Every finding on record at Care Manor Nursing and Rehab

Number of residents sampled: Number of residents cited: Based on document review, interviews and policy review the facility failed to prevent abuse for one (Resident#12) of five residents reviewed for abuse. The findings include: Resident #62 A review of Resident #62’s “Quarterly Minimum Data Set” (MDS) with Assessment Reference Date (ARD) of 07/05/2025, indicated that Resident #62 had a Brief Interview of Mental Status (BIMS) with a score of two, which indicated the resident had severe cognitive impairment. A review of Resident #62’s “Care Plan” revealed that Resident #62 has decreased physical mobility related to muscle wasting and weakness. A review of Resident #62 “Physician Order Summary” revealed the facility admitted Resident #62 on 01/02/2025, with medical diagnoses which included decreased cognition without behavioral disturbance, loss of touch with reality, mood disturbance or anxiety, irregular heartbeat, muscle wasting and weakness, and assault by unspecified means. Resident #62’s medications included Aspirin EC 81 mg daily. Resident #12 A review of Resident #12’s “Quarterly MDS” with ARD of 06/06/2025 indicated that Resident #12 had a Brief Interview of Mental Status (BIMS) with a score of four, which indicated the resident had severe cognitive impairment. No behaviors were documented in the look back period. A review of Resident #12’s “admission Record” revealed that the facility admitted Resident #12 on 10/01/2025 with medical diagnoses which included decline in cognition without behavioral disturbance, loss of touch with reality, mood disturbance and anxiety, and other symptoms of appearance and behavior, with a major depressive disorder. Incident 1 A review of Resident #12’s “Nursing Progress Note” dated 06/24/2025 at 10:45 AM indicated that the Director of Nurses (DON) responded to the secured unit where Resident #12 was threatening Resident #62. Resident #12 threatened that if roommate (Resident #62) opened [pronoun] mouth [pronoun] was not going to like what happened and Resident #12 had put up with enough of [Resident #62’s [expletive] and was not going to put up with it anymore. The DON informed Resident #12 that they could not touch their roommate. Resident #12 replied with “I will knock [Resident #62’s] [expletive] head off.” The Nursing Progress Note revealed that Resident #12 continued to yell and threaten Resident #62 and curse at the DON. The Progress Note revealed that Resident #12 also continued to yell and cuss at other residents in the hallway. A review of a “Nursing Progress Note” dated 06/24/2025 at 11:05 PM indicated a urine specimen was obtained from Resident #12. A review of “UA results” dated 06/24/2025, was with in normal limits. A review of “Every (Q) 15 Minute (Min) Monitoring” form, dated 06/24/2025, revealed Resident #12 was monitored every 15 min from 11: 00 am to 2:00 pm. Incident 2 A review of Resident #62’s “Nursing Progress Notes” dated 08/21/2025 at 8:05 PM, revealed staff heard yelling from Resident #12 and Resident #62’s room and staff went to observe. Resident #62 was lying in bed and Resident #12 was standing over Resident #62 holding a remote with their hand raised. Resident #62 was observed with blood on their left forehead. Resident #62 reported “they are beating the [expletive] out of me with something hard and I didn’t even do anything.” Resident #12 was moved to the other side of the room, while treatment was provided to Resident #62’s area on the left forehead. A Skin Audit was completed for Resident #62, and no other injuries were observed by staff. Neuro checks were also initiated. A review of Resident #12’s “Nursing Progress Note” dated 08/21/2025 11:37 PM, indicated yelling was heard coming from Resident #12 and Resident #62’s room and staff responded. Staff reported upon entering the room, Resident #12 was standing at the foot of the bed where Resident #62 was lying on the bed. Resident #12 was observed standing with their right hand upholding a remote in their hand. Blood was dripping from Resident #62’s forehead from being struck with a remote control by Resident #12. Resident #12 admitted hitting Resident #62 after being cursed by Resident #62. Resident #12 was agitated, the APRN (Advanced Practice Registered Nurse) gave orders to send Resident #12 to the emergency room for a psychiatric evaluation. Resident #12 was placed on one-on-one with a staff member until the ambulance arrived. During an interview on 08/26/2025 at 12:32 PM, Resident #62 stated the incident occurred about a week ago, the room was shared with Resident #12, and they were not together in the room often. Resident #62 reported that they were sleeping and were woken up by Resident #12 hitting them on the head with a remote. Resident #62 could not recall threatening behavior prior to the incident on 08/24/2025 and did remember that Resident #12 had not being in the room since the incident. During an interview with Certified Nursing Assistant (CNA) #11 on 08/26/2025 at 12:55 PM, she indicated Resident #12 had threatened other residents on 08/20/2025. During an interview on 08/26/2025 at 1:01 PM, CNA #10 revealed Resident #12 threatened to beat up Resident #62 a couple of times and it was reported to the nurse. During an interview on 08/26/2025 at 1:22 PM, the DON read the Nursing Progress Note dated 06/24/2025 to this surveyor. Then it was revealed that CNA #10, remained one on one with Resident #12 until they wanted to get up and go to the dining room, in which Resident #12 had calmed down at that point, a urinalysis was obtained for Resident #12, and the results were negative. The DON stated there were no further incidents of threatening behavior. A room change was not done because the DON was not aware of threatening behavior on 08/20/2025. The APRN was notified on 06/24/2025, no psych consultation was obtained at that time. The DON revealed that on 08/21/2025 Resident #62 got up and hit Resident #12 in the head with the remote. The injury did not require sutures or stitches. During an interview on 08/26/2025 at 1:32 PM, the Administrator stated there were no beds open to move Resident #12 to, except the opposite gender had two beds open, and would not be able to move Resident #12 or Resident #62 into those beds. The Administrator stated Resident #62 curses at times and had threatened other residents before, but had not hit anyone. The Administrator believes Resident #12 hallucinates things and then gets agitated with others. The Administrator did not remember the incident on 06/24/2025. During an interview on 08/26/2025, the DON was asked to provide one on one documentation for the time period after the incident on 08/21/2025 until Resident #12 went to hospital. The documentation was not provided. During an interview on 08/26/2025 at 1:58 pm, the Social Director revealed a follow up was completed with Resident #12 after the incident on 06/24/2025, and Resident #12 did not remember saying anything to Resident #62. On 06/25/2025 she returned to Resident #12, and Resident #12 was calm and had no threatening behaviors. During a visit with Resident #62 on 08/22/2025, Resident #62 reported feeling safe with staff however, they did not feel safe with Resident #12. During a follow-up visit on the following Monday, Resident #62 reported feeling safe. Resident #12 was admitted to Geri-psych unit and was not in the facility. The Social Director could not recall discussions from the administration of moving either resident to new rooms to separate them or interventions put in place after the incident on 06/24/2025, During an interview on 08/27/2025 at 9:51 AM, CNA #10 revealed on 06/24/2025, from the time of the altercation to the end of the shift at 2 PM, CNA #10 completed 15-minute checks on Resident #12. CNA #10 did not recall any other physical altercations. CNA #10 did recall yelling and screaming by Resident #12 at times, and Resident #12 made threats to beat up Resident #62, which was reported to the nurse. CNA #10 did not recall which nurse the threats were reported to. CNA #10 reported that Resident #62 would yell out at times in the shared room with Resident #12. Resident #12 would walk over to Resident #62, but the staff would redirect Resident #12 before a physical altercation took place. The threatening behavior happened about 4 to 5 times over a month or two period. During an interview on 08/27/2025 at 1:18 PM, LPN #12 indicated she was aware of one verbal altercation involving Resident #12 and Resident #62 escalating to Resident #12 swinging at Resident #62 but did not make physical contact. The residents were separated for the night. LPN #12 could not indicate the date or time that altercation occurred. LPN #12 stated Resident #12 cursed while adjusting to the secure unit. Resident #12 becomes confused when not wearing oxygen and staff monitors for oxygen needs. During an interview on 08/28/2025 at 3:06 PM, the APRN revealed she was made aware of the verbal altercation and had ordered one dose of anxiety medication. The APRN conducted a follow-up visit within 24 hours and Resident #62 stated there was no intent to hurt anyone. The APRN stated she would have ordered a Geri-psych consult if she was made aware of further threatening behavior prior to the 08/21/2025 altercation. During an interview on 08/29/2025 at 9:19 AM, the APRN reported a decrease in Resident #62’s dose of [an anticonvulsant and mood-stabilizing medication used to treat epilepsy and bipolar disorder] was done in November of 2024, but due to staff reports of Resident #62 becoming agitated and threatening, the dose was increased, and a Gradual Dose Reduction was declined due to reported behaviors. She reported that Resident #62 had been roommates with all the same genders but couldn’t get along with them. She was aware of verbal aggression but no physical aggression to other residents. She reported that she had questioned if they were going to move the rooms, but it didn’t happen. She reported that LPN # 12 had reported to her that Resident #62 couldn’t room with other residents due to yelling and screaming. A review of a policy titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” dated (enter date or if undated state undated) indicated that residents have the right to free from abuse, the facility will protect residents from abuse by other residents, and the facility will handle other residents’ aggressive behaviors.

Number of residents sampled: Number of residents cited: Based on record review and interview it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for five (Resident #7, Resident #4, Resident #69, Resident # 34, and Resident #58) of 10 residents reviewed for MDS accuracy. The findings include: Resident #7 Review of Resident #7's Medical Records on 08/26/2025 at 9:16 AM indicated there was no Preadmission Screening and Resident Review (PASRR) information available in the electronic medical record. Review of an admission Record indicated the facility admitted Resident #7 on 04/24/2025 with diagnoses which included depression, generalized anxiety disorder, altered mental status and cognitive communication deficit. Review of an Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2025, indicated Resident #7 had a diagnosis of a psychotic disorder. Review of medical diagnoses indicated the resident had no diagnosis of a psychotic disorder requiring a PASARR. A modification of the MDS dated [DATE], following surveyor inquiry, indicated a correction of the MDS with the psychotic disorder removed. Review of resident #7's Care Plan did show an entry for psychotropic medication that stated the drug was given related to a diagnosis of depression. Resident #4 Review of a Quarterly MDS with an ARD of 06/02/2025, indicated Resident #4 had a psychotic disorder. Review of medical diagnoses indicated the resident had no diagnosis of a psychotic disorder. A modification of the MDS dated [DATE], following surveyor inquiry, indicated a correction of the MDS with the psychotic disorder removed. Resident #69 Review of a Quarterly MDS with an ARD of 06/19/2025, indicated Resident #69 had a psychotic disorder. Review of medical diagnoses indicated the resident had no diagnosis of a psychotic disorder. A modification of the MDS dated [DATE], following surveyor inquiry, indicated a correction of the MDS with the psychotic disorder removed. Resident #34 Review of a Quarterly MDS with an ARD of 07/21/2025, indicated Resident #34 had a psychotic disorder. Review of medical diagnoses indicated the resident had no diagnosis of other psychotic disorder. A modification of the MDS dated [DATE], following surveyor inquiry, indicated a correction of the MDS with the psychotic disorder removed. Resident #58 Review of a Quarterly MDS with an ARD of 06/21/2025, indicated Resident #58 had a psychotic disorder other than Schizophrenia. Review of medical diagnoses indicated the resident had no diagnosis of psychotic disorder other than Schizophrenia. A modification of the MDS dated [DATE], following surveyor inquiry, indicated a correction of the MDS with the psychotic disorder removed. During an interview on 08/29/2025 at 11:19 AM, the MDS Coordinator stated admission Records are completed by an admission Licensed Practical Nurse (LPN). The MDS Coordinator confirmed she completed the MDS documents and that the MDS's had been coded incorrectly, because Resident #7, #4, #69, #34, and #58, did not have a diagnosis of other psychotic disorder when the MDS was completed. The admission Records had been completed correctly but the Psychotic Disorder other than Schizophrenia had been indicated in error on five of ten MDS documents reviewed. The MDS Coordinator also stated the facility did not have a policy for the Minimum Data Set (MDS) and the facility used the Resident Assessment Instrument (RAI) 3.0 manual.

Number of residents sampled: Number of residents cited: Based on record review and interviews it was determined that the facility failed to address intravenous therapy, primary diagnoses, and antibiotic therapy in the comprehensive care plan for one (Resident #52) of one resident reviewed. The findings include: A review of Resident #52's admission Record revealed that the facility admitted Resident #52 on 07/29/2025 with medical diagnoses which included brain dysfunction caused by liver damage and bacteria in the blood. A review of Resident #52's admission Minimum Data Set (MDS) with assessment reference date (ARD) of 08/01/2025, revealed that Resident #52 had a Brief Status of Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS also revealed that Resident #52 received antibiotics and had intravenous (IV) access. A review of Resident #52's Order Summary dated 07/29/2025 revealed that Resident #52 received two IV antibiotics for brain dysfunction caused by liver damage and bacteria in the blood. A review of Resident #52's Care Plan did not address the resident's medical diagnoses, antibiotic therapy, or IV therapy. During an interview on 08/29/2025 at 12:33 PM, Registered Nurse (RN) #13 reported that she adds medical diagnoses, IV therapy, and antibiotic therapy on all resident's care plans that receives them. She reported that she did not add the medical diagnoses for brain dysfunction caused by liver damage and bacteria in the blood, IV therapy, or antibiotic therapy on Resident #52's care plan because she overlooked it. RN #13 reported that nurses review the care plans and that it guides them in taking care of the resident. During an interview on 08/29/2025 at 12:44 PM, the Director of Nurses (DON) revealed that RN #13 was responsible for developing and implementing care plans for the residents. She also revealed that infections, antibiotic therapy, and IV therapy should be addressed in the care plans. The DON reported that the care plan guides the nursing staff on how to take care of the residents. During an interview on 08/29/2025 12:50 AM with the Administrator, he revealed that RN #13 was responsible for completing and updating care plans. He reported that the floor nurses can update care plans, but it was typically RN #13 who does that as well.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure a written bed hold notification was issued prior to a hospital transfer for 1 (Resident #1) of 1 resident reviewed for transfer process. The findings include: A review of Resident #1's, Admission Agreement, signed 07/27/2021 by Resident #1's authorized representative indicated, except for emergent situations, before the facility transfers a resident to a hospital the facility will provide written information to the resident specifying the amount of time a bed will be held and any corresponding charges. A review of Resident #1's progress note dated 11/18/2024 at 10:53 PM revealed, Resident #1 was transferred via Emergency Medical Services (EMS) to the hospital at 10:00 PM for a fracture to the right femur neck. A review of Resident #1's hospital record titled, Patient Care Report for the ambulance run indicated the transport priority was Non-Emergent Stable. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #1 had a Brief Interview of Mental Status score of 12 which indicated the resident had moderate cognitive impairment. During an interview on 01/16/2025 at 9:07 AM, the resident's representative stated while in the hospital the facility stated they could only hold the resident's bed for 5 days then they would lose it. The resident's representative stated they did not know what to do. No other information was provided. During an interview on 01/16/2025 at 3:50 PM, Licensed Practical Nurse (LPN) #1 stated if a resident was transported to the hospital she printed a face sheet, a transfer sheet, the medication administration record (MAR), active orders, and a Do Not Resuscitate (DNR) order if applicable. She did not have any knowledge about a bed hold and stated it was above my pay grade. During an interview on 01/16/2025 at 4:02 PM, the Business Office Manager (BOM) stated she had not generated a bed hold since she took over the position on 11/01/2024. She stated if one was required, she would either hand deliver one to the resident in the hospital, mail one to their representative, or just give it to the resident when they returned to the facility. During an interview on 01/16/2025 at 4:08 PM, the Director of Nursing (DON) stated she was unaware how a bed hold worked or who was responsible for it. During an interview on 01/16/2025 at 4:09 PM, the Administrator stated residents received information regarding bed holds upon admission in the admission packets. The Administrator stated we do not give one every time a resident goes to the hospital, residents come and go so often it would not be consistent. During an interview on 01/17/2025 at 11:00 AM, the Administrator stated he misunderstood the question about bed holds the prior day. He stated he answered regarding when the residents were educated on bed holds. He stated he was unaware as an administrator a bed hold regulation required notification given when a resident left the building and assumed the BOM must had been handling it. The Administrator stated the BOM was new to her position and was evidently never instructed by the BOM consultant who was previously filling the role.

Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan was revised or updated for 1 (Resident #47) sampled resident. The findings are: Review of an Order Summary revealed Resident #47 had a diagnosis of malignant neoplasm of brain. On a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/2024 Resident #47 received a score of 3 (0-7 indicates severely cognitive impaired) on the Brief Interview for Mental Status. The MDS documented the resident requires substantial/maximum assistance with personal hygiene. On 05/14/2024 at 12:56 PM, a review of the residents electronic medical record revealed a physician's order for admission to Elite Hospice on 03/27/24. A nurses progresses notes recorded on 03/27/2024 at 2:48 PM recorded, [named hospice provider] RN here and resident admitted to their care. No new orders received at this time. On 05/15/2024 at 8:53 PM, a review of Resident #47's care plan identified a focus area of, The resident has a terminal diagnosis or poor prognosis related to end stage disease process and/or multiple comorbidities and has not elected hospice. On 05/16/2024 at 8:45 AM, the MDS Coordinator was asked when a resident's care plan should be updated and she stated every 3 months. When asked if there were other times when an update would be necessary the MDS coordinator replied, When changes occur. When asked if admission to hospice would be one of those time the MDS Coordinator replied, Yes. When asked to review Resident #47's care plan which documented the resident had not elected to receive hospice care the MDS Coordinator said that she had forgotten to remove the not from the focus area. The MDS Coordinator continued to describe how the system offers choices based on the care area and she didn't make the necessary changes.

Based on interview, observation, and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days without documentation from the attending physician or prescribing practitioner indicating their rationale in the resident's medical record for 2 (Residents #11 and #42) sampled residents that were selected for medication review. The findings are: 1. Review of Medical Diagnoses indicated Resident #11 had diagnoses of unspecified dementia, depression, cerebral infarction, and anxiety disorder. a. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 02/16/2024 indicated Resident #11 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the assessment could not be completed. b. Review of a Physician's Order indicated an order dated 01/17/2024 for Clonazepam 0.5 milligram (mg) every 6 hours as needed for anxiety. c. Review of Medication Administration Records (MAR) for January ,February, March, and April of 2024 revealed that Clonazepam 0.5mg was being administered every 6 hours as needed. d. Review of the medical records and the monthly pharmacy reviews did not reveal a justification by the attending physician indicating why Resident #11 should continue Clonazepam 0.5mg every 6 hours as needed past 14 days. 2. Review of Medical Diagnoses indicated Resident #42 had diagnoses of vascular dementia, cerebral infarction, and anxiety disorder. a. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2024 indicated Resident #42 had a Brief Interview for Mental Status (BIMS) score of 9 (8-12 indicates moderately impaired). b. Review of a Physician's Order indicated an order dated 07/23/2023 for Ativan 1mg every 6 hours as needed for behaviors. c. Review of Medication Administration Records (MAR) for January ,February, March, April, and May of 2024 revealed that that R#42 was continuing to take Ativan 1mg every 6 hours as needed. d. On 05/15/2024 at 2:45 PM, the surveyor asked the Director of Nursing (DON), If the resident is receiving a PRN (as needed) psychotropic or antipsychotic medication, how is this medication monitored and how does the Interdisciplinary Team determine if the PRN medication is clinically indicated and ensure the PRN orders are consistent with PRN requirements for psychotropic and antipsychotic medications? The DON said, The Interdisciplinary Team (IDT) monitors the nurses, if they are administering the medication or if they are not taking it. The IDT then asks the nurses weekly to go over any behaviors or unusual occurrences, the IDT meets weekly, and look to see if the medication is needed to be discontinued or scheduled. They also discuss if the medication isn't working effectively, then they try an alternate therapeutic intervention. The DON was asked, When should a resident be evaluated to either continue the medication or stop the medication? The DON said, After 14 days, if they are taking it often then they need to schedule it, if they haven't taken it then they need to discontinue the medication.

Based on observation, record review, and interview, the facility failed to ensure that narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property, that multi-use vials were dated when opened, and medications from discharged residents were appropriately accounted for and secured to prevent misappropriation of medications. The findings are: 1. On [DATE] at 5:57 PM, two surveyors entered the medication room with Licensed Practical Nurse (LPN) # 4. The facility narcotic box was easily removed from the refrigerator and placed upon the counter. LPN #4 was asked to unlock the narcotic box. Inside the box were two vials of Ativan 2 milligrams per millimeter (mg/ml) that were prescribed to a resident that had expired, as well as five syringes and two vials of Ativan injectables, 2 mg/ml, intended for facility use. a. On [DATE] at 6:15 PM, two surveyors accompanied by LPN #4 observed a vial of multi-use vial Tuberculin with no opened date, lot number 3CA26C1, expiration date ,d+[DATE]. Another vial of multi-use opened Tuberculin with no opened date Lot number 3CA18C1 with an expiration date of ,d+[DATE] was also observed. On [DATE] at 6:35 PM LPN #4 was asked who had keys to the medication room. LPN #4 stated, All the nurses. LPN # 4 was asked if the narcotic box should be able to be removed from the refrigerator. LPN #4 stated, It always has. On [DATE] at 6:48 PM, the Director of Nurses (DON) was asked if the narcotic box was able to be removed from the refrigerator. The DON stated, Yes, so the nurses can get to the medications. The DON was asked if the nurse who was responsible for the narcotic box gave the keys to another nurse without counting. The DON stated, No. The DON was asked if a resident had expired or discontinued what should happen with the medications. The DON stated, Take the tag off, count them and put them in the box. The DON was asked, if this process does not occur and medications are not locked up what could happen? The DON stated, Anything could happen such as misappropriation of medications. The DON was asked how often the narcotics were surrendered to her. The DON stated, Monthly.

Based on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected after use to prevent potential spread of infection for 1 (Resident #45) who had physician orders for capillary blood glucose (CBG) monitoring. The findings are: 1. Review of an Order Summary Report revealed Resident #45 had a diagnosis of type II diabetes mellitus and a physician's order for a fast-acting insulin to be administered according to a sliding scale (The term sliding scale refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges, and is dependent on CBG monitoring). 2. On 05/15/2024 at 7:36 AM, during an observation of medication administration Licensed Practical Nurse (LPN) #1 performed a blood glucose test on Resident #45. LPN #1 took the glucometer out of a medication cart drawer and then took it to Resident #45's room and performed a CBG test (CBG testing uses a drop of blood from a finger prick to get a blood glucose reading using a blood glucose meter, or glucometer). LPN#1 then returned to the cart and replaced the glucometer without sanitizing it. 3. On 05/15/2024 at 7:54 AM, LPN #1 stated they should wipe the glucometer down with sanitizer cloth before and after using it on a resident to prevent spreading germs/infections from person to person. 4. On 05/16/2024 at 8:48 AM, the Director of Nursing (DON) said a glucometer should be cleaned before and after performing a CBG test for infection control. The DON said staff are trained to perform this test correctly during new hire orientation and are retrained annually. 5. Review of a Policy titled, Obtaining a Fingerstick Glucose Level indicated that staff were to utilize, Disinfected blood glucose meter (glucometer) with sterile lancet; or single-resident use spring-loaded device or automatic or safety type lancet .

Based on record review and interview, the facility failed to ensure that an Infection Preventionist was employed by the facility during the time frame of 01/02/2024 to 02/08/2024 in which a COVID-19 outbreak occurred. The findings are: On 05/15/2024 at 10:05 AM, the Director of Nursing (DON) was asked who the Infection Preventionist (IP) during the COVID-19 outbreak in January 2024. The DON said it was another nurse but they quit either during or before the COVID-19 outbreak. The DON was asked how long the facility operated without an IP. The DON said the facility did not have an IP for roughly a month. The surveyor asked how the COVID-19 outbreak was handled with no IP. The DON reported they (the DON) looked at the policies and procedures and ensured that infection control was followed during the outbreak. The DON reported they did not have an IP license or certification. On 05/15/2024 at 2:00 PM, the Administrator was asked to describe the importance of having a trained and certified IP. The Administrator stated it is a requirement.

Based on observation, record review, and interview, the facility failed to ensure that a residents expressed preference for having their bed made was honored for one (Resident #32) sampled resident. The findings are: Review of an Order Summary Report revealed Resident #32 had diagnoses of type 2 diabetes mellitus and bipolar disorder. On the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/24 Resident #32 received a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). On 05/13/24 at 02:23 PM, Resident #32 was observed sitting in his/her room adjacent to the bed. During discussion Resident #32 expressed a preference for his/her bed to be made each day. Resident #32 described feeling as if the certified nursing assistants (CNA's) ignore the unmade bed due to their being short staffed. Resident #32 reported that their bed is frequently unmade. On 05/15/24 at 08:57 AM, Resident #32 reported that his/her bed has not been made this week. When asked if he/she has requested that the bed be made the resident reported that he/she stopped asking. On 05/15/24 at 09:30 AM, Certified Nursing Assistant (CNA) #2 was asked when the resident's beds are normally made. CNA #2 described that there is no assigned time, that beds are made as they get to them, depending on the needs of the residents. She reported that bed are typically made prior to the lunch meal. CNA #2 could not recall if Resident #32's bed had been made this week, just that it should have been. CNA #2 added that some days the beds may not get made. On 05/15/24 at 09:36 AM, CNA #3 was asked when resident beds are made. CNA #3 reported that beds are made according to how busy they are. CNA #3 said that staff attempts to make the bed as soon as the resident is up for breakfast. CNA #3 expressed her belief that she made the resident's bed on Monday sometime after breakfast. On 05/16/24 by 09:28 AM, a policy entitled Homelike Environment documented, .residents are provided with a safe, clean, comfortable, and homelike environment . Policy Interpretations includes a clean, sanitary, and orderly environment. The accommodation of needs policy describes that the environment and staff behaviors and directed toward assisting the resident in maintaining and /or achieving safe independent functioning, dignity, and well-being .

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment; food items stored in the refrigerator /freezer were covered, sealed and dated; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received or opened to assure first in first out usage and hot foods on the steam table were maintained at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 44 residents who received meals from the kitchen (total census: 45), as documented on a list provided by the Dietary Supervisor on [DATE] and the findings are: 1. On [DATE] at 9:45 AM., Dietary Employee #1 turned on the faucet in the dish washing room and washed his hands. He turned the faucet off with his bare hands, picked up plates and placed them on the shelf with his fingers inside of the plates. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 2. On [DATE] at 9:47 AM., the following observations were made in the freezer. a. An opened box of dinner rolls with no opened date. b. An opened box of hamburger patties with no opened date. c. A box of dough with no received date 3. On [DATE] at 9:54 AM., The following were on the bread rack in the storage room: a. Nine bags of bread that had expiration date of [DATE]. b. Three bags of Texas toast bread had expiration dates of [DATE]. 4. On [DATE] at 9:52 AM., the following spices stored on a rack in the storage room and had no received or opened dates: a. Red pepper b. Montreal Steak Seasoning c. Italian Seasoning d. Oregano e. Ground Cumin f. Garlic powder g. Ground cinnamon h. Ground Cumin i. Pure lemon extract j. Parmesan cheese k. Lemon and peppers 5. On [DATE] at 10:06 AM., the following observations were made in the freezer: a. An opened box of broccoli had no opened date. b. A box of peas and carrots had no opened date. c. A box of chocolate chip cookies had no opened date. 6. On [DATE] at 10:19 PM., the following observations were made in the Hydration room refrigerator and freezer by the Nurses Station: a. One bottle of prune juice had no received date or opened date. b. A carton of chocolate cherry ice cream in the freezer icicles on it. The Surveyor asked the Dietary Supervisor to describe the appearance. She stated, It had icicles It needs to be tossed out. c. One box of [pizza pockets] hot pockets in the freezer had no received date. d. An opened box of super pretzel in the freezer had no opened or received date. 7. On [DATE] at 10:34 AM., Dietary Employee #2 walked into the kitchen from the dining room and did not wash his hands. He picked up glasses that contained beverages by the rims and placed them on the shelf. 8. On [DATE] at 11:15 AM., Dietary Employee #3 wore mittens on her hands to remove a pan of vegetable blend from the oven and placed it on the counter. Dietary Employee #3 did not wash her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed diets. The Surveyor immediately asked Dietary Employee #3 What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 9. On [DATE] at 11:19 AM., Dietary Employee #3 opened the door from the dining room leading to the kitchen. He picked up bowls from the storage and placed them on the counter with his fingers inside the bowls. He did not wash his hands before he picked up the bowls. As he was about to put low fat cottage cheese in the bowls, the Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 10. On [DATE] at 12:02 PM., the temperatures of the food items on the steam table tested by Dietary Employee #2 in the small dining room kitchen were: a. The smothered chicken was 123 degrees Fahrenheit. b. The ground chicken with gravy was 115 degrees Fahrenheit. 11. When Dietary Employee #2 was ready to send the meal tray to the resident, the Surveyor asked, What should you do when food items are not hot enough to be served to the residents? He stated, I will reheat them. 12. The facility policy titled, Employee Cleanliness and Handwashing Technique provided by the Dietary Supervisor on [DATE] at 1:54 PM documented, Before beginning shift and any other time deemed necessary.

Based on record review and interview, the facility failed to ensure a comprehensive, person-centered Care Plan was developed to address the necessary care and monitoring related to the administration of antipsychotic, antianxiety, antidepressant, anticoagulant, and diuretic medications, to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #26) of 1 sampled resident who received Risperdal, for 1 (Resident #35) of 2 (Resident #35 and #41) sampled residents who received Buspirone; for 1 (Resident #35) of 3 (# 2, #34, and #35) sampled residents who received Trazodone; for 1 (Resident #26) of 2 (#14 and #26) sampled residents who receive Sertraline; for 1 (Resident #26) of 3 (#16, #26, and #43) sampled residents who received Eliquis; for 1 (Resident #26) of 3 (Resident #16, #26 and #36) sampled residents who received Hydrochlorothiazide; for 1 (Resident #35) of 3 Residents (#5, #35 and #36) who received Bumex. The findings are: 1. Resident #26 had diagnoses of Depression, Psychotic and Mood Disturbance and Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/22 documented the resident scored 4 (0-7 indicates Severe impairment) on a Brief Interview for Mental Status (BIMS) and received an Antipsychotic, Antidepressant, Anticoagulant and Diuretic. a. A Physician's Order dated 12/03/22 documented, Hydrochlorothiazide (HCTZ) Tablet 12.5 MG Give 1 tablet by mouth one time a day for diuretic . b. A Physician's Order dated 12/03/22 documented, Risperidone Tablet 0.5 MG [milligram] Give 1 tablet by mouth at bedtime for antipsychotic . c. A Physician's Order dated 12/03/22 documented, Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day for antidepressant . d. A Physician's Order dated 02/28/23 documented, Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for protocol . e. A review of Resident #26's Care Plan was completed and there was no documentation pertaining to Eliquis, Hydrochlorothiazide, Risperidone or Sertraline. 2. Resident #35 had diagnoses of Chronic Kidney Disease, Depression and Anxiety. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/23 documented the resident had a BIMS of 15 (13-15 indicates Cognitively Intact); and received an Antidepression, Antianxiety and Diuretic. a. A Physician's Order dated 10/01/22 documented, Buspirone HCl Tablet 5 MG Give 1 tablet by mouth one time a day for mood . b. A Physician's Order dated 12/03/22 documented, Bumex Tablet 1 MG (Bumetanide) Give 1 tablet via [by way of] J-Tube three times a day for diuretic . c. A Physician's Order dated, 02/26/23 documented, Trazodone HCl Tablet 100 MG Give 1 tablet via J-Tube at bedtime for sleep . d. A review of Resident #35's Care Plan was completed and there was no documentation pertaining to Bumex, Buspirone or Trazodone. 3. On 03/09/23 at 11:05 AM., the Surveyor asked Registered Nurse (RN #1), Who develops the Residents' Care Plan? RN #1 stated, I do. The Surveyor asked, How many days do you have to complete the resident's Admission Care Plan? RN #1 stated, 14 days. The Surveyor asked, Resident #35 has a Physician Order for BUMEX, Buspirone and Trazodone, should these medications be monitored? RN #1 stated, Yes. The Surveyor asked, For what? RN #1 stated, For the side effects and if they have a black box warning the information needs to be documented. The Surveyor asked, Where is it documented in the resident's Care Plan for these medications and the interventions to monitor for the side effects? RN #1 stated, The medications are not in the Care Plan. The Surveyor asked, Why? RN #1 stated, To be honest, I've been working the floor, I missed doing that and they did not get care planned. The Surveyor asked, Does Resident #26 have a Physician Order for Eliquis, HCTZ, Risperidone and Sertraline, should these medications be monitored? RN #1 stated, Yes. The Surveyor stated, For what? RN #1 stated, For side effects and if they have a black box warning that information needs to be documented. The Surveyor asked, Where is it documented in the resident's Care Plan for these medications and the interventions to monitor for the side effects? RN #1 stated, the medications are not in the Care Plan. 4. The facility policy titled, Goals and Objectives, Care Plans provided by the Administrator on 03/09/23 at 3:12 PM documented, . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.

Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 2 (Residents #31 and #34) of 13 (Residents #2, #3, #5, #10, #14, #15, #16, #17, #21, #28, #31, #34, #41) case mix residents who were dependent on staff for bathing. This failed practice had the potential to affect 14 residents residing on the 300 hall, who were dependent on staff for bathing/showers, according to a list provided by the Administrator on 03/09/23 at 14:16 [2:16] pm. The findings are: 1.Resident #31 had diagnoses of Type 2 Diabetes Mellitus without Complications, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Pressure Ulcer of Right Buttock, Stage 3 and Personal History of Urinary (Tract) Infections. A Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) dated 02/06/23 documented a Brief Interview of Mental Status (BIMS) score of 15 (score of 13-15 indicates cognitively intact). She required Extensive assistance of 2 for toilet use and bathing, Extensive assistance of 1 for bed mobility, transfer, dressing and personal hygiene, Independent after setting up for eating, was frequently incontinent of bladder and always continent of bowel. a. A Care Plan dated 05/10/21 documented, {named} has an Activity of Daily Living (ADL) self-care performance deficit related to [r/t] advancing Diabetes .Provide sponge bath when a full bath or shower cannot be tolerated . requires extensive to dependent assist of two staff for at least two showers/baths weekly and as necessary . b. A Care Plan dated 5/10/21 documented, [named] has potential for impaired skin integrity r/t Decreased Mobility . c. A. Physician Order dated 01/06/23 documented, Weekly Skin and Wound Assessment every day shift every Wed (Wednesday) for wound progress. d. A. Physician Order dated 03/08/23 documented, Cleanse stage 3 pressure ulcer to right buttock with wound cleanser .change daily and PRN (as needed) until healed, every day shift for wound care AND as needed for wound care. e. On 03/06/23 at 10:34 am., during initial rounds, the resident was seated in her wheelchair in her room. She stated, my showers are scheduled for twice weekly, but I've only gotten one a week for the past month. f. On 03/09/23 at 10:08 am., the Bathing Tasks schedule documented the resident's shower days are Tuesday and Friday and as needed (PRN). Shower documentation for Resident #31 showed: Shower on 02/07/23 [Tues] at 12:23 pm, Shower on 02/14/23 [Tues] at 13:32 [1:32] pm. Shower on 02/22/23 [Wed] at 07:12 am. Shower on 02/28/23 [Tues] at 11:04 am. Not applicable on 03/03/23 at 13:50 pm. Shower on 03/07/23 [Tues] at 11:07 am. g. On 03/09/23 at 02:42 pm., the Surveyor asked Licensed Practical Nurse (LPN) #1, How much assistance does the resident need with ADLs? She stated, She is 1 person transfer with gait belt. The Surveyor asked, How often does the resident receive showers/baths? She stated, She is supposed to get one twice weekly. The Surveyor asked if the resident ever refuses showers. She stated, Very rarely. h. On 03/09/23 at 02:50 pm., the Surveyor asked Certified Nurse Assistant (CNA) #1, How much assistance does the resident need with ADLs? She stated, She requires limited with 1 assist. The Surveyor asked, How often does the resident receive showers/baths? She stated, She is supposed to get one twice a week. The Surveyor asked if the resident ever refused showers. She stated, Not to my knowledge. The Surveyor asked if the resident had ever asked to have more than one shower a week. She stated, She has said that it would be great if she could but has never asks me for more than one. i. On 03/09/23 at 03:01 pm., the Surveyor asked the Director of Nursing (DON), How much assistance does the resident need with ADLs? She stated, She can stand at the bar but needs assistance pulling her pants down, she can turn and sit on toilet herself, but needs help wiping and pulling her pants up. The Surveyor asked How often does the resident receive showers/baths? She stated, She is scheduled for twice a week, I know we just did a shower check on her, so she is getting one regularly. 2. Resident #34 had diagnoses of Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Left Dominant Side, Osteomyelitis of Vertebra, Site Unspecified, Paroxysmal Atrial Fibrillation and Acute Respiratory Failure with Hypoxia. The Quarterly MDS with ARD dated 02/02/23 documented a BIMS score of 15 (score of 13-15 indicates cognitively intact). He required Extensive assistance of 2 for bed mobility, transfer and toilet use, Extensive assistance of 1 for dressing and personal hygiene, Physical assistance of 1 for bathing, Independent after set up for eating, was always continent of bladder and occasionally incontinent of bowel. a. A Care Plan with a revision date of 11/22/22 documented, [R #34] has an ADL self-care performance deficit r/t Hemiplegia following CVA .resident prefers shower Wednesday and Saturday on day shift .Provide sponge bath when a full bath or shower cannot be tolerated .requires extensive assist x 1 staff for showering/bathing 2 x week and as necessary . b. A Physician Order dated 03/01/23 showed, Lantiseptic to red area on right buttock every shift for redness. c. On 03/06/23 at 11:00 am., during initial rounds Resident #34 was lying in his bed, he stated, I'm supposed to get showers on Wednesday and Saturdays, but sometimes go a month without one. d. On 03/08/23 at 03:24 pm., Resident #34 was lying in bed. The Surveyor asked if he had received a shower. He stated, Yes, I had one today and last Wednesday also. Last week's shower was the first one I received in a month. e. On 03/09/23 at 10:08 am., the Surveyor received a Bathing Tasks scheduled documenting the resident's shower days were Wednesday, Saturday and PRN. Shower documentation is as follows: 02/08/23 13:59 [1:59] [Wed] Shower. 02/15/23 13:59 [Wed] Shower. 02/19/23 13:59 [Sun] Shower. 02/22/23 13:59 [Wed] Shower. 03/01/23 13:46 [Wed] Shower. 03/04/23 13:59 [Sat] Not Applicable. 03/08/23 09:35 [Wed] Shower. f. On 03/09/23 at 02:27 pm., the Surveyor asked CNA #1 if she was familiar with resident. She stated, Yes. The Surveyor asked how much assistance he needed with ADLs. She stated, I believe he is extensive assist. The Surveyor asked, How often does the resident receive showers/baths? She stated, He is supposed to get one twice a week. The Surveyor asked, Has the resident ever refused showers? She stated, Not to my knowledge. The Surveyor asked if resident ever asked to have more than one shower a week. She stated, He has complained about not getting a shower before, but I don't remember him ever asking to have more than one. g. On 03/09/23 at 02:46 pm., the Surveyor asked LPN #1 How much assistance does the resident need with ADLs? She stated, He is a 2 person with lift. The Surveyor asked, How often does the resident receive showers/baths? She stated, He is supposed to get them twice a week, on Wednesday and Saturday. The Surveyor asked if resident ever refuses showers. She stated, He has refused showers but usually it's because he doesn't feel good. h. On 03/09/23 at 03:01 pm., the Surveyor asked the DON, Do you know much assistance the resident needs with ADLs? She started, I know he uses a urinal, but is incontinent of bowel. I'm almost certain he needs a lift, which is 2 assists, but I've only been here for a month, so I'm still learning the residents. The Surveyor asked, How often does the resident receive showers/baths? She stated, He is scheduled for 2 a week. 3. The facility policy titled, Activities of Daily Living (ADLs), Supporting with revision date of March 2018 provided by the Administrator on 03/09/23 at 03:12 pm documented, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

Based on observation, record review, and interview, the facility failed to ensure the oxygen/updraft mouthpiece/mask was stored in a bag or other closed container when not in use to prevent potential contamination for 1 (Resident #304) of 5 (Residents #5, #18, #28, and #34, and #304) sampled residents who had an order for an updraft and for 2 (Residents #18 and #304) of 6 (Residents #2 #5, #18 #31, #34, and #304) sampled residents who had an order for oxygen. The findings are: 1.Resident #18 had diagnoses of Cardiomegaly and Shortness of Breath. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documented the resident scored 15 (13-15 indicates Cognitively intact) on a Brief Interview for Mental Status (BIMS), required total assistance with two-person assist for transferring, extensive assist with two-person assist for bed mobility and toilet use, had no shortness of breath and was not on oxygen therapy. a. A Physician's Order dated 12/13/21 documented, Oxygen 2-3 lpm [liters per minute] PRN as needed for SOB [Shortness of Breath] . b. A Initial Care Plan dated, 12/15/21 documented, [Resident's Name] has oxygen therapy r/t [related to] SOB . [Resident's Name] will have no s/sx [signs/symptoms] of poor oxygen absorption through the review date. . Monitor for s/sx of respiratory distress and report to MD . c. A Physician's Order dated 11/07/21 documented, Albuterol Sulfate Nebulization Solution 2.5 MG/3ML [Milligram/Milliliters] 0.083% 3 ml inhale orally via [by way of] nebulizer every 4 hours as needed for Shortness of Breath . d. On 03/07/23 at 9:37 AM., Resident #18 was lying in bed and had oxygen in place via nasal cannula at 3 liters. An updraft mask was lying on the bed side dresser connected to the updraft machine. e. On 03/07/23 at 10:47 AM., the Surveyor asked Registered Nurse (RN #1), What is the proper way to store an updraft mask or oxygen tubing when not in use? RN #1 stated, They should be stored in a dated plastic bag. f. On 03/07/23 at 10:51 AM., RN #1 accompanied the Surveyor to Resident #18's room. Resident #18 was lying in bed, and his updraft mask was laying on the bedside dresser. The Surveyor asked RN #1, Is Resident #18's updraft mask, properly stored? RN #1 stated, No it's not, it should be in a plastic bag. 2.Resident #304 had diagnoses of Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease and Shortness of Breath. The Admission MDS dated [DATE] documented, In progress. a. A Nursing Admit/Readmit Assessment and Care Plan dated 03/01/23 documented, BIMS 8 . Shortness of breath or trouble breathing when lying flat . Oxygen Rate 2 . b. A Physician's Order dated 03/01/23 documented, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3ml inhale orally every 6 hours for SOB . c. A Physician's Order dated 03/07/23 documented, Change and date o2 [oxygen] tubing and water bottle q [every] week one time a day every 7 day(s) related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA . OXYGEN as needed for SHORTNESS OF BREATH 2 LITERS/MIN PER NASAL CANNULA PRN . OXYGEN every shift for Shortness of Breath . d. On 03/07/23 at 9:54 AM., Resident #304 was out of her room, an updraft mask was laying on the bedside dresser. e. On 03/07/23 at 10:54 AM., RN #1 accompanied the Surveyor to Resident # (304's) room. The Surveyor asked RN #1, Is the resident's nasal cannula and updraft mask stored properly? RN #1 stated, No, they should be in a plastic bag. The resident was sitting in her recliner, the oxygen concentrator was on at 2 liters, the nasal cannula was draped over the top of recliner (not in place), and the updraft mask was laying on the bedside dresser. The Surveyor asked RN #1 Is the resident's nasal canula and updraft mask stored properly? RN #1 stated, No, they should be in a plastic bag. 3. The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection provided by the Administrator on 03/09/23 at 3:01 PM documented, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection Control Considerations Related to Medication Nebulizer . Store the circuit in plastic bag, marked with date and resident's name, between uses.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 4 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/07/23. The findings are: 1. On 03/06/23 at 11:08 AM., Dietary Employee #1 used a #10 scoop and placed 8 servings of boiled diced chicken into a blender, added warm milk and pureed. At 11:10 AM, she poured the pureed chicken into a pan, covered the pan with a lid and placed it on the steam table. The consistency of the pureed chicken was gritty. 2. On 03/06/23 at 11:24 AM., Dietary Employee #1 used #10 scoop and placed 10 servings of vegetable blend into a bowl. At 11:28 AM, she poured the pureed vegetables into a pan, covered the pan with a lid and placed it on the steamtable. The consistency of the pureed vegetables was lumpy. 3. On 03/06/23 at 11:34 AM., Dietary Employee #1 placed 5 servings of bread sticks into a blender, added a carton of warm whole milk and pureed. At 11:35 AM, she poured the pureed bread sticks in a pan, covered the pan with a lid and placed the pan on the steam table. The consistency of the pureed bread was thick and not smooth. 4. On 03/06/23 at 12:33 PM., the Surveyor asked the Dietary Supervisor to describe the pureed food items served to the residents who required pureed diets for lunch. She stated, Pureed meat needed to be pureed a little longer. It was thick and has grainy texture. Pureed vegetables needed to be pureed a little longer. Pureed bread was thick and had pieces of bread flakes. 5. On 03/07/23 at 8:15 AM., the following Pureed food items were served to the residents who required pureed diets: a. The biscuits and gravy was thick and not smooth. b. The sausage was gritty and not smooth. c. On 03/07/23 at 8:20 AM., the Surveyor asked the Dietary Supervisor to describe the pureed food items served to the residents on pureed diets. She stated, Pureed biscuits were thick with pieces of biscuit and pureed sausage was grainy.

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #26) of 11 (Resident (#10, #17, #18, #26, #31, #34, #35, #36, #39, #41, and #304) case mix residents selected for MDS accuracy review. This failed practice had the potential to affect all 45 residents who resided in the facility, as documented on a Resident Census and Conditions of Resident dated 03/06/23. The findings are: Resident #26 had diagnoses of Depression, Psychotic and Mood Disturbance. The Admission MDS with an Assessment Reference Date (ARD) of 12/10/22 documented the resident scored 4 (0-7 indicates Severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); had no active diagnoses of depression or a psychotic disorder and had received an Antipsychotic and an Antidepressant. a. A Physician's Order dated 12/03/22 documented, Risperidone Tablet 0.5 MG [milligrams] Give 1 tablet by mouth at bedtime for Antipsychotic . b. A Physician's Order dated 12/03/22 documented, Sertraline HCl [Hydrochloride] Tablet 50 MG Give 1 tablet by mouth one time a day for Antidepressant . c. A MDS section I documented, Active Diagnoses . PSYCHIATRIC/MOOD DISORDER . Depression (Not checked) . Psychotic Disorder (not checked) . d. A MDS section N documented, . Medication received: Days: Antipsychotic 7 . Medication received: Days: Antidepression 7 . e. On 03/09/23 at 11:05 AM., the Surveyor asked Registered Nurse (RN) #1, Who is responsible for completing section I in the Admission MDS? RN #1 stated, I am. The Surveyor asked, Does Resident #26 have a diagnosis for Depression and a Psychotic disorder? RN #1 stated, No, according to the doctor's clinical note, she does not have those diagnoses. The Surveyor asked, In section I under Psychiatric/Mood disorder, is Depression and Psychotic Disorder coded correctly? RN #1 stated, Yes. The Surveyor asked, In section N, under medications is the resident receive an Antidepressant and an Antipsychotic? RN #1 stated, yes. The Surveyor asked, If the resident is not taking those medications for Depression and a Psychotic Disorder what is she taking them for? RN #1 stated, I do not know. f. The facility policy titled, Resident Assessment Instrument provided by the Administrator on 03/09/23 at 3:12 PM documented, . A comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: Within 14 days of the resident's admission to the facility . Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest level of functioning. All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting the accuracy of such information.

Based on observations, interviews, and record review, the facility failed to ensure 2 Residents (Resident #1 and R #4) of 6 (Resident #1, R #2, R #3, R #4, R #5, and R #6) were free from abuse/neglect, as evidenced by the facilities failure to ensure staff reported allegations of physical abuse and injury of an unknown source in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 6 (Resident #1, R #2, R #3, R #4, R #5, and R #6) sampled residents. The findings are: 1.Resident #1 had diagnoses of Anxiety Disorder, Depression, and bipolar disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2022 documented the resident scored 7 on the Brief Interview for Mental Status (BIMS), had verbal behavioral symptoms directed toward others, put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, and significantly interfered with the resident's participation or social interaction, resident rejected evaluation or care that occurred 1 to 3 days, resident had wandered 1 to 3 days, resident's wandering placed the resident at significant risk of getting in to a potentially dangerous place. Required supervision for most all activities of daily living (ADL's). a. The Admission assessment dated [DATE] documented the resident scored 11 (high risk for wandering/elopement) and had a history of wandering. (moved up to keep in order) b. The Care Plan with an initiated date of 12/29/22 and a revision date of 1/11/23 documented, The resident is an elopement risk/wanderer. The resident's safety will be maintained through the review date. c. The Elopement Risk assessment dated [DATE] documented Resident #1 was high risk (11) for elopement/wandering. d. A Progress Note dated 1/7/23 at 12:28 a.m., by Licensed Practical Nurse (LPN) #1 documented, Resident awake pacing halls and lobby, rearranging furniture, unable to redirect her not to, constant monitoring . e. A Progress Note dated 1/7/23 at 10:06 p.m., by LPN #1 documented, Resident opened front door of lobby and sat at outside chairs; other staff nurse escorted her back in facility without issues. Resident cont.(continues) to amb (ambulate) around halls and lobby. Resident is calm when left alone. Easily agitated. Cont to monitor her behavior . f. An Office of Long-Term Care (OLTC) DMS-772 Form with a date and time of incident 1/7/2023 at 4:30 p.m., date and time of discovery 1/8/2023 at 6:00 a.m., date incident reported to OLTC 1/8/2023 at 07:06 a.m., documented, .physical abuse .Resident was exit seeking and had just gone out the front door after a visitor. An assistant witnessed her going out the door and went outside to get her back in. Resident had sat down in a chair on the porch and was not attempting to leave the premises. Two other assistants and Licensed Practical Nurse (LPN) #2, (the alleged perpetrator) responded as well and went outside to get her to come back in. She refused to come back in, LPN #2 grabbed her by the upper arm to guide her back inside the building. Once inside the building, the resident became agitated and began to swing at LPN #2. He blocked her attempts to hit him and then maneuvered the resident into a loose head lock to prevent further hitting by the resident. He then yelled at the resident to stop and to sit down. The resident complied and there was no further incident .The resident had continuous exit seeking behavior. After reviewing staff witness statements and interviewing the resident, we have concluded that the alleged perpetrator, LPN #2 used excessive force with R #1 when a simple redirection would have sufficed .The resident was transferred to a facility, with a locked memory care unit for her safety. g. Resident #1 was not transferred to a facility with a locked Memory Care Unit. R #1 eloped from the facility again on 1/9/2023 and wasn't discharged to another facility until 1/11/2023. See pertinent staff witness statements from the physical abuse incident regarding LPN #2 and Resident #1 dated 1/8/2023 for the incident occurring on 1/7/2023. 2. Resident #4 had diagnoses of dementia, and fracture of base of third metacarpal bone, right hand. The Quarterly Minimum Data Set QMDS with an ARD of 12/13/2022 documented the resident scored 00 on the BIMS, required extensive assist for most all Activity of Daily Living (ADL)'s, and had no functional limitation in Range of Motion (ROM) with upper or lower extremities. a. A Nursing Skin Audit dated 8/29/2022 at 8:00 A.M. documented, Large dark bruise on the right back of hand through the thumb, skin is intact. b. A Nursing Skin Audit dated 9/3/22 at 9:14 a.m., documented, Resident has combination new and old bruising to Rt (right) anterior hand, dark blue with fade to purple and yellow. Resident has limit in his range of motion due to pain. c. A Physician Order with a start date of 9/3/22 documented, AP (anterior/posterior) and lateral x ray of right (rt) hand one time only for bruising and pain. d. A Radiology Report dated 9/3/22 at 2:51p.m., documented, Impression .minimally displaced oblique fractures of the second through fourth, and possibly fifth metacarpals. e. A Progress Note dated 9/3/22 at 5:32 p.m., documented, Nursing (Nsg) Incident and Accident (I and A) Note .Incident Description: Received x-ray results, fracture (fx) found Advanced Practical Registered Nurse (APRN) notified, gave orders to ship to the emergency room (er) for evaluation and treatment (tx). f. A Hospital Exam Report dated 9/3/22 at 6:30 p.m., documented, .impression: Spiral fracture essentially nondisplaced of the second, third and fourth metacarpals. Follow-up is recommended . g. An Office of Long Term Care (OLTC) DMS-772 Form with a date and time of the incident 9/3/22 at 9:12 a.m., date incident reported to OLTC 9/3/22 at 5:45 p.m., documented, physical abuse .Summary of Incident .Nurse went into residents room this A.M. to administer morning medications and observed that the resident's right hand had some dark bruising along (the inside of his thumb into the palm of his hand, the remaining digits where swollen and a yellowish color. When asked the resident had no recollection of how he had bruised his hand. Results of X-ray: minimally displaced oblique fractures of the second through fourth and possibly fifth metacarpals. Nurse unable to determine cause of injury at this time . Resident and staff witness statements were obtained three and four days after the incident on 9/3/2022. h. On 1/18/2023 10:31 A.M., the Surveyor asked the Administrator; can you tell me about Resident #4 and the abuse reportable. The Administrator stated, I wasn't here at that time. The Surveyor asked the Administrator, when are staff trained on abuse and reporting? The Administrator stated, it should have been on general orientation upon hire, I have in-serviced staff on the 1st (first) incident regarding reporting and dementia. 3. On 1/19/2023 at 9:38 A.M., the Surveyor asked Housekeeper (HK) #1, when should allegations of abuse be reported? HK #1 stated, immediately. The Surveyor asked HK #1, who should allegations of abuse be reported to? HK #1 stated, immediate supervisor, the Administrator. The Surveyor asked HK #1, what do you do if you find an injury of unknown origin? HK #1 stated, talk to Administrator. The Surveyor asked HK #1, have you been trained on abuse and reporting? HK #1 stated, yes. The Surveyor asked HK #1, why should allegations of abuse be reported immediately? HK #1 stated, for resident's safety. 4. On 1/19/2023 at 10:03 A.M., the Surveyor asked Certified Nursing Assistant (CNA) #1, when should allegations of abuse be reported? CNA #1 stated, immediately. The Surveyor asked CNA #1, who should allegations of abuse be reported to? CNA #1 stated, charge nurse and Administrator. The Surveyor asked CNA #1, what do you do if you find an injury of unknown origin? CNA #1 stated, tell the nurse. The Surveyor asked CNA #1, have you been trained on abuse and reporting? CNA #1 stated, yes. The Surveyor asked CNA #1, why should allegations of abuse be reported immediately? CNA #1 stated, safety of residents. 5. On 1/19/2023 at 10:08 A.M., the Surveyor asked the MDS Coordinator, when should allegations of abuse be reported? The MDS Coordinator stated, immediately. The Surveyor asked the MDS Coordinator, who should allegations of abuse be reported to? The MDS Coordinator stated, supervisor and Administrator. The Surveyor asked the MDS Coordinator, what do you do if you find an injury of unknown origin? The MDS Coordinator stated, report to charge nurse. The Surveyor asked the MDS Coordinator, what if the nurse finds it? The MDS Coordinator stated, she needs to report to the Director of Nursing (DON). The Surveyor asked the MDS Coordinator, have you been trained on abuse and reporting? The MDS Coordinator stated, yes. The Surveyor asked the MDS Coordinator, why should allegations of abuse be reported immediately? The MDS Coordinator stated, for the safety of the residents. The Surveyor asked the MDS Coordinator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc (ecetera) The MDS Coordinator stated, within two hours. The Surveyor asked the MDS Coordinator, what happens when allegations of abuse are not reported in a timely manner? The MDS Coordinator stated, could result in an Immediate Jeopardy (IJ). 6. On 1/19/2023 at 1:18 P.M., the Surveyor asked the Assistant Director of Nursing (ADON), when should allegations of abuse be reported? The ADON stated, anytime. The Surveyor asked the ADON, who should allegations of abuse be reported to? The ADON stated, supervisor, follow the chain of command. The Surveyor asked the ADON, what do you do if you find an injury of unknown origin? The ADON stated, report to nurse. The Surveyor asked the ADON, what if the nurse finds it? The ADON stated, she investigates. The Surveyor asked the ADON, have you been trained on abuse and reporting? The ADON stated, yes. The Surveyor asked the ADON, why should allegations of abuse be reported immediately? The ADON stated, for resident's safety. The Surveyor asked the ADON, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The ADON stated, anytime it occurs. The Surveyor asked the ADON, what happens when allegations of abuse are not reported in a timely manner? The ADON stated, run the risk of further abuse. The Surveyor asked the ADON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid (CMS) guidelines regarding allegations of abuse and reporting allegations of abuse to the Administrator and the OLTC? The ADON stated, they are to do it (my expectations). 7. On 1/19/2023 at 1:30 P.M., the Surveyor asked the Administrator, when should allegations of abuse be reported? The Administrator stated, immediately upon discovery. The Surveyor asked the Administrator, who should allegations of abuse be reported to? The Administrator stated, immediate supervisor and then to me. The Surveyor asked the Administrator, what do you do if you find an injury of unknown origin? The Administrator stated, report to supervisor. The Surveyor asked the Administrator, what if the nurse finds it? The Administrator stated, notify supervisor, make sure residents are safe, then investigate. The Surveyor asked the Administrator, have you been trained on abuse and reporting? The Administrator stated, yes. The Surveyor asked the Administrator, why should allegations of abuse be reported immediately? The Administrator stated, so we can ensure the residents are safe. The Surveyor asked the Administrator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc.? The Administrator stated, within two hours of discovery. The Surveyor asked the Administrator, what happens when allegations of abuse are not reported in a timely manner? The Administrator stated, potential harm to other resident's or that resident. The Surveyor asked the Administrator, when should staff have notified you of the allegation of abuse regarding Resident #1? The Administrator stated, should have notified immediately. The Surveyor asked the Administrator, did LPN #2 continue to work after the abuse allegation? The Administrator stated, yes. The Surveyor asked the Administrator, how were the residents protected after that incident? The Administrator stated, other than the other staff were there, they weren't. The Surveyor asked the Administrator, when should Resident #4's injury of unknown origin with the right hand been reported. The Administrator stated, I would have reported with in the two-hour time period. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines regarding allegations of abuse and reporting allegations of abuse to the Administrator and the OLTC? The Administrator stated, they will report to me immediately, either me or my designee will report to OLTC in the allotted time frame. 8. A policy provided by the Administrator on 1/17/2023 at 11:51 A.M. documented, Reporting Abuse .it is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source .to the Administrator or his/her designee .all reports of abuse, neglect .will be immediately reported to the Administrator or designee and promptly investigated .such incidents occur or are discovered after normal business office hours, the Administrator or designee must be notified .neglect .is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition.

Based on observations, interviews, and record review, the facility failed to ensure 2 (Resident #1 and R #4) of 6 (Resident #1, #2, #3, #4, #5, and #6) were free from abuse/neglect, as evidenced by the facility failure to ensure staff reported allegations of physical abuse and injury of an unknown source in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 6 (Resident #1, #2, #3, #4, #5, and #6) sampled residents. The findings are: 1.Resident #1 had diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2022 documented the resident scored 7 on the Brief Interview for Mental Status (BIMS), had verbal behavioral symptoms directed toward others, put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, and significantly interfered with the resident's participation or social interaction, resident rejected evaluation or care that occurred 1 to 3 days, resident had wandered 1 to 3 days, resident's wandering placed the resident at significant risk of getting to a potentially dangerous place, required supervision for most all activities of daily living (ADL's). a. The Care Plan with an initiated date of 12/29/2022 and a revision date of 1/11/23 documented, .The resident is an elopement risk/wanderer .The resident's safety will be maintained through the review date b. The Admission assessment dated [DATE] documented the resident scored 11 (high risk for wandering/elopement) and had a history of wandering. c. The Elopement Risk assessment dated [DATE] documented R#1 was high risk (11) for elopement/wandering. d. A Progress Note dated 1/7/2023 at 12:28 a.m., by Licensed Practical Nurse (LPN) #1 documented, .Resident awake pacing halls and lobby rearranging furniture, Unable to redirect her not to. Constant monitoring . e. A Progress Note dated 1/7/2023 at 10:06 p.m., by LPN #1 documented, .Resident opened front door of lobby and sat at outside chairs; other staff nurse escorted her back in facility without issues. Resident cont (continues) to amb (ambulate) around halls and lobby. Resident is calm when left alone. Easily agitated. Cont to monitor her behavior . f. An Office of Long-Term Care (OLTC) DMS-772 Form with a date and time incident 1/7/2023 at 4:30 p.m., date and time of discovery 1/8/2023 at 06:00 a.m., date incident reported to OLTC 1/8/2023 at 07:06 a.m., documented, .physical abuse .Resident was exit seeking and had just gone out the front door after a visitor. An assistant witnessed her going out the door and went outside to get her back in. Resident had sat down in a chair on the porch and was not attempting to leave the premises. Two other assistants and a nurse - Licensed Practical Nurse (LPN) #2, (the alleged perpetrator) responded as well and went outside to get her to come back in. She refused to come back in, and LPN #2 grabbed her by the upper arm in order to guide her back inside the building. Once inside the building, the resident became agitated and began to swing at LPN #2. He blocked her attempts to hit him and then maneuvered the resident into a loose head lock to prevent further hitting by the resident. He then yelled at the resident to stop and to sit down. The resident complied and there was no further incident .The resident had continuous exit seeking behavior. After revieing staff witness statements and interviewing the resident, we have concluded that the alleged perpetrator LPN #2 used excessive force with R #1 when a simple redirection would have sufficed .The resident was transferred to a facility, with a locked memory care unit for her safety . R #1 was not transferred to a facility with a locked memory care unit. R #1 eloped from the facility again on 1/9/2023 and wasn't discharged to another facility until 1/11/2023. See pertinent staff witness statements from the physical abuse incident regarding LPN #2 and R #1 dated 1/8/2023 for the incident occurring on 1/7/2023. 2.Resident (R #4) had a diagnoses of dementia, and fracture of base of third metacarpal bone, right hand. The Quarterly MDS with an ARD of 12/13/2022 documented the resident scored 00 on the BIMS, required extensive assist for most all Activity of Daily Living ADLs, and had no functional limitation in range of motion (ROM) with upper or lower extremities. a. A Nursing Skin Audit dated 8/29/2022 at 8:00 A.M. documented, .Large dark bruise on the right back of hand threw the thumb. skin is intact . b. A Nursing Skin Audit dated 9/3/2022 at 9:14 A.M. documented, .Resident has combination new and old bruising to Rt (right) anterior hand. Dark blue with fade to purple and yellow. Resident has limit in his range of motion due to pain . c. A Physician Order with a start date of 9/3/2022 documented, .AP (anterior/posterior) and lateral x ray of right (rt) hand one time only for bruising and pain . d. A Radiology Report dated 9/3/2022 at 2:51 p.m., documented, .Impression .minimally displaced oblique fractures of the second through fourth, and possibly fifth metacarpals . e. A Progress Note dated 9/3/2022 at 5:32 p.m., documented, .Nursing (Nsg) Incident and Accident (I and A) Note .Incident Description: Received X ray results, fracture (fx) found Advanced Practical Registered Nurse (APRN) notified, gave orders to ship to the emergency room (er) for evaluation and treatment (tx) . f. A Hospital Exam report dated 9/3/2022 at 6:30 p.m., documented, .impression: Spiral fracture essentially nondisplaced of the second, third and fourth metacarpals. Follow-up is recommended . g. An Office of Long Term Care (OLTC) DMS-772 Form with a date and time incident 9/3/2022 at 9:12 A.M . date incident reported to OLTC 9/3/2022 at 5:45 p.m., documented, .physical abuse .Summary of Incident .Nurse went into residents room this a.m. to administer morning medications and observed that the resident's right hand had some dark bruising along (he inside of his thumb into fie palm of his hand, the remaining digits where swollen and a yellowish color. When asked the resident had no recollection of how he had bruised his hand. Results of X-ray: minimally displaced oblique fractures of the second through fourth and possibly fifth metacarpals. Nurse unable to determine cause of injury at this time . Resident and staff witness statements were obtained three and four days after the incident on 9/3/2022. 3. A policy provided by the Administrator on 1/17/2023 at 11:51 A.M. documented .Reporting Abuse .it is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source .to the administrator or his/her designee .all reports of abuse, neglect .will be immediately reported to the administrator or designee and promptly investigated .such incidents occur or are discovered after normal business office hours, the Administrator or designee must be notified .neglect .is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition . 4. On 1/18/2023 10:31 A.M. the Surveyor asked the Administrator; can you tell me about R #4 and the abuse reportable. The Administrator stated, I wasn't here at that time. The Surveyor asked the Administrator, when are staff trained on abuse and reporting? The Administrator stated, it should have been on general orientation upon hire, I have in-serviced staff on the 1st (first) incident regarding reporting and dementia. 5. On 1/19/2023 at 9:38 A.M. the Surveyor asked Housekeeper (HK) #1, when should allegations of abuse be reported? HK #1 stated, immediately. The Surveyor asked HK #1, who should allegations of abuse be reported to? HK #1 stated, Immediate Supervisor, the Administrator. The Surveyor asked HK #1, what do you do if you find an injury of unknown origin? HK #1 stated, talk to Administrator. The Surveyor asked HK #1, have you been trained on abuse and reporting? HK #1 stated, yes. The Surveyor asked HK #1, why should allegations of abuse be reported immediately? HK #1 stated, for resident's safety. 6. On 1/19/2023 at 10:03 A.M. the Surveyor asked Certified Nursing Assistant (CNA) #1, when should allegations of abuse be reported? CNA #1 stated, immediately. The Surveyor asked CNA #1, who should allegations of abuse be reported to? CNA #1 stated, charge nurse and Administrator. The Surveyor asked CNA #1, what do you do if you find an injury of unknown origin? CNA #1 stated, tell the nurse. The Surveyor asked CNA #1, have you been trained on abuse and reporting? CNA #1 stated, yes. The Surveyor asked CNA #1, why should allegations of abuse be reported immediately? CNA #1 stated, safety of residents. 7. On 1/19/2023 at 10:08 A.M. the Surveyor asked the Minimum Data Set (MDS) Coordinator, when should allegations of abuse be reported? The MDS Coordinator stated, immediately. The Surveyor asked the MDS Coordinator, who should allegations of abuse be reported to? The MDS Coordinator stated, supervisor and Administrator. The Surveyor asked the MDS Coordinator, what do you do if you find an injury of unknown origin? The MDS Coordinator stated, report to charge nurse. The Surveyor asked the MDS Coordinator, what if the nurse finds it? The MDS Coordinator stated, she needs to report to the Director of Nursing (DON). The Surveyor asked the MDS Coordinator, have you been trained on abuse and reporting. The MDS Coordinator stated, yes. The Surveyor asked the MDS Coordinator, why should allegations of abuse be reported immediately? The MDS Coordinator stated, for the safety of the residents. The Surveyor asked the MDS Coordinator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The MDS Coordinator stated, within two hours. The Surveyor asked the MDS Coordinator, what happens when allegations of abuse are not reported in a timely manner? The MDS Coordinator stated, could result in an Immediate Jeopardy (IJ). 8. On 1/19/2023 at 1:18 P.M. the Surveyor asked the Assistant Director of Nursing (ADON), when should allegations of abuse be reported? The ADON stated, anytime. The Surveyor asked the ADON, who should allegations of abuse be reported to? The ADON stated, supervisor, follow the chain of command. The Surveyor asked the ADON, what do you do if you find an injury of unknown origin? The ADON stated, report to nurse. The Surveyor asked the ADON, what if the nurse finds it? The ADON stated, she investigates. The Surveyor asked the ADON, have you been trained on abuse and reporting? The ADON stated, yes. The Surveyor asked the ADON, why should allegations of abuse be reported immediately? The ADON stated, for resident's safety. The Surveyor asked the ADON, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The ADON stated, anytime it occurs. The Surveyor asked the ADON, what happens when allegations of abuse are not reported in a timely manner? The ADON stated, run the risk of further abuse. The Surveyor asked the ADON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid (CMS) guidelines regarding allegations of abuse and reporting allegations of abuse to the Administrator and the OLTC? The ADON stated, they are to do it (my expectations). 9. On 1/19/2023 at 1:30 P.M, the Surveyor asked the Administrator, when should allegations of abuse be reported? The Administrator stated, immediately upon discovery. The Surveyor asked the Administrator, who should allegations of abuse be reported to? The Administrator stated, immediate supervisor and then to me. The Surveyor asked the Administrator, what do you do if you find an injury of unknown origin? The Administrator stated, report to supervisor. The Surveyor asked the Administrator, what if the nurse finds it? The Administrator stated, notify supervisor, make sure residents are safe, then investigate. The Surveyor asked the Administrator, have you been trained on abuse and reporting? The Administrator stated, yes. The Surveyor asked the Administrator, why should allegations of abuse be reported immediately? The Administrator stated, so we can ensure the residents are safe. The Surveyor asked the Administrator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The Administrator stated, within two hours of discovery. The Surveyor asked the Administrator, what happens when allegations of abuse are not reported in a timely manner? The Administrator stated, potential harm to other resident's or that resident. The Surveyor asked the Administrator, when should staff have notified you of the allegation of abuse regarding R #1? The Administrator stated, should have notified immediately. The Surveyor asked the Administrator, did LPN #2 continue to work after the abuse allegation? The Administrator stated, yes. The Surveyor asked the Administrator, how were the residents protected after that incident? The Administrator stated, other than the other staff were there, they weren't. The Surveyor asked the Administrator, when should R #4 injury of unknown origin with the right hand been reported? The Administrator stated, I would have reported with in the two-hour time period. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines regarding allegations of abuse and reporting allegations of abuse to the Administrator and the OLTC? The Administrator stated, they will report to me immediately, either me or my designee will report to OLTC in the allotted time frame.

Based on record review and interview, the facility failed to ensure residents were provided with adequate supervision to prevent accidents/injuries to the extent possible, as evidenced by failure to ensure residents who were high risk for elopement were supervised to prevent elopement with serious injuries for 1 (Resident #1) of 6 (Resident #1, R #2, R #3, R #4, R #5, and R #6) sample mix residents. The failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, who was left unsupervised and eloped from the facility a second time, and had the potential to cause more than minimal harm to 6 residents who were high risk for elopement, as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 1/18/2023 at 1:11 P.M. The findings are: Resident (R #1) had diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2022 documented the resident scored 7 on the Brief Interview for Mental Status (BIMS), had verbal behavioral symptoms directed toward others, put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, and significantly interfered with the resident's participation or social interaction, resident rejected evaluation or care that occurred 1 to 3 days, resident had wandered 1 to 3 days, resident's wandering placed the resident at significant risk of getting to a potentially dangerous place, resident required supervision for most all Activities of Daily Living (ADL's). 1. The Care Plan with an initiated date of 12/29/20221 and a revision date of 1/11/23 documented, The resident is an elopement risk/wanderer .The resident's safety will be maintained through the review date 2. The Admission assessment dated [DATE] documented the resident scored 11 (high risk for wandering/elopement) and had a history of wandering. 3. The Elopement Risk assessment dated [DATE] documented R #1 was high risk (11) for elopement/wandering. 4. A Progress Note dated 1/7/2023 at 12:28 a.m., by Licensed Practical Nurse (LPN) #1 documented, .Resident awake pacing halls and lobby rearranging furniture, Unable to redirect her not to. Constant monitoring . 5. A Progress Note dated 1/7/2023 at 10:06 p.m., by LPN #1 documented, .Resident opened front door of lobby and sat at outside chairs; other staff nurse escorted her back in facility without issues. Resident cont.(continues) to amb (ambulate) around halls and lobby. Resident is calm when left alone. Easily agitated. Cont to monitor her behavior . 6. A Progress Note dated 1/8/2023 at 5:55 a.m., by LPN #1 documented, . Resident remains awake, pacing around room, rearranging her room . 7. A Progress Note dated 1/9/2023 at 11:35 a.m., by Registered Nurse (RN) #1 documented, .Resident continues to pace around facility and asks any person she sees to let her out of the building, states she needs to go to the hospital . 8. An Office of Long-Term Care (OLTC) Incident and Accident Report (I and A) DMS-7734 form dated 1/9/2023 at 4:53 p.m., documented, .Administrator witnessed resident walk past his office and as he was going to get her, the facility received call from hospice that resident was seen ambulating down the sidewalk towards hospital. The resident was moving very quickly and so had to be picked up by administrator and social director and returned to facility without incident, Resident was let out of facility by incoming visitor that was not aware that was in fact a resident and not a visitor or staff member. Resident stated she was going home .Resident was picked up by Administrator and Social director and brought back to facility without incident. Resident was reoriented to facility and re-educated on the need for her to stay inside. Nursing staff did a head-to-toe assessment and resident had no injury or ill effect. Resident was placed on our locked unit which was not previously locked. We locked the doors and assigned an employee to the unit for each shift until she could be transferred out. Arrangements are in the process to transfer resident to a different facility with a locked unit as soon as possible . 9. A witness statement dated 1/9/2023 at 4:53 p.m., by the Administrator documented, .This writer was leaving his office and noticed the resident leaving the porch. She was walking very quickly as she has no ambulation impairment. By the time I got to the door and outside, she had crossed the street and was walking down the sidewalk near the hospice building. I grabbed my keys and the social worker, and I drove over, picked her up and brought her back to the facility without incident . 10. A witness statement dated 1/9/2023 at 4:53 p.m., by the Social Worker (SW) documented, .This writer received a phone call from the hospice (facility) across the street that one of our residents was possibly walking in front of their building- I went toward the front of the building where I met the Administrator and he and I went up to get the resident and were able to bring her back without incident . 11. A progress note dated 1/9/2023 at 4:59 p.m., by Registered Nurse (RN) #1 documented, .: Resident was found by Administrator and Social Director walking down sidewalk near hospital, resident was brought back to facility by staff without incident. Upon investigation it was noted that resident was let out of facility by visitors that were not aware that she was a resident and not a visitor or staff member. Physical Assessment was completed no bruising/redness or injuries noted and resident reports that she did not fall Immediate Intervention: Resident was brought back to facility by administrator and social director, resident was reoriented to her room and to facility and re-educated that she needs to stay at facility for safety and supervision . 12. On 1/17/23 at 11:51 a.m., the Administrator provided a policy titled, Reporting Abuse it is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source .to the administrator or his/her designee .all reports of abuse, neglect .will be immediately reported to the Administrator or designee and promptly investigated .such incidents occur or are discovered after normal business office hours, the administrator or designee must be notified .neglect .is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition . 13. On 1/18/2023 at 10:09 A.M., The Administrator stated, the (OLTC) called this morning and said they didn't have the initial reporting form for the 7734 for R #1. The Administrator was asked, on the first reportable related to physical abuse on R #1, why was it not reported to the OLTC until 1/8/2023, the day after the incident. The Administrator stated, I didn't know about it till the next day, it happened that Saturday evening. The Surveyor asked the Administrator, what was the intervention after R #1 eloped on 1/7/2023? The Administrator stated, 1 on 1. The Surveyor asked the Administrator, how did you assess the cognitively impaired residents for abuse? The Administrator stated, I did not assess the cognitively impaired residents. The Surveyor asked the Administrator, tell me about R #'s elopement on 1/9/2023? The Administrator stated, well she got out the next day on Monday .she was fast, I was trying to get to her, by the time I got to my car, she was out of site .the Social Worker got a call from the hospice, stating there was somebody walking on the sidewalk. The Surveyor asked the Administrator, how far did R #1 get from the facility? The Administrator stated, she had gotten past the hospice building, before we got to her. The Surveyor asked the Administrator, what was the intervention after R #1 eloped the second time? The Administrator stated, we put her on the locked unit with a staff member. 14. On 1/18/2023 at 10:18 A.M., the Surveyor asked the Administrator, tell me about R #1 elopement on 1/9/2023. The Administrator stated, she was fast, I was trying to get to her and by the time I got to my car, she was out of site. The Social Worker (SW) got a call from hospice stating there was somebody walking on the sidewalk. The Surveyor asked the Administrator, what is the distance across the street? The Administrator stated, she had gotten past the hospice building before we got to her. After the second incident, we put her on the locked unit with a staff member. The Surveyor asked the Administrator, when are staff trained on abuse? The Administrator stated, it should have been in general orientation upon hire, I have in-serviced staff on the first incident regarding reporting and Dementia. 15. On 1/18/2023 at 10:31 A.M., the Surveyor asked the Administrator; can you tell me about R #1 and the abuse reportable? The Administrator stated, I wasn't here at that time. The Surveyor asked the Administrator, when are staff trained on abuse and reporting? The Administrator stated, it should have been on general orientation upon hire, I have in-serviced staff on the 1st (first) incident regarding reporting and dementia. 16. On 1/18/2023 at 11:19 A.M. the Surveyor asked the Administrator to verify the distance from the facility to the area across the street where R #1 was picked up on the second elopement. 17. On 1/18/2023 at 11:24 A.M. the Surveyor and Administrator entered the Administrator's vehicle. The trip odometer was set at 0.5 tenths of a mile for the beginning of the trip. The Surveyor and Administrator traveled across the street to the sidewalk in front of the hospice building where R #1 was picked up on 1/9/2023 after the second elopement. The trip odometer read 0.3 tenths of a mile. The Surveyor asked the Administrator, why did the report for R #1 read neglect if R #1 eloped from the building? The Administrator stated, there was no elopement to check on the form, so I put it under neglect, I did change it to elopement. 18. On 1/18/2023 at 11:33 A.M. the Surveyor asked the SW, tell me when R #1 eloped on 1/7/2023. The SW stated, I wasn't here. The Surveyor asked the SW, tell me about when R #1 eloped on 1/9/2023. The SW stated, I was in my office and (named hospice facility) called and described the resident and I hung up the phone, ran out to the sidewalk to see what direction she went. I believe the Administrator walked out the door and wanted to know what direction the resident had went, and I pointed across the road, and she was almost to the hospital parking lot at that point. The Administrator and I went and got his car, he was parked right in front of the building. The Surveyor asked the SW, can you see over the hill from the building to across the street? The SW stated, no. The SW stated, the Administrator and I drove and pulled up in front of R #1, she was at the back of the hospital underground parking garage and on the sidewalk, and opened the door, offered her, or asked her, if she wanted a ride, she climbed in, and we came back. The Surveyor asked the SW, what did you do for the intervention after this incident? The SW stated, we had the 400 Hall locked with staff back there. The SW stated, we don't have staff for a locked unit. The Surveyor asked the SW, what do you do for high-risk elopement residents? The SW stated, we do activities, we have them come to our office, we also have a (named guard) system. 19. On 1/18/2023 at 11:49 A.M., the Surveyor observed the Administrator checking the 400 Hall exit doors. The guard system did not function. 20. On 1/18/2023 at 11:55 A.M., the Surveyor observed the Administrator checking an exit door off the 200 Hall by the vending machine. The guard system did not function. 21. On 1/18/2023 at 11:57 A.M., the Surveyor observed the Administrator checking an exit door off the 200 Hall by the Dining Room. The guard system did not function. 22. On 1/18/2023 at 12:02 P.M., the Surveyor asked the Administrator, is the potential still there for elopement since there is no guard system in place on the exit doors? The Administrator stated, yes, if they hold down the doors (exit bars). The Surveyor asked the Administrator, how long/often are (named guard) system checked? The Administrator stated, they haven't been, we just got them last week. 23. On 1/18/2023 at 2:00 P.M., the Surveyor asked the Administrator, how did you keep site on R #1 if you and the SW were both in the car, and you can't see over the hill? The Administrator stated, we did lose sight of her. 24. On 1/18/23 at 2:18 p.m., the Administrator provided a policy titled Wandering Residents and Use of Monitoring System documented, to identify and keep safe, residents whose safety would be jeopardized by leaving the facility unsupervised .if a resident is deemed an elopement risk, they may be care planned for a monitoring bracelet .the monitoring system only works for the front door where there is visitor traffic .all other exits are either emergency exits or lead to a secured courtyard and are alarmed but can be opened after holding the door for 15 seconds . 25. On 1/19/2023 at 9:38 A.M., the Surveyor asked Housekeeper (HK) #1, when should allegations of abuse be reported? HK #1 stated, immediately. The Surveyor asked HK #1, who should allegations of abuse be reported to. HK #1 stated, immediate supervisor, the Administrator. The Surveyor asked HK #1, what do you do if you find an injury of unknown origin? HK #1 stated, talk to Administrator. The Surveyor asked HK #1, have you been trained on abuse and reporting? HK #1 stated, yes. The Surveyor asked HK #1, why should allegations of abuse be reported immediately? HK #1 stated, for resident's safety. 26. On 1/19/2023 at 10:03 A.M., the Surveyor asked Certified Nursing Assistant (CNA) #1, when should allegations of abuse be reported? CNA #1 stated, immediately. The Surveyor asked CNA #1, who should allegations of abuse be reported to? CNA #1 stated, charge nurse and Administrator. The Surveyor asked CNA #1, what do you do if you find an injury of unknown origin? CNA #1 stated, tell the nurse. The Surveyor asked CNA #1, have you been trained on abuse and reporting? CNA #1 stated, yes. The Surveyor asked CNA #1, why should allegations of abuse be reported immediately? CNA #1 stated, safety of residents. 27. On 1/19/2023 at 10:08 A.M., the Surveyor asked the Minimum Data Set (MDS) Coordinator, when should allegations of abuse be reported? The MDS Coordinator stated, immediately. The Surveyor asked the MDS Coordinator, who should allegations of abuse be reported to? The MDS Coordinator stated, supervisor and Administrator. The Surveyor asked the MDS Coordinator, what do you do if you find an injury of unknown origin? The MDS Coordinator stated, report to charge nurse. The Surveyor asked the MDS Coordinator, what if the nurse finds it? The MDS Coordinator stated, she needs to report to the Director of Nursing (DON). The Surveyor asked the MDS Coordinator, have you been trained on abuse and reporting. The MDS Coordinator stated, yes. The Surveyor asked the MDS Coordinator, why should allegations of abuse be reported immediately? The MDS Coordinator stated, for the safety of the residents. The Surveyor asked the MDS Coordinator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The MDS Coordinator stated, within two hours. The Surveyor asked the MDS Coordinator, what happens when allegations of abuse are not reported in a timely manner? The MDS Coordinator stated, could result in an Immediate Jeopardy (IJ). 28. On 1/19/2023 at 1:18 P.M., the Surveyor asked the Assistant Director of Nursing (ADON), when should allegations of abuse be reported? The ADON stated, anytime. The Surveyor asked the ADON, who should allegations of abuse be reported to? The ADON stated, supervisor, follow the chain of command. The Surveyor asked the ADON, what do you do if you find an injury of unknown origin? The ADON stated, report to nurse. The Surveyor asked the ADON, what if the nurse finds it? The ADON stated, she investigates. The Surveyor asked the ADON, have you been trained on abuse and reporting? The ADON stated, yes. The Surveyor asked the ADON, why should allegations of abuse be reported immediately? The ADON stated, for resident's safety. The Surveyor asked the ADON, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The ADON stated, anytime it occurs. The Surveyor asked the ADON, what happens when allegations of abuse are not reported in a timely manner? The ADON stated, run the risk of further abuse. The Surveyor asked the ADON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid (CMS) guidelines regarding allegations of abuse and reporting allegations of abuse to the Administrator and the OLTC? The ADON stated, they are to do it (my expectations). 29. On 1/19/2023 at 1:30 P.M., the Surveyor asked the Administrator, when should allegations of abuse be reported. The Administrator stated, immediately upon discovery. The Surveyor asked the Administrator, who should allegations of abuse be reported to. The Administrator stated, immediate supervisor and then to me. The Surveyor asked the Administrator, what do you do if you find an injury of unknown origin. The Administrator stated, report to supervisor. The Surveyor asked the Administrator, what if the nurse finds it? The Administrator stated, notify supervisor, make sure residents are safe, then investigate. The Surveyor asked the Administrator, have you been trained on abuse and reporting? The Administrator stated, yes. The Surveyor asked the Administrator, why should allegations of abuse be reported immediately? The Administrator stated, so we can ensure the residents are safe. The Surveyor asked the Administrator, when should the OLTC be notified of any allegations of abuse, injury of unknown origin, and elopement, etc? The Administrator stated, within two hours of discovery. The Surveyor asked the Administrator, what happens when allegations of abuse are not reported in a timely manner. The Administrator stated, potential harm to other resident's or that resident. The Surveyor asked the Administrator, when should staff have notified you of the allegation of abuse regarding R #1? The Administrator stated, should have notified immediately. The Surveyor asked the Administrator, did LPN #2 continue to work after the abuse allegation? The Administrator stated, yes. The Surveyor asked the Administrator, how were the residents protected after that incident? The Administrator stated, other than the other staff were there, they weren't.

Based on observation, record review, and interview the facility failed to ensure residents were getting showers, baths, and or bed baths per their schedule or at a minimum of two times a week to promote overall wellness, decrease the potential of skin breakdown, and prevent the increased risk of bacterial infections for 3 (Resident's #1, #3, and #4) of 4 case mix residents who were dependent on staff for assist with baths and or showers. This failed practice had the potential to affect all 46 residents who were dependent on staff for bathing care, according to the Daily Census dated 5/16/2022. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Condition Minimum Data Set with an Assessment Reference Date of 5/6/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, requiring one person-assistance with transfers and toileting needs. a. The Plan of Care documented, . BATHING/SHOWERING: The resident requires extensive to dependent assist of two staff for at least two showers/baths weekly and as necessary . b. The Grievance Form dated 5/8/2022 documented, .Statement of Concerns. I am appalled to hear that my mother [Resident #1] who is under your care has not been given a shower for 12 days, that would be a total of 14 days before she can get a shower. That is unacceptable. In my opinion that is neglect, and this situation needs to be resolved immediately . c. The Facility's ADL (Activities of Daily Living) Form documented, .Apr [April] -22 [2022] .Bathing Tuesday and Friday & PRN [as needed] .Friday 1 .sh [shower] .Tuesday 5 .[shower] .Friday 8 .[shower] .Tuesday 12 .[shower] .Friday 15 .[shower] .Friday 22 .[shower] .Friday 29 .[shower] . The resident had seven showers in the Month of April 2022 per facility documentation. d. The Facility's ADL Form documented, .May [2022] .Bathing Tuesday and Friday & PRN .May 6 .[shower] .May 9 .[shower] .May 13 .[shower] . The resident has had three showers in the month of May 2022 per facility documentation. e. As of 5/16/2022, there was no documentation in the Nursing Progress Notes the resident refused baths and or showers. f. On 5/16/2022 at 12:50 p.m., Resident #1 was sitting in her wheelchair in her room. The Administrator was also present. The room smelled of urine. g. On 5/16/2022 at 12:52 p.m., Resident #1 was asked, Are you getting your showers and or baths how you want or per your preference? Resident #1 stated, No, I am supposed to get them on Tuesday and Friday. Because they are not doing them. See, I get sores if I don't have my showers. (Resident #1 pointing out different places on her exposed skin. There was no evidence of any skin breakdown or rashes.) I get red under my breasts and around my waist. (Resident #1 pointing towards her groin region.) The problem with my legs is that they itch really bad. Resident #1 was asked, How many showers do you want in a week? Resident #1 stated, Two, is fine. For a while, I wasn't getting any because there was no help. It was like twelve days. Resident #1 was asked, Have you ever refused your showers? Resident #1 stated, No. I love my showers. I was told by an aide today that there would be no showers. I think because not enough help. Resident #1 was asked, I thought you got your showers on Tuesday and Friday? Resident #1 stated, I know, but my roommate was supposed to get one today. 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 4/14/2022 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status, requiring two-person assistance with transfers and toileting needs. a. The Plan of Care documented, . [Resident #3] has an ADL self-care performance deficit r/t [related to] age-related [CONDITION(S)], Moderate Intellectual Disabilities .· Resident refuses showering/bathing at times. Date Initiated: 11/10/2020 .· BATHING/SHOWERING: The resident requires physical help in part of bathing by 1 staff with bathing/showering 2X weekly and as necessary . v. The Facility's ADL Form documented, . [April] [2022] .Bathing Monday and Thursday & PRN .Monday 4 .[shower] .Thursday 7 .[shower] .Monday 11 .[shower] . The resident had three showers for the month of April 2022 per facility documentation. c. The Facility's ADL Form documented, . [May] [2022] .Bathing Monday and Thursday & PRN [As Needed] .May 5 .[shower] .May 9 .[shower] .May 10 .[shower] . The resident has had three showers in the month of May 2022 per facility documentation. d. As of 5/16/2022, there was no documentation in the Nursing Progress Notes the resident refused baths and or showers. e. On 5/16/2022 at 1:23 p.m., Resident #3 was in the hallway in a wheelchair. The Administrator was also present. Resident #4 had multiple stains on her blouse. The resident's hair was oily and unkempt. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/10/2022 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status, requiring two-person assistance with transfers and toileting needs. a. The Plan of Care documented, . (Resident #4) has an ADL self-care performance deficit r/t [related to] [CONDITION(S)] [[CONDITION(S)]], [CONDITION(S)] AND [CONDITION(S)] .BATHING/SHOWERING: The resident requires physical help in part of bathing x 1 staff 2 x a week and as necessary . b. The Facility's ADL Form documented, . [April] [2022] .Bathing Monday and Thursday & PRN .Monday 4 .[shower] .Thursday 7 .[shower] .Monday 11 .[shower] . The resident had three showers for the month of April 2022 per facility documentation. c. The Facility's ADL form documented, . [May] [2022] .Bathing Monday and Thursday & PRN .May 5 .[shower] .May 9 .[shower] . The resident has had two showers for the month of May 2022 per facility documentation. d. As of 5/16/2022, there was no documentation in the Nursing Progress Notes the resident refused baths and or showers. e. On 5/16/2022 at 1:06 p.m., Resident #4 was lying in bed. The Administrator was also present. Resident #4 sat up on the side of her bed when asked if we could talk to her. f. On 5/16/2022 at 1:08 p.m., Resident #4 was asked, Do you get your showers and or baths how you want them or per your preference? Resident #4 stated, No, not well, not recently. I did all the time before. I was due one on Thursday and the girl said they had all the men that day. They said they would get to me on another day. I just go in the restroom and scrub up the best I can. My hair needs washed although it has not been that long since I went to the Beauty Shop. Resident #4 was asked, How may showers do you want in a week? Resident #4 stated, I would like to get three showers a week at least. I am supposed to get a shower today. I wish they would. I need one. Resident #4 was asked, Have you ever refused a shower? Resident #4 stated, I have never refused a shower. 4. On 5/16/2022 at 10:53 a.m., Certified Nursing Assistant (CNA #1) was asked, Does [Resident #1], [Resident #3] and [Resident #4] refuse showers and or baths? CNA #1 stated, No, not that I am aware of. I usually don't do showers, but I will assist if they need me. CNA #1 was asked, Are residents getting showers and or baths at least two times a week? CNA #1 stated, When we have the staffing they do. Sometimes, they are not getting done. It's not just happening to [Resident #1] it's happening to other residents. CNA #1 was asked, Are resident's showers scheduled on the evening shift (2:00-10:00 p.m.)? CNA #1 stated, No, but sometimes if we do not get to a shower on the day shift, they will get it done on the evening shift. But, then again, it depends on if we have enough staff. The staffing is off and on. It just depends on the people we have here.

Complaint # (AR 088) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure repositioning and incontinence checks were provided at least every 2 hours in accordance with the plan of care to relieve pressure and prevent actual pressure ulcer development and deep tissue injury for 1 (Resident #1) and potential moisture-associated or pressure-related skin breakdown for 2 (Residents #3 and #6) of 6 (Residents #1 through #6) case mix residents who were dependent for repositioning and at risk for the development of pressure ulcers. This failed practice resulted in actual harm for Resident #1, who developed a deep tissue injury and a Stage II pressure ulcer, and had the potential to cause more than minimal harm for 68 residents who were at risk for the development of pressure ulcers, including 4 residents who had existing pressure ulcers, as documented on a list provided by the Director of Nursing on 2/25/18 at 3:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/17 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on two-plus persons for transfers, required extensive assistance from two-plus persons for bed mobility and toilet use, required extensive one-person assistance for personal hygiene, used a wheelchair for mobility, was always incontinent of bladder, was at risk for pressure ulcer development, had no existing pressure ulcers, had a pressure reducing device in chair, and was on a turning / repositioning program. a. A physician's orders [REDACTED].[MEDICATION NAME] (diuretic) tablet 50 mg (milligrams) give 1 tablet by mouth in the morning for [MEDICAL CONDITION] . A physician's orders [REDACTED].[MEDICATION NAME] (diuretic) tablet 40 mg (milligrams) give 40 mg by mouth one time a day for [MEDICAL CONDITION] . b. The Plan of Care dated as revised 12/27/17 documented, .The resident has an ADL (activities of daily living) self-care performance deficit . the resident requires extensive 1 to 2 staff to turn and reposition in bed every shift as necessary . Use mechanical lift for transfer with 2 assist each shift . the resident has limited physical mobility . the resident is on diuretic therapy . The resident has potential impairment to skin r/t (related to) fragile skin and impaired mobility . resident has functional bladder incontinence . check every two hours and as required for incontinence . The Plan of Care did not address the need to turn / reposition the resident. c. On 2/25/18 at 10:10 a.m., the resident was sitting in a wheelchair at her bedside. She stated that her, .butt hurts. She was asked, Have you been laid down since breakfast? She stated, No. d. On 2/25/18 at 10:30 a.m., the Treatment Nurse was asked for a body audit of the resident. e. On 2/25/18 at 11:00 a.m., the resident was transferred from the wheelchair to the bed by Certified Nursing Assistant (CNA) #1 and the Treatment Nurse, and was turned to her right side. There was a dark-purple, linear area on the resident's left buttock, which extended to the resident's inner buttock. There was also a scabbed area located laterally from the purple area. f. On 2/25/18 at 11:00 a.m., Licensed Practical Nurse (LPN) #1 stated the resident had been sitting up in her wheelchair since approximately 7:15 a.m. that morning. g. On 2/25/18 at 12:15 a.m., Certified Nursing Assistant (CNA) #1 was asked, Did you change (provide incontinent care for) this resident this morning? She stated, No. h. On 2/25/18 at 12:17 p.m., CNA #2 was asked, Did you change, or check (for incontinence), this resident this morning? She stated, No. The resident was left sitting up in her wheelchair from approximately 7:15 a.m. to 11:00 a.m., a period of 3 hours and 45 minutes, with no repositioning, toileting, or incontinent care provided by staff. i. On 2/25/18 at 12:15 p.m., the Treatment Nurse was asked to perform a body audit on the resident. Upon assessing the resident's left buttock, she was asked, What do you see? She stated, Deep tissue injury, unstageable, 10 centimeters by 1-centimeter linear area, and a Stage II measuring 1.6 centimeters by 0.9 centimeters, lateral to the linear area. She stated she had performed a body audit on the resident on Friday, 2/23/18, and the resident did not have this skin breakdown to her buttock at that time. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/29/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, was totally dependent on two-plus persons for transfers, required extensive assistance from two staff persons for bed mobility, toilet use, and personal hygiene, was frequently incontinent of bladder and of bowel, had functional limitation in range of motion to both lower extremities, was at risk for the development of pressure ulcers, had no existing pressure ulcers, had a pressure reducing device for chair and bed, and was on a turning / repositioning program. a. The Plan of Care with a revised date of 12/16/17 documented, .The resident has limited physical mobility related to weakness, chronic pai[DIAGNOSES REDACTED], [MEDICAL CONDITION] . Resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION] . requires extensive assistance by 2 staff for toileting . requires mechanical lift (Hoyer) with 2 staff assistance for transfers . Resident has bowel incontinence related to impaired mobility . bladder incontinence related to kidney failure . check every two hours and as required for incontinence . The resident has potential impairment to skin integrity of the buttocks and bilateral heels r/t (related to) fragile skin . Keep skin clean and dry . The resident needs ROHO cushion to protect the skin while up in wheelchair and recliner at all times . The Plan of Care did not address the need to turn and reposition the resident. b. On 2/25/18 at 9:31 a.m., the resident was sitting in a reclined Geri-chair, and was being pushed from the dining room into the hallway outside of her room by CNA #1. c. On 2/25/18 at 10:00 a.m., the resident remained in the Geri-chair outside of her room in the hallway. d. On 2/25/18 at 12:30 p.m., the resident was asked, Did they lie you down this morning? She stated, No. e. On 2/25/18 at 1:05 p.m., CNA #1 was asked, What time did this resident get up? She stated she got the resident out of bed, .around 7:00 a.m. She was asked, Have you laid her down since then? She stated, We laid her down around 11:30 a.m., when CNA #2 came back from lunch. f. On 2/25/18 at 1:07 a.m., CNA #2 stated they laid the resident down around 11:15 a.m., when she came back from lunch. The resident was left in the geri-chair in the same position for approximately 4 to 4.5 hours, with no repositioning, toileting or incontinent care provided by the staff. g. On 2/25/18 from 11:15 a.m. to 3:15 p.m., the resident was observed sitting up in the geri-chair. At 3:15 p.m., the resident was transferred from the geri-chair to the bed by CNA #1 and #2. The resident's buttocks had deep creases visible from the incontinent brief, but no skin breakdown was present. 3. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/7/17 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance of two-plus persons for bed mobility, transfers, toilet use, and personal hygiene, was always incontinent of bladder and of bowel, was at risk for the development of pressure ulcers, had no existing pressure ulcers, had a pressure reducing device for chair and bed, and was on a turning / repositioning program. a. The Plan of Care dated as revised 11/15/17 documented, .Resident has an ADL self-care performance deficit related to weakness / Dementia . requires extensive assistance by 1 to 2 staff to turn and reposition in bed every two hours and as necessary . requires extensive assistance by 2 staff for toileting . Resident has limited physical mobility . The resident has potential / actual impaired skin integrity r/t (related to) weakness and decreased mobility . keep skin clean and dry . b. On 2/25/18 at 9:30 a.m., the resident was sitting up in a Broda chair, which was being pushed by her spouse. c. On 2/25/18 at 10:55 a.m., the resident was transferred from the Broda chair to bed by CNA #3 for incontinent care. d. On 2/25/18 at 11:00 a.m., CNA #3 was asked, What time did you come in to work this morning? She stated, At 7:00 a.m. She was asked, Was this resident up in her chair when you came in this morning? She stated, 'Yes, she was. She was asked if the resident had been checked for incontinence or provided incontinent care between 7:00 a.m. and 10:55 a.m. and stated, I just laid her down and changed her, and got her back up because she didn't want to lay down. CNA #3 stated the resident was sitting up in the chair in the same position for approximately 4 hours, and had not been repositioned or toileted by the staff. e. On 2/25/18 at 12:15 p.m., the Treatment Nurse was asked for a body audit of the resident. The resident's buttocks were slightly red, but the redness was blanchable. 4. On 2/25/18 at 2:20 p.m., the Treatment Nurse was asked, How often should a resident who is at risk for pressure ulcer formation be turned and repositioned? She stated, Every 2 hours.

Based on observation, record review and interview, the facility failed to ensure necessary treatment and services to promote healing, prevent infection and the development of new pressure ulcers sores were provided for 1 (Resident #1) of 2 (Residents #1 and 17) case mix residents who had or were at risk for pressure ulcers, as evidenced by: failure to ensure Resident #1's physician was immediately consulted and wound care was restarted for a pressure ulcer to the coccyx after a readmission from the hospital; failure to ensure Resident #1's pressure ulcers were assessed at least weekly, to include measurements, staging and a description of the condition of wound bed and surrounding tissue, drainage and odor to enable tracking of healing progress or deterioration; failure to ensure Resident #1 was repositioned at least every 2 hours to prevent potential deterioration of a Stage II pressure ulcer to the coccyx; failure to ensure incontinent care was provided at least every two hours and an alternating air mattress was properly inflated for Resident #1 to prevent further potential skin breakdown; and, failure to ensure the physician was consulted regarding deterioration or lack of healing progress on pressure ulcers to Resident #1's heels. These failed practices resulted in a pattern of actual harm for Resident #1, who experienced deterioration in pressure ulcers to both heels and the coccyx, and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as documented on a list provided by the Administrator on 4/26/13 at 8:30a.m. The facility also failed to ensure pressure relief boots were consistently applied in accordance with the physician's orders [REDACTED].#3) of 4 (Residents #3, #11, #17 and #19) case mix residents who had physician's orders [REDACTED]. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/13 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for transfers, toilet use and personal hygiene, was non ambulatory, was incontinent of bladder, had an [MEDICAL CONDITION], had one Stage II pressure ulcer, one healed Stage II pressure ulcer, required pressure reducing device in chair and bed and required pressure ulcer care. a. A Nurses Note dated 1/9/13 (not timed) documented, "Admit to (Facility Name) skilled Bed ... PT/OT (Physical Therapy/Occupational Therapy) (and) treat. Dx (Diagnosis) Pneumonia (with) weakness." 1.) A Nurses Note dated 1/9/13 (not timed) documented, "(Resident) returned to (Facility Name) ... very weak, skin clammy. Hypoactive BS (bowel sounds) lungs CTA (clear to auscultation) at this time. C/O (Complaint of) pain when pressure (light) applied to Rt (right) shin. (No) pain noted to left shin. Will continue to monitor." 2.) A Resident-Data Collection form for readmitted d 1/9/13 at 5:50 p.m. documented, "Skin Condition, Comments: Bruise Rt (right) wrist, [MEDICATION NAME] to m (mid) back and coccyx, pressure sore to BL (bilateral) heels." There was no documentation on the Resident-Data Collection or Nurse's Notes to include the size of the wound, stage, odor, the condition of wound bed and surrounding tissue for the wounds identified on the heels and coccyx area. 3.) The admission orders [REDACTED]. b. An Occupational Therapy Daily Treatment Documentation form dated 1/11/13 documented, "Nurse notified of R (right) LE (lower extremity) heel (and) calf possible need for Doppler of LE as pt (patient) painful (and) warm to touch." c. A Nurses Note dated 1/14/13 (not timed) documented, "O.C. (order clarification) 1) Apply [MEDICATION NAME] to buttock and coccyx Q (every) shift (and) prn (as needed). 2) Apply [MEDICATION NAME] Border Drsg (dressing) to coccyx, (change) Q3D (every three days) (and) prn. Dx Stage II." There was no documentation of treatment orders for the areas on the resident's heels. d. The Weekly Body Audit form dated 1/15/13 documented, :[MEDICATION NAME] to gluteal crease BLheels discolored and drsg (dressing) discoloration. ..." On the anatomical diagram that there was no open area to the coccyx. The Weekly Body Audit dated 2/5/13 documented, Rectal area red (with) pressure ulcer to coccyx ...discoloration to heels." There was no documentation of measurements or wound descriptions on the forms for any of the above dates. e. The Weekly Wound Assessment Documentation dated from 1/14/13 through 2/7/13 documented measurements as follows: 1/14/13: 3 x (by) 2 x .1 (Length xWidth x Depth) centimeter (cm). 1/18/13: 3 x 2 x .1 cm. 1/25/13: 2 x 1.5 x .2 cm. 2/7/13: 2 x 1.5 x .2 cm. There were no measurements of the heels documented on the forms. f. The Care Plan dated 1/18/13 documented, "1/18/13 Txt (treatment) as ordered ... Off loading boots when in bed ... Turn and reposition q (every) 2 (hours) (and) prn (as needed) when in bed ... 2/1/13 - Pressure area to coccyx and discoloration to Bil. (bilateral) heels ...Approaches - Report changes in skin status (i.e. (such as): s/s (signs and symptoms) of infection, non healing, new areas) to physician ... Complete Weekly skin check by the Treatment Nurse ...Assist prn (as needed) to reposition/shift weight to relieve pressure ...Provide prompt incontinence care after incontinence episodes, apply barrier cream prn (as needed) ..." g. The April 2013 Medication and Treatment Administration Record Report document, "Wound Care-Coccyx. Apply Santyl, cover with moist gauze and [MEDICATION NAME]. Change ever three days." The order had a start date of 2/8/13. There was not order for treatment on this record for the heels. h. The Braden Scale For Predicting Pressure Sore Risk form dated 2/11/13 documented a score of 14, with a score of 18 or less indicating that the resident was at risk for the development of pressure sores. i. A Weekly Wound Assessment Documentation form dated 2/12/13 documented, "Wound type: Pressure; Location L heel; Stage: eschar; Size: Length: 1 cm (centimeter) by width 2cm." There was no documentation regarding the condition of the resident's right heel at this time. A Physician order [REDACTED].O. (New order) EZ boots to be worn while in bed Dx (diagnosis) Prevention." j. Weekly Body Audits dated 2/19/13 and 2/26/13 documented, "BL (bilateral lower) heel discoloration no open areas to heels." k. A Nurses Note dated 2/26/13 at 4:00 p.m. documented, "(Resident) lying in bed ...Dark discolored (left) heel. EZ boot to BLE (bilateral lower extremities) in place ..." l. Weekly Body Audits dated 3/6/13 and 3/12/13 documented, "Both heels dry." m. Weekly Body Audits dated 3/19/13 and 3/27/13 documented, " ...necrotic areas to both heels..." Weekly Body Audits dated 4/3/13 and 4/9/13 documented, " ...heels necrotic ..." A Weekly Body Audit dated 4/16/13 documented, " ...necrotic area to bilat (bilateral) heels." There was no documentation on the Body Audit forms regarding the condition and measurements of the necrotic areas or surrounding tissue, or whether odor or drainage was present. n. On 4/24/13 at 9:30 a.m., the resident was sitting in a wheelchair in the her room. Certified Nursing Assistant (CNA) #1 was present and was asked, "Was (Resident #1) up when you got here?" The CNA stated, "Yes ma'am." The CNA was asked, "What time do you get here?" The CNA stated, "Five forty-five (5:45 a.m.). I get report between 6 to 6:05 (a.m.)." The CNA was asked, "When did you first see her up?" The CNA stated, "At about 5:50 (a.m.)." The CNA was asked if the resident had been removed from the chair/placed in bed at all that morning and stated, "No, ma'am." At 9:30 a.m.., the resident was assisted to bed by CNA #1. The resident's pants were removed. The incontinent brief was wet and there was no dressing on an open area to the coccyx, granulation tissue present, a Stage III pressure ulcer, immediate tissue surrounding the wound edges macerated and white. The resident had been sitting up in the wheelchair for at least 3 hours and 40 minutes with no repositioning or incontinent care. There was not wound dressing in the incontinent brief. At 9:35 a.m., Licensed Practical Nurse (LPN) #1 provided wound care to the resident's coccyx. The pressure ulcer had granulation tissue to the inside of the wound, but the wound edges were macerated. The LPN was asked, "Was there a dressing?" The LPN stated, "Not that I took off." The LPN was asked, "Did anyone tell you the dressing was off?" The LPN stated, "No, they did not." The low air loss mattress under the resident was deeply indented in the middle, with the resident lying in a supine position. 0. On 4/24/13 at 3:44 p.m., the resident was lying in bed. When LPN #2 removed the covers, the resident's feet were not offloaded and her heels were resting directly on the mattress. The EZ boots were on the floor, next to the overbed table. The LPN and surveyor slid a hand under the air mattress, between the mattress and bed springs. The resident's bottom could be felt pressing against the bed springs. Resident #1 stated, "I have a place on my bottom and it's hurting; I can't hardly stand it." The LPN was asked, "Do you think there is enough air in the mattress?" The LPN stated, "If it was my butt on it, I would want more air in it." LPN #2 was asked to remove the resident's socks. There were necrotic areas to both of the resident's heels. The LPN was asked if there was an order for [REDACTED]." p. On 4/25/13 at 9:30 a.m., the resident was sitting in a wheelchair in her room. The resident stated, "My bottom hurts, aches." 1.) At 9:35 a.m., CNA #3 was asked, "Did you get (Resident #1) up this morning?" The CNA stated, "No ma'am, the other CNA did, on the night shift. I think it was around 5:00 (a.m.)." The CNA was asked, "What time did you first see her up in the wheelchair this morning?" The CNA stated, "Around 5:00 (a.m.)." The CNA was asked if the resident had been removed from the chair/placed in bed at any time that morning and stated, "No, ma'am." 2.) At 9:55a.m, the resident was assisted to bed by CNA #5 and CNA #6. When the resident's brief was removed, it was wet and the dressing covering the Stage III pressure ulcer on the resident's coccyx was loose on three sides. When CNA #6 wiped the resident's left hip, the dressing, which was saturated with urine, fell off of the wound. The wound edges were macerated. Resident #1 had been sitting in the wheelchair for at least 4 hours and 55 minutes with no repositioning or incontinent care provided. q. On 4/25/13 at 10:40a.m., Licensed Practical Nurse (LPN) #1 obtained measurements of the wounds to the resident's heels as follows: Left lateral heel area: 1 x 1centimeter - eschar. There was no sponginess noted to heel tissue. Right posterior heel area: 2.5 cm x 1.5cm - eschar. Right lateral heel area: 1.25 cm x .5 cm - eschar. After the measurements were provided, LPN #1 was asked, "What did the heels look like at first?" The LPN stated, "When we started this process, they were mushy." The LPN was asked when the areas became necrotic or covered with eschar and stated, "I don't know the exact time, but it's been a couple of months." When asked if there were physician orders [REDACTED]." r. On 4/25/13 at 11:40 a.m., the Treatment Nurse was asked , "When did you first notice (Resident #1) had problems with her heels?" The Treatment Nurse stated, "When she first came back from the hospital, had a little discoloration, purple and boggy. We got the order for the EZ boots." The Treatment Nurse was asked, "Can you describe what they look like now?" She stated, "Last time I saw them was on Monday (4/22/13). She had a dry, purple discoloration; it wasn't like a necrotic spot, more like a dried out blood blister look, like a blood blister scab." The Treatment Nurse was asked, "Did you notify the Doctor when you noticed the change?" The Treatment Nurse stated, "The last time (Advanced Practice Nurse #1) was in the building, I had her look at them ... she said to continue the EZ boots and Santyl to the coccyx." The Treatment Nurse was asked, "Did you measure the wounds?" and stated, "No, it was my understanding that if the surface was not removed, we could not measure or stage them. I'm new at doing wound care. I just attended a wound workshop with my DON (Director of Nursing)." The Treatment Nurse was asked, "When the APN saw the resident's heels, were they still the dark purple color?" She stated, "Yes." The Treatment Nurse was asked, "Was it necrotic then?" The nurse stated, "No, it looked like the top of a blood blister, dark purple, scabbed. It was looking slightly necrotic since then." The Treatment Nurse was asked, "Did you notify the Doctor that the heel was looking necrotic?" She stated, "Not since the last time she was in our facility." The Treatment Nurse was asked if this was the APN and stated, "Yes. I have to cover every floor when someone calls in. I was on the floor for about 2 weeks straight the last 2 weeks..." s. On 4/25/13 at 12:35 p.m., the Physician was asked, "Have (Resident #1's) heels been reported to you? If so, what description were you given?" The physician stated, "Red and painful." The physician was asked, "Were you told they were necrotic?" The physician stated, "No, I saw her about a month ago. It wasn't too bad; petechiae on heels, but not open. Looks like this lady has slipped through the cracks." t. On 4/26/13 at 9:35a.m., the Director of Nursing (DON) was asked, "When are the Nurses or Treatment Nurse to notify the physician regarding a pressure ulcer?" The DON stated, "Anytime there is a new one; after 2 weeks, if not showing improvement and any time there is a major change." The DON was asked, "Should a resident with a Stage III pressure ulcer to the coccyx be left sitting up in a wheelchair for 4 to 5 hours?" The DON stated, "No." The DON was asked, "If a low air loss mattress on a resident's bed is not functioning properly, what should happen?" The DON stated, "Find the maintenance man to see if it's anything he can fix. If he cannot fix it, get ahold of (name of company) our supply company; if it's deflated, place a pressure reducing mattress on the bed until we get the new one." The DON was asked, "If a resident with a Stage III pressure ulcer on the coccyx is on a low air loss mattress and the resident's bottom is touching the springs through the air mattress, would you consider the mattress to be properly inflated?" The DON stated, "No." u. The facility's Pressure Ulcer Prevention and Treatment policy and procedure, provided by the Administrator on 4/25/13 at 4:15 p.m., documented, "TREATMENT: 1. All ulcers admitted or acquired within the facility will have a complete ulcer assessment upon identification and the start of a PUSH tool. The assessment will contain the type and/or stage of ulcer, if known, size depth, ulcer edge, wound bed, shape and surrounding tissue condition. The assessment will be completed by the charge nurse and/or admitting nurse. 6. Every pressure ulcer that is found to be not healing within 2-4 weeds will have an analysis of the treatment plan. The charge nurse and/or QA (Quality Assurance) nurse will analyze the treatment plan to include, but not limited to, the treatment order, care plan, adherence to the treatment plan, pressure relief in bed and/or chair, heel relief, nutritional intake, signs of infection, etc (et cetera). The medical record should reflect a treatment plan analysis at two weeks for non-healing ulcers and reflect a change in the treatment plan within 4 weeks of non-healing ulcers. The charge nurse and/or QA nurse will notify the treating physician about any ulcers that are found not to be healing within the 2-4weeks based on either the weekly ulcer assessment and/or PUSH (Pressure Ulcer Scale for Healing) graph ..." 2. Resident #3 had [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]." b. The Care Plan updated 1/28/13 documented, "Risk for skin breakdown due to total dependence for all positioning and total incontinence ... Approaches ... 10/25/12 EZ boots at all times except for shower & (and) personal care." c. The April 2013 ADL (Activities of Daily Living) flow sheet did not address the need for EZ boots for this resident. d. The April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]". The MAR indicated [REDACTED]. e. The Braden Scale assessment dated [DATE] documented the resident's pressure ulcer risk score was 17, with a score of 18 or less indicating a risk for pressure sores. f. On 4/23/13 at 10:48 a.m., the resident was taken to the shower in a shower chair by Certified Nurse Assistant (CNA) #3. The resident had no EZ boots in place. CNA #3 did not put EZ boots on the resident's feet after the shower was completed. g. On 4/24/13 at 8:55 a.m., the resident was sitting in a Broda chair in her room. Had on non skin socks. She did not have EZ boots on her feet. h. On 4/24/13 at 4:00 p.m., the resident was in her room in a Broda chair.. The resident did not have on EZ boots. i. On 4/25/13 at 8:39 a.m., CNA #1 was asked if she was aware that Resident #3 had an order for [REDACTED]." CNA #1 was asked if there was a pair of EZ boots in the resident's room. CNA #1 stated, "I don't think so, unless they're back in her closet somewhere. I haven't seen 'em." CNA #1 was asked if she had placed EZ boots on the resident today or at any time this week. CNA #1 stated, "The night shift stated they tried, but she kicked them off and doubled up her fist at them. I did tell in shift report yesterday that the surveyor said she was supposed to have them on, so none of us CNA's knew that before you (Surveyor) said something." j. On 4/25/13 at 9:05 a.m., the Assistant Director of Nursing (ADON) was asked if Resident #3 had any history of skin breakdown to her feet. The ADON stated, "I don't know, I don't think so." The ADON was asked why there was an order for [REDACTED]."