Every finding on record at Caprice Health Care Center

Based on observations, medical record reviews, resident interviews, staff interviews, and facility policy review, the facility failed to ensure call lights were within reach of residents. This affected two residents (#11 and #12) of seven residents reviewed for call lights. The facility census was 69.Findings include: 1. Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, spinal stenosis of the lumbar region with neurogenic claudication, and discitis.Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. Resident #11 was impaired on one side of upper extremities and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 09/26/25 revealed Resident #11 was at risk for falls related to decreased physical mobility, weakness, Alzheimer's disease, and a history of falling with interventions that included, but not limited to, encourage use of call light to ask for assistance, explain use of call light, and keep call light within reach at all times when in room.Review of the physician orders dated 09/25/25 revealed an order for safety checks every two hours.Review of the physician orders dated 10/15/25 revealed an order for the left side of bed to always be against the wall and offer Resident #11 to lay down in bed after meals for rest periods.Review of the physician orders dated 01/16/26 revealed an order for Hoyer lift (mechanical lift) for all transfers (two staff member assistance).Interview and observation on 03/09/26 at 9:15 A.M. revealed Resident #11 sitting up in bed with his call light was not visible. Resident #11 stated What is that? when questioned where his call light was.Interview and observation on 03/09/26 at 9:18 A.M. with Licensed Practical Nurse (LPN) #612 revealed Resident #11 was total care, dependent on staff for ADLs and his call light should always be within reach. Upon entering Resident 11's room, he was sitting up in bed with his call light not visible or in reach. LPN #612 was then observed following the cord connected to the wall outlet designated for the call light, around the privacy curtain, around the bedside table, which was located approximately five feet away, tucked beneath various items on Resident #11's recliner. LPN #612 stated Oh, this shouldn't be here, and clipped the call light to Resident #11's shirt. Resident #11 was then observed asking LPN #612, What is this? So, they can come in? after explanation of use of call light. Resident #11 then stated, I think they brought this in the beginning when I got here, then it slowly drifted away day by day and I never seen it again. LPN #612 confirmed and verified the above findings at the time of observation. 2. Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy, dependence on respirator ventilator, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a memory problem and was severely impaired for decision making regarding tasks of daily living. Resident #12 was dependent on staff for ADLs.Review of the care plan dated 12/24/25 revealed Resident #12 was at risk for falls related to decreased physical mobility with interventions that included, but not limited to, encourage use of call light to ask for assistance, explain use of call light, and keep call light within reach at all times when in room.Review of the physician orders dated 12/23/25 revealed an order for safety checks every two hours.Review of the physician orders dated 12/23/25 revealed an order for Hoyer lift for all transfers (two staff member assistance) every day and night shift for safety.Observation on 03/09/26 at 9:03 A.M. revealed Resident #12 lying in bed with the call light not visible. When asked where her call light was, Resident #12 was observed to shrug her shoulders. Interview and observation on 03/09/26 at 9:06 A.M. with Certified Nursing Assistant (CNA) #508 revealed Resident #12 required assistance from staff for ADLs. CNA #508, upon entrance into Resident #12 room, revealed she did not know where Resident #12's call light was. Resident #12 was observed lying in bed without the call light within reach or visible. CNA #508 was then observed following the cord connected to the wall outlet designated for the call light and located the call light on the floor behind the cart of supplies, approximately five feet away. CNA #508 was observed placing call light near Resident #12 hand. CNA #508 confirmed and verified the above findings at the time of observation.Review of the facility policy labeled, Answering the Call Light, undated, revealed the facility had a policy in place to explain and demonstrate the call light and its use and ensure the call light was within reach of the resident.

Based on record review, staff interview, and observations, the facility failed to ensure all residents were treated in a dignified manner. This affected four (Resident #40, Resident #6, Resident #22, Resident #34) of 29 residents that required a mechanical lift for transfers. The facility census was 64. Findings include: Review of Resident #40's clinical record revealed an admitted [DATE] with diagnoses including vascular dementia, hemiplegia, neurogenic bladder, chronic respiratory failure, and calorie malnutrition. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #40 required a mechanical lift for transfers. Review of Resident #6's clinical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, major depressive disorder, history of falls, and chronic congestive heart failure. Review of Resident #22's clinical record revealed an admitted [DATE] and diagnoses including hemiplegia, kyphosis (abnormally curved spine), contractures of right and left shoulders, left wrist, and left and right knee. Review of Resident #34's clinical record revealed an admitted [DATE] with diagnoses of Alzheimer's disease, major depressive disorder, hypokalemia, and generalized edema. Observation on 04/21/25 at 11:10 A.M. revealed Resident #40 was sleeping in her bed with a mechanical lift pad underneath her. Interview with Certified Nurse Aide (CNA) #833, at the time of the observation, confirmed the lift pad beneath Resident #40. CNA #833 also confirmed that when Resident #40 was returned to bed via a mechanical lift the lift pad was not removed. Observation on 04/21/25 at 11:30 A.M. revealed Resident #6 was in bed with a mechanical lift pad underneath her as she slept. Interview with CNA #833, at the time of the observation, confirmed the lift pad beneath Resident #6. CNA #833 also confirmed that when Resident #6 was returned to bed via a mechanical lift the lift pad was not removed. Observation on 04/22/25 at 9:35 A.M. revealed Resident #22 was in his bed sleeping with a mechanical lift pad underneath him. Interview with Director of Nursing (DON) #819, at the time of the observation, confirmed the lift pad beneath Resident #22. DON #819 said it was not the facility procedure to leave mechanical lift pads underneath residents. Observation on 04/22/25 at 11:25 A.M. revealed Resident #34 was in bed with a mechanical lift pad underneath the resident. Interview with Wound Licensed Practical Nurse (LPN) #891, at the time of the observation, confirmed the lift pad beneath Resident #34. Interview with DON #819 and Wound LPN #891 on 04/23/25 at 12:51 P.M. confirmed the mechanical lift pads were left underneath Resident #40, Resident #6, Resident #22, and Resident #34 when they were placed back into bed after meals. They also indicated leaving the lift pads underneath the residents did not promote the dignity and skin integrity of the residents. Review of the facility's undated Quality of Life- Dignity policy revealed that each resident would be cared for in a manner that promoted and enhanced the quality of life, dignity, and respect.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure respiratory equipment was dated to make certain it was changed at appropriate intervals to decrease the risk of acquired pneumonia or infection. This affected three residents (#26, #27, #127) of six residents reviewed for respiratory care. The facility census was 64. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, dependence on respirator (breathing machine), tracheostomy, quadriplegia, and gastrostomy (feeding tube). Review of Resident #26's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition and altered level of consciousness. Resident #26 was also completely dependent for all activities of daily living (ADL) and hygiene needs. Review of the care plan dated 03/11/25 revealed Resident #26 had respiratory failure, a tracheostomy and was ventilator dependent. Interventions included changing tracheostomy setup per physician orders and as needed per respiratory therapist (RT). Review of Resident #26's physician orders dated 10/19/22 revealed ventilator circuits and all related ventilator, tracheostomy, oxygen setup to be changed per respiratory therapist (RT). Observation on 04/22/25 at 9:23 A.M. revealed Resident #26's ventilator circuit and oxygen tubing was not dated. Interview on 04/22/25 at 9:23 A.M. with RT #881 and Registered Nurse (RN) # 801 verified that ventilator circuit and oxygen tubing was not dated. RT #881 stated ventilator circuits were to be changed every ninety days or as needed. RT #881 also verified that the ventilator circuits were the responsibility of the respiratory therapy department and therapist and the initials of the RT and change date should be labeled on the circuit/humidified water system. 2. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure with hypercapnia, stenosis of larynx, tracheostomy, and dependence on supplemental oxygen. Review of the MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The functional assessment noted Resident #27 needed moderate assistance with ADLs and hygiene needs. Review of the care plan dated 04/16/25 revealed Resident #27 had impaired air exchange due to acute and chronic respiratory failure and chronic obstructive pulmonary disease. Interventions included maintaining oxygen saturation levels greater than 88 percent, keeping airway patent through tracheostomy, oxygen via tracheostomy mask at 35 percent, and have tracheostomy, oxygen and nebulizers set up and changed per RT. Review of Resident #27's physician orders dated 12/27/23 revealed tracheostomy, oxygen, and nebulizer set would be changed per RT. Observation on 04/22/25 at 9:36 A.M. revealed Resident #27's tracheostomy collar oxygen set up was not dated. Interview on 04/22/25 at 9:36 A.M. with RT #881 and RN #801 verified the oxygen setup was not dated to ensure it was changed at an appropriate time interval. 3. Review of the medical record for Resident #127 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, tracheostomy, dependence on supplemental oxygen, gastrostomy, anoxic brain damage and seizures. Review of the MDS 3.0 assessment dated [DATE] revealed severe cognition impairment and response to painful stimuli only. Resident #127 had complete dependence for all ADLs and hygiene needs. Review of the care plan dated 04/13/25 revealed Resident #127 had impairment related to anoxic brain injury and had a tracheostomy. Resident #127 was high risk for self-decannulation and/or disconnection from oxygen. Interventions included assessing the need to suction to clear airway, avoidance of respiratory depression medications, closed suction system, and monitoring respiratory status. Tracheostomy, oxygen and nebulizer set up to be changed per RT. Review of Resident #127's physician orders dated 04/11/25 revealed to change tracheostomy per RT every 90 days and as needed, suction via airway as needed and to change the tracheostomy ties twice a week and as needed. Observation on 04/22/25 at 9:43 A.M. revealed Resident #127's trach collar oxygen set up was not dated. Interview on 04/22/25 at 9:43 A.M. with RT #881 and RN #801 verified the trach collar oxygen set up was not dated to ensure it was changed at an appropriate time interval. Review of facility policy titled Respiratory Therapy: Aerosol/Tracheostomy Set up revised on 07/15/21 revealed the oxygen setup required a label or tape on tubing indicating the date and initials of person changing the system. Review of facility polity titled Respiratory Therapy: Oxygen Therapy revised on 7/15/21 revealed that masks, cannulas and tubing should be changed as follows: a. For ventilator and tracheostomy residents: change on admit then every thirty days and again as needed. b. For non-ventilator tracheostomy residents: change on admit then every thirty days as needed.

Based on record review and staff interview, the facility failed to ensure the accuracy of medical records. This affected one of 32 residents whose records were reviewed, Resident #40. Facility census was 64. Findings include: Review of Resident #40's clinical record revealed an admitted [DATE] with diagnoses including vascular dementia, hemiplegia, neurogenic bladder, chronic respiratory failure, and calorie malnutrition. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 did not have any unhealed pressure ulcers or injuries. Review of the Nurses Skin/ Wound notes dated 04/10/25 timed 10:05 A.M. revealed Resident #40 was at high risk for impaired skin integrity. Resident #40 required maximum to total assistance for bed mobility. Diagnosis of hemiplegia, incontinent of bowel, and use of Foley (urinary) catheter for neurogenic bladder. Resident #40 had a history of pressure injuries and the use of left resting-hand splint to left hand. Skin integrity was maintained and would continue current preventative care. Review of the Nurse Practitioner visit notes dated 04/22/25 timed 9:37 A.M. revealed documentation indicating Resident #40 had current wounds. Further review of the Nurse Practitioner notes dated 04/18/25, 04/16/25, and 04/15/25 indicated Resident #40 had wounds. Interview with Wound Licensed Practical Nurse #894 on 04/23/25 at 9:45 A.M. revealed Resident #40 did not have any wounds or skin impairment at this time. Interview with Director of Nursing # 819 and Nurse Practitioner #123 on 04/23/25 at 9:49 A.M. verified the Nurse Practitioner notes dated 04/15/25, 04/16/25, 04/18/25, and 04/22/25, were not accurate regarding Resident #40 having wounds; the entries were made in error. Nurse Practitioner #123 indicated because she was in a hurry when documenting she copied and pasted the information from another entry and did not make the necessary revisions to accurately reflect Resident #40's current status.

Based observation, interview, record review, and policy review the facility failed to ensure monitoring and evaluation of bilateral wrist restraints was documented while used for Resident #28. This affected one resident (Resident #28) of two residents reviewed for abuse, neglect, and exploitation. The facility reported one resident (Resident #28) who had physical restraints. The facility census was 66. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/14/22, revealed Resident #28 had severely impaired cognition. Resident #28 was dependent on two staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and was dependent on one staff assistance for eating. Resident #28 was always incontinent of urine and bowel. Review of the plan of care completed 09/29/22 revealed Resident #28 had cognitive impairment secondary to severe intellectual abilities which affected decision making skills; had impaired communication skills related to dysphasia (deficiency in generation of speech) and difficulty being understood due to usually nonverbal secondary to history of [CONDITION(S)], intellectual disability and [CONDITION(S)]; would blink eyes to communicate yes and no answers or used lips and tongue to respond in affirmative or negative and said a couple of words at times; used bilateral wrist restraints as needed related to risk of interruption of life sustaining devices and risk for decannulation with least restrictive measures previously attempted were unsuccessful. Interventions included to administer medications as ordered; to allow independent functioning to safest degree possible; provide cues and supervision; use simple one word commands; observe for signs of frustration and anxiety, change activity if observed ; with increased anxiety attempt to calm or refocus attention; ensure correct position and proper body alignment while restrained; monitor, document, and report as needed any changes regarding effectiveness, least restrictive devices, any negative or adverse effects noted including: decline or change in behavior, decrease in ADL (activities of daily living) self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, signs or symptoms of [CONDITION(S)], accidents or injuries, agitation, or weakness; apply bilateral wrist restraints as needed and release every two hours for ten minutes for range of motion (ROM) and hygiene; and document restraint use and release per facility protocol. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's enabler/device/restraint evaluation dated 09/14/22 revealed the bilateral wrist restraints were used for signs and symptoms of interfering with life sustaining devices to prevent the interruption of life sustaining devices. In part two of the evaluation the bilateral wrist restraints were assessed to restrict Resident #28's freedom of movement or normal access to one's body and Resident #28 was unable to remove the devices on command. The bilateral wrist restraints were indicated as an assistance in the improvement of Resident #28's functional status or necessary to enhance compliance with physician's treatment plan. The evaluation determined the bilateral wrist restraints were both an enabler and a restraint, and to follow the restraint protocol. In part three of the evaluation the bilateral wrist restraints were assessed as a device used to treat medical symptoms. The evaluation determined to follow restraint protocol. In the restraint protocol of the evaluation, Resident #28 was determined to need the bilateral wrist restraints for pulling on the tube feed tubing and dislodging set and pulling and disconnecting ventilator tubing. The bilateral wrist restraints restricted Resident #28's freedom of movement and it was concluded as a restraint and to proceed with protocol. This device was the least restrictive device. Previous interventions tried included suctioning, lighting change, [CONDITION(S)] care, movies, distraction, medications, tube feeding binder, tubing out of reach, and repositioning. Alternatives did not work due to Resident #28 wiggled around in bed until items were within reach and hand mitts were removeable. Review of the treatment administration record for October 2022 revealed Resident #28 had bilateral wrist restraints applied as ordered on 10/12/22, 10/15/22, 10/17/22 and on 10/23/22. Review of the orders administration note dated 10/12/22 at 3:58 A.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . One-on-one was ineffective. Review of the medical record including progress notes for Resident #28 revealed there was no documented evidence of the monitoring and evaluation for the use of bilateral wrist restraints applied on 10/12/22 at 3:58 A.M. and when removed. Review of the orders administration note dated 10/15/22 at 2:51 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the orders administration note dated 10/15/22 at 6:52 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record including progress notes for Resident #28 revealed there was no documented evidence of the monitoring and evaluation for the use of bilateral wrist restraints applied on 10/15/22 at 2:51 P.M. and if removed at 6:52 P.M, and the signs and symptoms present to validate the reapplication of the bilateral wrist restraints once released for ten minutes after the first two hours or if the reapplication took place. Review of the orders administration note dated 10/17/22 at 1:11 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the orders administration note dated 10/17/22 at 1:11 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record including progress notes for Resident #28 revealed there was no documented evidence of the monitoring and evaluation for the use of bilateral wrist restraints applied on 10/17/22 at 1:11 P.M. and when removed. Review of the orders administration note dated 10/23/22 at 12:36 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the orders administration note dated 10/23/22 at 2:37 P.M. revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record including progress notes for Resident #28 revealed there was no documented evidence of the monitoring and evaluation for the use of bilateral wrist restraints applied on 10/23/22 at 12:36 P.M. and if removed at 2:37 P.M. Interview on 10/26/22 at 2:05 P.M. with Director of Nursing (DON), Corporate DON #701 and Corporate Nurse #702 verified there was no documentation for Resident #28's bilateral wrist restraints to clearly indicate start of application and removal to identify length of time in use and if or when released, and assessments which occurred during use of the restraint. Interview and observation on 10/27/22 at 8:38 A.M. with Licensed Practical Nurse (LPN) #703 of Resident #28's bed revealed two wrist restraints attached to the moveable portion of the bedframe, one restraint secured to the right bedframe and one secured to the left bedframe. Observation of Resident #28's bilateral wrists revealed the wrist restraints were not applied at the time. Interview at the time of the observation with LPN #703 verified the bilateral wrist restraints were attached to Resident #28's bed and prepared for use as needed. LPN #703 stated when the restraints were used, the purpose was documented in the progress notes including assessments when performing 30 minute checks, releases, re-applications, and skin checks. LPN #703 confirmed Resident #28 did not like to have the restraints on so they had to be removed when it bothered Resident #28. LPN #703 verified not always documenting the checks or assessments as should be done. Interview on 10/27/22 at 9:00 A.M. with Unit Manager (UM) #700 verified Resident #28's restraint documentation was limited to the treatment administration record and orders administration notes located in the progress notes of the medical record which were identified in the above findings. UM #700 confirmed there was no documented evidence of Resident #28's restraint release on 10/12/22 and 10/17/22, and monitoring or reapplication of the restraint including skin assessments when removed. UM #700 stated the facility charted by exception so only a negative finding would be noted in the chart and it was presumed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the undated facility's policy titled Restraint Policy/Procedure revealed assessments will be completed to assess specific symptoms requiring restraint use, attempts to modify behavior, and how the restraint use will treat the cause of the symptom and assist the resident in reaching his/her highest degree of physical and psychosocial wellbeing.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on medical record reviews, hospital and emergency department record review, facility incident and fall investigation report and interview, the facility failed to provide a safe mechanical (Hoyer) lift transfer for one resident (Resident #1) of three residents reviewed for Hoyer lift transfers. Actual harm occurred when Resident #1 was being transferred by facility staff, State tested Nurse Aide (STNA) #600 and #601, from a wheelchair to a [MEDICAL TREATMENT] bed in the attached [MEDICAL TREATMENT] center, when the Resident fell from a Hoyer lift pad to the floor and fractured his left clavicle and left femur. The facility census was 68. Findings include: Review of the closed medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Resident #1 was transferred to the local hospital subsequent to a fall at the [MEDICAL TREATMENT] center. He was then transferred to another regional medical center on [DATE] where he expired on [DATE]. Review of the care plan dated [DATE] revealed Resident #1 required varying degrees of assistance with activities of daily living (ADLs) related to amputations of both lower extremities, end stage [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included the use of Hoyer lift per order for transfers. Resident #1 was at risk for falls related to bilateral lower extremity amputations, end stage [MEDICAL CONDITIONS] and antidepressant medication. Interventions included to eliminate environmental hazards, and to monitor for a pattern of risk or tendency to fall. Review of the comprehensive Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #1 had severe cognitive impairment with memory problems, required extensive two-person physical assistance with transfers and extensive one person assistance with bed mobility, dressing, toilet use and personal hygiene, and had no falls prior to or since admission. physician's orders [REDACTED]. Review of a Fall assessment dated [DATE] and an after-fall assessment dated [DATE], revealed Resident #1 was at high risk for falls. Review of nursing notes dated [DATE] at 11:36 A.M. revealed Registered Nurse (RN) #301 was called to the attached [MEDICAL TREATMENT] center by STNAs #600 and #601 stating Resident #1 slipped out of the Hoyer lift and fell to the floor. Resident #1 was observed laying on the floor next to the [MEDICAL TREATMENT] bed. According to [MEDICAL TREATMENT] staff, Resident #1 hit his shoulder and the left side of his head on the floor when he fell . The resident complained of pain. [MEDICAL TREATMENT] staff informed RN #301 that Resident #1 was going to be transferred to the local hospital emergency room for evaluation and treatment and the [MEDICAL TREATMENT] staff were notifying the resident's family of the fall. Review of hospital/ emergency department records dated [DATE] revealed Resident #1 was seen in the emergency department for pain to the left shoulder and left leg after a fall from a Hoyer lift at the [MEDICAL TREATMENT] center on [DATE]. Review of X-ray results of the left shoulder and left leg dated [DATE] revealed Resident #1 had a distal clavicular (collar bone) fracture and a minimally displaced [MEDICAL CONDITION] left femur. Computed Tomography (CT) scan results dated [DATE] of Resident #1's head and neck without contrast dye revealed no injury or trauma in Resident #1's head or neck. The records also demonstrated Resident #1 suffered [MEDICAL CONDITION] and [MEDICAL CONDITION] in the hospital emergency department, was intubated and placed on a ventilator, and was admitted to the intensive care unit of the hospital. Review of the facility incident report/ fall investigation dated [DATE] revealed, on [DATE] at 11:36 A.M., two nursing home staff, STNAs #600 and #601, were transferring Resident #1 from his wheelchair to the [MEDICAL TREATMENT] bed using a Hoyer lift. During the transfer from chair to bed, Resident #1 slid out of the Hoyer lift pad/ sling and fell on to his left side on the floor. [MEDICAL TREATMENT] facility staff were taking care of the resident and preparing him for transfer to the hospital. Interview on [DATE] at 10:41 A.M. with the Administrator and Director of Nursing (DON) verified on [DATE] around noon, STNAs #600 and #601 took Resident #1 to a scheduled [MEDICAL TREATMENT] treatment at the [MEDICAL TREATMENT] treatment facility attached to the nursing home. STNA #600 and STNA #601 were transferring Resident #1 from his wheelchair to the [MEDICAL TREATMENT] bed for his treatment using a Hoyer lift. The Administrator and DON stated, in the middle of transferring the resident from the chair to the bed, the resident leaned to one side and slipped out of the Hoyer pad/sling falling onto his left side onto the floor of the [MEDICAL TREATMENT] center. The Administrator and DON reported they have performed in-service training and competency reviews for Hoyer lift transfers of all of their nursing staff; they have performed safety inspections and audits of their Hoyer lifts and Hoyer lift pads/ slings; they have audited medical records and care plans for all of their residents ordered Hoyer/ mechanical lift transfers and performed random audits of the staff performance of mechanical lift transfers. They reported they have also reviewed the issue with the [MEDICAL TREATMENT] center management and have implemented a new policy regarding [MEDICAL TREATMENT] resident transfers for [MEDICAL TREATMENT] treatments to include hand off of residents to [MEDICAL TREATMENT] staff at the [MEDICAL TREATMENT] center doorway/ weight scale. The Administrator stated, on [DATE], Resident #1 was admitted to the hospital for treatment, and on [DATE] Resident #1 died at another hospital not the one he was initially admitted to after the fall. The Administrator and DON reported they have not had any other incidents of falls related to Hoyer lift transfers. Interview on ,[DATE] at 8:28 A.M. with STNA #601 revealed on [DATE] around 11:30 A.M., she and STNA #600 were transporting Resident #1 to his scheduled [MEDICAL TREATMENT] treatment at the attached [MEDICAL TREATMENT] center. STNA #601 stated while she was transferring Resident #1 from his wheelchair to the [MEDICAL TREATMENT] bed using a Hoyer lift, Resident #1 slid out of the lift pad and landed on his left side on the floor. STNA #601 stated she was handling the movement of the Hoyer lift and STNA #600 was handling the movement of the wheelchair and was actually standing a couple of feet away from the resident (no hands on contact with the resident) when he fell . STNA #601 stated Resident #1 was known to have a tendency to grab hold of the Hoyer lift cradle bar during transfers and said she had not asked him to cross his arms over his chest prior to lifting him out of the wheelchair. Resident #1 was not holding the bar on [DATE], but he unexpectedly leaned to one side and he fell . STNA #601 stated it had been the routine practice at the nursing home for the nursing home aides to transfer residents from their wheelchairs to the [MEDICAL TREATMENT] beds/ chairs. STNA #600 stated she was not sure what caused the Hoyer lift strap on the Hoyer pad/ sling to let go. STNA #601 stated she as not sure of what had happened with Resident #1 that caused him to fall because she was concentrating on the Hoyer lift movements. Interview by telephone on [DATE] at 9:37 A.M. with Registered Nurse (RN) #300 revealed, on [DATE] around 11:30 A.M., she received a call from their STNAs #600 and #601 who were over in the [MEDICAL TREATMENT] center reporting Resident #1 had fallen out of the Hoyer lift pad/ sling and landed on the floor. RN #600 stated she went to the [MEDICAL TREATMENT] center and found Resident #1 laying on his left side. She stated the STNAs told her one of the straps of the Hoyer pad came off the hook on the lift and Resident #1 slid out of the Hoyer sling onto the floor. She stated she examined the Hoyer lift as well as the pad/ sling and could find no problems with them. RN #300 stated she then provided education and competency checks for STNAs #600 and #601 concerning Hoyer transfers. RN #300 stated it was the routine practice at the facility for their STNAs to do transfers in the [MEDICAL TREATMENT] center. Interview on [DATE] at 9:56 A.M. with STNA #600 revealed on [DATE] she was assisting STNA #601 with the Hoyer lift transfer of Resident #1 from his wheelchair to the [MEDICAL TREATMENT] bed in the [MEDICAL TREATMENT] facility. STNA #600 stated she was moving the wheelchair out of the way and was only touching one of Resident #1's arms during the transfer. STNA #600 stated Resident #1 leaned to one side and one of the support straps disconnected from the lift and Resident #1 fell out of the sling onto the floor on his left side. STNA #600 stated they had not requested Resident #1 cross his arms over his chest prior to lifting him out of the wheelchair. STNA #600 stated she had not expected Resident #1 to lean to one side when he fell from the Hoyer lift pad to the floor. Interview on [DATE] at 11:58 A.M. with Medical Doctor (MD) #800 revealed, on [DATE], Resident #1 was admitted to their emergency department after a fall at a local [MEDICAL TREATMENT] center within the nursing home. MD #800 stated Resident #1 had suffered a fracture to his left clavicle and left femur with the fall. MD #800 stated, while in the emergency department, Resident #1 suffered an episode of [MEDICAL CONDITION] and [MEDICAL CONDITION] and required intubation (airway tube) and ventilator support and he was admitted to the hospital intensive care unit. MD #800 stated, on [DATE], Resident #1 was transferred to a larger hospital that was better able to meet his needs. Review of facility policy titled using a portable lifting machine dated ,[DATE] revealed Step 4; Instruct the resident to fold both arms over his or her chest, if possible. And Step 6; assist the resident in guiding his or her legs. Review of the facility [MEDICAL TREATMENT] Transport Info undated included with the [MEDICAL TREATMENT] contract revealed a statement (facility) staff assists residents receiving [MEDICAL TREATMENT] to and from their treatment on a daily basis as needed. They work together with the ([MEDICAL TREATMENT] center) staff. There was mention of facility staff transferring residents within the [MEDICAL TREATMENT] center. Review of the facility management plan for Resident Hoyer Lift Transfer Safety revealed the following corrective actions were implemented prior to this survey, and the deficiency was corrected as of [DATE]. a. On [DATE], the facility performed safety inspections and audits of all of their Hoyer/ mechanical lifts and Hoyer lift pads/ slings and found no damaged pads. b. On [DATE], the facility provided in-service training to STNAs #600 and #601 and all other nursing staff responsible for Hoyer lift transfers. c. On [DATE], the facility performed reviews and audits of medical records and care plans for all residents ordered Hoyer/ mechanical transfers and no problems were identified. d. Between [DATE] and [DATE], the facility performed three random observations of staff Hoyer lift transfers of residents per week. e. Beginnning on [DATE] the facility started audits of all Hoyer lift pads/slings and discarded/replaced any damaged or defective pads. This will be ongoing. f. On [DATE], the facility completed Hoyer/ mechanical lift competency reviews, initially begun on [DATE], for all of their nursing staff. g. On [DATE], the facility met with [MEDICAL TREATMENT] center management staff and implemented a new transport policy and procedure between the faculties to allow only [MEDICAL TREATMENT] staff to transport and transfer residents within the [MEDICAL TREATMENT] center. This deficiency substantiates Complaint Number OH 438.

Based on observations, interviews, and record reviews, the facility did not ensure the urinary catheter devices were maintained in a manner to decrease chance of infection. This affected two (Residents #21 and #46) of 10 residents observed who required urinary catheters. The facility census was 66 residents. Findings include: 1. Medical record review for Resident #21 revealed initial admission into the facility was on 05/31/10. Th resident's medical [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS 3.0) assessment, dated 07/18/19, revealed this resident had a brief interview for mental status (BIMS) score of 15 of a possible 15, indicating intact cognition. The comprehensive assessment dated [DATE] documented Resident #21 had an indwelling urinary catheter for a [MEDICAL CONDITION] bladder due to [MEDICAL CONDITION]. A plastic blue face cover for the bag covered the face of the drainage bag only. On 10/15/19 at 12:45 P.M., Resident #21 was observed sitting in the dining room during the meal service and a urinary catheter and urine collection bag was attached to the wheelchair. At the time of the observation the urinary collection bag and portion of the catheter tubing was observed on the floor as it hung from the chair and resident. On 10/15/19 at 1:00 P.M., Resident #21 was observed in the dining room and facing the open area of the room. The surveyor observed the resident in a wheelchair with the catheter bag attached to the wheelchair. At the time of the observation the urine collection bag hung in a position that the bottom of the bag was touching the floor along with the catheter tubing which was secured to the resident's left leg as the catheter was positioned along the resident's leg. Observations were made from 1:00 P.M. through 1:30 P.M., and dDuring this time various staff members including the nursing staff and nurse aide staff walked by the resident and talked to the resident. None of the staff members had noticed or attempted to raise the catheter bag and tubing and secure it in a position to prevent it from touching or dragging on the floor and thereby prevent possible urinary tract infection. On 10/15/19 at 1:35 P.M., after observing the resident wheeling herself down to her room and the catheter tubing and bag dragging on the floor, Resident #21 verified the catheter bag and catheter tubing was on the floor and this had occurred often. During interview on 10/15/19 at 1:50 P.M., Registered Nurse (RN) #505 verified the findings of the tubing and catheter bag on the floor while observing Resident #21 in her room. 2. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had an indwelling catheter and urinary drainage bag in place due to [MEDICAL CONDITION]. On 10/15/19 at 1:48 P.M. an observation was made of Resident #46 who had a urinary catheter and catheter bag dragging on the floor while in the television room on the 200 unit. At the time of the observation, State tested Nursing Aide #510 verified the findings of the catheter bag and tubing being on the floor. Review of the nursing notes from 06/30/19 through 10/15/19 and care plan revealed no evidence of interventions to keep the urinary bag and catheter tubing off the floor for Residents #21 and #46 Review of the document titled, Policy for Foley Catheter Care (undated) revealed it did not address the area of infection control as it related to ensuring the urinary catheter tubing and collection bag remaining off the floor to minimize the possiblity of a urinary tract infection. These findings were shared with the Administrator and Director of Nursing on 10/16/19 at 7:45 [NAME]M.

Based on observation, medical record review, and interview, the facility failed to reposition residents identified at risk of developing pressure injuries in accordance with physician orders. This affected five residents (Residents #3, #28, #33, #35, and #82) of 31 residents observed for positioning. The facility identified six residents with pressure injuries greater than stage I (intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED]), one (Resident #35) of which was facility acquired. The facility census was 85. Findings include: 1. Review of Resident #82's medical record revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), and anxiety disorder. A care plan initiated 06/13/18 indicated Resident #82 was at risk for altered skin integrity related to thin fragile skin that bruised and tore easily, impaired physical mobility, [MEDICAL CONDITION]/ventilator dependence and diabetes mellitus. The care plan indicated Resident #82 had compromised skin integrity. Interventions included turning Resident #82 every one-hour when in bed according to physician's orders [REDACTED].#82 was hospitalized [DATE] and returned 08/16/16 due to respiratory distress. An order dated 08/16/18 indicated Resident #82 was to continue to be repositioned every hour alternating between his right and left sides. A 14-day Minimum Data Set 3.0 (MDS) assessment, dated 08/28/18, indicated Resident #82 was usually able to make himself understood and usually understood others. The MDS indicated Resident #82 was moderately cognitively impaired and exhibited no behavioral symptoms or rejection of care. Resident #82 required the extensive assistance of two staff for bed mobility and was dependent on staff for toilet use. The MDS indicated Resident #82 had an indwelling catheter and was always incontinent of stool. Resident #82 was assessed at risk of developing pressure ulcers, had one stage 3 pressure ulcer present upon re-entry and one stage 4 pressure ulcer which was present upon re-entry. Resident #82 also had two unstageable pressure ulcers that were present upon re-entry. The pressure ulcer with the largest surface area measured 3.67 centimeters (cm) x 3.41 cm x 0.2 cm. The most severe tissue type was eschar (dead tissue found in a full thickness wound). Pressure ulcers were present on the prior assessment with no worsening. Skin and ulcer treatments included pressure reducing devices for the chair and bed, a turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of ointments/medications other than to the feet and application of dressings to the feet. On 08/30/18, the care plan was revised reflecting non-compliance with turning and repositioning and refusal of dressing changes at times. The most recent Braden Scale for predicting pressure sore risk dated 09/11/18 indicated risk factors included constantly moist skin, chairfast, very limited mobility, and a problem with friction and shear. The score was indicative of a moderate risk. Review of a 09/17/18 skin and wound assessment revealed Resident #82 had an unstageable pressure ulcer to the left heel present on admission on 06/13/18. The wound measured 2.2 cm x 2.5 cm x 0.2 cm. The wound bed had slough and there was a light amount of serosanguineous drainage (containing or relating to both blood and the liquid part of blood (serum)) with no odor. The wound was assessed as improving. 75-100 % of the wound bed had yellow slough with 25% [MEDICATION NAME] tissue with scattered areas of superficial skin loss within the [MEDICATION NAME] tissue. Review of a skin and wound assessment dated [DATE] indicated Resident #82 had an unstageable pressure ulcer on his right heel which was present on admission on 6/13/18. The wound measured 2.3 cm x 2.6 cm x 0.2 cm with light serosanguineous drainage and no odor. The wound bed contained 75% yellow slough (dead tissue, usually cream or yellow in color) and 25% pinkish red tissue. The wound was assessed as healing. Review of a skin and wound assessment, dated 09/18/18, indicated Resident #82 had a stage 3 pressure ulcer to the sacrum acquired externally 06/13/18. There was moderate serosanguineous drainage. The assessment indicated the wound was improving. The wound bed was 25-50% beefy red and 50% pink granulation tissue with islands of [MEDICATION NAME] tissue throughout the wound bed. The note indicated the resident remained non-compliant with offloading. Review of a 09/18/18 skin and wound assessment revealed Resident #82 had a stage 4 pressure ulcer to the spine acquired externally 06/13/18. The assessment Indicated the wound was improving. The wound was described as a full thickness structure exposing what appeared to be muscle measuring 6.5 cm x 1.8 cm x 0.6 cm with tunneling 1.1 cm @12:00, 1.8 cm at 3:00. There was 75% pale pink granulation tissue present. On 09/17/18 at 9:28 A.M., Resident #82 was observed lying in bed on his back with the head of the bed raised. Resident #82 wore Prevalon heel protectors which were pressing against the foot board of the bed. The plantar surface of the right foot above the heel protector was pressing directly into the footboard. No changes were noted in positioning on 09/17/18 at 11:27 A.M., 12:10 P.M., 12:41 P.M., 1:45 P.M., 2:25 P.M., 2:27 P.M. or 2:32 P.M. On 09/17/18 at 2:28 P.M., State tested Nursing Assistant (STNA) #60 was interviewed and verified Resident #82 had not been able to be repositioned according to his schedule due to staffing. STNA #60 stated Resident #82 had a history of [REDACTED]. STNA #60 stated the foot of the bed could be extended. On 09/18/18 at 8:02 A.M., Resident #82 was observed lying in bed on his back with the head of the bed raised. Bilateral Prevalon heel protectors were applied. A pillow was observed between the heel protectors and the foot board of the bed. On 09/18/18 at 1:06 P.M. and 2:37 P.M., Resident #82 was observed lying in bed on his right side with the head of his bed raised 30 degrees. Both Prevalon heel protectors were pressing against the foot board of the bed. On 09/18/18 at 2:42 P.M., Registered Nurse (RN) #70 stated the Prevalon heel protectors had cushioning on the soles which would protect his feet from pressure from the foot board. RN #70 stated Resident #82 frequently scooted down in the bed. RN #70 stated she would get assistance to reposition Resident #82. On 09/18/18 at 2:48 P.M., STNA #80 stated she was unaware Resident #82 was supposed to be repositioned every hour. STNA #80 stated all the residents on the 400 hall who needed repositioned were on a two hour turn schedule. On 09/19/18 at 5:37 A.M., Resident #82 was observed lying in bed on his back with the head of the bed raised. The Prevalon heel protectors were on but his feet were pressing against the foot board. On 09/19/18 at 5:44 A.M., Licensed Practical Nurse (LPN) #90 stated Resident #82 had his bed remote and would control the elevation of the head of his bed, requiring he be pulled up in the bed frequently due to his feet pressing against the foot board when he slid down in bed. LPN #90 stated she was unaware of any other interventions than the Prevalon heel protectors and repositioning which had been attempted to prevent pressure from Resident #82's feet pressing against the foot board. LPN #90 stated Resident #82 did not like to be told what to do and liked to lie on his back. On 09/19/18 at 7:30 A.M., STNA #100 was interviewed at the end of her shift and stated Resident #82 needed lifted in bed a lot and he was on a two hour turn schedule. On 09/19/18 at 2:10 P.M. LPN #10 was observed changing the dressing to Resident #82's spine. On 09/20/18 between 3:00 P.M. and 3:30 P.M., LPN #10 was observed changing the dressings to Resident #82's heels and sacrum. No new areas of skin breakdown or worsening of ulcers since the most recent assessments were noted. 2. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 01/05/18 indicated Resident #3 was at risk for altered skin integrity related to decreased physical mobility. The care plan indicated an intervention for every one-hour turns while in bed was initiated 02/19/18 and revised 04/09/18. On 04/06/18, an order was written to turn Resident #3 every hour. A Braden scale for predicting pressure sore risk dated 08/21/18 indicated Resident #3 was at high risk for development of pressure ulcers. Identified risk factors included very limited sensory perception, constantly moist skin, chairfast status, complete immobility with Resident #3 not making even slight changes in her body or extremity position without assistance, and problems with friction and shear. A quarterly MDS dated [DATE] indicated Resident #3 did not speak, was rarely/never understood, and rarely/never understood others. Resident #3 had long and short-term memory problems and severely impaired cognitive skills for daily decision making. Resident had altered levels of consciousness continuously. Resident #3 was dependent for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Resident #3 was always incontinent of bowel and bladder. Resident #3 was assessed at risk for developing pressure ulcers but had no pressure ulcers. Skin and ulcer treatments included pressure reducing devices for the chair and bed, a turning/repositioning program, nutrition or hydration interventions, application of non-surgical dressings and applications of ointments/medications. Review of a Skin and wound assessment dated [DATE] indicated Resident #3 had a venous ulcer to the left heel which was identified 09/11/18. No pressure ulcers were identified. On 09/17/18 at 12:02 P.M., 1:39 P.M., and 2:25 P.M., Resident #3 was observed with the head of the bed raised and positioned on her back. On 09/17/18 at 2:28 P.M., Resident #3's positioning was discussed with STNA #60 who reported she was unable to reposition residents as scheduled due to a staffing shortage. On 09/18/18 at 2:45 P.M., 2:52 P.M., 3:11 P.M., and 4:30 P.M., Resident #3 was observed lying in bed on her left side with the head of the bed raised. On 09/18/18 at 2:48 P.M., STNA #80 indicated she was unaware Resident #3 was supposed to be turned every hour, stating she believed she was scheduled to be turned every two hours. On 09/19/18 at 12:13 P.M., 1:36 P.M., and 2:18 P.M., Resident #3 was observed lying on her back with the head of the bed elevated. 3. Review of Resident #28's medical record revealed an initial admission to the facility on [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 06/20/16 indicated Resident #28 had a potential risk for altered skin integrity related to incontinence, decreased mobility, non-compliance with turns and out of bed intervals, and a history of pressure ulcers. An intervention dated 09/08/17 indicated Resident #28 was to be repositioned every one-hour. A Braden scale for predicting pressure sore risk dated 07/02/18 indicated risk factors including slightly limited sensory perception, constantly moist skin, chairfast status, very limited mobility, and a problem with friction and shear. The Braden scale assessment indicated Resident #28 was at high risk for developing pressure ulcers. A quarterly MDS assessment dated [DATE] indicated Resident #28 was sometimes able to make himself understood but had short- and long-term memory problems and severely impaired skills for daily decision making. The MDS indicated Resident #28 was dependent on two staff for bed mobility. A skin and wound assessment dated [DATE] indicated Resident #28 had newly identified moisture associated skin damage to the rear of his left thigh. An order was received to turn Resident #28 between his right and left sides every hour. On 09/17/18 at 9:28 A.M., Resident #28 was observed lying in bed on his back with the head of the bed raised. Resident #28's feet were raised from the surface of the bed with a pillow positioned under his lower legs. Heel protectors were applied. Observations on 09/17/18 at 11:32 A.M. and 1:45 P.M. revealed no change in position. On 09/17/18 at 2:28 P.M., STNA #60 was informed no repositioning for Resident #28 had been observed. STNA #60 stated she was unable to reposition residents as scheduled because of a staffing shortage that day. On 09/18/18 at 8:04 A.M., 1:11 P.M., and 2:36 P.M., Resident #28 was observed positioned on his right side with the head of the bed raised. At 2:55 P.M. and 4:15 P.M., Resident #28 was observed positioned on his left side. On 09/18/18 at 2:48 P.M., STNA #80 stated she was unaware Resident #28 had an order to be turned every hour, stating she believed all the residents who required positioning on her unit were scheduled to be turned every two hours. On 09/19/18 at 5:37 A.M., Resident #28 appeared to be lying on his back. However, a wedge cushion was noted under Resident #28's left shoulder area with his buttocks resting on the mattress. On 09/19/18 at 6:24 A.M., observation of STNA #100 and STNA #110 providing incontinence care revealed at the beginning of care Resident #28 was observed with the wedge behind the left shoulder. After care was provided the wedge was moved to the area behind the right hip to reposition Resident #28 onto his left side. The entire buttocks area was pink. On 09/19/18 at 7:30 A.M., STNA #100 was interviewed and was aware Resident #28 was supposed to be turned every hour. On 09/24/18 at 11:14 A.M., LPN #10 was interviewed and stated the moisture was due to perspiration. LPN #10 stated interventions to attempt to control moisture included off-loading to the back side. The goal was to offload the area of breakdown, which in Resident #28's case would be to remove pressure and moisture from his buttocks and thigh area. 4. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 10/27/17 indicated Resident #33 was at risk for altered skin integrity related to decreased physical mobility and needing assistance with bed mobility. Interventions included turning and repositioning every hour between her right side, left side and back (updated 02/21/18). On 02/20/18, an order was written to turn Resident #33 every hour, alternating between her left side, back, and right side. A Braden scale for predicting pressure sore risk dated 07/10/18 indicated Resident #33 was assessed at high risk. Identified risk factors included slightly limited sensory perception, constantly moist skin, chairfast status, very limited mobility, and a problem with friction and shear. A quarterly MDS dated [DATE] indicated Resident #33 did not speak and was rarely/never understood or able to understand others. Resident #33 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. Inattention and disorganized thinking was continuously present. No behavioral symptoms or rejection of care was noted. Resident #33 was dependent for bed mobility and transfers. Resident #33 was determined to be at risk for development of pressure ulcers. There were no unhealed pressure ulcers and no pressure ulcers on the prior assessment. Resident #33 had moisture associated skin damage at the time of the assessment. Skin and ulcer treatments included pressure reducing devices for the bed and chair, a turning and repositioning program, application of non-surgical dressings and applications of ointments/medications other than to the feet. Review of skin and wound assessments indicated Resident #33 had no skin impairment at the time of the survey. On 09/17/18 at 9:34 A.M., 11:19 A.M., 11:25 A.M., and 1:24 P.M., Resident #33 was observed lying on her back with the head of the bed elevated. On 09/17/18 at 2:28 P.M., lack of repositioning was discussed with STNA #60 who acknowledged she had been unable to reposition residents according to schedules and stating it was related to insufficient staffing that day related to a report off. On 09/18/18 at 8:04 A.M., Resident #33 was observed in bed on her back with the head of the bed elevated. Subsequent observations at 1:14 P.M., 2:32 P.M., 3:12 P.M. and 4:09 P.M. revealed Resident #33 was positioned on her right side with the head of the bed raised. On 09/18/18 at 2:48 P.M., STNA #80 stated she was unaware Resident #33 was supposed to be turned every hour. STNA #80 stated she attempted to turn residents as ordered but stated there was not enough staff. On 09/19/18 at 5:35 A.M. Resident #33 was observed lying on her back with the head of the bed raised. On 09/19/18 at 7:30 A.M. STNA #100 was interviewed regarding the needs of Resident #33 at the end of her shift. STNA #100 stated Resident #33 was turned every two hours. 5. Review of Resident #35's medical record revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 09/07/16 indicated Resident #35 was at risk for altered skin integrity related to debility, need for assistance with all activities of daily living, diabetes mellitus, [MEDICAL CONDITION], and compromised skin integrity. An update indicated it was difficult to maintain a turn schedule and off-load bilateral feet due to Resident #35 moving around in bed frequently. On 08/24/17, the care plan was updated to reflect the initiation of bilateral prevalon boots at all times except for hygiene on 08/24/17. A Braden scale for predicting pressure sore risk dated 07/11/18 indicated Resident #35 was at high risk for development of pressure ulcers. Risk factors included slightly limited sensory perception, constantly moist skin, chairfast, very limited mobility, and problems with friction and shear. An annual MDS dated [DATE] indicated Resident #35 had no speech, was rarely/never able to make himself understood and was rarely/never able to understand others. Resident #35 was assessed with [REDACTED]. Resident #35 had disorganized thinking and inattention which fluctuated. No behavioral symptoms were recorded. Resident #35 rejected care one to three days. Resident #35 was dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Resident #35 was always incontinent of bowel and bladder. Resident #35 was assessed at risk of developing pressure ulcers but had no unhealed pressure ulcers. One stage 3 pressure ulcer was noted on the prior assessment. Skin and ulcer treatments included pressure reducing devices for the chair and bed, a repositioning program, nutrition or hydration interventions, and application of ointments/medications other than to the feet. On 08/31/18, an order was written for Resident #35 to be turned every hour between his right side, left side and back. A skin and wound assessment dated [DATE] indicated Resident #35 had a stage 3 pressure ulcer to the left antecubital space acquired in-house. On 09/17/18 at 12:07 P.M. and 1:40 P.M., Resident #35 was observed lying in bed with his right Prevalon boot off and laying at the foot of the bed. His right leg was crossed over his left shin. No interventions were noted to prevent pressure from the areas of contact. Resident #35 was noted to make slight position changes independently but was not observed turning onto his sides. On 09/17/18 at 2:28 P.M., STNA #60 stated Resident #35 kicked his Prevalon boots off at times. On 09/18/18 at 8:00 A.M., Resident #35 was observed lying on his back with the head of the bed raised. At 1:19 P.M., Resident #35 was observed on his right side with the head of the bed raised. At 2:34 P.M., Resident #35 was observed lying on his right side with the head of the bed raised. The right Prevalon boot was off but laying near the foot of the bed. At 4:11 P.M., Resident #35 was lying on his back with the head of the bed raised. The right Prevalon boot was not applied and his right outer ankle was resting against the left lower shin. On 09/18/18 at 2:48 P.M., STNA #80 stated she was not aware Resident #35 was supposed to be repositioned every hour. On 09/19/18 at 5:37 A.M., Resident #35 was observed with the right Prevalon boot off. His right foot was over his left lower shin. On 09/19/18 at 5:44 A.M., LPN #90 stated staff were constantly trying to reapply Resident #35's boots because he kicked them off and liked to cross his legs. LPN #90 stated she was uncertain if any interventions had been attempted to prevent pressure from Resident #35 kicking the boots off and crossing his legs. No additional information was provided. On 09/19/18 at 7:30 A.M., STNA #100 stated Resident #35 liked to kick his right boot off and cross his legs. On 09/20/18 at 7:20 A.M., Resident #35 was observed lying in bed on his back but slightly tilted to the right side. The Prevalon boot to the right foot was off and Resident #35 was crossing his right leg over his left shin.

Based on observation, medical record review, and interview, the facility failed to ensure devices to assist in maintaining range of motion (ROM) were applied as ordered and/or were applied properly. The facility also failed to ensure restorative ROM programs were provided. This affected three (Residents #3, #33 and #35) of five residents reviewed for position/mobility. The facility identified 27 residents with contractures. Findings include: 1. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. On 04/18/18, the care plan regarding impaired physical mobility was updated to reflect restorative programs were to be delivered as ordered. On 05/03/18, an intervention was added to the activities of daily living care plan indicated a resting hand splint was to be applied according to physician orders. An occupational therapy discharge summary dated 05/25/18 indicated recommendations were made for a left elbow splint from hour of sleep to rise, a left resting hand splint form the time Resident #3 arose until dinner and a cervical collar from the time she arose until dinner. A restorative program was established, and training was provided for a restorative ROM program and restorative splint and brace programs. An order was written 05/31/18 for restorative program for passive range of motion to bilateral lower extremities, splinting of the left elbow splint from bed time to the time she arose and a left resting hand splint from the time she arose until dinner and a cervical collar from the time she arose to dinner. A quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated Resident #3 had short- and long-term memory problems, was severely cognitively impaired for daily decision making, was dependent on staff for dressing, and had functional limitation in range of motion of both upper and lower extremities. Review of restorative delivery records from (MONTH) (YEAR) revealed day shift staff documented application of restorative devices was not applicable. Night shift documented the provision of the restorative program was not applicable on 06/06/18, 06/25/18, 06/29/18 and 06/30/18. There was no documentation of night shift donning and doffing ordered splints on 06/05/18, 06/10/18, 06/12/18, 06/16/18, 06/21/18, 06/24/18, or 06/28/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of passive range of motion or splints being provided on day shift on 07/22/18. Staff on night shift did not document the provision of restorative services on 07/01/18, 07/04/18, 07/07/18, 07/10/18, 07/10/18, 07/14/18, 07/21/18, or 07/25/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of program deliver on night shift on 08/01/18, 08/06/18, 08/11/18, 08/16/18, 08/16/18, 08/19/18, 08/27/18 or 08/30/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of restorative programs being delivered on day shift on 09/15/18 or on night shift on 09/03/18 or 09/12/18. On 09/17/18 at 12:02 P.M., 1:39 P.M. and 2:25 P.M., Resident #3 was observed lying in bed. Her fingers were bent and appeared to have contractures. No devices were present in her hands. On 9/18/18 at 2:48 P.M., State tested Nursing Assistant (STNA) #80 was interviewed and demonstrated that Resident #3 was able to extend the fingers of her right hand. STNA #80 verified the left hand was contracted and she did not believe Resident #3 had appliances for her left hand. STNA #80 stated there was not enough staff to provide restorative programs as ordered. After the interview, STNA #80 opened Resident #3's dresser and stated Resident #3 did have a hand splint but she thought it might be applied at night. The splint was placed back in the drawer. On 09/19/18 at 5:44 A.M., Licensed Practical Nurse (LPN) #90 was interviewed and looked at orders then stated Resident #3 was supposed to wear a cervical collar, bilateral knee braces, bilateral upper splinting during day wears cervical collar. PT with bilateral knee brace, bilateral upper extremity splinting, and a left resting hand splint from rise to dinner. An elbow splint was ordered between bed time and the time Resident #3 arose. On 09/19/18 at 6:05 A.M., Resident #3 was observed lying in bed with no left-hand splint or elbow splint applied. On 09/19/18 at 7:30 A.M., STNA #100 was interviewed and stated she had applied the hand brace that morning but Resident #3 did not have her elbow splint applied during the night shift on 09/18/18. STNA #100 stated she was not sure if Resident #3 wore an elbow splint. 2. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. An occupational therapy (OT) evaluation dated 04/04/18 indicated Resident #33 appeared to have possible contractures/increased tone compared to her baseline. Resident #33 was evaluated to assess appropriate splinting interventions and address positioning. At the time, an evaluation was only done due to acquirement of splints taking a few weeks. The plan was to re-evaluate Resident #33 once the splints were acquired. An OT evaluation dated 05/09/18 indicated ROM to bilateral upper extremities was impaired. ROM to the left elbow/forearm was impaired. There was no function limitation present due to contractures. An OT discharge summary dated 05/25/18 Resident #33 did not tolerate hand splints. Discharge recommendations included use of wash cloths to tolerance to bilateral hands and a left elbow splint from the time of arising to dinner. A restorative program was established for passive ROM to the elbow and bilateral hands and for a splint program to the left elbow. An order dated 05/31/18 was written for a restorative ROM program and left elbow splint program and delivery was to be recorded by the STNA. On 05/31/18, an order was written for rolled washcloths in both hands 23-24 hours per day which could be removed for hygiene/skin checks. A quarterly MDS dated [DATE] indicated Resident #33 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. No behavioral symptoms or rejection of care was noted. Resident #33 was dependent on staff for dressing. Resident #33 was assessed with [REDACTED]. Review of restorative delivery records for (MONTH) (YEAR) did not reveal the restorative program for the left elbow splint or ROM was provided 08/05/18. On 08/26/18, staff documented the delivery of the restorative program was not applicable. Resident #33 refused the left elbow sapling and ROM on 08/18/18 and 08/30/18. The restorative delivery record revealed rolled washcloths were provided every day shift. There was no documentation of refusals of the rolled washcloths. Review of restorative delivery records for (MONTH) (YEAR) revealed Resident #33 refused the left elbow splint and left elbow ROM on 09/01/18 or 09/02/18 and ROM to the wrists and fingers, shoulder on 09/01/18. On day shift on 09/15/18, staff documented the restorative program for left elbow splints and ROM to the elbow before and after the elbow splints were applied was not applicable. The restorative record revealed the application of the rolled washcloths was not completed on day shift on 09/02/18 but did not indicate they were refused. On 09/17/18 at 9:34 A.M., 11:19 A.M. , and 1:24 P.M. Resident #33 was observed without any splints or rolled washcloths in place. On 09/18/18 at 8:04 A.M. and 1:14 P.M., Resident #33 was observed in bed. No splints or rolled washcloths were observed in place. On 09/18/18 at 1:19 P.M., STNA #60 was interviewed and first stated she was unsure if Resident #33's rolled washcloths to her hands had been discontinued then stated Resident #33 would not keep the rolled washcloths in her hands and stated she had had applied the washcloths earlier that morning and Resident #33 would not leave them in. On 09/18/18 at 2:32 P.M. and 3:12 P.M., Resident #33 was observed without washcloths or a left elbow splint applied. At 4:09 P.M., a washcloth was observed in Resident #33's right hand, but no left elbow splint was applied. On 09/18/18, an order was written for OT to re-evaluate Resident #33 for splinting and rolled washcloths. On 09/18/18 at 2:48 P.M., STNA #80 stated there was not enough staff to provide restorative programs. On 09/19/18 at 5:35 A.M. and 6:08 A.M., Resident #33 was observed without wash cloths in her hands or a left elbow splint applied. On 09/19/18 at 7:30 A.M., STNA #100 stated Resident #33 would refuse or pull washcloths out of her hands and was not sure if Resident #33 used arm splints. Subsequent observations at 9:14 A.M. revealed no washcloths or left arm splint was applied. At 12:17 P.M., Resident #33's upper extremities were covered with a towel. On 09/19/18 at 5:20 P.M., the Director of Nursing (DON) stated she spoke with staff and was told they attempted to put the washcloths in Resident #33's hands, but she sometimes only kept them in a short time and sometimes not at all. Staff were documenting the washcloths were administered because they were attempting to get her to wear them. On 09/19/18 at 5:30 P.M., Physical Therapy Assistant (PTA) #120 provided OT treatment notes regarding poor tolerance to roll splints to the bilateral hands. PTA #120 stated while Resident #33 was receiving OT she did not tolerate the use of rolled splints. PTA #120 verified the rolled splints were different from the rolled washcloths. PTA #120 stated discharge recommendations included use of wash cloths to tolerance to both hands and a left elbow splint from the time she arose until dinner. PTA #120 stated although she found documentation of poor tolerance of the roll splints to the hands, she did not find any indication of intolerance to the left elbow splint. On 09/20/18 at 7:26 A.M., Resident #33 was observed lying in bed on with a washcloth laying on the bed beside her hands. No elbow splint was applied. 3. Review of Resident #35's medical record revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. An annual MDS dated [DATE] indicated Resident #35 had no speech, was rarely/never able to make himself understood and rarely/never able to understand others. Resident #35 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. Resident #35 was dependent on staff for dressing. On 09/14/18, an order was written for bilateral elbow extension splints from 7:00 A.M. to 11:00 A.M. and bilateral resting hand splints from 11:00 A.M. to 3:00 P.M. daily. ROM was to be provided prior to donning splints. Staff were to monitor/check for redness. On 09/17/18 at 9:22 A.M., Resident #35 was observed wearing a right-hand splint, but the splint was only on the arm with the hand piece not applied. Subsequent observations at 12:07 P.M. and 1:40 P.M., revealed the hand splint was on but the hand part of the splint was not on the hand. On 09/18/18 at 1:19 P.M., STNA #60 observed Resident #35 with the surveyor. Resident #35's right hand splint was applied with the fingers wrapped around the splint. STNA #60 indicated the splint was applied correctly at the time. Review of information regarding the elbow wrist hand orthosis indicated when the hand portion was included, proper donning included placing the palmer section in the palm of the hand with the fingers and thumb wrapped around it. Care should be taken that the fingers were extended to the point where they were totally wrapped around the palmer section and the orthosis should be centered on the wrist.

Based on observation, medical record review, and interview, the facility failed to ensure there was sufficient staff to permit repositioning programs and restorative programs to be implemented as ordered. This affected four (Residents #3, #28, #33, and #82) of 31 residents observed for positioning and two (Residents #3 and #33) of five residents reviewed for range of motion. This had the potential to affect all 85 residents. Findings include: 1. Review of Resident #82's medical record revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), and anxiety disorder. A care plan initiated 06/13/18 indicated Resident #82 was at risk for altered skin integrity related to thin fragile skin that bruised and tore easily, impaired physical mobility, [MEDICAL CONDITION]/ventilator dependence and diabetes mellitus. The care plan indicated Resident #82 had compromised skin integrity. Interventions included turning Resident #82 every one hour when in bed according to physician's orders [REDACTED].#82 was hospitalized [DATE] and returned 08/16/16 due to respiratory distress. An order dated 08/16/18 indicated Resident #82 was to continue to be repositioned every hour alternating between his right and left sides. A 14 day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82 was usually able to make himself understood and usually understood others. The MDS indicated Resident #82 was moderately cognitively impaired and exhibited no behavioral symptoms or rejection of care. Resident #82 required the extensive assistance of two staff for bed mobility and was dependent on staff for toilet use. The MDS indicated Resident #82 had an indwelling catheter and was always incontinent of stool. Resident #82 was assessed at risk of developing pressure ulcers, had one stage 3 pressure ulcer present upon re-entry and one stage 4 pressure ulcer which was present upon re-entry. Resident #82 also had two unstageable pressure ulcers that were present upon re-entry. The pressure ulcer with the largest surface area measured 3.67 centimeters (cm) x 3.41 cm x 0.2 cm. The most severe tissue type was eschar (dead tissue found in a full thickness wound). Pressure ulcers were present on the prior assessment with no worsening. Skin and ulcer treatments included pressure reducing devices for the chair and bed, a turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care , application of ointments/medications other than to the feet and application of dressings to the feet. On 08/30/18, the care plan was revised reflecting non-compliance with turning and repositioning and refusal of dressing changes at times. The most recent Braden Scale for predicting pressure sore risk dated 09/11/18 indicated risk factors included constantly moist skin, chairfast, very limited mobility, and a problem with friction and shear. The score was indicative of a moderate risk. Review of a 09/17/18 skin and wound assessment revealed Resident #82 had an unstageable pressure ulcer to the left heel present on admission on 06/13/18. The wound measured 2.2 cm x 2.5 cm x 0.2 cm. The wound bed had slough and there was a light amount of serosanguineous drainage (containing or relating to both blood and the liquid part of blood (serum)) with no odor. The wound was assessed as improving. 75-100 % of the wound bed had yellow slough with 25% [MEDICATION NAME] tissue with scattered areas of superficial skin loss within the [MEDICATION NAME] tissue. Review of a skin and wound assessment dated [DATE] indicated Resident #82 had an unstageable pressure ulcer on his right heel which was present on admission on 6/13/18. The wound measured 2.3 cm x 2.6 cm x 0.2 cm with light serosanguineous drainage and no odor. The wound bed contained 75% yellow slough (dead tissue, usually cream or yellow in color) and 25% pinkish red tissue. The wound was assessed as healing. Review of a skin and wound assessment dated [DATE] indicated Resident #82 had a stage 3 pressure ulcer to the sacrum acquired externally 06/13/18. There was moderate serosanguineous drainage. The assessment Indicated the wound was improving. The wound bed was 25-50% beefy red and 50% pink granulation tissue with islands of [MEDICATION NAME] tissue throughout the wound bed. The note indicated the resident remained non-compliant with offloading. Review of a 09/18/18 skin and wound assessment revealed Resident #82 had a stage 4 pressure ulcer to the spine acquired externally 06/13/18. The assessment Indicated the wound was improving. The wound was described as a full thickness structure exposing what appeared to be muscle measuring 6.5 cm x 1.8 cm x 0.6 cm with tunneling 1.1 cm @12:00, 1.8 cm at 3:00. There was 75% pale pink granulation tissue present. On 09/17/18 at 9:28 A.M., Resident #82 was observed lying in bed on his back with the head of the bed raised. Resident #82 wore Prevalon heel protectors which were pressing against the foot board of the bed. The plantar surface of the right foot above the heel protector was pressing directly into the footboard. No changes were noted in positioning on 09/17/18 at 11:27 A.M., 12:10 P.M., 12:41 P.M., 1:45 P.M., 2:25 P.M., 2:27 P.M., or 2:32 P.M. On 09/17/18 at 2:28 P.M., State tested Nursing Assistant (STNA) #60 was interviewed and verified Resident #82 had not been able to be repositioned according to his schedule due to staffing. 2. a. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 01/05/18 indicated Resident #3 was at risk for altered skin integrity related to decreased physical mobility. The care plan indicated an intervention for every one hour turns while in bed was initiated 02/19/18 and revised 04/09/18. On 04/06/18, an order was written to turn Resident #3 every hour. A Braden scale for predicting pressure sore risk dated 08/21/18 indicated Resident #3 was at high risk for development of pressure ulcers. Identified risk factors included very limited sensory perception, constantly moist skin, chairfast status, complete immobility with Resident #3 not making even slight changes in her body or extremity position without assistance, and problems with friction and shear. A quarterly MDS dated [DATE] indicated Resident #3 did not speak, was rarely/never understood, and rarely/never understood others. Resident #3 had long and short term memory problems and severely impaired cognitive skills for daily decision making. Resident had altered levels of consciousness continuously. Resident #3 was dependent for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Resident #3 was always incontinent of bowel and bladder. Resident #3 was assessed at risk for developing pressure ulcers but had no pressure ulcers. Skin and ulcer treatments included pressure reducing devices for the chair and bed, a turning/repositioning program, nutrition or hydration interventions, application of non-surgical dressings and applications of ointments/medications. Review of a skin and wound assessment dated [DATE] indicated Resident #3 had a venous ulcer to the left heel which was identified 09/11/18. No pressure ulcers were identified. On 09/17/18 at 12:02 P.M., 1:39 P.M., and 2:25 P.M., Resident #3 was observed with the head of the bed raised and positioned on her back. On 09/17/18 at 2:28 P.M., Resident #3's positioning was discussed with STNA #60 who reported she was unable to reposition residents as scheduled due to a staffing shortage. b. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. On 04/18/18, the care plan regarding impaired physical mobility was updated to reflect restorative programs were to be delivered as ordered. On 05/03/18, an intervention was added to the activities of daily living care plan indicated a resting hand splint was to be applied according to physician orders. An occupational therapy discharge summary dated 05/25/18 indicated recommendations were made for a left elbow splint from hour of sleep to rise, a left resting hand splint form the time Resident #3 arose until dinner and a cervical collar from the time she arose until dinner. A restorative program was established and training was provided for a restorative ROM program and restorative splint and brace programs. An order was written 05/31/18 for restorative program for passive range of motion to bilateral lower extremities, splinting of the left elbow splint from bed time to the time she arose and a left resting hand splint from the time she arose until dinner and a cervical collar from the time she arose to dinner. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had short and long term memory problems, was severely cognitively impaired for daily decision making, was dependent on staff for dressing, and had functional limitation in range of motion of both upper and lower extremities. Review of restorative delivery records from (MONTH) (YEAR) revealed day shift staff documented application of restorative devices was not applicable. Night shift documented the provision of the restorative program was not applicable on 06/06/18, 06/25/18, 06/29/18 and 06/30/18. There was no documentation of night shift donning and doffing ordered splints on 06/05/18, 06/10/18, 06/12/18, 06/16/18, 06/21/18, 06/24/18, or 06/28/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of passive range of motion or splints being provided on day shift on 07/22/18. Staff on night shift did not document the provision of restorative services on 07/01/18, 07/04/18, 07/07/18, 07/10/18, 07/10/18, 07/14/18, 07/21/18, or 07/25/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of program deliver on night shift on 08/01/18, 08/06/18, 08/11/18, 08/16/18, 08/16/18, 08/19/18, 08/27/18 or 08/30/18. Review of restorative delivery records for (MONTH) (YEAR) revealed no documentation of restorative programs being delivered on day shift on 09/15/18 or on night shift on 09/03/18 or 09/12/18. On 09/17/18 at 12:02 P.M., 1:39 P.M. and 2:25 P.M., Resident #3 was observed lying in bed. Her fingers were bent and appeared to have contractures. No devices were present in her hands. On 9/18/18 at 2:48 P.M., State tested Nursing Assistant (STNA) #80 was interviewed and demonstrated that Resident #3 was able to extend the fingers of her right hand. STNA #80 verified the left hand was contracted and she did not believe Resident #3 had appliances for her left hand. STNA #80 stated there was not enough staff to provide restorative programs as ordered. After the interview, STNA #80 opened Resident #3's dresser and stated Resident #3 did have a hand splint but she thought it might be applied at night. The splint was placed back in the drawer. 3. Review of Resident #28's medical record revealed an initial admission to the facility on [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 06/20/16 indicated Resident #28 had a potential risk for altered skin integrity related to incontinence, decreased mobility, non-compliance with turns and out of bed intervals, and a history of pressure ulcers. An intervention dated 09/08/17 indicated Resident #28 was to be repositioned every one hour. A Braden scale for predicting pressure sore risk dated 07/02/18 indicated risk factors including slightly limited sensory perception, constantly moist skin, chairfast status, very limited mobility, and a problem with friction and shear. The Braden scale assessment indicated Resident #28 was at high risk for for developing pressure ulcers. A quarterly MDS assessment dated [DATE] indicated Resident #28 was sometimes able to make himself understood but had short and long term memory problems and severely impaired skills for daily decision making. The MDS indicated Resident #28 was dependent on two staff for bed mobility. A skin and wound assessment dated [DATE] indicated Resident #28 had newly identified moisture associated skin damage to the rear of his left thigh. An order was received to turn Resident #28 between his right and left sides every hour. On 09/17/18 at 9:28 A.M., Resident #28 was observed lying in bed on his back with the head of the bed raised. Resident #28's feet were raised from the surface of the bed with a pillow positioned under his lower legs. Heel protectors were applied. Observations on 09/17/18 at 11:32 A.M. and 1:45 P.M. revealed no change in position. On 09/17/18 at 2:28 P.M., STNA #60 was informed no repositioning for Resident #28 had been observed. STNA #60 stated she was unable to reposition residents as scheduled because of a staffing shortage that day. 4. a. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A care plan initiated 10/27/17 indicated Resident #33 was at risk for altered skin integrity related to decreased physical mobility and needing assistance with bed mobility. Interventions included turning and repositioning every hour between her right side, left side and back (updated 02/21/18). On 02/20/18, an order was written to turn Resident #33 every hour, alternating between her left side, back, and right side. A Braden scale for predicting pressure sore risk dated 07/10/18 indicated Resident #33 was assessed at high risk. Identified risk factors included slightly limited sensory perception, constantly moist skin, chairfast status, very limited mobility, and a problem with friction and shear. A quarterly MDS dated [DATE] indicated Resident #33 did not speak and was rarely/never understood or able to understand others. Resident #33 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Inattention and disorganized thinking was continuously present. No behavioral symptoms or rejection of care was noted. Resident #33 was dependent for bed mobility and transfers. Resident #33 was determined to be at risk for development of pressure ulcers. There were no unhealed pressure ulcers and no pressure ulcers on the prior assessment. Resident #33 had moisture associated skin damage at the time of the assessment. Skin and ulcer treatments included pressure reducing devices for the bed and chair, a turning and repositioning program, application of non-surgical dressings and applications of ointments/medications other than to the feet. Review of skin and wound assessments indicated Resident #33 had no skin impairment at the time of the survey. On 09/17/18 at 9:34 A.M., 11:19 A.M., 11:25 A.M., and 1:24 P.M., Resident #33 was observed lying on her back with the head of the bed elevated. On 09/17/18 at 2:28 P.M., lack of repositioning was discussed with STNA #60 who acknowledged she had been unable to reposition residents according to schedules and stating it was related to insufficient staffing that day related to a report off. On 09/18/18 at 8:04 A.M., Resident #33 was observed in bed on her back with the head of the bed elevated. Subsequent observations at 1:14 P.M., 2:32 P.M., 3:12 P.M., and 4:09 P.M. revealed Resident #33 was positioned on her right side with the head of the bed raised. On 09/18/18 at 2:48 P.M., STNA #80 stated she was unaware Resident #33 was supposed to be turned every hour. STNA #80 stated she attempted to turn residents as ordered but stated there was not enough staff. b. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. An occupational therapy (OT) evaluation dated 04/04/18 indicated Resident #33 appeared to have possible contractures/increased tone compared to her baseline. Resident #33 was evaluated to assess appropriate splinting interventions and address positioning. At the time, an evaluation was only done due to acquirement of splints taking a few weeks. The plan was to re-evaluate Resident #33 once the splints were acquired. An OT evaluation dated 05/09/18 indicated ROM to bilateral upper extremities was impaired. ROM to the left elbow/forearm was impaired. There was no function limitation present due to contractures. An OT discharge summary dated 05/25/18 Resident #33 did not tolerate hand splints. Discharge recommendations included use of wash cloths to tolerance to bilateral hands and a left elbow splint from the time of arising to dinner. A restorative program was established for passive ROM to the elbow and bilateral hands and for a splint program to the left elbow. An order dated 05/31/18 was written for a restorative ROM program and left elbow splint program and delivery was to be recorded by the STNA. On 05/31/18, an order was written for rolled washcloths in both hands 23-24 hours per day which could be removed for hygiene/skin checks. A quarterly MDS dated [DATE] indicated Resident #33 had short and long term memory problems and severely impaired cognitive skills for daily decision making. No behavioral symptoms or rejection of care was noted. Resident #33 was dependent on staff for dressing. Resident #33 was assessed with [REDACTED]. Review of restorative delivery records for (MONTH) (YEAR) did not reveal the restorative program for the left elbow splint or ROM was provided 08/05/18. On 08/26/18, staff documented the delivery of the restorative program was not applicable. Resident #33 refused the left elbow splint and ROM on 08/18/18 and 08/30/18. The restorative delivery record revealed rolled washcloths were provided every day shift. There was no documentation of refusals of the rolled washcloths. Review of restorative delivery records for (MONTH) (YEAR) revealed Resident #33 refused the left elbow splint and left elbow ROM on 09/01/18 or 09/02/18 and ROM to the wrists and fingers, shoulder on 09/01/18. On day shift on 09/15/18, staff documented the restorative program for left elbow splints and ROM to the elbow before and after the elbow splints were applied was not applicable. The restorative record revealed the application of the rolled washcloths was not completed on day shift on 09/02/18 but did not indicate they were refused. On 09/17/18 at 9:34 A.M., 11:19 A.M., and 1:24 P.M. Resident #33 was observed without any splints or rolled washcloths in place. On 09/18/18 at 8:04 A.M. and 1:14 P.M., Resident #33 was observed in bed. No splints or rolled washcloths were observed in place. On 09/18/18 at 1:19 P.M., STNA #60 was interviewed and first stated she was unsure if Resident #33's rolled washcloths to her hands had been discontinued then stated Resident #33 would not keep the rolled washcloths in her hands and stated she had had applied the washcloths earlier that morning and Resident #33 would not leave them in. On 09/18/18 at 2:32 P.M. and 3:12 P.M., Resident #33 was observed without washcloths or a left elbow splint applied. At 4:09 P.M., a washcloth was observed in Resident #33's right hand but no left elbow splint was applied. On 09/18/18, an order was written for OT to re-evaluate Resident #33 for splinting and rolled washcloths. On 09/18/18 at 2:48 P.M., STNA #80 stated there was not enough staff to provide restorative programs. 5. On 09/18/18 at 2:48 P.M., STNA #80 stated stated residents sometimes had to wait extended periods for assistance to get into their chairs due to staffing. 6. On 09/17/18 between 9:27 A.M. and 3:07 P.M., five residents who wished anonymity were interviewed and stated they did not believe there was enough staff to provide assistance in a timely manner. Explanations provided by the residents included waiting extended periods for incontinence care or assistance getting to the bathroom and staff rushing during the provision of care. 7. On 09/19/18 at 7:35 A.M., STNA #60 reported she did not feel there was sufficient staff to provide care to the residents in a timely manner, especially when there were report offs. A nursing assistant was pulled from the 400 hall to the split on the other side of the facility.

Based on observation, record review, and interview, the facility failed to ensure appropriate infection control interventions were maintained while providing Resident #75's care. This finding affected one (Resident #75) of three residents reviewed for infection control prevention requiring isolation precautions and had the potential to affect all residents residing on the 400 hall (Residents #3, #15, #16, #28, #33, #35, #66, #74, #76, #82, #344, #13, #86). Findings include: Observation on 09/19/18 at 7:27 A.M. with State tested Nursing Assistant (STNA) #60 revealed Resident #75 was in isolation precautions and the nursing assistant was observed in the resident's room picking up the resident's soiled bed linens from the floor without a yellow isolation gown (a yellow isolation gown prevents the cross contamination of the nursing assistant's clothing). Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff). Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #75's physician orders [REDACTED]. diff (infectious bacterium with symptoms which include watery diarrhea, fever, nausea and abdominal pain) every day and night shift. Interview on 09/19/18 at 7:31 A.M. with STNA #60 confirmed Resident #75 was in isolation precautions and a yellow isolation gown and gloves were to be worn while providing care or coming in direct contact with the resident's environment including soiled bed linens.

Based on medical record review, observation, policy review, and interview, the facility failed to implement their policy for humidification for a resident receiving oxygen. This affected one (Resident #66) of three residents investigated for respiratory care. The facility census was 85. Findings include: Review of Resident #66's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A plan of care initiated 05/07/18 indicated Resident #66 had impaired air exchange related to [MEDICAL CONDITIONS], shortness of breath, oxygen dependence, lung mass and nasal dryness. Interventions included applying oxygen according to physician orders [REDACTED]. Resident #66 had an order dated 05/08/18 for oxygen at three liters per minute via nasal cannula continuous. The order indicated the oxygen could be titrated to maintain oxygen saturation levels at 88% or higher for [MEDICAL CONDITION]. On 09/17/18 at 10:14 A.M., Resident #66 was observed lying in bed with the head of the bed raised. Resident #66 had a nasal cannula applied and oxygen was delivered via an oxygen concentrator set at 4.5 liters. The humidification bottle was empty. No date was noted on the bottle or tubing. On 09/17/18 at 10:38 A.M., Licensed Practical Nurse (LPN) #30 stated oxygen tubing was changed every month and as necessary (for example, if it fell on the floor). The date it was changed was documented on the Treatment Administration Record. LPN #30 verified the humidifier bottle on the oxygen concentrator was empty and the flow rate was set at 4.5 liters per minute. LPN #30 stated the policy was for residents with flow rates greater than 3 liters per minute to have humidification. On 09/19/18 at 9:20 A.M. and 12:12 P.M., Resident #66 was observed with the oxygen concentrator set at 4.5 liters and a small amount of solution in the humidification bottle. On 09/20/18 at 8:40 A.M., Resident #66 was observed with the oxygen flow rate set at 4.5 liters per minute. The humidification bottle dated 09/17/18 was empty. At 8:48 A.M., State tested Nursing Assistant #40 verified the humidifier bottle was empty and she would inform the nurse. On 09/24/18 at 8:48 A.M., two surveyors observed Resident #66 lying in bed with a nasal cannula in her nares. The oxygen concentrator was set on 4.5 liters and the humidification bottle dated 09/20/18 was empty. On 09/24/18 at 9:05 A.M., LPN #50 verified Resident #66's oxygen was running at 4.5 liters per minute via nasal cannula and the humidifier bottle was empty. Review of the facility's Oxygen Therapy policy (not dated) indicated if humidified oxygen delivery was ordered, disposable humidifier bottles were to be changed as needed to maintain proper water level for the humidifier. Review of the facility's policy, Use of Humidifiers with Oxygen Delivery (not dated) indicated the purpose was to provide moisture to the oxygen delivered by nasal cannula when the flow rate was above four liters per minute, or as determined by the need of the resident if delivered at less than or equal to 4 liters per minute. A physician's orders [REDACTED].

Based on medical record review and staff interview, the facility failed to ensure a resident receiving an antianxiety, which was ordered on both a routine and as necessary basis, had orders implemented regarding the frequency of medication administration. This affected one (Resident #66) of five residents reviewed for medication use. The facility identified 17 residents receiving antianxiety medication. The facility census was 85. Findings include: Review of Resident #66's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. On 06/04/18 an order was received for [MEDICATION NAME] (antianxiety medication) 0.5 milligrams (mg) every six hours as needed for anxiety. On 07/25/18, an order was received for routinely scheduled [MEDICATION NAME] 1 mg at bedtime for complaints of anxiousness with [MEDICAL CONDITION]. On 07/26/18, an order was written not to administer the [MEDICATION NAME] scheduled on an as necessary basis within six hours of the routine [MEDICATION NAME] ordered at bedtime. On 09/24/18 at 11:35 A.M., the Director of Nursing (DON) verified Resident #66 had an order instructing staff not to administer the [MEDICATION NAME] ordered on an as necessary basis within six hours of the routine [MEDICATION NAME] ordered at bedtime. The DON stated she spoke with the physician and his goal was for Resident #66 not to receive the [MEDICATION NAME] ordered on an as necessary basis in conjunction with the routinely scheduled [MEDICATION NAME]. The DON stated the nurses signed on the MAR indicated [REDACTED]. Review of Medication Administration Records (MARs) from (MONTH) (YEAR) to (MONTH) (YEAR) with Licensed Practical Nurse (LPN) #20 revealed of 11 days reviewed, Resident #66 had the [MEDICATION NAME] ordered on an as necessary basis administered outside the parameters set by the physician. The (MONTH) (YEAR) MAR indicated [REDACTED].M. Resident #20 had [MEDICATION NAME] 0.5 mg administered on an as necessary basis. LPN #20 stated records showed the routine [MEDICATION NAME] was administered on 09/03/18 at 9:54 P.M. The MAR indicated [REDACTED].M. LPN #20 stated the routine [MEDICATION NAME] scheduled at bedtime on 09/08/18 was administered on 09/09/18 at 2:42 A.M. The (MONTH) (YEAR) MAR indicated [REDACTED].M. On 09/24/18 after review of the MARs which began at 12:13 P.M., LPN #20 verified the order for the [MEDICATION NAME] ordered on an as necessary basis not to be administered within six hours of the scheduled [MEDICATION NAME] was not followed on three of the 11 days randomly selected for review.

Based on observation, interview and review of infection control policies revealed the facility failed to ensure housekeeping staff followed appropriate infection control procedures when cleaning isolation rooms. This finding had the potential to affect fourteen residents residing on the 300 hall and thirteen residents residing on the 400 hall for a total of twenty-seven residents. The facility census was 82. Findings include: Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #76's physician orders [REDACTED]. Observation on 07/24/17 at 12:17 P.M. revealed Housekeeper #17 was observed coming out of Resident #76's room with a yellow isolation gown and gloves on. She walked down the hall, removed her gloves and yellow isolation gown and discarded them in the clear trash bag on the housekeeping cart. Housekeeper #17 pushed her housekeeping cart down the hall and parked it at the nurses station between the 300 and 400 hall. She went into the common television lounge behind the nurses' station and washed her hands at the sink. On 07/24/17 at 12:20 P.M. Housekeeper #17 confirmed she was aware Resident #76 was in isolation and verified she did not remove and dispose of her gloves and gown or wash her hands prior to exiting the resident's room. On 07/26/17 at 3:10 P.M. Laundry Supervisor #22 verified Housekeeper #17 should have removed her gown and gloves, disposed of them in the red colored isolation trash bags available in the resident's room, and washed her hands prior to leaving Resident #76's room. This was the proper procedure to follow to prevent possible cross contamination. Review of the Clostridium Difficile Policy and Procedure dated 08/23/05 revealed if a resident was admitted to the facility with a current [DIAGNOSES REDACTED]. Protective apparel must be removed and discarded before leaving the room. Review of the Biohazard Labeling policy dated 2001 indicated red bags or other receptacles containing articles contaminated with potentially infectious material, shall be identified by a biohazard label, tag or sign. Review of the undated Policy for Bloodborne Pathogens Exposure Control Plan revealed all personal protective equipment shall be removed prior to leaving the work area and placed in an appropriate designed area or container for disposal.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review, interview and policy review the facility failed to prevent misappropriation of Resident #74's narcotic pain medications. This affected one (Resident #74) of three residents reviewed for misappropriation. Findings include: Review of Resident #74's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #74's physician orders [REDACTED]. Review of misappropriation of property self-reported incident investigation forms provided by the facility revealed on 04/02/17 staff reported a concern that Resident #74's [MEDICATION NAME] (medication for pain) 30 mg blistered pre-packaged narcotic card with 60 tablets in the package was missing. Review of the self-reported incident form dated 04/03/17 indicated Resident #74's narcotic pain medication was lost or stolen. Interview on 07/27/17 at 4:04 P.M. with the Administrator revealed the facility found Resident #74's empty [MEDICATION NAME] 30 mg blistered pre-packaged medication card in the shred bin with all the pills removed. The Administrator confirmed the police were contacted, the facility could not locate the missing pain medication. Licensed Practical Nurse (LPN) #101 pled guilty to theft of Resident #74's [MEDICATION NAME] pain medication and falsifying resident records. Interview on 07/27/17 at 4:07 P.M. with the Director of Nursing (DON) stated the narcotic count was accurate because LPN #101 falsified a narcotic sheet for thirty medications to match a sticker she had pulled from a different card to replace the 60 count card that she had taken. There have been no incidents of substantiated misappropriation since 04/02/17. Review of undated policy named Abuse Prohibition Policy and Contact Information revealed the facility should protect the resident and resident's property from misappropriation. Review of the facility's corrective action revealed the following were implemented prior to this complaint survey. a. On 04/03/17, the facility contracted pharmacy and resident's physician were notified and replacement of medication was arranged. b. On 04/03/17, interview with Resident #74 and reconciliation of the Medication Administration Record [REDACTED]. Interviews were conducted with all other interviewable residents in the facility and none reported not getting their medications, including pain medications when needed and as ordered. c. On 04/03/17, the local police were notified and came to the facility. The report dated 04/03/17 at 10:11 A.M. indicated the officer was dispatched to the facility for a reported theft of controlled substances. The controlled substance was listed as [MEDICATION NAME] 30 mg tablets. Facility staff were interviewed, onsite drug screens were conducted on the facility nurses, and all were found negative for opiates, except for LPN #101 who refused. d. On 04/03/17, the facility footage of security cameras was viewed and no relevant information was obtained. e. On 04/03/17, all staff were provided inservice on administration of controlled medications. f. On 04/03/17, a complaint/incident form was submitted to the Ohio Board of Nursing regarding theft of resident narcotics by LPN #101. g. On 04/03/17 the facility contracted pharmacy conducted audits for all residents ordered controlled medication and no controlled medications were unaccounted for.

Based on record review and staff interview the facility failed to ensure laboratory tests were completed as ordered to monitor for the use of an anticoagulant medication for Resident #22. This affected one of five residents reviewed for unnecessary medications. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physicians orders revealed an order for [REDACTED]. Review of laboratory results revealed no evidence the APTT was completed on 07/12/17 as per the physician orders. An interview was conducted with Licensed Practical Nurse(LPN) #15 on 07/26/17 at 10:30 A.M. and the laboratory results for Resident #22 were reviewed. LPN #15 confirmed the laboratory service did not complete an APTT test on 07/12/17. LPN #15 confirmed two weeks had passed from the order date and the facility had not identified that the order was not completed. During an interview on 07/26/17 at 11:00 A.M. LPN # 14 provided a copy of the facility requisition to the laboratory for the July monthly blood tests for Resident #22. LPN #14 confirmed the laboratory requisition did not include the APTT blood test which was why the test was not completed. Interview with the Facility Administrator and Director of Nursing (DON) on 07/27/17 at 3:20 P.M. revealed a list of all laboratory tests was provided to the unit manager each morning by the laboratory technician. The DON revealed the unit manager didn't complete an audit of the tests drawn until the last day of the month. They would have identified Resident #22's missed lab work then. The DON verified the APTT was specifically ordered to be done on the 12th of the month.

Based on observation, record review and interview, the facility failed to ensure a medication administration error rate of 5% (percent) or less. This affected one (Resident #22) of three residents observed for medication administration. There were two errors observed out of twenty-five opportunities resulting in a medication administration error rate of 8%. Findings include: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. Review of Resident #22's physician orders [REDACTED]. Observation on 07/25/17 at 7:27 A.M. with Licensed Practical Nurse (LPN) #16 of Resident #22's morning medication administration revealed the [MEDICATION NAME] fast acting insulin was administered prior to the breakfast meal. On 07/25/17 at 7:42 A.M. with LPN #16 of Resident #22's morning medication administration revealed the phos-nak medication was administered prior to the breakfast meal. On 07/25/17 at 10:30 A.M. LPN #16 verified Resident #22's insulin and phos-nak medications were both administered prior to the breakfast meal and not with meals as indicated in the physician orders.

The following finding pertains to an incident of past non-compliance that was subsequently corrected prior to this survey. Based on record review, observation and interview, the facility failed to ensure beds were not placed close to baseboard heaters. This affected one (Resident #88) of seven residents with severe cognitive impairment requiring assistance with bed mobility. Findings include: Review of the medical record revealed Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing progress note dated 04/25/17 indicated Resident #88 was found crawling out of the left side of her bed and her left lower leg was against the heater. The nurse assessed the left lower leg and found a popped blister. The area was beefy red with a darker red center. The surrounding skin was wrinkled. The nurse cleaned the area with normal saline, applied xeroform dressing and wrapped the leg with gauze. An interview with the Maintenance Director on 06/08/17 at 2:00 P.M. revealed the resident rooms were heated by electrical baseboard heaters. There was a thermostat in the resident rooms which residents/staff could adjust the temperature for the comfort of the residents. The Maintenance Director stated some residents liked their room very warm and turned the thermostat dial to the highest setting. An interview with STNA #1 on 06/08/17 at 3:41 P.M. revealed she found Resident #88 attempting to climb out of bed on 04/25/17. STNA #1 stated Resident #88 was confused and was unable to pull her leg away from the baseboard heater. Resident #88 had her legs dangling over the side of the bed and a blister was found on her left lateral calf. STNA #1 stated Resident #88's bed was pushed against the wall to discourage her from attempting to exit her bed unassisted. Resident #88's leg was between the bed and the wall. An interview with the Administrator on 06/08/17 at 4:03 P.M. verified the source of the second degree burn on Resident #88's calf was the baseboard heating unit located in Resident #88's room. The Administrator stated no other residents had sustained a burn from the baseboard heater in their room. Corrective action by the facility included: - on 04/25/17 at 2:22 P.M., staff repositioned Resident #88 and moved the resident's low bed and extra mattress to the opposite wall, perpendicular to the heater, and under the overbed light. - on 04/25/17 at 2:33 P.M., Licensed Practical Nurse (LPN) #22 evaluated the area on Resident #88's leg and applied a standing order treatment to the area. Ongoing treatment to the area was documented in the resident's record. - on 04/25/17 at 3:20 P.M., LPN #22 notified the Unit Manager, LPN #20, of the incident involving Resident #88. At 3:25 P.M., the Director of Nursing was notified. - on 04/25/17 at 3:45 P.M., LPN #20 inspected each resident room on the 100 and 200 wings to ensure all beds near the wall with the baseboard heater, had sufficient walkway space between the bed and the baseboard. At the same time, LPN #21 inspected each resident room on the 300, 400 and 600 units for appropriate space between the baseboard heater wall and the bed. - on 05/04/17 and on 05/08/17, the Ombudsman came to the facility, made rounds throughout the building to check bed placement, and found no concerns. - on 05/09/17, the DON completed a nursing in-service on general environment and bed safety. - the DON or designee conducts environmental audits three times a week to evaluate environmental safety. These will continue until otherwise directed by the facility's Quality Assurance Committee. - observations made on 06/08/17 revealed all beds in resident rooms were at least 12 to 18 inches away from the baseboard heaters. This deficiency substantiates Complaint Number OH 485.

Based on interview and record review, the facility failed to ensure accurate and complete assessments for a newly discovered pressure ulcer for Resident #8. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of the electronic medical record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an order note dated 02/08/17 revealed a newly developed pressure ulcer was discovered on Resident #8's right heel, however, the note included no measurements or description of the wound, other than an open blister. Additionally, no subsequent assessments, measurements, description or progression of the right heel pressure ulcer was found in the medical record since 02/08/17. Interview with the wound nurse, Licensed Practical Nurse (LPN) #34, on 03/27/17 at 12:49 P.M. revealed the facility recently began using electronic records and she had fallen behind on entering her information for wound assessments into the computer. LPN #34 provided handwritten notes/skin grids for Resident #8's wounds however some information was lacking. LPN #34 said she first saw the pressure ulcer on Resident #8's right heel on 02/14/17. On 02/14/17 the wound bed was yellow with brown slough (necrotic tissue) and measurements were 1.5 centimeters (cm) in length, by 2.2 cm width. However, since the initial assessment contained no information as to size or appearance, when it was first discovered on 02/08/17, she could not determine if the wound had improved or deteriorated. On 03/27/17 at 1:20 P.M. the Director of Nursing (DON) verified the lack of complete assessment of a right heel pressure ulcer discovered on 02/08/17 for Resident #8.

Based on interview and record review, the facility failed to ensure accurate and complete documentation was contained in Resident #8's medical record relative to pressure ulcers and skin impairment. This affected one of three residents reviewed for skin impairment. Findings include: Review of the record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 01/31/17 revealed several areas of skin breakdown were found upon initial assessment. The right elbow had a open area measured at 2.5 centimeters (cm) length (L) by 1.0 cm width (W), by 0.1 cm depth (D) and the wound bed was 75% red and 25 % yellow. The right ear had a small open area measured at 0.4 cm L , by 0.4 cm W, by 0.1 cm D with a yellow wound bed. The left groin had two open areas, one was measured at 1.0 cm L, by 1.0 cm W, by 0.1 cm D, and the other measured 0.3 cm L, by 0.3 cm W, by 0.1 cm D. Both areas had yellow wound beds with serous drainage. A reddened area on the resident's sacrum was measured at 11.0 cm L, by 9.0 cm W with intact skin. All areas were marked as pressure areas. The note also indicated the resident heels were boggy but intact and he had bruising to his bilateral upper extremities and left thigh. Review of Resident #8's electronic medical record revealed no further documentation such as assessments, measurements, description or progression of healing for the wounds since 01/31/17 could be found. Review of an order note dated 02/08/17 revealed a pressure ulcer was discovered on Resident #8's right heel, however, no information such as measurements or description of the wound, other than an open blister was found. Additionally, no documentation for subsequent assessments, measurements, description or progression of the right heel pressure ulcer was found in the medical record since 02/08/17. Review of an order note dated 02/17/17 at 7:06 P.M., revealed open bruises were discovered on Resident #8's right and left forearms. However, the note included no information as to how many bruises, measurements or any description other than open bruises. Additionally, no further documentation was found in the record of subsequent assessments, measurements, wound description or progression of the open bruises on Resident #8's right and left forearms. Interview with the wound nurse, Licensed Practical Nurse (LPN) #34, on 03/27/17 at 12:49 P.M. revealed the facility had recently started using electronic medical records, and she had fallen behind in completing her computerized documentation for resident wound status. LPN #34 provided hand written notes, with some information for Resident #8's wounds. LPN #34 verified the hand written notes were not a part of the resident's electronic record and she should have transcribed the information into Resident #8's record prior to his discharge from the facility on 02/18/18. LPN #34 first saw the open blister on Resident #8's right heel on 02/14/17. Her hand written notes indicated on 02/14/17, it was measured at 1.5 cm L, by 2.2 cm W and was yellow with brown slough. However, no documentation could be found as to size or appearance of the open blister when it was first discovered on 02/08/17. Additionally, no documentation of subsequent assessments or the progression of the wound was found in the electronic record. LPN #34 stated she had not seen the open bruises discovered on Resident #8's forearms on 02/17/17, and verified there was no documentation in the resident's record of subsequent assessments or the progression of the open bruises. On 03/27/17 at 1:20 P.M. interview with the Director of Nursing (DON) revealed all documentation related to wound status was to be recorded in the residents' electronic records timely. The DON verified Resident #8 had multiple areas of skin impairment noted on admission, with no evidence of documentation of ongoing assessment in the electronic record, some of which was from two months ago. The DON also verified lack of accurate and complete documentation both upon discovery and ongoing for a right heel pressure ulcer discovered on 02/08/17 and open bruises discovered on 02/14/17 on Resident #8's forearms.

Based on observation, interview and record review the facility failed to ensure interventions were in place and adequate supervision was provided to prevent a fall for Resident #39. This resulted in actual harm to Resident #39, who sustained a fractured femur as a result of a fall when left unattended by staff while toileting. This affected one resident (Resident #39) of three residents reviewed for falls. The facility census was 69. Findings include: Resident #39 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an admission Fall Risk assessment dated [DATE], revealed Resident #39 was at a high risk for falls due to age greater than [AGE] years old, a history of three or more falls in the past six months, impaired mental status with confusion most of the time, assistance required for elimination, medications and gait impairment. The Fall Risk Assessment score was 22. The Fall Risk scale revealed, a score of 10 or greater, indicated the resident was at a high risk for falls. Resident #39 was observed on 04/28/14 at 12:10 P.M. in a wheelchair with a lap buddy in place. A lap buddy is a pillow placed in the resident's lap and attached to the wheelchair. It is used to prevent falls. The resident's son was visiting at the time of the observation. An interview was completed with the resident's son. He said his mother had fallen after she was admitted to the facility and fractured her leg. The son said Resident #39 had been left alone while going to the bathroom. Review of a falls investigation dated 02/02/14 at 8:00 P.M., revealed Resident #39 was transferred to a bedside commode by licensed practical nurse (LPN) #1 and State tested nursing assistant (STNA) #2. The same investigation revealed at the time the resident was transferred she was not wearing shoes or socks with grippers, to prevent falls. The resident's daughter-in-law was visiting at the time of the transfer. Review of an employee investigation statement dated 02/02/14, revealed STNA #2 remained in the room while the resident used the commode. When Resident #39 was ready to return to bed, STNA #2 asked the daughter-in-law to "look out for the R (Resident #39)" and left the room to get the nurse to assist with the transfer. Before the staff returned to the room, the daughter-in-law came out of the room and told STNA #2 that Resident #39 had fallen off the bedside commode. Review of the falls investigation, nurse's note dated 02/04/14 and interview with the director of nursing (DON) on 04/29/14 at 2:00 P.M., revealed X-rays were completed, and initially, negative for fractures. However, when Resident #39 went to an orthopedic follow up appointment on 02/04/14, the orthopedic physician ordered X-rays which determined a "new right mid-femur fracture". On 04/29/14 at 2:00 P.M. during an interview with the DON, the DON verified STNA #2 should not have left the resident in the care of a family member and should not have transferred the resident without gripper socks. The DON said STNA #2 should have summoned assistance via the call light or asked the family member to get the nurse. This deficiency substantiates Complaint Number OH 387.

Based on record review and interview the facility failed to ensure adequate, comprehensive and individualized interventions were initiated for Resident #134, #119 and #128, who were assessed to be at nutritional risk. Harm resulted to Resident #134, Resident #119 and Resident #128, when these residents were assessed to sustain significant weight loss with a lack of adequate monitoring and intervention in an attempt to prevent further weight loss and stabilize weights. This affected three of seven residents reviewed related to weight loss and nutrition. The census was 74 residents. Findings include: 1. . Resident #134 had [DIAGNOSES REDACTED]. The nutritional assessment, dated 09/20/13 revealed the resident's diet order was for the enteral feeding, Diabetisource AC at 85 milliliters (ml) per hour continuous. The assessment revealed the resident's weight was 209 pounds. The assessment indicated the laboratory results dated [DATE] included an [MEDICATION NAME] level (an indicator of protein stores in the body) was low at 1.3. The resident's needs were adjusted to a body weight of 180 pounds. The resident was to have nothing by mouth. There was no documentation of a plan for any desired weight loss. The nurse's notes dated 09/16/13, 09/17/13, 09/18/13, 09/19/13 and 09/20/13 revealed the resident had [MEDICAL CONDITION] (swelling) to bilateral upper and lower extremities of 3+ [MEDICAL CONDITION]. The notes indicated on 09/21/13 at 7:00 A.M. there was bilateral upper and lower extremity 2+ [MEDICAL CONDITION], on 09/21/13 at 9:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 09/22/13 at 7:00 A.M. there was bilateral upper and lower extremity [MEDICAL CONDITION], on 09/22/13 at 10:40 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION] and on 09/23/13 at 8:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION]. There was no documentation the resident had any loss of body fluid/weight due to the use of medication or the absence of [MEDICAL CONDITION]. The weight variance report revealed the resident's weight dated 09/23/13 was 192 pounds which was a 17 pound weight loss that calculated to an 8.1 percent weight loss. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed the resident was dependent on one to more than two people for activities of daily living. The resident's weight was documented as 192 pounds. The resident had a feeding tube and was on a therapeutic diet. The nurse's notes indicated on 09/24/13 at 7:00 A.M. there was generalized 2+ [MEDICAL CONDITION], on 09/24/13 at 8:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 09/25/13 at 7:00 A.M. there was bilateral upper and lower extremity [MEDICAL CONDITION] and on 09/25/13 at 10:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION]. The dietary notes dated 09/25/13 revealed the resident had a weight of 192 pounds on 09/23/13 which was a weight loss of 17 pounds and 8.1 percent. The note indicated the weight loss might be related to the loss of [MEDICAL CONDITION]. However, there was no written documentation that indicated the [MEDICAL CONDITION] had resolved. The nurse's notes revealed on 09/26/13 at 8:00 A.M. there was generalized 2+ [MEDICAL CONDITION], on 09/26/13 at 8:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 09/27/13 at 10:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 09/28/13 at 9:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 10/01/13 at 8:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION], on 10/03/13 at 10:00 P.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION] and on 10/07/13 at 10:00 A.M. there was bilateral upper and lower extremity 3+ [MEDICAL CONDITION]. The care plan dated 10/02/13 indicated the resident had a gastric feeding via the percutaneous endoscopic gastrostomy (peg) tube and was to have nothing by mouth due to dysphagia (difficulty swallowing). The care plan dated 10/03/13 indicated the resident had [MEDICAL CONDITION] bilateral to the upper and lower extremities and had interventions that included to monitor the resident's weight and notify the physician of any changes. There was no care plan initiated that addressed the resident's nutritional needs or weight loss. The care plan dated 10/2013 revealed the resident had compromised skin areas that had been identified around the peg tube site as a Stage I wound, the sacral and distal coccyx wound, scabbed areas to the right upper extremity, bilateral heels as a Stage I and a discoloration of the left and right inner heels. There was no update to the plan of care to reflect any interventions had been initiated that addressed the need for increased supplements to assist in the wound healing. The dietary notes dated 10/22/13 indicated the resident's weight was 192 pounds on 10/01/13 and 10/07/13. There was no documentation of any new interventions initiated that addressed the weight loss that had occurred since 09/16/13. The notes dated 11/05/13 revealed the resident weighed 176 pounds on 11/05/13 which showed a significant weight loss of 8.3 percent in one month. The tube feeding of Diabetisource AC remained at 85 ml per hour continuous at that time. Nursing reported the resident continued to have treatments ordered for wounds to the heels, buttocks, coccyx and percutaneous endoscopic gastrostomy (peg) tube area. The laboratory results on 10/31/13 indicated a low [MEDICATION NAME] level of 2.3. The resident received the tube feeding 22 hours daily due to the tube feeding being shut off for therapy. The resident received 2244 calories, 112 grams of protein and approximately 1533 ml of free water daily. One packet of Prosource Plus mixed with 100 ml water once daily for an additional 100 calories and 10 grams of protein daily was initiated per the dietary note dated 11/05/13. The note also indicated staff would continue to monitor weight once a week for four weeks, tube feeding, skin and laboratory results. The nursing assessment, dated 11/13/13 upon readmission from the hospital to the facility revealed the resident had bilateral upper and lower extremity [MEDICAL CONDITION]. The readmission weight was 183 pounds. The resident remained on Diabetisource at 85 ml per hour at that time. An interview with registered dietitian licensed dietitian (RDLD) #7 on 11/20/13 at 10:45 A.M. verified the resident lost 17 pounds from 09/16/13 to 09/23/13 which was an 8.1% weight loss in one week. She verified the resident had multiple wounds and the laboratory results revealed a low [MEDICATION NAME] level (which was an indicator of protein stores). She verified there were no new interventions initiated that addressed the weight loss or the low protein. She verified there were no interventions related to the decreased protein stores until 11/05/13 when a protein supplement was added. She verified the resident's weight on 11/05/13 was 176 pounds which was an additional weight loss of 16 pounds which was a significant weight loss of 8.3% in one month. She verified she did not change the tube feeding to address the identified weight losses. She verified the resident received nothing by mouth and the only source of nutrition was the tube feeding via the percutaneous endoscopic gastrostomy tube. She verified there was no documentation that indicated the physician had been notified of the significant weight loss. She verified there was no care plan initiated that addressed the resident's nutritional status or significant weight losses. She verified the facility weight loss protocol did not include any information regarding the notification of the physician upon an identified significant weight loss. An interview with the RDLD #7 on 11/20/13 at 4:45 P.M. verified the weight protocol updated 06/15/11 did not include that the physician should be notified of a significant weight. The RDLD verified there was only a care plan that addressed the tube feeding, but did not initiate a nutritional care plan that addressed and contained interventions regarding the significant weight loss. She verified the physician was not notified of the significant weight loss. She verified there were no re-weights completed. She verified the weight protocol was not followed. The weight protocol updated 06/15/11 indicated the dietitian/technician would determine residents who needed re-weighed. The determination of re-weights would be based on the unexpected weight loss or weight gain of five percent in one month. The individuals with weight loss would receive appropriate nutrition intervention to prevent further weight loss, stabilize weight and/or regain weight if appropriate. 2. Resident #119 had [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] indicated the resident's weight was 143.8 pounds. The resident had a feeding tube and received the enteral product, [MEDICATION NAME] Renal at 45 milliliters per hour. The vitals report revealed the resident weighed 144 pounds on 05/29/13 and 133 pounds on 06/04/13. The MDS admission assessment dated [DATE] revealed the resident's weight was 133 pounds. The resident had a tube feeding, a therapeutic diet and was totally dependent on one to two plus people for activities of daily living. The care plan dated 06/10/13 indicated the resident had a gastric feeding via a tube and was to receive nothing by mouth. There was no care plan initiated that addressed the resident's nutritional needs, status or the 11 pound weight loss in one week. The vitals report revealed the resident weighed 117 pounds on 06/11/13. The weight dated 06/11/13 indicated the resident lost 27 pounds since 05/29/13 which was an 18.8% weight loss. There was no documentation that addressed the weight loss. The report indicated the resident weighed 138 pounds on 06/15/13. The social service note dated 06/18/13 revealed the resident was admitted to the hospital with [REDACTED]. The nursing admission assessment dated [DATE] at 5:30 P.M. indicated the resident's readmission weight was 118.4 pounds and that the resident received a tube feeding of [MEDICATION NAME] Renal. The nutrition services progress notes dated 07/08/13 revealed the resident was sent to the hospital on [DATE] and readmitted on [DATE]. The resident was nothing by mouth with a tube feeding order of [MEDICATION NAME] Renal at 40 ml per hour continuous via the percutaneous endoscopic gastrostomy (peg) tube with one packet of Prosource Plus (protein supplement) twice a day via the peg tube which provided an additional 200 calories and 20 grams of protein. The weight dated 07/03/13 was 118 pounds which was a 15 pound weight loss in one month. This was a significant weight loss of 11.2 percent in one month. The body mass index (BMI) was 20.9 which indicated the resident was underweight. The laboratory results dated [DATE] revealed the [MEDICATION NAME] (an indicator of protein stores in the body) was 2.8 which was low. The notes dated 07/15/13 revealed the tube feeding rate per hour was not increased to 55 ml per hour until it was requested by the registered dietitian, who worked for the [MEDICAL TREATMENT] company, to promote weight gain. The vitals report revealed the resident weighed 111 pounds on 07/16/13, 117 pounds on 07/23/13 and 114 pounds on 08/03/13. The MDS quarterly assessment dated [DATE] revealed the resident's weight was 133 pounds. The resident had a tube feeding, a therapeutic diet and was totally dependent on one to two plus people for activities of daily living. The vitals report dated 09/02/13 indicated the resident weighed 115 pounds. An interview with RDLD #7 on 11/21/13 at 9:45 A.M. verified there was no care plan that addressed the resident's nutritional needs. She verified the weight dated 05/29/13 on the vitals report was 144 pounds. She verified the weight dated 06/11/13 was documented at 117 pounds which was a 27 pound weight loss after two weeks. She verified there was no documentation of identification of the weight loss or any interventions initiated that addressed the weight loss. She verified the resident was nothing by mouth and only received tube feeding for nutrition. She verified all of the documented weights after admission were post [MEDICAL TREATMENT] weights. She verified the documentation dated 07/08/13 indicated the resident had a significant weight loss and there was no documentation that it was addressed. She stated she was unsure of the accuracy of the weights. She verified the documentation dated 07/15/13 revealed the tube feeding was increased after a request was made by the registered dietitian from the [MEDICAL TREATMENT] company. She verified there was no documentation that indicated the physician was notified of the significant weight loss. An interview with the RDLD #7 on 11/20/13 at 4:45 P.M. verified the weight protocol updated 06/15/11 did not include that the physician should be notified of a significant weight. The RDLD verified there was only a care plan that addressed the tube feeding, but did not initiate a nutritional care plan that addressed and contained interventions regarding the significant weight loss. She revealed all the weights were obtained post [MEDICAL TREATMENT]. She verified the physician was not notified of the significant weight loss. She verified there were no re-weights completed. She verified the weight protocol was not followed. The weight protocol updated 06/15/11 indicated the dietitian/technician would determine residents who needed re-weighed. The determination of re-weights would be based on the unexpected weight loss or weight gain of five percent in one month. The individuals with weight loss would receive appropriate nutrition intervention to prevent further weight loss, stabilize weight and/or regain weight if appropriate. 3. Resident # 128 was initially admitted to the facility on [DATE], then discharged to the hospital on [DATE] for spinal surgery and readmitted to the facility 10/02/13. The resident's [DIAGNOSES REDACTED]. The resident had an spinal fusion of the L4-S1. The resident's care plans were reviewed. Review of the care plan initiated 10/05/13 for potential for alteration in nutrition revealed the resident was on a low fat regular consistency diet. The interventions included to monitor weight loss and or gain. The resident also had a care plan initiated 10/13/13 for compromised skin areas. The interventions included to provide optimal nutrition and hydration. Review of the re-admission physician order [REDACTED]. Change daily and as needed. The order also included to cleanse the spinal incision with normal saline and leave open to air daily. The resident's weights were reviewed and were as follows; 10/02/13, (re-admission) 173 pounds (lbs); 10/07/13,169 lbs; 10/15/13, 166 lbs; 10/21/13, 163 lbs. The resident lost ten pounds in a 30 day period which constituted a 5.8 % significant weight loss. Review of the resident's October meal intake record revealed the resident average meal intake for the month was 36%. The resident's initial nutrition assessment dated [DATE] indicated historically the resident ate 50% of meals. The assessment referenced the resident's lab work, including glucose, total protein and [MEDICATION NAME], which were within normal limits. The hemoglobin and hematocrit were slightly decreased. The resident's estimated dietary needs were based on an admission weight of 162 pounds and a adjusted body weight of 127 pounds. The nutrition assessment was updated on 10/04/13 when the resident returned to the facility after spinal surgery. The note stated the resident had gained 11 pounds since the admission weight on 09/19/13. The note stated the weight gain may be related to a brace. The assessment stated there was no [MEDICAL CONDITION] per the nursing admission assessment. The dietitian stated the resident was on a low fat regular consistency diet. The assessment also indicated nursing reported a surgical incision to the lower back and a wound to the inside of the buttocks. The resident's most recent laboratory tests dated 10/02/13 were referenced. The dietitian noted the resident's total protein and [MEDICATION NAME] were low (they were within normal limits on the initial assessment) and it may be due to the resident's recent surgery. The dietitian wrote to continue the diet as ordered and that she would monitor the resident's weekly weights, oral intake, skin and labs. There were no other nutrition or dietary notes or assessments. There was nothing in the record to indicate the dietitian had addressed the resident's weight loss or poor oral intake. There were no orders for any supplements or any other dietary interventions in response to the weight loss and abnormal laboratory results. There was no indication the physician was notified of the significant weight loss. The dietitian, RDLD # 7, was interviewed on 11/20/2013 at 2:09 P.M. RDLD #7 stated she calculated the resident's estimated nutrient needs based on the resident's initial admission weight which was 162 lbs. RDLD #7 stated she used the initial admission nutrient needs calculation and did not reassess the residents nutritional needs based on her readmission weight and dietary needs post surgery. RDLD # 7 verified there was no documentation that she monitored the resident's weekly weights, the resident's oral intake, skin or labs after the re-admission assessment completed on 10/04/13. RDLD #7 verified there were no interventions initiated in response to the resident's weight loss or abnormal laboratory results.