pace in his room. On 01/23/24 at 03:08 PM Administrative Staff A stated R1 walked the hallways and was not very verbal. Administrative Staff A stated that upon arriving to the facility she reviewed this event to see what had been done or needed done for R1. Administrative Staff A revealed that she had read the referral for R1 and thought it might have said something about elopement. The facility's policy Wandering and Elopements revised [DATE] documented that if a resident was identified as a risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. The facility failed to identify and secure likely avenues of exit for R1, who was at high risk for elopement and severely cognitively impaired. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. The facility completed the following corrective actions by 01/04/24: The windows in the facility were secured with a screw in the window to prevent the window from opening farther then three to four inches and a wooden [NAME] was placed on the top of the window pan to prevent the window pain from being lifted out of the window frame on 12/28/23. The facility staff have received training on elopements and procedures for handling elopements completed on 01/04/24. The corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

The facility identified a census of 37 residents. The sample included four residents reviewed for abuse. Based on record review and interviews, the facility failed to prevent physical abuse when Certified Nurse Aide (CNA) M hit cognitively impaired Resident (R) 1, who had history of traumatic head injury, in the face on 09/08/23. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for continued abuse. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 09/17/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with other behavioral disturbance, personal history of traumatic head injury, and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R1 had inattention and disorganized thinking that was present and fluctuated during the review period. The Delirium [sudden severe confusion, disorientation and restlessness] Care Area Assessment (CAA) dated 08/27/23, documented R1 had a potential for alteration in delirium due to R1 triggering for inattention, such as being easily distracted with disorganized thinking. R1 was able to verbalize his needs but had difficulty understanding sometimes, due to his own perspective or delusional thinking and beliefs. The Cognitive Loss/Dementia CAA dated 08/27/23, documented R1 had a BIMS of five during assessment interview and had indicators of inattention and disorganized thinking noted. The Care Plan last revised on 09/09/23, directed staff R1 was at risk for verbal and physical aggression towards others and non-compliant with care related to impaired memory, poor impulse control, traumatic brain injury, and bipolar disorder. The Care Plan documented an intervention, dated 04/17/23, that directed staff when R1 became agitated, staff intervened before agitation escalated, guided R1 away from the source of distress, and engaged calmly in conversation. If R1's response was aggressive, staff walked away calmly and approached later. The facility's Investigation, dated 09/12/23, documented CNA M and two other CNAs were assisting R1 with care at approximately 06:00 AM on 09/08/23 during shift change rounds. CNA M stated R1 had spit on her and called her a black [expletive]. CNA M asked R1 not to spit on her and he spit on her again. At that time, CNA M stated she put her hand on his face so he would not do it again and when she took her hand off his face, R1 spit on her again. At that time, she stated she walked out of the room. The witnessing CNAs ( CNA O and CNA P) reported CNA M hit the resident and verbalized she did not care if she lost her job. Another resident witnessed CNA M in the hallway and reported CNA M stated she punched R1 in the face. CNA N sat at the nurses desk and witnessed CNA M come out of R1's room and down the hallway. CNA N asked CMA M what had occurred and CNA M stated R1 was just in her face and tried to punch her again, so she punched him in the face. CNA M gathered her belongings at that time while CNA N observed her until she left the building immediately after the incident. CNA N reported to Licensed Nurse (LN) G about the incident and LN G contacted Administrative Nurse D around 07:15 AM, regarding the incident. Administrative Nurse D contacted Administrative Staff A and the police were contacted at approximately 08:30 AM regarding the incident. LN G completed a skin assessment on R1 with no injuries noted. LN G notified R1's representative and physician of the incident. Police arrived at 08:40 AM and interviewed R1, both witnesses, and CNA M when she arrived back to the building at 09:45 AM to provide her written statement of the incident. When police and Administrative Staff A met with R1, he was unable to recall any incident or altercation from that morning. There was no visible injury noted on R1 at that time. In a Witness Statement on 09/12/23, CNA M stated she went to get R1 out of bed with the help of two other aides. As they placed the sit-to-stand (mechanical lift) behind R1, he called CNA M a black [expletive] and spit in her face. She stated she wiped her face and asked R1 not to spit on her as they were trying to pull him up with the sling. CNA M stated R1 said [expletive] you and spit on her one more time in her face. She told R1 that she asked him not to spit on her and she put her hand on his face to turn his face so he would not do it again. CNA M stated when she took her hand off R1's face, he did it again and at that time she walked out of the room. She washed her face and glasses, sat down to cool off, then left. In a Witness Statement on 09/12/23, CNA O stated on 09/08/23, he arrived at the facility that morning and was approached by CNA M to assist R1 with activities of daily living (ADLs). He stated he went to R1's room to assist, and while they were trying to assist R1 to sit up, R1 spit on CNA M. CNA M hit R1 and verbalized she did not care if she lost her job. CNA P was also assisting R1. In a Witness Statement on 09/12/23, CNA P stated on 09/08/23 at about 06:05 AM, CNA M, CNA O, and herself went in R1's room to try and change him and get him up. R1 refused and CNA M was determined to get him up so R1 spit in CNA M's face. CNA P stated CNA M grabbed R1's face and pushed it down on the pillow and R1 swung at CNA M. She stated CNA M hit R1 in the jaw. CNA P stated that was enough and they walked out of the room. In a Witness Statement on 09/12/23, CNA N stated on 09/08/23 at 06:10 AM, she sat at the nurses station giving information to the new hire when she heard CNA M walking down the hall towards them, yelling that she was done. CNA N asked CNA M what happened, while she was in the dining room collecting her belongings. CNA M replied R1 spit in her face three to four times and tried to punch her again, so she punched him in the face. CNA N stated she watched CNA M leave the building. CNA N stated she immediately reported to the charge nurse what had happened. On 09/21/23 at 02:14 PM, CNA N stated on 09/08/23, there was a new CNA working so she was sitting down talking about the residents. CNA M came out of R1's room screaming she was done and cussing. As CNA M walked closer to the desk, she stated R1 spit in her face two more times so she hit him in the face. CNA N stated after CNA M left the facility, she reported it to the nurse. On 09/21/23 at 02:19 PM, LN G stated on 09/08/23, she was getting report when CNA N opened the door and said she needed to tell her something. CNA N waited until CNA M left and reported CNA M hit R1. LN G stated she notified Administrative Nurse D, who notified Administrative Staff A, who was on her way into the facility. LN G checked on R1. On 09/21/23 at 02:29 PM, Administrative Nurse D stated on 09/08/23, LN G notified her that the CNAs reported R1 had been in CNA M's face. and called her a name, then she hit him. She stated she immediately called Administrative Staff A to let her know. CNA M returned to fill out a witness statement. Administrative Nurse D stated CNA M was terminated, and staff received education on abuse, neglect, and exploitation (ANE). On 09/21/23 at 02:35 PM, Administrative Staff A stated on 09/08/23, Administrative Nurse D notified her of the incident while she was on her way to work. She stated when she arrived at the facility, she asked what happened, but CNA M was already gone. She gathered statements and the nurse checked on R1 who was fine. Administrative Staff A stated she talked to CNA O and CNA P and notified the police who arrived and talked to everyone again. She stated CNA M did come back to the facility for a statement and talked to the police as well. Administrative Staff A stated CNA M did not tell her or the police that she hit R1. Based on the situation being witnessed by two CNAs, CNA M was terminated at that time. She stated ANE education was completed that day with everyone working and everyone that came in to work filled out the ANE form before they worked. CNA M was unavailable for interview on 09/26/23 at 04:54 PM. On 09/27/23 at 08:36 AM, CNA P stated on 09/08/23 she arrived to work around 05:54 AM and R1 was soiled with urine. She stated CNA M, CNA O, and herself were in R1's room trying to get him up. R1 was lying in bed and after they could not get the sling under R1, he spit in CNA M's face. She stated CNA M put her hand on R1's jaw then pushed his head into his pillow. They tried to get the sling underneath R1, and he tried to spit in CNA M's face again. CNA P stated CNA M used her right hand and hit R1. She stated R1 seemed upset and had said to CNA M, [expletive] if he could get up, he would punch her. At that time, CNA P told CNA M they needed to leave the room to give him time to calm down. CNA P stated she reported the incident within 10 minutes. The facility's Recognizing Signs and Symptoms of Abuse/Neglect/Exploitation policy, last revised October 2021, directed abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The facility failed to prevent physical abuse when CNA M hit R1 in the face on 09/08/23. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's mental illness and inability to self-identify and express his feelings. The facility put the following corrections into place by 09/12/23: CNA M was suspended then terminated on 09/08/23. All staff working on 09/08/23 were in-serviced on ANE and any additional staff, including agency staff were in-serviced prior to the start of their next shift. R1's care plan was updated on 09/09/23. R1 was seen by psychiatry on 09/12/23. All corrective actions were completed prior to the onsite survey therefore the citation was deemed past noncompliance.

The facility identified a census of 34 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to maintain an environment free from safety hazards. On 04/19/22 staff propelled Resident (R)1 down the hallway in her wheelchair without foot pedals. R1's right foot became entangled in the recessed area around the drain access, which caused R1's foot to bend underneath her wheelchair. Staff failed to recognize R1's foot was caught on the recessed area and continued to propel R1 forward in her wheelchair which resulted in R1's foot bending underneath the wheelchair, which resulted in a fracture to R1's right tibia (larger long bone of the lower leg) and right fibula (smaller long bone of the lower leg ). Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab documented diagnoses of pain, [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview revealed R1 had short and long-term memory problems. The MDS recorded R1 required extensive assistance of two staff for activities of daily living (ADL) andADL) and needed one-person physical assistance for locomotion on and off the unit. The Quarterly MDS dated [DATE] documented a staff interview, which revealed R1 had short and long-term memory problems. R1 required extensive assistance of two staff members for ADLs and supervision with set up help with locomotion on and off the unit. The Cognitive Loss Care Area Assessment (CAA) dated 10/10/21 documented R1 required extensive assistance with ADLs, transferred with use of the sit to stand lift, and self-propelled in her wheelchair at times. The ADL CAA dated 10/10/21 documented R1 required minimal assistance with ADLs. The ADL Self-Care Performance Care Plan revised 12/11/21 documented R1 did not use wheelchair pedals and propelled herself in a wheelchair. The care plan lacked any new interventions related to R1's incident on 04/19/22. The Incident Follow Up Note dated 04/19/22 at 02:04 PM documented Certified Nurse Aide (CNA) M wheeled R1 down the hall when R1's right foot got caught on the drainage hole in the hallway. CNA M failed to notice R1's foot was caught under R1's wheelchair. R1 reported pain. CNA M laid R1 down in bed and elevated her feet. Staff notified the physician and ordered a two-view x-ray to rule out any injury. The signed Witness Statement dated 04/19/22 documented Certified Nurse Aide (CNA) M propelled R1 in a wheelchair. R1 held her feet up until at the area of the drain access, outside of the housekeeping door. R1's foot got caught and bent R1's leg backwards under the wheelchair. R1 complained of pain after the incident. CNA M took R1 to her room, laid R1 down, elevated R1's feed and notified Licensed Nurse (LN) G of the situation. The Physician Order dated 04/19/22, under the Orders tab documented a two-view x-ray of right ankle and foot. The Incident Follow Up Note dated 04/21/22 at 08:58 AM documented R1's right lower leg was extremely swollen and bruised. Staff notified the physician and received an order for a two-view x-ray of the tibia and fibula. Staff notified R1's representative and he requested R1 be sent out to the hospital. The X-ray Report dated 04/20/22 for the right ankle two-view x-ray documented osteopenia (loss of bone mineral density) and soft tissue swelling. The X-ray Report dated 04/21/22 for right tibia and fibula two views documented acute fractures were present. On 04/25/22 at 10:10 AM observation revealed a silver lid over a drain access site approximately eight inches in diameter between the nurse's station and medication cart parallel to the nurse station alongside the wall. Further observation revealed a wet floor sign positioned right about the cover. At that time, the floor was not wet. The lid appeared flush/level with the floor. On 04/25/22 at 10:12 AM Licensed Nurse (LN) H stated the drain site always had the silver lid over it. On 04/25/22 at 10:15 AM Activity Z stated she was not aware of any issues with the drain access site. On 04/25/22 at 10:18 AM Administrative Staff B stated when propelling residents in their wheelchair over the area with the drain access site, she made sure to go around the area so the wheelchair or the resident did not get hung up on the drain site. Administrative Staff B revealed the silver lid over the drain site had a tendency to settle and be lower than the floor, but only a little lower. On 04/25/22 at 10:25 AM Administrative Staff A stated the silver cover at the drain access site had been known to settle and needed to be lifted occasionally, which was done by facility maintenance. Once lifted, the silver cover was flush with the floor. Administrative Staff A stated the drain access site with the silver lid had settled lower at one point when maintenance repaired the drain in the housekeeping closet. She reported at the time of the incident, LN G and CNA M took R1 back to her room because R1's foot hurt. Administrative Staff A further stated that the next day R1 was still in pain and another x-ray identified the leg fractures. Administrative Staff A hoped staff would have noted R1's foot caught and stopped the wheelchair before the foot was bent underneath. On 04/25/22 at 11:35 AM Administrative Staff A stated maintenance worked on the drain site on and off and tried to get it figured out. She said the gap happened when the floor settled. Administrative Staff A further stated that Maintenance U worked on the area and ensured it remained flush with the floor. On 04/25/22 at 12:25 PM CNA N stated that the drain access site, with the silver lid, behind the nurse's station was lower than the floor and facility staff worked on it and raised it up. CNA N revealed the wet floor sign was placed over the silver lid to help show residents that they should go around that area. CNA N stated that she was not working when R1's foot got caught. On 04/25/22 at 02:27 PM Maintenance U stated that the floor drain had been repaired over four months ago. Maintenance U revealed the drain access site with the silver lid remained flush with the floor, but he occasionally needed to re-seat the silver cover. He further revealed that he was researching further actions to help prevent settling of the area. On 04/25/22 at 03:45 PM Administrative Staff A stated R1 did not have foot pedals because R1 was known to self-propel. Administrative Staff A believed R1 could have held her legs up with no concerns while staff propelled her. On 04/28/22 at 01:15 PM CNA M stated that R1 held her feet up when propelled back to the dining room after toileting. CNA M further stated she was not sure if R1 was tired or just put her feet down, but when CNA M noted a difference in resistance, she stopped pushing the wheelchair and R1's foot was already underneath the wheelchair. CNA M stated at that moment she pulled the wheelchair backwards to get R1's foot free from underneath the chair. CNA M revealed the nurse looked at R1's foot at that moment and instructed CNA M and an unidentified staff member to put R1 into bed using the Hoyer lift (total body mechanical lift used to transfer residents). CNA M stated she was told if a resident could self-propel or ambulate by themselves, staff were not to use foot pedals. The facilities Safety and Supervision of Residents policy revised October 21 directed the interdisciplinary care team would analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The policy further directed to monitor the effectiveness of interventions and to modify or replace interventions as needed. The facility failed to maintain an environment free from safety hazards when R1's right foot became entangled in the recessed area around the drain access, which caused R1's foot to bend underneath her wheelchair. Staff failed to recognize R1's foot was caught on the recessed area and continued to propel R1 forward in her wheelchair which resulted in R1's foot bending underneath the wheelchair which resulted in a fracture to R1's right tibia and right fibula.

The facility reported a census of 44 residents with 21 residents in the sample. Based on observation, interview, and record review the facility failed to develop and implement timely interventions to promote healing of 1 unstageable pressure ulcer present on admission and the development of 5 additional unstageable pressure ulcers, which developed in the facility for 1 of 1 resident's sampled for pressure ulcers, which also increased in size and stage. (#39) Findings included: - Review of resident #39's signed physician order [REDACTED]. Review of the quarterly MDS (Minimum Data Set) dated 3/30/2015 documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident required extensive assistance of one staff with bed mobility, transfers, and toileting. The resident was frequently incontinent of urine, always continent of bowel and had no toileting schedule. The resident had no pressure ulcers (a 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) and had a pressure relieving device for his/her chair and bed and application of ointments/medications other than to feet. Review of a significant change in status MDS (Minimum Data Set) dated 6/24/2015 documented a BIMS score of 12, which indicated moderate cognitive impairment. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, and toileting. He/she was always incontinent of urine and bowel, and had no toileting program. The resident had one stage 4 pressure ulcer, one unstageable pressure ulcer due to slough (dead tissue, usually a cream or yellow color) and/or eschar (dead tissue), and one unstageable suspected deep tissue injury, which were present on admission/reentry. The dimensions of the largest pressure ulcer was 6.0 cm (centimeter) x (by) 5.0 with eschar. The resident received skin and ulcer treatments, had a pressure relieving device for his/her chair and bed, was on a turning/repositioning program, received nutrition/hydration to manage skin problems, pressure ulcer care, and application of nonsurgical dressings other than to feet and to feet with or without medications. The resident received hospice care. Review of the ADL (Activities of Daily Living) CAA dated 7/1/2015 documented the resident was alert and able to make his/her needs known. The resident returned from the hospital and admitted to hospice services on 6/17/2015. He/she experienced an overall decline in status and required extensive assistance of 1-2 staff with ADLs, was incontinent of urine and bowel and received scheduled and as needed pain medications. Review of Pressure Ulcer CAA dated 7/1/2015 documented the resident returned from the hospital and admitted with an unstageable area to his/her coccyx, was incontinent of bladder and bowel, and had a low air loss mattress and wheelchair cushion in his/her wheelchair. The resident had poor nutritional intake and received hospice services. A review of the resident's Braden Skin Risk Assessments documented a score of 12 on 6/16/2015, which indicated the resident was at high risk for the development of pressure ulcers. Review of the care plan dated 7/3/2015 documented the resident had impaired skin to include an unstageable area to his/her coccyx and dark areas to boot feet and ankles. The care plan directed staff to promote adequate nutrition and hygiene, consult the registered dietitian as needed, complete weekly skin assessments, provide pericare after incontinent episodes, use barrier cream as needed, provide a pressure reducing low air loss mattress and/or wheelchair cushion, assist with repositioning every 2 hours as the resident allows, and heel protectors while in bed. Staff revised the care plan 7/24/2015 to include treatment to the resident's bilateral lower extremities. Staff revised the care plan on 8/17/2015 to discontinue the resident's I-heel (a specialty mattress) mattress and a low air loss mattress was used. Review of skin assessment documented the following: Coccyx Wound- onset date 6/16/2015 on admission with the following measurements: 6/17/2015- 10 cm (centimeters) x (by) 10 cm with a 6 cm x 4 cm area of granulating tissue (the formation of small grains or particles) 6/23/2015- 5.5 cm x 4.5 cm with a 3.5 cm x 3.5 cm area of necrosis (dead tissue) 6/30/2015- 4.5 cm x 4.5 cm with undermining (a wider area of wounding that lies beneath the wound opening) of 1.5 cm at 12 o'clock and 1 cm at 3 and 6 o'clock and 0.5 cm at 9 o'clock. 7/7/2015- 10 cm x 10 cm with 3.5 cm x 1.8 cm of 100 percent slough and undermining 1.5 cm at 12 o'clock, 1 cm at 3 o'clock and 0,5 cm at 9 o'clock. 8/18/2015- 3 cm x 3 cm x 2 cm with several dark areas in the middle of wound and undermining 4 cm from 3-6 o'clock and 2 cm from 9-12 o'clock with moderate drainage. 8/26/2015- 3 cm x 3 cm x 1.8 cm and undermining 3 cm at 9 o'clock to 6 o'clock Right outer heel- onset date 7/7/2015 with the following measurements: 7/7/2015- 1 cm x 3 cm fluid filled area 7/15/2015- 3.5 cm x 5 cm dark and hard Right ankle- onset date 7/15/2015 with the following measurements: 7/15/2015- 3 cm x 2 cm redness with 1.5 cm x 1 cm dark area, 7/28/2015- 3.5 cm x 3.5 cm with 2.3 cm x 1 cm black area Right inner heel- onset date 7/15/2015 with the following measurements: 7/15/2015- 1.5 cm x 1 cm. 7/28/2015- 3.5 cm x 2 cm dark area 8/26/2015- 3.5 cm x 3 cm with black area Left ankle- onset date 7/15/2015 with the following measurements: 7/15/2015- 2.5 cm x 2 cm red area 7/28/2015- 3 cm x 2.5 cm with a 1.5 cm x 1.5 cm black area and redness around area 8/26/2015- 3 cm x 3 cm with 50% slough and 1 cm x 1 cm redness around the wound Left outer foot- onset date 7/15/2015 with the following measurements: 7/15/2015- 0.5 cm x 0.5 cm 8/18/2015- 1.5 cm x 1 cm 8/26/2015- 2.5 cm x 2.5 cm with 0.2 cm redness around the wound and a black area Left upper mid buttock- onset date 8/26/2015 with the following measurements: 8/26/2015- 1 cm x 1 cm x 0.6 cm Review of physician orders [REDACTED]. Skin prep to both heels every shift and heel protectors to each foot while in bed, effective 7/1/2015 [MEDICATION NAME] ag (an antimicrobial dressing to treat or fight infection), cut to fit tunneling of the sacral wound. Apply Hydrocel collagan gel (a medication to stimulate tissue growth and promote healing) to areas of eschar on bilateral feet, discontinue when Santyl (a medication used to destroy bacteria) available, then clean areas of eschar on bilateral feet with wound cleanser, irrigate with normal saline, apply Santyl to areas of eschar, cover with foam and secure with [MEDICATION NAME] daily and as needed, effective daily and as needed, effective 8/11/2015 Obtain wound culture due to increased drainage and odor, effective 8/21/2015 Santyl to smaller superior sacral wound, cover with foam and change every 3 days and as needed, effective 8/25/2015 During an observation on 8/31/2015 at 2:04 P.M. the resident laid in bed on his/her right side, eyes closed, with head of bed elevated to 30 degrees. There were pillows placed behind his/her back, a low air loss mattress on the bed, and a pillow between his/her legs and blue soft boots in place to both feet. At 4:04 P.M. the resident turned on his/her call light and requested to get out of bed. At 4:14 P.M. direct care staff R and S assisted the resident with dressing and transferred him/her into the resident's wheelchair. Observation revealed two golf ball sized dark brown areas of drainage on the bed chucks (absorbent cloth). Staff S told Staff R he/she informed the nurse and and said they expected the drainage. During an observation on 09/01/2015 at 6:15 A.M. the resident laid flat in the bed on his/her left side. Facility staff placed a pillow behind the resident's back, under his/her knees and he/she wore heel protectors. At 8:42 A.M. direct care staff T asked the resident if he/she wanted to get up for breakfast. The resident stated, yes, I need to get dressed first. Staff told the resident he/she needed to finish taking care of his/her roommate and would be back. At 8:54 A.M. direct care staff U assisted the resident with repositioning onto his/her back. Staff changed the resident's brief and the dressing to his/her coccyx (tailbone area) was unsecured. A moderate amount of dark brown drainage was on the resident's brief with an odorous smell. At 9:07 A.M. licensed nursing staff J removed the dressing to the resident's coccyx, which revealed a large amount of reddish brown drainage on the dressing. The wound was golf ball sized with darkened areas along the inside edge from 9-12 o'clock. The nurse completed wound care to the coccyx and opened area above the coccyx as follows: cleanse with wound cleanser, irrigate with normal saline, applied Aguacel ag, and covered with Allevyn. The coccyx wound was golf ball sized with a large amount of reddish brown drainage. The wound bed had scattered yellow and white substance. The wound above the coccyx was slightly smaller than dime sized with a dark black center. Following wound care, staff J applied an ointment to the resident's periarea. Facility staff failed to reposition the resident for 2 hours and 39 minutes. During observation on 09/01/2015 at 11:13 A.M. licensed nursing staff J cleansed wounds to the right ankle, right outer heel, left ankle, and left lateral foot with wound cleanser, irrigated with normal saline, applied Santyl to dry gauze, placed against the wound beds and secured with Omnifix. The right ankle wound was golf ball sized had a dark black area at 2 o'clock. and scattered white stringy substance throughout the wound bed. The wound to the right outer heel was half dollar sized with a dark spot in the center and at the top of the wound. The left ankle wound was quarter sized with a dark black spot in the center. The left lateral foot had a partial dime sized blistered area with a moderate of reddish brown drainage. During an interview on 08/31/2015 at 3:34 P.M. the resident stated he/she was unaware of when the wounds to his/her coccyx and feet occurred. He/she stated I do everything they ask me to do. The resident stated staff kept him/her up to 5 hours a day in his/her wheelchair. During an interview on 08/31/2015 at 6:44 P.M. direct care staff R reported the resident had thin skin, a sore on his/her bottom, and no other wounds. Staff R reported interventions to promote healing and prevent further skin breakdown included; repositioning every 2 hours, encouraging him/her to get out of bed, which (he/she) liked, and check and change for bowel incontinence. Staff R stated it was normal for the wound drainage to soak the resident's bed chucks. During an interview on 09/01/2015 at 10:48 A.M. direct care staff T stated the resident had a wound to his/her tailbone and some wounds on his/her heels. Staff T reported current interventions included; keeping the resident off his/her back, spending short periods of time in his/her wheelchair, and check and change for bowel incontinence. Staff T stated he/she Informed the nurse if drainage came through the resident's dressing on his/her coccyx. During an interview on 09/01/2015 T 1:27 P.M. licensed nursing staff J stated the resident had wounds located on the coccyx, 2 on the left foot and 2 on the right. Staff J reviewed the current wound care orders for the area above the coccyx and stated the order was to apply Santyl to the wound, cover with foam, change every 3 days and P.M. He/she confirmed staff did not follow wound care orders for today's dressing change. Staff J stated current interventions to promote wound healing and prevent further skin breakdown included; repositioning frequently, foley catheter placement on 8/25/2015, nutritional supplements, weekly skin assessments, low air loss mattress, and heel protectors. During an interview on 09/01/2015 at 6:22 P.M. administrative nursing staff D stated the resident returned to the facility with an unstageable area to the coccyx and hospice services. He/she stated hospice did not supply a low air loss mattress as agreed upon and had an overlay instead. Staff D stated he/she felt an overlay was not as effective as a low air loss mattress and even after requesting hospice provide a low air loss mattress, they did not. Staff D stated the facility had the option to obtain a low air loss mattress for the resident, but did not because he/she thought hospice would. On 7/22/2015 the resident received a low air loss mattress from the hospice company currently providing cares. During an interview on 9/2/2015 at 10:16 A.M. dietitian consultant EE stated he/she first assessed the resident on 8/10/2015 and made a recommendation to increase the resident's nutritional supplement. Staff EE stated he/she preferred to evaluate a resident with wounds within 7 days of admission. He/she said the facility needed a better system in place for notification of resident admission and their condition. During an interview on 9/2/2015 at 9:46 A.M. physician consultant GG stated he/she expected the facility staff to follow the care plan and reposition the resident every 2 hours, complete wound care treatments as ordered by the physician, and ensure the resident had an appropriate air mattress upon admission . Review of the facility's Prevention of Pressure Ulcers policy dated 2/2014 documented staff would reposition resident's identified at risk for pressure at least every 2 hours in bed or more frequently if needed and repositioning in a chair would occur at least every hour. Review of the facility's undated Pressure Ulcer Prevention/Treatment policy documented the dietitian was made aware of any resident with a Braden Score less than 16. The facility failed to promote healing of a unstageable coccyx wound, prevent the development of 5 unstageable wounds, by failing to provide repositioning every 2 hours as planned, physician ordered wound care, and securing a low air loss mattress for this mobility impaired resident.

The facility had a census of 43 residents. The sample included 7 residents. Based upon observation, record review and interviews the facility failed to promote the prevention of wounds development, and failed to promote the healing of the wounds that were present for 1 (#2) resident. Findings included: - Review of resident #2's Physician order [REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident did not have short or long term memory problems and had modified independence for cognitive skills, and displayed physical, verbal and other behavioral symptoms 1 to 3 days. The MDS coded the resident required staff assistance with bed mobility and transfers, did not walk in the room/or corridor, and always incontinent of bowel and bladder. The MDS identified the resident weighed 114 pounds, had not experienced a weight loss, was at risk for the development of pressure ulcers, did not have pressure ulcers nor skin problems, and was not on a turning/repositioning program. The resident's Activities of Daily Living (ADL's) /Rehabilitation Potential Care Area Assessment (CAA) dated 2/14/12 documented the resident required extensive staff assistance with ADL's, and was incontinent of bowel and bladder. The resident's care plan dated 5/9/12 included if the resident resisted care, staff allowed the resident to calm down and approached the resident at a later time. The care plan included staff offered the resident a snack if the resident refused meals, the registered dietician evaluated the resident's nutritional needs at least annually, and as needed, the resident received a regular diet with fortified foods, and provided the wound healing nutritional supplement as the physician ordered. The care plan included the resident was at risk for alteration in skin related to weakness and incontinence and the areas on the resident's back and buttock would heal. The care plan included the following interventions: staff performed weekly skin assessment, and routine wound care. An entry dated 5/23/12 documented the resident refused to get up frequently, required assistance of 2 staff with transfers and clothing manipulation, and staff assisted the resident with toileting upon rising, before and after meals, at bedtime and during routine rounds at night. A nurse's note dated 3/3/12 and timed 1:00 A.M. documented staff applied Calmo to the small open areas on the resident's coccyx. A nurse's note dated 3/11/12 and timed 4:00 P.M. documented the wound on the resident's right upper back re-opened, and the resident's buttock was red with 2 open areas. The note included the staff educated the resident on compliance with turning. The resident continued to be non-compliant with increased anxiety noted when staff turned and/or shifted the resident's weight, and the resident tolerated shifting of his/her weight with minimal turning. The resident's positioning ADL documentation from 3/23/12 to 5/23/12 lacked evidence the facility frequently turned and/or repositioned the resident. For example documentation included the facility repositioned the resident on 5/21/12 at 2:28 A.M., 8:00 A.M., and 7:30 P.M.; 3/30/12 at 1:30 A.M., 10:00 A.M., and 3:48 P.M. The resident's clinical record lacked evidence the facility thoroughly assessed the casual factor as to why the resident's anxiety increased when the facility turned the resident. On 5/9/12 the physician gave orders for the facility to mix [MEDICATION NAME] and moisture barrier 1:1, and apply to the resident's twice a day (BID) and as needed (PRN). Cleanse the resident's right sacrum with wound cleaner, apply Santyl approximately nickel thick to the wound bed, cover with Vaseline gauze and dry dressing, secure with tape, change daily and PRN; cleanse the wound on the resident's upper back with wound cleaner, mix Santyl and [MEDICATION NAME] 1:2, apply approximately nickel thick to the wound bed, cover with Vaseline gauze and dry dressing, secure with tape, change daily and PRN. The resident's May 2012 Treatment Administration Record (TAR) revealed the facility did not record staff performed the treatment to the resident's sacrum and upper back as physician ordered on 5/12-5/15/12, 5/17-5/18/12, and 5/22-5/23/12. During an interview with nursing administrative staff A on 5/24/12 at approximately 10:30 A.M. the staff confirmed the clinical record lacked evidence the facility performed the treatments as the physician ordered. Nursing administrative staff A stated the resident did not have a physician's orders [REDACTED]. A registered dietician's note dated 2/22/12 and not timed documented the resident weighed 116 pounds, and had a pressure wound. The note documented the resident received a regular diet with fortified foods, a multi vitamin with minerals which supported skin repair, snacks were available, and to continue with the resident's plan of care. A registered dietician's note dated 4/23/12 and not timed documented the resident received fortified foods, weighed 115 pound which was below the resident's ideal body weight, and the resident's body mass index (BMI) was 18.6. The note included the resident had an abrasion on his/her buttock, and the facility started the resident on [MEDICATION NAME] for an appetite stimulant. The note included the dietician recommended the resident to receive 90 cc's of house supplement BID to increase the resident's calories and weight. The registered dietician's note did not support the facility informed the dietician of the open area on the resident's right sacrum on 4/18/12 which measured 10 centimeters (cm) in length, 5.0 cm in width with a depth of 0.1 cm, had a scant amount of exudate, serous drainage, and the surrounding skin was reddened. A laboratory report dated 5/8/12 recorded the resident's serum [MEDICATION NAME] level was low at 3.1 grams/deciliter (g/dL) (normal reference range 3.5-5.7 g/dl), and the resident's serum protein level was low at 5.8 g/dL (normal reference range 6.4-8.9 g/dL) . The resident's weekly skin and hydration assessment dated [DATE] documented the resident had a discolored open area on the right side of his/her back, and dry skin with small open areas on his/her buttock. The resident's weekly skin and hydration assessment dated [DATE] documented the resident had an open area on his/her bottom. The resident's wound assessment dated [DATE] documented the resident had a Stage 2 pressure ulcer on his/her left buttock that measured 1.9 (units not defined) in length by 0.8 (unit not defined) in width and with a depth of 0.1 (units not defined). The resident's skin condition report dated 4/11/2012 and timed 4:15 P.M. documented the wound on the resident's buttock measured 8.0 cm in length, 5.0 cm in width, and .1 cm in depth with scant serious drainage. The resident's wound assessment dated [DATE] documented the resident had a new wound on his/her right sacrum caused by trauma that measured 10.0 centimeters (cm) in length, 5.0 cm in width and .1 cm in depth. The assessment included the sacrum wound had a scant amount of exudate, serous drainage, and the surrounding skin was reddened. The resident's skin condition report dated 4/25/12 and timed 11:00 A.M. documented the wound on the resident's buttock measured 8 cm by 5 cm by .10 cm. The resident's wound assessment dated [DATE] documented the wound on the resident right sacrum measured 1.7 cm in length, 2.0 cm in width and had a depth of 0.1. The assessment included the wound had a scant amount of blood, and the surrounding skin was macerated. The resident's skin condition report dated 5/9/12 timed 6:30 P.M. documented the wound on the resident's buttock measured 13.0 cm in length, 8 cm in width and had a depth of .10 cm. The resident's skin condition report dated 5/23/12 documented the wound on the resident's buttock measured 1.30 cm in length, 1.20 centimeters in width with a depth of .10 cm., and the wound bed contained eschar. During interview with nursing administrative staff A on 5/24/12 at approximately 10:30 A.M. the staff stated the sacrum and the buttock wound were the same wound. A wound assessment dated [DATE] documented staff observed the resident had a wound on his/her right shoulder that measured 4.0 cm in length by 3.0 cm in width with a depth of .2 cm. The assessment included the right shoulder wound had 50 percent (%) slough, a small amount of red fresh blood, and copious green drainage. The assessment included the facility nurse believed the resident repeatedly moved his/her arm and rubbed it on the bed. The resident's skin condition report dated 5/9/12 and timed 6:45 P.M. documented the open area on the resident's upper back measured 3.20 cm in length, 2.80 cm in width, with a depth of .20 cm, sanguineous drainage, and the wound bed with slough. The resident's skin condition report dated 5/16/12 and timed 3:00 P.M. documented the open area on the resident's upper back measured 1.40 cm in length, 1.50 cm in width, depth of .10, with a small amount of serous drainage. A physician's/provider's order dated 5/2/12 included orders for the facility to obtain a comprehensive metabolic panel, a pre-[MEDICATION NAME], consult the dietician to decide if the following were appropriate: Vitamin C 500 mg by mouth BID, Zinc 220 mg BID, Multivitamin with minerals daily, and/or supplement. The resident's clinical record did not support the facility consulted with the dietician to determine if the nutritional supplements as noted above were sufficient to promote the healing of the wounds on the resident's upper back and sacrum. A wound consultation report dated 5/9/12 documented for the facility to aggressively offload the resident off of these areas at all times. A wound consultation report dated 5/16/12 documented the resident had a wound on his/her right pelvis sacrum that measured 10.0 cm in length, by 8.0 cm in with with a depth of 0.1 cm, with a scant amount of exudate. The report also included the resident had a wound on his/her upper back (opened on 5/2/12) with 100% slough and measured 8.0 cm in length by 3.0 cm in width and an depth of 0.3 cm. The note included for the facility to aggressive offload the resident off of these areas at all times. On 4/23/12 the resident's physician (not timed) gave orders for the facility to administer Vitamin C 500 milligrams (mg) (a supplement) BID. A physician order [REDACTED]. On 5/22/12 at 8:55 A.M. the resident laid in bed on his/her back eating the breakfast meal. On 5/22/12 at 9:15 A.M., 9:30 A.M., 10:00 A.M., 10:30 A.M., 11:00 A.M., 11:15, 11:30 A.M., and 11:45 A.M. the resident laid in bed on his/her back without a change in position. On 5/22/12 at 2:00 P.M., 2:30 P.M., 2:45 A.M., 3:00 P.M., 3:30 P.M., 3:45 P.M., and 4:00 P.M. the resident laid in bed on his/her back without a change in position. On 5/23/12 at 7:20 A.M., 7:30 A.M., 7:45 A.M., 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:45 A.M., 9:00 A.M., 9:15 A.M., and 9:30 A.M. the resident laid in bed on his/her back without a change in position. On 5/23/12 at 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M. 12:45 P.M., 1:00 P.M., 1:15 P.M., 1:30 P.M., and 1:45 P.M., the resident sat in his/her wheelchair. During interview with direct care staff K on 5/23/12 the staff stated the resident had sat in the wheelchair since approximately 10:15 A.M. and had not been toileted or repositioned (duration of 3 hours and 30 minutes). On 5/23/12 at approximately 1:50 P.M. direct care staff K offered to take the resident to the bathroom and the resident pitch became louder (indicating the resident did not want to go to the bathroom). After explaining to the resident the purpose of toileting him/her the resident allowed direct care staff G and direct care staff K to toilet him/her. Observation revealed the wound on the resident's right sacrum without a dressing, black in color, measured approximately 2 cm long by 1 cm wide, and the resident was incontinent of urine. Direct care staff K confirmed the resident was incontinent of urine. On 5/23/12 at approximately 2:30 P.M., direct care staff L and licensed nurse E transferred the resident from the wheelchair to the bed. At that time licensed nurse E stated staff did not apply a dressing to wound on the resident's sacrum. Observation revealed the open area on the resident's upper back was located on a bony prominence, measured approximately 1 cm in length by 1 cm in width, and had a small amount of red drainage. On 5/24/12 at approximately 11:15 A.M. direct care staff G and direct care staff M transferred the resident from the wheelchair to be bed. Observation revealed the resident cried when staff turned him/her, and after staff positioned the resident, and placed the resident's right arm on a pillow the resident stopped crying. During interview with administrative staff A on 5/23/12 at approximately 3:00 P.M. the staff stated the facility did not have policies and procedures. Administrative staff A stated he/she spoke to the corporate office and was informed the state and federal regulations were the facility's policies and procedures. During interview with nursing administrative staff A on 5/23/12 at approximately 3:30 P.M. the staff reported the resident had shingles years ago, the resident lost some dermis on that area due to the shingles which caused the wound on the resident's upper back. Administrative nursing staff A confirmed the resident rubbed his/her back on the bed and the facility had not implemented measures to minimize the friction and/or shearing. Nursing administrative staff A stated the wound on the resident's sacrum area was due to shearing. During interview with nursing administrative staff A on 5/24/12 at approximately 10:30 A.M. the staff stated the wound on the resident's sacrum opened on 2/8/12, healed on 2/29/12 and reopened on 3/3/12. Nursing administrative staff A stated the wound on the resident's upper back opened on 1/19/12, healed on 2/12/12 and reopened on 3/11/12. Nursing administrative staff A stated the resident had not been out of bed the last couple of months and he/she did not know why the staff did not get the resident out of bed. The facility failed to implement measures to minimize shearing and friction, failed to frequently turn and reposition the resident, failed to perform the treatments as physician ordered for this resident with a history of pressure ulcers.

The facility had a census of 43 residents. The sample included 7 residents. Based upon observation, record review and staff interview the facility failed to provide adequate supervision to prevent falls for 1 (#1) residents. Findings included: - Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident had short and long term memory problems, severely impaired cognition, did not exhibit behaviors, totally dependent upon staff for bed mobility, transfers, personal hygiene, toilet use, did not walk in the room or corridor, unsteady balance and was only able to stabilize with human assistance when turning around while walking, and moving on and off the toilet. The MDS coded the resident required 2 plus person ' s physical assist done with transfers. The MDS coded the resident had functional limitations on both side of his/her lower extremities, and had not fallen since admission/entry, reentry or the prior assessment. The resident's fall Care Area assessment dated [DATE] included the resident required extensive staff assistance with activities of daily living and was at risk for falls. The resident's fall risk assessment dated [DATE] identified the resident scored 28 (score of 7 or higher represented the resident at a higher risk for falls). The resident's care plan dated 4/4/12 addressed the resident was at risk for falls related to a [DIAGNOSES REDACTED]. The care plan included the resident's call light within reach at all times, received physical and occupational therapy evaluation as needed, transferred and ambulated with the assistance of 2 staff for safety, staff monitored the resident for seizure activity, and the resident had a fall mat next to his/her bed. A handwritten entry dated 5/20/12 included: Post fall-physician's orders [REDACTED]. A nurse's note dated 10/8/11 and timed 3:15 A.M. documented the resident was on the floor next to his/her to bed, and laid on the landing pad. A nurse's note dated 12/17/11 and timed 1:50 P.M. documented the resident was on the floor in his/her bathroom. A nurse's note dated 12/17/11 and timed 9:45 P.M. documented the resident was sleeping in his/her wheelchair, leaned forward, staff transferred the resident to the easy chair in the lobby area and the resident slept until dinner. A nurse's note dated 4/20/12 and timed 8:00 A.M. documented staff was called to the lobby/living room, the resident laid face down on floor in front of his/her wheelchair, staff observed a skin tear on the resident's right hand, the resident's nose was bleeding, and the resident had a skin tear on his/her nose. The note included the resident was confused as usual, unable to state what had happened, 2 staff members assisted the resident back into the wheelchair, staff administered first aid, and wheeled the resident to the dining room for the breakfast meal. A nurse's note dated 4/20/12 and timed 3:00 P.M. documented the resident's nose was swollen and bruised. A nurse's note dated 4/21/12 timed 9:45 P.M. documented the resident's nose swollen and purple in color. A nurse's note dated 5/20/12 timed 10:07 A.M. documented the resident said he/she needed help, staff observed the resident on the floor with a large amount of blood on his/her face, a laceration on the bridge of his/her nose, a laceration above his/her right eye, and the resident stated his/her nose was broken. A nurses note dated 5/20/12 timed 5:45 P.M. documented the resident returned from the hospital, the resident's had 2 sutures and a hematoma with scant amount of bright red drainage above the right eye, the bridge of the resident's nose was swollen, bruised and had 3 sutures, and the resident had a closed fracture in the nasal area. The note included the facility spoke to the resident's durable power of attorney regarding the resident's wheelchair safety. The note included the resident was in the wheelchair for the dinner meal, with one on one staff viewing at all meals, then staff placed the resident in bed with frequent visual and health assessments. The note included physical therapy would evaluate the resident's wheelchair in the A.M. for possible placement of instrument/wedge to decrease the resident risk of falls and/or evaluation for safety. A hospital's emergency department note dated 5/20/12 documented the resident presented with facial injuries, the resident's family stated the resident was seated in his/her wheelchair, leaned over to reach for something, fell from his/her wheelchair, and the resident's chief complaint consisted of a laceration to the nose and forehead. The note included the resident had a superficial 1 centimeter (cm) laceration on his/her mid-forehead, a 1 cm laceration on the bridge of his/her nose, and the lacerations were closed with sutures. A computed tomography (CT scan) report dated 5/20/12 and timed 11:09 A.M. documented the resident had a comminuted fracture of the right nasal bones with a non-displaced fracture of the left nasal bone and angular deviation versus fracture of the nasal septum. A physical therapy (PT) note dated 3/1/12 and signed by the resident's physician on 3/4/12 documented the resident was referred to PT due to a decline in transfer and bed mobility. The note included the resident was at risk for falls and precautions included for the resident to be with staff at all times. An occupational therapy screening form dated 5/21/12 documented the resident fell due to leaning forward in his/her wheelchair, a wedge cushion was placed in the wheelchair to increase posture, and to decrease the resident leaning forward. The note included the wedge cushion prevented the resident's feet from touching the ground, the resident could not propel himself/herself in the wheelchair, and the decision was made for the maintenance department to raise the front of the resident's wheelchair which resulted in a slight wedge and no cushion was placed which allowed the resident to propel his/her wheelchair. The form included an entry dated 5/22/12 that documented therapy staff contacted a vendor regarding a super hemi reclining wheelchair for the resident. On 5/22/12 at 8:45 A.M. the resident sat in a high back wheelchair in the living room. Observation revealed the resident's bilateral eyes with reddish colored bruises, swelling around his/her eyes, and sutures by the resident's right eye and nose. On 5/22/12 at 11:00 A.M. the resident was in a low bed, and a fall mat beside the resident's bed. At that time direct care staff G transferred the resident from the bed to his/her wheelchair using the transfer pole. Observation revealed the resident did not understand the instructions direct care G provided regarding using the transfer pole, and direct care staff with much difficulty transferred the resident to the wheelchair. During that time the resident stated at times his/her nose and eyes hurt. After transferring the resident to the high back wheelchair and combing the resident's hair, direct care staff G propelled the resident to a dining room table. On 5/22/12 at 1:30 P.M. the resident was in the low bed, and the fall mat beside the resident's bed. On 5/22/12 at 4:35 P.M. direct care staff H and I entered the resident's room to get the resident up for the dinner meal. Observation revealed the resident had difficulty understanding the instructions the staff provided regarding how to use the transfer pole. The staff had some difficulty in transferring the resident via the transfer pole. Both staff stated the transfer pole should be closer to the head of the resident's bed which would allow staff to transfer the resident in a safer manner. Direct care staff H stated the resident required the assistance of 2 staff during transfers. On 5/23/12 at 7:45 A.M. the resident sat in the high back wheelchair at a dining room table. On 5/23/12 at 9:20 A.M. the resident sat in the high back wheelchair in the living room area in a slumped position. On 5/23/12 at 10:00 A.M., 10:15 A.M. 10:30 A.M. and 10:40 A.M. the resident sat in the high back wheelchair in the living room and observation revealed the resident appeared asleep and leaning forward in the wheelchair. On 5/24/12 at 7:13 A.M. the resident sat in the high back wheelchair at a dining room table and no staff in the vicinity. On 5/24/12 9:20 A.M. the resident sat in the high back chair in the living room in a slumped position. On 5/24/12 at 10:00 A.M. and 10:20 A.M. the resident in the high back chair in the living room and observation revealed the resident appeared asleep and leaning forward in the wheelchair. During interview with licensed nurse C on 5/22/12 at approximately 10:30 A.M. the staff stated the resident required the assist of one staff with transfers. During interview with direct care G on 5/22/12 at 11:00 A.M. the staff stated the resident had utilized the same high back wheelchair, had fallen twice in the last month, and the resident leaned forward at times when he/she sat in the wheelchair. During interview with direct care staff H on 5/22/12 at 4:35 P.M. the staff stated the resident repeatedly leaned forward in the high back wheelchair the morning of 5/20/12 (date of the fall) and staff reminded the resident to scoot back. During interview with direct care J on 5/23/12 at 10:40 A.M. the staff stated the resident leaned forward and sat in a slumped position when in the wheelchair, the resident could scoot himself/herself back but required staff to tell him/her to scoot back. During interview with therapy consultant O on 5/23/12 at 10:35 A.M. the therapy consultant stated the resident fell over the weekend, he/she placed a wedge cushion in the resident's wheelchair on Monday, the resident could not propel the wheelchair after the wedge was placed and the maintenance department raised the front of the resident's wheelchair which provided a wedge. Therapy consultant K stated he/she was looking for a super-hemi wheelchair for the resident. Therapy consultant K stated when the resident leaned forward, the resident may be sleeping and the nursing staff should place the resident in bed. During interview with nursing administrative staff A on 5/24/12 at approximately 10:45 A.M. the staff stated after the resident fell on [DATE] the facility replaced the back of the resident's wheelchair. Nursing staff A stated after the resident fell on [DATE] the facility placed the resident in a common area such as the living room or dining room. Nursing administrative staff A stated the common areas were high traffic areas and staff could see the resident when they passed those areas. Nursing administrative staff A stated the facility had not completed the investigation regarding the fall on 5/20/12 therefore the facility had not not implement any interventions. During interview with administrative staff A on 5/23/12 at approximately 3:00 P.M. the staff stated the facility did not have fall policies and procedures. Administrative staff A stated he/she spoke to the corporate office, and they informed him/her the state and federal regulations were the facility's policies and procedures. The facility failed to ensure that 2 staff's transferred this severely cognitively impaired resident at a high risk for falls, failed to implement timely and effective interventions to minimize the leaning who sustained a comminuted fracture of the right nasal bones with a non-displaced fracture off of the left nasal bone due to a fall from leaning forward in the wheelchair.

The facility identified a census of 44 residents with 12 residents sampled. Based on observation, interview and record review, the facility failed to ensure that 1 of 3 residents sampled with pressure ulcers, (#47) a cognitively impaired dependent resident, received necessary treatment and services to promote the healing of pressure ulcers. Findings included: - According to the physician's order [REDACTED]. Review of the reentry Minimum (MDS) data set [DATE] recorded the facility readmitted the resident on 9/4/10 from an acute care hospital stay. Review of the physician's order [REDACTED]. Review of the significant change Minimum Data Set (MDS) 2.0 assessment dated [DATE] recorded the resident with short- and long-term memory impairment, required extensive assistance from staff for bed mobility, transfers, personal hygiene, bathing and toilet use. This same MDS recorded the resident with functional loss of range of motion on one side of the body that included the neck, arm, hand, leg and foot, and three Stage II pressure ulcers with a history of a healed ulcer in the last 90 days. Review of the Resident Assessment Protocol summary (RAPs) dated 9/13/10 recorded the resident required extensive staff assistance for activities of daily living, received treatment for [REDACTED]. This same RAPs documented the resident with two Stage II areas to the right buttock and one Stage II area to the right malleolus and identified the resident at risk for development of pressure ulcers. Review of the residents clinical record revealed a BRADEN scale assessment (an assessment to determine the resident ' s risk for pressure ulcers) dated 9/4/10 that scored the resident at (14) - at moderate risk for pressure ulcers. Review of the Nutritional Progress notes dated 9/13/10 recorded a referral to the Registered Dietitian for the 14-day MDS assessment. This progress note recorded the resident received a regular diet with fortified foods, with multiple bruises, skin tears and wounds. This same record documented the resident ' s weight loss of 9% in 30 days and recommended supplements to [MEDICATION NAME] 1 packet twice daily for wound healing and increase Two-Cal to 90 cubic centimeters (cc) twice daily. Review on 9/22/10 of the resident ' s hand written September 4, 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the plan of care dated 9/18/10 directed staff to -provide pressure reducing mattress and wheelchair cushion -Braden scale quarterly and as needed -dressing changes per physician orders -wound healing supplements as ordered -assist with frequent turning when in bed and repositioning in wheelchair - Registered Dietitian to confer with nursing regarding skin integrity -Monitor weight as ordered The resident ' s plan of care lacked interventions for the resident ' s ankle wound such as: floating the resident ' s heals off surfaces or pressure preventive boots. Review of the Treatment Administration Record dated September 2010 recorded physician orders [REDACTED]. -cleanse Right ischial wounds with wound cleanser, apply Woun Dres to wound bed, cover with 4 by 4 gauze, secure with Hypofix tape daily until healed. -for right lateral malleolus, apply Santyl, cover with dry dressing daily and as needed. Review of an acute care hospital wound care dated 9/1/10 timed 11:30 A.M., recorded the following: Right lateral malleolus: Stage III measured length 1.0 cm by width 0.8 cm by depth 0.2 cm, slough 100% to wound bed, [DIAGNOSES REDACTED] around, with minimal serous exudate. Right ischium: Stage III measured length 3.4 cm by width 2.4 cm by depth 1.0 cm, both openings communicate with tunneling 2.5 cm at 3 o ' clock, undermining 3.0 cm at 9 o ' clock, red 70%, slough 30%, heavy exudates with serous drainage. Review of the facility nursing admission assessment dated [DATE] timed 7:45 P.M. recorded the resident with a pressure ulcer risk of 16 and identified a score of 7 or higher at risk for pressure ulcers. The facility nursing admission assessment lacked documentation regarding the resident ' s three Stage III pressure ulcers. The facility provided computer printout for Wound/Skin Observations dated 9/5/10 timed 1:00 P.M., recorded the onset of wounds 7/7/10 and documented: Right-lateral distal buttock Stage II pressure ulcer, measured length 1.50 cm by width 1.20 cm by depth 0.20 cm, undermining with sanguineous drainage, and the wound bed with granulation, moist and slough. Right-medial proximal buttock Stage II pressure ulcer, measured length 2.0 cm by width 1.20 cm by depth 0.10 centimeter with small amount of sanguineous drainage, and the wound bed with slough and moist granulation. Wound/Skin Observations dated 9/14/10 timed 6:30 P.M., recorded: Right-lateral distal buttock Stage II pressure ulcer, measured length 1.5 cm by width 1.2 cm by depth 0.2 cm, undermining at 7 o ' clock, with sanguineous drainage, moist granulation and slough in the wound bed. Right-medial proximal buttocks Stage (staff marked the Stage N/A (non-applicable)) pressure ulcer, measured length 2.0 cm by width 1.2 cm by depth 1.1 cm with moist slough and granulation in the wound bed. The clinical record lacked evidence staff assessed the wound for staging, undermining or tunneling. The clinical Wound/Skin Observation lacked evidence of the Stage III pressure ulcer on the right lateral malleolus. Observation of wound care on 9/21/10 at 10:33 A.M. revealed licensed nursing staff C used good hand washing and gloving techniques, and provided a protective barrier for wound care supplies. Direct care staff B helped position the resident on his/her far right side while licensed nursing staff C, cleansed the wound with normal saline, applied Hydrogel (Woun Dres) in the wound bed and then placed a folded 4 by 4 gauze dressing fixed with [MEDICATION NAME] tape to the resident ' s right buttock. During an interview on 9/21/10 at 10:35 A.M., licensed nursing staff C reported the facility currently lacked a supply of Wound Cleanser, therefore used Normal Saline. Observation on 9/21/10 at 11:00 A.M. revealed licensed nursing staff C used good hand washing and gloving techniques, provided a protective barrier for wound care supplies, then removed the resident ' s right sock, cleansed the wound with normal saline, applied Santyl in the center of the wound bed with a wooden spatula and covered the wound and treatment with a band aid. Licensed nursing staff C explained using a band aid to cover the wound as the treatment order just called for a dry dressing, Review of the resident ' s clinical record lacked evidence of any wound measurements on 9/21/10. Upon request by the surveyor, the facility staff obtained following wound measurements on 9/22/10 at 3:46 P.M. -Right-medial lateral ischial wound (wound #2) measured length 1.3 cm by width 0.9 cm by depth 0.4 cm. with tunneling of 2.2 cm at the 8 o ' clock position. -Right-proximal ischial wound (wound #1) measured length 1.5 cm by width 1.1 cm by depth 0.1 cm with no undermining/tunneling. Licensed nursing staff A, E, and G confirmed these as Stage III wounds. The surveyor requested to observe the resident ' s right ankle wound at which time, licensed nursing staff A reported, the computer wound sheets lacked documentation of any ankle wound. On 9/22/10 at 4:00 P.M., licensed nursing staff E confirmed the resident had a wound on the right malleolus that required treatment. Licensed nursing staff E positioned the resident ' s right leg and licensed nursing staff A cleansed the right lateral malleolus wound bed with 4 by 4s and wound cleanser. The resident cried out in pain, then covered his/her mouth with his/her left hand. Licensed nursing staff A measured the wound length 2.6 cm by 1.1 cm wide and depth of 0.1 cm with red a peri wound. Licensed nursing staff E recleansed the resident ' s wound with Wound Cleanser, applied Santyl to the wound bed with a sterile q-tip and covered the area with an island dressing. On 9/22/10 at 8:00 A.M., licensed nursing staff C reported, only the wound nurse did weekly wound measurements. On 9/22/10 at 10:26 A.M., licensed nursing staff A reported written communication in the nurses ' communication book that the wound care nurse (resigned) 2 days ago and that the Director of Nursing and Assistant Director of Nursing would do all wound measurements. Licensed nursing staff A continued that a wound with any depth was a Stage III wound and staff measure and document wounds on a weekly basis. On 9/22/10 at 4: 00 P.M., licensed nursing staff A reported the Wound/Skin Observation documentation lacked accurate assessment of the resident ' s Stage III wounds. The facility provided policy for Skin System Policy and Procedure dated 8/08 documented that a resident having a pressure sore received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The policy directed that " a weekly skin assessment will be done by a nurse and kept as part of the medical record. It is necessary to show all areas of compromise and use the facility reporting system to communicate the changes to the appropriate persons. " The facility provided policy for Steps of Basic Wound Treatment dated 2001, directed staff to: -assess resident ' s level of pain and administer [MEDICATION NAME], as ordered, before wound care if resident verbalizes or displays pain -clean area with normal saline (unless other physician order [REDACTED]. -apply dressing/treatment according to manufactures ' direction, care plan and physician orders. According to the National Pressure Ulcer Advisory Panel (NPUAP) reference guide directed that a Category/Stage III: Full thickness skin loss ...some slough may be present, may include undermining and tunneling. The malleolus does not have adipose subcutaneous tissue and Category/Stage III ulcers can be shallow. The panel directed: -assess the pressure ulcer initially and re-assess it at least weekly, document findings. -with each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment. -assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudates, necrotic tissue, odor, presence/absence of granulation tissue, and epithelization. -assess all individuals for pain related to a pressure ulcer or its treatment -an assessment of pain should include assessment of body language and nonverbal cues (e.g., change in activity, loss of appetite, guarding, grimacing, and moaning). -reduce pressure ulcer pain by keeping the wound bed covered, moist, and using a non-adherent dressing -choose a dressing to keep the wound bed moist -refer all individual with a pressure ulcer to the dietitian for early assessment of and intervention for nutritional problems. -use pillows or other positioning devices to offload and prevent skin-on-skin pressure -position the individual off of the area(s) -if pressure over the area cannot be relieved by repositioning, provide a support surface properly matched to his/her needs, considering redistribution The facility failed to follow physician orders [REDACTED].