Every finding on record at Church of Christ Care Center

Based on interview and record review, the facility failed to report an allegation of abuse to the state agency for one resident (R901) of three reviewed for verbal abuse. Findings include: This citation pertains to Intake 3068069.On 07/02/26 in a complaint received by the state agency stated: On 7/1/26 (R901) asked staff to be changed (cleaned up) while they were simultaneously on the phone with their friend (F1). F1 overheard a staff member verbally abusing (R901) allegedly saying they (the alleged staff member) wished (R901) was dead, a burden to staff, no one wants to care for them and not worth the air they breathe.A review of the state's Facility Reported Incidents (FRI) for Long Term Care (LTC) reporting system revealed no facility reported FRI that R901 had reported anything related these allegations.On 07/09/26 at 9:17 AM and 2:24 PM, R901 reported two occasions of verbal abuse by facility staff saying the verbal exchanges were hurtful and subsequently becoming quieter and tearful. On 07/09/26 at 10:52 AM, F1 confirmed the details of the reported allegations and said they had been reported to R901's Responsible Party.On 07/09/26 at 12:10 PM, the Responsible Party for R901 reported F1 had informed them of the verbal abuse allegations, who then on 7/1/26 informed the facility Administrator and Director of Nursing (DON).On 07/09/26 at 3:12 PM, the Administrator and DON were asked about the incident and why the allegations had not been reported to the state agency. The Administrator reported the allegations had not been reported because their investigation did not substantiate the allegations. A review of an investigation report confirmed facility's knowledge of the allegations on 07/01/26 at approximately 1:30 PM.A review of the electronic medical record for R901 revealed the resident was admitted into the facility on [DATE] and readmitted [DATE]. R901's diagnoses included Depression, Anxiety Disorder, and bipolar disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score, no rejection of care, limited range of motion in the upper and lower extremities and the need for substantial/maximal assistance for toileting and bathing and dependence on staff for lower body dressing and transfers. A review of the facility policy titled, Abuse, Neglect and Exploitation date Implemented: 01/30/2023, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

This citation pertains to Intake: 3030980 Based on interview and record review, the facility failed to prevent misappropriation of property for one resident (R901) of three residents reviewed for misappropriation. Findings include:A review of a complaint submitted to the State Agency (SA) revealed (R901's) money ($60.00) was reported missing (0n 5/14/26) from their possession after receiving from trust fund on 5/11/26. Upon investigation identified Housekeeper A had entered into R901's room on three separate occasions outside of their job duties. On 6/11/26 at 9:57 AM, an interview was completed with R901 who reported they obtain $60.00 monthly from the resident trust fund and allocates the money to family members to run errands on their behalf. The resident confirmed they obtained their $60.00 for the month of May, placed it inside a pouch, and placed it on their overbed table. Upon waking up one morning they discovered the money was missing. R901 explained they do not know who took the money but explained they did not leave their room after receiving the money and getting up in their wheelchair is too uncomfortable, saying they did not give the money to anyone. R901 said they spoke to the Nursing Home Administrator (NHA) about the missing money, as well as the local police.A review of R901's medical record revealed they were admitted into the facility on 7/25/25 with diagnoses which included Chronic Kidney Disease, Diabetes, and Obesity. Further review revealed the resident was cognitively intact and required extensive assistance for some activities of daily living. On 6/11/26 at 11:48 AM, it was confirmed through the Nursing Home Administrator (NHA) R901 did not have any visitors between 5/11/26 and 5/14/26. On 6/11/26 at 11:36 AM, an attempt to interview Housekeeper A was unsuccessful as they disconnected the call once the surveyor identified themselves.On 6/11/26 at 1:35pm, an interview was completed with the NHA regarding their investigation into the missing money. They explained during the initial interview conducted with Housekeeper A; they explained walking past R901's room when the resident requested for them to get the assigned staff for the day to report stolen money. The NHA explained after the interview, they reviewed camera footage and observed Housekeeper A entering R901's room on three separate occasions prior to their scheduled shift, and when confronted about those occasions provided different contradictory reasons as to why they had entered the room, none being related to the duties of the job.A review of documentation submitted to the SA, Housekeeper A was terminated on 5/19/26 for the following, Failure to cooperate with an active investigation and willful disobedience of management directives/insubordination.Regarding the outcome of the facility's investigation, they noted it as inconclusive, and noted, .It is possible that [R901] may still have the money, or that [they] gave the money to a relative, or misplaced it.A review of the facility's, Abuse, Neglect and Exploitation policy revealed the following, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .

This citation pertains to Incident 2984504.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff, affecting one resident (R701) of three reviewed for abuse.Findings include: An allegation of staff to resident abuse was submitted to the state agency on 3/27/26 documenting; On the afternoon of 3/27/26, a hospice representative told the Administrator that [R701] had concerns regarding the midnight shift and was afraid of the two ladies that cared for her. Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CNA) C were assigned to [R701] from 11 p.m. on 3/26/26 until 7 a.m. on 3/27/2026. An investigation revealed that around 11:30 p.m. on 3/26/26, [R701] began calling out for help. LPN B and CNA C entered the room. LPN B told [R701] to stop yelling and they are not the only patient on this floor. [R701] began calling out for help again that they could not reach they're call cord. When LPN B and CNA C entered the resident's room, [R701] explained they needed to be turned/repositioned. The nurse and aide told the resident that it had not been two hours. [R701] expressed they was in pain and the nurse replied, I gave you your pain medication. Goodnight.On 4/15/26 at 1:00 PM, R701 was observed laying in their bed. R701 appeared anxious and had just received assistance from the nurse on the floor. When R701 was asked about the incident on 3/26/26 during the midnight shift, they said about the staff, They were mean to me and wouldn't help me. I kept yelling for help.On 4/15/26 at 1:30 PM, a phone was placed to Licensed Practical Nurse (LPN) B, there was no answer and a voicemail message was left. There was no return call prior to end of survey.On 4/15/26 at 1:40 PM, a phone call was placed to Certified Nursing Assistant (CNA) C, there was no answer and a voicemail message was left. There was no return call prior to end of survey.On 4/15/26 at 2:30 PM, the Nursing Home Administrator (NHA) was interviewed in their office. The NHA stated there was video footage and audio of the hallway outside of resident's room from the date of the incident. A review of the video footage revealed the following: R701 can be heard yelling for help while the LBN B is outside of room for several minutes before LPN B and CNA C enter the room. LPN B is heard telling R701 to stop yelling and told her she is not the only patient on this floor. Both staff are seen leaving the room, and R701 is heard yelling again saying she could not reach her call light. Both LPN B and CNA C were observed responding to R701's room after several minutes. R701 was heard telling the two staff members that they needed to be turned due to being in pain. LPN B was heard telling R701 that it had not been two hours. When R701 stated they were in pain, LPN B replied, I gave you pain medication. Goodnight. Both staff members exited the room and ignored R701's calls for help and request to be turned. CNA C entered the room sometime later and then exited the room and stated Goodnight. If you get messed up (soil on self), that's on you to R701.The NHA was asked what their expectation regarding residents and abuse. The NHA replied, All residents should be free from abuse and neglect.R701's medical record was reviewed and revealed the resident was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the brain and Radiculopathy thoracic region. Further review revealed R701's Brief Interview for Mental status (BIMS) assessment dated [DATE] was 12/15 indicating intact cognition and they required staff's assistance with activities of daily living (ADLs). A review of the Abuse, Neglect and Exploitation Policy dated 1/30/23 revealed, 'It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included interviews, skin, and pain assessments on all residents, all staff abuse education, weekly abuse audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Date of Compliance was 4/10/26.A review of the plan of correction revealed the following actions:Immediately suspended employees upon notification from resident.Resident was assessed, no injuries noted, and no pain was reported. Physician and family were notified of alleged incident.Resident's roommates were interviewed.Staff statements were taken.Facility Social Work completed 3 days well check visits for Resident.Behavioral Health Psychiatric Services offered to Resident.Police were called, and a report was filed, Detective was assigned, and the case was closed.Both staff were given disciplinary action related to abuse and resident rights resulted in termination. Interview able residents within the assignment set were queried.Facility policy on Resident Rights and Abuse was reviewed and deemed appropriate.Facility staff were reeducated on Resident Rights and Abuse Policies. The Administrator or designee will conduct audits of random interviewable residents to ensure they have not received rough treatment or inappropriate verbal conversation from staff.The Administrator is responsible for overall compliance by 4/10/26.

This citation pertains to intake 1238200.Based on interview and record review the facility failed to utilize the required two staff to complete incontinence care for one sampled resident (R4) of four residents reviewed for accidents, resulting in a fall from the bed and a fracture of the right arm. Findings include:During a closed record review of R4's medical record it was noted that R4 was transferred to the hospital after a fall during care. A review of R4's medical record progress notes revealed, 8/17/25 -Writer called to room by nurse assistance. Res (resident) observed on floor, lying on right side. Lying next to bed closest to the window. Nightstand and bed side table next to [R4], close to [R4's] head. Res is alert and verbal. Verbal complaints of pain to right side. Physician in house. Assessed at bedside while on floor. Order received to send to ER (Emergency Room) via 911. Res kept in same position. No active bleeding noted at this time. Awaiting EMT's (Emergency Medical Technicians).Further review revealed, 8/17/25 -Physician Progress Note: Patient was seen today per nursing request due to the above-mentioned concern. No fever or chills no chest pain or SOB (Shortness of Breath) no abdominal pain no headache. Patient fell out of bed during care, [R4] landed on [R4's] right side, [R4] reported that [R4] struck [their] head against on the floor. [R4] is on Eliquis (blood thinner) due to a history of A-Fib. [R4] complains of pain over right arm and wrist. No LOC (Loss of Consciousness). [R4] complains of pain over right arm and wrist. Assessment and plan; 1. S/P (status post) fall on Eliquis 2. Closed head injury, no LOC 3. Paroxysmal atrial fibrillation; on Eliquis 4. Morbid obesity 5. Old CVA (cerebrovascular accident) with right hemiparesis 6. Debility; continue supportive care 7. Plan of care was discussed with nursing Call 911 and transfer patient. to ER for further evaluation and treatment. A continued review of R4's medical record revealed that R4 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE]. A review of R6's Minimum Data Set quarterly assessment dated , 7/3/25 noted R4 with an intact cognition.A review of R4's care plan revealed, . Focus: Self Care Deficit r/t (related to) Physical Weakness, poor endurance, bilateral cataracts, right hemiparesis, and impaired mobility. Goal: Resident Care needs will be met daily. Interventions: Bathing: I am dependent on 2 staff members to provide for my bathing needs. Dressing: I require extensive assistance of 2 staff to assist me with dressing. I am incontinent of bowel and bladder and require total assistance of 2 staff to provide incontinence care. Bed Mobility: I require extensive assistance of 2 staff member and my right-side enabler bar for bed mobility.Toileting Provide extensive assistance with personal hygiene care: nails, hair, oral care, bathing. PHO Care: I am incontinent of bowel and bladder and require total assistance of 2 staff to provide incontinence care. BED MOBILITY: I require extensive assistance of 2 staff member and my right side enabler bar for bed mobility. On 8/20/2025 at 1:18 PM, the Director of Nursing (DON), called R4 at the hospital for an interview regarding the fall. R4 explained they were being assisted by Certified Nursing Assistant (CNA) N to get ready for the day. R4 explained CNA N was the only CNA in the room. R4 continued and explained, they were rolled on to their side and CNA N turned to get the cream for their bottom and that is when they rolled out of bed. R4 stated they hit their head, and their arm was in pain after the fall and was transferred to the hospital.The DON was asked their expectations for following the care plan. The DON explained, staff is to follow the minimum number for staff assistance and to follow the Kardex (CNA care guide). The DON confirmed R4 stated they had an Acute proximal humerus fracture of the right arm. On 8/20/2025 at 3:56 PM, CNA N was asked via phone about the fall with R4. CNA N explained it was during care they asked R4 to grab the bar to turn to the side, because they had a small bowel movement. CNA N explained they had turned their back to get the cream and that is when R4 fell out the bed. CNA N was asked if they knew R4 was a two person assist for ADLs. CNA N confirmed they did know but was unable to locate another staff person to help at that time. A review of the facility's policy titled, Fall prevention Program dated, 2/5/22, noted Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines .3. Interventions will be implemented by the care team.

Based on observation, interview, and record review, the facility failed to ensure the ice machine near the main kitchen was backflow protected. This deficient practice had the potential to affect all residents in the facility. Findings include: On 08/18/2025 at 11:45 AM, the ice machine drain line was observed to extend down inside the floor drain. There was no air gap between the bottom of the drain line pipe and the flood rim of the floor drain. Dietary Manager O confirmed the lack of an air gap and stated she would let Maintenance know. According to the Food & Drug Administration (FDA) 2022 Model Food Code, Section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review, the facility failed to have available and don/doff (put on and take off) personal protective equipment (PPE-gowns, gloves, masks, etc.) for one resident on Enhanced Barrier Precautions (EBP) (R117) out of six reviewed for infection control. Findings include:R117On 8/19/2025 at 2:00PM, R117's door was observed with a sign stating the room was on Enhanced Barrier Precautions (EBP). No PPE was observed on the door, or in the room.On 8/19/2025 at 2:08 PM, Certified Nursing Assistant (CNA) J was observed going into R117's room and provided care to R117 and their roommate, both were on EBP. CNA J was noted to have on gloves and a mask. CNA J was asked if they put on a gown while providing care. CNA J reported they did not put on a gown and that there was not one available.On 8/20/2025 at 11:00 AM, an infection control meeting was held with the Director of Nursing (DON). The DON reported they completed EBP training earlier in the year and they have been facing some challenges since changes in staffing. A review of a facility policy titled, Enhanced Barrier Precautions noted the following, .3. Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or upon entrance into the resident's room.

Based on observation, interview, and record review, the facility failed to develop/implement comprehensive care plans for three residents (R13, R88, and R99) out of four reviewed for Care Plans. Findings Include:R13 On 8/18/25 at 9:00 AM, R13 was observed sitting on the side of the bed. R13 appeared anxious with nervous speech and finger movements. A review of the medical record for R13 occurred and revealed the following: R13 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with following diagnoses including: Dementia, Schizophrenia, Depression and Chronic Obstruction Pulmonary Disease. A review of R13's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental status (BIMS) assessment score of 14/15 indicating intact cognition. Further review of R13's medical record revealed a care plan for antipsychotic medications and an intervention noted was for staff to monitor behaviors. Care plan interventions documented Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 08/19/2025 at 2:00 PM a request was made for R13's behavior monitoring log. On 8/20/25 at 2:45 PM, the Director of Nursing (DON) was interviewed. The DON stated that there was no monitoring tool for behaviors for R13. When asked what their expectation for residents and behavior monitoring. The DON replied, My expectation is that residents on psychotropics will be monitored for care plan per policy. On 8/20/25 a review of the Comprehensive Care Plan Policy dated 10/28/2022 revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. R88 On 8/18/2025 at 12:48 PM, R88 was observed in their room. R88 was observed to be bending down and fixing the covers on their bed and their wheelchair behind them. R88's wheelchair was noted to be unlocked and moved when R88 sat back down in their chair. A review of the medical record revealed that R88 was admitted into the facility on 2/22/2021 with the following medical diagnoses, Dementia and a Fall. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R88 also required assistance with bed mobility and transfers. A review of an Incident and Accident (I/A) report revealed that R88 had a fall on 2/18/2025. The I/A reported that R88 was observed sitting behind facing the door next to their wheelchair. R88 reported they were trying to get into their wheelchair. Further review of the fall care plan revealed an active intervention for anti-roll backs to wheelchair dated 3/11/2025. On 8/19/2025 at 10:47 AM, R88 was in their room and had just returned from therapy. No anti-roll backs were observed on the wheelchair. On 8/20/2025 at 9:22 AM, R88 was observed in their room. R88 was out of their wheelchair and bending over, attempting to fix the covers on their bed. R88 wheelchair was not locked. Occupational Therapist (OT) D was asked if R88 had anti-roll backs on their wheelchair. OT D reported R88 did not have them on their chair and that they probably needed them. OT D then was observed asking R88 to sit down and locked R88's wheelchair. OT D reported they were going to make a note of it and get them in the right chair. On 8/20/2025 at 12:18 PM, an interview was completed with the Director of Nursing (DON). The DON reported R88 will have the anti-roll backs put on their chair today. The DON reported that the intervention was put in, however there is still a process, and it has to be put in the system for maintenance to install them on the wheelchair. The DON reported it has to be communicated properly. R99 On 8/18/2025 at 12:34 PM, R99 was observed in their room. R99 was tearful and stated that they get sad and depressed sometimes in the facility. R99 reported they are seen by the psychologist in the facility and that helps with their mood. A review of the medical record revealed that R99 admitted into the facility on 8/16/2024 with the following medical diagnoses, Muscle Weakness and Bi-Polar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R99 also required assistance with bed mobility and transfers. Further review of a note from the Psychiatry group dated 3/5/2025 listed Post-Traumatic Stress Disorder (PTSD) as a current, chronic, and unchanged diagnosis for R99. Further review of R99's care plans revealed that R99 did not have a care plan addressing their PTSD diagnosis. On 8/19/2025 at 9:44 AM, an interview was conducted with Social Service Director (SSD) C. SSD C reported it was brought to their attention that R99 did not have an PTSD care plan, and they entered one. SSD C reported they will be following up with psychiatrist to ensure it is an accurate diagnosis as well.

Based on observation, interview, and record review the facility failed to reposition one resident (R113) in a timely manner out of two reviewed for interventions for pressure ulcers. Findings include:On 08/18/2025 at 9:56 AM, 12:25 PM, and 4:05 PM, R113 was observed lying on their back in bed with arms down on sides. The head of the bed was elevated to 40 degrees. R113 was on an air mattress, wearing a hospital gown with heel boots on. On 08/19/2025 at 10:01 AM, observed R113's family in room providing mouth care, and grooming for R113. The family member stated they were at the facility for a care conference and expressed concerns that since R113 returned from the hospital, the resident has not been talking, and staff are not assisting R113 to get out of bed. On 08/19/2025 at 12:12 PM, 1:59 PM, and 3:43 PM, observed R113 lying on their in bed with wedge cushion slightly under left hand. The head of the bed was elevated to 40 degrees. R113 was on an air mattress, wearing a hospital gown with heel boots on. A review of the medical record for R113 revealed R113 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure, Urinary Tract Infection, and Muscle Weakness. A review of the Minimum Data Set assessment dated [DATE], revealed R113 was dependent relying on staff for Activities of Daily Living (ADLS) including bed mobility. A review of admission nursing assessment dated [DATE], R113 was admitted into the facility with a Stage 2 (top layer of the skin is open and red in color) Pressure wound on his buttocks. A care plan dated 05/27/2025 indicated resident is at risk for skin breakdown.On 08/19/2025 at 11:07 AM, Certified Nursing Assistant (CNA) I was asked about how often dependent residents are repositioned. The CNA stated, every 2 hours or as needed. On 08/20/2025 at 1:26 PM, an interview with Wound Care Nurse/Licensed Practical Nurse (LPN) G was asked what interventions were in place for R113 related to repositioning for wound care. LPN G revealed turning and repositioned as needed, elevating heels in bed as tolerated, and a pressure reducing mattress (bed that floats). LPN G further explained that the expectations for R113 would be for the CNAs to reposition R113 throughout the day, at least every two hours or more often, due to the presence of a wound, even though a pressure-reducing mattress is in use. On 08/20/2025 at 2:00 PM, in an interview with the Director of Nursing (DON) they were queried regarding what are the expectations of repositioning residents to which they confirmed, every two hours or more if needed. for wound care. A review of the Policy titled Turning and repositioning dated 05/17/2022, revealed turning and repositioning as part of our systematic approach to pressure injury prevention and management. A turn schedule includes using both side-lying and back positions, alternating from the right, back and left side.

Based on observation, interview, and record review, the facility failed to provide built up utensils for one resident (R99) out of one reviewed for Adaptive Equipment. Findings include:On 8/18/2025 at 9:25 AM, R99 was observed eating breakfast. R99's meal ticket was noted to have a note stating built up utensils highlighted in blue. R99 was observed eating with regular utensils. R99 stated they rarely get the right utensils, and that the built-up utensils really help them with their meals and the pain they have in their hands.A review of the medical record revealed that R99 admitted into the facility on 8/16/2024 with the following medical diagnoses, Muscle Weakness and Bi-Polar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R99 also required assistance with bed mobility and transfers. On 8/18/2025 at 9:30 AM, Occupational Therapist (OT) E was shown R99's meal ticket and the regular utensils. OT E reported R99 should have built up utensils and they will have to check with the kitchen to see why they were given regular utensils.On 8/20/2025 at 10:19 AM, an interview was completed with Registered Dietitian (RD) D. RD D reported R99 still required their built-up utensils and would follow up on why they did not receive them.On 8/20/2025 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they would speak with dietary to see why they did not receive their built-up utensils. The DON reported R99 eats in their room and should have them on the tray. A review of a facility policy titled, Activities of Daily Living noted the following, .1.The facility will support resident autonomy in the performance of ADLs consistent with their physical and cognitive abilities.

Based on observation, interview, and record review the facility failed to complete an accurate resident assessment for one sampled resident (R36) of 23 reviewed for assessments. Findings include:On 8/18/25 at 9:17 AM, R36 was observed in their bed and asked if they had a pressure ulcer. R36 replied, Yes.On 8/19/2025 at 10:13 AM, an observation of R36's skin was completed with a nurse and a Physician. R36's skin was observed with a rash that started from the middle of their back to the back of R36's legs. R36's skin was observed to no longer have a pressure ulcer.A review of R36's medical record noted R36 was admitted to the facility on [DATE] with a diagnosis of Chronic Respiratory failure. A review of R36's Minimum Data Set (MDS) annual assessment dated [DATE], noted R36 with a moderately impaired cognition and R36 required assistance by staff to complete activities of daily living. Further review of R36's MDS noted, that R36 had one unhealed stage two pressure ulcer (characterized by a partial thickness loss of skin, meaning the outer layer (epidermis and part of the inner layer-dermis are damaged), a pressure reducing device for bed, and chair.A review of R36's progress note dated 5/12/25 revealed, .Patient seen for: stage 2 left ischium. Patient seen per nursing staff request for the above concern. staff reports patient has developed a stage 2 area to left ischium. Upon assessment today, area has resolved along with abrasion to scrotum . Skin; intact, rash and scabs remain allover body . Assessment and Plan; Stage 2 pressure injury; Resolved as of today. Apply house barrier cream and report any changes to MD (medical doctor) . Plan of care discussed with nursing staff.On 8/20/2025 at 10:06 AM, MDS Nurse F was interviewed via phone and informed that on the 7/30/25 MDS R36 is marked as having a current unhealed stage two pressure ulcer, when it was noted as healed on 5/12/2025. MDS Nurse F explained, they would have to speak with the other MDS Nurse because they did not complete the assessment for R36. A review of the facility policy titled, MDS Completion dated, 3/12/25 noted, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State .

Based on observation, interview and record review the facility failed to apply oxygen per physician order for one resident (17) out of 2 reviewed for respiratory care. Findings include.On 08/18/2025 at 9:01 AM, and 12:05 PM, R17 was observed sitting on the side of the bed without oxygen in use. The oxygen concentrator was on, and the tubing was lying on the floor by the bedside. On 08/19/2025 at 7:15 AM, R17 was observed sitting at the side of the bed without oxygen in use. The oxygen concentrator was on, and the tubing wrapped around concentrator. On 08/19/2025 at 9:56 AM, R17 was observed leaving the facility with a family member and no oxygen in use.On 08/19/2025 at 10:15 AM, during an interview with Registered Nurse (RN) M regarding oxygen for R17, RN M replied, I think [R17] oxygen is ordered as needed, I do believe. A review of the medical record for R17 revealed R17 was admitted into the facility 03/15/2024 with diagnoses included Respiratory Failure, Chronic Kidney Disease, and Congestive Heart Failure. R17 was admitted to the facility with an order dated 03/15/2024 for continuous oxygen at four liters per minute via nasal cannula. A review of R17's care plan noted, Focus: R17 has Oxygen Therapy related to shortness of breath when needed, history of respiratory failure Date Initiated: 02/04/2020. Goal: for R17 will have no signs or symptoms of poor oxygen absorption through the review date. Date Initiated: 06/16/2020 Provide oxygen in the following manner: cannula continuous Date Initiated: 06/16/2020. On 08/20/2025 at 1:57 PM, an interview was conducted with the Director of Nursing (DON) regarding the expectations for oxygen therapy orders. The DON replied that when a physician orders oxygen at a set liter flow continuously and a resident is not wearing it, nurses are expected to repeatedly encourage resident to use the oxygen as ordered and monitor oxygen saturation (Spo2) closely, and notify the physician of the noncompliance and discuss the possibility of changing to PRN (as needed) or trialing discontinuation of oxygen.

This citation pertains to intake 1238202.Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for one resident (R16) and grooming assistance for one resident (R20) out of three reviewed for Activities of Daily Living (ADL). Findings include:R16 On 8/18/2025 at 10:44 AM, R16 was observed in bed. R16 was noted to be sitting with the head of bed (HOB) elevated and a clothing protector on. The bedside table was pulled over them and their breakfast tray was sitting in front of them. R16 was noted to have a hash brown and eggs on their clothing protector and eggs on their face. R16 was observed attempting to pick up their eggs with their fingers. The meal ticket was noted to have 1:1 assistance and highlighted in yellow. A review of the medical record revealed that R16 was admitted into the facility on 1/6/2022 with the following diagnoses, Cerebrovascular Disease and Alzheimer's Disease. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 0/15 indicating an impaired cognition. R16 also required assistance with bed mobility and transfers. Further review of the physician’s orders revealed an active order dated 5/15/2025 for 1:1 assistance with feeding. On 8/18/2025 at 1:17 PM and 1:30 PM, R16 was observed in their room with their lunch tray in front of them. No one was observed in the room assisting R16 with eating. R16 was observed with chicken and green beans on their clothing protector and chin. On 8/20/2025 at 9:19 AM, Certified Nursing Assistant (CNA) “A” was asked if R16 requires assistance with feeding. CNA “A” reported R16 does better in the dining room, but if they are in the room then they need assistance and encouragement to eat. On 8/20/2025 at 9:35 AM, an interview was conducted with Registered Dietitian (RD) “B”. RD “B” reported R16 needs more assistance with their meals, and it can sometimes take them a while to get warmed up. On 8/20/2025 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that if a resident requires feeding assistance, then they should be fed and get the help that they need. R20 On 08/18/2025 at 9:41 AM, R20 was observed sitting in their wheelchair in the hallway. They were observed to have facial stubble that appeared to be unshaven for approximately three to four days. Review of the facility record for R20 revealed they were admitted into the facility on [DATE] with diagnoses including Hypertensive Heart Disease with Heart Failure and Mood Disorder with Depressive Features. Due to the limited time since admission, R20's Minimum Data Set (MDS) information was not available however the resident's baseline care plan indicated they required one-person assistance for self-care tasks. On 08/20/2025 at 1:09 PM, R20 was observed during an interview to continue to have longer facial stubble unshaven since the 08/18/2025 observation. They were asked if they preferred to have their facial hair growing out or to be cleanly shaven and they reported they preferred to stay clean shaven but they have trouble doing it themselves. They were asked if the staff assist them to shave and they stated They have but not very often. On 08/20/2025 at 1:23 PM, Certified Nursing Assistant (CNA) K reported they had provided care for R20 on a regular basis. CNA K was asked if they assist R20 to shave and they reported A male aide shaves [R20] on their shower days twice a week. On 08/20/2025 at 1:31 PM, the facility Director of Nursing (DON) reported that being shaved on shower days is the current facility protocol unless requested otherwise by the resident. The DON was asked if resident's preference for frequency of shaving is assessed upon admission and they reported the preference for frequency of shaving is not specifically addressed during establishment of the care plan. Review of the facility policy titled Activities of Daily Living dated 08/03/20 revealed the policy statements 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .4. The resident's needs and care approaches will be updated in the care plan and reviewed on an as needed basis.

This citation pertains to Intake MI00146997. Based on observation, interview, and record review, the facility failed to protect one resident's (R700) right to be free from physical abuse by staff of one resident reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R700 was the victim of a staff to resident abuse incident. It was alleged that during care of R700, Certified Nurse Aide (CNA) C was observed phycially slapping the resident with two other staff members present. On 9/18/24 at 10:35 AM, R700 was observed sitting up in the dinimg room. R700 could not remember the alleged incident and had no concerns for their safety. A review of R700's clinical record revealed R700 was admitted into the facility on [DATE] with diagnoses of dementia, Adjustment Disorder and Anxiety. A review of a R700's Minimum Data Set (MDS) assessment dated [DATE] revealed R700's Brief Interview of Mental Status (BIMS) assessment score of 3 indicating severely impaired cognition. On 9/18/24, a call was attempted to CNA C to discuss incident and there was no answer and message was left. An interview was held on 9/18/24 at 2:00 PM via phone with CNA A. CNA A confirmed being a witness to the incident saying, I saw the incident. I was orienting with another CNA (CNA B) and CNA C asked for asssistance with the resident. While we were in there caring for resident, CNA C just hauled off and slapped her across her face. I was so suprised. I immediated told the nurse supervisor. I knew this wasn't right. On 9/18/24 at 2:50 PM, an interview occurred with the Director of Nursing (DON) about the incident. The DON stated, Once I received the call about the incident, we reported it to the State Agency, reported it to the police and started our investigation. Unfortunately, it was substantiated and the CNA was terminated. At 3:00 PM, an interview with the Nursing Home Administrator (NHA) occurred. The NHA stated We did a complete investigation. It is my expectation that all residents will be protected from abuse and neglect. A review of the policy titled. Abuse, Neglect and Misappropriation of Resident Funds or Property revealed Church of Christ Care [NAME] will not tolerate verbal, sexual, physical or mental abuse, involuntary seclusi of and or neglect of its residents or misappropriation of resident funds or property by anyone .Center staff shall report any incident or suspicion of abuse, neglect or misappropriation of property to the administrator immediately or in his/her abscence the director of nursing. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. The Administrator reviewed the staffing assignment sheets for the prior month to identify the work location of the involved staff. 2. Resident with a BIMS score of 10 or greater were interviewed by a member of the leadership team by 9/11/24. 3. Residents with a BIMS of 10 or less were provided with a skin and pain assessment by 9/11/24. Measures systemic changes made to ensure that deficient practice will not occur and affect others 1. The administrator /designee re-educated staff on abuse by 9/9/24. 2. The administrator /designee queried facility staff regarding knowledge of any unreported potential abuse events by 9/9/24. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. 1. The Administrator / Designee will perform interview audits review of 10 residents regarding their treatment and sense of safety in the facility weekly x 4 weeks and monthly thereafter until sustained compliance is met and audits are discontinued by QAPI. 2. The Director of Nursing / designee will review 10 skin assessments weekly of residents with BIMS less than 10, weekly X 4 weeks who require 2 person assist, to ensure that ed mobility is completed properly weekly for 4 weeks, and monthly thereafter until sustained compliance is met and audits are discontinued by QAPI. Date of compliance 9/11/24. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to assess, identify, provide treatment and prevent pressure ulcers for two residents (R78 and R21) of seven reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: R78 On 07/31/24 at 11:12 AM, Registered Nurse (RN) H was observed assessing R78's wound in their room. A strong foul odor was noted coming from the wound when RN H pulled R78's covers back. A review of R78's record revealed they were initially admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses: Muscle weakness generalized, wounds and unspecified encephalopathy. The Brief Interview for Mental Status (BIMS) revealed a score of 6/15 indicating a cognitive impairment. On admission R78 was identified as high risk for developing pressure ulcers. A review of the readmission physician note dated 5/24/24 documented, Wound care physician progress note: .L (left) foot callus/hallux- Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed), lower left thigh, anterior (skin graphed area) measuring 3.5 x 1 x 0.0 centimeters (cm)-Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle), upper left thigh anterior measuring 4 x 1.3 x 3.5cm- left knee diabetic ulcer 2 x 2.5cm. Left hip/Gluteal P/U (pressure ulcer) debrided - measuring 19 x 14.5 x 16cm with undermining of 4cm.- Right buttock Stage 3 (Full thickness tissue loss) 2.5 x 2 x 0.1cm- Pressure ulcer to coccyx 3.8 x 2 x 0.1 cm. See Mar (medication administration record) for new treatment orders-R (right)-Upper Abdomen discolored scar with scabbed area. A review of the physician order dated 5/24/24, and the MAR/TAR (treatment administration record) revealed the following, Cleanse Coccyx with wound cleaner, apply honey and calcium alginate, cover with foam dressing daily and PRN (as needed). Review of the May, June and July MAR/TAR revealed between the dates of 5/24/24 to 7/6/24 there was no documentation showing that treatment was completed for the coccyx wound. Review of physician orders dated for 5/28/24: (Weekly) Skin assessment every Thursday AM (morning) shift. A review of the weekly nursing skin assessments revealed that between the dates of 5/28/24 to 7/11/24, two weekly nursing skin assessments were completed. There was no documented wound assessments or measurements of the coccyx wound between the dates of 6/3/24 to 7/1/24. Further review of the Wound Care Physician Progress Notes documented on 5/26/24, 6/3/24, 6/10/24, 6/17/24 and 6/24/24, measurements and descriptions of left hip wound, left back thigh, upper left thigh surgical site, and documented: Other areas (coccyx and left heel) not measured today due to patient being frustrated and uncomfortable .Other areas not measured Coccyx assessed area remains open continue current treatment and other areas not measured staff reports coccyx is doing well. Patient has been unable to tolerate changing positions. A Wound Care Physician Progress Note dated 7/1/24 includes description and measurements for left hip wound, left back thigh, upper left thigh and stated, Coccyx was able to be viewed today due to positioning area measures 15.1cmx8.7cmx0.5cm. Has thick slough tissue present. Coccyx Cleanse with wound cleanser, apply Santyl to slough tissue, cover with foam dressing daily. 7/15/24-Wound Care Physician Progress Note includes description and measurements of left hip wound, left back thigh wound, upper left thigh, and stated, Coccyx measures 10.9x7.7cmx0.5 (which was previously measured on 5/24/24 at 3.8 x 2 x 0.1 cm). Has thick slough present. A review of a Wound Care Physician progress note dated 7/22/24 lists descriptions and measurements for left hip wound and upper left thigh and coccyx, and stated, .Wound looks worse. Spoke with daughter in person and discussed hospice care. On 8/1/24 at 9:23 AM, Licensed Practical Nurse (LPN) Fand LPN G were observed performing wound care to R78. When queried about an oberserved open area approximately 1cm (centimeter) x 0.5cm was noted at the top right area above the large coccyx wound, LPN F said, I think thats new. A foam dressing was observed on R78's left ankle and a gauze wrap was observed on R78's left foot, both of which were not dated. LPN G was asked if there were any wound on R78's foot or ankle and was observed to remove the dressing from R78's foot and ankle revealing multiple unstageable pressure ulcers with eschar (dead tissue) to the bony prominences of R78's inner left foot and a 3cmx1cm linear wound on R78's anterior ankle. R78's left heel was noted to be black over the entirety of the heel and up both sides of the foot. A review of the resident's medical record revealed no assessments, treatments, or physician orders for R78's left heel. On 8/1/24 at 11:42 AM, during a phone interview, Nurse Practitioner (NP I) was asked about R78's wound progression and care since their facility admission. NP I stated (R78) was [initially] admitted to the facility with a left hip wound, some excoriation to their bottom and a surgical incision to their left thigh.NP I stated, I did not look at (R78's) bottom because the nursing staff said it was stable and they did not want to cause R78 any trauma. NP I explained around 7/15/24 they realized that R78's coccyx had declined and had to be addressed saying, there was dead tissue, and the slough was so thick it was like leather. NP I stated they talked to R78's daughter about hospice. NP I' confirmed the assessments were not performed and explains that it was their expectation that the nurses would notify them of a change. NP I was asked if they had seen the wounds on R78's left foot. NP I responded that they do not remember seeing areas on the left foot. On 8/1/24 at 11:59 AM, an interview was conducted with the Director of Nursing (DON). The DON explained the unit nurses do the daily wound care treatments even when the wound care nurse is not on leave. The DON was asked if the unit nurses document a skin and wound assessment. The DON explained a comprehensive wound and skin assessment is done on admission and then weekly. The DON was asked who places the orders for wound care and how the orders get entered into the EMR (electronic medical record). The DON stated, It depends, sometimes the wound care nurse puts them in and sometimes NP I enters them. Either one can put orders in. The DON was informed that there was no documentation of treatment of or assessment of R78's Coccyx wound between 6/3/23 and 7/1/24. The DON stated, I'm not sure how that could be because (NP I) was the person that was monitoring it. The DON confirmed that there was an assessment of R78's buttocks/sacral area documented on 6/3/24 and the next documented assessment of R78's coccyx is on 7/1/24. It was brought to the DON's attention that wound care orders placed for the coccyx wound were not implemented on the treatment record and were not performed. The DON is observed reviewing the EMR and stated, I agree. I don't see that and I don't know why. The DON confirmed that the wound care order placed 5/24 for R78's coccyx wound does not have a schedule and does not appear on the treatment record. The DON stated Nope, it didn't even show up. 40384 R21 On 7/30/24 at 12:40 PM, R21 was observed lying in bed on their back, feet flat on the bed. Attempts to ask the resident questions were to no avail due to their cognition. A review of the facility's acquired pressure ulcers revealed R21 had developed a new Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising) pressure ulcer. A review of R21's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Cerebrovascular Disease, Multiple Sclerosis, and Hyperlipidemia. Further review revealed the resident was cognitively impaired, and required dependence for Activities of Daily Living. Further review of the medical record revealed the Stage 2 pressure ulcer on R21's coccyx worsened, and they also developed a Stage 2 pressure ulcer on their buttocks. A review of R21's Care Plan revealed the following, Focus: [R21] has a potential/actual impairment to skin integrity r/t immobility and incontinence. Date initiated: 04/20/2024 .Outcome: [R21] will have no seruous complications related to skin. Date Initiated: 04/20/2024 .[R21] skin injury of the coccyx will not worsen due to unavoidable clinical status, and will progress through the healing stages through next review date. Date initited :05/01/2024 . A review of R21's Nursing Skin Evaluations for the month of April 2024 revealed that evaluations on 4/2/24, 4/23/24 and 4/30/24, there were no skin impairments noted for R21. A review of the 5/14/24 Nursing Skin Evaluation noted a wound to the resident's coccyx. A review of R21's skin/wound progress notes revealed the following: -4/22/2024 15:38 (3:38pm), Wound Care Physician Progress Note: Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.3cmx2.0cm (centimeters). Minimal drainage observed . -5/13/2024 15:24 (3:24pm), Wound Care Physician Progress Note: Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 5.6cm x 5.6 cm x 0.3cm. Minimal drainage observed. No c/o (complaint of) pain. Wound measured larger today . -5/20/2024 16:16 (4:16pm), Wound Care Physician Progress Note; Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.6cmx 3.6 cmx 0.1cm. Minimal drainage observed. No c/o pain . -5/26/202419:28 (4:28pm), Wound Care Physician Progress Note; Patient was seen today per nursing staff request due to the above concerns, patientlying in bed, Patient developed a stage 2 to coccyx. Area measures 2.3cmx 2.1 cmx 0.2cm. Minimal drainage observed. No c/o pain. Wound looks better. Skin growing over top of wound . -6/4/2024 17:06 (5:06pm), Skin/Wound Note. [R21] was seen by wound caretoday for p/u to coccyx measuring 2 x 2 x 0.1cm. Wound bed is pink with even edges, has min (minimal) drainage, non-painful to touch.Continue current wound care orders . -6/10/2024 15:30 (3:30pm); Wound Care Physician Progress Note: Patient was seen for; pressure injury, lump right breast .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 3.7cm x 3.1 cm x 0.2cm . -6/24/2024 15:12 (3:12pm), Wound Care Physician Progress Note: Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 tococcyx. Area measures 5.0cm x 5.3 cm x 0.1cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Was larger this week . -7/1/2024 17:26 (5:26pm); Wound Care Physician Progress Note: Patient was seen today per nursing staffrequest due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.9cm x 2.9 cm x 0.1cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Developed MASD (Moisture associated skin damage). Coccyx measures; 4.5cm x 2.0cm x 0.1cm . -7/15/2024 13:45 (1:45pm), Wound Care Physician Progress Note: Patient was seen today per nursing staffrequest due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 1.7cm x 0.8 cm x 0.2cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Developed MASD. Coccyx measures; 3.4cm x 2.0cm x 0.5cm . -7/29/2024 15:51 (3:51pm), Wound Care Physician Progress Note: Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx and right buttock. Area measure to right buttock measures 3.0cm x 2.1 cm x 0.8cm. Minimal drainage observed. No c/o pain. Wound bed beefy red. Coccyx measures; 6.0cm x 4.2cm x 0.3cm . On 8/1/24 at 12:05 PM, the Nursing Home Administrator was asked about the concerns with pressure ulcers amnd acknowledged the concern is something the facility is aware of, and is being followed in their Quality Assurance meetings. A review of the Pressure Injury Prevention Guidelines revealed the following, .Policy Explanation and Compliance Guidelines:1.Individualized interventions will address specific factors identified in the resident ' s risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .3.Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders .8.Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b.For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9.The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a.Development of a new pressure injury. b.Lack of progression towards healing or changes in wound characteristics. c.Changes in the resident ' s goals and preferences, such as at end-of-life or in accordance with his/her rights .

Based on interview and record review, the facility failed to review and report monthly pharmacist medication recommendations for four residents, (R19, R31, R35 and R70) of five residents reviewed for unnecessary medications. Findings include: R31 A review of R31's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Major Depression, Hypertension, and Diabetes. Further review revealed the resident was cognitively intact and requires extensive assistance for Activities of Daily Living. Further review of R31's medical record revealed that five medication regimen reviews were completed on 7/29/24, 4/26/24, 1/24/24, 12/23/23, and 9/23/23 and noted the following, See report for any noted irregularities and/or recommendations. Action: [blank]. Response: [blank] 34851 R19 A review of R19's medical record revealed they were admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included Generalized Anxiety disorder, Anxiety disorder due to known Physiological condition, Schizoaffective disorder, Bipolar type, Psychosis, Bipolar disorder. Further review revealed the resident was cognitively impaired and requires extensive assistance for Activities of Daily Living. Further review of R19's medical record revealed a medication regimen review was completed on 7/26/24, and noted the following, See report for any noted irregularities and/or recommendations. Action: [blank]. Response: [blank]. R35 A review of R35's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, Dementia, Cognitive communication, and Major depressive disorder. Further review revealed that the resident was cognitively impaired and requires extensive assistance for Activities of Daily Living. Further review of R35's medical record revealed five medication regimen reviews were completed on 11/30/23 and 7/27/24, and noted the following, See report for any noted irregularities and/or recommendations. Action: [blank] Response: [blank]. R70 A review of R70's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Major Depression, Alzheimer's, Dementia, and Depressive disorder. Further review revealed that the resident was impaired cognition and requires extensive assistance for Activities of Daily Living. Further review of R70's medical record revealed that four medication regimen reviews were completed on 12/27/23 and 7/16/24 and noted the following, See report for any noted irregularities and/or recommendations. Action: [blank]. Response: [blank]. On 7/31/24 at 12:30 PM, the irregularities and/or recommendation reports from the pharmacist were requested from the facility. On 8/1/24 at 10:39 AM, the Nursing Home Administrator (NHA) indicated they were unable to obtain the reports from the pharmacy. On 8/1/24 at 3:07 PM, the Director of Nursing (DON) was asked about the missing pharmacy recommendations, and admitted the facility needed to come up with a better system to ensure the irregularities and recommendations are reviewed by the physician, and communicated to the pharmacist. A review of the Drug Regimen Review revealed the following, .PROCEDURE: 2. The Pharmacy Consultant will perform a monthly drug regimen review on each resident unless the resident condition/risk will indicate a more frequent schedule that is individualized and communicated between the facility clinical staff and the Pharmacy Consultant. 3. Irregularities identified will be documented on a separate, written report and sent to the attending physician, medical director, and director of nursing, listing the resident name, relevant drug and irregularity the pharmacist has identified. If in the professional judgement of the pharmacy consultant that an irregularity requires urgent action, the pharmacy consultant will immediately report the irregularity to the Director of Nursing and/or Unit Charge Nurse and the attending physician by phone .5. The attending physician will document in the resident record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record .

This citation has two deficient practices. Deficient practice #1. This citation pertains to Intake MI00145622. Based on interview and record review, the facility failed to follow hospital discharge instructions and orders for one sampled resident (R158) of three residents reviewed for continuum of care. Findings include: R158 was admitted on [DATE] with the diagnoses of displaced intertrochanteric fracture of left femur, retention of urine, and dementia. R158 was discharged to the hospital on 5/18/24 due to a change in condition. A review of R158's closed medical record revealed a hospital discharge form titled, Patient Summary -Discharge Instructions, Orders and Medications. A review of this form revealed the following: Discharge Orders: Remove foley catheter in four days on May 6th for trial of void. Further review of hospital discharge instructions revealed, Follow up appointment with Urology with in 5 to 7 days ; Follow up with primary care physician within 5-7 days; Call to set up appointment with Orthopedics within 2 weeks; and Call for follow up appointment with Trauma Clinic within 2 weeks; On 8/1/24 at 1:30 PM an interview was held with the unit secretary (Staff C) who makes the follow up appointments. When asked about R158's follow up appointments. Staff C stated, I dont know what happened with this resident. I dont think the appointments were made and I cant find my copies. On 8/1/24 at 1:45 PM an interview was held the unit manager, Nurse D and when asked about the process of follow up with hospital instructions, Nurse D stated The nurse is supposed to follow up with all orders and ensure they are followed. On 8/1/24 at 2:00 PM an interview was held with the Director of Nursing (DON) about the process of ensuring follow up instructions and orders on discharge from hospital are followed. The DON stated, The nurses are responsible for ensuring the orders and instructions are followed. It is my expectation that orders are followed and nurses transcribe orders accordingly. On 8/01/24 at 3:01 PM, a request was made for a new admission orders policy and it was not recieved by the end of the survey. 50223 Deficient practice #2. Based on interview and record review the facility failed to assess and address a change in condition and control pain for one (R107) out of one resident reviewed. Findings include: A review of R107's record reveals they were admitted to the facility on [DATE] with diagnosis as follows: Alzheimer's and essential hypertension (high blood pressure). A Brief Interview for Mental Status on 7/10/24 reveal a score of 4 indicating cognitive impairment. A review of R107's record revealed progress notes stated the following: -4/30/24 Nursing progress note: Resident observed by activities staff sitting upright next to wheelchair near counter in activities room. When asked by activities staff how (they) fell resident stated, I was standing up and tried to step back and I fell down. Resident assisted back into wheelchair by staff. Writer assessed vitals 129/79 98.3 96% 65 17, mild pain 2/10 to lower back, no injuries noted. Writer administered PRN (as needed) Tylenol for pain. Neurochecks initiated. Response: attending physician, Responsible party and Director of Nursing (DON) made aware. No new orders at this time. -5/2/24 Nursing progress note: Nurse observed resident standing up in hallway next to w/c (wheelchair) when (they) lost (their) balance, fell backwards hitting (their) back against the wall and slid to the floor. Resident was wearing non skid shoes at the time, had not had a incontinent episode in brief. Has a diagnosis of Alzheimers disease and is very compulsive. Action: Resident skin was assessed with no injuries noted, denies pain/discomfort, no s/s of scute distress noted. Resident was assisted off the floor by nurse and PT (physical therapist), v/s (vital signs) stable, and ROM (range of motion) WNL (within normal limits). Physician, POA (power of attorney) and nurse manager made aware. -5/3/24 Physician progress note: Patient was seen for: fall 5/2/24. Patient was seen today per nursing staff request due to above concerns. nursing staff observed patient sitting on the floor next to wheelchair. Denied any pain or discomfort. Able to move all extremities. Denied hitting head or LOC (loss of consciousness). Nurse reported (they) believe patient is having pain .Assessment and plan s/p (status post) fall: no significant musculoskeletal injury. Monitor and report any changes to physician. Pain management: will order tramadol (pain medication) 50mg (milligram) every 6 hours PRN (as needed). -5/3/24 2:30 PM, Order: Tramadol 50 mg Give 1 tablet by mouth every six hours as needed for pain management for seven days. Discontinued 5/10/24 -5/3/24 9:11 PM, medication administration note: PRN Administration was effective. Follow up pain scale was: 10 (severe pain) -5/4/24 7:55 PM, Nurses progress note: Received the resident at 7 am up in a wheelchair sitting in the hallway by the nurses station. The resident is alert x1-2 and can answer some yes or no question. The resident consumed 50% of breakfast and is very anxious. Resident had a grimace on his face, and the resident toileted and repositioned. Resident states (they) are having back pain, and prn medication was given. Resident states during dinner, I haven't been eating like I normally do due to I am in pain, my back and stomach hurts very bad. PRN pain medication was administered, repositioned, and in bed. The resident states he is still very uncomfortable and in a lot of pain. MD notified. The resident refused lunch and dinner, nutritional supplement and boost pudding were offered, and (R107) consumed 50% of both. Staff will continue to encourage meals and fluids. - A 5/5/24 Change in condition evaluation reveals the following: food or fluid intake decreased or unable to eat and/or drink adequate amounts .Pain (uncontrolled) .fall .no oral intake for 2 consecutive meals .lower abdominal pain or tenderness . repeated troubled calling out .Loud moaning or groaning crying facial grimacing body language tense fidgeting .abdominal pain back injuries and complaints .abrupt onset of severe pain secondary to fall or injury or pain with new neurological signs. -5/5/24 3:02 PM, Nursing progress note: Received resident at 7 am up in wheelchair sitting by nurses station. The resident is alert and orientedx1-2 with some confusion. The resident consumed 25-50% of breakfast and lunch. The resident stated (they) are in a lot of pain, prn pain medication was administered, and the resident was put back in bed. The resident still complains of pain and discomfort. -5/16/24 Behavior note: Before dinner, writer assessed resident's vitals and blood pressure was low. Resident was located in chair with no complication. The CNA (certified nursing assistant) assisted the resident with dinner and the resident did not complete the meal. Resident stated that he did not want to eat anymore food. Resident showed slight lethargic but still was able to communicate. After dinner family member comes to hall and say that (R107) isn't being (themself). Writer assessed resident and tried waking (them) up. Resident showed he had lethargic and could not speak clear. Writer assessed blood pressure again and resident blood pressure have gotten lower. Writer contacted doctor regarding residents' behavior and (they) requested for resident to be sent out to nearest hospital. Resident was hospitalized [DATE]-[DATE] A review of the hospital records revealed that R107 was admitted for acute kidney injury, dehydration and hypotension (low blood pressure). Hospital record indicates that R107's blood pressure was low on admission and R107 was given intravenous fluids. The hospital admission history and physical notes indicate they were not informed or aware of any recent falls or trauma. 5/21/24 Physician history and physical: This is an 82 yo (year old) male who was admitted from an acute care facility after he was treated for worsening confusion fatigue and weakness. Patient is confused and all info in this cart was obtained from the chart. 5/21/24 nurses progress note: requires total assistance from nursing staff with care 5/27/24 nurses progress note: received resident at 3 pm up in wheelchair at nursing station. Resident is alert and oriented x2 and able to make some needs known . resident is in a pleasant mood. Resident consumed 25-50% of dinner. Resident complains of pain. Prn pain medication given. 5/31/24 behavior note: resident alert and oriented x2. Resident has confusion and cannot verbalize all needs or pain. Further record review reveals that R107 was hospitalized [DATE] for altered mental status and difficulty breathing. 7/13/24 2:34 PM Hospital admission history and physical stated: presented to the ED (emergency department) on 7/12 due to concerns of altered mental status and difficulty breathing. Patient is A&Ox2 and is a poor historian. Information is obtained from chart review and patients' son via phone call only. Patient was reportedly noted to be coughing for the last two days as well as having difficulty breathing and decreased volume of his voice. Son has asked for patient to be brought to the hospital for evaluation. Facility doctor did not see the patient and decided against hospital transfer at that time. Patients status declined last night and was noted to have increased coughing, more drooling and AMS (altered mental status) prompting a visit to the ED. On arrival to the ED patient was at 92% o2 (oxygen) saturation on RA (room air) but was having difficulty breathing. Was placed on 2L (two liters per minute) NC (nasal canula) and given two breathing treatments that did help. Patient was also tachycardic (fast heart rate) and tachypneic (fast breathing). Patients WBC (white blood cells) were elevated at 11.6. Chest CT (computed tomography) showed consolidation in the right lower lobe concerning for aspiration pneumonia. Also showed calcification of the 8th and 9th ribs concerning for healing rib fractures.Ct findings concerning of healing rib fractures. Consider speaking to case management after clarifying with son if this is from a known fracture. Further review of the hospital record revealed that the R107's condition deteriorated on 7/13/24 and the patient was placed on a ventilator (breathing machine). Patient was transitioned to comfort care and removed from the ventilator on 7/23/24, was transferred back to skilled nursing facility on 7/26/24 on hospice and passed away on 7/30/24. Death certificate lists cause of death as coronary artery disease and aspiration pneumonia. On 8/1/24 at 12:40 PM, During an interview, the DON was asked what the process is when a resident falls. The DON responded, Step one they're on the floor. Nurse assesses them prior to moving them. Then they are transferred back into bed then further assessment, vital signs, i&A (incidents and accidents) report is made, physician and responsible party are notified and preferably I am also notified. The nurses do a Fall risk evaluation, check vital signs (vital signs), pain assessment and they try to determine route cause of fall so it can be added to the care plan. Progress notes are entered. Neuro checks are done. The DON was asked what occurs if a resident is complaining of pain after the fall? The DON stated, It's the same process and they would notify the physician of the location of the pain then we would usually get an x-ray. On 8/1/24 at 2:26 PM, during an interview, Certified nurse assistant (CNA K) was asked, what the process is when a resident falls. (CNA K) stated, I would notify the nurse immediately then they would evaluate and make sure nothing is broken and do vitals. On 8/1/24 at 2:30 PM, during an interview with Unit Manager (UM D) was asked what the process is when a resident complains of pain after a fall. (UM D) explained the nurse should do a pain assessment, notify the doctor and try nonpharmacological pain relief methods first. (UM D) was asked to review the record for R107 related to their falls, pain, and hospitalization s. (UM D) is observed reviewing the record. (UM D) was asked what her expectation would be for this resident and if she believes the proper steps were followed. (UM D) stated no. the pain was not addressed. When you put a note in about an issue you have to do something about it and follow up. If that issue is not resolved, they have to do something about it. They have to call the MD (medical doctor) back then take it to the DON. The expectation is that we would address it. If his appetite is already decreasing and its interfering with his activities its already serious and we need to do something. (UM D) was asked if they suspected that there may have been an injury from the recent fall. (UM D) stated Oh yes that's why I said we have to address it. A review of the facility's policy titled Notification of Changes states the following, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must notify the resident's physician and notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents / Falls2.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.3. Circumstances that require a need to alter treatment. A pain management policy was requested and not returned prior to the end of the survey.

Based on observations, interview, and record review the facility failed to provide showers for one sampled resident (R19) of six reviewed for activities of daily living. Findings include: On 7/30/24 at 9:20 AM, R19 was asked about their care at the facility. R19 explained it had been three weeks since they had a shower. R19 continued and stated, I'm supposed to get one today on the afternoon shift. R19 further explained the agency staff can be rude at times, they don't do their jobs with changing their brief timely. R19 also stated, The agency staff don't know how to take care of me before they come in, I have to tell them how to care for me. On 7/30/24 at 8:55 AM, R19 was asked if they received their shower yesterday. R19 stated, No. She said I came back too late. R19 was asked to further explain. R19 explained the Certified Nursing Assistant (CNA E) told them R19 came back too late to their room and could no longer get their scheduled shower. On 7/31/24 at 8:58 AM, the Minimum Data Set (MDS) Nurse assisted in finding the documentation in the Electronic Medical Record (EMR) for R19's showers. A review of R19 shower documentation noted N/A which meant not applicable/not given on Tuesday, 7/30/24. A review of R19 medical record revealed R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute respirator failure with hypoxia. Further review of R19's medical record noted R19 with a moderately impaired cognition. A review of R19's shower schedule noted, Tuesday PM shift and Friday AM shift. Further review of the shower documentation noted blanks without documentation of shower being provided on Tuesday July 23rd and Friday July 26th. On 8/01/24 at 1:30 PM, the Unit Manager was asked about R19's shower documentation for July 30th and the report the CNA told the resident that it was too late to give a shower. The Unit Manager reported she was not sure why the shower wasn't given and the CNA should not tell the resident it was too late. The Unit Manager was given the CNA's name and was asked if that CNA was the facility staff of if they were agency staff. The Unit Manager stated, Agency (staff). A review of the facility's policy titled, Activities of Daily Living (ADLs) dated, 3/14/24, revealed, Policy: The facility will, based on the resident ' s comprehensive assessment and consistent with the resident ' s needs and choices will implement a care plan to assure ADL needs are met. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems. Policy Explanation and Compliance Guidelines: 1. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Based on assessment of the resident ' s ADL capabilities and needs, a care plan will be personalized to meet his/her needs & preferences. 3. The clinical staff will implement the ADL care plan. 4. The ADL care plan will be modified on an ongoing to basis to reflect the resident ' s functional status and personal preferences.

Based on observation, interview, and record review, the facility failed to follow an OBRA II Evaluation (Omnibus Budget Reconciliation Act, federal law aimed at improving the quality of care and life for resident's of long term care facilities) recommendation timely, inform the resident of their rights regarding their trust, and address guardianship for one resident, (R22) of one resident reviewed for life satisfaction. Findings include: On [DATE] at 11:51 AM, R22 was observed lying in bed and asked how they were feeling. They explained they were unhappy living in the facility and would like to have a cell phone in order to communicate with individuals outside of the facility. They further explained they have a guardian in place whom is their [NAME] who does not come to visit or communicate with them. R22 explained they have inquired and wondered if their was any money available to them to purchase personal items, but no one ever tells them if they do or not, No one ever comes back to talk to me about my concerns. A review of R22's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Depression, Acute Respiratory Failure, Peripheral Vascular Disease, and Hemiplegia and Hemipareses following Cerebral Infarction. Further review of the medical record revealed the resident was cognitively intact, and required total dependence for toileting and transfers. In addition, the medical record revealed R22 had a guardian in place until [DATE] when the guardianship expired. Further review of R22's medical record revealed an OBRA II Evaluation dated [DATE] which revealed the following, B. Subjective Evaluation. [R22] presented with depressed mood. [They] denied concernes expressing emotions, but reported, 'no one cares.' [R22] denied concerns coping with changes, but reported, 'it doesn't matter.' Ongoing depressed mood was evident .[R22] stated that all [they] wanted was a cell phone to talk to family and friends; this was reported to the guardian and NF (nursing facility) social worker who stated they would work on this matter .NF staff report they have looked into getting [R22] a cell phone, but reports they are running into the issue that [R22] does not have State ID (identification), which is now required. Requested that this be followed up with the guardian as well as being able to communicate with family/friends this may halp reduce [their] overall symptoms of depression and provide support . On [DATE] at 9:21 AM, Social Worker Director A (SWD A) was asked about the OBRA Evaluation's recommendations regarding a cell phone for R22, and she reported there were attempts to obtain a cell phone and conversations with the resident's guardian regarding R22's need for a an ID however, they are still in the process of obtaining the cell phone. Regarding R22 not having a guardian in place, SWD A explained the resident's son was willing to be the resident's guardian however, when asked where they were in the guardianship process, SWD A did not provide an explainantion, and later indicated an outside agency would be coming to the facility to help manage the guardianship for R22. A review of R22's Social Work progress notes did not reveal any form of communication with the resident, their previous guardian, R22's son, or with any phone service related to attempts to obtain a phone for the resident. In addition, progress notes revealed there has not been any contact with the resident's guardian since [DATE]. On [DATE] at 1:31 PM, Business Office employee (BO) B was asked if R22 had a resident trust in place, which was confirmed, noting a positive balance. BO employee B was asked how residents are made aware of their resident trust balance, and explained quarterly statements are sent to the resident and/or their responsible party. On [DATE] at 1:31 PM, R22 was asked if they had received any statements regarding their resident trust, and appeared confused, and explained they weren't aware they had a trust with funds available to them although they had asked about it. In addition, R22 explained no one had spoken to them from the facility regarding attempts to obtain a cell phone. R22 was asked if they had spoken to their son recently, and explained they are estranged, and could not recall the last time they had spoken to them. On [DATE] at 3:12 PM, The Director of Nursing (DON) was asked about her expectations for recommendations regarding OBRA assessments, and acknowledged that recommendations should be followed. Regarding concerns of a resident trust, the DON acknowledged that she did not have enough knowledge to answer the question. Regarding guardianship, the DON acknowledged their should be a guardian in place. On [DATE] at 12:50 PM, policies regarding social work services, guardianship, and resident rights were requested from the facility, and the Nursing Home Administrator explained the facility does not have a social work services or guardianship policy, and that they only have an umbrella resident rights policy, only specific rights.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive wound care plan for two (R78 and R91) of two residents reviewed. Findings include: R78 On 8/1/24 at 9:23 AM, wound care was observed. A review of R78's record revealed they were admitted to the facility on [DATE] with the following diagnosis: Muscle weakness generalized, need for assistance with personal care, and unspecified encephalopathy. A review of R78's minimum data set revealed a brief interview for mental status (BIMS) score of 6, indicating cognitive impairment. Further record review revealed that R78 had multiple wounds on their sacrum/coccyx, left hip, left foot, and left thigh. A review of R78's care plan documents; R78 is at risk for impairment to skin integrity r/t (related to) fragile skin, impaired mobility, incontinence, and pressure ulcers on admission. Interventions as follows: cushion while up in chair. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Monitor skin during care for changes and report any changes as required. Pressure reducing mattress, pillows on bed. Reposition R78 frequently and use pressure reducing devices between legs to off load pressure to bony prominences. Skin assessment weekly. R78's care plan does not address R78's wounds. R91 On 07/31/24 at 11:21 AM, the pressure wound on R91's coccyx was observed. A review of R91's record reveals they were admitted to the facility on [DATE] with a diagnosis of osteomyelitis of vertebra (spine infection). A review of R91's minimum data set revealed a brief interview for mental status score of 15, indicating intact cognition. Further record review revealed R91 was being treated for a wound on their coccyx. A review of R91's care plan revealed the following; R91 has potential for impairment to skin integrity r/t fragile skin, impaired mobility and incontinent episodes. Cushion while up in chair. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Monitor skin for changes during care and report alterations as required. Pressure reducing mattress. Weekly skin assessment. The care plan does not address R91's wounds. On 8/1/24 at 11:59AM, during an interview with the Director of Nursing (DON) and Unit Manager UM D they were asked what should be included in the care plan of a resident with wounds. The DON explained they expect the location of the wound and a general treatment plan to be included in the care plan. The DON reviewed R78's care plan and stated, I would expect it to be much more elaborate and to mention specific wounds and locations. UM D stated, It should be much more specific. A review of the facility's policy titled states Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them .7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record.

This citation pertains to intake M100144181. Based on observation, interview and record review, the facility failed to implement measures to prevent multiple falls for one (R701) of eight residents reviewed for falls, resulting in a right femur fracture that required a surgical repair, additional assistance with transfers and pain management. Findings include: Review of the facility record for R701 revealed an admitted [DATE] with diagnoses that included Alzheimer's Disease, Diabetes Mellitus, and Difficulty in Walking. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Mental Status (BIMS) score of 03/15 indicating Severe Cognitive Impairment. Review of R701's admission Fall Risk Evaluation dated 05/19/23 revealed a score of 10 (evaluation instructions state If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.) On 05/01/24 at 11:45 PM, R701 was observed sitting in their wheelchair in their room. R701 responded verbally to the surveyor but was not able to answer questions in a reliable manner. Further review of R701's record revealed an initial fall on 05/26/23 (one week after admission). Review of R701's care plan history indicated that a fall prevention care plan focus and interventions were not established until 05/30/23. The care plan intervention initiated on 05/30/23 stated Monitor/document/report PRN (as needed) x 72h (every 72 hours) to MD (physician) for s/sx (signs/symptoms): Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. R701's next fall occurred on 09/06/23. Review of the care plan history revealed no new fall prevention interventions were added in response to this fall. R701's next fall occurred on 09/12/23. On 09/13/23 the following interventions were added: 1. Provide activities that promote exercise and strength building where possible. 2. PT (Physical Therapy) consult for strength and mobility. R701's next fall occurred on 10/04/23 and no new fall prevention interventions were added to the care plan in response. R701's next fall occurred on 11/18/23. No new fall prevention interventions were added to the care plan in response. R701's 11/19/23 progress note indicated that the resident was expressing signs/symptoms of pain and X-ray results on 11/20/23 revealed R701 sustained a right femur/hip fracture. R701 was discharged to hospital for surgical repair of the right hip. R701 was readmitted to the facility on [DATE]. The new admission Fall Risk Evaluation was scored 9 (lower risk score than at original admission). The evaluation question History of falls (past 3 months) was answered B. 1-2 falls in past 3 months. R701 actually had four falls in the prior three months. Review of the care plan established upon readmission revealed the same three fall prevention interventions that were previously in place were renewed and no new interventions were recommended or added. R701's next fall occurred on 12/24/23. No new fall risk care plan interventions were added in response. Further review of R701's care plan history indicated per the transfer safety focus area that R701 required hand-held assist for transfers at admission and at readmission following the fall with right femur fracture Maximum (approximately 75% of workload) assistance for transfers was required. R701's 11/28/23 readmission progress note indicated that the resident required a right hip surgical site pain pump. On 05/02/24 at 3:30 PM, the facility Director of Nursing (DON) acknowledged that the fall prevention care plan had not been established until after R701's first fall rather than following the admission Fall Risk Evaluation indicating High Risk. The DON acknowledged that new interventions had not been added to the fall prevention care plan after four of six falls but indicated that their understanding was that there was also a safety focus area in the care plan that may have fall interventions added. Review of the Safety focus area in R701's care plan revealed no fall prevention interventions. When asked what their expectation was regarding revision of the care plan following repeated falls the DON reported that it would be their preference that new interventions be added in the fall prevention focus area. Review of the facility policy Fall Prevention Program dated 02/05/22 revealed the Policy statement Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The Policy Explanation and Compliance Guidelines section includes the following entries: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the FALL COMS the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

This citation pertains to Intake: MI 039 Based on observation, interview and record review, the facility failed institute and operationalize policies and procedures and honor the rights of one sampled Resident (R702) of one resident reviewed for resident rights resulting in, Cardiopulmonary Resuscitation (CPR) being provided against the resident/resident representative's wishes, and pain. Findings include: A review of intake MI 039 revealed the following, Incident Summary Dining Room Nursing Attendant observed resident's eyes rolling upward and skin discoloration. CODE BLUE (cardiac or respiratory arrest) was called and resident was rushed to [their]room. Since the resident was unresponsive and had no pulse or respiration, one of the nurses responding to the CODE BLUE started CPR. After one chest compression, she was told to stop compressions, because the resident was DNR (do not resuscitate)- NO CPR. However, after the one compression the resident started to regain consciences (consciousness). Resident complained of chest pain due to the compression, but xrays results were negative for fractures . On [DATE] at 2:22 PM, R702 was observed lying in bed pleasantly confused. A review of R702's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R702's Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of ,d+[DATE] indicating a severely impaired cognition and required extensive assistance for activities of daily living. Further review of R702's medical record revealed an Advanced Directive (a legal document that allows a person to identify decisions about end-of-life care ahead of time), dated for [DATE] and signed by two facility staff members, and a facility physician on [DATE]. The Advanced Directive revealed the following: CPR (Cardiopulmonary Resuscitation) with a box checked that stated, DO NOT WANT. Located at the bottom of the Advanced Directive was the following statement (telephone call) with DPOA (durable power of attorney, DPOA E), He desires DNR . Further review of R702's medical record revealed the following progress notes: [DATE] 12:00 (12:00 PM) Nurses Data: Dining room Nursing attendant observed resident eyes rolling upward and skin discoloration in w/c (wheelchair) while in dining room for lunch. Resident escorted to room, resident became unresponsive, CPR initiated, code blue called. The resident become responsive to verbal commands and stimuli, c/o (complain of) of pain. Dr.(doctor) in facility to witness, new orders in place . [DATE] 13:32 (1:32 PM) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . patient received chest compression and was complaining of severe chest pain with palpation due to the possibility of rib fractures during chest compressions on exam Chest clear to auscultation, very tender with minimal palpation of the chest .musculoskeletal chest pain with possible rib fracture following chest compressions will apply [MEDICATION(S)] for relief will add [MEDICATION(S)] 5 mg (milligram) q6 hour (every 6 hours) prn (as needed) plan was d/w (discussed with) nursing staff. [DATE] 14:01 (2:01 PM) Nurses Data: Writer spoke with [facility physician] and asked if he wanted to order a chest x-ray to r/o (rule out) fracture d/t (due to) resident's pain. Physician stated, 'no.' And prescribed [MEDICATION(S)] sulfate solution 0.25 mL (milliliters) every six hours PRN (as needed). Resident's RP (responsible party)-POA (power of attorney) of care contacted writer. Writer informed RP of the resident becoming unresponsive and having no pulse or respiration and that CPR was initiated by one of our staff nurses. RP stated, [R702] is a no CPR. Writer informed him that it was not [R702's] assigned nurse that initiated CPR, once the nurse called out no CPR it was already started, and CPR was successful. RP was asked to update resident's advance directives since [R702] is no longer on hospice case load. He stated he would like for it to remain the same (No CPR, no tube feeding, no hospitalization , no IV's (intravenous) and yes to ABT's (antibiotics). [DATE] 14:00 (2:00 PM) eMar - Medication Administration Note Note Text: C/o pain to right chest area underneath breast. [DATE] 15:52 (3:52 PM) Social Services Note Note Text: Social Service note~ Writer talked to POA of [R702] and he voiced he is thinking of hospice services for [R702] due to a situation that occurred this weekend .writer will message MD (medical doctor) in regards to this and will send orders off once obtained. [DATE] 20:00 (8:00 PM) eMar - Medication Administration NoteNote Text: Observed Resident with non-verbal indicators of pain. Continue to assess fo (for) effectiveness. On [DATE] at 3:07 PM, DPOA E for R702 was interviewed via phone and asked about the incident regarding R702's code status not being followed. DPOA E explained that [R702] was basically dead, and they revived [them]. They further explained that they were informed that R702 was in the dining room eating, stopped eating, turned blue and their heart stopped. DPOA E explained that CPR was used on R702 when the DNR order was accessible to the facility, and that following the incident was told that R702 remained in bed for about 2 weeks. DPOA E explained that they were concerned because the DNR had not been followed but was told that CPR was administered by someone who is not R702's regular nurse. DPOA E also explained that they thought R702 was going to be in a vegetative state due to their heart stopping, and explained that following the incident, R702 was placed back onto hospice, but reports that although they are unable to visit with the resident, their family member does visit and indicates that they are doing better since the incident. On [DATE] at 8:41 AM, Nurse F was interviewed via phone and asked about R702 and the incident regarding their code status. Nurse F explained that they had gone into the dining room to get something for another resident when they observed R702 not looking like themselves. Nurse F explained that they walked up to [R702] and called their name, but they did not respond. Nurse F explained that she and another nurse took the resident to their room and laid them down, and she went to obtain the vital machine and to obtain additional assistance. Nurse F explained that she called a Code Blue however, Nurse I explained that R702 was not a full code. Nurse F was asked if they observed the resident obtaining chest compressions from Nurse G, and explained that they did not, as they were outside the room when that occurred. On [DATE] at 8:53 AM, an attempt to contact Nurse G via phone was made to no avail however, a review of the interview between Nurse G and the Director of Nursing (DON) revealed the following: DON: I am trying to look into this 'Code Blue' that was called. How did you happen to be the nurse who did chest compressions? Nurse G: I was the dining room nurse. I had started taking people down to their rooms. I heard the nurse who usually works on unit one calling [R702's] name. [R702] was in [their] wheelchair but [they were] blue and slumped over in the wheelchair. She was taking [R702] down the hall towards [their] room. Then [R702] went unresponsive. DON: Did you happen to check [R702] for a pulse or check [their] breathing? Nurse G: No, she had already called the code so I just went to assist her. DON: How many compressions did you do? Nurse G: I could say like one and a half. I mean I did a compression and then I was about to tap [R702's] cheek and call [their] name and [they] started coming around. DON: Had [R702] choked? Nurse G: I asked them had [R702] choked. But [R702] was coming around so I went to my unit. On [DATE] at 9:03 AM, Nurse H was interviewed via phone about the incident with R702 obtaining CPR. Nurse H explained that R702 was in the dining room eating and the nurse came out of the dining room and said R702's not responding. Nurse H explained that they were already on the computer charting, looked up R702's information and saw that they were a DNR, no hospitalization . Nurse H explained that they yelled out that the resident was not a full code but does not believe they heard her as they had initiated CPR. Nurse H explained that by the time she arrived to R702's room, the resident was alert, as opposed to when she saw them being wheeled to their room, as they were slumped over. On [DATE] at 11:36 AM, an interview was completed with Nurse I regarding R702 and the Code Blue that was called. Nurse I explained that a Code Blue was called for R702 and upon arrival to the room, she observed two chest compressions being completed on the resident but was unsure of the number of chest compressions completed before arriving to the room. Nurse I explained that she observed the resident regaining their color and started to moan. Nurse I explained that they contacted the family, who were upset, but it was explained that the nurse who administered the chest compressions was not the resident's regular nurse. Nurse I also indicated that they were able to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:56 AM, the DON was asked about the incident regarding R702 receiving life sustaining treatment. The DON explained that she interviewed the nurses involved and confirmed that the resident received life sustaining treatment when their Advance Directive indicated otherwise. The DON was asked if education was provided to the staff following the incident, and she explained that Nurse F and Nurse G were able to explain what a Code Blue is, and when it should be called. The DON also explained that they reviewed all the residents' code status to confirm accuracy. A review of the facility's Advanced Directives policy revealed the following, .Cardiopulmonary Resuscitation. It is the policy of this facility will provide basic life support, including CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to assess, monitor, and ensure appropriate catheter care was provided for one (R14) of two residents reviewed for catheter care, resulting in pain, urethra laceration and acute transfer to the hospital. Findings include: Review of the closed record revealed R14 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R14 had moderately impaired cognition and required the extensive assistance of staff for all activities of daily living (ADL's). The MDS assessment also indicated R14 had an indwelling catheter. Review of R14's progress notes revealed: A Nurses note by Licensed Practical Nurse (LPN) Y, dated 4/25/22 at 10:06 PM read in part, Resident c/o (complaining of) discomfort at foley (catheter) site. Writer assessed and noticed a split in penis where foley connects with green discharge . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] with obstructioncontinue [sic] with Foley catheter; complicated with a split in the urethra/penis; I called his urologist and discussed the case with him who recommended to monitor patient for now, he needs to be assessed in the office for possible need for SPC (suprapubic catheter - a flexible tube that empties the bladder through an incision in the belly instead of a tube in the urethra) . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Urethra laceration induced by chronic indwelling Foley catheter, worse and longer in length with possible infection, needs immediate attention by urology and cannot be handled as an outpatient . A Nurses note by LPN C dated 4/28/22 at 2:40 PM read in part, Resident c/o pain to penis and groin . Resident will transfer to [Name Redacted - Local Hospital] for Urethral Laceration r/t (related to) Foley. Area is red and swollen . A Nurse note by LPN C dated 4/28/22 at 2:40 PM read in part, Resident transferred to [Name Redacted - Local Hospital] via ambulance at 1420 (2:40 PM) r/t urethral laceration . On 5/3/22 at 2:17 PM, LPN Y was interviewed by phone and asked about what happened with R14's catheter on 4/25/22. LPN Y explained R14 started to yell that his penis hurt, so she and a Certified Nursing Assistant (CNA) stood him up and looked at his penis and it was starting to split, but there was no blood. LPN Y was asked if she had asked R14 how it happened. LPN Y explained R14 told her she knew how it happened but was confused at the time. When asked if she had started an I&A, LPN Y explained she had not. On 5/3/22 at 2:32 PM, LPN C was interviewed and asked about R14. LPN C explained when she had seen the resident in the morning, he was complaining of pain, so when she examined him, she saw the penis was split just above the head approximately 3/4-1 inch in length. LPN C was asked if she had asked R14 how it happened. LPN C explained he did not know. When asked if she had received in the nursing hand-off report that R14 had a urethral laceration, LPN C explained she had not received a report and did not know he had a laceration. Review of R14's catheter care plan revealed the care plan, and all interventions were resolved on 2/11/22. It should be noted R14 continued to have an indwelling catheter up to the time he was discharged on [DATE]. Review of R14's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's April 2022 CNA documentation revealed no documentation of catheter care or amount of output from the catheter. On 5/3/22 at 2:46 PM, the Director of Nursing (DON) was asked for any documentation of catheter care, monitoring, or anchor placement for April 2022 for R14. On 5/4/22 at 9:17 AM, the DON explained there was no documentation for R14's catheter in April 2022. The DON was asked if there should be documentation of catheter care, and placement of an anchor device, monitoring of the catheter, and output. The DON explained documentation should be done every day. When asked who should be documenting on the catheter, nurses, CNA's or both, the DON did not answer. Review of an undated facility policy titled, Catheter Care Policy read in part, .Catheter care will be performed every shift and as needed by nursing personnel .

This citation has two Deficient Practice Statements (DPS). #1 DPS Based on observation, interview and record review the facility failed to implement a fall care plan for a resident at risk for falls upon admission, implement, modify, and review the effectiveness of the interventions once the care plan was implemented, and identify the root cause analysis for multiple falls for one (R45) of eight residents reviewed for accidents, resulting in R45 having to be transferred to the hospital and receiving four staples to their head. Findings include: On 5/2/22 at 9:51 AM, an observation of R45 was made sitting in a broda chair (specialized chair) in the hallway at the nurse's station. When interviewed the resident didn't consistently answer the questions appropriately. Review of the clinical record revealed the following: R45 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, falls, difficulty in walking and hypertension. A Minimum Data Set (MDS) assessment dated [DATE] documented Severely Impaired for cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). A hospital Clinical Discharge Instructions provided to the facility dated 2/2/22 at 1:43 PM, documented in part . Principal Diagnosis at Discharge: 1: Frequent falls . An admission Fall Risk Evaluation dated 2/2/22 at 7:11 PM, documented a score of 14 At Risk. Further review of the fall risk evaluation revealed the Medication section documented as None of these medications take currently or within last 7 days was marked for Medications. On the top of the fall risk evaluation, the form documented in part, . Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics . Review of the resident's discharge orders and physician orders at the facility revealed the resident was currently taking a hypertensive medication ([MEDICATION(S)]) . The admission fall risk evaluation did not acknowledge the hypertensive medication and was not completed accurately. Review of the clinical record revealed six falls documented from 2/4/22 to 4/16/22. Review of a Physician note dated 2/3/22 at 9:43 AM, documented in part . admitted from an acute care facility after she was treated for Status post fall at home . confused and a poor historian . complains of weakness . unsteady gait . dementia . Gait disturbance: start fall precautions . Review of a care plan titled in part . risk for falls r/t Confusion, Gait/balance problems, Incontinence, and a HX (history) of falls . was implemented on 2/18/22, more than two weeks after the resident was admitted into the facility. Review of the clinical record revealed the following: A Nursing note dated 2/5/22 at 3:16 PM, documented in part . 11:45 AM Fall was witnessed . fall location: dining room, Activity at the time of fall: standing alone . Reason for fall: wheelchair not locked standing unassisted . resident in dining room at table awaiting lunch service, resident attempted to stand unassisted, wheelchair wasn't locked. Resident a/o (alert and oriented) x 1 . Contributing factors note: confusion new admit . History of falls at home - prior to admission . Clinical Suggestions (blank) . A Post Fall Evaluation dated 2/5/22 at 3:16 PM, documented in part . Date/ Time of Fall - 02/04/2022 11:45 . Reason for fall - wheelchair not locked standing unassisted . Pre-Fall/Post Fall Risk Score (blank) . Date of safety evaluation (blank) . Contributing Factors Note - confusion new admit . Conclusion Note (blank) Review of a facility fall incident report dated 2/4/22 at 12:04 PM, documented the same information as the progress note and post fall evaluation. Further review of the clinical record revealed no implementation of interventions to prevent further falls or documentation of the Interdisciplinary team (IDT) reviewing the root analysis of the fall. Review of a facility policy titled Falls and Fall Risk, Managing and Prevention dated 2/28/2008 documented in part, . Based on previous evaluations and current data, interventions will be identified related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The interdisciplinary team will identify appropriate interventions to reduce the risk of falls . The Interdisciplinary treatment team will identify and implement relevant interventions (e.g., w/c (wheelchair) positioning or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling . Review of a facility incident report dated 3/14/22 at 7:38 PM, documented in part . Resident found sitting up against bathroom door. Flat on resident's buttocks, resident experienced a fall . Resident stated the floor was slippery as she tried to walk to the bathroom from her bed . Predisposing Situation Factors - Improper Footwear, Ambulating without Assist . No Witnesses found . Further review of the record revealed no documented progress note, post fall evaluation, modification of interventions or documentation from the IDT team identifying the root cause analysis of the fall. Review of a Nursing note dated 3/16/22 at 10:02 PM, documented in part . Writer found resident in the bathroom next to toilet sitting up on her bottom. Resident has minor skin tear on left elbow . Resident was placed at the nurses' station in wheelchair to be monitored for the remainder of the night . Review of a Nursing note dated 3/20/22 at 12:25 AM, documented in part . 03/19/2022 10:30 AM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: Attempting to walk The reason for the fall was not evident. Was a safety evaluation completed/documented prior to the fall: No. Safety teaching documented before the fall: No . Any similarities between current and post falls: No . Clinical Suggestions: (blank) . Review of a Post Fall Evaluation dated 3/20/22 at 12:25 AM, documented the same description as documented in the 3/20/22 Nursing note. Review of a facility incident report dated 3/19/22 at 10:12 PM, documented in part . Nursing Description: Patient observed on floor in hallway . Resident Description: Patient is confused. Continues to want to get up and do things . Mental Status - (blank) . Predisposing Environmental Factors - (blank) . Predisposing Situation Factors - (blank) . No witnesses found . Further review of the clinical record revealed no identification of the root cause analysis of the fall by the Interdisciplinary team. Review of a Nursing note dated 3/28/22 at 9:18 PM, documented in part . 03/28/2022 6:30 PM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: standing/walking w/o (without) assistance. The reason for the fall was not evident. Was a safety evaluation completed/documented prior to the fall: No . History of falls at the facility. Any similarities between current and post falls: Yes . Clinical Suggestions: (blank) . Review of the Post Fall Evaluation dated 3/28/22 at 9:18 PM, documented the same documentation of the fall as the 3/28/22 Nurse's note. Review of a facility incident report dated 3/28/22 at 10:11 PM, documented in part . Writer observed resident laying on the floor on the right side of her body with her right arm under her head. Resident denies pain or discomfort at this time . Resident stated, I fall trying to walk over to that table . Mental Status (blank) . Predisposing Environmental Factors - None . Predisposing Physiological Factors - None . Predisposing Situation Factors - None . Further review of the clinical record revealed no documentation by the Interdisciplinary team identifying the root cause analysis of the fall or modification/implementation of additional interventions to prevent further falls. Review of a Nursing note dated, 4/16/22 at 10:17 PM, documented in part . Resident was sitting in her w/c (wheelchair) at the nursing station, she was trying to self-transfer and fell in <sic> hit the back of her head. She had on non-skid socks, w/c was found behind her with the locks on. Action: Writer assessed patient from head to toe, writer seen blood coming from the back of the head, writer cleaned with normal saline and wrapped to stop bleeding . Resident was discharged to hospital . Review of a hospital Discharge Instructions dated 4/16/22 at 9:55 PM, documented in part . Stapled skin wound; 2: Head injury . 4 staples . Review of the clinical record revealed no post fall evaluation completed for the 4/16/22 fall. Further review of the clinical record and incident report revealed no identification of the root cause analysis of the resident repeated falls or interventions modified and/or additional interventions implemented to prevent further falls. On 5/4/22 at 9:18 AM, the Director of Nursing (DON) was interviewed and asked about the delay in implementation of a fall care plan for a R45 admitted with a diagnosis of falls, the accuracy of the admission fall risk assessment, each of the falls was reviewed and asked if the Interdisciplinary team identified the root cause analysis for the falls to modify/implement additional interventions and to review the effectiveness of the existing interventions to prevent further falls. The DON stated they would look into it. At 3:07 PM, the DON returned and stated they did not have any further information or documentation to provide. No further documentation was provided by the end of survey. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to determine the root cause of injuries (bruises) obtained from assistive devices (wheelchair) and during a transfer; and failed to implement interventions to prevent further injury for two (R32 and R60) of seven residents reviewed for accidents. Findings include: Resident #32 On 5/2/22 at approximately 9:30 AM, R32 was observed seated in a wheelchair in their room. On 5/2/22 at 11:50 AM, R32 was observed self-propelling in a wheelchair, using their right hand to propel the wheel forward. R32 was not observed to be wearing a bra and their right breast was observed near the waist line pressed between and through the arm rest of the wheelchair. On 5/3/22 at approximately 3:30 PM, R32 was observed self-propelling in a wheelchair. They were not wearing a bra and their right breast was observed near the waist line and pressed into the arm rest of the wheelchair as they propelled the wheel forward with their right hand. Review of R32's clinical record revealed R32 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R32 had severely impaired cognition and required supervision for locomotion via wheelchair on the unit. Review of R32's progress notes revealed the following documentation: A Skin Only Evaluation note dated 4/30/22 documented, .Resident has current skin issues. Skin Issue: Bruising. Skin Issue Location: (R-right) Breast . A Nurses progress note dated 4/30/22 written by Licensed Practical Nurse (LPN) U documented, Observed resident leaning to right side of w/c (wheelchair), while in hallway with (R) breast in between armrest, some bruising noted to (R) breast area, some discomfort noted .DON (Director of Nursing) notified .Resident repositioned in w/c, Therapy to screen . A Physician Progress Note dated 5/2/22 written by Nurse Practitioner (NP) BB documented, Patient was seen for brusie <sic> to right out breast .Patient was seen today per nursing staff request .staff report patient was observed with purple bruise to right out breast. Staff observed patient leaning to her right in the wheelchair .Does not appear to be of a suspicious nature .Ecchymosis (bruise); continue to monitor status . On 5/3/22 at 8:03 AM, all incident reports and associated investigations for R32 for the past three months were requested from the Administrator. Review of an incident report for R32 dated 4/30/22 at 7:52 PM, completed by LPN U revealed the following documentation: Observed resident leaning to right side of w/c; while in hallway with (R) breast in between armrest, some bruising noted to (R) breast area, some discomfort noted. Resident Unable to give Description. Skin assess (sic) completed .Predisposing Environmental Factors .Resident Equipment . Attached to the incident report was a physician order dated 4/30/22 for Therapy to screen. No additional information was provided. On 5/3/22 at 1:33 PM, the DON was interviewed regarding the bruise observed on R32's right breast and the incident report that documented it was due to R32 leaning in her wheelchair. The DON reported LPN U thought it was likely from the wheelchair, so the physician was notified, and therapy screened the resident. When queried about any interventions implemented to prevent further bruising to R32's breast, the DON reported she was referred to be screened by therapy and did not know. On 5/3/22 at 1:48 PM, an interview was conducted with LPN U via the telephone. When queried about the bruise to R32's right breast, LPN U reported a Certified Nursing Assistant alerted her about the bruise, LPN U assessed R32 and discovered a bruise to the right breast. LPN U reported that she observed R32 leaning to the right of her wheelchair when self-propelling and her posture appeared off so that was likely what caused the bruise. LPN U reported she notified the physician and DON and ordered a therapy screen. When queried about any interventions implemented as a result of the therapy screen, the DON reported she was not sure. On 5/4/22 at approximately 4:30 PM, Therapy Director V was interviewed. When queried about whether R32 was recently referred for a therapy screen, Therapy Director V reported R32 was referred for Physical Therapy (PT) and Occupational therapy (OT) due to generalized weakness. When queried about whether R32 was evaluated for positioning in her wheelchair due to obtaining a bruise on her breast, Therapy Director V reported he had not heard of that but would check into it. Therapy Director V provided a PT Evaluation & Plan of Care that revealed R32 was evaluated for PT on 4/27/22 due to a fall. Review of an OT Evaluation & Plan of Care revealed R32 was evaluated for OT on 5/3/22 to assess for safety and increase independence with activities of daily living. The PT evaluation was prior to the discovery of the bruise to R32's breast and the OT evaluation did not address potential positioning issues in the wheelchair that were said to cause a bruise to R32's breast. Review of R32's care plans revealed a care plan initiated on 10/13/20 that documented, .actual skin impairments . The care plan did not address the bruising to R32's breast and there were no updated interventions since 10/13/20. Resident #60 On 5/2/22 at 9:30 AM, R60 was observed eating breakfast. R60 did not respond when talked to. At 11:53 AM, R60 was observed sleeping. At 1:38 PM, R60 was observed eating lunch with their plate of food on their mattress. R60 explained they were not interested in talking. Review of R60's clinical record revealed R60 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hypertension, dementia, and [CONDITION(S)]. Review of a MDS assessment dated [DATE] revealed R60 had intact cognition and required extensive physical assistance from at least two staff members for transfers. Review of a Skin Only Evaluation progress note dated 3/24/22 revealed the following documentation, .Resident has current skin issues. Skin Issue: Bruising. Skin Issue Location: right chest area and right breast Tissue: Painful. determined that area bruised from sling while using sit to stand lift . Review of a Skin Only Evaluation progress note dated 3/27/22 noted, . Skin Issue: Bruising. Skin Issue Location: (R) breast area . Review of a Skin Only Evaluation progress note dated 4/7/22 noted, .Skin Issue Location: right chest area Tissue: Painful . On 5/3/22 at 8:03 AM, the Administrator was asked to provide any incident reports and associated investigations for R60 for the past three months. No incident reports or investigations were provided regarding the documented bruising to R60's right chest and breast area. Further review of R60's progress notes revealed the following: A Draft Nurses progress note dated 3/23/22 at 4:56 AM, written by LPN Y, noted the following: CNA observed bruising on resident's right side of breast while providing care, CNA called writer into room. Resident stated 'I've been sore since the Cena earlier today transferred me' . A Late Entry Alert progress note dated 3/23/22 at 7:30 AM, written by the DON, noted the following: The resident has some bruising to the right side of her breast. Resident who is alert and able to make her needs known explained to staff that she sustained the bruise during a Sit to Stand transfer . On 5/3/22 at 9:56 AM, an observation of R60's skin was conducted with LPN F. A bruise was observed on the lateral aspect of R60's right breast, below the nipple line. It appeared to be linear in shape, was a dark color, and slightly fading along the edges to yellow. LPN F measured the bruise to be 4 cm x 2 cm. When asked how the bruise happened, R60 explained they tried to pick her up and put her in the chair and that it hurt. On 5/3/22 at 3:52 PM, LPN Y was interviewed. When queried about the bruise observed on R60's breast on 3/23/22, LPN Y reported around 4:00 AM the CNA notified her that R60 had a bruise on her breast and chest. LPN Y could not recall who the CNA was, but reported she notified the Administrator and DON. On 5/3/22 at 4:06 PM, LPN Y followed up and reported that she spoke with the Administrator and DON and now remembered the event and that the bruise lined up with the sit to stand lift. On 5/3/22 at approximately 4:30 PM, the DON was interviewed about any investigation into the bruise on R60's breast and the documented statement from the resident that is occurred during a transfer. The DON reported she remembered investigating it but did not have any documentation of the investigation. When queried about how R60 sustained a bruise to the breast and chest from a sit to stand lift, the DON did not offer a response. When queried about who was involved in the transfer and any intervention implemented to prevent further injuries to residents during transfers, the DON reported she did not remember. Review of R60's care plans revealed a plan that was initiated on 8/5/21 that noted, Safe Transfers/Injury prevention R/T (related to) debility, poor/no safety awareness. Interventions initiated on 8/5/21 were, Nursing staff should be evaluating at all times the residents response to the ordered transfer - if the resident needs more assit <sic> and the use of a lift the nursing staff should obtain an order for the new level, place it in the 24 hour report and update the communication board .One person assist Maximum x 2 - gait belt required .When a resident has fluctuating performance with transfers due to fatigue write an order that covers both the least assist needed and also the max assist needed . Review of a facility policy titled, Incident and Accident Assessment, Reporting and Monitoring, reviewed on 10/8/19, revealed, in part, the following: .Incident and Accident Reporting .The Director of Nursing is to be notified of ALL falls &/or resident injuries .The DON will notify the Dominions and it will be determine if the incident is then reportable to the (State Agency) .The Shift Supervisor is to: Initiate investigation by obtaining statements and attempting to determine how the incident & accident occurred .The Nurse manager or designee will: .Review incident and accident reports and follow up with further investigation .Review and finalizes updated care plans .Summarize the incident and follow up actions/outcomes in the note section of I&A .File all completed incident and accident reports and maintain binders .Monitor the incident and accident reports and the reporting process to ensure compliance .

This citation pertains to intake: MI 355. Based on observation, interview and record review, the facility failed to prevent, accurately assess and identify, and notify the physician of worsening of pressure ulcers, for two (R's 27 and 74) of two residents reviewed for Pressure Ulcers, resulting in a facility acquired Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) Pressue Ulcer that required surgical debridement and a Stage IV infected coccxy Pressure Ulcer for R74. Findings include: R27 On 5/2/22 at 9:37 AM, R27 was observed lying in bed. An intravenous (IV) bag of [MEDICATION(S)] (antibiotic) 500 mg/100 ml (milligrams per milliliter) was hanging on an IV pole next to the bed. R27 was asked what the antibiotic was for. R27 appeared confused and did not know the answer. Review of the clinical record revealed R27 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R27 had severely cognitive impairment and required the extensive to total assistance of staff for all activities of daily living (ADL's), including bed mobility. Review of R27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's pressure ulcer care plan initiated 4/14/22 revealed interventions that read in part, .Follow CfCC [sic] policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R27's wound care notes revealed an initial Wound Care note dated 2/9/21, signed by Dr. DD read in part, .Rt (right) Parasacral (coccyx) UTD (unable to determine) . chronic . Length 4.2 Width 5.2 . It should be noted that the only wound R27 had upon admission was a chronic wound to the coccyx. A Wound Assessment Report dated 2/28/22, by NP BB read in part, .Pressure Injury - Stage II . Gluteus, Left . 2.4 x 3.1 x 0.2 cm (centimeters) A Wound Care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Bedside debridement performed, removed moderate amount of slough/necrotic tissue with curette and suture removal kit. Large amount of malodorous drainage present. Wound has deteriorated. lower spine exposed, slow to blanche [CONDITION(S)] around wound .Will sent patient to hospital for further evaluation . Review of the progress notes from 2/28/22 to 4/5/22 revealed no documentation by the nurses of the identification of large amounts of foul-smelling exudate from the left gluteal wound and no documentation of notification to the physician of the wound worsening. Review of a hospital admission note dated 4/5/22 read in part, .a transfer from ECF (extended care facility) for further evaluation of worsening sacral decubitus ulcer and concern for infection vs osteo ([CONDITION(S)] - infection the bone) . was given IV fluids in the ED (Emergency Department) and started on broad-spectrum antibiotics . admitted for further monitoring and treatment with consults made to infectious disease and general surgery . A Wound Care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient returned from hospital, where she had surgical debridement. Along with IV ABt (antibiotic therapy) therapy . A Wound Assessment Report dated 5/2/22 by NP BB read in part, .Pressure Injury - Stage IV . Gluteus, Left . 11.7 x 6.8 x 2 cm . Review of R27's Braden Scales revealed the initial score on 2/6/21 was 16, indicating At Risk. No documentation of a Braden Scale until a year later on 2/2/22 with a score of 13, indicating Moderate Risk. The next Braden Scale was 4/14/22 with a score of 11, indicating High Risk. It should be noted that both the 2/22/22 and the 4/14/22 listed R27 as chairfast not bedbound and the 2/2/22 listed Friction & Shear as Potential Problem not Problem, therefore due to the score indcating moderate Risk, no interventions to prevent pressure injuries were put into place until 4/14/22 when R27 was deemed High Risk for pressure injury development. On 5/3/22 at 11:06 AM, an observation of R27's wounds was performed by LPN B. The Left Gluteal wound appeared to have a pink base with slough (non-viable . tissue .), and undermining at the edges. On 5/4/22 at 11:51 AM, NP BB was interviewed and asked about R27's wounds. NP BB explained she had started as the facility's Wound Care NP in mid-February 2022 and identified wounds on R27's bottom area. NP BB continued to explain that the coccyx wound was chronic, and she had been admitted with that one, and the Left Gluteal had worsened and required surgical debridement and antibiotics. When asked why the Left Gluteal had required surgical debridement, NP BB explained she had done bedside debridement, and had started to use a chemical debridement treatment, and the wound opened up and then they could see it was necrotic, down to the bone and needed surgical debridement. On 5/4/22 at 1:06 PM, the DON was interviewed and asked how a facility acquired wound progressed to a Stage IV and required surgical debridement and IV antibiotics. The DON explained R27 was quite compromised and required total care. When asked how frequently a Braden Scale should be done on a resident, the DON explained they should be done at lease quarterly, or more frequently if there were new pressure injuries. The DON was asked about R27 having only three Braden Scale assessments since her admission and why none of the assessments scored her has Very High Risk when she had aquired pressure ulcers at the faciliy. The DON had no answer. This citation pertains to intake: MI 355. Based on observation, interview and record review, the facility failed to prevent, accurately assess and identify, and notify the physician of worsening of pressure ulcers, for two (R's 74 and 27) of two residents reviewed for Pressure Ulcers, resulting in a facility acquired Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) infected coccxy Pressure Ulcer for R74 and a Stage IV Left Gleuteus Pressure Ulcer that required surgical debridement for R27. Findings include: R74 Observations were made of R74 lying in bed on their back on 5/2/22 at 9:07 AM, 5/3/22 at 10:43 AM and 5/4/22 at 11:16 AM with the mattress pressure device setting on normal pressure. The device had two pressure settings, normal and low pressure. The device was set at normal pressure all three days of observation. Review of the clinical record revealed R74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] documented a BIMS score of two indicating severely impaired cognition and required staff assistance for all ADLs. Review of an admission Skin Only Evaluation dated 1/4/22 at 9:33 PM, revealed a skin tear to the left shoulder, left hip, left elbow (no measurements documented), bruising to the left ankle, left hip (no measurements documented) and a deep tissue injury to the right lateral foot (no measurements documented) and Resident has dry flaky LLE (left lower extremity), and Bil (bilateral) feet. Resident fungal toenails, and dry scab to right ankle and scab to right knee. Further review revealed no skin issues or concerns to the resident sacral/coccyx area. Review of an admission Braden Scale for Predicting Pressure Ulcer Risk dated 1/4/22 at 3:48 PM, documented a score of 14, indicating Moderate Risk. The Abnormalities section documented must be acknowledged, when staff check off the concerns and acknowledge the abnormalities the facility program generate clinical suggestions also known as interventions for the staff to implement to prevent development of or worsening of pressure ulcers. The abnormalities section was not acknowledged by the staff; therefore the clinical suggestions were not generated for the staff to implement per the facilities protocol. Review of a facility policy titled Wound Care Policy revised 10/16/19, documented in part . Care Plans will be completed that are reflective of the resident's risk factor for pressure development in association with their current Braden Score . If a resident's Braden score is 14 or lower, they will be considered moderate risk and the following preventative measures will be care planned and put into place . Turn and reposition resident while in bed at least every two hours, as tolerated, Use positioning devices as needed to maintain position and prevent pressure development on high-risk pressure area . Float heels while in bed, as tolerated . Pressure reduction mattress . These interventions were not timely implemented as instructed in the policy. Review of the clinical record revealed the following: A Nursing note dated 1/17/22 at 3:36 PM, documented in part . Writer called into room by CNA (Certified Nursing Assistant) upon AM care, Observed partial skin opening to res (resident) coccyx. Res has thin skin and frail in body type, high risk for pressure injury. Dependent on staff for bed mobility. Cleanse area to coccyx, apply allevyn, Order to change q (every) 3 days. Order for res to have I-heal mattress . A weekly Skin Only Evaluation dated 1/17/22 at 3:00 PM (36 minutes before the CNA notified the nurse of a coccyx opening), the nurse completed a body skin assessment and there was no documentation of skin issues or an opening to the coccyx area noted. A Nursing noted dated 1/17/22 at 8:04 AM, documented in part . noted to have open area to coccyx measuring 2x3 cm with slough present in the wound center and pink tissues on edges . Resident was on a standard mattress new order for IHEAL mattress to be in place. No cloth incontinent pads, frequent turning and repositioning . Will re-assess per policy as needed . A Wound Care Progress Note dated 1/26/22, documented in part . Coccyx stg (stage) III . Slough % 5 . Serous . Clean wound with NS (Normal Saline) . Apply to wound bed . [MEDICATION(S)] gel . Frequency: Q (every) day . Review of a care plan titled . has actual skin impairment, deep tissue injury . revealed interventions to Follow (name of facility) policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan titled Skin Tear, Bruise, Scabbed Area, DTI . documented an intervention for a low air loss mattress implemented on 1/25/22. This intervention was implemented eight days after the identification of the coccyx wound and three weeks after being admitted into the facility. On 5/4/22 at 1:15 PM, the Director of Nursing (DON) was interviewed and asked about the delay of interventions to prevent the development of R74's coccyx wound, the accuracy of the admission Braden assessment score, the accuracy of the weekly body assessment completed on 1/17/22 and why the resident's bed was currently set at normal pressure instead of low pressure. The DON stated they would look into it. Further review of the medical record revealed the following: A Wound Assessment Report consultation dated 3/14/22 at 10:41 AM, documented the following in part . Pressure injury - Stage III . Sacrum/Buttock, Coccyx . L (Length) x W (Width) x D (Depth): 4.8 x 3.4 x 0.4 cm2 (centimeter squared), Area: 9.7 cm2, Volume: 3.9 cm2 . Odor: malodorous . A Wound Care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Coccyx measures 8.6 cmx7.2cm.1.2cm, area opened up, large amount of foul-smelling exudate. Possible tendon exposure. WBC (White Blood Cell) have been elevated, believe this is the source of infections . Stage 4 wound is unavoidable . Will order [MEDICATION(S)] 100 mg (milligram) BID (twice a day) x 7 days . Review of a laboratory report dated 3/4/22 at 10:46 AM, documented a WBC of 17.2 (normal 4.00 - 11.00). Indicating a high reading, which usually indicates the body producing increased WBC to fight an infection. Review of the progress notes revealed no documentation by the nurses from 3/14/22 to 3/21/22 of the identification of large amounts of foul-smelling exudate from the coccyx wound and no documentation of notification to the physician of the wound worsening. On 5/4/22 at 5:31 PM, Wound Nurse Practitioner (WNP) BB was interviewed and asked if they were notified prior to 3/21/22 wound consultation of the wound worsening, WNP BB stated they were not notified. WNP BB stated the wound had opened up and the foul odor was horrific. WNP stated that it didn't just worsen that day and was unsure on why the facility staff did not notify them of it worsening prior to the 3/21/22 visit. On 5/4/22 at 1:15 PM, the DON was also asked why the front-line staff (CNAs & Nurses) failed to identify the worsening of the coccyx wound and report the changes to the practitioner and the DON stated they would look into it. At 3:06 PM, the DON returned and stated they could not provide any further explanation or documentation regarding all questions asked. Further review of the care plan titled . has actual skin impairment, deep tissue injury . documented the following interventions in part, . Report . declines to the MD (Medical Doctor) . Any changes or findings; please document, inform wound care, unit manager, DON, and physician . report to MD PRN (as needed) changes in skin status . Further review of a care plan titled Skin Tear, Bruise, Scabbed Area, DTI . documented the following intervention in part, . Monitor skin for increased redness, drainage, foul odor, secretions, and temperature. Notify MD or MD extender as occurs . No further documentation was provided by the end of survey.

This citation pertains to Intakes: MI 044 and MI 045. Based on observation, interview and record review, the facility failed to prevent Certified Nurse Aide (CNA) staff to resident physical, verbal and psycho-social abuse during a shower for two sampled Residents (R800 & R801), resulting in Immediate Jeopardy with both residents being exposed to what was described as unbearable/scalding hot water, physical penetration and covering the residents mouth (R800), fear of taking showers, and the need for an psychiatric consult and anti-anxiety medication for (R801). This deficient practice placed the residents at risk for serious injury, serious harm and/or death. Findings include: R800 A review of the Facility Reported Incident reported by the NHA (Nursing Home Administrator) noted the following: Incident Summary: Resident reported that CNA A was mean to (R800). (R800) stated that as (CNA A) was taking (R800) to the shower room (R800) asked where (their) glasses and watch where. (CNA A) told (R800) to be quiet, placed (their) hand over (R800's) mouth and told (R800) that (they) didn't want to hear about it. In the shower, (CNA A) turned on the water and it was warm. As (CNA A) washed (R800's) vagina and rectum, (CNA A) was rough. (CNA A) stuck (their) finger in (R800's) rectum and then turned the hot water on more. On 7/6/21 at 9:48 AM, R800 was observed in bed with their eyes closed. A medication cup of pink liquid was observed on R800's bedside table. R800 said that they did not feel good and did not want to talk. In addition, R800 was very hard of hearing. A review of R800's electronic medical record noted an original admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R800 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (Intact cognitive response) and required extensive assistance with Activities of Daily Living. R800's care plan noted the following: Focus: (R800) Self Care Deficit Physical Weakness Date Initiated: 11/06/2020 .Interventions: Encourage conversation and active participation with care .Encourage personal choices Date Initiated: 11/06/2020 .Focus: (R800) is at risk for Privacy and/or Dignity Violations related to: lack of self awareness Date Initiated: 11/06/2020 .Monitor for privacy and dignity during all activities of daily living .Anticipate and meet (R800's) needs. Date Initiated: 11/06/2020 .(R800) has potential pain r/t (related to) disease process Date Initiated: 11/06/2020 .Intervention: Monitor for expressions of pain both verbal and non-verbal 11/06/2020 .Intervention: if (R800) becomes agitated/annoyed leave alone and re approach at a later time Date Initiated: 03/29/2021. A review of R800's progress notes in the medical record entered by the Director of Nursing (DON) dated 6/25/21 at 7:46 PM noted the following: Resident said staff was rough with (R800) during (their) shower. Resident stated that (CNA A) was taking me to the shower room as (CNA A) hit my hand on the door. I ask (CNA A) where is my watch and glasses. I wanted them. (CNA A) told me to be quiet and put (their) hand over my mouth and said (they) don't want to hear about it. (CNA A) turned on the water it was warm. (CNA A) didn't wash under my arms, only my back hair. as (CNA A) washed my vagina/rectum she was rough. (CNA A) stuck (their) finger in my rectum and then (CNA A) turned the hot water on more it was boiling. I asked (CNA A) what was wrong with (them). On 7/6/21 at 11:51 AM, Guardian C for R800 was called to discuss the allegation. Guardian C stated, A nurse called me on midnights on 6/18/21 .I was told that somebody was mean to (R800) .(R800) gets a shower twice a week . (R800) said (CNA A) burned (them) in the shower. On 7/6/21 at 12:24 PM, Maintenance Director D was interviewed and was requested to check the shower water temperatures. Maintenance Director D said, We check the water temperatures weekly. A review of the facility's water temperature binder noted that there were no water temperature checks of the facility's showers from January 1, 2021 thru July 1, 2021. Maintenance worker E stated, We don't check the temperature in the shower because it's on the same water line .We only check the first three rooms. Maintenance Director D stated, We will start checking the shower temperatures weekly. On 7/6/21 at 12:45 PM, CNA B was interviewed and said, I went to the room to peak in on (R800). I woke (R800) up to let (R800) know breakfast was there .(R800) said that on Thursday (CNA A) gave (them) a shower and was so mean .(R800) said (CNA A) burned (them) so hard . (R800) said (CNA A) rubbed (their) skin too hard .(CNA A) put (their) hand over (R800's) mouth and told (R800) to shut up .(R800) said they told the agency nurse (unknown) and then told (Nurse Supervisor F). On 7/7/21 at 8:30 AM, R800 was observed in bed with their eyes closed. Upon calling R800's name, R800 indicated that they did not feel like talking at this time. On 7/7/21 at 8:52 AM, Nurse Supervisor F was called via phone and interviewed about the allegation of R800 and CNA A. Nurse Supervisor F stated, (R800) reported to CNA B that the other CNA (CNA A) was mean and that the water was too hot. (R800) also said that (CNA A) stuck (their) finger into (R800's) rectum. (R800) said that CNA A put (their) hand over (R800's) mouth .R800 talked about it (the incident) the whole day .I notified the DON and the NHA. The NHA came in on Sunday. I also talked to the (Guardian C). On 7/7/21 at 9:18 AM, Social Worker H was interviewed about the allegation of R800 and (CNA A). Social Worker H said, (R800) said (they) almost got burned and that the (CNA A) put (their) hand over (their) mouth and told (R800) to shut-up. (R800) was very upset about (CNA A) .(R800) said Why would (CNA A) do this to me .(R800) said that (they) were sad and depressed and missed (Guardian C) and their favorite CNAs. On 7/7/21 at 9:45 AM, the NHA was interviewed and asked about the allegation of R800 and (CNA A). The NHA said, (R800) was very direct about what happened. (R800) said 'Let me tell you what happened, (CNA A) rammed my hand into the doorway of the shower . (CNA A) would not turn the hot water in the shower down . (CNA A) was mean from the beginning.' The NHA was asked about the allegation from R800 about CNA A sticking their finger into R800's rectum and the NHA stated, Yes, (R800) said that, but, I'm not sure about how true that is .That's not normal to do (putting a finger into the rectum) . Why would (CNA A) do that? In addition, the NHA was informed and shown the water temperature binder without the shower water temperatures logged from January 1, 2021 thru July 1, 2021. The NHA was asked their expectation of checking the water temperatures in the shower rooms and the NHA stated, It should be checked. On 7/7/21 at 3:57 PM, R800 was interviewed about the allegation with CNA A. R800 said, This (CNA A) put me in the wheelchair and took me to the shower .I told (CNA A) that I did not want to go and that I needed my watch and glasses but (CNA A) kept taking me and hit my hand on the door . (CNA A) put the water on me and it was boiling hot. I asked (CNA A's) name but (CNA A) would not tell me .I asked for my watch and (CNA A) said shut up. I said what are you trying to do to me, the water was too hot, (CNA A) ignored me. (CNA A) did not test the water. I said what the hell are you doing, trying to burn me. (CNA A) was rubbing and rubbing my skin. (CNA A) stuck (their) finger all the way up my rear end where #2 (stool) comes out. I told my favorite aide (CNA B) and the nurse. They told me (CNA A) was fired and I said oh good. R800 was asked how the incident made them feel and R800 said, It made me feel bad. That was so mean. Why would (CNA A) do that to me? On 7/7/21 at 11:22 AM, CNA A was called via phone and queried about the allegation with R800 and CNA A stated, I was told that I allegedly held a rag (wash cloth) over (R800's) mouth in the shower . I recall taking (R800) to the shower .(R800) was very agitated and was concerned about going to the shower .I was talking to someone and (R800) put (Their) hand down and hit it on the door .I told the nurse that (R800) hit their hand .Why did it take two days for (R800) to tell someone .(R800) always give the aides a hard time .everybody laughs about it because they know how (R800) be acting out .(R800) know I did not do anything .I've been doing this type of work for a long time .This place is all wrong .they give us too many residents to take care of .they are just using this as a cover up. R801 A review of Intake #MI 045 revealed the following, Incident Summary: Resident stated that CNA (Certified Nursing Assistant) took [them] to the Shower Room, the water was hot and [they] asked the CNA to turn it down because it was scalding [them]. The CNA told [R801] that it wasn't that hot and continued to shower [them] with the scalding hot water. Resident was not harmed by this incident. A review of R801's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R801's Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status Score of 13/15 indicating an intact cognition and required extensive assistance for activities of daily living. A review of R801's Care Plan revealed the following, Focus: [R801] has potential pain r/t (related to) Disease Process, impaired mobility, and DX (diagnosis) of DJD (degenerative joint disease). Date Initiated: 05/05/2021. Interventions: Monitor for expressions of pain both verbal and non-verbal (facial grimacing, bracing, rubbing, etc.). Date Initiated: 05/05/2021. On 7/6/21 at 9:58 AM, an interview was completed with R801 regarding the incident in the shower room with the CNA. R801 explained that the CNA was rushing and being rough with them while taking their clothes off in the shower room. R801 explained that once they were assisted into the shower chair and the water was turned on, it was cold, so they asked the CNA to turn up the temperature. R801 explained that once the CNA adjusted the water it became, scalding hot at which point the CNA used the shower hose and put it over the top of their head causing the skin on their face to burn as the water ran down. R801 stated, I kept telling her to turn it down and she told me, 'It's not that hot, you can take it.' R801 further explained that the CNA took the shower hose with the hot water, placed it underneath the shower chair opening where their perineal area (the area between the anus and vulva) was located, Burning my bottom. R801 stated, I kept thinking that I was going to have to go to the hospital and explain what happened. If she had the hot water on me, imagine what she's doing to the little old ladies. R801 explained that they did not know what to do after the incident occurred, so they waited to tell a CNA they felt comfortable with. R801 was asked how the incident made them feel and stated, Rotten. I still have memories of it. Review of R801's progress notes revealed the following: 6/20/2021, 11:41(AM) Nurses Data: Resident made staff aware that CNA was careless. Resident stated that she took me to the shower the water was steaming hot. I asked her to turn it down it was scolding [sic] hot. It was very hot I thought my privates was going to fall off. I asked her to put it on cool and she said it's not that hot. She continued to shower me with the scolding [sic] hot hot water . 6/21/2021,11:00 (AM) Social Services Note Note Text: Social Service note. Writer visited with [R801] on this date to see how [they were] doing. [They] shared with writer what had happened last week. Writer offered non-judgmental support. Writer inquired with [them] how [their] mood was and [they] not only looked down but also stated [they] felt sad and that it was more so because of what happened . [They] too had voiced [they have] been having more trouble sleeping, feeling tired and that [their] appetite has not been too good as well as [they have] been feeling restless. [Their) overall PHQ9 (Patient Health Questionnaire which assess Depression) score was 5/27 indicating mild depression. Writer informed [them] I will have the psych team see [them] . 6/22/2021 09:13 (9:13AM) Social Services Note Note Text: Social Service note. Writer visited with [R801] on this morning to see how [they were] doing . [R801] voiced [they were] feeling a little tired and a little restless still when asked. [They] did state it is a little better then yesterday. [Their] PHQ9 score was the same 5/27. Writer allowed [R801] to vent and offered non-judgmental support. Writer will have [them] seen by psych this week and next . 6/25/2021 18:50 (6:50 PM) Interdisciplinary Team Note Data: Resident made staff aware that CNA was careless. Resident stated that she took me to the shower the water was steaming hot. I asked her to turn it down it was scolding hot. It was very hot I thought my privates was going to fall off. I asked her to put it on cool and she said it's not that hot. She continued to shower me with the scolding [sic] hot hot water. Action: . Senior psychiatric services were consulted, social work completed wellness visits and offered social support daily . Response: Resident was interviewed by the facility Administrator and DON (Director Of Nursing). Per the resident interviews [their] story remained concurrent. The resident stated [they] felt safe in the facility as long as the alleged CENA was not working there which was confirmed by the DON. Social work will continue daily wellness visits and no major concerns were noted. Senior psychiatric services assessed and will continue follow up appropriately. An investigation was initiated and will remain ongoing . On 7/6/21 at 11:43 AM, an interview was completed with Nurse F regarding the incident with R801 and CNA A. Nurse F explained that on 6/20/21, a CNA reported R801's concerns to her, and in response she and another nurse went to assess and interview R801. Nurse F explained that R801 reported that CNA A showered them on their shower day and that the CNA used scalding hot water, and when asked for her to turn the water down, the CNA refused to adjust the water after several complaints that the water was too hot. Nurse F explained that R801 reported that they did not report it that day because they felt intimidated because the CNA was still there. Nurse F was asked if R801 described how the water felt, and she stated that R801 reported that their skin felt like it was burning. On 7/6/21 at 2:17 PM, an interview was completed with the DON regarding R801 and CNA A. The DON explained that she was notified of the incident on the Saturday following the incident, and that the resident waited to report it to their favorite CNA. The DON further explained the steps the facility took to initiate the investigation which included sending the CNA home immediately who when interviewed, denied the incident. The DON further explained that the CNA worked for a staffing agency that the facility utilizes. On 7/6/21 at 2:57 PM, an interview was completed with the staffing agency owner that CNA A was hired through. The owner explained that they hired CNA A in March and had met her working at another nursing home facility. They explained that they observed her work, and liked how she completed rounds, passed waters, and took vitals as soon as she came on her shift. The owner further stated that when they received a call about what occurred, they were Shocked. The owner explained that CNA A denied that the incident occurred with R800 but was unaware that there was another resident (R801) who also made allegations about CNA A. The owner further explained that they terminated employment with CNA A on 6/23/21. On 7/7/21 at 9:14 AM, an interview was completed with Social Worker H regarding the incident involving R801 and CNA A in the shower. Social Worker H explained that R801 reported to her that it was the Shower from Hell and further explained that while R801 was in the shower with the CNA, they asked for the water to be turned down because it was too hot, and the CNA refused. Social Worker H was asked about R801's mental state following the incident, and they explained that R801 was concerned and nervous about having to either testify or talk about the experience. Social Worker H was queried regarding R801 being prescribed anti-anxiety medication following the incident, and they confirmed that R801 was placed on [MEDICATION(S)] following the incident because the incident really bothered them. Social Worker H was asked if R801 needed the anti-anxiety prior to the incident and explained that they did not. A review of R801's medical record revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth as needed for Anxiety related to Generalized Anxiety until 7/6/21 .Give one tablet PRN (as needed) at HS (at bedtime) X (for) 14 days. A review of R801's June and July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/21 at 9:45 AM, an interview was completed with the NHA (Nursing Home Administrator) about the incident involving R801 and CNA A. The NHA explained that R801 was, Upset and fearful that the CNA was going to come back and hurt [them]. The NHA further explained that R801 talked about the incident regularly, and this week, appeared to be more Composed. The NHA also explained that R801 would not take a shower the following week because they were afraid, and when they did take their first shower, it was with a nurse monitoring the shower to ensure the water was not too hot for the resident. On 7/7/21 at 11:22 AM, CNA A was interviewed regarding the incident with R801 at which point she denied that she knew R801, or that there had been any allegations regarding a resident complaining of the water temperature being uncomfortable during a shower. A review of the staffing schedule for the date of the incident, revealed that CNA A worked both the day and afternoon shift on 6/16/21 and was assigned to the unit and room of R801 on the day shift. Further review revealed that R801 received a shower on 6/16/21 at 10:03 AM. A review of the facility's policy Abuse Program/Elder Justice Law with a review date of 12/2017 noted the following: The resident has the right to be free from verbal, sexual, physical, and mental abuse .Residents will not be subjected to abuse by anyone including .facility staff, other residents, consultants or volunteers, staff or other agencies servicing the resident. Facility's Removal Plan: On 7/7/2021 this plan was submitted to [State Agency] by [NHA]. We request this plan be accepted as our allegation Immediate Jeopardy removal and that a survey exit and removal of Immediate Jeopardy be conducted. Facility has implemented the following: -Resident R800 received a skin, pain, and psychiatric assessment. No skin or pain issues noted on assessment. Psychiatric services assessed and new anti-anxiety medications were ordered. Social services continues to follow up for wellness visits. DON interviewed resident with no significant findings of fear or harm - Resident R801 received a skin, pain, and psychiatric assessment no abnormal findings were noted on assessment. Social services continues to follow up for wellness visits. DON interviewed resident with no significant findings of fear or harm - Residents are receiving showers and care from staff that have been educated on facilities abuse policy - All employees' files were audited for abuse training and background checks -Staffing agencies utilized by the facility will have to show proof of abuse training and background checks prior to being scheduled in the facility. -A Modified General Orientation Form has been developed that will be used to in-serviced new Agency Staffing personnel upon their first assignment to this Facility. This Orientation covers the following subjects: -Facility Floor Plan & Chain of Command and Abuse Coordinator -Fire and Disaster Plan -Abuse Policies and Elder Justice Act -Resident Rights -HIPAA -Code of Conduct Handbook -Infection Control Standards and Isolation Precautions -Hand Hygiene -Cough Etiquette -Reportable Communicable Diseases -Blood borne Pathogens. -Covid Updates and precautions - Residents in the facility have been interviewed and all negative findings will be immediately addressed. - Water temperatures are checked weekly per facility protocol. - Water temperatures for shower room have been added to water temperature logs and checked weekly. Any water temperature above 110 Degrees Fahrenheit will be immediately corrected. - The facility administrative staff held a QAPI Ad Hoc meeting on 7/7/2021 to review the Facility Abuse Policy. It was deemed appropriate. - Administrative staff will reeducate Facility staff on identifying and reporting all types of abuse. - Maintenance Director will be responsible for auditing shower temperatures weekly and reporting findings to the QAPI Committee monthly. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: July 7, 2021

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices per the Centers for Disease Control (CDC) guidance during a COVID-19 (a severe and highly contagious respiratory infection) Infection Control Survey, by not implementing a comprehensive and readily accessible Covid-19 tracking and surveillance documentation and not placing a resident (R900) in isolation when readmitted to the facility, and placed back into the room with three residents (R901,R 902, R903) on 8/20/20. Resident 900 was placed in a private room on droplet precaution (for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) after testing positive for Covid-19 on 9/1/20. Residents 901, 902, and 903 remained in the same room and not placed on precaution/isolation after known exposure to Covid-19 per CDC guidance, resulting in the likelihood of serious illness or death from the spread of COVID-19 to residents and/or other staff. Findings include: The Immediate Jeopardy (IJ) started on 8/20/20 and was identified on 9/10/20. The Administrator was notified of the Immediate Jeopardy on 9/10/20 at 3:00 PM and was asked for a plan to remove the immediacy. The IJ was removed on 9/10/20, based on the facility's implementation of the removal plan as verified onsite on 9/11/20. Although the immediacy was removed, the facility's deficient practice remained at a pattern. No actual harm with potential for more than minimal harm that is not immediate jeopardy. On 9/10/20 at 8:20 AM, upon entering the facility, this Surveyor was greeted by the Administrator stating that they had two Covid-19 cases that came from the hospital. The Administrator was queried if their facility was a hub (Regional nursing home facilities that admit and care for COVID-19 positive nursing residents who do not require acute care provided in a hospital, or who have gone to the hospital, been medically stabilized, and determined ready for discharge) and the Administrator said, No. We have another facility for that. We have a designated Covid unit. On 9/10/20 at 8:55 AM, the Director of Nursing (DON) was asked the name of the facility's infection preventionist/specialist. The DON explained that the infection control specialist was on a medical leave of absence. The DON was asked who was covering for the infection control specialist and the DON said, Well, I guess it's me. On 9/10/20 at 9:55 AM, the DON was queried if R900 was placed in isolation/precaution after being readmitted to the facility after hospitalization on [DATE]. The DON stated, (R900) returned to the room with three other residents (R901, R902, R903). The DON was asked if it was the facility's process to isolate residents after hospitalization . The DON said, Residents do not need to go in isolation if the hospital tests them on the same day of discharge. Since (R900) was tested for COVID on their discharge date , we placed (R900) back into the same room. (R900) tested negative while in the hospital. The DON stated that the nurses perform a COVID Assessment once per shift. During the tour of the facility, there were several empty and clean rooms observed. On 9/10/20 at 10:15AM, R900's electronic medical record was reviewed and noted the readmission date of [DATE] and [DIAGNOSES REDACTED]. A review of R900's care plan initiated on 8/20/20 noted minimal to maximum assistance with activities of daily living .Private room or cohort with appropriate roommate Date Initiated 9/1/20. A record review of the COVID-19 test results for R900 revealed positive results on 9/1/20. R901's electronic medical record was reviewed and noted the admission date of [DATE] and [DIAGNOSES REDACTED]. R901 requires one person assist with activities of daily living. A care plan review noted the following: Observe standard precautions for infection control Date Initiated: 05/17/20. R902's electronic medical record was reviewed and noted the admission date of [DATE] and [DIAGNOSES REDACTED]. R902 requires one to two persons assist with activities of daily living. A care plan review noted the following: Observe standard precautions for infection control Date Initiated 5/17/20. R903's electronic medical record was reviewed and noted the admission date of [DATE] and [DIAGNOSES REDACTED]. R903 requires minimal assistance with activities of daily living. A care plan review noted the following: Observe standard precautions for infection control Date Initiated 5/17/20 .Private room or cohort with appropriate roommate Date Initiated 5/17/20. On 9/10/20 at 11:42 AM, a review of the facility's Infection Control Tracking log noted the last infection tracking was noted on 7/22/20. The DON was interviewed and queried about the facility's tracking of infection after 7/22/20 through 9/10/20. The DON said, Well, I was looking on (the infection control specialist) desk and I can't find the other documents. The DON was asked if they were covering during the absence of the Infection Control specialist and the DON said, I'm not the expert. I'm just covering. I don't know the policies and procedures. I can't do both jobs. I write the infections on my board in the office .but that's it. I've been trying to call (the infection control specialist). On 9/10/20 at 12:45 AM, the Administrator was interviewed and queried regarding R900 being readmitted into the same room with R901, R902, and R903 and that these residents not being on precaution/isolation after known exposure to the Covid-19. The Administrator said, Wow, I see what you are saying. I see what you are saying. No additional information received. On 9/10/20 at 2:22 PM, Nurse A was queried about the location of R901, R902 and R903. Nurse A said, They (R901, R902) are (siblings). They always go up front and look out of the window together. They hang out by the front window all the time. They might be in the TV room right now .R903 should be up front also. On 9/10/20 at 2:28 PM, R901 and R902 were observed in the Residents' Room (TV Room) across from the main nurses station. There were several staff and residents in the hallway. R901 was observed sitting in a wheelchair, in the TV Room without a mask. R902 was also observed in a wheelchair in the TV room with a mask. Two additional, unsampled residents (905 and 906) were observed in the TV room watching TV. R905 was wearing the mask underneath their chin. A review of the facility's Novel Coronavirus Prevention and Response policy and procedure dated 3/6/20 and updated 9/10/20 noted the following: i. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected [DIAGNOSES REDACTED].g., [MEDICAL CONDITION]). ii .Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community. 8.The Infection Preventionist shall maintain communication with the transfer facility to obtain results of the medical evaluation (i.e. COVID-19 is confirmed or ruled out), and shall implement procedures to identify and monitor others who may have been exposed if COVID-19 disease is confirmed. Per CDC Guidelines: Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). *Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. *Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. F880 Abatement Plan -On September 10, 2020, the facility moved resident 901, 902, and 903 to airborne isolation precautions. -On September 10, 2020, the facility looked back 14 days of all resident that were admitted , went out on appointments, and [MEDICAL TREATMENT] put them on airborne isolation. -On September 10, 2020, reviewed policies and deemed them to be appropriate. The Administrator meet with the Management team and provided re-education for Admission Process and room placement of resident who are potentially exposed and resident who are Covid-19 positive. On-going re-education with direct care staff. -On September 10, 2020, two residents including resident 900 was moved to a HUB facility. -The facility audited the covid screen to ensure all resident were not experiencing sign and symptoms of Covid-19 and will continue daily to ensure safety of all residents. Nursing staff will complete the Covid-19 screening every shift and Nurse Manager will review daily. If a resident exhibit any sign and symptoms the nurse will contact the DON/IFC to troubleshoot and the resident will be placed in a private room on airborne isolation precaution. The DON/IFC will log the resident information on the log for tracking. -On September 10, 2020, all admission within the last 14 days was reviewed by the Administrator, Director of Nursing, and Admission Director . The Admission Director will review all referral and place all admission and re-admission in airborne isolation precaution for 14 days. The DON will be responsible for weekly audit for admission, re-admission, and room changes. All admissions, re-admissions, [MEDICAL TREATMENT], LOA, and resident that experience sign and symptoms will be placed in a private room on airborne isolation precaution. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: September 10, 2020

This Citation Pertains to Intake MI 130. Based on observation, interview and record review, the facility failed to ensure beverages were within reach for two (#'s 703 and 704) and fourteen non-sampled Residents on the Second and Fourth Bays of the facility and failed to operationalize policies and procedures to ensure adequate oral intake was provided and documented for one (#702) of three Residents reviewed for dehydration, resulting in beverages being inaccessible to Residents, lack of documentation of oral intake, and Resident #702 experiencing a change in condition and requiring emergency treatment and hospitalization for dehydration. Findings include: A tour of the Second Bay of the facility was completed on 7/8/20 beginning at 11:15 AM. During the tour, 10 Residents had beverages in their rooms that were not within their reach including Resident #703 and Resident #704. On 7/8/20 at 11:30 AM, Resident #703 was observed laying in bed in their room. The Resident's water cup was noted not within the Resident's reach, approximately three feet away from their bed on a stationary table. An interview was conducted with the Resident's at this time. When asked if they were hungry, Resident #703 stated, I'm always thirsty. When asked about their water and availability of beverages, Resident's #703 did not provide a response. Record review revealed Resident #703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed Resident's #703 was severely cognitively impaired and required total assistance to perform ADLs. Review of Resident #703's care plans revealed a care plan entitled, Alteration in nutritional status potential for inadequate oral intake, beverage intake, difficulty chewing/swallowing, needs a mechanically altered diet (Initiated: 11/1/19; Revised:12/18/19). The care plan included the intervention, Offer snacks/beverages in between meals, PRN, and with activities (Initiated: 11/1/19). At 12:00 PM on 7/8/20, Nursing Assistant D was observed providing care to Resident #704 from the hallway of the facility. The Resident was sitting in a wheelchair with an overbed table positioned in front of them. Nursing Assistant D exited the room at 12:05 PM and an interview was conducted with the Resident at this time. The Resident was noted to have contractures in both of their hands but no limitations in movement were observed in the Resident's neck. The overbed table remained positioned directly in front of the Resident with nothing on it. A cup of water was across the room, on the Resident's dresser. When queried regarding their water being on the dresser, Resident's #704 indicated they could not get to it when it was on the dresser. With further inquiry regarding the frequency their water is not placed within their reach, Resident's #704 stated, Yes, it is usually on the table on the other side of the room. When asked if they are able to drink the water without assistance is positioned in front of them on the table, Resident #704 indicated they could. Resident #704 was then asked how they are able to get a drink of water when they want it and stated, I use the push button call light. The call light was observed hooked to the bed not within the reach of the Resident's. Resident #704 was then asked about the location of their call light and replied, I can't reach it where (Nursing Assistant D) put it. When queried how often their call light is positioned somewhere they cannot reach it, Nursing Assistant D displayed a sorrowful facial expression but did not provide a response. When queried if their water being placed somewhere they could not reach it was a concern, Resident #704 replied, Yes. Record review revealed Resident #704 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required limited assistance with eating and extensive assistance to complete all other ADLs. Review of Resident #704's care plans revealed a care plan titled, Alteration in nutritional status: Difficulty chewing/swallowing r/t (related to) dysphagia AEB (As Evidenced By) needs mechanical soft chopped . (Initiated: 4/19/17; Revised: 1/22/20). The care plan included the intervention, Offer snacks/beverages PRN (as needed) and activities (Initiated: 4/19/17). An interview was conducted with Nursing Assistant C on 7/8/20 at 12:10 PM. When queried regarding facility policy/procedure related to water/beverages for Residents, Nursing Assistant C revealed facility Nursing Assistants pass out water to Residents. When asked if the water cup should be within the Resident's reach, Nursing Assistant C replied, Yes, always. A brief tour of the Second Bay unit was completed with Nursing Assistant C at this time. When queried regarding observation of multiple Resident's water cups not being within their reach, Nursing Assistant C replied, Shouldn't be. Nursing Assistant C was then observed repositioning the water cups to within the reach of the Residents. On 7/8/20 at 12:15 PM, an interview was completed with Nursing Assistant D. When queried regarding observation of Resident #704's call light and water not being in their reach upon them exiting the room following the provision of care, Nursing Assistant D did not provide an explanation. A tour of the Fourth Bay facility was completed on 7/8/20 beginning at 12:15 PM. During the tour, four Residents had beverages in their rooms not within their reach. Resident # 702 Review of intake documentation for Resident #702, dated as received on 2/12/20, revealed Resident #702 was in the hospital at the time related to dehydration. The intake documentation further detailed Resident #702 is not offered water and their water is placed out of their reach at the facility. Record review revealed Resident #702 was originally admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to extensive assistance to perform Activities of Daily Living (ADLs) including one person supervision for eating. The MDS further indicated the Resident triggered for a nutritional Care Area Assessment (CAA) on 1/28/20. Review of Resident #702's medical record revealed the following progress note documentation: -2/6/20 at 10:21 AM: Nurses Data: Resident slept entire shift. Refused dinner x 3. Pressed lips together offer fluids and food . Physician notified. No new orders. -2/6/20 at 3:11 PM: Nurses Data: Resident has slept all shift. VS within normal limits. -2/7/20 at 11:19 AM: Nurses Data: Writer received in report that resident has been sleeping since yesterday, slept through all meals and was still asleep when writer came on to shift. Resident was moaning and groaning during care, would not open her eyes, mouth clenched unable to administer any medication . Resident lethargic would not respond using any kind of words . (Physician) notified, assessed resident, sent out 911 to (Hospital) . -2/7/20 at 1:42 PM: physician progress notes [REDACTED]. Patient was seen today per nursing staff request . apparently the patient has been somnolent since yesterday, refusing meals. Currently the patient is obtunded, responds to tactile stimulus . Assessment and plan . Patient will be sent STAT 911 via ambulance to ED for further care . An interview was conducted with Hospital Social Worker B on 7/8/20 at 10:00 AM. When queried regarding Resident #702, Hospital Social Worker B revealed the concerns related to the Resident had been pertaining to adequate fluid intake to prevent dehydration and a decline in condition upon admission to the hospital. Review of Resident #702's closed/discontinued care plans revealed the Resident did not have a care plan in place related to nutrition. Resident #702's medical record also contained an assessment titled, Long Form Nutritional Risk Assessment (Dated 1/28/20). The assessment included the following, Admission . Estimated Nutritional Needs . 4.b 2032 mL Fluid per day (minimum 1500 mL/day) . Risk Assessment: At risk for Unintended Weight Loss . Inadequate PO (oral) intake, ALZ (Alzheimer Disease) . needs assistance, cueing and encouragement with PO intake . Care Plan: Consume at least 75% of meals/fluids; Adequate hydration . Provide necessary assistance at meal time and between meals . Monitor oral intake of food and fluids . Snacks at PM and hs (bedtime) . [MEDICATION NAME] with carb steady (nutritional supplement)- 4 ounces TID (three times a day) with med pass . Offer snacks/beverages in between meals, at activities, and PRN (as needed) . Provide assistance . Provide 1440 cc (cubic centimeters- 1 cc= 1 mL) fluids with means, provide water/beverages at bedside, at activities and PRN. Encourage fluid intake . Comments: Resident is on consistent carb diet . PO intake varies, approximately 50% of for meals/fluids . receives adequate supplements in between meals to meet the estimates nutritional and hydration needs . Upon request for documentation pertaining to Resident #702's oral intake, hydration, and nutrition, the Director of Nursing (DON) provided a report of intake titled, Documentation Survey Report for January and February 2020. Review of the documentation revealed the total Intake: Amount of fluids at meals less than 800 milliliters (mL) for all meals on the following dates: -1/19/20: 600 milliliters (mL) -1/20/20: 200 mL -1/21/20: 540 mL -1/23/20: 560 mL -1/30/20: 750 mL -1/31/20: 480 mL -2/2/20: 320 mL -2/3/20: 120 mL -2/4/20: 200 mL -2/5/20: 750 mL -2/6/20: No fluid intake -2/7/20: 300 ml Review of the provided report also revealed, during Resident #702's stay at the facility, revealed the Resident did not receive any snacks, during morning, evening, or night shift, on 1/26/20, 2/3/20, 2/5/20, and 2/6/20. The documentation further revealed the following dates in which the Resident did not receive snacks and/or consumed 0 to 25% of the provided snack: -1/19/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/20/20: Evening shift; consumed 0 to 25%. No snack given on Night shift. -1/21/20: Evening shift; consumed 0 to 25%. No snack given on Day shift. -1/22/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/23/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/24/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/25/20: No snack given on Day or Night shift. -1/27/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/28/20: No snack given on Day shift. -1/29/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -1/30/20: Evening shift; consumed 0 to 25%; No snack given on Day or Night shift. -1/31/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -2/1/20: Evening shift; consumed 0 to 25%. No snack given on Day shift. -2/2/20: Evening shift; consumed 0 to 25%. No snack given on Day or Night shift. -2/4/20: No snack given on Day or Night shift. The documentation provided for February 2020 also included a section tilted Fluids-PRN (as needed). The only documentation included was NA (not applicable) on 2/3/20. Review of Resident #704's Medication Administration Record [REDACTED]. An interview was completed with the Director of Nursing (DON) on 7/8/20 at 1:30 PM. When queried regarding facility policy/procedure pertaining to availability of beverages/hydration for Residents, the DON indicated water is provided to Residents. When queried if water/beverages should be maintained within Resident's reach per facility policy/procedure, the DON replied, Always. Observations of all Residents on the Second and Fourth Bays of the facility who did not have water and/or a beverage within their reach were reviewed with the DON at this time. The DON proceeded to state that they would in-service staff. An interview was conducted with Registered Dietician (RD) A on 7/8/20 at 1:46 PM. When queried regarding Resident's #702's hydration status, RD A reviewed the Resident's documentation and stated, Their fluid needs were 2100 mL (per day). When queried regarding facility policy/procedure pertaining to follow up and documentation for Resident's identified as being at risk for altered nutrition, RD A stated, It depends on the status, status change, etc. When queried why Resident's #702 did not have any follow up nutritional documentation in their medical record when documentation reveals they were consuming less that their needs related to hydration, RD A reviewed the documentation of fluid intake and indicated they believe that staff are just not documenting intake. When queried if intake is supposed to be documented per facility policy/procedure, RD A replied, Yes. RD A then stated, (Resident #702) was also getting four ounces of med pass TID. When queried regarding Resident's #702 meeting their hydration needs, with 12 ounces (355 mL) of additional fluid, RD A did not provide an explanation and indicated they round on Residents eating in the dining room during the day to ensure they are eating and drinking. When asked how they are able to accurately observe 40-80 Resident's intake, RD A indicated they are present in the dining room. When queried regarding the Resident's being transferred to the hospital and admitted for dehydration, RD A was unable to provide an explanation. An interview was conducted with the facility Administer and Director of Nursing (DON) on 7/8/20 at 2:30 PM. When queried regarding documentation indicating Resident #702 did not receive adequate intake to meet their hydration needs, transfer to the hospital for altered mental status, and [DIAGNOSES REDACTED]. Review of facility policy/procedure entitled, Nutrition and Hydration Care (Reviewed: 10/10/09) revealed, Dehydration . Most Residents need at least 6 cups of liquids to stay hydrated .

Based on observation, interview and record review, the facility failed to assess, implement planned interventions, ensure appropriate infection control techniques and standards of practice for wound care measurement and assessment for two (#34 and #84) of 14 Residents reviewed for pressure ulcers (wounds caused by pressure) resulting facility acquired pressure sores for Resident #34 developing two stage two pressure ulcers and Resident #84 developing a stage four pressure ulcer and a Deep Tissue Injury (DTI), and the increased likelihood for decline in overall health status. In addition, the facility failed to assess, monitor, implement interventions and infection prevention principles during wound care for three (#'s 63, 81 and 93) resulting in pressure ulcer worsening, lack of implementation of planned interventions, and the likelihood for decline in overall health status. Findings include: Resident #34 Record review revealed Resident #34 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision with eating and extensive to total assistance to complete all other Activities of Daily Living (ADLs). The MDS revealed that the resident was at risk for pressure ulcer development but did not have any pressure ulcers. Review of facility provided pressure ulcer documentation revealed Resident #34 had a Rt. (right) buttocks Stage II (pressure ulcer); Facility Acquired. Review of a care plan entitled, (Resident #34) has pressure ulcer development r/t (related to) Disease process, incontinence, limited mobility (Initiated: 12/31/13; Revised: 10/22/19). The care plan included the interventions: -Administer treatments as ordered and monitor for effectiveness (Initiated: 12/21/13; Revised: 12/11/15) -Need to turn/reposition at least every 2 hours, more often as needed or requested (Initiated: 12/21/13; Revised: 7/25/18) -Requires the bed as flat as possible to reduce shear (Initiated: 12/21/13; Revised: 12/11/15) -Float heels while in bed (Initiated: 12/31/19) On 11/5/19 at 1:43 PM, Resident #34 was not observed in their room and Nursing Assistant K was queried regarding the whereabouts of resident #34. Nursing Assistant K stated, They are gone with their family. When asked about the level of care and assistance required by the resident, Nursing Assistant K revealed that the resident required extensive assistance. When asked if the Resident had a pressure ulcer, Nursing Assistant K indicated they did. Review of resident #34's Skin/Wound Note revealed the two following most recent notes: -2/13/18: Upon assessment writer observed resident's bilateral buttock with minimal light pink excoriation, skin is dry and intact, writer educated staff with the appearance of intact skin vs non-intact skin, and the application with the proper ordered treatment for [REDACTED]. -10/26/19: Upon assessment writer observed resident's Stage 2 pressure injury right inner buttock measuring size 2.3 cm x 0.7 cm x flat, ill-defined edges, red moist wound base, no drainage no odor. (Resident) has a Stage 2 pressure to right lateral buttock measuring 1.5 cm x 1.0 cm x flat, ill-defined wound edges, wound bed red and moist, no drainage, no odor. Treatment ongoing with Allevyn dressing to provide moist wound healing . On 11/6/19 at 9:37 AM, Resident #34 was observed in bed with the head of the bed elevated, positioned on their back with their heels directly on the mattress. Wound care observation for resident #34 was completed on 11/6/19 at 9:45 AM with Wound Care Nurse G. When queried regarding the resident's pressure ulcers, Nurse G stated, I think there are two, the right inner buttocks and the right lateral buttocks. Upon entering the room, resident # 34 was observed in bed, leaning to the left side with their heels directly on the mattress. After removal of the blankets, the resident's brief was observed soaked with urine and unhooked on one side. Once on their side, stool was observed on the resident's buttocks. An open, bleeding area was observed on the back of the resident's left upper thigh where the edge of the brief had been. The distal end of the wound was dark brown and black in color and the proximal end was red with peeling skin surrounding the area. When asked about the wound and the bleeding, Nurse G replied, It's just excoriation. When asked if the wound bed was blanchable, Nurse G pressed on the reddened area of the wound bed and indicated it was blanchable. When queried regarding the distal end of the wound bed, Nurse G pressed on the area. Blanching was not observed when pressure was applied to the dark brown/black colored area of the wound. Nurse G measured the open area of the wound bed and stated, It's 1 centimeter (cm) by 3 (cm). Another wound was observed on the Resident's upper right buttocks. The wound was irregularly shaped with black colored areas of tissue noted within the wound. After washing both areas, Nurse G applied [MEDICATION NAME] Skin Protectant to both wound beds using the same applicator. At this time, Nurse G indicated the wound care treatment was completed. When asked, Resident #34 was rolled onto their other side. An additional open area was observed on the Resident's right lower buttocks/upper thigh. The open area was irregularly shaped and dark in color with a scant amount of bleeding noted. The open area was surrounded by peeling tissue. Nurse G measured the open area of the wound bed and stated, It's 3.5 cm by 1 cm. When queried regarding Resident #34's heels, the Resident's legs were lifted. Both heels were dark with a ruddy, red color. When queried, Nurse G indicated the Resident's heels were blanchable. An interview was conducted with Wound Care Nurse G on 11/6/19 at 10:56 AM. When queried regarding Resident #34 having three pressure wounds when they indicated the Resident only had two, Nurse G did not provide an explanation. When queried regarding use of the same [MEDICATION NAME] Skin Protectant applicator for both wounds and infection control concerns including cross- contamination, Nurse G replied, I can see what you mean. On 11/6/19 at 12:04 PM, Resident #34 was observed in bed and positioned on their back with the head of the bed elevated and their heels directly on the mattress. An interview was conducted with Confidential Witness H and Resident #34 at this time. When queried regarding their ability to move themselves in bed, Resident #34 revealed they required assistance. When asked about staff assistance and how often they are repositioned, Confidential Witness H stated, (Resident #34) is always on their back when I am here. When asked how often they see the Resident, Confidential Witness H revealed they are frequently at the facility. With further inquiry regarding how many times during the day they are repositioned in bed by staff, Resident #34 stated, Two times a day. With further inquiry regarding repositioning when they are in their wheelchair, Resident #34 indicated they have a cushion in their wheelchair. On 11/6/19 at 12:10 PM, an interview was conducted with Nursing Assistant I. When queried how often Residents are repositioned in their wheelchairs, Nursing Assistant I replied, We try to lay them (Residents) down after meals. Record review of Resident #34's Treatment Administrator Record (TAR) revealed the following wound care treatment orders: -Cleanse open areas to right buttock with NS (Normal Saline). Pat dry. Apply Allevyn Gentle Q (every) 72 hours and PRN (as needed) every 72 hours for open area. The TAR revealed the last treatment completed on 11/3/19. -[MEDICATION NAME] skin protectant-cleanse buttock with soap and water, pat completely dry, apply [MEDICATION NAME] skin protectant to bilateral buttocks-let air dry. To be applied on Sun- Wed scheduled shower days. (DO NOT APPLY CREAMS OR LOTIONS TO THIS AREA) every day shift every Wed, Sun. The TAR revealed the treatment was documented as completed on 11/6/19. Resident #84 Record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], depression, diabetes mellitus, weakness and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive to total assistance to complete ADLs. The MDS further indicated the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. The Resident was admitted to Hospice on 10/30/19. On 11/5/19 at 2:27 PM, Resident #84 was observed in their room, laying in bed. The resident would make eye contact but did not verbally respond to questions. Review of resident #84's care plan revealed a care plan entitled, (Resident #84) has pressure ulcer development r/t Disease process, Immobility, Incontinence . (Initiated: 10/22/19). Care plan interventions included: -Administer treatments as ordered and monitor for effectiveness (Initiated: 10/22/19) -Bilateral blue skilled boots at all times (Initiated: 10/23/19) -Pressure reducing device on bed and wheel chair (Initiated: 10/22/19) On 11/5/19 at 3:50 PM, Resident #84 was observed to be positioned on their back in bed with their heels directly on the mattress. A strong foul odor was noted in the room. Observation of wound care for Resident #84's coccyx pressure ulcer occurred on 11/5/19 at 4:11 PM with Wound Care Nurse G and Nurse P. Upon removal of Resident #84's brief, a large amount of soft stool was observed. Wound Care Nurse G did not clean the Resident prior to removing the dressing covering the wound bed. A foul odor was noted on the removed dressing and was strongest near the wound bed. After the dressing was removed, Nurse P removed the stool sitting on the Resident's brief with a disposable wipe and pushed the brief under the Resident but did not cleanse the Resident's skin. Wound Care Nurse G then cleansed the wound bed with gauze soaked in saline. The wound bed was oblong with irregular edges, visible depth, and dark purple in color. The deepest aspect of the wound bed was lighter in color and approximately the size of a half dollar. The wound edges were observed to have attached and unattached areas and were black in color on the medial aspect of the wound bed and the proximal aspect of the wound bed edges were bright red with visible bleeding observed. The tissue surrounding the wound bed was dark purple in color. When queried if the tissue surrounding the wound was blanchable, Wound Care Nurse G pressed on the area. The tissue was observed to be non-blanchable. Wound Care Nurse G obtained measurements of the open area of the wound bed and stated, It's 9.8 (cm) by 6 (cm). Nurse G did not measure the depth of the wound and did not include the non-blanchable tissue surrounding the wound bed in the measurement. Wound Care Nurse G and Nurse P then placed the soiled brief back on the Resident and Wound Care Nurse G stated, The Aides (Nursing Assistants) will come back (to change brief). Review of documentation for Resident #84 revealed the following two Skin/Wound notes. -10/1/19: Nurses Note . Received resident in geri chair . Skin assessment done. skin has redness in groin areas with [MEDICATION NAME] powder treatment in place . -10/2/19: Skin/Wound: Resident is a new admit to the facility on [DATE] . skin assessment reveals . excoriated skin with redness to groin areas . skin is dry and intact no open areas noted . -10/22/19: Skin/Wound: Upon assessment writer observed resident's RT (right) heel with a dark discolored area measuring 7.5 cm x 9.5 cm with a flat smooth appearance, defined edges, oval in shape. The inner aspect of this area is dark beige with outer inner edges with a maroon color . -10/27/19: Nurses Note . Writer observed skin excoriation to resident right buttocks and coccyx. Right Buttocks measures 3 cm by 4.3 cm, coccyx is 6.5 cm by 1.9 cm. There is also a deep tissue injury to the right buttocks that Measures 6.5 cm 1.9 cm . -10/28/19: Interdisciplinary Team Note . Skin excoriation observed to resident right buttocks and coccyx with a deep tissue injury observed to the center of the right buttocks while rendering care . An interview was conducted with Wound Care Nurse G on 11/6/19 at 9:15 AM. When queried regarding documentation indicating Resident #84 had a pressure ulcer on their heel in addition to the pressure ulcer on their coccyx, Wound Care Nurse G stated, (Resident #84) does have a DTI (Deep Tissue Injury) on their heel. When queried why the dressing change was not completed on 11/5/19 when observation of wound care for all Resident #84's pressure ulcers was requested to be observed, Wound Care Nurse G did not provide an explanation. When queried regarding recent measurements and condition of the Resident's heel pressure ulcer, Wound Care Nurse G indicated the wound was dry. No further explanation was provided. When asked about the Resident's coccyx pressure ulcer, Nurse G indicated the pressure ulcer was a Kennedy ulcer (pressure ulcer that develops during the late stages of dying, typically on the sacrum in a pear, butterfly or horseshoe shape) and that the Resident was on Hospice. With further inquiry regarding the [DIAGNOSES REDACTED]. On 11/6/19 at 12:13 PM, Resident #84 was observed in their bed with heels positioned directly on the mattress. Resident #63 On 11/4/19 at 9:18 AM, Resident #63 was observed in bed, positioned on their back. When queried, Resident #63 revealed they had a pressure ulcer. Record review revealed Resident #63 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review further revealed a [DIAGNOSES REDACTED]. onset date: 5/13/19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete Activities of Daily Living (ADLs). The MDS further revealed the Resident did not display any behaviors including rejection of care and had one stage four pressure ulcer. On 11/5/19 at 10:30 AM, Resident #63 was observed in bed, positioned on their back with their heels directly on the mattress. The head of the bed was elevated in a sitting position. When asked about their pressure ulcer, Resident #63 stated, It started here. Review of Resident #63's care plan entitled, (Resident #63) has pressure ulcer development r/t Disease process, Immobility, Incontinence, Debility, Hx (History) of ulcers (Initiated: 10/17/19). The care plan included the interventions: -Administer treatments as ordered and monitor for effectiveness (Initiated: 10/17/19; Revised: 10/18/19) -Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Initiated: 10/17/19) -Bed as flat as possible to reduce shear (Initiated: 10/17/19; Revised: 10/18/19) -Float heels off bed (Initiated: 10/17/19) -Pressure reducing device on bed and wheelchair (Initiated: 10/17/19) On 11/5/19 at 1:14 PM, and 2:23 PM, Resident #63 was observed in bed, positioned on their back with the head of the bed elevated and their heels directly on the mattress. Resident #63 was visibly upset and was observed telling Nurse J, It's driving me crazy, this pain. It just hasn't stopped. On 11/5/19 at 2:30 PM and 4:14 PM, observation occurred of Resident #63. At each observation, the Resident was in bed, with the head of the bed elevated, and positioned on their back with their heels directly on the mattress. Record review of Resident #63's medical record revealed the following documentation: -2/25/19: Skin/Wound Note . Resident is a re-admit to the facility on [DATE] from (hospital) . ST II (Stage two) pressure injury to coccyx measuring size is 3 cm x 2 cm x 0.2 cm undefined edges, wound bed is pink 50% / white 50% and moist, no drainage no odor . -9/5/19: Skin/Wound Note . ST IV (Stage 4) coccyx wound . measuring size is 5 cm x 6.5 cm x 1.2 cm, wound base has pink granulation moist uneven wound base, edges are ill defined, drainage is small serous, no odor -10/26/19: Skin/Wound Note . Upon assessment writer observed resident's ST (stage) 4 pressure injury to coccyx . new measuring size 5.5 cm x 4 cm x 1 cm, circular in shape, ill-defined edges, red hollow moist wound base with no bone or tendon exposure, no drainage no odor . On 11/6/19 at 8:15 AM, Resident #63 was observed in bed, positioned on their back. The head of the bed was elevated and their heels were on the mattress. At 10:11 AM on 11/6/19, observation occurred of Resident #63 in their bed and positioned on their back with the head of the bed elevated and their heels positioned directly on the mattress. The alternating air mattress on the Resident's bed was noted to have a flashing light indicating Alarm Reset. With palpation, the air mattress was noted to be very soft and easily compressed. An interview was completed on 11/6/19 at 10:39 AM with Wound Care Nurse G. At this time, observation of Resident #63's alternating air mattress was completed with Wound Care Nurse G. When queried regarding the flashing light indicating Alarm Reset and the mattress compression level, Nurse G stated, I don't know. I think it is okay. Wound care observation for Resident #63 occurred on 11/6/19 at 10:45 AM with Wound Care Nurse G and Nurse [NAME] Resident #63's pain level was not assessed by facility staff prior to beginning the dressing change. Upon removing the Resident's brief to expose their coccyx pressure ulcer, a large amount of stool was observed. The bottom aspect of the current dressing was covered with stool. Prior to removing the stool and restoring the Resident's hygiene, Nurse G removed the dressing covering the wound bed. The wound bed was observed to be irregularly, oblong shaped with the largest aspect of the open wound being approximately the size of a baseball. The wound bed had significant depth with red with white colored tissue. Tunneling and areas of greater depth were observed at approximately the seven and five o'clock positions within the wound bed. The wound edges were noted to be unattached in various areas. The tissue surrounding the open area was a very dark red/purple color with yellow colored tissue noted at approximately the seven o'clock position. The very dark red/purple color extended further to the Resident's right buttocks in an irregularly shaped circle and was larger in size than a softball. Bright red skin was noted on the Resident's lower back. When queried regarding the redness, Nurse J stated, I think it is from the tape. After the dressing was removed, Nurse J began cleaning the Resident. When cleaning the bowel movement, Nurse J was observed wiping the stool back towards the open, uncovered wound. At this time, Wound Care Nurse G cleansed the wound bed with gauze saturated in normal saline. While cleaning the wound bed, Wound Care Nurse G scrubbed the area of yellow tissue noted on the edge of the wound. Wound Care Nurse G then used their fingers to pull off the attached tissue. The area where the tissue was removed began to bleed. Wound Care Nurse G then measured the open area of the wound but did not include the impaired skin on the wound bed edges, and stated, It's 4.8 (cm) by 3 (cm). When queried regarding the depth of the wound, Wound Care Nurse G folded the paper measuring tape in half lengthwise and placed the non-rigid measuring tape into the wound base. The folded tape measure was -observed to have blank paper on the end prior to where the measurement lines began and was not placed into the tunneled areas of the wound bed. Wound Care Nurse G proceeded to apply gauze with Triad (wound ointment) in the wound bed, covered by an ABD gauze pad and secured with [MEDICATION NAME] tape. The [MEDICATION NAME] tape was placed directly over the red colored skin. Resident #63 was then positioned on their back. When asked about repositioning, Wound Care Nurse G stated, (Resident #63) is non-compliant. No other explanation was provided, and the Resident was not offered to be assisted into a different position. An interview was conducted with Resident #63 at this time. When queried regarding their current pain level, Resident #63 stated, It's a 8 (on a scale of zero to 10 with 10 being the worst imaginable pain). When asked where their pain was located, Resident #63 replied, In my butt. When asked when they last received pain medication, Resident #63 replied, I don't know. Nurse J then stated, It was with morning med's, approximately 8:00 AM. Record review revealed Resident #63 did not have a care plan in place pertaining to refusal and/or denial of care. An interview was conducted with Resident #63 on 11/6/19 at 11:05 AM. When queried regarding turning and repositioning in bed, Resident #63 revealed they have pain in their shoulders when they turn in bed. When asked if staff have attempted different methods of repositioning to reduce pressure on their wound and pain in their shoulders, Resident #63 indicated staff have only attempted to place a wedge behind them which increased the pain but have not attempted other methods. Resident #93 On 11/05/19 at 7:48 AM, Resident #93 was asked about wounds acquired at the facility and their ability to move while laying on their back and stated, It is really painful. I have had a stroke on one side and can shift off of it a little. That does help. I do need help to move onto my side. (Resident #93 was observed to be able to move their hips slightly, but not shift onto the left or right side.) Therapy showed me how to shift off it when I am up in the chair. When asked how they thought it developed, Resident #93 stated, Therapy said it was because I wasn't turning enough. Record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform ADLs. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. On 11/5/19 at 1:53 PM. Resident #93 was observed sitting in a wheelchair in their room. When queried regarding their pressure ulcer, Resident #93 stated, I got it the first week I was here. It started hurting but they (facility staff) didn't do nothing at first. Then they put [MEDICATION NAME] on it and finally got the wound nurse to look at it. Resident #93 then stated, It hurt so bad last night I couldn't sleep. When queried regarding their ability to move themselves in bed and in their wheelchair, Resident #93 replied, No, I can't move myself. I'm paralyzed on the left side. Resident #93 further revealed staff transferred them utilizing a Hoyer lift (mechanical lift). Resident #93 then stated, Have you ever had one of these (pressure ulcers)? It it the worst pain I have ever had. It hurts so bad all the time, just brings me to tears. I can't even take it. Review of Resident #93's care plans revealed a care plan entitled, (Resident #93) has pressure ulcer development r/t Disease process, Immobility, Incontinence (Initiated and Revised: 10/18/19). The care plan included the interventions: -Administer treatments as ordered and monitor for effectiveness (initiated and Revised: 10/18/19) -Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (initiated and Revised: 10/18/19) -Pressure reducing device on bed and wheel chair (initiated and Revised: 10/18/19) On 11/6/19 at 8:57 AM, Resident #93 was observed in their room in bed. The Resident was positioned slightly on their right side. A bowel movement odor was distinctly noticeable in the room. When asked how they were doing, Resident #93 stated, Oh, I was on my back all night. It hurt, I couldn't sleep. When asked the last time they were repositioned by staff, Resident #93 stated, When they put the wedge in . around 5:00 or 5:30 AM. Wound care observation of Resident #93's pressure ulcer occurred on 11/6/19 at 9:18 AM with Wound Care Nurse G. After Resident #93 was positioned on their side, Wound Care Nurse G removed the dressing in place over the Resident's coccyx pressure ulcer. A small open area, approximately the size of a pencil eraser was observed in the center of the Resident's coccyx. The area was open with white tissue noted along the wound edge. The depth of the wound was unable to be visualized. A red, discolored area of skin was noted left of the Resident's coccyx. Another area, slightly larger than a pencil eraser was observed on the right side of the coccyx. The area surrounding the wounds was dark in color with peeling tissue. Wound Care Nurse G measured the area on the right side of the coccyx and stated, It's 3 (cm) by 0.5 (cm). Wound Care Nurse G then measured the area directly over the Resident's coccyx and stated, It's 1 (cm) by 0.5 (cm). When asked about the skin surrounding the open wounds, Wound Care Nurse G indicated the area was excoriated. Wound Care Nurse G proceeded to cleanse the areas, without performing hand hygiene between each open wound, and then applied Allevyn treatment to the areas and cover with a single dressing over the Resident's entire coccyx region. Record review of Resident #93's Electronic Medical Record (EMR) revealed the following Skin/Wound Note documentation: -10/7/19: Resident is a new admit to the facility on [DATE] from (Hospital) . skin assessment reveals . blanchable redness to bilateral buttock and sacrum . -10/18/19: Assessment . Writer observed resident's ST II (Stage two) pressure injury to coccyx documented on 10/16/19. Measuring size is 2 cm x 1.5 cm x 0.2 cm, ill-defined edges with irregular shape, wound bed is red/pink moist no drainage, no odor . -10/28/19: Assessment . resident's ST II pressure injury to coccyx healing well at this time. Measuring size is 1.8 cm x 1 cm x flat, ill defined edges with irregular shape, wound bed is red/pink moist no drainage, no odor Record review revealed no Wound Care Physician documentation in the EMR for Resident #93. An interview was completed with Wound Care Nurse G on 11/6/19 at 10:45 AM. When queried regarding wound measurements, Wound Care Nurse G stated, We only measure the open area. With further inquiry regarding facility policy/procedure pertaining to wound measurements and impaired tissue surrounding the open area of the wound bed, Nurse G stated, Yes, we do not measure any discolored areas or anything like that. When queried if they regularly measure wound depth using a folded paper measuring tape, Nurse G replied, Yeah. When queried regarding accuracy of measurements and facility policy/procedure, Nurse G indicated they can also use Q-tips to measure depth but there were none available. An interview was conducted with the Director of Nursing (DON) on 11/6/19 at 2:30 PM. When queried regarding facility policy/procedure pertaining to wound measurements, the DON stated, Measure all the impaired tissue. When asked about observations of wound measurements completed by Wound Nurse G, the DON stated, I think there is a competency issue in that area. When queried regarding Resident #84's pressure ulcer and observations, the DON revealed the pressure ulcer was facility acquired and could not be called a Kennedy ulcer without evaluation by a physician. When queried regarding observations of bowel movements during wound care, the DON indicated Resident's should be cleaned prior to removing the dressing due to infection risk. No further explanation was provided. R81 On 11/04/19 at 10:05 AM, R81 was observed seated in a wheelchair on the right side of their bed. On 11/04/19 at 12:26 PM, R81 was observed seated in a wheelchair up to a table in the main dining room for lunch. On 11/05/19 at 7:53 AM, R81 was observed seated in a wheelchair at their bedside. R81 was then moved to the main dining room for breakfast. On 11/05/19 at 9:56 AM, R81 was observed to be in their room seated in a wheelchair, asleep. On 11/05/19 at 1:32 PM, R81 was observed to be laying on their back in bed. On 11/05/19 at 2:15 PM, R 81's wound to the tailbone/sacrum was observed with the Wound Care Nurse Staff G and Certified Nursing Assistant (CNA) [MI] R81 was observed with a dime size wound with 100% white slough to the base. Staff G described this as biofilm and indicated it may have to be removed to assist the wound to heal. The tissue directly around the wound was light pink as recently healed tissue would appear, outside of that was a purple ring about an sixteenth to an eighth inch wide, which did not appear to completely blanch on the application of pressure by staff G. The wound nurse was asked about the purple coloration around the sacrum wound of R81 and acknowledged that it could be evidence of a deep tissue injury. R81 was positioned by staff onto the left side after the observation. No positioning device was used to maintain the resident on their left side. R81 stated, It hurts when they put me on the bed pan. R81 was not able to lift the left arm or leg independently. On 11/05/19 at 4:14 PM, R81 was observed in bed, laying slightly on their left side. On 11/05/19 at 5:01 PM, R81 continued in bed as before on left hip area. R81 would demonstrate putting their right hand behind the buttocks to relieve pressure. No positioning device was used to maintain the resident on their left side. On 11/06/19 at 7:16 AM, R81 was observed seated in a wheelchair on the right side of bed. R81 was then taken by staff down to the main dining room for breakfast. On 11/06/19 at 9:50 AM, A review of the facility Pressure Injury QA Log revealed the sacrum wound for R81 was acquired on 10/01/19, was a stage two, the Braden score was 13 and on 10/18/19 and 10/25/19 the wound was noted as moist and white. On 11/06/19 at 12:28 PM, R81 was observed to be in bed, slightly on to the left side, but still laying on their back. R81 requested to get up to eat their lunch and CNA L assisted R81 into their wheelchair. On 11/06/19 at 1:25 PM, 2:28, 3:23 and 3:30 PM, R81 was in their bed laying on their back. No positioning device was used to maintain the resident on their side or offload pressure from the sacrum. A review of the facility record for R81 revealed: R81 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition, the need for the extensive assistance of one person for bed mobility, transfer, dressing, bathing, hygiene, toilet needs and locomotion and frequently incontinent of urine and stool. The MDS date 09/30/19, 12/28/18 and 06/30/19 indicated no pressure sores or other wounds were present, but R81 was at risk for pressure injuries. The care plan indicated: Decreased (activities of daily living) ADL ability, (Other: Left side weakness, decline in overall condition). revised 01/03/19. The care plan (R81) has [MEDICAL CONDITION] (stroke) related to [MEDICAL CONDITION], initiated 12/24/19, indicated turn and reposition every two hours and (as needed) PRN. Keep body in good alignmen (TRUNCATED)

Based on observation, interview and record review, the facility failed to transfer one resident (Resident #17) with two persons and a mechanical lift as care planned, for one resident reviewed for rehospitalization , resulting in increased unnecessary pain, anxiety, and a fractured tibia and fibula (broken ankle) requiring a hospitalization . Findings include: On 1/8/19 at 10:24 AM, Resident #17 was observed lying in a fetal position on their right side in bed. Resident #17's bilateral legs were contracted at the knees and hips, at the hands, leaving them with limited mobility and dependant for all care and activities of daily living (ADLs). Resident #17 had clear speech and was alert and oriented to person, place, time and medical situation. During an interview, Resident #17 stated, In (MONTH) a nurse aide (Certified Nursing Assistant/CNA) transferred me by picking me up and plopping me in the chair. She was supposed to use a lift. I said something to her, but she did it anyway and I broke my leg. Resident #17 started to cry during the interview and stated, I have a lot more pain in my leg now, in fact, I am having a lot of pain now and asked for a pain pill. A record review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #17 was dependent for transfers and needed extensive to total assist for all other ADLs. The MDS also revealed that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. Resident #17 was admitted to the facility on [DATE] and then readmitted on [DATE] following their hospitalization from the above fracture. Admission [DIAGNOSES REDACTED]. A record review of the Progress Notes for Resident #17 revealed the following: 9/27/18 2:53 PM (Physician)-Patient was seen for left leg pain .reviewed Patient was seen today per nursing staff request due to new onset pain in the left leg happened after a transfer with Hoyer lift (mechanical lift used to lift people that cannot bare weight) earlier today. Patient stated that the pain started when they were in the lift and heard the bone cracking Left leg examination; deformity and tenderness over the distal end of the left leg with mild skin bruising .Acute left leg pain suspicious for acute fracture in tibia/fibula .Transfer patient to the ED (Emergency Department) ASAP (as soon as possible) for stat X-Ray and orthopedic surgery evaluation . 9/27/18 3:46 PM (Restorative Nursing)-Writer was informed by Desk Nurse Supervisor that resident had verbalized a complaint about their CNA not completing a transfer correctly. Resident had requested an x-ray to be completed and the Physician was notified of the request and circumstances surrounding it and said that he would be in to see the resident prior to ordering x-rays. I went down and interviewed the resident and had them walk me thru what they said occurred. Resident is alert and oriented and can make their needs known. Resident was admitted to the facility with contractures in both upper and lower extremities .resident requires the assistance of staff for all their ADL needs. When assessing the resident's left leg there was no bruising noted to the area that was visible, there appeared to be some slight swelling to the lower area of the left leg, tenderness noted to touch, and resident complained of pain. When physician arrived, he came down and assessed resident and had them inform him of what occurred . 9/27/18 (Nursing) 4:00 PM-Nurses Late Entry-At 9:50 AM resident's bed was reported to not be working. I looked at it but was unable to find a reason for the malfunction. Maintenance was informed and came to look at it, said the motor was broke and they needed to get out of the broken bed unto another bed. At that time, CNA was informed of need for the patient to be transferred so that the bed could be fixed. Resident was brought out into the hallway so that the beds could be moved around. They were crying at the onset of coming out and stated their left leg had severe pain unlike any pain they had had before .At 10:50 AM they requested to talk to the DON (Director of Nursing) . On 1/8/18 at 3:00 PM, an interview was completed with the Administrator regarding the above situation. The Administrator confirmed that Resident #17 had suffered from a fractured leg and stated, The CNA made a poor choice. She chose not to use a hoyer lift (to transfer the resident out of bed). We terminated the CNA. On 1/8/18 at 4:24 PM, Resident #17 was further queried regarding the above incident and stated, They needed to fix my bed, the CNA came in and grabbed me with one arm holding on to the back of my pants. I told her she was supposed to use a lift but she told me she was in a hurry because she had to get me out of the broken bed. I was scared but I let her because she was a bigger lady and figured she could handle me. When she plopped me in my chair, my legs got caught underneath me and I heard a snap. I thought that both my legs broke. I can't control my legs, that's why they are supposed to use the lift. I cried for hours from the pain .they finally sent me out to the hospital. My ankle was fractured. I had a cast on. I didn't need this with all that has happened to me so far. On 1/8/19 at 5:00 PM, Family Member G was interviewed in regards to the ankle fracture and improper transfer of Resident #17 on 9/27/18. Family Member G stated, I know that it was an accident. I didn't really know the aide. It caused a lot of pain and now (Resident #17) is a lot more sensitive in that leg. I was upset about it but didn't want to get involved in it because I was afraid of retaliation (from the facility). A record review of the hospital discharge records dated 9/30/18 for Resident #17 revealed the following: Diagnosis-Left fibular fracture-displaced; tibia fracture. A record review of the Transfer Care Plan for Resident #17 revealed the following: Focus-Safe Transfers/injury prevention Outcome-(Resident #17) will transfer in a way that promotes safety .(created 4/20/18). Interventions-Hoyer lift 2 staff members must always be present .(initiated 4/18/18). On 1/9/19 at 12:04 PM, an interview was completed with the DON in regards to the fractured ankle of Resident #17. The DON stated, (Resident #17) told us that they were transferred without the hoyer lift. The CNA denies it but we felt the resident was credible enough so we let her (the CNA) go. She was a long standing employee. A record review of the Incident Report for Resident #17 dated 9/28/18 revealed the following: Description-Observed resident sitting in their wheelchair crying stated had severe pain in left lower leg and requested to speak to DON. Mental Status-Oriented to Person .Place .Time .Situation. Injury-Lump/goose egg .left lower leg (front). Level of Pain-10 (10 is highest pain ranking on standard 1-10 pain scale). Level of Consciousness-Alert. On 1/9/19 at 1:30 PM, an interview was completed with the Administrator regarding CNAs not following transfer techniques as care planned, particularly with the transfer of Resident #17 on 9/27/18. The Administrator stated, The CNA said she did use the hoyer lift, she never admitted to not. It was a tricky situation for us. We let the CNA go after we investigated for that and other issues we had with her. We let her go about ten days later. A record review of the facility policy titled, Transfer Status/Transfer Orders with a recent revision date of 10/2018 revealed the following: Procedure-A. Upon admission to the facility all residents will receive a transfer status based on their weight bearing status and abilities. #5-Hoyer lift-two staff member must ALWAYS be present .

THIS CITATION PERTAINS TO INTAKE MI 012 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#502) OF FOUR RESIDENTS REVIEWED FOR BEHAVIORS RECEIVED APPROPRIATE BEHAVIORAL INTERVENTIONS PRIOR TO RECEIVING AN "AS NEEDED" ANTI-ANXIETY MEDICATION. THIS RESULTED IN RESIDENT #502 SUSTAINING A FALL RESULTING IN A RIB FRACTURE AND LACERATION TO HIS FOREHEAD. FINDINGS INCLUDE: RESIDENT #502 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET assessment dated [DATE] DOCUMENTED A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 13 WHICH INDICATED THAT RESIDENT #502 WAS COGNITIVELY INTACT. IN AN INTERVIEW WITH FACILITY ADMINISTRATOR #1 ON 03/13/2012 AT APPROXIMATELY 9:25 A.M., SHE EXPLAINED THAT ON 01/29/2013, RESIDENT #502 "WAS ALERT AND ORIENTATED TIMES THREE, USED A WHEEL CHAIR FOR AMBULATION AND REQUIRED ASSISTANCE FOR MOBILITY. HE (#502) SEEMED MORE AGITATED THAN USUAL THAT (1/29/2013) MORNING. HE ROLLED OUT OF THE BED EARLY THAT MORNING AND LATER HE ATTEMPTED TO AMBULATE FROM HIS WHEEL CHAIR AND fell . HE SUSTAINED A RIB FRACTURE AND A LACERATION TO HIS FOREHEAD." ACCORDING TO ADMINISTRATOR #1, THE FALL OCCURRED AT 10:30 A.M. ON 1/29/2013. ON 03/13/2013 AT APPROXIMATELY 9:40 A.M., CERTIFIED NURSING ASSISTANT (CNA) #6 EXPLAINED THAT ON 01/29/2013 AT AROUND 9:30 A.M., "I (CNA #6) WAS PASSING HIS (#502'S) ROOM AND I SAW HIM ON THE FLOOR. HE HAD BEEN AGITATED EARLIER THAT DAY. HE (#502) HAD BEEN TREATED WITH MEDICATION FOR SCABIES THE NIGHT BEFORE AND HE SEEMED TO BE UNCOMFORTABLE." ACCORDING TO THE LATE ENTRY NURSES NOTES DATED 01/29/2013 (09:25 A.M.), "WRITER (LICENSED PRACTICAL NURSE/LPN #2) INTO RESIDENT'S ROOM. RESIDENT (#502) WITH INCREASED AGITATION...EXPLAINED TO RESIDENT (#502) THAT HE WAS GOING TO HAVE A SHOWER DUE TO THE MEDICATION OF [MEDICATION NAME] (MEDICATION USED [MEDICATION NAME] FOR THE treatment of [REDACTED].#2) WAS GOING TO CHECK TO SEE IF HE (#502) HAD A PRN (MEDICATION AS NEEDED) ORDERED FOR AGITATION AND IF NOT AN ORDER WOULD BE OBTAINED FOR ONE. WRITER (LPN #1) LEFT THE ROOM AND WENT TO CHARGE NURSE TO MAKE HER AWARE OF THE AGITATION. ASKED FLOOR NURSE TO CHECK TO SEE IF PRN WAS AVAILABLE. FLOOR NURSE STATED THAT HE (#502) DID NOT HAVE A PRN ORDER. WRITER TO DESK NURSE AND ASKED THAT SHE CALL THE PHYSICIAN TO OBTAIN an order for [REDACTED]. REVIEW OF A physician's orders [REDACTED].#502. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. ON THE MORNING OF 01/29/2013. DURING AN INTERVIEW WITH LPN #2 ON 03/13/2013 AT APPROXIMATELY 12:30 P.M., LPN #2 EXPLAINED THAT THE [MEDICATION NAME] WAS APPLIED TO RESIDENT #502'S SKIN THE NIGHT BEFORE, AND HAD BEEN APPLIED TO ALL RESIDENTS AS A PREVENTION METHOD BECAUSE THERE HAD BEEN KNOWN CASES OF SCABIES IN THE FACILITY AT THAT TIME. LPN #2 STATED THAT THE [MEDICATION NAME] WAS ADMINISTERED TO RESIDENT #502 FOR AGITATION. LPN #2 WAS UNABLE TO CONFIRM IF RESIDENT #302 RECEIVED HIS SHOWER OR IF OTHER NON-MEDICATION METHODS OF CALMING WERE PROVIDED TO RESIDENT #502 BEFORE THE [MEDICATION NAME] WAS ADMINISTERED. NURSE'S NOTES DATED 01/29/2013 DOCUMENTED, "CNA OBSERVED RESIDENT (#502) ON FLOOR IN ROOM NEAR BED LYING ON LEFT SIDE. OBSERVED BLOOD ON RIGHT SIDE OF FACE AND LACERATION TO RIGHT TEMPORAL AREA. SKIN TEAR TO RIGHT WRIST." ON 03/15/2013 AT 9:40 A.M., LPN #5 EXPLAINED THAT SHE WAS PRESENT ON THE DAY THAT RESIDENT #502 SUSTAINED THE INJURY. "THERE WERE QUITE A FEW PEOPLE IN THE ROOM WHEN I GOT THERE. HE (#502) WAS LYING ON HIS LEFT SIDE. THERE WAS A POOL OF BLOOD NEXT TO HIM AND A GASH ON HIS FOREHEAD. HE HAD INCREASED CONFUSION THAT DAY." ON 03/15/2013 AT APPROXIMATELY 12:30 P.M., THE FACILITY ADMINISTRATOR WAS ASKED IF RESIDENT #502 EVER RECEIVED A SHOWER TO WASH OFF THE [MEDICATION NAME] THAT MORNING, AND ABOUT OTHER NON-MEDICATION INTERVENTIONS THAT MAY HAVE BEEN UTILIZED INSTEAD OF THE [MEDICATION NAME]. THE FACILITY ADMINISTRATOR REPORTED THAT HE (#502) DID NOT RECEIVE A SHOWER, AS HE WAS TOO AGITATED TO GO INTO THE SHOWER ROOM. ACCORDING TO THE GERIATRIC DOSAGE HANDBOOK 12 TH EDITION, "[MEDICATION NAME] ([MEDICATION NAME]) MAY CAUSE PARADOXICAL REACTIONS (OPPOSITE TO THE EFFECT WHICH WOULD NORMALLY BE EXPECTED), INCLUDING HYPERACTIVE OR AGGRESSIVE BEHAVIOR THAT HAVE BEEN REPORTED WITH BENZODIAZEPINES..." ACCORDING TO THE X-RAY RESULTS DATED 01/29/2013, "THERE IS A [MEDICAL CONDITION] LATERAL 3RD RIB. CORTICAL IRREGULARITY OF THE DISTAL CLAVICLE IS NOTED, SUSPICIOUS FOR FRACTURES." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 216 AND MI 406. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#101) OF 3 SAMPLED RESIDENTS REVIEWED FOR SAFE ENVIRONMENT, FROM A TOTAL SAMPLE OF 3 RESIDENTS, RECEIVED ADEQUATE SUPERVISION TO PREVENT ACCIDENTS WHEN RESIDENT #101 WAS LEFT UNATTENDED AND fell , RESULTING IN MULTIPLE FACIAL INJURIES INCLUDING FACIAL FRACTURES. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET DATED 11/07/12 REVEALED THAT RESIDENT #101 WAS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #101 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, NEEDED EXTENSIVE ASSISTANCE AND ONE PERSON PHYSICAL ASSISTANCE FOR BED MOBILITY, WAS TOTALLY DEPENDENT AND NEEDED TWO + PERSONS FOR TRANSFER, WALKING IN ROOM AND CORRIDOR DID NOT OCCUR, AND WAS TOTALLY DEPENDENT AND NEEDED ONE PERSON PHYSICAL ASSISTANCE FOR LOCOMOTION OFF UNIT, EATING, AND PERSONAL HYGIENE. THIS MDS ALSO INDICATED THAT RESIDENT #101 WAS NOT STEADY AND ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE WHILE MOVING FROM A SEATED TO STANDING POSITION AND SURFACE-TO-SURFACE TRANSFER. REVIEW OF A SAFETY DEVICE/RESTRAINT assessment dated [DATE] REVEALED THAT RESIDENT #101 HAD UNSTEADY GAIT, POOR RECOVERY OF BALANCE WHILE SEATED, AND A HISTORY OF MULTIPLE FALLS. THIS ASSESSMENT INDICATED UNDER THE SECTION ENTITLED DECISIONS TO APPLY SAFETY DEVICES, RESIDENT #101 WAS TO HAVE A SOFT TABLE TOP TRAY APPLIED TO CHAIR FOR POSITIONING. REVIEW OF THE FACILITY INCIDENT REPORT 24 HOURS DATED 11/12/12 REVEALED THAT ON 11/12/12 AT 7:15 AM, "EMPLOYEE SAT RESIDENT UP AT SIDE OF BED. RESIDENT fell on THE FLOOR AND HIT HER HEAD." THIS REPORT ALSO INDICATED THAT A CERTIFIED NURSE AIDE (CNA) (#3) SAT THE RESIDENT (RESIDENT #101) "AT SIDE OF BED TO FINISH DRESSING HER AND WAS BY SINK, TO GET WASH CLOTH WET..." REVIEW OF THE INCIDENT AND ACCIDENT INVESTIGATION REPORT DATED 11/12/12 REVEALED THAT RESIDENT #101 had a history of [REDACTED]. REVIEW OF DIAGNOSTIC TEST RESULTS (COMPUTED TOMOGRAPGHY SCANS) FROM AN OUTSIDE PROVIDER DATED 11/12/12 REVEALED THAT RESIDENT #101 HAD SUSTAINED A FRACTURE OF SUPEROMEDIAL LEFT ORBIT. THE TEST RESULTS DID INDICATE THAT THERE WERE FLUID LEVELS IN HER PARANASAL SINUSES, NASAL BONE FRACTURES WITH SEVERAL SEPARATE OSSIFIC/CALCIFIC DENSITIES BETWEEN THE NASAL SPINE AND NASAL BONE THAT MAY (HAVE) REFLECT(ED) DEBRIS, SENSE OF SOFT TISSUE SWELLING, AND EDEMA HEMORRHAGE WITHIN THE PERIORBITAL SOFT TISSUES SUPERIOR TO THE LEFT GLOBE. HOWEVER, THERE WAS NO EVIDENCE THAT RESIDENT #101 HAD SUSTAINED AN INTRACRANIAL HEMORRHAGE. REVIEW OF THE 5-DAY SELF-REPORT DATED 11/16/12 REVEALED THAT THE INCIDENT (FALL) INVOLVING RESIDENT #101 WAS SUBSTANTIATED BASED ON STAFF OBSERVATION (CNA #3). THIS REPORT INDICATED RESIDENT #101 WAS BLEEDING FROM THE LEFT SIDE OF HER FACE, GUMS, MOUTH, AND NOSE AND HAD A LARGE BLUISH HEMATOMA TO HER LEFT EYE AND LEFT EYELID WAS CLOSED SHUT. THIS REPORT DOCUMENTED THAT FACILITY CLINICIANS ASSESSED RESIDENT #101 IMMEDIATELY, PROVIDED TREATMENT AND TRANSPORTED RESIDENT #101 TO AN OUTSIDE HOSPITAL VIA AN EMERGENT SERVICE PROVIDER. THIS REPORT INDICATED RESIDENT #101 HAD SEVERE CONFUSION RELATED TO DEMENTIA, WAS NON-VERBAL MOST OF THE TIME, REQUIRED TOTAL CARE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS), HAD NO SAFETY AWARENESS, WAS NON-AMBULATORY, USED A HOYER (MECHANICAL) LIFT FOR TRANSFERS, AND USED A SOFT LAP TRAY FOR POSITIONING WHEN UP IN HER CHAIR. DURING INTERVIEWS WITH THE DIRECTOR OF NURSING (DON) (EMPLOYEE #2) ON 11/27/12 AT 10:05 AM AND 11/27/12 AT 11:20 AM, THE DON SAID THAT ON 11/21/12 AT 7:15 AM, DURING PROVISION OF MORNING CARE, CERTIFIED NURSE AIDE (CNA) #3 SAT RESIDENT #101 ON EDGE OF BED AND LEFT HER UNSUPERVISED FOR A BRIEF TIME PERIOD WHILE CNA #3 WENT TO THE SINK INSIDE ROOM TO DAMPEN A WASHCLOTH. THE DON SAID DURING THIS UNSUPERVISED TIME PERIOD, RESIDENT #101 fell TO FLOOR AND SUSTAINED FACIAL INJURIES INCLUDING MULTIPLE FACIAL FRACTURES. THE DON SAID IT WAS INAPPROPRIATE FOR CERTIFIED NURSE AIDE (CNA) #3 TO LEAVE RESIDENT #101 SITTING ON EDGE OF BED UNSUPERVISED. THE DON SAID RESIDENT #101 had a history of [REDACTED]. THE DON SAID IT IS THE EXPECTATION THAT CNAS PREPARE ADL SUPPLIES IN ADVANCE TO ANTICIPATE RESIDENT CARE NEEDS AND THAT THE CNA CAN CALL FOR ASSISTANCE IF NEEDED. THE DON SAID THAT RESIDENT #101 WAS IN AN OUTSIDE HOSPITAL. DURING AN INTERVIEW WITH REHABILITATION TECH (RT) #4 ON 11/27/12 AT 10:15 AM, RT #4 SAID, BASED ON PAST CLINICAL EXPERIENCE, RESIDENT #101 WOULD NOT BE AN APPROPRIATE CANDIDATE TO LEAVE UNSUPERVISED WHILE SITTING ON EDGE OF BED. RT #4 SAID RESIDENT #101 DID NOT HAVE SUFFICIENT BALANCE AND MUSCLE STRENGTH TO BE LEFT UNATTENDED. ON 11/27/12 AT 10:25 AM, WITH THE DIRECTOR OF NURSING PRESENT, THE SURVEYOR OBSERVED RESIDENT #101'S ROOM. THIS WAS THE ROOM IN WHICH RESIDENT #101 fell . THE SURVEYOR MEASURED THE DISTANCE FROM RESIDENT #101'S BED TO SINK INSIDE ROOM TO BE APPROXIMATELY 12 FEET. THE FLOOR IN ROOM CONSISTED OF HARD TILES. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #3 ON 11/27/12 AT 10:55 AM, CNA #3 SAID ON 11/12/12 AT APPROXIMATELY 7:15 AM, SHE SAT RESIDENT #101 AT THE EDGE OF BED WHILE PERFORMING ADL CARE AND "WALKED AWAY" FROM RESIDENT #101 TOWARD SINK INSIDE ROOM TO DAMPEN A WASHCLOTH. CNA #3 SAID SHE WAS NEAR THE SINK AND "WITHIN SECONDS" RESIDENT #101 ATTEMPTED TO AMBULATE FROM EDGE OF BED AND fell TO FLOOR. CNA #3 SAID IT WAS AN ACCIDENT AND SHE SHOULD HAVE NEVER LEFT RESIDENT #101 ALONE EVEN FOR A SHORT TIME PERIOD. CNA #3 SAID RESIDENT #101 DID NOT HAVE SUFFICIENT STRENGTH AND BALANCE TO SIT ALONE AT EDGE OF BED. CNA #3 SAID THAT RESIDENT #101 had a history of [REDACTED]. CNA #3 SAID RESIDENT #101 COULD NOT AMBULATE ALONE AND UNASSISTED AND NEEDED A STAND-UP LIFT (MECHANICAL LIFT) FOR TRANSFERS. CNA #3 SAID SHE AND RESIDENT #101 WERE THE ONLY PERSONS IN THE ROOM PRIOR TO THE FALL. CNA #3 SAID OTHERS CAME IN TO ASSIST IMMEDIATELY AFTER RESIDENT #101 fell . CNA #3 SAID THE FACILITY SUSPENDED HER DURING THE INVESTIGATION AND SHE SUBSEQUENTLY RESIGNED FROM THE FACILITY. DURING THE TIME FRAMES OF THE INVESTIGATION, RESIDENT #101 WAS NOT RESIDING IN THE FACILITY AND WAS UNABLE TO BE OBSERVED OR INTERVIEWED. REVIEW OF THE POLICY/PROCEDURE MANUAL TITLED ADL SAFE CARE PRACTICE DATED NOVEMBER 2012 REVEALED THAT, UNDER GENERAL GUIDELINES SECTION, "ASSEMBLE THE EQUIPMENT AND SUPPLIES PRIOR TO CARE, DO NOT LEAVE THE RESIDENT UNATTENDED. PRESS THE CALL LIGHT FOR ASSISTANCE IF AVAILABLE OR CALL FOR ASSISTANCE."

THIS CITATION PERTAINS TO INTAKES MI 362 AND MI 494. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 2 OF 3 SAMPLED RESIDENTS AT RISK FOR FALL ACCIDENTS (#201 AND #202) FROM A TOTAL SAMPLE OF 3, RECEIVED THE NECESSARY SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT AVOIDABLE ACCIDENTS, RESULTING IN INJURY (HUMERAL FRACTURE FOR #201 AND HIP FRACTURE FOR #202). FINDINGS INCLUDE: RESIDENT #201 REVIEW OF THE ADMISSION FACE SHEET FOR RESIDENT #201 INDICATED THAT SHE WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 11/29/10. [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT RESIDENT #201 HAD MINIMAL COGNITIVE IMPAIRMENT AND REQUIRED MAXIMAL ASSISTANCE WITH TRANSFERS AND A WHEELCHAIR FOR MOBILITY. THE COMPREHENSIVE ASSESSMENT ALSO INDICATED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS AND REQUIRED MAXIMAL ASSISTANCE WITH TRANSFERS AND THE SUPPORT OF TWO PERSONS. REVIEW OF THE APRIL 2012, CNA (CERTIFIED NURSING ASSISTANT) CARE GUIDE FOR RESIDENT #201 INDICATED THAT SHE WAS A MAXIMAL 2 PERSON PHYSICAL ASSIST FOR TRANSFERS. REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 4/20/12, INDICATED THAT AT APPROXIMATELY 5:30 A.M., WHILE BEING TRANSFERRED INTO HER WHEELCHAIR BY EMPLOYEE "A", THE RESIDENT'S WHEELCHAIR ROLLED BACK AND THE RESIDENT WAS LOWERED DOWN TO THE FLOOR ON HER BUTTOCKS. THE RESIDENT COMPLAINED OF PAIN IN HER LEFT ARM AND WAS TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT AND EVALUATION ON 4/21/12. THE RESIDENT WAS diagnosed with [REDACTED]. ON 4/30/12, AT 10:30 A.M., INTERVIEW WITH EMPLOYEE "A" VERIFIED THAT SHE WAS ASSIGNED AS THE CNA (CERTIFIED NURSING ASSISTANT) DURING THE MIDNIGHT SHIFT ON 4/20/12. EMPLOYEE "A" STATED THAT AT APPROXIMATELY 5:30 A.M., SHE HAD PROVIDED MORNING CARE TO RESIDENT #201, AND WHEN SHE ATTEMPTED TO TRANSFER THE RESIDENT INTO THE WHEELCHAIR THE CHAIR ROLLED AWAY AND SHE HAD TO LOWER THE RESIDENT DOWN TO THE FLOOR ON HER BUTTOCKS. EMPLOYEE "A" STATED THAT THE BRAKES ON THE RESIDENT'S WHEELCHAIR WERE LOOSE AND DID NOT LOCK SECURELY. EMPLOYEE "A" STATED THAT SHE WAS UNAWARE THAT RESIDENT #201 WAS A TWO PERSON TRANSFER AT THE TIME OF THE INCIDENT BECAUSE SHE HAD NOT CHECKED THE CNA CARE GUIDE. EMPLOYEE "A" FURTHER STATED SHE WAS A PROBATIONARY EMPLOYEE. REVIEW OF HER PERSONNEL FILE REVEALED THAT HER DATE OF HIRE WAS 3/12/12. FURTHER REVIEW OF THE FACILITY INCIDENT/ACCIDENT REPORT DATED 4/20/12, INDICATED FOLLOWING THE ACCIDENT, A WORK ORDER REFERRAL WAS SENT TO THE MAINTENANCE WORKER TO REPAIR THE BRAKES ON THE RESIDENT'S WHEELCHAIR. ON 4/26/12, AT 11:45 A.M., INTERVIEW WITH A MAINTENANCE WORKER VERIFIED THAT HE RECEIVED A WORK ORDER TO CHECK THE WHEELCHAIR BRAKES ON THE RESIDENT'S WHEELCHAIR. THE MAINTENANCE WORKER VERIFIED THAT HE HAD TIGHTENED THE BRAKES ON THE RESIDENT'S WHEELCHAIR THAT HAD BEEN LOOSE AND FAILED TO LOCK SECURELY. ON 4/26/12, AT 10:30 A.M., OBSERVATION REVEALED THAT RESIDENT #201 HAD A SLING APPLIED TO HER LEFT UPPER EXTREMITY. INTERVIEW WITH RESIDENT #201 REVEALED THAT SHE INJURED HER LEFT ARM DURING A FALL INCIDENT. THE RESIDENT DESCRIBED THE EVENT IN A SIMILAR MANNER TO THE FACILITY'S INCIDENT/ACCIDENT REPORT DATED 4/20/12. RESIDENT #201 FURTHER STATED THAT AT THE TIME OF THE ACCIDENT SHE WAS BEING ASSISTED AND TRANSFERRED BY ONLY ONE CNA (CERTIFIED NURSING ASSISTANT) KNOWN AS EMPLOYEE "A". RESIDENT #201 FURTHER REPORTED THAT "EVEN THIS MORNING ONLY ONE GIRL (CERTIFIED NURSING ASSISTANT KNOWN AS EMPLOYEE "D") GOT ME UP." ON 4/26/12, AT 1:30 A.M., INTERVIEW WITH EMPLOYEE "D" REVEALED THAT SHE WAS ASSIGNED AS THE CNA (CERTIFIED NURSING ASSISTANT) ON THE MIDNIGHT SHIFT ON 4/25/12 FOR RESIDENT #201. EMPLOYEE "D" STATED THAT SHE PROVIDED RESIDENT #201 WITH MORNING CARE AND TRANSFERRED HER OUT OF BED AND INTO HER WHEELCHAIR. EMPLOYEE "D" STATED THAT SHE COMPLETED THE TRANSFER INDEPENDENTLY AND DID NOT SEEK THE ASSISTANCE OF ANOTHER CNA. EMPLOYEE "D" STATED THAT SHE WAS A PROBATIONARY EMPLOYEE. REVIEW OF HER PERSONNEL FILE REVEALED A DATE OF HIRE ON 3/27/12. EMPLOYEE "D" STATED THAT SHE WAS UNAWARE THAT RESIDENT #201 WAS A TWO PERSON TRANSFER BECAUSE SHE DID NOT REVIEW THE RESIDENT'S CARE GUIDE. RESIDENT #202 REVIEW OF THE ADMISSION FACE SHEET FOR RESIDENT #202 INDICATED THAT SHE WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 07/16/2010. [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT HAD IMPAIRED COGNITION AND REQUIRED MAXIMAL ASSISTANCE WITH TRANSFERS AND USED A WHEELCHAIR FOR MOBILITY. THE COMPREHENSIVE ASSESSMENT INDICATED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS AND REQUIRED MAXIMAL ASSIST WITH TRANSFERS AND THE SUPPORT OF TWO PERSONS. REVIEW OF THE APRIL 2012, CARE GUIDE FOR RESIDENT #202 INDICATED THAT SHE WAS A MAXIMAL 2 PERSON PHYSICAL ASSIST. REVIEW OF THE COMPREHENSIVE CARE PLAN INITIALLY DEVELOPED ON 7/1/10 AND REVISED AS CURRENT AS 3/6/12, INDICATED THAT RESIDENT #202 WAS AT HIGH RISK FOR FALLS DUE TO POOR SAFETY AWARENESS. CARE PLAN INTERVENTIONS LISTED INCLUDED ALARM ALERTS ON THE BED AND WHEELCHAIR. REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 4/21/12, INDICATED THAT AT APPROXIMATELY 11:00 A.M., EMPLOYEES "B" AND "C" FOUND RESIDENT #202 ON THE FLOOR IN HER ROOM. FURTHER REVIEW OF THE FACILITY INCIDENT/ACCIDENT REPORT INDICATED THAT THE RESIDENT COMPLAINED OF PAIN IN HER LEFT LOWER EXTREMITY FOLLOWING THE ACCIDENT AND WAS TRANSFERRED TO AN AREA HOSPITAL WHERE SHE WAS diagnosed with [REDACTED]. ON 4/30/12, AT 10:00 A.M., INTERVIEW WITH EMPLOYEE "B" REVEALED THAT SHE WAS ASSIGNED AS THE CERTIFIED NURSING ASSISTANT (CNA) FOR RESIDENT #202 ON 4/21/12 ON THE DAY SHIFT. EMPLOYEE "B" VERIFIED THAT SHE OBSERVED RESIDENT #202 ON THE FLOOR IN HER ROOM AS INDICATED ON THE INCIDENT REPORT. EMPLOYEE "B" STATED THAT EMPLOYEE "C" WAS PRESENT IN THE ROOM AT THE TIME OF HER OBSERVATION. EMPLOYEE "B" STATED THAT SHE ASSISTED EMPLOYEE "C" IN LIFTING RESIDENT #202 OFF THE FLOOR AND IN POSITIONING HER IN A STRAIGHT BACK CHAIR. EMPLOYEE "B" STATED THAT THE RESIDENT WAS NOT ASSESSED BY A LICENSED NURSE PRIOR TO THE TWO CNAS LIFTING RESIDENT #202 OFF THE FLOOR. EMPLOYEE "B" STATED THAT SHE WAS NOT AWARE THAT A LICENSED NURSE WAS REQUIRED TO ASSESS THE RESIDENT PRIOR TO MOVING A RESIDENT WHO HAD A FALL ACCIDENT. EMPLOYEE "B" STATED SHE WAS A PROBATIONARY EMPLOYEE. REVIEW OF THE PERSONNEL FILE FOR EMPLOYEE "B" INDICATED A DATE OF HIRE ON 2/28/12, ON 4/30/12, AT 11:30 A.M., INTERVIEW WITH EMPLOYEE "C" VERIFIED THAT SHE DISCOVERED RESIDENT #202 ON THE FLOOR IN HER ROOM AND WAS ASSISTED BY EMPLOYEE "B" IN LIFTING THE RESIDENT UP FROM THE FLOOR AND INTO A CHAIR. EMPLOYEE "C" STATED THAT SHE SUGGESTED LIFTING RESIDENT #202 OFF THE FLOOR AND INTO A CHAIR DESPITE THE FACILITY'S ACCIDENT POLICY THAT REQUIRED THE LICENSED NURSE TO ASSESS THE RESIDENT FOR INJURIES PRIOR TO BEING MOVED. REVIEW OF THE FACILITY'S ACCIDENT PROTOCOL DATED 10/8/07, AND REVISED AS CURRENT AS 4/13/10 INDICATED THE FOLLOWING: ? AT THE TIME AN INCIDENT OCCURS THE RESIDENT IS NOT TO BE MOVED ? THE RESIDENT IS NOT TO BE MOVED UNTIL A FULL BODY ASSESSMENT IS COMPLETED BY A NURSE FURTHER REVIEW OF THE FACILITY'S INTERNAL INVESTIGATION OF THE ACCIDENT FOR RESIDENT #202 INDICATED THAT LESS THAN 30 MINUTES PRIOR TO THE ACCIDENT THE FACILITY'S NURSE PRACTITIONER HAD OBSERVED RESIDENT #202 AMBULATING IN HER ROOM. THE REPORT INDICATED THAT THE NURSE PRACTITIONER HAD PLACED THE RESIDENT IN HER WHEELCHAIR AND APPLIED HER ALARMED VELCRO SAFETY BELT. THE NURSE PRACTITIONER HAD ALSO REPORTED THE OBSERVATION TO EMPLOYEE "C" AND REQUESTED THAT SHE CHECK ON RESIDENT #202. ON 4/30/12, AT 12:00 NOON, INTERVIEW WITH THE FACILITY'S NURSE PRACTITIONER VERIFIED THAT SHE HAD OBSERVED RESIDENT #202 AMBULATING IN HER ROOM. THE NURSE PRACTITIONER STATED THAT THE RESIDENT WAS A HIGH FALL RISK AND IMMEDIATELY PLACED THE RESIDENT IN HER WHEELCHAIR AND APPLIED AN ALARMED VELCRO SAFETY BELT. THE NURSE PRACTITIONER FURTHER REPORTED THAT SHE WAS "UNCERTAIN IF SHE HAD APPLIED THE SAFETY DEVICE PROPERLY" AND THEREFORE ASKED FOR EMPLOYEE "C" TO CHECK ON THE RESIDENT. THE NURSE PRACTITIONER STATED THAT THE FALL INCIDENT OCCURRED APPROXIMATELY 20 MINUTES AFTER HER OBSERVATION. FURTHER REVIEW OF THE CLINICAL RECORD FOR RESIDENT #202 REVEALED THAT SHE COMPLAINED OF PAIN IN HER LEFT LOWER EXTREMITY FOLLOWING THE FALL INCIDENT. THE CLINICAL RECORD INDICATED THAT THE RESIDENT WAS TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT AND EVALUATION. REVIEW OF THE HOSPITAL RECORD REVEALED AN ADMISSION [DIAGNOSES REDACTED]." FURTHER REVIEW OF THE HOSPITAL RECORD REVEALED THAT THE RESIDENT REQUIRED (ORIF) OPEN REDUCTION INTERNAL FIXATION SURGERY OF THE LEFT HIP. SUBSEQUENT TO THE hospitalization , RESIDENT #202 WAS TRANSFERRED BACK TO THE FACILITY.

THIS CITATION PERTAINS TO INTAKE #MI 362 AND MI 494 BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 3 OF 4 RESIDENTS REVIEWED FOR FALLS (#101, #102, AND #103) FROM A TOTAL SAMPLE OF 4, RECEIVED THE NECESSARY SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT ACCIDENTS RESULTING IN A FRACTURED RIGHT HIP FOR RESIDENT #101, A FRACTURED BACK (THORACIC-12) FOR RESIDENT #102 AND THE POTENTIAL FOR FUTURE FALLS WITH INJURY FOR RESIDENT #103. RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 01/06/2012, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 0/06/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA DATED 1/18/2012, RESIDENT #101 WAS COGNITIVELY IMPAIRED WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE WAS NOT STEADY WHEN WALKING AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL TRANSFERS AND AMBULATION. ADMISSION PHYSICIAN ORDERS [REDACTED]. ADDITIONALLY THE PHYSICIAN ORDERED, THERAPY EVALUATIONS AND TREATMENTS WITH A PHYSICAL THERAPIST AND OCCUPATIONAL THERAPIST. THE OCCUPATIONAL THERAPY EVALUATION DATED 1/06/2012 DOCUMENTED THAT RESIDENT #101 HAD MUSCLE WEAKNESS. THE OCCUPATIONAL THERAPIST DOCUMENTED RESIDENT #101 HAD IMPAIRED SAFETY AWARENESS, IMPAIRED MEMORY AND REQUIRED STAFF TO SUPERVISE AND ASSIST WITH ALL TRANSFERS. THE PHYSICAL THERAPY EVALUATION DATED 1/06/2012 DOCUMENTED THAT RESIDENT #101 HAD "GOOD REHAB (REHABILITATION) POTENTIAL... (AND) SHOULD MAKE SIGNIFICANT GAINS." THE PHYSICAL THERAPIST DOCUMENTED THAT RESIDENT #101 HAD WEAKNESS, IMPAIRED SAFETY AWARENESS AND REQUIRED STAFF TO PROVIDE CONTACT GUARD ASSISTANCE WITH ALL SIT TO STAND MOVEMENTS, TRANSFERS AND WALKING. (PAGE 224 OF THE INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPY ASSISTANTS WRITTEN BY OLGA DREEBEN IN 2006, DEFINED CONTACT GUARD ASSISTANCE AS "...THE PATIENT IS ABLE TO PERFORM THE ACTIVITY INDEPENDENTLY BUT CONSTANTLY NEEDS PHYSICAL ASSISTANCE...") THE FALL RISK assessment dated [DATE] IDENTIFIED RESIDENT #101 AT RISK FOR FALLS BASED ON HER INTERMITTENT CONFUSION, HER PROBLEM WITH BALANCE WHEN SHE STOOD FROM A CHAIR, LOSS OF BALANCE WHEN SHE STOOD, LOSS OF BALANCE WHEN SHE TRANSFERRED, BALANCE PROBLEMS WHEN SHE WALKED, HER INSTABILITY MAKING TURNS, HER INSTABILITY NEGOTIATING DOORWAYS, HER POOR SAFETY SKILLS AND THE POTENTIAL FOR SIDE EFFECTS FROM PRESCRIBED MEDICATIONS. THE ADMISSION NURSING assessment dated [DATE] DOCUMENTED THAT RESIDENT #101 HAD COGNITIVE IMPAIRMENTS, NO PAIN AND REQUIRED ASSISTANCE TO WALK. THE INITIAL CARE PLAN DATED 1/06/2012, FAILED TO ADDRESS ANY OF THESE DOCUMENTED ASSESSMENT CONCERNS. NURSING NOTES, DATED 1/06/2012 AT 2:20 P.M., DOCUMENTED, "RESIDENT (#101) TRANSFERRED (HER) SELF TO (THE) BATHROOM...(WITH) NOTED...MINIMAL UNSTEADINESS." DAILY SKILLED NURSING NOTES DATED 1/06/2012, BETWEEN 3:00 P.M. TO 11:00 P.M., DOCUMENTED THAT RESIDENT #101 HAD NO STAFF ASSISTANCE WHEN SHE TRANSFERRED OR TOILETED. A LATE ENTRY FOR 1/06/2012 AT 10:00 P.M. DOCUMENTED THAT NURSING STAFF WITNESSED RESIDENT #101 AS SHE TRANSFERRED "SEVERAL TIMES, AMBULATING TO (THE) RESTROOM BY HERSELF." STAFF FAILED TO INITIATE ANY ADDITIONAL SUPERVISION OR SAFETY DEVICES TO MAINTAIN RESIDENT #101'S SAFETY IN RESPONSE TO HER ONGOING, WITNESSED SELF-TRANSFER BEHAVIORS. ACCORDING TO NURSING NOTES DATED 1/07/2012 AT 4:10 A.M., STAFF FOUND RESIDENT #101 AT 3:30 A.M., "SITTING UPRIGHT...ON (THE) FLOOR NEAR (HER) BATHROOM DOORWAY." RESIDENT #101 IMMEDIATELY COMPLAINED OF PAIN TO HER LEFT HIP. FOUR HOURS LATER STAFF DOCUMENTED, "RESIDENT SOBBING HARD CRYING OUT FOR HER SISTER." THE FALL INJURY ASSESSMENT FORM, DATED 1/07/2012, DOCUMENTED THAT RESIDENT #101 HAD PAIN AND CRIED THROUGHOUT THE NIGHT SHIFT AND BOTH THE DAY AND EVENING SHIFTS THAT FOLLOWED. RESIDENT #101 HAD CONTINUED PAIN ON 01/08/2012 AND 01/09/2012 BASED ON THESE FORMS. NURSING NOTES DATED 01/10/2012 AT 2:25 P.M., DOCUMENTED THAT RESIDENT #101 HAD INCREASED FLANK PAIN AND A SLIGHTLY ELEVATED WHITE BLOOD CELL COUNT. SHE WAS TRANSFERRED TO A LOCAL AREA HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. HOSPITAL RECORDS INDICATED RESIDENT #101 REQUIRED AN ABDOMINAL AND PELVIC CAT SCAN (CT) ON 1/10/2012. THIS CT WAS COMPARED TO AN "ABDOMEN PELVIS CT...(COMPLETED)...1/04/2012 AT 11:23 P.M." THE RADIOLOGIST FOUND A "NEW COMPRESSION DEFORMITY" THAT INVOLVED "THE T12 VERTEBRAL BODY (THE 12TH BONE IN HER THORACIC SPINE) WITH AT LEAST 50% (PERCENT) HEIGHT LOSS." ON 2/08/2012 AT 3:00 P.M., THE DIRECTOR OF NURSING SAID STAFF DID NOT ASSIST RESIDENT #101 WHEN SHE TRANSFERRED AND AMBULATED FROM HER BED ON 01/07/2012, WALKED TOWARD THE BATHROOM AND fell AT 3:30 A.M. THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD AND SAID STAFF DID NOT IMPLEMENT ANY ADDITIONAL SUPERVISION OR SAFETY DEVICES AFTER THEY IDENTIFIED RESIDENT #101 FREQUENTLY SELF-TRANSFERRED AND SELF-AMBULATED DESPITE HER ASSESSED NEED FOR STAFF ASSISTANCE. RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 1/18/2012, RESIDENT #102 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 1/18/2012. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD SOME COGNITIVE DIFFICULTY IN NEW SITUATIONS. HE COULD NOT BALANCE, DID NOT WALK AND HAD FUNCTIONAL LIMITATIONS IN ONE OF HIS LOWER EXTREMITIES. RESIDENT #102 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH ALL TRANSFERS. A LOCAL HOSPITAL history and physical examination SIGNIFICANT...FATIGUE AND UNSTEADY GAIT." THE PHYSICIAN DOCUMENTED RESIDENT #102 HAD FALLEN AT THE hospital on [DATE], FROM A STANDING POSITION WHILE GETTING OUT OF BED AND "NEEDED ASSISTANCE WITH EATING, DRESSING, TRANSFERS, TOILETING, BATHING AND CONTINENCE." THE ADMISSION PHYSICIAN ORDERS [REDACTED].#102. THE PHYSICIAN ORDERED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH HIS MOBILITY NEEDS. THE OCCUPATIONAL THERAPY EVALUATION DATED 1/19/2012, DOCUMENTED THAT RESIDENT #102 WAS A FALL RISK WITH "MUSCLE WEAKNESS." THE OCCUPATIONAL THERAPIST DOCUMENTED RESIDENT #102 HAD IMPAIRED SAFETY AWARENESS, SOME SHORT TERM MEMORY LOSS AND DIFFICULTY FOLLOWING INSTRUCTIONS. THE THERAPIST ASSESSED RESIDENT #102 AND DETERMINED HE NEEDED STAFF ASSISTANCE TO BE TRANSFERRED AND TOILETED. THE PHYSICAL THERAPY EVALUATION DATED 1/19/2012 DOCUMENTED THAT RESIDENT #102 HAD "GOOD REHAB (REHABILITATION) POTENTIAL... (AND HE), SHOULD MAKE SIGNIFICANT FUNCTIONAL GAINS." THE PHYSICAL THERAPIST DOCUMENTED RESIDENT #102 HAD DIFFICULTY WALKING, MUSCLE WEAKNESS AND REQUIRED FALL PRECAUTIONS. THE THERAPIST ASSESSED RESIDENT #102 AND DETERMINED HE REQUIRED STAFF ASSISTANCE EACH TIME HE STOOD, TURNED AND WALKED. THE FALL RISK assessment dated [DATE], DOCUMENTED THAT RESIDENT #102 WAS AT RISK FOR FALLS DUE TO HIS HISTORY OF RECENT FALLS, HIS NEED FOR TOILETING ASSISTANCE, HIS REQUIRED NEED FOR AN ASSISTIVE DEVICE WHEN HE WALKED, HIS REQUIRED NEED FOR STAFF ASSISTANCE WHEN HE WALKED, HIS DECREASED MUSCULAR COORDINATION, HIS POOR SAFETY SKILLS AND THE POTENTIAL FOR SIDE EFFECTS FROM HIS PRESCRIBED MEDICATION. THE ADMISSION NURSING assessment dated [DATE] DOCUMENTED THAT RESIDENT #102 had a history of [REDACTED]. THE INITIAL CARE PLAN DATED 1/19/2012 DOCUMENTED THAT RESIDENT #102 HAD WEAKNESS AND "...ASSISTANCE (WAS) NEEDED WITH TRANSFERS (AND) AMBULATION." TO ENSURE RESIDENT #102 WAS SAFE STAFF WERE REQUIRED TO MAINTAIN HIS BED IN A LOW POSITION AND PROVIDE A CALL LIGHT WITHIN REACH. NURSING NOTES DATED 1/18/2012 AT 10:00 P.M. DOCUMENTED STAFF HAD KNOWLEDGE "RESIDENT (#102) REPEATEDLY AMBULATED BY HIMSELF (AND) REFUSED TO USE (A) CALL LIGHT..." IN RESPONSE, STAFF PLACED AN ALARM ON HIS BED TO ALERT THEM OF ANY UNDESIRED SELF-TRANSFER ATTEMPTS. IN A TELEPHONE INTERVIEW ON 2/08/2012 AT 1:10 P.M. LPN #1 (LICENSED PRACTICAL NURSE) SAID ON ADMISSION RESIDENT #102 WAS CONFUSED TO HIS ENVIRONMENT AND WANTED TO "GO HOME." LPN #1 DOCUMENTED RESIDENT #102 WAS NOT STEADY WHEN HE STOOD, TURNED OR WALKED. LPN #1 SAID RESIDENT #102 WOULD NOT USE HIS CALL LIGHT TO OBTAIN STAFF ASSISTANCE. LPN #1 SAID RESIDENT #102 SELF-TRANSFERRED, SELF-AMBULATED AND SELF-TOILETED MULTIPLE TIMES THROUGHOUT HER SHIFT ON 1/18/2012. LPN #1 SAID AT APPROXIMATELY 8:30 P.M. A BED ALARM WAS IMPLEMENTED TO KEEP HIM SAFE BUT "IT DID NOT WORK." LPN #1 SAID RESIDENT #102 CONTINUED TO SELF-TRANSFER FROM HIS BED TO THE TOILET USING HIS WHEELCHAIR TO MOVE THROUGHOUT HIS ROOM AND THE FACILITY. LPN #1 SAID RESIDENT #102 ACTIVATED HIS PRESSURE SENSITIVE BED ALARM "AT LEAST 10 TIMES " BEFORE THE END OF HER SHIFT, THREE AND A HALF HOURS LATER. LPN #1 SAID THE BED ALARM WOULD SOUND BUT FAILED TO ALERT STAFF IN TIME TO PREVENT RESIDENT #102 FROM SELF-TRANSFERRING. LPN #1 SAID RESIDENT #102 FREQUENTLY MADE IT TO THE BATHROOM AND EVEN THE NURSING STATION BEFORE STAFF RESPONDED TO THE ALARM. LPN #1 SAID SHE NOTIFIED HER SUPERVISOR OF RESIDENT #102'S ONGOING BEHAVIORS. LPN #1 SAID SHE DID NOT FURTHER INCREASE THE SUPERVISION OR SAFETY DEVICES NECESSARY TO KEEP RESIDENT #102 SAFE WHEN STAFF IDENTIFIED THE IMPLEMENTED CARE PLANNED MEASURES WERE INEFFECTIVE. DAILY SKILLED NURSING NOTES DATED 1/19/2012 BETWEEN 7:00 A.M. AND 11:00 P.M. DOCUMENTED RESIDENT #102 CONTINUED TO HAVE AN UNSTEADY GAIT AND BALANCE PROBLEMS. AN ADDITIONAL CARE PLAN DATED 1/19/2012 FAILED TO PROVIDE ANY ADDITIONAL SUPERVISION OR SAFETY DEVICES TO MAINTAIN THE SAFETY OF RESIDENT #102 AS HE CONTINUED TO SELF-TRANSFER, SELF-AMBULATE AND SELF-TOILET. IN AN INTERVIEW ON 2/08/2012 AT 1:20 P.M. LPN #2 SAID WHEN SHE RECEIVED REPORT ON RESIDENT #102 ON 1/19/2012 AROUND 11:00 P.M. LPN #2 SAID STAFF INFORMED HER THEN THAT SINCE ADMISSION RESIDENT #102 HAD BEEN UNSTEADY ON HIS FEET AND FREQUENTLY SELF-TRANSFERRED, SELF-AMBULATED AND SELF-TOILETED. DESPITE THESE ONGOING OBSERVATIONS AND ASSESSMENTS LPN #2 COULD NOT IDENTIFY ANY SAFETY INTERVENTIONS IMPLEMENTED AFTER 1/18/2012 AT 8:30 P.M. WHEN THE INEFFECTIVE BED ALARM WAS PLACED. LPN #2 SAID RESIDENT #102 WAS AWAKE IN HIS BED ON 1/19/2012 AT 11:30 P.M. WHEN SHE INFORMED HIM THE COLLECTION OF A URINE SPECIMEN WAS NECESSARY. LPN #2 SAID 35 MINUTES LATER SHE FOUND RESIDENT #102 ON THE FLOOR NEXT TO HIS BED AFTER HE SELF-TRANSFERRED. LPN #2 SAID STAFF DID NOT PROVIDE RESIDENT #102 WITH THE ASSISTANCE NECESSARY TO ENSURE HIS SAFETY WHEN HE TRANSFERRED FROM HIS BED AND fell TO THE FLOOR ON 1/20/2012 AT 12:05 P.M. LPN #2 SAID THE REASON RESIDENT #102 REQUIRED A URINE SPECIMEN TEST WAS BECAUSE HIS FREQUENT TOILETING BEHAVIORS INDICATED TO STAFF HE MAY HAVE AN INFECTION. A LATE NURSING NOTE ENTRY ON 1/20/2012 AT 1:00 A.M., FOR 12:05 A.M., DOCUMENTED THAT RESIDENT #102 COMPLAINED OF LEFT HIP PAIN WHEN STAFF FOUND HIM ON THE FLOOR. NURSES ASSESSED RESIDENT #102 AND FOUND HIS RIGHT LEG WAS "EXTERNALLY ROTATED...SHORTER THAN (HIS) LEFT LEG." RESIDENT #102 WAS SENT TO A LOCAL AREA HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. LOCAL AREA HOSPITAL RECORDS DATED 1/20/2011, DOCUMENTED THAT RESIDENT #102 SUSTAINED A FRACTURE OF THE RIGHT HIP AFTER HE fell . THIS FRACTURE REQUIRED SURGICAL REPAIR. DURING AN INTERVIEW ON 2/08/2012 AT 3:00 P.M., THE DIRECTOR OF NURSING SAID STAFF DID NOT PROVIDE RESIDENT #102 WITH THE REQUIRED LEVEL OF ASSISTANCE WHEN HE TRANSFERRED FROM HIS BED TO THE FLOOR ON 1/20/2012 AT 12:05 A.M. THE DIRECTOR OF NURSING SAID STAFF WHO RECEIVED REPORT AND/OR WITNESSED FREQUENT SELF-TRANSFER AND SELF-AMBULATE ATTEMPTS AT THE FACILITY NEEDED TO ENSURE ADDITIONAL SUPERVISION AND/OR SAFETY DEVICES WERE IMPLEMENTED TO KEEP RESIDENT #103 SAFE, BUT DID NOT. RESIDENT #103 ACCORDING TO THE FACE SHEET DATED 6/11/2011, RESIDENT #103 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 5/02/2003. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #103 HAD SEVERELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. HE COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH ALL TRANSFERS AND WALKING. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. THE FALL RISK assessment dated [DATE] IDENTIFIED THAT RESIDENT #103 WAS AT RISK FOR FALLS DUE TO HIS HISTORY OF INTERMITTENT CONFUSION, HIS INCONTINENCE, HIS NEED FOR ASSISTANCE TO BE TOILETED, HIS NEED FOR ASSISTANCE WHEN HE STOOD, HIS LOSS OF BALANCE WHEN HE STOOD, HIS LOSS OF BALANCE WHEN HE TRANSFERRED, HIS LOSS OF BALANCE WHEN HE WALKED, HIS NEED FOR ASSISTANCE WHEN HE WALKED, HIS NEED FOR ASSISTANCE WHEN HE TURNED, HIS NEED FOR ASSISTANCE TO NAVIGATE DOORWAYS, HIS DECREASED MUSCULAR COORDINATION, HIS POOR SAFETY SKILLS, HIS PREDISPOSING DISEASE PROCESSES, HIS FAILURE TO UNDERSTAND THE FUNCTION AND USE OF A CALL LIGHT AND THE POTENTIAL FOR SIDE EFFECTS FROM HIS PRESCRIBED MEDICATION. A CARE PLAN DATED 4/29/2011 INDICATED THAT RESIDENT #103'S WHEELCHAIR REQUIRED ANTI-TIP BARS AND AN ALARM TO ALERT STAFF OF INDEPENDENT TRANSFER ATTEMPTS. SOCIAL SERVICE PROGRESS NOTES DATED 10/25/2012 DOCUMENTED THAT RESIDENT #103 WAS "VERY CONFUSED" AND HAD "POOR SAFETY AWARENESS - MAKES SELF TRANSFER ATTEMPTS FREQUENTLY." ACTIVITY PROGRESS NOTES DATED 1/24/2012 DOCUMENTED RESIDENT #103 CONTINUED TO REQUIRE STAFF MONITORING "AS HE FREQ. (FREQUENTLY) ATTEMPTS SELF-TRANSFERS TO TOILET OR BED." DURING OBSERVATIONS ON 2/08/2012 AT 10:30 A.M., RESIDENT #103 WAS UNSUPERVISED IN HIS BEDROOM. HE WAS PLEASANT, CONFUSED AND SAT UPRIGHT IN HIS WHEELCHAIR. THE WHEELCHAIR WAS NOT EQUIPPED WITH ANTI-TIP BARS. THE WHEELCHAIR WAS EQUIPPED WITH A PAD ALARM, HOWEVER, IT WAS NOT TURNED ON. LPN #3 (THE UNIT MANAGER) WAS CALLED TO THE BEDROOM AND ASKED WHY RESIDENT #103 WAS UNSUPERVISED IN HIS ROOM WITH HIS WHEELCHAIR ALARM TURNED OFF. LPN #3 LOOKED AT THE CHAIR ALARM, CONFIRMED THE ALARM WOULD NOT FUNCTION BECAUSE IT WAS TURNED OFF AND THEN LEFT RESIDENT #103. SHE DID NOT TURN THE WHEELCHAIR ALARM BACK ON. FIFTEEN MINUTES LATER, THE CNA #1 (CERTIFIED NURSING ASSISTANT) ASSIGNED TO RESIDENT #103 CAME INTO HIS BEDROOM. WHEN CNA #1 WAS ASKED WHY HIS WHEELCHAIR ALARM HAD BEEN TURNED OFF SHE SAID RESIDENT #103 HAD THE ABILITY TO TURNED OFF THE WHEELCHAIR ALARMS. CNA #1 SAID THAT PERMITTED RESIDENT #103 TO SELF-TRANSFER AND SELF-TOILET WITHOUT STAFF ASSISTANCE. CNA #1 SAID THAT SHE NEVER SAW ANTI-TIP BARS APPLIED TO RESIDENT #103'S WHEELCHAIR AND DID NOT KNOW HE NEEDED THEM FOR SAFETY. DURING AN INTERVIEW ON 2/08/2012 AT 11:00 A.M., LPN #3 (THE UNIT MANAGER) SAID SHE FAILED TO REACTIVATE THE WHEELCHAIR ALARM AND LEFT RESIDENT #103 UNSUPERVISED IN HIS WHEELCHAIR AT 10:30 A.M. WITH "NO EXCUSE." LPN #3 FAILED TO EXPLAIN WHY RESIDENT #103'S ORDERED ANTI-TIP BARS WERE NOT ON HIS WHEELCHAIR. LPN #3 SAID RESIDENT #103 WAS "CONFUSED" AND TURNED OFF HIS OWN WHEELCHAIR ALARM OFF FOR SELF-TRANSFERS FOR "AS LONG AS I CAN REMEMBER." LPN #3 SAID, "WE KIND OF WATCH HIM WHEN WE CAN." DURING AN INTERVIEW ON 2/08/2012 AT 3:00 P.M. THE DIRECTOR OF NURSING SAID A SAFETY DEVICE IS NO LONGER CONSIDERED FUNCTIONAL FOR A RESIDENT IF THEY THEMSELVES CAN REMOVE IT WITHOUT STAFF KNOWLEDGE. THE DIRECTOR OF NURSING SAID FURTHER STAFF EDUCATION WOULD BE NECESSARY TO ENSURE RESIDENTS SAFETY WHEN THEY WERE ASSESSED UNSAFE TO INDEPENDENTLY TRANSFER AND/OR AMBULATE.