Every finding on record at Brookside Retirement Community

The facility identified a census of 47 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from accidents when Activity Staff Z did not utilize the seatbelt to secure R1 in the facility transportation van before transporting. On 02/02/26 at approximately 03:25 PM, Activity Staff Z pressed on the brakes quickly upon seeing a stopped school bus and cars in their lane of the highway. The sudden braking, with no seatbelt applied, caused R1 to fall forward onto the floor of the facility van. Activity Staff Z stated there was no place to pull over, so Activity Staff Z continued to drive R1 back to the facility, about a mile and half away, with R1 on the floor of the vehicle. Once they arrived at the facility, the staff called for Emergency Medical Services (EMS) and an ambulance took R1 to the hospital. As a result of the fall, R1 suffered an abrasion to forehead, skin tear to left lower leg, and a right humerus (upper arm) fracture. The staff failure to secure R1 in the transportation van prior to transporting R1, placed R1 in immediate jeopardy. Findings Included:- R1's Electronic Medical Record (EMR) documented diagnoses of unspecified fracture of upper end of right humerus, 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), obesity (excessive body fat), chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dependence on wheelchair, long term use of anticoagulants (medications that prevent or reduce the blood's ability to form clots), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction affecting right dominant side, and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 used a wheelchair. The MDS further documented R1 was dependent on staff for toileting hygiene, bathing, lower body dressing, bed mobility, and changing from a seated to standing position. The MDS documented R1 required substantial to maximal assistance for upper body dressing, putting on or taking off footwear, personal hygiene, toileting transfers and shower transfers.The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/18/26, documented R1 had a history of cerebrovascular accident (CVA- stroke) with right side flaccid hemiplegia; osteoarthritis (disease, where the protective cartilage cushioning the ends of bones breaks down over time. It causes joint pain, stiffness, and reduced mobility) of both knees, occasional but improved dyspnea (difficulty breathing), and osteoporosis. The CAA further documented R1 continued with dyspnea and shortness of breath (SOB) when flat in bed.R1's 04/17/23 Care Plan documented R1 required assistance with ADLs due to weakness, mobility impairment, and right-side hemiparesis associated with an old CVA. The Care Plan documented the following interventions:08/11/24 - Wheelchair was primary transport and generally R1 was independent throughout facility in a wheelchair.04/17/23 - As of 01/29/25 R1 needed two staff for transfers, toileting and use of gait belt. As of 06/20/25 R1 used a sit to stand lift (powered or manual lift designed to safely raise a person with limited mobility from a sitting position to a standing position) for transfers but may still use on staff gait belt transfers if able in bathroom only. As of 08/6/25 R1 used a sit to stand with all transfers.04/17/23 - Approach directed staff to encourage and assist R1 as needed to reposition or transfer in the morning, before meals, after meals, at activities, at bedtime, during the night, and as needed.R1's 04/17/23 Care Plan documented R1 was at risk for falls due to weakness and was at greater risk of injury and fractures due to osteoporosis.An investigation document provided by the facility, dated 02/06/26 with a CP number of 2734007, documented on 02/02/26 at approximately 03:15 PM, R1 was being transported back to the facility after a physician's office visit at a hospital in Topeka. R1 was being transported in a facility transport van and was in a wheelchair in the van. Activity Staff Z drove the van at the time. The investigation document recorded per Activity Staff Z's witness statement, they were traveling eastbound on a highway toward the facility. The documented recorded as they neared an intersection, they crested the hill, and on the east side of the hill, a school bus was stopped in the west bound lane. In front of them, in the eastbound lane, five or six cars were stopped because of the school bus. Per the investigation document, Activity Staff Z had to apply the brakes quickly, and as a result, R1 slid out of her wheelchair onto the floor. Per the investigation document, Activity Staff Z realized he did not have a gait belt holding R1 in the wheelchair and R1 was on the floor of the van, behind the front seats. The investigation documented further recorded they were in traffic, and the highway no shoulder in which to pull over. R1 and Activity Staff Z discussed what to do and since they were only a couple of minutes from the facility, they decided to drive on to the facility for help. The investigation documented that once they arrived at the facility, Activity Staff Z immediately went inside for help and nursing staff quickly came out to assess and provide first aid to R1. Nursing assessment documented staff found R1 lying on her back, alert and oriented, with a small abrasion on her forehead. Per the investigation document, R1 expressed significant pain in her right forearm, particularly when she attempted to move it. The investigation documented staff observed a skin tear on R1's left lower extremity, and staff promptly applied first-aid. Per investigation staff contacted EMS and R1 went to a hospital. Per the investigation document, R1's X-Ray indicated her right humerus was fractured, and she had sustained a small abrasion on her forehead.A Nursing note dated 02/02/26, documented at approximately 03:30 PM, a Certified Nurse Aide (CNA) alerted the nurse that R1 had recently returned from an appointment and experienced a fall in the van. The note documented the nurse, accompanied by another nurse, proceeded to assess R1 in the van. Staff found R1 lying on her back, alert and oriented, with a small abrasion on her forehead. She denied any associated pain and exhibited no visual concerns or speech difficulties. The note documented R1 expressed significant pain in her right forearm, particularly when R1 attempted to move it. The staff observed a skin tear on R1's left lower extremity and promptly applied first-aid. The staff obtained vital signs and due to the persistent pain in R1's right forearm and the presence of a skin tear, the staff called for an ambulance. The note documented the staff carefully transferred R1 directly from the van to the ambulance for transport to a hospital.An Emergency Department (ED) Provider Note dated 02/02/26 at 10:27 PM, documented R1 had a fall from a wheelchair while in a moving transport vehicle. The note further documented R1 had multiple injuries after falling, including proximal humerus fracture and a large skin tear of her lower leg. The note documented R1 had significant generalized weakness and was a frail elderly woman. The note documented the large skin tear and noted the laceration was pulled together and looked better. R1 admitted for observation and further evaluation.On 02/11/26 at 11:17 AM observation revealed the facility had two transport vans. Both transport vans had a have you fastened your seat belt sign placed in the vehicle. The Van R1 was transported in had large metal floor with straps to secure wheelchairs for transport.On 02/11/26 at 12:51 PM R1 sat in her wheelchair in an office room. R1 had a bruised area around the top of her right eye. R1 had a black sling on her right arm. R1's right arm rested across her abdomen, and she used her left hand to hold her right arm in place. R1 stated Activity Staff Z was taking her back to the facility in the transport van. She stated when they went over a hill, they could see a bus stopped and there were cars in front of them. R1 stated Activity Staff Z put on his brake, and she was propelled forward out of her wheelchair. R1 stated she did not have a seatbelt on at the time. R1 stated she was normally not able to use her right arm as it was paralyzed, but she stated she kept saying her arm was broken after she fell out of her wheelchair. She stated she normally moves her right arm with her left hand and was not able to move it due to the pain. R1 stated the amount of pain she had, and not being able to move it, was why she knew it had to have been broken. R1 stated she must have hit her head because she ended up with a bruise over her eye. R1 further stated she had a skin tear on her left skin and it was bleeding. She stated she did not notice her skin tear until she arrived at the hospital. R1 stated once she arrived at the hospital, they performed x-rays and found she had a fracture to her right arm. R1 stated Activity Staff Z and herself had both forgotten to put her seatbelt on. R1 stated she did not know what happened to cause them to forget to put her seatbelt on. She stated it has never happened before, but this time it did for some reason. On 02/11/26 at 01:23 PM Activity Staff Z stated he had taken R1 to a doctor's appointment at a local hospital and was on the way back to the facility with her. Activity Staff Z stated he was traveling down a local highway and crested a hill. He stated as he was going over the hill he saw a school bus in the other lane that had stopped to let children off. He stated there were cars in his lane and he had to apply the brakes quickly. Activity Staff Z stated when he put on the brakes, R1 fell out of her wheelchair and onto the floor of the transport vehicle. He stated there was no shoulder to pull off from and he knew he could not get R1 back in the wheelchair. Activity Staff Z stated he and R1 were only a few minutes away from the facility, he thought about a mile and a half, so he drove her back to the facility for help. Activity Staff Z stated R1 was lying on her right side while driving back. He stated once they arrived at the facility, staff had called an ambulance. Activity Staff Z stated staff and EMS responders assisted R1 in the ambulance and she was taken to the hospital. Activity Staff Z stated staff later found out R1's arm was broken. Activity Z stated he felt terrible about the situation and the two of them had been friends for over 30 years. He stated he typically transported residents about once per week, and he had never forgotten to put a resident's seatbelt on before. He stated that was the only time I have had that happen. There was no excuse. I screwed up. He stated he has not been allowed to transport residents further and will instead help with activities in the facility. He stated he was suspended and had to go over safety and transfer protocols. On 02/11/26 at 03:36 PM Licensed Nurse (LN) G stated she was with another resident when Activity Staff Z arrived at the facility with R1. LN G stated she went out and was told that R1 had a fall in the van. LN G stated R1 was lying on her back in the van. She stated R1 had a wound to her left lower leg that was bleeding. She stated staff obtain supplies to treat her leg wound. She stated she got R1's vitals and they were good. LN G stated R1 complained of pain in right arm, so staff called the ambulance and R1 was transferred over to the hospital. She sated staff did not move R1 due to pain until the ambulance arrived. LN G stated once EMS arrived, the ambulance team and a few staff assisted with getting R1 onto the stretcher and she was transported to the hospital. On 02/11/26 at 11:33 AM Administrative Staff A stated Activity Staff Z was a backup driver for the facility. She stated the facility had transported residents 28 times since 01/01/26, and Activity Staff Z had done eight of those transports. She stated Activity Staff Z was suspended pending an investigation and was told he would not be able to transport residents further until the facility finished their investigation and corrective actions were taken. She stated R1 had asked the facility not to fire Activity Staff Z as he was loved by the residents in the facility. Administrative Staff A stated they decided to only have Activity Staff Z do activities with residents going forward. She stated Activity Staff Z would no longer be able to transport residents. Administrative Staff A stated the facility placed signs in the transport vans to remind staff, and residents, to use the seat belts. She stated since Activity Staff Z was no longer going to be a driver, the facility had to train three other staff to be back-up drivers. She stated they provided education and in-services for those staff. She stated they covered everything that was expected of them and went through a checklist with those staff. Administrative Staff A stated the incident was covered in their QA meetings and the incident would be discussed further today in their next meeting. She stated she spoke to three other alert and oriented residents that had been transported by Activity Staff Z before, and they had informed her Activity Staff Z always used a seatbelt with them. Administrative Staff A stated R1 had an x-ray and was found to have had a right humerus fracture and was in a sling. Administrative Staff A stated the fracture did not require surgical repair. Administrative Staff A stated R1 further had a skin tear to her left shin and was being treated by wound care for it. She stated R1 must have hit her head during the incident as R1 had a contusion to her forehead, above her right eye. She stated R1 was alert and oriented. Administrative Staff A stated R1 would be able to say what exactly happened as she was with it cognitively.The facility's undated Resident Abuse and Neglect policy documented it was the policy that every resident should be free from neglect or abuse of any type. Any allegation of neglect or abuse, either verbal, physical, mental or sexual will be investigated and if corroborated, reported to the appropriate state agency. All alleged perpetrators employed by the community may be suspended pending the completion of the investigation.The facility's undated Vehicle Use by Qualified Drivers General Procedures policy documented the purpose of this policy is to outline qualified drivers and general transportation procedures. This policy applies to anyone using a facility transportation vehicle. Qualified drivers and those who accompany elders will see that elders are safe and secure during transports. If the elder is transported in a manual wheelchair or a motorized wheelchair/scooter, the qualified driver will secure the device in the van per securement device. Any and all elders and passengers, including the qualified driver, will wear a seat belt at all times the vehicle is in motion, without exceptionOn 02/11/26 Administrative Staff A was provided a copy of the IJ template and notified of the facility failure to ensure staff applied the seatbelt to R1 prior to transporting in the facility transportation van, which led to R1 falling forward to the floor of the facility van after rapidly breaking on the highway and caused a fractured arm to R1, and placed R1 in immediate jeopardy.On 02/03/26 the facility completed corrective actions which included suspension of Activity Staff Z, education provided regarding transportation safety to their only other facility driver and placed signs in the vehicles to provide visual reminders to residents and the driver to put on seat belts. Activity staff Z was no longer allowed to drive for the facility going forward.Due to the corrective actions completed prior to the onsite survey, the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to handle all soiled linen as contaminated and use appropriate barriers while sorting soiled laundry to prevent contamination of clean linens. This placed the residents at increased risk for infectious diseases. Findings included: - On 12/10/24 at 02:38 PM, observation of the Laundry area with Housekeeping U revealed two commercial washing machines and dryers. The area was divided into a soiled and clean area. The soiled side had the washing machine and the clean side had the dryer and folding areas. Housekeeping U reported a company tests the water temperatures and the dispensing machine for correct settings. Housekeeping U stated if there was an infectious process happening in the building, she would receive this information in a verbal report. Housekeeping U reported she only used gloves to sort the soiled laundry and did not don a gown or apron. She said she tried not to let any soiled laundry touch her clothing but could understand the possible transfer of soiled or infectious materials from her clothing, after sorting the soiled linens, to the clean laundry while sorting and folding. On 12/10/24 at 02:55 PM, Administrative Nurse D stated the laundry personnel should wear a barrier of some type while sorting through soiled laundry. The facility's undated Laundry Protocols policy documented it was the policy of the facility to prevent the spread of infection by appropriate separation, collection, laundry, and storage of laundry. Facility staff will handle, store, process, and transport linens in a method to prevent the spread of infection. The laundry room will be equipped with a handwashing sink and alcohol gel dispensers in addition to appropriate supplies of personal protective equipment including but not limited to impervious gowns and gloves of appropriate sizes. The facility failed to handle all soiled linens as contaminated and use appropriate barriers while sorting soiled laundry. This placed the residents at risk for infectious diseases.

The facility had a census of 49 residents. The sample included 13 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R)25 with written information regarding the facility's 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: - R25's Electronic Medical Record (EMR) recorded diagnoses of pleural effusion (abnormal accumulation of fluid in the lungs), cellulitis (a bacterial infection that affects the skin and tissues beneath it), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and hypertension (HTN-elevated blood pressure). R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had severely impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADL). The Activities of Daily Living Care Area Assessment (CAA), dated 08/27/24, recorded R25 had a significant change in care needs and was less talkative and mumbled at times. R25 had decreased intake with weight loss and a cellulitis infection. The CAA documented R25 has had a gradual decline in mobility, incontinence, and pain; she was sleeping more, and using a full-body lift. R25's Care Plan, dated 12/04/24 recorded R25 chose hospice due to a diagnosis of hypertensive heart disease and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The care plan documented that staff would observe and report signs of localized infection, pain, redness, swelling, tenderness, loss of function, or heat at the infected area. The care plan documented that staff would watch for nonverbal signs of pain, increased restlessness, agitation, and grimacing. The Nurse's Note dated 08/23/24, at 10:56 AM, documented the nurse went into the resident's room that morning to administer morning medications. R25 was very red, flushed in the face, and sweating. The nurse assessed the cellulitis in R25's abdominal folds and noted the cellulitis had spread to her left leg and across her abdomen. The resident was in a lot of pain and staff administered pain medication. The nurse spoke with the resident's representative and the representative requested the resident be sent to the hospital for evaluation. At 10:48 AM the resident was transported to the hospital. The Nurses Note dated 08/25/24 at 01:39 PM documented the resident was admitted to the hospital. R25's clinical record lacked evidence a copy of the bed hold policy was provided to the resident and the facility was unable to provide evidence upon request. On 12/11/24 at 09:15 AM, Social Service X verified the facility had not provided the resident or her representative the bed hold notice when R25 was transferred and admitted to the hospital on 08/23/24. The facility's Bed Hold policy, undated, documented before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility would provide information to the resident and/or resident representative that specifies the duration of the state bed hold policy during which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; the facilities' policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The policy documented at the time of admission, the resident and/or representative/legal guardian and interested family member would be provided verbal and written copies of the bed hold policy, and signed confirmation of receipt of the policy would be maintained in the resident's clinical record. Facility staff would follow up with the resident/representative if confirmation is not received in three business days. The facility staff would call the resident/representative for phone confirmation of receipt and a reminder to return the form to the facility at the first possible opportunity and phone confirmation of receipt would be documented in the resident's clinical record. The facility failed to provide R25 with a copy of the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to notify the physician and seek treatment for Resident (R)11, who's genitals were red and swollen. This placed the resident at risk for pain and infection. Findings Included: - The Electronic Medical Record (EMR)for R11 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), overactive bladder (the muscles of the bladder start to contract on their own even when the volume of urine in the bladder was low), and chronic kidney disease, stage three (mild to moderate kidney damage). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R11 had frequent bladder incontinence and had no skin issues. The Care Plan, dated 10/16/22, documented R11 was at risk for urinary tract infections, was frequently incontinent of urine, and directed staff to monitor his skin daily during cares and with showers and baths. The Nurse's Note, dated 12/10/22 at 11:20 AM, documented R11's genitals were swollen and red. The note further documented R11 was uncircumcised (retains the foreskin, which covers the head of a nonerect male genitalia), and the head of the male genitalia was red, swollen, and tight to the touch. The note documented the skin on the glans (the rounded part forming the end of the male genitalia) was noted to be covered with large flakes that appeared to be skin. R11 reported that the entire area was uncomfortable. The note lacked documentation the physician was notified for treatment. The Nurse's Note, dated 01/03/23 at 09:57 AM, documented R11's genitals was red and swollen, and he stated he had some discomfort. The note further documented R11 often fondled himself, and the physician would be notified. The Physician Order, dated 01/03/23, directed staff to administer Diflucan (an antifungal medication), 150 milligrams (mg), by mouth, weekly and doxycycline (an antibiotic), 100 mg, by mouth, twice a day, for 10 days. The ordered documented a diagnosis of phimosis (abnormal tightness of the foreskin). On 01/03/23 at 09:45 AM, observation revealed the skin that covered R11's male genitalia was red and he stated it was uncomfortable. On 01/03/23 at 08:58 AM, Licensed Nurse (LN) I stated she had not contacted the physician regarding R11's genitals in December and thought that it was getting better. LN I further stated she had thought it was from urinary discomfort and she stated she should have contacted the physician for treatment. On 01/03/23 at 01:07 PM, Certified Nurse Aide (CNA) M stated she noticed R11's genitalia were red for the last two days and the nurse was already aware. On 01/04/23 at 11:00 AM, Administrative Nurse D stated she did not know if she would have contacted R11's physician about the redness because R11 was a complicated resident and often messed with his genitals. On 01/04/23 at 01:14 PM, LN J stated she wrote the nurse's note on 12/10/22 and the resident's genitals were better the next day. LN J stated she should have documented that his skin was better the next day. The facility Nurse Notification of Physician, Resident Representative of Changes policy, undated, documented the facility made appropriate notification to the physician and delegated Non-Practioner and immediate notification to the resident and/or representative when there was a change in the resident's condition, or an accident that may require physician intervention. The facility failed to notify the physician and seek treatment for R11,who had red, swollen genitalia. This placed the resident at risk for pain and infection.

The facility had a census of 49 residents. The sample included 13 residents, with three reviewed for non-pressure related skin conditions. Based on observation, record review, and interview, the facility failed to treat Resident (R) 11's male genitalia which was swollen and red. The facility further failed to implement interventions to prevent skin tears for R36, who received four skin tears during transfers and cares. This placed the residents at risk for infection and further injury. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), overactive bladder (the muscles of the bladder start to contract on their own even when the volume of urine in the bladder was low), and chronic kidney disease, stage three (mild to moderate kidney damage). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R11 had frequent bladder incontinence and had no skin issues. The Care Plan, dated 10/16/22, documented R11 was at risk for urinary tract infections, was frequently incontinent of urine, and directed staff to monitor his skin daily during cares and with showers and baths. The Nurse's Note, dated 12/10/22 at 11:20 AM, documented R11's genitals were swollen and red. The note further documented R11 was uncircumcised (retains the foreskin, which covers the head of a nonerect male genitalia), and the head of the male genitalia was red, swollen, and tight to the touch. The note documented the skin on the glans (the rounded part forming the end of the male genitaia) was noted to be covered with large flakes that appeared to be skin. R11 reported that the entire area was uncomfortable. The note lacked documentation the physician was notified for treatment. The Nurse's Note, dated 01/03/23 at 09:57 AM, documented R11's genitals was red and swollen, and he stated he had some discomfort. The note further documented R11 often fondled himself, and the physician would be notified. The Physician Order, dated 01/03/23, directed staff to administer Diflucan (an antifungal medication), 150 milligrams (mg), by mouth, weekly and doxycylcine (an antibiotic), 100 mg, by mouth, twice a day, for 10 days. The ordered documented a diagnosis of phimosis (abnormal tightness of the foreskin). On 01/03/23 at 09:45 AM, observation revealed the skin that covered R11's male genitalia was red and he stated it was uncomfortable. On 01/03/23 at 08:58 AM, Licensed Nurse (LN) I stated she had not contacted the physician regarding R11's genitals in December and she thought that it was getting better. LN I further stated she had thought it was from urinary discomfort and should have contacted the physician for treatment. On 01/03/23 at 01:07 PM, Certified Nurse Aide (CNA) M stated she noticed R11's genitalia were red for the last two days and the nurse was already aware. On 01/04/23 at 11:00 AM, Administrative Nurse D stated she did not know if she would have contacted R11's physician about the redness because R11 was a complicated resident who often messed with his genitals. On 01/04/23 at 01:14 PM, LN J stated she had written the nurse's note on 12/10/22 and the resident's genitals were better the next day. LN J stated she should have documented that R11's skin was better the next day. The facility's Perineal Care Protocol policy, undated, documented perineal care would be provided q shift and as needed based on the individualized needs of the elder. For male elders, the penis would be cleansed from the tip of the male genitalia, pulling back the foreskin on uncircumcised males and cleaned. The facility failed to provide treatment timely to cognitively impaired R11, who had reddened, swollen genitals, which placed the resident at risk for pain and infection. - The Electronic Medical Record (EMR) for R36 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), leg edema (swelling), chronic kidney disease, stage 3 (mild to moderate kidney damage), and hypertension (high blood pressure ) The Annual Minimum Data Set (MDS), dated [DATE], documented R36 had intact cognition and required extensive assistance for transfers, toileting, and dressing. The MDS further documented R36 had no skin tears. The Skin Care Plan, dated 10/20/22, documented R36 was at risk for skin breakdown, and had a history of multiple skin issues. The care plan directed staff to monitor her skin daily during showers and cares for any changes. The Nurse's Note, dated 11/27/22, documented R36 obtained a skin tear to her right shin (the front of the leg below the knee) which measured 0.5 centimeter (cm) x 0.5 cm while transferred from her bed the her wheelchair. The note further documented the area was cleansed with normal saline, the edges of the skin were approximated, and steri strips (wound closure tape) applied. The Nurse's Note, dated 12/24/22 at 01:00 PM, documented R36 obtained a small skin tear to her right shin which measured three cm in length. The note further documented the edges of the wound were approximated, and steri strips were applied. The Nurse's Note, dated 12/28/22 at 09:06 AM, documented R36 had obtained two new skin tears which measured 1cm across, to her right shin from the zipper of her jeans during staff assistance. The note further documented the skin tears were cleansed with normal saline, wound edges approximated and Mepitel (a transparent wound dressing) applied. On 01/03/23 at 09:00 AM, observation revealed R36 sat in her wheelchair. Further observation revealed the lower part of her legs were exposed and she had ankle socks on; there were two areas on her right shin that were covered with a thin transparent dressing. On 01/03/23 at 01:00 PM, observation revealed brown geri sleeves (protective sleeves used to protect arms and legs from friction and shearing) on R36's legs. On 01/04/23 at 12:14 PM, observation revealed R36 did not have any geri sleeves on her legs for protection. On 01/03/23 at 09:07 AM, Licensed Nurse (LN) I stated she had planned to put geri sleeves on R36, but had just not gotten to it yet. On 01/03/23 at 02:20 PM, Certified Nurse Aide (CNA) M stated she was unsure how the resident had obtained the last skin tears. CNA M said she knew staff were told R36 would be wearing geri sleeves for protection. On 01/04/23 at 11:00 AM, Administrative Nurse D stated she probably would not have put anything on R36's legs for protection because she did not feel there was a pattern to R36's skin tears on the right shin. On 01/04/23 at 12:15 PM, LN J stated she was unaware that R36 was to wear geri sleeves on her legs but would put them on her. The facility's Wound Management policy, undated, documented staff would be involved in prevention and treatment of wounds and the facility expectation of all caregivers would be to observe resident's skin integrity during the daily provision of the resident's personal care. The facility failed to implement interventions to prevent skin tears for R36, who had fragile skin and a history of repeated skin tears, placing the resident at risk for further injury.

The facility had a census of 49 residents. The sample included 13 residents with two reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 26's environment remained free of accident hazards, when staff failed to include an air mattress and grab bar on R26's side rail assessment in order to identify risk factors. This placed the resident at risk for accidents and related injuries. Findings included: - R26's Electronic Medical Record (EMR) documented she had diagnoses of history of falling, osteoarthritis (degenerative joint disease), and weakness. R26's Admission Minimum Data Set (MDS), dated [DATE], documented the resident required extensive staff assistance with activities of daily living (ADLs) and was independent with eating. The MDS documented R26 had a fracture related to a fall in the last six months. R26's ADL Care Area Assessment (CAA), dated 11/27/22, documented R26 was a new admit to facility, had been declining in mobility and ADL functioning and required staff assistance with daily ADL functioning. R26's Side Rail Assessment, dated 11/21/22, documented she had poor bed mobility, or difficulty moving to a sitting position. She was not currently using a side rail for positioning or support, did not express a desire to have side rails raised while in bed. The assessment further revealed a half side rail, full side rail, or grab bar was not indicated at that time for positioning or support. The assessment documented R26 did not have a low air loss mattress on her bed and there was not a gap between the side rails, between the mattress and bottom side rail or between lower rail and footboard. R26's clinical record lacked further Side Rail Assessment after 11/21/22 but prior to 12/09/22. R26's Pressure Ulcer Care Plan, revised 12/01/22, documented she had a low air loss mattress to bed. R26's ADL Care Plan, revised 12/01/22, documented R26 required one to two staff assistance with bed mobility and repositioning. The care plan documented R26 did not have rails on her bed to assist her with mobility and repositioning. The Nurse's Note, dated 12/09/2022, documented R26 was heard yelling out for help at 02:25 AM. Upon entering the room, R26 was observed with her head between the mattress and guardrail, lying on her left side. R26's body was in the bed, her feet dangled off the bed, all her bedding had been pushed off the bed onto the floor, and the mattress was shoved back against the wall exposing three inches (in) of the bed frame. The note documented R26 was noted to have a faint red mark to left side of her face and scraped her left knee on the bed frame while struggling to push herself back up into bed. When staff asked R26 if she was ok, she stated I'm okay, I was just scared. The note documented staff changed and repositioned R26 in bed with several pillows to avoid a reoccurrence. On 12/29/22 at 08:52 AM, observation revealed R26 rested in bed on a low air mattress, on her back, with her eyes closed. Further observation revealed the grab bar on the left side of her bed was in the up position. On 12/29/22 at 01:01 PM, Licensed Nurse (LN) G verified she completed the 11/21/22 side rail assessment and failed to document R26 had a grab bar. LN G stated R6 did have one at the time of the assessment. LN G stated R26 was up in the rail on 12/09/22 but was not caught and it never transpired again. On 12/29/22 at 09:31 PM, LN H, per telephone interview, stated she was the nurse that witnessed the occurrence on 12/09/22. LN H stated she jotted down a quick note. LN H stated R26 yelled out, she entered R26's room. R26 was lying on her left side, her thighs and trunk were still on the bed, her lower legs dangled off the bed, her head was in a V position with her left check touching the mattress and right cheek touched the grab bar, but R26 was not wedged in and her face did not touch the bed frame. LN H stated she asked the resident what she was doing and the resident stated oh honey and went on to say she was glad LN H was there, R26 was trying to get up and was scared. LN H stated R26 had a red mark on the right side of her cheek. LN H said after the incident, she kept checking on R26 and after 30 minutes, the mark resolved. On 12/29/22 at 12:50 PM, Administrative Nurse D stated she was aware of R26's occurrence when she had her head against the grab bar on 12/09/22, and the nurse reported to her R26's head was not caught between the side rail and mattress. Administrative Nurse D verified the 11/21/22 side rail assessment lacked documentation regarding assessment of R26's air mattress and grab bar. The facility's Bed Inspection Policy, undated, documented it was the policy of the facility to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of potential entrapment or other safety hazards. The facility failed to ensure R26's environment remained free from accidents, when staff failed to include documentation regarding assessment of R26's low air mattress and grab bar on her side rail assessment, dated 11/21/22, and R26 had an occurrence with the gap between them. This placed the resident at risk for an accident.

The facility had a census of 49 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to follow physician orders to treat and report elevated blood sugars for one sampled resident, Resident (R) 13. This placed the resident at risk for continued elevated blood sugars and adverse side effects. Findings included: - The Physician Order Sheet, dated 11/01/22, recorded R13 had diagnoses of insulin dependent diabetes (body requires insulin to regulate blood sugar levels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), chronic respiratory failure with hypoxemia (abnormal deficiency of oxygen in the arterial blood) and long-term insulin use. The Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R13 had a Brief Interview for Mental Status score of 15 (cognitively intact) with disorganized thinking. The MDS recorded R13 required limited to extensive staff assistance with activities of daily living (ADLs) and received insulin seven days a week. Review of R13's Diabetic Care Plan, dated 10/29/22, directed staff to check the resident's blood sugar and administer insulin as ordered by the physician. The Diabetic Care Plan directed staff to monitor R13 for symptoms of hypoglycemia (low blood sugars) and hyperglycemia (elevated blood sugars) and notify the physician as needed. The Physician's Order, dated 10/02/22, directed staff to administer Novolog insulin (fast-acting insulin to control blood sugars around mealtime) per the insulin sliding scale (varies the dose of insulin based on blood sugar levels), recheck blood sugars in one hour after administering ten or more units of insulin (blood sugars greater than 300 milligrams per deciliter (mg/dl) and notify the physician when administering 14 or more units of insulin (blood sugars greater than 350 mg/dl). The Pharmacist Consult Recommendation, dated 12/15/22, directed the nurses to complete documentation regarding the physician ordered treatment and notification of R13's elevated blood sugars Review of R13's December 2022 Medication Administration Record (MAR) revealed the following blood sugars above the physician ordered parameters and no documentation of reassessment after one hour or physician notification: 12/16/22 at 12:30 PM - 350 mg/dl 12/19/22 at 04:52 PM - 318 mg/dl 12/23/22 at 12:36 PM - 335 mg/dl 12/24/22 at 09:24 AM - 331 mg/dl 12/27/22 at 04:44 PM - 395 mg/dl 12/28/22 at 04:29 PM - 340 mg/dl 12/28/22 at 07:37 PM - 355 mg/dl 12/29/22 at 07:42 PM - 313 mg/dl 12/31/22 at 04:34 PM - 323 mg/dl On 12/28/22 at 12:21 PM, observation revealed R13 sat in a wheelchair at the dining table eating lunch. On 01/04/22 at 08:51 AM, Administrative Nurse D stated staff should check R13's blood sugar as ordered by the physician and provide treatment and physician notification for elevated blood sugars as ordered by the physician. The undated Diabetic Guidelines Policy directed staff to follow physician orders to check blood sugars, provide assessments, treatments and physician notification. The facility failed to follow physician orders to treat and report R13's elevated blood sugars, placing the resident at risk for continued elevated blood sugars and adverse side effects.

The facility had a census of 60 residents. Based on record review and interview, the facility failed to provide 12 hours of training as required in the past year, for 13 of 13 certified nurse aides reviewed, who have been employed at the facility over a year to ensure competency in appropriate care for the residents of the facility. Findings included: - Review of 13 Certified Nurse Aide employee records revealed the following staff lacked the required 12 hours of education, in the past year. 1. Certified Nurse Aide LL, hire date of 06/02/2015. 2. Certified Nurse Aide MM, hire date of 10/29/13. 3. Certified Nurse Aide NN, hire date of 01/26/18. 4. Certified Nurse Aide OO, hire date of 06/30/17. 5. Certified Nurse Aide PP, hire date of 01/17/18. 6. Certified Nurse Aide, QQ, hire date of 12/04/17. 7. Certified Nurse Aide RR, hire date of 12/15/17. 8. Certified Nurse Aide SS, hire date of 01/10/17. 9. Certified Nurse Aide TT, hire date of 05/08/12. 10. Certified Nurse Aide UU, hire date of 10/27/15. 11. Certified Nurse Aide VV, hire date of 05/31/16. 12. Certified Nurse Aide WW, hire date of 01/29/13. 13. Certified Nurse Aide XX, hire date of 08/11/10. On 08/21/19 at 7:45 AM, Administrative Nurse D and Administrative Staff A reported the facility had a meeting monthly, and sometimes twice a month about an hour long. On 08/21/19 at 12:05 PM, Certified Nurse Aide (CNA) N reported the staff have an inservice monthly, which was usually around an hour or less, but longer then 30 minutes. On 08/21/2019 at 12:17 PM, Administrative Nurse D reported she does not keep track of the minutes at the inservices. The meetings cover areas such as oral care, charting, abuse and restorative. Nurse D further reported she did not have a breakdown of how long each training of each subject was and could not provide verification as she does not track the training. The undated facility policy entitled Required Training and Inservices of Certified Nursing Assistants documented it was the policy of the facility that all certified personnel including, but not limited to, Certified Nurse Aides (CNA) and Certified Medication Aides (CNA) participate in regularly scheduled inservice training classes based on Federal Rules of Participation and on identified educational needs of each individual staff member through competency evaluations. The facility Human Resource department documents that each applicant has the education and experience required by their job responsibilities. The facility failed to complete the required 12 hours of education for the 13 CNAs reviewed, who had been employed over a year and based on each staff's completed performance evaluations to ensure competency in providing care to the residents of the facility.

The facility reported a census of 60 residents. Based on observation, interview, and record review, the facility failed to maintain a sanitary, orderly, and comfortable interior in two of three neighborhood hallways, two spas, and five resident rooms, for the residents of the facility. Findings included: - Observations during the initial tour of the facility, on 08/19/19 at 10:20 AM, and during the environmental tour with Maintenance staff U, on 08/22/19 at 09:04 AM, revealed the following areas/items noted to be in need of repair and/or cleaning: The Evergreen Neighborhood Two resident rooms with carpeted floors had a heavy brown discoloration, the largest approximately two by three feet in diameter. Two carpeted hallways with numerous brown discolorations. One resident room had a recliner, identified as a facility recliner, with an area on the arm rest that lacked fabric. Two resident wheelchairs that had torn arm rests. One resident wheelchair had black electrical tape on both wheelchair locks. Two resident hallways had dead bugs in the ceiling light fixtures. One resident hallway had three ceiling tiles with brown discolorations. A spa room had hair in the bottom of a drawer. A spa room contained five unlabeled dirty electric razors, a facility razor with a build-up of hair, and five, unlabeled combs, that had hair and a white build-up between the teeth of the combs. A spa room had two wheelchair cushions stored directly on the floor. The Lilac Neighborhood A community shower room had a brown discoloration on the outside of the wall. The resident hallway had dead bugs in two of the ceiling light fixtures. On 08/21/19 at 01:40 PM, Administrative Nurse D reported razors and combs should be labeled. Staff should store resident items in the resident rooms. On 08/22/19 at 09:04 AM, Maintenance staff U verified the above noted areas of concern. The facility's undated policy for General Cleaning and Maintenance of Resident Environment, documented environmental Service and Custodial staff would keep furnishings and equipment safe and in good repair. Management staff and clinical Nursing staff would follow an infection prevention and control plan, and staff would provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, functional, and comfortable interior. The facility failed to maintain a sanitary, orderly, and comfortable interior in two of three neighborhood hallways, two spas, and five resident rooms, for the residents of the facility.

The facility reported a census of 60 residents. The sample of 17 residents, included one resident reviewed for baseline care plans. Based on observation, interview, and record review, the facility failed to provide the one resident reviewed, Resident (R) 159 with a summary of the baseline care plan. Findings included: - The signed physician order [REDACTED]. The Interim Plan of Care (base line care plan), dated 08/09/19, documented the resident required assistance with personal hygiene, bathing, dental hygiene, toileting, and mobility. He required a wheelchair for mobility. The resident had bruising/swelling to his right groin area. He received Physical and Occupational therapy. He required safety fall prevention, and staff should keep his call light in place and provide frequent checks. The care plan, dated 08/15/19, for constipation and dehydration risk documented to assess the resident for unusual pattern of elimination each shift. The care plan included for staff to encourage the resident to drink fluids throughout the day as well as meal times unless contraindicated due to a medical condition. Provide the resident and family with a written list of medications and instructions when the resident was able to return home after therapy. Staff should minimize background noise as possible due to the resident's hearing impairment. Staff should provide large print items and books for the resident's visual impairment. The resident required assistance with oral care twice a day. The facility failed to complete his/her favorite foods. Offer and include the resident in activities pain and back pain relief included changing positions, lying down, walking Staff should assist and encourage the use of compression hose due to his [MEDICAL CONDITION] in his legs However, staff failed to provide a written summary of his care plan. On 08/19/19 09:50 AM, the resident reported, I haven't been to any care plan meetings. On 08/20/19 at 11:55 AM, Administrative Nurse E, reported staff completed the resident's base line care plan on 08/09/19, and staff completed the comprehensive care plan on 08/15/19. She verified she failed to give the resident a written summary of the resident's care plan. On 08/20/19 at 01:18 PM, Licensed Nurse (LN) G, reported staff completed an initial care plan on the day a resident admits to the facility, however, staff do not give the resident a copy of the care plan. The facility's undated policy for Baseline Care Plan, documented the facility would develop an initial person-centered care plan . and to ensure the resident and representative are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan or a copy of the baseline care plan. The facility failed to provide the resident with a summary of his baseline care plan, in writing that he could understand, that included the initial goals of the resident, a summary of his medications and dietary instructions, and services and treatments administered by the facility.

The facility reported a census of 62 residents. The facility had 1 main facility kitchen, and 2 kitchenettes. Based on observation and interview, the facility failed to store prepare and store, prepare, and store food under sanitary conditions for the residents of the facility, in the main kitchen and 2 kitchenettes. Findings included: - On 9/26/18 at 2:48 PM, observation of 1 kitchenette identified the following areas in need of cleaning: 1.) One cabinet above the sink, had peeling veneer on the shelves exposing the wood beneath, which made the shelves a non-cleanable surface. 2.) The cabinet by the coffee machine contained two shelves with a layer of grime. 3.) The cabinet below the ice machine contained a shelve with peeling veneer, exposing the wood beneath, causing a non-cleanable surface. 4.) A large pull out drawer under the microwave contained brown colored stains in it. 5.) A small pull out drawer contained discolored spots in it. On 9/27/18 at 12:50 PM, administrative staff A acknowledged the areas required cleaning. The undated facility policy for dietary cleaning procedures, advised the staff would use a clean as you go technique to keep the facility and neighborhood kitchen areas clean, functional and attractive. The staff members are responsible for checking the cleaning schedule daily to ensure that tasks scheduled for that day are performed. The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for the residents of the facility, in the first kitchenette. - On 9/26/2018 at 10:00 am, a tour of the main kitchen, with dietary staff F revealed the following areas required cleaning: 1.) One ceiling vent in the dry storage area a contained a layer of grime. 2.) Five cutting boards contained deep cuts, creating a non-cleanable surface. 3.) One non stick skillet with flaking, nonstick surface. 4.) The hood vent, above the cooking stove, with a thick layer of grime on the vent. 5.) The ceiling vent, in the dish washing area, with layer of grime build-up. On 9/26/18 at 11:00 am, a tour in the second kitchenette area revealed the following areas required cleaning. 1.) Eight nonstick skillets with flaking non stick surfaces. The kitchen environment checklist, identified on 8/13/18, an outside company cleaned hood vent. The undated facility dietary cleaning procedures policy , documented the following: 1.) Follow and document kitchen cleaning schedule form monthly the following equipment will be cleaned: Stove hood and filters. 2.) Staff will use clean as you go technique to keep the facility and neighborhood kitchen areas clean functional and attractive. 3.) Staff members are responsible for checking and cleaning the schedule daily to ensure that tasks scheduled for that day are preformed. The facility failed to store, prepare, distribute and serve food in a safe and sanitary manner in the main kitchen and in the second kitchenette to the residents of the facility.

Based on observation, interview and record review, the facility failed to accurately assess the level of assistance required for the performance of Activities of Daily Living (ADLs) for two of 18 residents (Resident (R) 15 and 47) selected for review. Furthermore, the facility failed to accurately assess resident (#38) related to hospice services. Findings include: - Review of R15's annual Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 07/15/18, specified under Section G, Functional Status, identified staff assessed for bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, the Activity occurred only once or twice in the seven-day assessment period. Review of the MDS specified under Section C: Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS) (a cognitive evaluation) score of 15 out of 15, which indicated the resident had no long or short-term memory impairment. Observation on 09/26/18 at 11:09 AM, R15 propelled his/her wheelchair towards the dining room independently. He/she stated that he/she typically required very little assistance from staff. He/She stated he/she was able to perform most of his/her care him/herself. During an interview on 09/26/18 at 11:12 AM, Certified Nursing Assistant (CNA) E stated R15 was usually independent with his/her daily care, requiring set-up or cueing at times. She/He stated he/she was able to transfer into and out of bed, dressed him/herself, used the toilet independently and was able to feed him/herself his/her meals. During an interview on 09/25/18 at 3:01 PM, MDS Coordinator D, reviewed the assessment in question. She/He explained the assessment was completed in this manner because the resident was typically independent but required supervision once or twice for each ADL during the assessment period. She/He explained this prevented the assessment from being coded Independent and so the staff coded the times the resident required assistance. The facility failed to accurately assess the level of assistance required for the performance of Activities of Daily Living (ADLs) for this resident. - Review of R47's annual MDS, with an ARD of 06/10/18, specified under Section G, Functional Status, staff assessed for bed mobility, transfers, walk in room, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, the Activity occurred only once or twice in the seven-day period. Review of R47's quarterly MDS with an ARD of 09/10/18, specified under Section G, Functional Status, staff assessed the resident as Independent for bed mobility, dressing, eating, toilet use and personal hygiene; and required supervision for locomotion on and off the unit and transfers. Review of R47's MDS with an ARD of 06/10/18 and quarterly MDS with an ARD of 09/10/18, specified under Section C: Cognitive Patterns, the resident had a BIMS score of 15 out of 15, which indicated the resident had no long or short-term memory impairment. Observation on 09/25/18 at 12:19 PM, revealed R47 in the dining room feeding him/herself lunch. He/She stated staff had walked him/her to the dining room and that once they set-up his/her lunch, he/she was able to feed him/herself. During an interview on 09/25/18 at 3:04 PM, MDS Coordinator D stated R47 was usually independent with care but required supervision at times. He/She explained because the resident was not always independent during the assessment period but required assistance only once or twice for each ADL, the assessment was coded as the Activity occurred only once or twice in the seven-day period. On 09/25/18 at 3:42 PM, MDS Coordinator D stated both resident's assessments should have been coded as Supervision based on the available information. The facility failed to accurately assess the level of assistance required for the performance of Activities of Daily Living (ADLs) for this resident. - This deficient practice of the facility failure to complete an accurate MDS also affected hospice resident number 38. The resident's 6/3/18 significant change MDS, failed to identify the resident received hospice services and did identify the resident with 6 months or less life expectancy.

The facility reported a census of 62 residents. The 18 sampled residents, included 5 reviewed for unnecessary medications. Based on interview and record review, the facility failed to monitor blood pressures with antihypertensive medications, for 2 (#4 and #50) of the 5 residents reviewed. Also, the facility failed to follow physician orders [REDACTED].#51) when the resident's blood pressure did not meet physician ordered parameters, the resident received numerous doses of the medications outside of the physician ordered parameters. Findings included: - Resident #4 admitted on [DATE], with the [DIAGNOSES REDACTED]. The CAA (care area assessment), dated 4/4/18, documented the resident had a [DIAGNOSES REDACTED]. The care plan, dated 9/13/18, advised the staff that the resident was at risk for altered cardiac function related to the [DIAGNOSES REDACTED]. (Systolic and diastolic blood pressure are the two values that determine whether blood pressure is normal, too high or too low). A physician's orders [REDACTED]. If the systolic blood pressure was greater than 160 or the diastolic blood pressure was greater than 100, give the medication then notify the charge nurse, ordered on [DATE]. Review of the Medication Administration records for July, (MONTH) and September, (YEAR) revealed the following abnormal pressures: 1.) Blood pressures out of physician parameters of 164/75 on 7/19, 172/93 on 7/21 and 176/83 on 7/28. There was no documentation related to notification and follow-up by the charge nurse. 2.) Blood pressures out of physician parameters of 168/79 on 8/3, 169/88 on 8/4, 167/81 on 8/8 and 187/126 on 8/11. There was no documentation related to notification and follow-up by the charge nurse. 3.) A diastolic blood pressure of 102 on 9/1 and a systolic blood pressure of 165 on 9/8. There was no documentation related to notification and follow-up by the charge nurse. Interview, on 9/27/18 at 8:33 am, with Direct Care Staff C, stated that he/she documented blood pressures in the computer on the Medication Administration Record [REDACTED]. The nurse should follow-up according to physician orders. Interview, on 9/27/18 at 10:13 am, with Licensed Nursing staff G, stated blood pressures out of physician parameters were rechecked with a manual cuff and should be documented in the nurse's note. There should be documentation of the recheck or it was not done. Interview, on 9/27/18 at 9:47 am, with Administrative Nursing staff B, verified there should be nursing documentation and follow-up for blood pressures outside physician parameters. The facility lacked a policy for notification of blood pressures outside of physician parameters. The facility failed to monitor this resident's blood pressures per physician order, to ensure no unnecessary medications for this resident. - The deficient practice also affected resident #50 , who received antihypertensive medications and required blood pressure monitoring. The facility failed to monitor this resident's blood pressures per physician order, to ensure no unnecessary medications for this resident. - Review of the facility's undated policy titled, Medication Administration Policy indicated All medications will be administered to every elder as ordered by a physician in a safe and sanitary manner . The policy directed staff to Take pulse rate PRIOR to cardiac rhythm medication IF physician orders [REDACTED]. The policy also directed, Blood pressures should be taken on all anti-hypertensives IF ordered by physician and holding parameters should be followed IF ordered by physician. Review of the current active Care Plan in R51's electronic medical record (EMR) under the Care Planning section and dated as revised 09/19/18, revealed R51 was at risk for altered cardiac function related to a recent [DIAGNOSES REDACTED]. An additional approach indicated the resident received an anti-hypertensive medication that was to be held for a pulse less than 70. Review of current physician's orders [REDACTED]. The order directed staff to hold the medication for a pulse less than 70. An order dated 09/12/18 directed staff to administer the medication [MEDICATION NAME], extended release, 50 mg once a morning. Staff were to hold the medication if the SBP was less than 100 or the DBP was less than 50 and promptly notify charge nurse. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, on 08/11/18 and 08/12/18, staff administered the [MEDICATION NAME] medication despite R51 having a pulse of less than 70. Staff recorded a pulse of 69 and 66 respectively and that the medication was administered. Review of the (MONTH) MAR indicated [REDACTED]. The medication was administered on 09/07/18 (pulse 67), 09/08/18 (pulse 68), 09/18/18 (pulse 69) and 09/25/18 (pulse 50). In addition, the [MEDICATION NAME] medication was administered on 09/15/18 (DBP 45) and 09/16/18 (DBP 38) even though the resident's blood pressure was outside the physician ordered parameters. In an interview on 09/26/18 at 4:12 PM, Medication Aide C, explained he/she obtained the blood pressure and pulses, and recorded them in the electronic record for each resident on his/her neighborhood who required them prior to administering medications. He/She stated that if the blood pressure or pulse were outside of parameters, he/she would typically obtain them again later and if they had improved, he/she would administer the medication. He/She stated the computer system did not always allow the updated vital signs to be recorded so they would still show the original value. He/She stated he/she did not write a note or notify the charge nurse when this occurred. In an interview on 09/26/18 at 3:00 PM, the Director of Nursing confirmed that the medications had been administered outside the physician ordered parameters. He/She stated staff were expected to follow physician's orders [REDACTED]. He/She stated if a vital sign was obtained that was outside of the physician ordered parameters the Medication Aide should notify the charge nurse at that time. The facility failed to monitor cardiac medications for this resident, when the resident's blood pressure did not meet physician ordered parameters, the resident received numerous doses of the medications outside of the physician ordered parameters.

The facility reported a census of 66 residents. Based on observation, interview and record review, the facility failed to maintain an infection control program to prevent, recognize and control to the extent possible, the onset and spread of infection within the facility with; failure to track and trend infections within the facility with the failure to trend infection and antibiotic use; failure to properly sanitize the glucometer (device to measure blood sugar) and Coagucheck (device to measure clotting time of blood); failure to educate staff in the effective use of chemicals for sanitizing resident room surfaces (wet to dry time); and the failure to provide policies for laundry procedures for isolation laundry as expected, to prevent the spread of infection for the residents of the facility. Findings included: - Interview, on 4-26-17 at 3:00 pm, revealed laundry staff F, revealed he/she did not know if there was a policy for processing isolation linen, but he/she would follow the guideline for the washing machine setting for laundry in red bags. Staff F stated he/she would wear gloves and wash the laundry in red bags separately. Interview, on 4-27-17 at 8:30 am, with administrative staff A, revealed the policy for laundry reflected a water temperature of of 140 degrees to melt the water soluble bag, and he/she would need to revise the policy to advise staff of the water temperature to be 160 degrees for 25 minutes for isolation laundry. The facility policy for laundry and bedding isolation procedures, revised September 2005, advised staff hot water soluble bags are placed directly into the washer and will be washed for a minimum of 10 minutes in water of 140 degrees Fahrenheit or higher to ensure the bag dissolves and the contaminated laundry is decontaminated. The facility failed to ensure the laundry policy included instructions to the staff to measure the water temperature of 160 degrees for 25 minutes to ensure sanitation of isolation laundry. - Observation, on 4-27-17 at 8:31 am, with housekeeping staff D, revealed staff sprayed the surface of the shared resident bathroom sink with(NAME)LD 64 disinfectant spray, and then immediately wiped the sink with paper towels. Staff D states he/she did not know if there was a wet time needed to ensure sanitation of the surface. The label on this product, revealed a 10 minute wet time of the surface for adequate sanitation of the surface. Interview, on 4-27-17 at 8:44 am, with housekeeping staff D, revealed he/she used the(NAME)LD 64 spray cleaner for cleaning the residents bathroom sink and toilet surfaces. Staff d stated he/she did not know if the surfaces needed to stay wet for a period of time before spraying them. Furthermore, staff D stated he/she did not have a procedure for cleaning isolation rooms, but would check with the charge nurse. The label on this product, revealed a 10 minute wet time of the surface for adequate sanitation of the surface. The facility failed to ensure staff education on the wet to dry time of the cleaning products to ensure adequate sanitation of resident room surfaces to prevent the spread of infection amongst the residents of the facility. - Observation on 4-27-17 at 8:47 a.m., revealed licensed nursing staff C, obtained a blood sugar from a resident. Staff C cleaned the glucometer (devise to measure blood sugar) using an alcohol wipe before obtaining the blood sugar. When finished obtaining the blood sugar, staff C wiped the glucometer with a new alcohol wipe before placing it into the medication/treatment cart. On 4-27-17 at 8:47 a.m., nursing staff C stated, he/she usually cleaned the glucometer using an alcohol wipe. Staff C stated the alcohol does not kill any germs, but it was what he/she used. Staff C stated he/she should use the Clorox Commercial Solutions Disinfecting Wipes, which are available to the staff on each nursing unit. At that time, staff C cleaned the glucometer with the disinfecting wipe for approximately 15 seconds. Review of the Clorox Commercial Solutions Disinfecting Wipes label, revealed the necessary wet time for the glucometer to be disinfected was 4 minutes. The wipes did not kill hepatitis viruses. On 4-27-17 at 9:10 a.m., administrative nursing staff B stated, there was currently 15 residents who use the glucometers. Staff B stated the staff were to use a wipe which kills Hepatitis viruses. Staff should not have used alcohol wipes to clean the glucometer. The facility policy for cleaning and decontamination of the glucometer, revised September, 2015, included: Equipment that has been contaminated with blood or other bodily fluids must be decontaminated. Disinfecting needs to be done by using a Germicidal Disposable Wipe such as Sani-Cloth Bleach or a bleach solution with a 1 to 10 ration. It is important to ensure a wet time minimum of 4 minutes is allowed to ensure decontamination has occurred. The facility failed to properly clean the glucometer used by 15 residents of the facility, to prevent spread of infection amongst the residents. - Observation on 4-24-17 at 2:03 p.m., revealed licensed staff G, cleansed the coagucheck (devise to measure clotting time of blood) machine with a Clorox Disinfectant wipe, for approximately 10 seconds. On 4-27-17 at 10:40 a.m., staff G stated, the coagucheck machine was cleaned with Clorox Disinfectant following each use. Review of the Clorox Commercial Solutions, Clorox Disinfecting Wipes, revealed the necessary wet time for the wipes to be effective was 4 minutes. On 4-27-17 at 9:10 a.m., administrative nursing staff B stated, there was currently 9 residents who use the coagucheck machine. Staff B stated the staff were to use a wipe which kills Hepatitis viruses. Staff B stated the Clorox Commercial Solutions, Clorox Disinfecting Wipes did not contain bleach and was not to be used to clean the coagucheck machine. The facility policy for cleaning and decontamination of the glucometer and coagucheck, revised September, 2005, included: Equipment that has been contaminated with blood or other bodily fluids must be decontaminated. Disinfecting needs to be done by using a Germicidal Disposable Wipe such as Sani-Cloth Bleach or a bleach solution with a 1 to 10 ratio. It is important to ensure a wet time for a minimum of 4 minutes is allowed to ensure decontamination has occurred. The facility failed to properly clean the coagucheck used by 9 residents of the facility, to prevent the spread of infection among the residents. - Review of the monthly infection surveillance logs, from April 2016 until April 2017, revealed surveillance documentation from August 2016 until April 2017. No logs were available for the months of April, May, June and July, 2016. Interview, on 4/26/17 at 1:27 pm, with Administrative Nursing Staff B, revealed that no logs were available for April through July, 2016. He/she started working at the facility in August, 2016 and the infection control surveillance was started at that time. The facility failed to maintain an infection control program to prevent, recognize and control, to the extent possible, the onset and spread of infection within the facility by failing to track and trend infections and antibiotic use, for the residents of the facility.

The facility had a census of 70 residents. The sample size was 19. The facility failed to present the development of pressure for 2 of 2 residents sampled with pressure ulcers and to promote healing (#47, #62). Findings included: - The physician's orders [REDACTED].#47 revealed [DIAGNOSES REDACTED]. blood to the area). The Quarterly MDS dated [DATE] documented the resident had long and short term memory problems and severely impaired decision making skills. He/She presented with inattention, which was continuously present and psychomotor [MEDICAL CONDITION] that fluctuated. He/She was totally dependent on 2 staff for bed mobility, transfer, dressing, toilet use and personal hygiene; and extensive assistance of 1 staff for eating. He/She had range of motion impairment to the lower extremities on one side. He/she was always incontinent of bowel and bladder. The resident weighted 183-pounds.He/she had swallowing disorders such as holding food in his/her mouth or cheeks or residual food in mouth after meals after meals, coughing or choking during meals or when swallowing medications. He/she had not experienced weight loss or gain and received a mechanically altered diet. The resident was at risk for developing pressure ulcers and did not have one at the time of assessment. He/she had a pressure reducing device to bed and chair and applications of ointments or medications. He/She was on a turning/repositioning schedule. The Significant Change Status Minimum Data Set ((MDS) dated [DATE] documented staff did not perform the Brief Interview for Mental Status, he/she had sort and long term memory problems and severely impaired decision making skills. He/She was inattentive at all times, and psychomotor [MEDICAL CONDITION] that fluctuates. The mood score of 1 indicated the resident had minimal depression. He/She was totally dependent of 2 staff for bed mobility, transfer, dressing, toilet use, and extensive assistance of 1 staff with eating. He/She had obvious broken teeth or cavities. He/She displayed non-verbal, verbal and pained facial expressions of pain 1-2 days during the look back period. The pressure ulcer measured 3 centimeter (cm) x 2.5-cm x 0.3-cm on 08/20/2015 with increased infection on the foot. A pressure ulcer was not present or at a lesser stage on prior assessment and was documented at a stage 2. The resident utilized a pressure reducing device in his/her chair and bed, a turning/repositioning program and the applications to the feet. The Care Area Assessment (CAA) dated 09/13/2015 for cognitive loss documented the resident had impaired cognition related to end stage Alzheimer ' s dementia and was unable to express needs which placed him/her at risk for unmet needs. The resident was at nutritional risk related to a mechanically altered diet, history of pocketing food, overweight, late stage Alzheimer ' s dementia and medication use. He/She required assistance with all meals. The care plan interventions prior to the development of the pressure ulcer on 08/08/2015 were a low air loss mattress and to assist the resident with changing positions in his/her bed or chair. The care plan revised on 08/08/2015 for pressure ulcers documented the resident had a wound on his/her right outer ankle and to keep heels floated while in bed. The resident needed help changing positions when in the bed or sitting in the chair and wound care as ordered by the physician. The Annual Braden Risk Assessments used to determine a resident ' s risk for pressure ulcer development revealed on 01/15/2015, 04/16/2015, and 07/16/2015 with a score of 10, indicating the resident was at high risk. Dietary notes revealed the following diet orders: 05/14.2015 Liquid: Mechanical soft with pureed meats 08/12/2015 ProSource nutritional supplement (liquid protein) 30-ml daily The Skin/Wound assessments revealed the following: 08/08/2015 documented a pressure ulcer on the right outer ankle 4-centimeter x 4-centimeter x 0.6 centimeter depth, granulation tissue, no tunneling, clear exudate, surrounding tissue was intact, 3+ [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues), no pain present, pressure relieving device to chair and bed, and pressure ulcer care. Dietary referral requested. 08/10/2015 documented a pressure ulcer on the right outer leg which measured 3 centimeter x 2.5 centimeter x 0.4 centimeter tunneling, with moderate amount of exudate, serous skin around ulcer was red, and 1+ [MEDICAL CONDITION] of the lower extremity. 08/17/2015 documented a pressure ulcer on the resident ' s right outer ankle measured 5.0 cm x 4.0 cm x 0.1 cm. Eighty percent of the wound bed was necrotic (pertaining to the death of tissue in response to disease or injury), with no tunneling, moderate exudate purulent (producing or containing pus) with foul odor, macerated (necrotic tissue that has been moist for a prolonged period and has undergone deterioration) around the ulcer, trace [MEDICAL CONDITION]. Wound bed from 3 to 9 o ' clock was macerated. 08/26/2015 documented a pressure ulcer on the right ankle measured 5.5 centimeter x 5.0 centimeter x 0.3 centimeter with necrotic tissue in the center of the wound with the surrounding tissue showing new growth. There was no tunneling, had purulent exudate with a slight odor, surrounding tissue was macerated, and 1+ [MEDICAL CONDITION] of the lower extremity. 09/02/2015 documented a pressure ulcer on right outer leg that measured 5.2 cm x 4.5 cm x 0.2 cm necrotic tissue, new growth appearing in and around the wound, no tunneling, moderate amount of exudate, purulent drainage with slight odor. The area around wound was macerated and 1+ [MEDICAL CONDITION]. 09/09/2015 documented a pressure ulcer on right outer ankle measured 7 centimeter x 5 centimeter x 1.0 centimeter slough-yellow or white tissue that adhered to the ulcer bed in strings or thick clumps. There was no tunneling, moderate amount of exudate, purulent, with foul odor, area around ulcer was macerated, [MEDICAL CONDITION] to the affected area. 09/16/2015 documented a pressure ulcer on right outer ankle 6 centimeter x 4.5 centermiter x 1.0 centimeter slough moderate amount of purulent draining, no odor, macerated, trace, and showed signs and symptoms of pain with non-verbal and facial expressions, protective body movement or postures. A nursing note dated 07/17/2015 at 3:14 P.M. documented clear fluid filled blisters to the right anterior (front) thigh, skin intact, no signs or symptoms of pain during the assessment. Staff applied skin prep applied. The staff were educated to leave brief unfastened while in bed. Staff to continue to apply skin prep twice until resolved. A nursing note dated 07/29/2015 at 1:17 P.M. documented resident received new orders from the dietician for daily multi-vitamin for wound healing. A nursing note dated 07/30/2015 at 11:57 A.M. documented the resident continued to have 2+ [MEDICAL CONDITION] in the left foot. Staff encouraged the resident to keep foot elevated when possible. Physician JJ wanted nursing staff to observe [MEDICAL CONDITION] for the next 5-days, and notify if [MEDICAL CONDITION] got worse. Re-evaluate need for further evaluation in 5-days. A nursing note dated 08/01/2015 at 8:44 A.M. documented the resident had with 3 to 4+ [MEDICAL CONDITION] in bilateral lower extremities and signs and symptoms of pain when staff moved his/her legs. No discoloration, redness, or extra warmth noted, staff notified the on-call physician notified and received new order to increase [MEDICATION NAME] (diuretic) to 40-mg twice a day, and follow up with primary care physician. A nursing note dated 08/08/2015 at 11:52 A.M. documented during care this AM, direct care staff reported the resident had an open area on the right outer ankle. The area measured: 4-centimeters x 4-centimeters with a depth of 0.6. The wound bed beefy red, with lose skin covering the edges were rolled, with normal looking skin around the area. The resident had 3+ [MEDICAL CONDITION] in bilateral lower extremities, and staff notified the notified the physician. A nursing note dated 08/12/2015 documented the resident started on an antibiotic this morning for wound on outer right ankle. A nursing note dated 08/15/2015 at 11:44 A.M. documented increased swelling, redness and necrotic of the wound bed. Nursing contacted the physician. The physician ordered [MEDICATION NAME] (antibiotic) 500-milligrams daily x 2 days, and hold the PO (by mouth) [MEDICATION NAME] (antibiotic) for 2-days after [MEDICATION NAME] was utilized reinstate PO (by mouth) [MEDICATION NAME]. A nursing note dated 08/17/2015 at 2:41 P.M. a STAT (right now) wound culture taken during observation, warmth and redness noted around the wound. A nursing note dated 08/19/2015 at 11:10 A.M. Resident continued on the antibiotic. The wound bed was necrotic, with moderate drainage with a slight odor. A nursing note dated 08/20/2015 at 3:43 P.M. the physician ordered Bactrim DS (antibiotic) twice a day x 5-days A nursing note dated 08/26/2015 at 3:50 P.M. documented the resident finished the antibiotic. The wound bed continued to grow new tissue but the middle of wound bed continued to be black and brown. A nursing note dated 09/02/2015 documented the physician extended order of Santyl (wound debridement) until 9/08/2015 for continued healing. If the area around wound appeared irritated, contact the physician for orders. A physician order [REDACTED].M. The resident was seen today by the physician JJ. He/She ordered an ace wrap to be loosely placed on left lower extremity only and start at the foot and work up to the knee. Resident refused vital signs. The resident had 2+ [MEDICAL CONDITION] with no pain or discomfort this shift. A physician note dated 08/11/2015 at 11:52 A.M. physician JJ saw the resident regarding the pressure ulcer. He/She was not very mobile and had a tendency to externally rotate her right leg so that there is pressure on the right malleolus (a bony projection with a shape likened to a hammer head, especially each of those on either side of the ankle) and he/she had an ulcer on that ankle. The open area measured approximately 1-2 cm probably 2nd degree, a little moist and surrounded by [DIAGNOSES REDACTED] (redness or inflammation of the skin). A physician treatment note dated 09/13/2015 documented apply Santyl ointment 250-units/gram, one application topically. Special instructions: apply nickel thick amount to wound bed only after gently cleaning wound with normal saline and pat dry. Cover with [MEDICATION NAME] foam wrap and wrap with gauze, once daily in the A.M. An observation on 08/15/2015 at 4:00 P.M. the resident sat up in the geri-chair with a pressure reducing seat cushion, boots on bilaterally and eyes closed. An observation on 09/17/2015 at 8:34 A.M. licensed staff J performed wound care on the resident. Staff removed the old dressing and there was a large amount of bloody drainage with a foul odor, the bottom portion of the wound area had a dark purple/black area of beefy tissues, with some slough in the middle and red area at the top. The surrounding area was pink and dry. The right foot rotated inward, and the bony prominence protrudes. Staff dressed the wound and placed back in to the boot. The boot had an approximate 1.5-2 inch foam, stiff, with open in the heel area, and boot was firmly attached with the velcro straps. The great toe laid over the next toe with a red pencil size area on the toe. The left foot had a black area on the end of the second toe about eraser size and the outer edge of the foot near the distal toe was black, about the size of a quarter. Staff replaced the boot replaced and wrapped it tight with velcro. An interview on 09/16/2015 at 2:31 P.M. with direct care staff S stated prior to the heel wounds, staff repositioned him/her in the bed and chair. Since the wound, they added the boots and floated his/her heels. On 09/16/2015 at 3:35 P.M. an interview with licensed nursing staff J stated the resident was at risk for pressure ulcers and he/she developed it the facility. We had issues with [MEDICAL CONDITION] in both lower of his/her lower extremities. The booties were ordered after staff noted the pressure area. The licensed staff confirmed he/she could not find documentation that staff floated heels prior to the pressure ulcer. An interview on 09/17/2015 at 3:05 P.M. administrative nursing staff E stated this resident ' s intake was not monitored nor were the nutritional supplements. On 09/17/2015 at 2:02 P.M. administrative nursing staff D stated this resident had the air loss mattress and staff turned him/her before and after meals and at bedtime. He/She had small booties on but they did not have the heel cut out. He/She was at risk for developing pressure ulcers due to immobility. His/her immobility and nutritional status slowed the process, but he/she did receive ProSource as a supplement. He/She stated the dressing should protect the skin from rubbing, should not cause an indentation. The [MEDICAL CONDITION] compromised the area, which could cause more injury. On 09/21/2015 at 9:09 P.M. physician JJ stated the prevention of pressure ulcers included an individualized care plan that addressed interventions to prevent the development of pressure ulcers, good nutrition, turning/repositioning every 2 hours, and for heel pressure ulcers, a splint versus heel protectors/booties to remove all pressure away the heels. The pressure ulcer policy revised April 2006 documented the facility assessed for risk of developing pressure ulcers and implement appropriate interventions to prevent impaired skin integrity. The facility failed to develop and implement interventions to prevent the development of an unstageable pressure ulcer and failed to ensure this dependent resident with pressure sores received necessary treatment and interventions to promote healing, prevent infection, and prevent the sore from deteriorating. - Resident #62's electronic medical record identified the resident had [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set ((MDS) dated [DATE] identified the resident had short and long term memory impairment, had severely impaired cognition, displayed physical and verbal behavioral and rejected care 1 to 3 days of the 7 day assessment period. The MDS recorded the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, and personal hygiene. The resident was totally dependent upon staff with toilet use and eating, and the activity of walking in the room/corridor did not occur. The resident was occasionally incontinent of bladder, weighed 179 pounds and had not experienced a weight loss. The resident was at risk for the development of pressure ulcer and had no unhealed pressure ulcers. The resident had moisture associated skin damage and had a pressure relieving device in his/her chair. The MDS did not identify the resident had a pressure relieving device on his/her bed and /or was a turning/repositioning program. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 7/3/15 documented the resident spoke in word salad (confused or unintelligible mixture of seemingly random words and phrases, most often used to describe a symptom of a neurological or mental disorder) was inattentive, was not able to make his/her needs known or understand others and was at risk for unmet needs. The resident's Nutritional Status CAA dated 7/3/15 included the resident had a high body mass index (BMI) indicating obesity. The resident was able to feed himself/herself but required staff encouragement at times. The resident had dementia and was at risk for decline in his/her nutrition. The resident's Pressure Ulcer CAA dated 7/3/15 documented the resident was at risk for the development of pressure ulcers due to incontinence and required extensive to total staff assistance with perineum care and was totally dependent upon staff for transfers. The resident did not reposition himself/herself. The resident's care plan dated 7/2/15 addressed the resident was at risk for nutritional impairment related to not being aware of his/her nutritionally needs, dysphagia (swallowing difficulty ) and variable meal consumption intake. The resident might not be able to express his/her likes and dislikes, staff gave the resident time to make choices and offered the resident food alternatives as needed. The resident required staff assistance and/or cueing with meals and staff monitored the resident's intake. The resident ate better if he/she was in a quiet area. Review of the resident's care plan on 9/15/15 at 4:00 P.M. revealed the care plan did not address the resident was at risk for the development of pressure ulcers or currently had an unhealed pressure ulcer. The resident's care plan did not include interventions as to how staff prevented the development of pressure ulcers for this resident. A Physician Facsimile Communication Form dated 7/22/15 included the resident had a tear in the crack (intergluteal cleft -the groove between the buttock that runs from just below the sacrum to the perineum) and staff applied [MEDICATION NAME] (a moisture barrier) and started wound observations. A Skin/Wound assessment dated [DATE] included the resident had multi-colored discoloration on his/her left heel and the ball of his/her left foot. The purplish, black discoloration on the resident's left heel was 4.0 cm wide and 4 cm in length, and the area on the ball of the resident's left foot measured 1.0 cm in length and 1.5 cm in width. A Skin/Wound assessment dated [DATE] documented the area on the resident's intergluteal cleft measured 1 centimeter (cm) in length by 0.5 cm in width. The resident's Skin/Wound assessment dated [DATE] documented the blister on the resident's left heel measured 2.5 cm by 2.5 cm. The resident's Skin/Wound assessment dated [DATE] documented the pressure ulcer on the resident's left heel measured 3.3 cm by 3.0 cm and the pressure ulcer was black, purplish and had a tan soft area that was not open or fluid filled. A Skin/Wound assessment dated [DATE] documented the resident had a pressure ulcer on the right side of his/her intergluteal cleft. The clinical record did not show if/when the pressure ulcer on the resident's intergluteal cleft healed. The resident's Skin/Wound assessment dated [DATE] documented the pressure ulcer on the resident's left heel measured 1.2 cm by 1.1 cm by less than 0.1 cm. The resident's Skin/Wound assessment dated [DATE] included the pressure ulcer on the resident's left heel measured 3.0 cm by 2.5 cm by 0.1 cm (increase in size from the previous week). The pressure ulcer was purplish, brown, and black in color. The resident left foot had 1 plus [MEDICAL CONDITION], the resident had a pressure relieving device on his/her bed, was on a turning/repositioning program, and staff applied a dressing to the resident's foot and the resident utilized heel protectors. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. On 9/11/15 the physician changed the order for the resident to receive 30 ml of liquid protein twice a day. On 9/15/15 the facility recieved a physician's orders [REDACTED]. Review of this resident's weights revealed the following weights: 6/22/15 179 pounds 7/1/15: 178 pounds 7/14/15: 172 pounds 7/28/15: 167 pounds (the resident lost 12 pounds and/or experienced a significant weight loss of 6.70 % (percent) in 36 days and during this time developed a suspected deep tissue injury pressure ulcer on his/her left heel) 8/18/15: 164 pounds 9/3/15: 160 pounds 9/8/15: 158 pounds (a further decrease of 9 pounds or 5.38% of his/her body weight in less than 2 months). Review of the resident's Lab Value Initial Nutritional assessment dated [DATE] included the resident's laboratory report dated 6/19/15 documented the resident's [MEDICATION NAME] level was low at 3.2 grams/deciliter (normal reference range 3.4 to 5.0 grams/deciliter). A registered dietician (RD) note dated 07/28/2015 and timed 2:19 P.M. documented the resident continued to eat poorly at meals. The resident had multiple skin issues and the RD recommended [MEDICATION NAME] (a protein supplement) once a day and magic cups twice a day. A RD note dated 08/13/2015 and timed 2:29 P.M. documented the resident had skin issues of which one was a suspected deep injury. The resident started on house supplement three times a day for extra protein for healing plus poor intake at times, the resident also received a multivitamin for healing and 30 cubic centimeters of liquid protein once a day. If the resident consumed 100% of the liquid protein, the liquid protein supplied 15 grams of protein. Review of the resident's clinical record lacked evidence the facility consistently monitored the resident's nutritional intake or the amount of nutritional supplements the resident received. Review of the resident's 9/2015 Medication Administration Record [REDACTED].M., 9/19/15 at 11:36 A.M. and on 9/20/15 at 11:03 A.M. because the resident was asleep. The resident's clinical record lacked evidence the facility administered the liquid protein to the resident at another time or adjusted the time of administration when the resident was awake. On 9/15/15 at 2:45 P.M., the resident laid in bed, on his/her left side. Observation revealed the resident's bed had a low air loss mattress and a pressure relieving device in his/her wheelchair. On 9/16/15 at 8:15 AM direct care staff S and T entered the resident's room to assist the resident with A.M. care. Observation revealed the resident laid in bed with heel protectors on bilaterally, the resident's heels were not floated and/or off loaded, and no device was between the resident's legs to prevent skin to skin contact. Further observation revealed the resident's left foot was wrapped with gauze, and the resident's left foot was [MEDICAL CONDITION] (swollen). Direct care staff S stated the resident had a bad heel which was why the resident's left foot was wrapped. Direct care staff T stated the resident's left foot was puffier than usual. The resident had on an incontinent brief and direct care staff S and T performed incontinent care. Observation revealed cream on the resident's buttock and direct care staff S cleaned the area and removed the cream. Observation revealed the resident had a slit in his/her intergluteal cleft (the groove between the buttock that runs from just below the sacrum to the perineum) that measured approximately 0.5 cm by 0.5 cm. Direct care staff S stated prior to the development of the area on the resident's left heel the resident did not utilize heel protectors nor did staff float the resident's heels. On 9/16/15 at 8:55 A.M. the resident ate his/her breakfast meal which consisted of a 2.5 ounce waffle, 1/3 cup of smashed banana, 8 ounces of juice and water and 16 ounces of a chocolate drink (the protein shake mixed with the Carnation Instant Breakfast). On 9/16/15 at 9:10 A.M. the resident had consumed all of the chocolate shake, 50% of the juice and water, 75% of the waffle and a fourth of the banana. On 9/16/15 at 9:20 A.M. the resident had finished eating. Observation revealed the resident ate 100% of the waffle and 1/4 or less of the banana. On 9/16/15 at 11:15 A.M. licensed nurse J entered the resident's room to perform the treatment on the resident's left heel. Observation revealed the resident laid in bed, had heel protectors on bilaterally, a pillow between his/her legs, and the resident's heels were not floated/off loaded. Observation revealed the resident's left foot remained [MEDICAL CONDITION]. Licensed nurse J stated the resident's left foot was always [MEDICAL CONDITION]. Licensed nurse J removed the wrap and the Allevyn heel dressing from the resident's left foot. Observation revealed the imprint of the heel dressing on the resident's left foot after licensed nurse J removed the dressing. Licensed nurse J stated the imprint of the dressing was always there when he/she removed the dressing. Observation revealed the resident had a nonstageable pressure ulcer that measured 2.5 cm by 3.0 cm Further observation revealed the pressure ulcer measured 2.5 cm by 3.0 cm (measurements provided by licensed nurse J) on his/her left heel. Observation revealed the pressure ulcer was purple and black in color. Licensed nurse J stated the pressure ulcer was facility acquired and that licensed nurse J stated the pressure ulcer was not stageable. Licensed nurse J cleansed the area, applied skin prep and the Allevyn heel dressing and secure the dressing with gauze. Licensed nurse J cleaned the resident's intergluteal cleft. Licensed nurse J stated previously the resident had a split in his/her intergluteal cleft, the area was much larger than the current slit but in the same area as the previous slit. He/she stated the previous slit had healed. On 9/16/15 at 12:00 P.M., 12:15 P.M., 12:30 P.M., 1:00 P.M., 1:30 P.M. and 2:00 P.M. the resident laid in bed. Observations during this time revealed the facility served the lunch meal. Further observation revealed the facility did not offer the resident the lunch meal. On 9/16/15 at 11:25 P.M. administrative nursing staff E confirmed the resident's care plan did not address the resident was at risk for the development of pressure ulcer or that the resident had an unhealed pressure ulcer. Administrative nursing staff E confirmed the resident's care plan did not include interventions to prevent the development of pressure ulcers and/or to promote healing. He/she stated during daily stand up meetings, staff informed him/her of issues that needed to be added to resident's care plans. Administrative nursing staff E stated the charge nurse developed the temporary care plans and he/she did the comprehensive care plans and any revisions. On 9/16/15 at 4:00 P.M. dietary staff DD stated the resident did not receive the lunch meal. He/she stated due to culture change the facility did not wake residents up for meals. He/she stated the facility offered the resident supplements, snacks and/or the meal when he/she woke up. Review of the resident's clinical record lacked evidence to support the facility offered the resident additional supplements, snacks or food alternatives when the resident missed meals. On 9/17/15 at 3:01 P.M. licensed staff J stated the facility placed the heel protectors, started the Allevyn heel dressing and skin prep on 7/28/15. He/she stated the facility had not changed the treatment since it started. Licensed nurse J stated prior to the facility placing the heel protector on 7/28/15 (after the development of the pressure ulcer) the facility did not float and/or off load the resident's heels. On 9/17/15 3:13 P.M. administrative nursing staff D stated the pressure ulcer on the resident's left foot was facility acquired. He/she stated the heel dressing was to protect the pressure ulcer and should not leave an indentation. He/she stated this could cause more damage to the resident's pressure ulcer since the [MEDICAL CONDITION] compromised the resident. Administrative nursing staff D stated staff turned/repositioned the resident before and after meals and every 2 hours during the night. He/she stated the resident's care plan should address interventions to prevent and promote the healing of pressure ulcers. On 9/21/15 at 9:08 P.M. physician JJ stated the prevention of pressure ulcers included an individualized care plan that addressed interventions to prevent the development of pressure ulcers, good nutrition, turning/repositioning every 2 hours, and for heel pressure ulcers, a splint versus heel protectors/booties to remove all pressure away from the heels. The facility's Pressure Ulcer Prevention and Management Policy and Procedure revised April 2006 included the facility would assess resident for the risk of developing pressure ulcers and implement appropriate interventions to prevent impaired skin integrity. The facility failed to develop a care plan that addressed the resident was at risk for the development of pressure ulcers and failed to revise the care plan to address the resident had an unhealed pressure ulcer. The facility failed to place timely and effective interventions in place for this resident the facility assessed to be at risk for the development of pressure ulcers prior to the development of an unstageable pressure ulcer. The facility also failed to consistently monitor the resident's meal intake and nutritional supplements as planned.

The facility identified a census of 70 residents and 1 kitchen. Based on observation, and interview the facility failed to ensure there was no risk for ice contamination as evidenced by an air gap. Findings included: - Observation on 9/14/15 at 8:23 A.M. revealed the tube draining from the ice machine was resting on the drain. Staff failed to ensure the presence of an air gap. Interview on 9/14/15 at 8:25 A.M. maintence staff X acknowledged the draining tube did not have an air gap. The facility failed to provide a policy regarding an air gap for the ice machine. The facility failed to ensure the ice machine drainage tube had an air gap to reduce the risk for bacteria contamination to the ice.

The facility had a census of 70 residents with 3 neighborhoods. Based upon observation, record review and interview the facility failed to track and trend infection control data and failed to follow manufacturer's instructions for cleaning solutions while cleaning a resident's room. Findings included: - Review of the facility's infection control logs from 1/15 to 8/30/15 included the type of infection but did not identify if the infection was facility or community acquired. The logs failed to have tracking/trending of the infections, which looked for clusters or an infection control rate. There was no evidence to support the facility maintained corrective actions related to infections. On 9/17/15 at 1:35 P.M. administrative nursing staff E confirmed the infection control logs from 1/15 to 8/30/15 did not include tracking/trending of the infections which looked for clusters or an infection control rate and stated there was no evidence to support the facility maintained corrective actions related to infections. The facility's Infection Control Policy and Procedure revised 9/2005 did not include the tracking and trending of infections. The facility failed to have an effective infection control program. - On 9/17/15 from 10:54 A.M. until 11:10 A.M. housekeeping staff Z cleaned a resident's room. At 10:54 A.M. housekeeping staff Z wiped the outside of the toilet with LD 64, a disinfectant. At 10:56 A.M. housekeeping staff Z used an applicator to apply a toilet bowl /porcelain shower tile cleaner to the inside of the toilet. After applying the cleaner to the toilet bowl, the staff wiped down the inside of the sink, and the outside of the toilet (less than 3 minutes after applying the disinfectant. At 11:00 A.M. housekeeping staff Z flushed the toilet. Further observation revealed the staff did not clean the frequent touched surfaces in the resident's room. Housekeeping staff Z stated he/she was not aware that either of the products had a contact time. The manufacturer's label on the toilet bowl cleaner read to rinse and remove application and to allow to remain on the surface for 10 minutes. The bottle of LD 64 did not have a manufacturer's label. Housekeeping staff Z stated staff diluted the LD 64 and placed it into a smaller bottle. Review of the LD 64 manufacturer's label reveled the contact time to disinfect was 10 minutes. At 11:20 A.M. housekeeping staff Z stated when he/she deep cleaned a room he/she did not flush the toilet for 10 minutes but on a day to day basis he/she did not allow the product to sit for 10 minutes. The facility's Infection Control Policy and Procedure revised 9/2005 included staff ensured environmental surfaces, beds bedrails, bedside equipment and other frequently touched surfaces were appropriately cleaned. The facility failed to follow the manufacturer's instructions regarding contact time and failed to clean frequently touched items.

The facility identified a census of 70 residents with 41 residents having a personal funds account managed by the facility. Based on interview and record review the facility failed to post interest quarterly to 8 (#72,11, 2,30,80,86,31,and #18) of 41 resident funds accounts. The facility also failed to notify 4 unsampled Medicaid residents of account balances within $200.00 of the eligibility limit. Findings included: - Review of the resident trust account statement for resident #2 reviewed on 9/17/15 listed a balance of $85.76. The statement did not show interest posted to the account. On 9/17/15 at approximately 3:00 P.M. administrative staff B and C stated quarterly interest was not posted to this resident's personal fund account. Review of the Resident Trust Balancing Report and the statements for residents (#72,11,30,80,86,31,and #18) revealed the residents were not paid quarterly interest. On 9/17/15 at approximately 3:00 P.M. administrative staff B and C confirmed quarterly interest was not posted to these resident's personal funds accounts. Review of the facility policy for Resident Funds dated revised December 2006 stated interest would be paid on resident accounts who maintained an average balance of $50.00. The facility failed to post interest to all resident fund accounts on a quarterly basis. - Review of account balances for 4 unsampled Medicaid residents revealed balances of $1874.26, $1949.20, $1946.00, and $1947.00. On 9/17/15 at approximately 3:00 P.M. administrative staff B and C confirmed neither the resident nor the responsible party for financial were notified of the account balances for continued Medicaid eligibility . The facility failed to notify each resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the resource limit for one person, so the resident would not lose eligibility for Medicaid.

The facility had a census of 70 residents. The sample included 19 residents. Based upon observation, record review and interview the facility failed to develop a comprehensive care plan for 6 (#62, ,#99, #38, #86, #47, #8) of the 19 sampled residents. Findings included: -Resident #62's electronic medical record identified the resident had [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set ((MDS) dated [DATE] identified the resident had short and long term memory impairment, had severely impaired cognition, displayed physical and verbal behavioral and rejected care 1 to 3 days of the 7 day assessment period. The MDS recorded the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, and personal hygiene. The resident was totally dependent upon staff with toilet use and eating, and the activity of walking in the room/corridor did not occur. The resident was occasionally incontinent of bladder, weighed 179 pounds and had not experienced a weight loss. The resident was at risk for the development of pressure ulcer and had no unhealed pressure ulcers. The resident had moisture associated skin damage and had a pressure relieving device in his/her chair. The MDS did not identify the resident had a pressure relieving device on his/her bed and /or was a turning/repositioning program. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 7/3/15 documented the resident spoke in word salad (confused or unintelligible mixture of seemingly random words and phrases, most often used to describe a symptom of a neurological or mental disorder). He/she was inattentive, was not able to make his/her needs known or understand others and was at risk for unmet needs. The resident's Nutritional Status CAA dated 7/3/15 included the resident had a high body mass index (BMI) indicating obesity. The resident was able to feed himself/herself but required staff encouragement at times. The resident had dementia and was at risk for decline in his/her nutrition. The resident's Pressure Ulcer CAA dated 7/3/15 documented the resident was at risk for the development of pressure ulcers due to incontinence and required extensive to total staff assistance with perineum care and was totally dependent upon staff for transfers. The resident did not reposition himself/herself. The resident's care plan dated 7/2/15 addressed the resident was at risk for nutritional impairment related to not being aware of his/her nutritionally needs, dysphagia (swallowing difficulty ) and variable meal consumption intake. The resident might not be able to express his/her likes and dislikes; staff gave the resident time to make choices and offered the resident food alternatives as needed. The resident required staff assistance and/or cueing with meals and staff monitored the resident's intake. The resident ate better if he/she was in a quiet area. Review of the resident's care plan on 9/15/15 at 4:00 P.M. revealed the care plan did not address the resident was at risk for the development of pressure ulcers or currently had an unhealed pressure ulcer. The resident's care plan did not include interventions as to how staff prevented the development of pressure ulcers for this resident. A Skin/Wound assessment dated [DATE] included the resident had multi-colored discoloration on his/her left heel and the ball of his/her left foot. The purplish, black discoloration on the resident's left heel was 4.0 centimeter (cm) wide and 4 cm in length, and the area on the ball of the resident's left foot measured 1.0 cm in length and 1.5 cm in width. A Skin/Wound assessment dated [DATE] documented the resident had a pressure ulcer on the right side of his/her intergluteal cleft. On 9/16/15 at 11:15 A.M. licensed nurse J entered the resident's room to perform the treatment on the resident's left heel. Observation revealed the resident laid in bed, had heel protectors on bilaterally, a pillow between his/her legs, and the resident's heels were not floated/off loaded. Observation revealed the resident's left foot remained [MEDICAL CONDITION]. Licensed nurse J stated the resident's left foot was always [MEDICAL CONDITION]. Licensed nurse J removed the wrap and the Allevyn heel dressing from the resident's left foot. Observation revealed the imprint of the heel dressing on the resident's left foot after licensed nurse J removed the dressing. Licensed nurse J stated the imprint of the dressing was always there when he/she removed the dressing. Further observation revealed the pressure ulcer measured 2.5 cm by 3.0 cm (measurements provided by licensed nurse J) on his/her left heel. Observation revealed the pressure ulcer was purple and black in color. Licensed nurse J stated the pressure ulcer was facility acquired and that licensed nurse J stated the pressure ulcer was not stageable. Licensed nurse J cleansed the area, applied skin prep and the Allevyn heel dressing and secured the dressing with gauze. Licensed nurse J cleaned the resident's intergluteal cleft. Licensed nurse J stated previously the resident had a split in his/her intergluteal cleft, the area was much larger than the current slit but in the same area as the previous slit. He/she stated the previous slit had healed. On 9/16/15 at 11:25 P.M. administrative nursing staff E confirmed the resident's care plan did not address the resident was at risk for the development of pressure ulcer or that the resident had an unhealed pressure ulcer. Administrative nursing staff E confirmed the resident's care plan did not include interventions to prevent the development of pressure ulcers and/or to promote healing. He/she stated during daily stand up meetings, staff informed him/her of issues that needed to be added to resident's care plans. Administrative nursing staff E stated the charge nurse developed the temporary care plans and he/she did the comprehensive care plans and any revisions. On 9/17/15 3:13 P.M. administrative nursing staff D stated the pressure ulcer on the resident's left foot was facility acquired. He/she stated the resident's care plan should address interventions to prevent and promote the healing of pressure ulcers. The facility's Comprehensive Care Plan Policy and Procedure revised April 2006 included each resident's comprehensive care plan had was designed to incorporate identified problems areas, incorporate risk factors associated with identified problems . The facility failed to develop a care plan that addressed the resident was at risk for the development of pressure ulcers prior to the development of the pressure ulcer. - Resident #8's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident had short and long term memory problems, severely impaired cognition, displayed physical behaviors 4 to 6 days of the 7 day assessment period, was totally dependent upon staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use and personal hygiene. The activity of walking in the room/corridor and locomotion off the unit did not occur during the 7-day assessment period. The MDS identified the resident did not have a functionally limitation in his/her upper or lower extremities and did not received restorative nursing services during the 7 day assessment period. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 3/16/15 included the resident had impaired thought processes related to end-stage dementia and was unable to verbally express his/her needs. The resident's ADL (Activity of Daily Living) Functional Status CAA did not trigger. The resident's care plan dated 6/18/15 addressed the resident had late stage dementia and no longer communicated his/her needs and no longer participated in his/her ADLs. The resident's care plan did not include the resident had a functional limitation in his/her upper/lower extremities or that the resident received restorative nursing. A physician progress notes [REDACTED]. On 9/15/15 at 2:46 P.M. the resident laid in bed on his/her back. Observation revealed the resident's legs were not fully extended. On 9/16/15 at 9:25 A.M. the resident sat in the dining room in his/her wheelchair. Observation revealed the resident's legs were contracted. Licensed staff H stated the resident's arms were contracted bilaterally and he/she was unsure if the resident's legs were contracted. At 10:00 A.M. licensed nurse H stated the resident's legs were contracted and direct care staff performed range of motion exercises on the resident's lower extremities. On 9/17/15 at 8:45 A.M. direct care staff O and P entered the resident's room to perform A.M. care. Observation revealed the resident laid in bed, the resident's legs were contracted and the resident's arms were crossed and appeared to be in a fixed position against the resident's chest. Further observation revealed the resident was totally dependent upon staff for dressing and it was difficult for the staff to place the resident's arms through his/her shirt. Direct care staff O stated staff performed range of motion exercises to the resident's upper extremities after lunch when staff placed the resident in bed. The facility's Comprehensive Care Plan Policy and Procedure revised April 2006 included each resident's comprehensive care plan had was designed to incorporate identified problems areas, incorporate risk factors associated with identified problems . The facility failed to develop a care plan that addressed the resident's function. - Resident #99 was admitted to the facility on [DATE]. The Admission Minimum Data Set ((MDS) dated [DATE] listed long and short memory problems, the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use. He/she required extensive assistance of 1 staff for locomotion on and off the unit and had 1 non-injury fall since admission. The Care Area Assessment (CAA) for falls dated 9/7/15 listed the resident was admitted post hospitalization for pneumonia. He/she had poor balance, was weak, had confusion and forgetfulness due to dementia ( progressive mental disorder characterized by failing memory, confusion). He/she had a personal alarm in his/her chair, an alarmed mat at bedside, and was at risk for falls and subsequent injury. Review of the undated interim plan of care did not identify the resident was a fall risk or identify the fall on 8/31/15 at 5:48 A.M. or the interventions in place. The comprehensive care plan was not developed for this resident until 9/16/15 for falls. On 9/17/15 at 2:45 P.M. administrative nursing staff E stated the fall care plan was added on 9/16/15, the interim care plan did not address the residents fall risk or the date of the implementation of the personal safety alarm, or alarmed pad on the floor. Review of the facility policy for Comprehensive Care Plan date revised April 2006, stated a comprehensive care plan was developed within 7 days of the comprehensive assessment (MDS). The facility failed to develop a comprehensive care plan for this resident for falls. - Resident #38 admitted to the facility on [DATE] Admission Minimum Data Set MDS dated [DATE] listed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, was at risk for pressure ulcers and had 3 stage 2 pressure ulcers present on admission. Review of the Care Area assessment dated [DATE] listed resident admitted with a pressure ulcer to coccyx/buttocks. He/she had issues with loose stool and had a treatment order for [MEDICATION NAME] (skin barrier cream) . He/she often did not reposition self and required staff to do it. The assessment revealed he/she was working with therapy to go home and was at risk for worsening of pressure ulcer or development of new pressure ulcer. Review of the care plan revealed no care plan was developed for pressure ulcers. On 9/17/15 at 2:45 P.M. administrative nursing staff E confirmed the resident did not have a care plan for pressure ulcers. Review of the facility policy for Comprehensive Care Plan date revised April 2006, stated a comprehensive care plan was developed within 7 days of the comprehensive assessment (MDS). The facility failed to develop a comprehensive care plan for this resident for pressure ulcers. - The September 2015 Physician's Order Sheet for resident #86 documented [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) of 8 (moderately cognitively impaired). It documented the resident was occasionally incontinent of urine (involuntary loss of urine), but was independent with toileting. The Care Area Assessment (CAA) dated 4/15/15 revealed the resident had a low BIMS score, [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure), and periods of confusion. It noted he/she required assistance with incontinence care. It documented the resident was occasionally incontinent of bladder and required assistance for personal care and for changing his/her brief. The care plan dated 04/23/15 documented the resident needed assistance with bathing and incontinent care. It failed to list specific interventions for incontinence. Bladder record dated 4/8/15 to 4/15/15 revealed resident was incontinent of urine. Observation on 09/16/15 at 10:17 A.M. staff assisted the resident to the restroom. His/her brief appeared wet. Staff provided personal hygiene. Interview on 09/15/2015 at 3:54 P.M. the resident's spouse stated he/she required assistance changing his/her brief. Interview on 09/17/2015 at 3:16 P.M. direct care staff Q stated the resident was incontinent of urine. Staff assisted the resident to use the restroom every 2 hours and to use the call light. He/she said the resident required assistance with personal hygiene and changing his/her brief. Interview on 09/16/2015 5:11 P.M. licensed nursing staff I stated a care plan did not need developed for incontinence as the resident is mostly independent. Interview on 9/17/2015 at 4:51 P.M. administrative nursing staff D stated there should be incontinence interventions on the care plan. The facility failed to provide a policy about care plan development. The facility failed to develop an individualized care plan for incontinence for this cognitively impaired resident. - The Physician ' s Order Sheet (POS) dated 08/17/2015-09/17/2015 for resident #47 revealed [DIAGNOSES REDACTED]. blood to the area). The Quarterly MDS dated [DATE] documented the resident had long and short term memory problems and severely impaired decision making skills. He/She presented with inattention was continuously present and psychomotor [MEDICAL CONDITION] that fluctuated, was totally dependent on 2 staff for bed mobility, transfer, dressing, toilet use and personal hygiene and extensive assistance of 1 staff for eating. He/She had impairment to the lower extremities on one side. He/she was always incontinent of bowel and bladder, did not exhibit any evidence of pain. The resident was at risk for developing pressure ulcers and did not have one at the time of assessment. He/she had a pressure reducing device to bed and chair and received applications of ointments or medications. He/She received 7-days of diuretics in the look back period. The Significant Change Status Minimum Data Set ((MDS) dated [DATE] documented staff did not perform the Brief Interview for Mental Status, he/she had sort and long term memory problems and severely impaired decision making skills. He/She was inattentive at all times, and psychomotor [MEDICAL CONDITION] that fluctuated. He/She was totally dependent of 2 staff for bed mobility, transfer, dressing, toilet use, and extensive assistance of 1 staff with eating, had a pressure ulcer that measured 3.0 centimeters (cm) by 2.5-cm by 0.3-cm on 08/20/2015 with increased infection on the foot. A pressure ulcer was not present or at a lesser stage on prior assessment and documented at a stage 2. The resident utilized a pressure reducing device in his/her chair and bed, a turning/repositioning program, and the applications of ointments to the feet. The Care Area Assessment (CAA) dated 09/13/2015 for cognitive loss documented the resident had impaired cognition related to end stage Alzheimer ' s dementia and was unable to express his/her needs, which put him/her at risk. The resident was at nutritional risk related to a mechanically altered diet, history of pocketing food and was overweight with a BMI (body mass index-a measure of body fat based on height and weight) of 28.56, late stage Alzheimer ' s dementia and medication use. He/She required assistance with all meals. The care plan dated 1/23/15 included interventions in place prior to the development of the pressure ulcer on 08/08/2015 were for a low air loss mattress for the bed and to assist with changing the resident ' s positions while he/she was in his/her bed or chair. An interview on 09/16/2015 at 2:31 P.M. stated prior to the heel wounds, staff repositioned the resident in bed and in the chair. Since the wound they added the boots and floating of the heels. An interview on 09/16/2015 at 3:35 P.M. licensed nursing staff J stated the booties were a new intervention after staff found the pressure area. An interview on 09/17/2015 at 2:03 P.M. administrative nursing staff D stated if the resident was immobile, staff used boots to protect the residents ' feet. This resident had booties. On 9/21/15 at 9:08 P.M. physician JJ stated the prevention of pressure ulcers included an individualized care plan that addressed interventions to prevent the development of pressure ulcers, good nutrition, turning/repositioning every 2 hours, and for heel pressure ulcers, a splint versus heel protectors/booties to relieve pressure from the heels. The facility policy dated April 2006 documented an individualized comprehensive care plan that included measureable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs if developed for each resident. The facility failed to update the care plan to include interventions used to prevent the development of pressure ulcers and promote healing for this dependent resident at risk for pressure ulcers who developed a lower extremity pressure ulcer while in the facility.

The facility identified a census of 70 residents with 41 residents having a personal funds account managed by the facility. Based on interview and record review the facility failed to convey a final accounting of resident funds within 30 days for 2 unsampled expired residents. Findings included: - The Resident Trust Balancing account showed a $1341.77 balance for an unsampled resident who had deceased . On [DATE] at approximately 3:00 P.M. administrative staff A stated he/she was informed by the previous business office manager that a bill was outstanding and the facility was waiting to convey a final accounting, but so far the bill had not come to the facility. The facility failed to convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate. - An unsampled resident who expired on [DATE] had personal fund account balance of $1254.50. The funds were not sent to the Kansas Estate Recovery System until [DATE] in excess of the 30 day requirement. On [DATE] at approximately 3:00 P.M. administrative staff B and C confirmed the funds were not sent in the required timeframe. The facility failed to convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate.

The facility identified a census of 66 residents. The sample included 3 residents reviewed for falls. Based on observation, record review and interview, the facility failed to provide adequate supervision and failed to develop and implement appropriate interventions for fall prevention for 1 of 3 residents sampled for falls. The resident was left in his/her room unattended, walked unassisted in his/her room and fell , which resulted in a hip fracture. (#1) Findings included: -Resident #1's [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory impairment and severely impaired decision making skills. The resident required total assist with locomotion; extensive assist with bed mobility, transfers, dressing, toileting and personal hygiene; limited assist with eating; and walking did not occur. The resident did not have any falls since readmission. The admission MDS assessment dated [DATE] recorded the resident had short and long term memory loss with severely impaired decision making skills. The resident required extensive assist with bed mobility, transfers, locomotion, dressing, toileting and personal hygiene; limited with bathing; balance was not steady and the resident was only able to stabilize with staff assist; and walking did not occur. The fall care area assessment dated [DATE] recorded the resident was at risk for falls due to his/her poor safety awareness, incontinence, medication use and weakness with poor balance. The care plan dated 12/26/14 documented the resident required 2 assist for transfers and extensive to total care for all his/her ADLs (activities of daily living). The resident had a personal safety alarm on his/her bed and wheelchair. The care plan revised on 1/16/15 recorded the resident recently had a fall resulting in a hip fracture that required surgical repair. The resident required 2 assist for transfers and required extensive to total care for all his/her ADLs. The resident had a personal safety alarm in his/her chair and mat alarms on each side of the bed to help remind the resident of the need for assist with transfers. The progress note dated 1/1/15 at 4:15 PM recorded the resident's roommate observed him/her get up from the recliner, walk to the bed and tripped and fell . Staff then placed an alarm in the resident's recliner. (The resident previously had an alarm only on the wheelchair and bed) The fall scene report dated 1/1/15 at 4:52 PM recorded the resident was in his/her recliner then stood and began ambulating alone and unattended in his/her room, and fell to the floor in his/her resident room. Staff added the immediate intervention of a personal safety alarm in the recliner. The progress note 1/2/15 10:12 AM resident was lying in bed, and being dressed this morning and was grimacing and rising up off of bed complaining of pain while pointing to his/her right hip. Staff notified the physician and received orders for a right hip x-ray for a possible fracture. The radiology report dated 1/2/15 at 11:50 AM revealed a femur fracture. The progress note dated 1/2/15 at 5:28 PM, the radiologist confirmed the fracture and the resident transferred to the hospital. The 1/7/15 hospital discharge referral directed staff to keep the resident's right hip incision dry, change the dressing daily, and remove staples on 1/19/15. The progress note dated 1/7/15 at 2:50 PM revealed the resident arrived at facility via gurney transferred from the hospital, after hip surgery. Observation on 2/11/15 at 8:41 AM revealed the resident sat at the dining room at table with a personal safety alarm attached to the wheelchair. Observation on 2/11/15 at 1:34 PM revealed the resident in a low bed with a bed alarm and fall mats in place. During an interview on 2/11/15 at 11:27 AM, administrative nursing staff A stated the resident had an alarm in his/her wheelchair and bed. The resident had not really sat in the recliner before the fall. Staff transferred the resident to the recliner which did not have an alarm. Residents should have an alarm in all places they sit, so now he/she has one in his/her bed, wheelchair and recliner. Staff did have access to additional alarms at all times. During an interview on 2/11/15 at 1:15 PM, licensed nursing staff B stated he/she was working the day the resident fell and fractured his/her hip. Licensed nursing staff B stated he/she thought staff put the chair alarm in place after the fall. During an interview on 2/11/15 at 1:31 PM, direct care staff C stated typically if a resident had an alarm in their wheelchair, they should also have one in the bed and recliner. During an interview on 2/11/15 at 1:42 PM administrative nursing staff A stated during the investigation they identified quickly that staff forgot to put the alarm in the chair as the cause of the fall. During an interview on 2/11/15 at 1:54 PM direct care staff D stated that generally if a resident had an alarm in their bed they also had one in their wheelchair and recliner. If a resident did not have an alarm in each place they sat, staff would just move the alarm to wherever the resident was. The fall policy entitled Managing Falls and Fall Risk, dated 4/2/14, recorded staff would identify and implement relevant interventions to try to minimize serious consequences of falling. The facility failed to provide adequate supervision and failed to develop and implement interventions for this cognitively impaired, dependent resident at risk for falls when staff left the resident in a recliner in his/her room unattended. The resident fell and fractured his/her hip.

The facility identified a census of 66 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to provide effective assessment and pain management for one resident (#1) of the sample. Findings included: - According to the clinical face sheet, the facility admitted resident #1 on 6/13/14 with the record of personal history of a fall, dementia (progressive mental disorder characterized by failing memory, confusion), and [MEDICAL CONDITION] (a progressive mental deterioration characterized by confusion and memory failure). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. The resident exhibited verbal behaviors and rejected care. The resident required supervision with transfers and bed mobility, and limited assistance with dressing, toileting, and personal hygiene. This same MDS documented the resident used a cane for mobility, had no pain and balance was unsteady, but the resident was able to stabilize without staff assistance. Electronic Health Records documented the resident readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE] documented a BIMS score of 3, which indicated the resident was severely cognitively impaired. The resident experienced [MEDICAL CONDITION] (sudden severe confusion, disorientation, and restlessness), had verbal and other behaviors, rejected cares, and required extensive assistance from staff for activities of daily living (adls). The resident experienced occasional severe pain, and was unable to answer the interview for the pain assessment. Review of the CAA for pain dated 8/25/14 recorded the resident with a surgical repair of a right [MEDICAL CONDITION] on 8/9/14. The resident experienced intermittent pain, which worsened with movement and weight bearing, and made better by lying still and receiving pain medication. The resident was unable to describe the pain, and displayed vocal behaviors (moaning, yelling), facial expressions, and protective movements related to right hip pain with movement. The adverse effects of the resident's pain included decreased appetite, adversely affected mood, limited day-to-day activities, and limited independence with at least some adls. Analysis of the collected data recorded the resident frequently complained of pain, and yelled out in pain with movement of his/her right lower extremity following the surgical repair for a right [MEDICAL CONDITION]. The resident received PRN (as needed) pain medication two to three times per day, typically experienced effective pain relief, although resident continued to moan or cry out with right hip movement. The resident's pain increased his/her risk for falls, mood decline, decreased mobility, and a decline in physical functioning. The plan of care dated 6/20/14 documented the resident was at risk for falls, was very independent and staff monitored the resident daily for decline or pain as the resident may not tell the staff. Staff monitored for signs and symptoms of pain, slower moving, guarding, and decreased activity. The resident was hard of hearing and staff monitored the resident during daily interactions for needs he/she was not able to express: hunger, pain, toileting needs, thirst, etcetera. The comprehensive care plan updated 8/12/14 lacked interventions to address the resident's pain from a recent surgical intervention for a right [MEDICAL CONDITION]. Nursing note dated 8/12/14 at 4:08 P.M. documented the resident was admitted to an acute care hospital on [DATE] after falling out of recliner and breaking his/her hip and had surgery. The resident returned to the facility on [DATE] with the [DIAGNOSES REDACTED]. Nursing note dated 8/13/14 at 3:43 A.M. recorded the resident rested in bed without complaints and was able to independently position his/her right leg in a multitude of positions without pain or discomfort. Nursing note dated 8/14/14 at 1:56 P.M. documented the resident was alert to self, became restless when in pain, and staff administered pain medication at 9:30 A.M. with good results. Nursing note dated 8/15/14 at 12:39 P.M. recorded the resident was able to answer simple questions, speech was slurred and mumbled at times, and was hard of hearing. He/she was noted with facial grimacing, appeared anxious and agitated, pain assessed at 10 of 10 per faces scale. The staff administered PRN (as needed) pain medication after much teaching and verbal cueing. Right hip surgical incision dressing changed and entire right leg from knee to groin area discolored and bruised. The Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED].M. 8/19/14 at 9:47 P.M., 8/20/14 at 10:13 P.M., and 8/25/14 at 6:17 P.M. This same MAR indicated [REDACTED] 8/12/14 at 5:09 P.M. 8/13/14 at 2:30 P.M., and 11:13 P.M. 8/14/14 at 9:30 A.M. and 7:37 P.M. 8/15/14 at 7:17 A.M., 2:56 P.M., and 10:45 P.M. 8/16/14 at 9:05 A.M., 2:56 P.M., and 9:28 P.M. 8/17/14 at 6:15 A.M., 1:48 P.M., and 8:38 P.M. 8/18/14 at 7:44 A.M., 2:30 P.M., and 8:51 P.M. 8/19/14 at 3:56 A.M., 4:46 P.M., and 12:03 A.M. 8/20/14 at 8:46 A.M. and 5:20 P.M. 8/21/14 at 1:25 A.M., 7:35 A.M., 4:18 P.M., 9:58 P.M. 8/22/14 at 11:19 A.M. 8/23/14 at 6:27 A.M. Review of the MAR indicated [REDACTED]. Nursing note dated 8/23/14 at 12:09 P.M. recorded the resident was yelling out in pain, "help me," PRN pain medication not holding the resident long enough. Staff placed a call to the primary care physician and received new orders to give PRN [MEDICATION NAME] every four hours PRN. Review of the MAR indicated [REDACTED] 8/23/14 at 12:10 P.M. 8/24/14 at 12:58 A.M. and 2:29 P.M. 8/25/14 at 3:14 A.M., 11:34 A.M., 4:53 P.M., and 11:33 P.M. 8/26/14 at 1:01 A.M., 5:08 P.M., and 9:48 P.M. 8/27/14 at 1:24 A.M., 4:34 P.M., 4:40 P.M. (repeated entry), and 9:00 P.M. 8/28/14 at 6:19 A.M., 11:46 A.M., and 7:54 P.M. 8/29/14 at 12:51 A.M., 8:27 A.M., and 1:16 P.M. Review of the MAR indicated [REDACTED]. Nursing note dated 8/29/14 at 2:00 P.M. recorded the resident's family declined the x-ray and just wanted the resident kept comfortable. Observation on 8/29/14 at 7:40 A.M. revealed the resident quietly slept on his/her left side on an air mattress in a low bed with continuous supplemental oxygen. On 8/29/14 at 8:05 A.M., direct care staff P and Q assisted the resident with morning cares and dressing. The resident continually yelled out with facial grimacing, " I, I, I, I, Oh, Oh, Oh" intermingled with "Oh Lord Jesus. Please hun." Staff continued cares and as direct care staff P raised the resident's right leg to place socks and pants, the resident cried out "My God." Direct care staff responded to the resident," I know it hurts. I know, I know. Oh hun, it's okay. We're getting up for breakfast." Direct care staff continued to dress resident and roll him/her over in the bed and the resident moaned and yelled during all cares and called out, "Oh Lord Jesus, please." During an interview at this time, direct care staff P reported the resident probably got pain medication at 6 A.M. with his/her medications. Direct care staff P and Q continued with cares, transferred the resident from the bed to the wheelchair with a gait belt, and lifted the resident under his/her arms, and dragged the resident to the wheelchair. The resident was unable to bear weight on his/her legs. Direct care staff P and Q then pulled the slouched resident up in the wheelchair lifting under the resident's arms and the resident cried out, "Oh, oh, Lord Jesus please." Staff placed protective boots on the resident and began to push the resident out of the room. Direct care staff Q reported the resident liked to drag his/her feet. Direct care staff P placed foot pedals on the wheelchair and as the staff member placed the resident's right foot on the footrest, the resident screamed out, "I, I, I" and dropped the foot off the wheelchair footrest. Direct care staff Q continued to place the resident's foot four to five times on the foot rest as he/she pushed the resident down the hallway, and the resident yelled each time staff moved his/her right leg. Direct care staff P spoke to the resident and said, "I know, I know, it's like torture to him/her." During an interview on 8/29/14 at 8:15 A.M. direct care staff N reported the resident did not have any physician ordered scheduled pain medication and staff last administered PRN pain medication on 8/29/14 at 12:50 A.M. (Seven and one-half hours prior). On 8/29/14 at 8:15 A.M., direct care staff N asked the resident if he/she needed a pain pill. The resident responded, I don't want nothing," and continued to moan loudly and called out. When direct care staff N asked the resident if he/she was hurting, the resident responded, "I don't want nothing. Oh Lord!" On 8/29/14 at 8:20 A.M., direct care staff N again asked the (cognitively impaired) resident if he/she wanted pain medication and the resident declined and continued to call out. On 8/29/14 at 8:27 A.M., direct care staff N administered [MEDICATION NAME] 5 mg for the resident's pain. Direct care staff N documented assessment of the pain level of 7 out of 10 for pain on a scale of 0 to 10. On 8/29/14 at 8:40 A.M., as the resident ate at the dining room table, he/she continued mumbling, "I, I, I, oh Lord please, please." On 8/29/14 at 9:00 A.M., the resident sat in his/her wheelchair at the dining table and the resident called out, "Oh Lord please help me." On 8/29/14 at 9:44 A.M., direct care staff N and O pushed the resident in the wheelchair to his/her room, had the resident lean forward in the wheelchair and placed a gait belt, the resident yelled out when he/she leaned forward and called out "hey, hey, hey." Staff transferred the resident to the recliner and the resident yelled out "Gosh all mighty," and squinted his/her eyes tightly shut. When resting still and the movement stopped, the resident stated, "I feel better now." Intermittent observations on 8/29/14 from approximately 9:45 A.M. to 12:00 P.M. revealed the resident sat quietly in the recliner with his/her eyes closed. On 8/29/14 at 12:05 P.M. direct care staff P and O transferred the resident from the recliner to the wheelchair with a gait belt and the resident yelled, "No, No, No," with a pained grimacing look on his/her face. On 8/29/14 at 12:44 P.M. the resident sat in his/her wheelchair in the dining room at the table and called out "I, I, I, please help me." On 8/29/14 at 1:01 P.M., direct care staff N asked the resident if he/she was hurting and needed a pain pill. The resident told direct care staff N he/she could not hear staff. Direct care staff attempted to ask the resident again if he/she needed a pain pill. The resident continued calling out "Oh, Lord. Oh, please Lord. Oh Lord Jesus, please. Oh, oh, oh." Observation revealed direct care staff N did not administer pain medication at this time. On 8/29/14 at 1:14 P.M. the resident continued loudly calling out, "Please, please, please." Licensed nursing staff H asked the resident if he/she wanted pain medication now. The resident requested some aspirin and voice getting louder and louder, calling out "Please, please, please. I, I, I, I, oh, oh, please, please." Licensed nursing staff H directed the certified medication aide to administer pain medication to the resident. Review of the electronic Medication Administration Record [REDACTED].M. (one and one-half hours after staff noted the resident's facial expressions and verbalization of pain). On 8/29/14 at 1:19 P.M., direct care staff P and Q pushed the resident in his/her wheelchair down to his/her room. As direct care staff Q lifted and held the resident's right leg off the floor for transport, the resident scrunched up his/her face and yelled, "Please, please." Staff leaned the resident forward and placed a gait belt, and the resident yelled, "quit jerking me around." Direct care staff transferred the resident to the bed on his/her left side with the resident calling out, "Oh Lord. Oh, oh, oh, oh, Lord please." The resident leaned on his/her left side and did not attempt to lay on his/her right side. On 8/29/14 at 3:02 P.M. the resident moaned out once and then laid quietly on his/her left side in bed. On 8/29/14 at 4:01 P.M., direct care staff N asked the resident if he/she was hurting anywhere. The resident responded, "I don't know." On 8/29/14 at 4:07 P.M. the resident lay quietly on his/her left side in a low bed as direct care staff P and Q started dressing the resident in pants. The resident started screaming and grabbed his/her right hip, "Oh Lord, please, hun, oh, oh, oh, oh my God. Oh[***] oh Christ, please hun, please." The resident constantly moaned and direct care staff continued to move, dress, and transfer the resident from the bed to a wheelchair. The resident did not bear any weight on his/her legs during the transfer and called out with any movement of his/her right leg. On 8/29/14 at 1:19 P.M., direct care staff N reported he/she rated the resident's pain a score of 10 out of 10 because of his/her yelling and all points (facial expression and body language). Direct care staff N reported the resident would tell staff if he/she wanted something. Direct care staff N continued he/she assessed the resident's pain medication was effective if he/she was comfortable and then documented the finding in the electronic medication record. On 8/29/14 at 2:50 P.M., direct care staff P reported the resident was in a lot of pain this morning during cares. On 8/29/14 at 4:30 P.M., licensed nursing staff I reported nursing staff reviewed a resident's overall complaint of pain, include body language, verbal response and rate pain on a face pain scale. A certified medication aide told the nurse when a resident had pain and the licensed nurse did an assessment. On 9/3/14 at 9:40 A.M., licensed nursing staff H reported he/she just assessed the resident's pain, he/she was admitted to hospice services on Friday, and said the resident's family declined the hip x-ray and just wanted the resident comfortable. Licensed nursing staff H reported staff monitored the residents for pain and if a resident with dementia had signs and symptoms, restlessness, and facial grimacing, and cannot say had pain, but appeared in pain, staff would give pain medication. Licensed nurses did an assessment for the resident's pain. The floor nurse also assessed the resident for pain and effectiveness of PRN pain medications. Licensed nursing staff only assessed residents on scheduled pain medication daily and resident's with PRN pain medication were assessed as needed. On 9/3/14 at 10:40 A.M., administrative nursing staff D reported any staff member could assess a resident for pain with guarding or unusual behaviors and then reported to the licensed nurse. The licensed nurse was responsible for the assessment of a resident's pain. Licensed nursing staff assessed the resident for the type of pain and checked for physician medication orders available. The electronic MAR indicated [REDACTED]. On 9/3/14 at 12:10 P.M. licensed nursing staff J reported licensed nurses rated a resident's pain. A resident may be able to verbalize level of pain and location, however a resident that was not able to rate or verbalize pain may become agitated, lash out, and yell. If a resident was acting out more with more agitation, staff would give a PRN pain medication if available. Licensed nurses reevaluated the effectiveness of pain medication on the electronic medication record. On 9/4/14 at 4:44 P.M. consultant physician EE stated when the PRN pain medication was ordered every 4 or 6 hours, he/she expected nursing staff to reassess the resident for pain with signs and symptoms that included verbalizations and body language for this cognitively impaired resident and to administer the pain medications as ordered. Review of the facility's undated policy Pain Management, recorded any resident who displayed or complained of pain, or who had a [DIAGNOSES REDACTED]. All residents will receive quarterly pain assessments. A full pain assessment was conducted with a significant change in pain or the onset of new pain. Scheduled pain medications were administered per physician orders [REDACTED]. Ineffectiveness was addressed promptly with the physician. PRN pain medications were administered per physician orders [REDACTED]. (The pain medication and reason for administration was recorded on the electronic MAR by the nurse or CMA along with the rating (ex: [MEDICATION NAME] 5/500 one given orally for complaint of headache 6/10.) Pain not effectively relieved by the administration of a PRN pain medication was reassessed and follow up intervention or the physician was notified by phone. The facility failed to assess and provide effective pain management by qualified nursing personnel for this cognitively impaired dependent resident after a recent surgical repair of a [MEDICAL CONDITION].