Every finding on record at Citizens Medical Center Ltcu

Based on observation, interview, and record review, the facility failed to ensure the required annual performance reviews were completed for four randomly selected nurse aides reviewed. Findings included:- A review of the facility nurse aide performance evaluations revealed that Certified Nurse Aide (CNA) O, with an employment date of 10/23/24, CNA P, with an employment date of 03/12/24, CNA Q, with an employment date of 10/05/10, and CNA R with an employment date of 12/06/23, randomly selected employees who had been employed for over a year, lacked an annual performance review. On 07/07/2026 at 02:30 PM, Administrative Staff A reported that the CNAs lacked annual performance reviews. The facility had changed the platform system, and the performance reviews had not been completed for the past two years. On 07/08/2026 at 10:56 AM, Administrative Nurse D verified that annual performance reviews had not been completed. The facility's Personnel Policies and Code of Conduct policy, dated 01/01/2024, documents that the facility views performance management as a continuous process. Each associate creates goals. Throughout the year, the associate provides an update on their goals and completes a self-assessment. Leaders meet with each associate throughout the year to review progress toward achieving goals, review the self-assessment, and provide feedback. The performance year runs January through December, and final performance documentation is due by December 31. Annual goal setting and look-back occur in January.

Based on record review and interview, the facility failed to implement a policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation when the facility failed to obtain a criminal background check and license verification upon hire of a Licensed Nurse (LN) I. Findings included:- Upon request, a randomly selected LN I, who had an employee start date of 02/14/2022, the facility was unable to provide documentation of criminal background and nurse registry check. On 07/07/2026 at 02:30 PM, Administrative Staff A reported a change in the system which had the verification of criminal background check and licensing verification documentation. Administrative Staff A reported the facility was unable to locate the information which would have the licensed and registry checks through the human resources department. On 07/08/2026 at 10:56 AM, Administrative Nurse D reported the facility's human resources department was responsible for the criminal background and license verification checks. The facility's Personnel Policies and Code of Conduct, dated 01/01/24, states that all individuals to whom conditional offers of employment are made will be subject to a job-related background check. Current associates may be subject to a background check that includes prior employment verification requirements. A background check may consist of prior employment verification, professional reference checks, education confirmation, criminal history checks, credit checks, and other inquiries based on job requirements.

Based on observation, interview, and record review, the facility failed to ensure one resident, Resident (R) 14, maintained skin integrity when she received numerous skin tears (traumatic wounds caused by friction, shear, or blunt force that separate the top layer of the skin from the layer beneath it) during staff-assisted care. Findings included:- R14's Electronic Health Record (EMR) documented diagnoses of malignant neoplasm of the bone, lung, and brain (the medical term for cancer), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (high blood pressure), and pain.The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition. R14 required total staff assistance for all activities of daily living (ADL). R14 had upper and lower functional impairment on both sides, was on a turning and repositioning program, and had skin tears.The Quarterly MDS, dated 04/17/2026, documented R14 had severely impaired cognition. R14 required total staff assistance for all ADLs. R14 had upper and lower functional impairment on both sides, was on a turning and repositioning program, and did not have any skin issues.R14's 04/22/2026 Care Plan included the following interventions:07/31/2020- full body skin assessment weekly by the charge nurse.06/17/2022- observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse.02/26/2024- Change of position to be done every two hours to help prevent skin breakdown and pressure injuries.01/16/2026- ensure R14 wore Geri sleeves (protective, non-compression fabric tubes designed to shield fragile, thinning skin from tears, bruises, and abrasions (scrapes).The Skin Integrity Form, dated 09/11/2025 at 12:36 PM, documented R14 had small, scattered bruising to her left hand. The bruises were red/purple in color and had possibly happened during a transfer with the sit-to-stand lift (a mobility aid designed to help individuals move from a seated position to a standing position). The staff were educated to ensure R14's hands were properly placed to avoid rubbing on the sling.The Skin Integrity Form, dated 10/12/2025 at 08:00 PM, documented R14 had a skin tear to her left forearm, which measured 3 cm x 0.5 cm. The area was cleaned, dried, edges approximated (pulled together), and Tegaderm (a sterile, transparent, and waterproof film dressing) applied. The skin tear occurred from friction during a transfer, and the staff was educated to have Geri sleeves on her during all transfers. The Skin Integrity Form, dated 11/16/2025 at 11:32 AM, documented R14's left hand fell against the sling of the lift and she sustained a 0.5 cm x 0.5 cm skin tear to her left dorsal (back) hand. Staff was educated on proper transferring and maintaining alignment during transfers. The Skin Integrity Form, dated 11/25/2025 at 09:08 AM, documented R14 sustained a 1.5 cm x 1 cm skin tear to her left forearm during a transfer. The Certified Nurse Aide (CNA) told the nurse that she scraped her arm on something during the transfer. The skin tear would be monitored, and education was provided to the CNA. The Skin Integrity Form, dated 12/12/2025 at 11:30 PM, documented R14 had an opening on her right elbow that was bleeding. The area was a 1 cm x 1 cm superficial abrasion. The nurse cleansed the wound and applied Tegaderm to the area. The Skin Integrity Form, dated 01/08/2026 at 08:10 PM, documented R14 had three skin tears to her left elbow area, and scratch marks were noticeable around the skin tears. The distal (below) skin tear was 1 cm x 1 cm and superficial in nature. Some bleeding was noticed with the wound. The proximal (upper) skin tear was 0.5 cm x 0.5 cm and superficial in nature. Scant bleeding was also noticed with this wound. The area was cleansed; skin was approximated as best as possible, and Tegaderm was applied to the area. The nurse educated the CNA's bout always using protective sleeves for her and to use lotion on her skin if R14 complained of itching or dry skin was noticed.The Skin Integrity Form, dated 011/2026 at 05:30 AM, documented R14 had a skin tear to her left pointer finger. The area measured 0.3 cm x 0.1 cm. The area was cleansed, edges approximated, and a band-aid was applied. R14 had turned towards the CNA during personal care, and her finger had rubbed or snagged against a [NAME] on the CNA's uniform top. The CNA was educated to be more careful.The Skin Integrity Form, dated 03/02/2026 at 01:02 PM, documented R14 had a skin tear on her left dorsal forearm. The skin tear measured 1 cm x 1 cm and caught her arm on the sling of the lift during a transfer. The area was cleansed, and Tegaderm was applied. Education was provided to the CNA.The Skin Integrity Form, dated 03/09/2026 at 09:33 AM, documented R14 sustained a 1 cm x 0.5 cm skin tear to her left elbow. R14 had caught her elbow on the armrest of the wheelchair. Staff caught it on the wheelchair armrest while attempting to apply the sling for the lift. Verbal education was provided to the CNA.The Skin Integrity Form, dated 06/08/2026 at 08:32 AM, documented R14 sustained a 0.7 cm x 0.7 cm bruise to her right second toe. R14 hit her toe on the lift. The staff was educated to watch foot placement on the lift.The Skin Integrity Form, dated 07/05/2026 at 10:00 AM, documented R14 sustained a skin tear to her left elbow while staff dressed her after her bath. The skin tear was 0.5 cm x 0.5 cm, with scant bleeding. The area was covered with Tegaderm.On 07/06/2026 at 12:15 PM, R14 sat in her recliner, feet elevated. She had on a short-sleeved top and Geri sleeves on both arms that went from the top of her hands to just below her elbows. R14 had a healing skin tear on her left elbow.On 07/07/2026 at 08:25 AM, R14 sat in her recliner, feet elevated. She had on a short-sleeved top and Geri sleeves on both arms that went from the top of her hands to just below her elbows. R14 had a healing skin tear on her left elbow.On 07/08/2026 at 09:25 AM, CNA N stated R14 had sustained a lot of skin tears during care, and she had to wear the Geri sleeves for protection.On 07/08/2026 at 09:45 AM, Licensed Nurse (LN) H stated R14 had gotten her arm caught a few times on the armrest of the wheelchair. She had arm sleeves for protection that were always to be worn. When asked about R14 wearing long sleeves to protect her whole arm, LN H stated that most of her shirts are short-sleeved, and the resident's preference.On 07/08/2026 at 10:45 AM, Administrative Nurse G stated R14's skin was very fragile and should always have on Geri sleeves. When asked why they only went up to below the elbow, she stated that R14 did have longer ones and did not know why the shorter ones were on her. Administrative Nurse D further stated that staff have been educated to be very careful with her but was unsure how else to keep her from sustaining more skin tears.The facility's Skin Integrity Management policy, dated 09/18/2025, documented that the facility identified residents at risk for skin breakdown. They had guidelines to identify residents at risk for skin breakdown, reduce or relieve pressure, maintain skin integrity, and provide appropriate interventions. The preventative methods, interventions, and treatment options for residents who were at risk or who had abnormal skin conditions included: applications of cream bath soaks to prevent dryness/or scaling, application of a protective elbow and/or heel pads, and application of Derma arm and/or Derma leg protectors.

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 and R17 and their representatives were provided with a bed hold policy. The facility failed to ensure R2 and R17 and their representatives were provided with a written notification of transfer that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable upon their transfer to the hospital. The facility failed to ensure the long-term care ombudsman (LTCO) was notified of R2 and R17's transfer to the hospital as soon as practicable. Findings included:- 1. R2's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set dated [DATE], which documented an unplanned discharge to an acute hospital with a return anticipated.R2's Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital.R2's Resident Documents in the EMR lacked documentation that a bed hold that included the facility's per diem rate to hold a bed. The EMR lacked documentation that R2 and their representatives were provided with a written notification of transfer that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable upon their transfer to the hospital on [DATE]. The facility was unable to provide the documentation upon request.On [DATE] at 12:00 PM, the facility provided the monthly list of notifications to the ombudsman for discharges and transfers for 2026. The lists lacked R2's discharge to the hospital on [DATE] on the ombudsman notifications for [DATE]. - 2. R17's EMR recorded a Discharge Minimum Data Set dated [DATE], which documented an unplanned discharge to an acute hospital with a return anticipated.R17's Entry MDS dated [DATE] documented a re-entry to the facility from an acute hospital.R17's Resident Documents in the EMR lacked documentation that a bed hold that included the facility's per diem rate to hold a bed. The EMR lacked documentation that R17 and their representatives were provided with a written notification of transfer that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable upon their transfer to the hospital [DATE]. The facility was unable to provide the documentation upon request.On [DATE] at 12:00 PM, the facility provided the monthly list of notifications to the ombudsman for discharges and transfers. The lists lacked R17's discharge to the hospital on [DATE] for the [DATE] notification to the ombudsman.On [DATE] at 12:04 PM, Administrative Staff A stated that the facility had dropped the ball on the bed holds, notification to the ombudsman. She stated that their social services person was off this week, but she had found the ombudsman notifications and had realized that they had not been notifying the ombudsman when residents were transferred out to the hospital, only of transfers home or to other facilities. Administrative Staff A went on to state that, for some reason a paper bed holds had not been completed as they should have. She stated that representatives were called by nursing staff, and they gave verbal consent for the bed hold. Administrative Staff A stated that a performance improvement plan (PIP) would be initiated, and staff education would be provided on the issue.The facility's undated Transfer or Discharge, Facility-Initiated policy documented when residents are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or; a resident has not resided in the facility for 30 days. Notice of Transfer was provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. Notice of Facility Bed-Hold and Return policies were provided to the resident and representative within 24 hours of emergency transfer. Notices were provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. Nursing notes would include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. If a resident chooses to appeal a discharge, the facility will not discharge residents while the appeal was pending. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. Residents had the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals. Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge, including: the name, address, email and telephone number of the entity which receives such requests; information about how to obtain, complete and submit an appeal form; how to get assistance completing the appeal process; and the facility bed-hold policy. The facility's Bed-Holds and Returns policy documented: all residents/representatives were provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer [NAME]-cc, are provided written notice about these policies at least twice: notice1: well in advance of any transfer (e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which 1he resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Residents who seek to return to the facility within the bed-hold period defined in the state plan are allowed to return to their previous room, if available. Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: still requires the services provided by the facility: and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with a rationale for Resident (R) 11's ongoing as-needed (PRN) antianxiety medication (a class of medications that calm and relax people). Findings included:- R11's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), malignant neoplasm of the colon (a disease that forms in the tissues of the colon [the longest part of the large intestine]), pain, and dementia (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition. R11 was dependent on staff for lower-body dressing, mobility, and transfers, and required substantial staff assistance for showers, upper-body dressing, and personal hygiene. The MDS further documented R11 received antianxiety and antidepressant (a class of medication used to treat mood disorders) medications daily.The Significant Change MDS, dated 06/19/2026, documented R11 had severely impaired cognition. R11 was dependent upon staff assistance for toileting, hygiene, showers, dressing, transfers, and substantial staff assistance for personal hygiene and mobility. The MDS further documented R11 had inattention, disorganized thinking that fluctuated, and did not receive any medications.R11's 04/01/2026 Care Plan included the following interventions:06/08/2026- R11 had a terminal diagnosis (a progressive medical condition that cannot be cured and is expected to result in death, usually within a timeline of months or less), administer medication as ordered, and adjust provision of activities of daily living (ADL) to compensate for R11's changing abilities.R11's Physician's Order dated 06/08/2026, directed the staff to administer Ativan (antianxiety) 2 milligram (mg)/per milliliter (ml) 0.25 ml, every four hours as needed for anxiety. The order lacked a stop date.R11's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN Ativan.On 07/06/2026 at 09:00 AM, R11 lay in bed with her eyes closed.On 07/07/2026 at 08:00 AM, Certified Nurse Aide (CNA)N stated R11 had not had any periods of anxiety or behaviors.On 07/07/2026 at 08:10 AM, Licensed Nurse (LN) H stated R11 only received pain and anxiety medication as she was on comfort care and had PRN Ativan if she was having anxiety.On 07/08/2026 at 10:45 AM, Administrative Nurse D stated that when they get the initial order for Ativan, they put an automatic 14-day stop date. The physician reassessed the resident for continued need of the medication and would then put a stop date on the medication. Administrative Nurse D stated that they did not think about putting stop dates on residents who were on comfort care.The facility's Psychotropic Drug Use policy, dated 09/18/25, documented that prn orders for psychotropic drugs were limited to fourteen (14) days unless the resident's provider believed that it was appropriate for the prn order to be extended beyond 14 days. The provider must document their rationale for continuation in the resident's medical record and indicate the duration for the prn order.

The facility had a census of 43 residents. The sample included 12 residents with two residents sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility staff failed to implement interventions to prevent development and promote healing of pressure ulcers for Resident (R)26, who had a Stage 4 pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone) when staff did not reposition R26 per the plan of care. This placed R26 at risk for the development of new pressure injuries or delayed healing of the existing pressure ulcer. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had a diagnosis of Stage 4 pressure ulcer of the sacral (large triangular bone/area between the two hip bones) region. R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R26 was dependent on staff for most activities of daily living (ADLs). The MDS documented R26 had a stage 4 pressure ulcer. R26's Care Plan, revised 05/08/24 documented R26 had a stage four pressure ulcer and instructed staff to turn and reposition R26 every hour while sitting up in a chair. The plan directed staff that if R25 was in a recliner or wheelchair, staff were to stand R26 and encourage her to take a walk or lay down for 15 minutes, every hour, 12 times a day, starting at 08:00 AM and ending at 07:00 PM. On 08/05/24 at 01:30 PM, observation revealed R26 sat in a wheelchair in the activity room. Continued observation revealed R26 remained in the same position in the same place, without staff assisting the resident to stand or encourage her to lie down in bed. Continued observation revealed from 01:30 PM to 03:35 PM ( two hours and five minutes) R26 remained in the same position in her chair without staff assisting her to stand, reposition, or encourage her to lie down in bed. On 08/06/24 at 07:33 AM, observation revealed R26 sat in a wheelchair, leaning forward. R26 looked in a mirror and independently applied her makeup. Continued observation revealed at 07:49 AM Certified Nurse Aide (CNA) P entered R26's room and asked R26 if she was done putting on her makeup, and R26 replied Yes. CNA P told the resident he would take out the trash and come back and get her but did not offer to assist her to stand or encourage her to lie down in bed. At 07:58 AM CNA P came back to the room, placed the foot pedals on the resident's wheelchair, placed her feet up on the foot pedals and, without assisting R26 to stand or reposition, propelled R26 from her room to hallway. CNA Q then propelled R26 to the dining room table. Continued observation revealed from 08:13 AM to 08:55 AM R26 remained in the same position at the dining room table, without staff repositioning, standing her, or encouraging her to lie down. At 08:55 AM, observation revealed CNA R propelled R26 away from the table to the activity room and placed her facing the television. Staff did not attempt or offer to assist R26 to stand, reposition, or encourage her to lie down in bed. At 09:09 AM R26 remained in the wheelchair in the activity room; staff removed her foot pedals and R26 exercised by minimally lifting her legs one at a time up from the wheelchair. Continuous observation for one hour 39 minutes during which no staff assisted R26 with standing, repositioning, or encouraging her to lie down in bed. On 08/05/24 at 03:56 PM, Certified Nurse Aide (CNA) M stated staff were to assist R26 with changing position, every hour, while she was in her chair. CNA M stated she did not know how long R26 had been in her wheelchair due to the activity staff placed her in it. On 08/07/24 at 11:08 AM, Licensed Nurse (LN) J, the facility's wound care nurse, said she was uncertain if the lack of repositioning could delay the healing of R26's pressure ulcer since it was not expected to heal. LN J said the plan was just to maintain it. On 08/07/24 at 10:32 AM, Administrative Nurse D verified R26's Care Plan and instructed staff to reposition R26 every hour when in her chair. Admin Nurse D stated the CNA's ADL plan did not include those instructions. The facility's Care Planning Policy, revised 06/30/20, documented all associates were responsible for following the care plan. The facility's Skin Integrity Policy, revised 08/20/18, documented that staff would identify residents at risk for skin breakdown, reduce or relieve pressure, maintain skin integrity, and provide appropriate interventions to manage pressure injuries. The facility failed to implement interventions to prevent the development and promote the healing of pressure ulcers for R26, who had a Stage 4 pressure ulcer when staff did not reposition R26 per the plan of care. This placed R26 at risk for the development of new pressure injuries or delayed healing of the existing pressure ulcer.

The facility had a census of 43 residents. The sample included 12 residents, with three reviewed for skin conditions, not pressure-related. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3, who received anticoagulant (medication that inhibits the coagulation of blood), received the care as required to prevent skin injuries including Dermasaver sleeves (protects fragile skin prone to skin tears and bruises) and sheepskin surface padding. This placed R3 at risk for further skin injury. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertensive heart disease (complications of high blood pressure that affect the heart), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), psychotic disorder with hallucinations (a mental health condition that causes people to lose touch with reality), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had long-term and short-term memory problems with severely impaired decision-making skills. R3 was dependent upon staff for personal hygiene, dressing, mobility, and toileting, and did not ambulate. The MDS documented R3 had no skin issues. R3's Care Plan, dated 07/03/24 and initiated on 05/24/17, documented R3 was at risk for skin integrity injuries due to incontinence, low activity level, use of a lift, agitation, behaviors, and dementia. The update. dated 04/05/23, directed staff to inspect her skin daily, observe for redness, open areas, scratches, cuts, and bruises, and report changes to the nurse. The update, dated, 10/13/21, directed staff to keep fingernails smooth and trimmed to prevent jagged edges. The update, dated 11/10/23, documented R3 had sheepskin on her wheelchair arms. The update, dated 07/03/24, directed staff to use a trough pressure relief cushion in R3's wheelchair to help prevent pressure injuries and to ensure R3 did not slide out of the wheelchair. The care plan lacked direction for R3's Dermasaver sleeves. The Physician's Order, dated 03/20/23, directed staff to administer Eliquis (an anticoagulant), 2.5 milligrams (mg), by mouth, for atrial fibrillation. The Physician's Order, dated 06/20/23, directed staff to have the charge nurse to perform a full body skin assessment on the resident weekly, check fingernails, trim or file if broken or jagged, and document skin assessment in the progress Note. The Physician's Order, dated 01/19/24, directed staff to apply derma sleeves and remove them at bedtime. On 08/05/24 at 08:15 AM, observation revealed R3 had Dermasaver sleeves on both forearms. The sleeves were bunched up and were not pulled up to cover her elbows. Further observation revealed R3's wheelchair arms did not have sheepskin on them. On 08/05/24 at 11:00 AM, observation revealed R3 did not have the Dermasaver sleeves on and the wheelchair arms did not have sheepskin on them. On 08/06/24 at 08:20 AM, observation revealed R3 had the Dermasaver sleeves on, the sleeves were not pulled up over her elbows and the wheelchair arms did not have sheepskin on them. On 08/06/24 at 11:15 AM, observation revealed R3 did not have the Dermasaver sleeves on or sheepskin on the arms of the wheelchair. Further observation revealed R3 continuously rubbed her left arm during the noon meal. On 08/06/24 at 12:11 PM, Certified Nurse Aide (CNA) O stated R3 had a recent skin tear on her right elbow and was supposed to have her Dermasaver sleeves on for protection and sheepskin on the arms of the wheelchair. CNA O further stated she did not know why R3 did not have them on as she was at risk for bruising and skin tears. On 08/06/24 at 12:12 PM, Administrative Nurse D stated R3's Dermasaver sleeves were ordered for protection due to her fragile skin and stated the sleeves had been on her care plan at one time but somehow got deleted. On 08/07/24 at -9:40 AM, Licensed Nurse (LN) I stated R3 had a risk of bruising her arms because she had hit her arms on things so the Dermasaver sleeves were put on her arms for protection. The facility's Skin Integrity Management policy, dated 02/20/18, documented it was the responsibility of all nursing, activity, dietary, and social service staff to report any abnormal skin conditions to the resident's charge nurse. Preventative methods, interventions, and treatment options for residents who are at risk for or who have abnormal skin conditions/breakdown, including application of derma arm and/or derma leg protectors. The facility failed to ensure R3 received the necessary interventions including Dermasaver sleeves and sheepskin surface padding to prevent skin injuries This placed the resident at risk for further skin injury.

The facility has a census of 43 residents. The sample included 12 residents, with three reviewed for skin conditions, not pressure-related. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 3 to include the use of protective sleeves to prevent skin injury. This placed the resident at risk for further skin injury due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertensive heart disease (complications of high blood pressure that affect the heart), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), psychotic disorder with hallucinations (a mental health condition that causes people to lose touch with reality), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had long-term and short-term memory problems with severely impaired decision-making skills. R3 was dependent upon staff for personal hygiene, dressing, mobility, and toileting, and did not ambulate. The MDS documented R3 had no skin issues. R3's Care Plan, dated 07/03/24 and initiated on 05/24/17, documented R3 was at risk for skin integrity injuries due to incontinence, low activity level, use of a lift, agitation, behaviors, and dementia. The update. dated 04/05/23, directed staff to inspect her skin daily, observe for redness, open areas, scratches, cuts, and bruises, and report changes to the nurse. The update, dated, 10/13/21, directed staff to keep fingernails smooth and trimmed to prevent jagged edges. The update, dated 11/10/23, documented R3 had sheepskin on her wheelchair arms. The update, dated 07/03/24, directed staff to use a trough pressure relief cushion in R3's wheelchair to help prevent pressure injuries and to ensure R3 did not slide out of the wheelchair. The care plan lacked direction for R3's Dermasaver sleeves. The Physician's Order, dated 03/20/23, directed staff to administer Eliquis (an anticoagulant), 2.5 milligrams (mg), by mouth, for atrial fibrillation. The Physician's Order, dated 06/20/23, directed staff to have the charge nurse to perform a full body skin assessment on the resident weekly, check fingernails, trim or file if broken or jagged, and document skin assessment in the progress notes. The Physician's Order, dated 01/19/24, directed staff to apply derma sleeves and remove them at bedtime. On 08/05/24 at 08:15 AM, observation revealed R3 had Dermasaver sleeves on both forearms. The sleeves were bunched up and were not pulled up to cover her elbows. Further observation revealed that R3's wheelchair arms did not have sheepskin on them. On 08/05/24 at 11:00 AM, observation revealed R3 did not have the Dermasaver sleeves on and the wheelchair arms did not have sheepskin on them. On 08/06/24 at 08:20 AM, observation revealed R3 had the Dermasaver sleeves on, the sleeves were not pulled up over her elbows and the wheelchair arms did not have sheepskin on them. On 08/06/24 at 11:15 AM, observation revealed R3 did not have the Dermasaver sleeves on or sheepskin on the arms of the wheelchair. Further observation revealed R3 continuously rubbed her left arm during the noon meal. On 08/06/24 at 12:11 PM, Certified Nurse Aide (CNA) O stated R3 had a recent skin tear on her right elbow and was supposed to have her Dermasaver sleeves on for protection and sheepskin on the arms of the wheelchair. CNA O further stated she did not know why R3 did not have them on as she was at risk for bruising and skin tears. On 08/06/24 at 12:12 PM, Administrative Nurse D stated that R3's Dermasaver sleeves were ordered for protection due to her fragile skin. Administrative Nurse D stated the sleeves had been on R3's Care Plan at one time but somehow got deleted. Administrative Nurse D said she expected staff to follow the care plan. The facility's Care Planning policy, dated 6/30/20, documented the plan of care shall be individualized based on the diagnosis, culture, resident assessment, personal goals of the resident, resident interests, preferences, strengths, and trauma-informed care plan. The plan of care shall be reviewed and revised quarterly by the MDS Coordinator and as resident needs change by any qualified individual, with revisions reflecting the reassessment of the needs of the resident. The resident and/or resident representative will review the changes and sign the plan of care. The facility failed to revise the care plan for R3 to include Dermasaver sleeves to prevent skin injury. This placed the resident at risk for further injury due to uncommunicated care needs.

The facility had a census of 43 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a written risk versus benefit rationale from the physician for the continued use of four psychotropic (alters mood or thought) drugs for Resident (R) 7. This placed R7 at risk for unnecessary psychotropic medications and related side effects. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), recurrent major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorders, psychotic (any major mental disorder characterized by gross impairment in reality perception) disorder, and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R7 was independent with eating, required supervision for upper body dressing, moderate staff assistance for transfers, walking, donning footwear, and maximum staff assistance for lower body dressing, toileting, and sitting to standing. The MDS documented R7 had no behaviors and received antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), and antidepressant (class of medications used to treat mood disorders) medications. R7's Care Plan, dated 07/24/24, directed staff to give medications as ordered, monitor, document, and report any signs or symptoms of medication side effects. The care plan for psychotropic drugs stated a gradual dose reduction (GDR) was to be attempted when clinically appropriate, within the first year of medication start, and two GDR attempts were to be trialed within two different quarters unless documentation for clinical contraindication was present. The care plan included the target behaviors for the use of risperidone (antipsychotic), clonazepam (antianxiety), Trazodone (antidepressant), and Zoloft (antidepressant). The Physician Order, dated 01/16/23, directed staff to administer Trazodone 100 milligrams (mg) at bedtime, for insomnia. The Physician Order, dated 05/19/23, directed staff to administer clonazepam 0.5 mg every day upon rising, and at 02:30 PM, for anxiety disorder. The Physician Order, dated 10/17/23, directed staff to administer clonazepam 0.5 mg (3 tabs) at bedtime for anxiety disorder. The Physician Order, dated 10/18/23, directed staff to administer risperidone 0.25 mg twice daily (BID) for psychotic disorder with delusions. The Physician Order, dated 10/18/23, directed staff to administer Zoloft 150 mg upon rising, for recurrent depression. The Consultant Pharmacist Monthly Medication Review dated 03/19/24, recommended a GDR of risperidone. The physician wrote dose adjustment not advised without documenting an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Review dated 04/23/24, recommended a GDR of Trazodone. The physician wrote, See if family wants to decrease dose. The physician did not provide an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Review dated 05/22/24, recommended a GDR of clonazepam. The physician wrote no changes without documenting an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Reviews dated 06/18/24, and 07/16/24, documented no irregularities. On 08/06/24 at 08:04 AM, observation revealed Licensed Nurse (LN) H administered medications including Zoloft, clonazepam, and risperidone to R7 who took the pills whole with much encouragement. On 08/07/24 at 903 AM, Administrative Nurse E verified the lack of risk versus benefit rationales for the continued use of clonazepam, risperidone, Trazodone, and Zoloft. The facility's Psychotropic Drug Use policy, dated 02/24/2021, stated residents who use psychotropic drugs would receive periodical gradual dose reductions and behavioral interventions unless clinically contraindicated. The MDS coordinator would review psychotropic medications with each MDS assessment and request the physician review the usage of psychotropic medications. The facility failed to obtain a written risk versus benefit rationale from the physician for the continued use of four psychotropic drugs for R7, placing R7 at risk for unnecessary psychotropic medications and related side effects.

The facility had a census of 43 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to administer two blood pressure medications based on the blood pressure monitoring per the physician's orders for Resident (R) 7. This placed the resident at risk for unnecessary medication resulting from abnormal blood pressure. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R7 was independent with eating and required supervision for upper body dressing, moderate staff assistance for transfers, walking, and donning footwear. R7 required maximum staff assistance for lower body dressing, toileting, and sitting to standing. The MDS documented R7 had one non-injury fall since the prior MDS. R7's Care Plan, dated 07/24/24, directed staff to give medications as ordered, monitor, document, and report any signs or symptoms of medication side effects. Encourage R7 to assume a standing position slowly, and avoid standing or transferring without assistance. The plan directed staff that when R7 reported feeling dizzy or was having symptoms of hypotension, assist her to sit down or sit with her head lowered between her legs. The Physician Order, dated 12/12/23 directed staff to administer an as-needed (PRN) dose of metoprolol (a drug to reduce blood pressure) 12.5 milligrams (mg) for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) greater than (>) 160 millimeters of mercury (mm/Hg). The Physician Order, dated 04/05/23 directed staff to perform blood pressure checks three times per day (TID) and administer Midodrine (a drug to increase blood pressure) 2.5 mg PRN for SBP less than (<) 90 mm/Hg, three times daily. The Physician Order, dated 04/23/2023, directed staff to report blood pressures greater than 200/110 mm/Hg or less than 80/30 mm/Hg or if the resident was symptomatic. R7's May Medication Administration Record lacked documentation staff administered Midodrine 2.5 mg for SBP <90 mm/HG six times. R7's June Medication Administration Record lacked documentation staff administered PRN metoprolol 12.5 mg for SBP >160 mm/HG 42 times and lacked documentation that staff administered Midodrine 2.5 mg PRN for SBP <90 mm/HG two times. R7's July Medication Administration Record lacked documentation staff administered PRN metoprolol 12.5 mg for SBP >160 mm/HG 21 times the SBP exceeded the parameter and lacked documentation that the staff administered Midodrine 2.5 mg PRN for SBP <90 mmHG seven times. R7's August Medication Administration Record lacked documentation staff administered PRN Metoprolol 12.5 mg for SBP >160 mm/HG four times the SBP exceeded the parameter. On 08/06/24 at 08:04 AM, observation revealed Licensed Nurse (LN) H administered medications to R7 after obtaining a blood pressure of 185/112 mm/Hg. The medications included metoprolol 12.5 mg, and PRN metoprolol 12.5 mg. R7 took the pills whole with much encouragement. On 08/07/24 at 09:40 AM, Administrative Nurse D verified staff failed to administer the PRN metoprolol and the PRN Midodrine as the physician ordered numerous times in May, June, and July 2024. She stated some of the high blood pressure readings were obtained just prior to the resident receiving the scheduled dose of metoprolol. The facility's Medication Administration policy, dated 02/13/2017, stated staff would administer all medications to each resident as ordered by a physician or provider, and the drug regimen would be free from unnecessary drugs. The facility failed to administer blood pressure medications as the physician ordered, placing R7 at risk for high or low blood pressure effects.

The facility had a census of 43 residents. The sample included 12 residents with one resident reviewed for discharge. Based on record review and interview the facility failed to complete a recapitulation (a concise summary of stay and course of treatment in the facility) of Resident (R) 45's stay in the facility. This placed the resident at risk of unmet care needs. Findings included: - The Electronic Medical Record (EMR), documented R45 admitted to the facility on [DATE] and documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) with dyskinesia (inability to execute voluntary movements), unsteadiness on feet, weakness, urine retention, dementia (progressive mental disorder characterized by failing memory, confusion), altered mental status, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), acute cystitis (type of urinary tract infection that causes inflammation of the bladder), and malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of the prostate. The Admission Minimum Data Set (MDS), dated [DATE], documented R45 had intact cognition. He was dependent on staff assistance with oral hygiene, toileting hygiene, lower body dressing, putting on and taking off footwear, and mobility from lying to sitting and sitting to standing. R45 required substantial assistance with showers, upper body dressing, toilet transfers, rolling left and right in bed, sitting to lying, and chair-to-bed and bed-to-chair transfers. The discharge goal performance had not been completed. The MDS further documented R45 was always continent of urine and occasionally incontinent of bowel. R45 received an antibiotic, and speech, occupational and physical therapies. The Activity of Daily Living Care Area Assessment (CAA), dated 04/08/24, documented R45 had been admitted for short-term rehabilitation. The goal was to return home with family. but it depended on how well R45 responded to therapy. The CAA further documented R45 had Parkinson's disease, was admitted to the hospital because of weakness and g urine incontinence, and was found to have COVID-19 ( a highly infectious, potentially fatal respiratory infection)19, urinary tract infection, and acute cystitis. R45's Care Plan dated 04/11/24 documented R45 had a goal of discharging back to an apartment with his spouse. The care plan directed staff to anticipate discharge with home health services and involve R45 and his family in the discharge process. The Physician Order, dated 05/29/24, directed staff to discharge R45 to home with his spouse. The Progress Note, dated 05/29/24 at 12:56 PM, documented R45 assisted by wheelchair to the front entrance and assisted into a vehicle with his spouse. R45's clinical record lacked a recapitulation of the stay. On 08/07/24 at 08:33 AM Administrative Nurse D reported the nurses, social services, and therapy each do their discharge summaries, but the facility had not done a recapitulation of R45's stay. The facility's Discharge policy, dated 12/12/16, documented the policy that the nursing department, social services, physicians, and care team work together towards the organized timely discharge of all residents. It is the purpose of the policy to outline the proper procedure for discharging residents upon the order of a physician and the resident's goals. The policy lacked the need for a recapitulation of the resident's course of stay. The facility failed to complete a recapitulation of R45's stay in the facility. This placed the resident at risk of unmet care needs.

The facility had a census of 43 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist identified and reported to facility administration the lack of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by gross impairment in reality testing) and/or for not attempting a gradual dose reduction (GDR) for psychotropic (alters mood or thought) medications and that staff had not administered the physician ordered as needed (PRN) blood pressure medication when the blood pressure was out of parameters, placing R7 at risk for further issues related to uncontrolled blood pressures and for receiving unnecessary psychotropic medications. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R7 was independent with eating and required supervision for upper body dressing, moderate staff assistance for transfers, walking, and donning footwear. R7 required maximum staff assistance for lower body dressing, toileting, and sitting to standing. The MDS documented R7 had one non-injury fall since the prior MDS. R7's Care Plan, dated 07/24/24, directed staff to give medications as ordered, monitor, document, and report any signs or symptoms of medication side effects. Encourage R7 to assume a standing position slowly, and avoid standing or transferring without assistance. The plan directed staff that when R7 reported feeling dizzy or was having symptoms of hypotension, assist her to sit down or sit with her head lowered between her legs. The Physician Order, dated 12/12/23 directed staff to administer an as-needed (PRN) dose of metoprolol (a drug to reduce blood pressure) 12.5 milligrams (mg) for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) greater than (>) 160 millimeters of mercury (mm/Hg). The Physician Order, dated 04/05/23 directed staff to perform blood pressure checks three times per day (TID) and administer Midodrine (a drug to increase blood pressure) 2.5 mg PRN for SBP less than (<) 90 mm/Hg, three times daily. The Physician Order, dated 04/23/2023, directed staff to report blood pressures greater than 200/110 mm/Hg or less than 80/30 mm/Hg or if the resident was symptomatic. R7's May Medication Administration Record lacked documentation that staff administered Midodrine 2.5 mg for SBP <90 mm/HG six times. R7's June Medication Administration Record lacked documentation staff administered PRN metoprolol 12.5 mg for SBP >160 mm/HG 42 times and lacked documentation that staff administered Midodrine 2.5 mg PRN for SBP <90 mm/HG two times. R7's July Medication Administration Record lacked documentation staff administered PRN metoprolol 12.5 mg for SBP >160 mm/HG 21 times the SBP exceeded the parameter and lacked documentation that the staff administered Midodrine 2.5 mg PRN for SBP <90 mmHG seven times. R7's August Medication Administration Record lacked documentation staff administered PRN Metoprolol 12.5 mg for SBP >160 mm/HG four times the SBP exceeded the parameter. The Consultant Pharmacist Monthly Medication Reviews, dated 06/18/24 and 07/16/24, documented there were no irregularities in the medication record. The Physician Order, dated 01/16/23, directed staff to administer Trazodone 100 milligrams (mg) at bedtime, for insomnia. The Physician Order, dated 05/19/23, directed staff to administer clonazepam 0.5 mg every day upon rising, and at 02:30 PM, for anxiety disorder. The Physician Order, dated 10/17/23, directed staff to administer clonazepam 0.5 mg (3 tabs) at bedtime for anxiety disorder. The Physician Order, dated 10/18/23, directed staff to administer risperidone 0.25 mg twice daily (BID) for psychotic disorder with delusions. The Physician Order, dated 10/18/23, directed staff to administer Zoloft 150 mg upon rising, for recurrent depression. The Consultant Pharmacist Monthly Medication Review dated 03/19/24, recommended a GDR of risperidone. The physician wrote dose adjustment not advised without documenting an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Review dated 04/23/24, recommended a GDR of Trazodone. The physician wrote, See if the family wants to decrease the dose. The physician did not provide an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Review dated 05/22/24, recommended a GDR of clonazepam. The physician wrote no changes without documenting an explanation of why the benefits of continuing the drug outweighed the risks. The Consultant Pharmacist Monthly Medication Reviews dated 06/18/24, and 07/16/24, documented no irregularities. On 08/06/24 at 08:04 AM, observation revealed Licensed Nurse (LN) H administered medications to R7 after obtaining a blood pressure of 185/112 mm/Hg. The medications included metoprolol 12.5 mg, and PRN metoprolol 12.5 mg. R7 took the pills whole with much encouragement. On 08/07/24 at 903 AM, Administrative Nurse E verified the lack of risk versus benefit rationales for the continued use of clonazepam, risperidone, Trazodone, and Zoloft. and confirmed the pharmacist had not reported this to the facility. On 08/07/24 at 09:40 AM, Administrative Nurse D verified the facility's consultant pharmacist had failed to notify her of the lack of administration of the PRN metoprolol and the PRN Midodrine as the physician ordered numerous times in May, June, and July 2024. The facility's Pharmacy Review policy, dated 03/19/18, stated the pharmacist consultant would review the resident's Electronic Health Records (EHR) and Electronic Medical Record (EMR) of all residents on a monthly basis to ensure the residents were receiving appropriate medication therapy that was safe and efficacious. The pharmacist would review medication administration for timely administration and reasons for non-administration. The pharmacist would review for possible unnecessary medications where the resident might benefit from a gradual dose reduction to the lowest effective dose. The pharmacist would review for appropriate orders, diagnosis, and response to medications. The pharmacist would document a review of irregularities and what if any action was taken to address it. If no action was taken the physician must then document a rationale on the report. The Medical Director would review the pharmacy irregularities and omissions reviews monthly. The facility failed to ensure the Consultant Pharmacist identified and reported to facility administration the lack of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic and/or for not attempting a GDR for psychotropic medications and that staff had not administered the physician ordered PRN blood pressure medication when the blood pressure was out of parameters, placing R7 at risk for further issues related to uncontrolled blood pressures and for receiving unnecessary psychotropic medications.

The facility identified a census of 44 residents with three residents reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 who had a history of respiratory failure and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) received the required respiratory services. On 05/21/24 at 09:58 AM Certified Nurse Aide (CNA) M failed to provide R1's continuous oxygen at 4 Liters (L) per minute for forty-five minutes, while staff provided R1 a bath. At 10:45 AM CNA M assisted R1 back to his wheelchair after bathing and dressing him; when R1 sat down he became unresponsive. Certified Medication Aide (CMA) R entered the bathhouse and noted R1 had no color and was struggling to breathe. Licensed Nurse (LN) G then entered the bathhouse and noted R1 with his head back and was extremely pale. LN H entered the bathhouse and saw R1's eyes rolled into the back of his head, greyish skin color, and no respirations. The staff obtained R1's vital signs and noted zero respirations and an oxygen saturation of 76 percent (%). LN H noticed R1 did not have his oxygen on and requested an oxygen cylinder be brought to the room. Staff administered R1 oxygen at 4L per minute by nasal cannula per R1's orders. R1 became responsive for a moment and verbalized he could hear staff and then lost consciousness again. R1's breathing was irregular and labored and R1 was transferred to a higher level of care. R1 returned to the facility with orders for continuous oxygen even during baths. The facility failed to ensure R1 received his physician-ordered oxygen as required resulting in respiratory distress and arrest. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), COPD, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 was dependent on staff for toileting, hygiene, and donning footwear. R1 required maximum assistance from staff for bathing, lower body dressing, transferring to the bath, and ambulating ten feet. The MDS documented R1 required moderate staff assistance for upper body dressing, lying to sitting, sit to stand, chair to bed transfers, and toilet transfers. The MDS documented R1 required continuous oxygen and a non-invasive mechanical ventilator (Bi-Pap - a type of positive pressure ventilator to assist with breathing). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/12/24, documented R1 used oxygen continuously and used a Bi-pap. R1 received breathing treatments to help manage his respiratory status. R1 would become short of air with activities, at rest, and when lying flat. R1 slept in his recliner. The CAA documented R1 had multiple diagnoses that could cause alterations in his cognition. The Activities of Daily Living/Functional Rehabilitation Potential CAA, dated 05/12/24, documented R1 had required increased staff assistance since his readmission with supervision to dependent staff assistance with most care. R1's Care Plan documented R1 had COPD with shortness of breath and a history of hypoxic and hypercapnic (a condition where the blood has abnormally high levels of carbon dioxide) respiratory failure. The care plan directed staff to ensure R1 had oxygen on at 4L via nasal cannula while awake/during the day, continuously. The care plan directed staff to change R1's oxygen to a Bi-pap with oxygen at 4L during the night. Staff were to notify the nurse if R1 was complaining of shortness of breath or having signs and symptoms of difficulty breathing. The care plan directed staff to elevate R1's head of bed to semi-Fowlers (semi-upright) to fowlers (upright) or out of bed upright in a chair during episodes of difficulty breathing. The Physician's Order, dated 02/06/24, documented R1 was to have oxygen administered at 4L continuously. The Progress Note, dated 05/21/24 at 11:03 AM, documented LN H was called to the whirlpool room by LN G and CNA M at approximately 10:45 AM. LN G entered the room and saw R1's eyes rolled into the back of his head; R1 had a grey skin color and no respirations. R1 had no response to verbal or painful stimulation. LN H asked for assistance from Administrative Nurse D and Administrative Nurse E. LN H noted R1 did not have any supplemental oxygen on. CNA N retrieved the vital signs cart. R1's vital signs were assessed and R1 had a pulse of 66 beats per minute, a blood pressure of 154/71 millimeters per mercury (mmHg), zero respirations, and oxygen saturation of 76% (normal range between 95% to 100%). R1 did respond briefly and stated, I hear you, before going unresponsive again. Once supplemental oxygen was placed on R1 via nasal cannula, LN H instructed staff to set up R1's CPAP (continuous positive airway pressure [CPAP] ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and R1 was taken immediately back to his room and the CPAP was applied with 4L of oxygen bled through. R1 became more responsive but continued to have irregular respirations. Staff transferred R1 to his bed with the full body lift. R1's oxygen saturation continued to be in the mid-80th percentile. After R1 was transferred to bed, the head of the bed was elevated, the CPAP mask was adjusted to reduce leaking, R1's oxygen saturation rose to the low 90s but his skin had a grey pallor (pale skin color). LN H remained with R1 until Emergency Medical Service (EMS) arrived to transfer R1 to the hospital. The Emergency Department Discharge Instructions, dated 05/21/24 at 01:55 PM, directed R1 to wear oxygen at all times as ordered even in the shower. The undated Facility Incident Report documented on 05/21/24 at 09:58 AM CNA N assisted CNA M in transferring R1 from his recliner to the wheelchair so CNA M could take him for his bath. CNA M assisted R1 to the bath without any incident and notified LN G she completed R1's bath. LN G performed a skin assessment and performed skin treatments at approximately 10:30 AM to 10:35 AM and left the bathhouse to allow CNA M to finish getting R1 dressed. After getting R1 dressed, CNA M transferred R1 to his wheelchair. As soon as R1 sat in his wheelchair, R1 lost consciousness. CMA R entered the whirlpool room at the same time and saw R1 had lost his color and struggled to breathe. LN G was alerted and went to the whirlpool room. When LN G entered the whirlpool room, she saw R1's head laid back and R1 was extremely pale. LN G then requested help from LN H and sent CNA N for the vital signs cart. LN H entered the whirlpool room and saw R1 leaning back in his wheelchair, eyes rolled into the back of his head, skin pale and grey, and without visible spontaneous respirations. LN G requested assistance from Administrative Nurse D and Administrative Nurse E. R1's vital signs were assessed and R1 had no respirations and an oxygen saturation of 76%. LN G noted R1 did not have oxygen on and obtained and administered oxygen at 4L per minute per nasal cannula per orders. R1 became responsive for a moment and verbalized he could hear staff and again lost consciousness. R1's respirations remained irregular and labored. R1 was assisted back to his room where his Bi-Pap was administered. Staff notified R1's primary care provider who ordered to send R1 to the emergency room if R1's responsible party was okay with it. Staff contacted R1's responsible party who requested R1 be sent to the emergency room . Staff assisted R1 to bed via the full body lift and R1 gradually returned to normal alertness. EMS arrived at 10:58 AM. R1 continued to be pale with labored respirations but was alert and oxygen saturations were back in the low 90th percentile. Staff assisted EMS in transferring R1 to a stretcher and turned over care. EMS exited the facility at 11:10 AM. R1 was seen at the local hospital, and they reported no respiratory distress upon R1's arrival. CNA M's undated Witness Statement documented that while CNA M bathed R1, CNA M forgot to put R1's oxygen on. CNA M stated R1 was doing okay when she asked him. CNA M stated R1 talked to her while she gave him a bath. CNA M stated after she got R1 dressed and back into his wheelchair, R1 lost consciousness. CNA M stated she got the charge nurse right away. CNA M stated R1 got his CPAP on and transferred to his bed and then was transferred to the emergency room by EMS. CMA R's undated Witness Statement documented R1 was in the bathhouse with CNA M. CMA R walked into the bathhouse to see how far along the bath was. CMA R stated when she opened the door, she saw R1 in his wheelchair and he had started to turn pale, almost white, and struggled to breathe. CMA R stated she called LN G and LN H over and then stepped out of the way while another aide obtained R1's vital signs. LN G's undated Witness Statement documented LN G was at the nurse's station when CMA R hollered and waved to LN G to come to the bathhouse. LN G stated when she got to the door, she saw R1 laid back in his wheelchair and was pale in color. LN G stated she hollered at LN H and ran to get the vitals sign cart and a stethoscope. LN G stated at that point LN H took over and LN G assisted with getting oxygen applied and getting R1 ready for transfer to the emergency room . LN H's undated Witness Statement documented LN H was called to the 300-hall whirlpool room at approximately 10:45 AM by LN G and CNA M. When LN H arrived at the whirlpool room, she saw R1 leaning back in his wheelchair; he had no signs of spontaneous respirations. LN H stated R1's eyes were rolled back, his skin was grey/pale in pallor, and he was unresponsive to verbal or painful stimuli. LN G stated she called for assistance from the administrative nurses. CNA M retrieved the vital signs cart and began to obtain vital signs. LN G stated she observed R1 did not have any supplemental oxygen, nor was there any oxygen in the whirlpool room. R1's oxygen saturation was 76%. CNA N arrived with an oxygen cylinder and supplemental oxygen was placed on R1 at 4L via nasal cannula. R1 briefly responded and stated, I hear you, before he became unresponsive again. LN G stated once oxygen was on R1, she took R1 to his room and immediately placed his CPAP on with supplemental oxygen bled in at 4L. R1 was then transferred to his bed utilizing the full body lift. R1 began to become more responsive though his oxygen saturation continued to read in the mid 80th percentile. R1 was placed in bed with the head of the bed elevated and the CPAP adjusted to reduce leaking air. R1's oxygen saturation began to rise to the low 90s. R1's skin continued to be pale and grey. LN H stated she stayed with R1 until EMS arrived and assisted in transferring the resident to the stretcher. Administrative Nurse E's undated Witness Statement documented she was in her office when a CNA knocked on her door and stated LN H needed help in the whirlpool room. Administrative Nurse E stated she saw R1 in his wheelchair with his head tilted back and flaccid (hanging loosely or limply) upper extremities. Administrative Nurse E stated LN H was already with R1 along with a couple of CNAs. R1 had agonal (intermittent gasps triggered as a brain stem reflex to lack of oxygen-rich blood, and a sign of impending death) breathing; a CNA brought in oxygen to place on R1. Since LN H was with R1, Administrative Nurse E went to get paperwork printed for transfer and then returned to the whirlpool room. LN H instructed staff to take R1 to his room to get his CPAP on and in bed to prepare for EMS transport. Once R1 was in his room, he knew where he was and was speaking. LN H applied R1's CPAP. CNA O's undated Witness Statement documented she witnessed CNA M holler for LN G. LN G went to the bathhouse and then got LN H. CNA O documented the nurses asked the CNAs to get R1's oxygen. CNA O stated she went to R1's room to look for the oxygen. CNA N came into the room and grabbed the tank and took it to the bathhouse. They wheeled R1 to his room and CNA O stated she assisted in getting R1 to bed and put his CPAP on R1. On 06/05/24 at 10:15 AM, observation revealed the whirlpool room/shower room was free of clutter and contained no supplemental oxygen in the room. During an interview on 06/05/24 at 10:20 AM, CNA N stated he helped CNA M get R1 up for the bath and into his wheelchair. CNA N stated R1 did not have any oxygen on when he left the room for the bath a little before 10:00 AM. CNA N stated CNA M asked him if R1 required oxygen and he told her that he did not know. CNA N went to R1's room to get R1's oxygen cylinder and saw the oxygen cylinder on the bed and not in R1's wheelchair holder. During an interview on 06/05/24 at 10:30 AM, LN G stated she went into the bathroom and saw R1 laid back in his wheelchair and his color was pale. LN G said she got another nurse to come help and LN H took over the situation. LN G stated R1 did not have oxygen on. During an interview on 06/05/24 at 10:35 AM, Administrative Nurse D stated she expected all of her CNAs to know the residents who required continuous oxygen and ensure that the oxygen was administered per the care plan. Administrative Nurse D stated CNA M said she simply forgot the oxygen and R1 was doing okay at first in the bath and then, after she got him out and dressed, he went unresponsive. During an interview on 06/05/24 at 01:10 PM Administrative Staff A stated the situation should not reflect badly on the facility. Administrative Staff A stated the situation was human error and the facility had done everything right: reported the incident, provided education, and had the appropriate protocols in place. Administrative Staff A stated the situation was not a sentinel event and should be scoped as such. The facility's Abuse, Neglect, Exploitation Policy, revised 10/01/22, documented neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's Oxygen Therapy Policy, revised 08/20/18, documented it is the facility's policy that oxygen will be administered as ordered by the physician or in emergent situations until an order for flow rate can be obtained. On 06/05/24 at 01:15 PM Administrative Staff A was provided the Immediate Jeopardy [IJ] Template and notified the facility failure to provide R1 with continuous supplemental oxygen as ordered by the physician placed the resident in immediate jeopardy. The facility identified and implemented corrective actions, which were completed on 05/31/24, and included reeducation for all nursing staff on the importance of providing the necessary care including administering oxygen appropriately per orders. Appropriate staff completed an oxygen competency check-off completed. The incident was reviewed by the Quality Assurance Committee. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance.

The facility had a census of 48 residents. The sample included 13 residents, with three reviewed for nutrition. Based on observation, record review, and interview, the facility failed to identify weight loss and involve the Registered Dietician (RD) for weight loss interventions to address the significant unplanned weight loss for one sampled resident, Residents (R) 20. The facility further failed to monitor nutritional supplement intake for R20 after the significant loss to evaluate the effectiveness of the intervention. R20 had a significant unplanned weight loss of 14.06 percent (%) in three months and remained at risk for further loss and impaired nutrition. Findings included: - The Physician Order Sheet, dated 10/03/22, recorded R20 had diagnoses of dementia (persistent mental disorder marked by memory loss and impaired reasoning), Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and involuntary movements), macular degeneration (eye disease that cause vision loss in the center field of vision), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R20 had a Brief Interview for Mental Status score of 10 (moderately impaired cognition) with disorganized thinking, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), physical and verbal behaviors that disrupted other residents, and rejection of cares. The MDS recorded R20 required limited staff assistance with eating, weighed 159 pounds (lbs.) and had no recent weight loss. The MDS reflected R20 did not receive hospice services. The Nutrition Care Area Assessment (CAA), dated 07/23/22, recorded R20 was at risk for nutritional deficits and significant weight loss due to Parkinson's disease, increased behaviors, decreased mobility, and vision problems. R20 did not report any recent weight loss and felt she was eating well. R20 received multiple medications that could affect her nutritional status or ability to eat. R20 fed herself with meal set-up due to visual loss. The CAA further recorded weight loss and nutritional deficits, which placed R20 at risk for falls, infections, dignity issues, social isolation, cognitive loss, depression, and impaired skin integrity. The Nutrition Care Plan, dated 08/29/22, recorded R20 had a risk for nutritional problems and weight loss due to her Parkinson's disease, anxiety, vision problems, and increased behaviors. The care plan directed staff to monitor R20's weight weekly and report nutrition problems and significant weight loss to the physician and RD. The care plan directed R20 required a plate guard, regular diet with bite sized food, and snack three times daily. The RD Admission Nutritional Assessment, dated 03/16/22, recorded R20 weighed 153.3 lbs., received a regular diet with bite size pieces on a plate with a guard, and ate independently. The RD Admission Nutritional Assessment, directed staff to monitor R20's weight weekly and notify the RD if the resident had nutritional problems and/or weight loss. The facility Weight Report, dated 07/17/22, recorded R20 weighed 163.6 lbs. The Certified Dietary Manager (CDM) Nutrition Assessment, dated 07/21/22, recorded R20 weighed 163.6 lbs., and continued to receive a regular diet with bite size pieces and snacks of choice. The facility Weight Report, dated 08/14/22, recorded R20 weighed 150.2 lbs. which reflected a loss of 6.48 % in 28 days. The facility Weight Report, dated 09/11/22/22, recorded R20 weighed 151 lbs. and on 09/18/22 weighed 144.6 lbs. Review of R20's medical record lacked documentation the RD or CDM completed a nutritional assessment to address the resident's significant weight loss. The Progress Note, dated 09/25/22, recorded the nursing staff contacted the R20's provider to report R20 had a poor appetite, and an average meal intake less than 25% this month, and a weight loss in the last week. The Physician Order, dated 09/26/22, directed staff to administer four ounces of Med Pass (nutritional supplement) or six ounces of Ensure (nutritional supplement) two times a day. The facility Weight Report, dated 10/09/22, recorded R20 weighed 140.6 lbs. which reflected a 14.06% weight loss in 3 months. Review of R20's medical record lacked documentation staff notified the RD of the resident's significant weight loss. Review of R20's September and October 2022 Medication Administration Record (MAR)/Treatment Administration Record (TAR) lacked evidence staff monitored the resident's nutritional supplement intake. On 10/12/22 at 08:22 AM, observation revealed R2 sat in a wheelchair at the dining table and ate breakfast independently with staff supervision. Continued observation revealed R2 ate less than 25% of the meal and only took a few sips of the supplement. On 10/12/22 at 08:26 AM, Licensed Nurse (LN) G stated R2 had a poor appetite, recent weight loss, and received a supplement at breakfast and supper. LN G stated staff did not monitor R2's supplement intake. On 10/12/22 at 12:43 PM, Dietary Staff BB stated R2 had a significant weight loss and staff had not notified the RD for a nutritional assessment and weight loss interventions. On 10/13/22 at 08:05 AM, Administrative Nurse D stated the facility should have accurately monitored R2's significant weight loss and notified the physician and RD for nutritional interventions. On 10/13/22 at 09:14 AM, Dietary Consultant GG stated the facility had not reported R2's significant weight loss for a nutritional assessment and weight loss interventions. Consultant GG said typically the CDM contacted him if weight loss was identified. If immediate interventions were recommended, the RD would contact the CDM and nursing staff. Consultant GG stated if weight loss was reported, he would review the resident's medical record, review current weight loss interventions, and implement additional interventions as needed. The facility's Weight Monitoring Policy, dated 12/17/20, directed staff to monitor resident's weights as directed and inform the physician and RD of changes in nutritional status. The facility failed to identify weight loss and involve the RD for weight loss interventions to address the significant weight loss for R20. The facility further failed to monitor nutritional supplement intake for R20 after the significant loss to evaluate the effectiveness of the intervention. As a result, R20 had a significant unplanned weight loss of 14.06 % in three months and remained at risk for further loss and impaired nutrition.

The facility had a census of 48 residents. The sample included 13 residents, with two reviewed for urinary catheters (tube inserted into the bladder to drain urine into a collection bag). Based on observation, record review, and interview, the facility failed to maintain catheter tubing in a sanitary manner when the catheter tubing touched the floor for one sample resident, Resident (R) 45. This placed the resident at risk for urinary tract infections (UTIs). Findings included: - The Physician Order Sheet, dated 10/02/22, recorded R45 had diagnoses of diabetes mellitus (the body cannot use glucose, not enough insulin produced, or the body does not respond to the insulin), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history UTIs The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R45 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) with no behaviors. The MDS recorded R45 required extensive staff assistance with transfers, had a urinary catheter, and used a wheelchair for mobility. The Urinary Catheter Care Plan, dated 09/22/22, recorded R45 had a urinary catheter for the diagnosis of neurogenic bladder, and a history of recurrent UTIs. The Urinary Catheter Care Plan directed staff to monitor R45 for signs and symptoms of a UTI, and provide sanitary catheter cares every shift to prevent infection. On 10/10/22 at 02:00 PM, observation revealed R45 sat in his wheelchair, and staff propelled the resident to the dining room. Continued observation revealed R45's urinary catheter tubing sticking out of the bottom of the resident's pants, and the catheter tubing contacted the floor. Continued observation revealed R45's catheter tubing remained touching the concrete throughout an outdoor activity, and staff did not attempt to reposition the catheter tubing. On 10/12/22 at 07:37 AM, observation revealed R45 sat in her wheelchair, and staff propelled the resident to the dining room. Continued observation revealed R45's urinary catheter tubing sticking out of the bottom of the resident's pants, and the catheter tubing bag contacted the floor. Continued observation revealed R45's catheter tubing remained touching the floor throughout the meal, and staff did not attempt to reposition the catheter tubing. On 10/12/22 at 01:41 PM, Certified Nurse Aide (CNA) O stated staff should ensure R45's catheter tubing was positioned to not contact the floor, while the resident sat in his wheelchair. On 10/13/22 at 08:05 AM, Administrative Nurse D stated staff should ensure R45's catheter tubing does not contact the floor due to infection risks. The Urinary Catheter Cares, policy, dated 09/08/14, directed staff to ensure the resident's urinary catheter tubing did not contact the floor to minimize infection risks, and to clean urinary catheter tubing with disinfecting wipes if it did contact the floor. The facility failed to ensure R45's urinary catheter tubing did not contact the floor, placing the resident at risk for urinary tract infections (UTIs).

The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide the necessary cares and services to ensure appropriate wheelchair posture and positioning for one sampled resident, Resident (R) 34. This placed the resident at risk for pain and skin breakdown. Findings included: - The Physician Order Sheet, dated 10/03/22, recorded R34 had diagnoses of advanced dementia (persistent mental disorder marked by memory loss and impaired reasoning), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and severe muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], recorded R34 had a severe cognitive impairment with short- and long-term memory problems. The MDS recorded R34 required extensive staff assistance with all activities of daily living (ADLs), had impaired balance, limited range of motion in all extremities and used a wheelchair for mobility. The ADL Care Plan, dated 09/12/22, recorded R34 had advanced dementia, was non-verbal, and required extensive staff assistance with bed mobility and transfers. The ADL Care Plan recorded R34 had impaired balance, was a high fall risk and used a wheelchair for mobility. The Physical Therapy Evaluation, dated 09/02/22, recorded R34 (new admission evaluated for wheelchair safety) was not able to maintain sitting balance, and the resident required extensive staff assistance to reposition. On 10/10/22 at 11:34 AM, observation revealed R34, sat in her wheelchair at the dining table, leaned to the right with her right arm pressed against the inside of the wheelchair arm and the resident's head tilted forward. Continued observation revealed staff provided total assistance for R34 to eat and drink and repositioned the resident four times to maintain appropriate posture for dining. On 10/11/22 at 11:36 AM, observation revealed R34, sat in her wheelchair at the dining table, leaned forward with her face/chin nearly touching the tabletop. Continued observation revealed two staff provided total assistance to reposition the resident three times during the meal. On 10/12/22 at 09:50 AM, observation revealed R34 leaned to the left in the wheelchair with her left arm dangling over the left side of wheelchair. Continued observation revealed staff had wedged a bed pillow into the right side of the resident's wheelchair in an attempt to maintain R34's posture. On 10/12/22 at 07:39 AM, Certified Nurse Aide (CNA) M stated R34 was not able to maintain wheelchair posture and staff provided total assistance to reposition the resident multiple times each day. On 10/12/22 at 08:00 AM, Licensed Nurse (LN) G stated R34, admitted approximately one month ago, was not able to maintain wheelchair posture and required total staff assistance to reposition. On 10/13/22 at 08:05 AM, Administrative Nurse D stated R34 frequently leaned in her wheelchair, was not able to reposition herself, and the facility had not obtained a therapy evaluation to address the resident's wheelchair posture' The facility's Positioning Policy, dated 08/20/18, directed staff ensure the residents maintained proper body alignment for comfort and function. The facility failed to provide the necessary cares and services to ensure appropriate wheelchair posture and positioning for R34, placing the resident at risk for pain and skin breakdown.

The facility had a census of 48 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility staff failed to report Resident (R) 35 and R32's allegations of abuse to facility administration as required. This deficient practice placed R35, and R32 at risk of ongoing abuse. Findings included: -The Medical Diagnosis section of R35's Electronic Medical Record (EMR) included diagnoses of compression fracture of second lumbar vertebra (broken bone in the middle of the back), dementia with behavioral disturbance (group of thinking and social symptoms which interferes with daily functioning), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear),and hypertension (the force of the blood flow against the artery walls is too high). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R35 had severely impaired cognition. Required extensive assistance from staff for bed mobility, transfers and used a walker or wheelchair for mobility. The Activities of Daily Living, (ADL),Care Area Assessment (CAA), dated 05/29/22, documented the resident required extensive staff assistance with all ADL's. The Psychotropic Drug Use CAA , dated 05/29/22, documented R35 received antianxiety medications routinely. The Care Plan, dated 09/01/22, documented R35 had behavioral symptoms related to diagnoses of anxiety and dementia. The care plan instructed staff to use two staff members for all transfers and mobility when she ambulated with her walker. The Nurses Note on 08/29/22 at 06:11PM, documented a dietary aide reported to the charge nurse R35 stated, the chocolate guy hit me, and told me that I had to go down there. The Nurses Note further documented R35 was upset and stated, He had no right to tell me to go down there. On 10/10/22 at 02:45PM, observation revealed R35 lying in her bed on her back, covered with a blanket, eyes closed. On 10/11/22 at 09:30AM, Certified Nurse Aide (CNA) N stated if a resident reported abuse to them, they would report it to the charge nurse. On 10/11/22 at 11:00AM, Licensed Nurse (LN) I stated if a resident or a staff member report any kind of abuse, verbal or physical, LN I would immediately report it to the administrator or director of nursing. On 10/12/22 at 09:10AM, Administrative Nurse D stated she was not aware of the Nurses Note which was documented on 08/29/22 at 06:11PM. Administrative Nurse D stated she expected the charge nurse to have reported the incident to her and the administrator. On 10/12/22 at 09:30AM, Administrative Staff A verified the Nurses Note documented on 08/29/22 at 06:11PM, and stated this incident was not reported to her or the director of nursing. Administrative Staff A also stated she would start an investigation of this incident. The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy, dated 12/12/16, stated patients/residents are free from abuse, neglect, misappropriation of patient/resident property, exploitation, corporal punishment and involuntary seclusion. Any known abuse, neglect or exploitation must be immediately reported to the Administrator or his/her designee. An associate/agent can be disciplined for not reporting abuse. The Administrator or his/her designee will investigate the report and notify the appropriate state agency. The facility will thoroughly investigate any and all forms of abuse and will prevent further potential abuse while the investigation is in progress. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made. The facility staff failed to report R35's allegation of verbal and physical abuse to the facility administrator and/or abuse coordinator. This failure placed the resident at risk of further abuse. - R32's Medical Diagnosis section of the Electronic Medical Record (EMR) included diagnoses of heart failure (chronic condition of the heart cannot pump or fill with blood), osteoarthritis of the left shoulder(flexible tissue at the end of bones wears down), gastro-esophageal reflux disease (digestive disease in which stomach acid or bile irritates). The Admission Minimum Data Set (MDS), dated [DATE], documented R32 had intact cognition. R32 required moderate assistance from staff for bed mobility, transfers and used a walker or wheelchair for mobility. The Activities of Daily Living (ADL),Care Area Assessment (CAA), dated 08/22/22, documented the resident required staff assistance with transfers and toileting. The ADL Care Plan, dated 08/22/22, instructed the staff to assist R32 to and from the bathroom, due to her shoulder pain; R32 was able to use the call light for assistance. The Nurses Note on 10/10/22 at 04:29AM, documented R32 was upset because she rang her call light for assistance to the bathroom and a nurses aid came into her room and stuck three fingers in her face and rudely told her that three other people had their call lights on and the nurse aid needed to go and assist those residents first. On 10/11/22 at 09:45AM, observation of R32 revealed the resident sat in her recliner chair. R32 stated the other night I put on my call light and a nurse aid came into my room and he stuck three fingers in my face and said, I have three other people who need help. R32 verbalized she felt the nurse aid was rude, and she felt threatened by him. On 10/11/22 at 09:30AM, Certified Nurse Aide (CNA) N stated if a resident reported abuse to them, they would report it to the charge nurse. On 10/11/22 at 11:00AM, Licensed Nurse (LN) I stated if a resident or a staff member report any kind of abuse, verbal or physical, LN I would immediately report it to the administrator or director of nursing. On 10/12/22 at 09:10AM, Administrative Nurse D stated she was not aware of the Nurses Note which was documented on 10/10/22 at 04:29AM. Administrative Nurse D stated she expected the charge nurse to have reported this incident to her and the administrator. On 10/12/22 at 09:30AM, Administrative Staff A verified the Nurses Note documented on 10/10/22 at 04:29AM, and stated this incident was not reported to her or the director of nursing. Administrative Staff A also stated she would start and investigation of this incident and call to the state agency. The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy, dated 12/12/16, stated patients/residents are free from abuse, neglect, misappropriation of patient/resident property, exploitation, corporal punishment and involuntary seclusion. Any known abuse, neglect or exploitation must be immediately reported to the Administrator or his/her designee. An associate/agent can be disciplined for not reporting abuse. The Administrator or his/her designee will investigate the report and notify the appropriate state agency. The facility will thoroughly investigate any and all forms of abuse, and will prevent further potential abuse while the investigation is in progress. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made. The facility staff failed to report R32's allegation of verbal abuse to the facility administrator and/or abuse coordinator. This failure placed the resident at risk of further abuse.

The facility had a census of 48 residents. The sample included 13 residents, with two reviewed for urinary catheters (tube inserted into the bladder to drain urine into a collection bag). Based on observation, record review, and interview, the facility failed to cover the urinary catheter bag for one sampled resident, Resident (R) 45. This placed the resident at risk for impaired dignity and respect. Findings included: - The Physician Order Sheet, dated 10/02/22, recorded R45 had diagnoses of diabetes mellitus (the body cannot use glucose, not enough insulin produced, or the body does not respond to the insulin), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and a history Urinary Tract Infections (UTI). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R45 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) with no behaviors. The MDS recorded R45 required extensive staff assistance with transfers, had a urinary catheter, and used a wheelchair for mobility. The Urinary Catheter Care Plan, dated 09/22/22, recorded R45 had a urinary catheter for the diagnosis of neurogenic bladder, and a history of recurrent UTIs. The Urinary Catheter Care Plan directed staff to monitor R45 for signs and symptoms of a UTI, and provide sanitary catheter cares every shift to prevent infection. On 10/12/22 at 07:37 AM, observation revealed R45 sat in his wheelchair, and staff propelled the resident to the dining room. Continued observation revealed R45's urinary catheter bag suspended from the bottom of the wheelchair and exposed due to the torn bottom of the privacy bag. Continued observation revealed R45's urinary catheter bag remained exposed throughout the meal, and staff did not attempt to reposition or cover the urinary catheter bag. On 10/12/22 at 11:22 AM, observation revealed R45 sat in his wheelchair, and staff propelled the resident to the dining room. Continued observation revealed R45's urinary catheter bag suspended from the bottom of the wheelchair and exposed due to the torn bottom of the privacy bag. Continued observation revealed R45's urinary catheter bag remained exposed throughout the meal, and staff did not attempt to reposition or cover the urinary catheter bag. On 10/12/22 at 01:41 PM, Certified Nurse Aide (CNA) O stated he was not aware of a torn privacy bag for R45's catheter bag, and verified staff took the resident to the dining room with an uncovered catheter bag. On 10/13/22 at 08:05 AM, Administrative Nurse D stated staff should cover R45's catheter bag to maintain the resident's dignity. The facility Catheter Care Policy, dated 09/08/14 directed staff to place the resident's urinary catheter bag in a privacy bag to maintain the resident's dignity. The facility failed to cover R45's urinary catheter bag placing the resident at risk for impaired dignity and respect.

The facility documented a census of 48 residents. The sample included three residents with three reviewed for falls. Based on observation, record review, and interview, the facility failed to implement safety protocols while using a whirlpool lift chair to prevent falls. As a result of this deficient practice, Resident (R) 1 fell out of the whirlpool lift chair and sustained a right [CONDITION(S)]. Findings included: - R1's Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), repeated falls, and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS further documented R1 required extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. R1 required one staff extensive assistance for locomotion on and off the unit, personal hygiene, and bathing. The MDS recorded R1 had a fall prior to admission but no falls since admission to the facility. The Activities of Daily Living Care Area Assessment (CAA), dated 12/26/21, documented R1 required extensive assistance with most all activities of daily living and was at risk for functional decline related to [CONDITION(S)], falls, cognitive loss, and [CONDITION(S)] (sensation of spinning, dizziness). The Fall CAA, dated 12/26/21, documented R1 was at risk for falls related to his instability with transfers and ambulation, need for assistance, and history of falls. R1 had multiple falls prior to his admission to the facility secondary to [CONDITION(S)] ([CONDITION(S)] or passing out) and dehydration. The Fall Care Plan, dated 12/22/21, directed staff to meet and anticipate R1's needs, encourage R1 to assume a standing position slowly, and give R1 verbal reminders to not ambulate or transfer without assistance. The Morse Fall Risk Assessment, dated 12/21, documented R1 was a high risk for falls. The Progress Note, dated 02/10/22, documented R1 fell when Certified Nurse's Aide (CNA) N assisted R1, who was sitting in a whirlpool lift chair, out of the whirlpool. R1 leaned forward and grabbed the whirlpool door and pulled himself out of the whirlpool lift chair. Initial assessment noted R1 had full range of motion with all extremities, no rotation or deformities noted, and R1 denied any pain. Two (unidentified) staff assisted R1 to a standing position. R1 was able to bear weight, but was weak and staff assisted him into his wheelchair. After R1 sat in the wheelchair, he complained of right hip pain and staff noted rotation to the right lower extremity. Staff transferred R1 to the local hospital and then transferred to another hospital that could provide a higher level of care for the diagnosis of a right [CONDITION(S)]. The facility's Post Fall Huddle, dated 02/10/22, documented R1 fell out of the whirlpool chair lift because he felt unsafe due to the safety bars not being down. CNA N did not have the safety bars down on the whirlpool lift chair while she moved it out of the whirlpool bath. The Witness Statement dated 02/10/22 by CNA N documented CNA N pulled R1 out of the bath on the lift and R1 grabbed the tub door in front of him as CNA N was moving the lift out of the tub and R1 fell forward. The Facility Investigation documented on 02/10/22 at approximately 03:10 PM staff assisted R1 out of the whirlpool. As CNA N moved the chair to transfer R1, he reached forward to grab the whirlpool tub door and fell forward out of the chair. When the nurse entered the whirlpool, she noted R1 laid on the floor on his right side. Staff assisted R1 to his back per his choice. R1 complained of mild pain to the right side of his face. R1 had a skin tear to his right ear. R1 had range of motion to all extremities with no rotation noted at that time. CNA N went for the mechanical lift to assist R1 up, however, R1 became inpatient, and agitated. He started to fight to get up, so two staff assisted R1 to stand. During the transfer to the wheelchair from floor, R1 was able to bear weight, although he was weak. Once R1 sat in the wheelchair, he began to complain of mild right hip pain and the nurse noted external rotation. Staff notified R1's primary care physician and asked to send R1 to the emergency room for further evaluation. At 05:30 PM emergency room staff notified the facility that R1 had a right [CONDITION(S)]. At 10:07 PM R1's representative notified the facility that R1 transferred to a higher level of acute care center to receive treatment for the [CONDITION(S)]. The investigation further recorded CNA N stated she must have forgot to put the safety bars down on the whirlpool lift chair because R1 was anxious to get out of the tub. CNA N verbalized she knew the bars needed to be down. The Progress Note, dated 02/21/22, documented R1 stayed at the hospital for inpatient hospice (end of life) care services. On 03/22/22 at 10:00 AM, observation revealed CNA M transferred R2 onto the whirlpool lift chair. CNA M placed the whirlpool lift chair behind R2, who stood at a handrail. CNA locked the whirlpool lift chair's casters, assisted the resident to sit on the whirlpool lift chair, and placed the whirlpool lift chair's safety bars down in front of R2. CNA M then unlocked the casters, raised the whirlpool lift chair to a height that lifted R2's feet above the whirlpool bath and moved the whirlpool lift chair into the whirlpool bath. On 03/22/22 CNA N was unavailable for interview. On 03/22/22 at 10:30 AM, CNA M stated that all the CNA's were trained on the use of the whirlpool lift chair. She stated staff were supposed to always put the safety bars down while a resident sat in the whirlpool lift chair. On 03/22/22 at 10:45 AM, Administrative Nurse D stated that all the CNA's were trained on how to use the whirlpool lift chair when hired and then yearly during competencies. She stated that she expected all the CNA's to put the safety bars down on the whirlpool lift chair when using it to transfer a resident into the whirlpool bath. On 03/22/22 at 11:00 AM, Administrative Staff A stated CNA N, who transferred R1 from the whirlpool bath using the whirlpool lift chair when the fall occurred, knew that the safety bars on the whirlpool lift chair should have been down, but CNA N did not put the safety bars down. The facility's Whirlpool Bathing System, Bath Lift policy, dated 07/11/16, documented staff were to bring the lift into position with the resident, lock the two rear casters on the lift by pressing down on the locking pedal with foot, swing the safety arm rests up and back, transfer the resident to the bath lift per the resident's care plan, and slowly bring the safety arm rests down in front of the resident. The facility's Fall Reduction and Management policy, revised 06/29/21, documented It is the intent of the facility to ensure that all residents upon admission, re-admission, quarterly and with any significant change in status be assessed of their risk for falls. Manipulation of the environment to prevent falls and appropriate management of those who experience a fall will be completed. The purpose of this policy is to assess residents' risk for falls, manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. The facility failed to ensure the use of safety bars while R1 was in the whirlpool lift chair that resulted in a fall, causing a right [CONDITION(S)]. On 02/14/22 the facility implemented the following corrective actions: The facility provided CNA N with a Teachable Moment to re-educate her that the safety bars on the whirlpool chair needed to be down while chair was moving. Safety arms could be up while the chair was locked and in the down position. The facility had CNA N complete a competency checklist regarding whirlpool bathing. The facility ensured all relevant staff were re-trained on operating the bath lift. The deficient practice was cited at past non-compliance.

The facility had a census of 45 residents. The sample included 12 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two of three sampled residents, Resident (R) 20 and R26 (or their representative) the completed Notice of Medicare Non-Coverage Form (NOMNC) Centers for Medicare and Medicare Services (CMS), and one of the sampled residents, R27 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage Form (SNF ABN) form. Findings included: - Medicare Form informed the beneficiary that Medicare may not pay for future skilled therapy. The form included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. Medicare Form informed the beneficiary that Medicare may not pay for skilled therapy services and provided a cost estimate for continued services. It explained: (1) if Medicare does not pay, the resident would be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, would be responsible for payment for services, or (3) does not want the listed services. A provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end. The facility lacked documentation staff provided R20, or her representative, form which included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. The resident's skilled nursing services ended on 04/14/21. The facility lacked documentation staff provided R26, or her representative, form which included options for the beneficiary to receive specific services listed, and bill Medicare for a decision on payment. The resident's skilled services ended on 05/19/21. The facility lacked documentation staff provided R27, or her representative, form which included the estimated cost documentation for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing she may have to pay out of pocket. The resident's skilled services ended on 08/11/21. On 08/18/2021 at 01:30 PM, Administrative Nurse D verified the facility had not provided the residents and/or DPOAs form CMS and form . Upon request, the facility failed to provide a policy for Beneficiary notices. The facility failed to provide R20 and R26, or their representatives, CMS form and failed to provide R27, or their representatives, CMS form , when discharged from skilled care, placing the residents, or their representatives, at risk to make uninformed decisions about continuation of their skilled care

The facility identified a census of 52 residents. The sample included 5 residents reviewed for accidents. Based on observation, interview and record review, the facility failed to provide 1 of 5 sampled residents, with adequate supervision to prevent accidents and failed to develop and implement timely and effective interventions to prevent falls and burns when staff failed to thoroughly assess for causative factors for falls and a burn, and to implement appropriate interventions to prevent additional falls and/or accidents. Resident #1 experienced multiple falls, one which resulted in a laceration which required staples to the head. Findings included: - The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. (involuntary series of contractions of a group of muscles), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and history of falls. The significant change (MDS) Minimum Data Set assessment, dated 1/30/17, documented Resident #1 had a (BIMS) Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. The resident rejected care at times, required limited assistance of 1 staff for (ADLs) Activities of Daily Living except eating, and was frequently incontinent of urine and occasionally incontinent of bowel. The MDS further documented the resident's balance was unsteady, required staff assistance to rebalance, used a wheelchair and walker for mobility, had 2 or more falls, no range of motion impairment, and received an antipsychotic (medication that treats any major mental disorder characterized by a gross impairment in reality testing) medication for 7 of 7 days of the look back period. The significant change MDS, dated [DATE], documented Resident #1 had a BIMS score of 9, indicating moderately impaired cognition. The resident rejected care at times, required extensive assistance of 2 staff for ADLs except eating, and was frequently incontinent of urine and bowel. The MDS further documented the resident's balance was unsteady, required staff assistance to rebalance, used a wheelchair and walker for mobility,had 2 or more falls, 1 fall resulted in minor injury, had no range of motion impairment, and received antipsychotic and antidepressant medications for 7 of 7 days of the look back period. The 4/10/17 Falls (CAA) Care Area Assessment documented the resident had 3 falls in February, had poor balance, was a high risk for falling, used a wheelchair, and a wheeled walker with a platform on the left side, with a 10 pound lift restriction, due to his/her fractured left wrist. The CAA further stated the resident was a high risk for falls related to his/her prior history of falls, standing without staff assistance, and daily use of psychotropic medications. The 11/16/16 care plan directed staff to provide arm rests on the toilet, provide assistance with cares with 2 staff, and to remain with the resident during bathing, except when in the tub. The care plan further directed staff to provide a scoop mattress (mattress with a raised ridge on each side, which defines the edge and has an opening to exit the bed) on the bed, assist with putting on his/her night clothes between 6:00 PM and 6:30PM, to assist the resident into the dining room last, assist him/her to leave the dining room first, and encourage the resident to go to the dining room or the hallway sitting area for snacks. The 2/16/17 care plan update directed staff to provide a change of position with meals between 7:30-8:00 AM, 9:00-9:30 AM, 11:30 AM-12:00 PM, 2:30-3:00 PM, 4:30-5:00 PM, 6:00-6:30 PM, 7:30-8:00 PM, 10:30-11:00 PM, and 1:00-1:30 AM. The 2/18/17 care plan update directed staff to provide assistance to the resident with toileting between 7:30-8:00 AM, 9:00-9:30 AM, 11:30 AM-12:00 PM, 2:30-3:00 PM, 4:30-5:00 PM, 6:00-6:30 PM, 7:30-8:00 PM, 10:30-11:00 PM, 1:00-1:30 AM, documented the resident would use the call light to ring for assistance and directed staff to not leave the resident unattended on the toilet or in the bathroom. The 4/10/17 care plan update directed staff to walk the resident with a gait belt, a wheeled walker, 1 assist from staff, and a 2nd staff member to follow behind the resident with the wheelchair. The 4/16/17 care plan entry documented the orthostatic blood pressure readings did not indicate the resident had a significant decline in his/her blood pressure values and staff discontinued the care plan intervention for the test. The 4/25/17 care plan update directed staff to ensure the toilet is firmly placed via maintenance evaluation, and provide a riser with its own support in place. The 4/26/17 care plan update directed staff to ensure the resident's room door remained open at all times to visualize the resident. The 11/7/16 to 11/13/16, Bowel and Bladder Assessment lacked a documented summary/conclusion, based on the findings, with a recommendation for a toileting plan based on the resident's needs. The 1/24/17 at 12:46 PM, Fall Risk Assessment documented a score of 25 points, a high risk for falls. The 1/26/17 at 11:04 AM, Tinetti Tool Assessment (to assess gait and balance) documented the resident required 1 staff stand by assistance for transfers, with a gait belt and wheeled walker in his/her room and for long distances. The 2/9/17 at 1:26 PM, Fall Risk Assessment documented a score of 25 points, a high risk for falls. The 2/17/17 at 9:40 PM, nurse's note reported staff found the resident on the floor in front of his/her closet, with his/her left arm tucked under his/her body, and the right arm supporting his/her head. The note documented the resident reported he/she attempted to get his/her clothes for the next day, out of the closet, and fell . The care plan had directed staff to assist the resident with preparation for bed between 6 and 6:30 PM and assist him/her with night clothing. The nurse's notes and care plan lacked documentation for further interventions. The 2/18/17 at 9:50 PM, nurse's note documented staff found the resident on the floor, in front of his/her recliner, with legs outstretched if front of his/her body, sitting on his/her bottom, with no shoes or gripper socks on, walker by the bed, along with an empty bedside table. The note documented the resident reported he/she packed stuff up to take to his/her room. The note documented the resident was incontinent of urine, and staff assisted the resident to the bathroom. The note documented the physician gave an order for [REDACTED]. The 2/18/19 at 9:50 PM, event report documented the staff last toileted the resident at 5:15 PM, prior to the time of the incident at 9:50 PM. The 2/19/17, urinalysis report indicated the urine was contaminated. The medical record revealed staff did not obtain a follow-up urinalysis. The 2/20/17 at 8:55 PM, nurse's note documented staff found the resident on the floor on his/her knees in the doorway of his/her room. The note documented the resident reported he/she had gotten out of bed to go into the bathroom to get a drink of warm water, although the water pitcher was available on the bedside table within easy reach. The note further documented the resident was last toileted by staff at 8:00 PM, was continent of urine at the time of the fall, had gripper socks on, with the walker by the bedside table. The note documented staff updated the care plan to include visual checks every 15 minutes between 6:00 PM to 12:00 PM for 3 days, but lacked a long term intervention to prevent falls. The 3/30/17 at 3:46 PM, Fall Risk Assessment documented a score of 27 points, a high risk for falls. Review of the physical therapy treatment notes dated 4/6/17 through 4/24/17, documented the therapist treated the resident for ambulation, transfer training for use of the wheeled walker, and postural corrections for safety and decreased fall risk. The 4/8/17 at 3:55 PM, nurse's note documented staff found the resident on the floor by his/her bed and night stand. He/she was alert, but confused, responded to questions, and complained of his/her head hurting. The note further documented the resident was transported to the hospital emergency room for treatment of [REDACTED]. The 4/9/17 at 6:44 AM, nurse's note documented the resident had 4 staples to the laceration on the back of his/her head, with a small amount of bleeding noted. The note documented the hospital discharge instructions directed staff to wash the wound site with soap and water twice daily. The 4/12/17 at 11:59 AM, nurse's note documented staff observed the resident standing up, leaning on his/her walker, appeared unsteady, and the resident complained of feeling dizzy when standing up. The note documented the resident continued on fall precautions, but lacked intervention to address the resident's complaint of dizziness. The 4/12/17 at 1:00 AM, nurse's note documented staff found the resident lying on the bathroom floor on 4/11/17 at 8:35 PM, a soiled brief observed next to the trash can, with his/her pajama top on, and the bottoms next to the resident's left hip. The note further documented the resident was confused, stated he/she hit his/her head, and staff noted red skin discoloration/bruising to the resident's right upper back measuring 3 (cm) centimeters by 4 cm. The note documented staff assisted the resident to the bathroom at the scheduled toileting times and the nurse initiated visual checks every 15 minutes from 1:00 AM to 9:00 AM on that date, then visual checks every 30 minutes, for 3 days from 4/12/17 to 4/15/17, with no care plan change for a long term intervention to prevent falls. The 4/13/17 at 3:30 AM, nurse's note documented staff found the resident on the bathroom floor, with the resident's head resting on the floor between the wall and the toilet, and he/she had red skin discoloration/bruising to the left temple measuring 3 cm by 4 cm. The note documented the resident attempted to change his/her pants in the bathroom. At 5:52 AM, the nurse's note documented staff initiated orthostatic (measurements of blood pressure and pulse taken with the patient in the lying, sitting, and standing positons to assess for change of position causing low blood pressure and possible blood pooling in the lower extremities resulting in dizziness, lightheadedness, and nausea) blood pressure readings every shift for 72 hours, and hourly toileting until 4/17/17. The note documented staff were directed to maintain constant visualization through the day, with no further root cause analysis documented on the findings, or an on-going intervention initiated. The 4/16/17 care plan entry documented the orthostatic blood pressure readings did not indicate the resident had a significant decline in his/her blood pressure values and staff discontinued the care plan intervention for the test. The 4/19/17 at 5:15 PM, nurse's note documented staff reported to the charge nurse, the resident spilled hot tea in the dining room from a stoneware cup. Staff escorted the resident back to his/her room, removed the wet clothing, the resident's inner thigh was pink and blanchable (the tissue loses redness when pressed), skin warm to touch, with no blisters or open areas. Staff assisted the resident to redress and assisted him/her back to the dining room. The note further documented staff updated the care plan to serve hot beverages in a plastic mug (which did not include placing a lid on the cup) and cooled with ice before serving it to the resident. The 4/19/17 at 6:50 PM, (45 minutes after the burn occurred) nurse's note documented the resident complained of discomfort to his/her thighs bilaterally, and staff applied a cool cloth to the area. The note further stated the resident obtained relief from the application, with skin to the left thigh area a light pink and intact, and the right thigh had red areas, as well as light pink coloration to the skin. The 4/19/17 at 7:45 PM, nurse's note documented the resident complained of discomfort to his/her thighs, and the nurse applied a cool cloths to the areas. The 4/20/17 at 5:13 AM, nurse's note documented the resident's skin on the inside right thigh red in color, measured 5 cm by 4 cm, skin intact, the skin on the inside left thigh noted to be red, measured 10 cm by 4 cm, with an open area, (not measured). The 4/20/17 at 5:47 AM, nurse's note documented the physician directed staff to apply telfa (non-adherent dressing0 and biafine (a substance placed on the skin to help repair damage) to the resident's left thigh, and secure with a quick release tape. On 5/1/17 at 1:25 PM, observation revealed the resident in bed with eyes closed, the head of the bed elevated 30 degrees, a scoop mattress in place, the call light within reach, lights off, and the walker/wheelchair placed in the room away from the resident, not within reach. On 5/1/17 at 5:03 PM, observation revealed Nurse Aide B prepared hot tea for the resident in a plastic coffee cup, with water dispensed from the hot coffee/water machine, cooled the coffee with ice chips, and then allowed the resident to add sugar to the tea. Observation further revealed the resident took 2 sips and stated the tea was not too hot. Nurse Aide B then added a plastic lid to the cup. On 5/2/17 at 8:02 AM, observation revealed Nurse Aide C assisted the resident to pivot to a sitting position on the side of the bed, as the aide released his/her hold on the resident shoulders, the resident fell back across the bed. Observation further revealed Nurse Aide C returned the resident to a sitting position, applied a gait belt, and walked the resident using the wheeled walker into the bathroom. Observation revealed Nurse E entered the room to change the dressing to the resident's left thigh. Nurse E removed the soiled dressing, and revealed an open wound approximately the size of a pencil head, surrounded by reddened, inflamed tissue, spreading approximately 3 inches toward the groin, 1/2 inch wide, and approximately the same sized area of reddened tissue spreading away from the wound in the opposite direction. On 5/2/17 at 8:29 AM, observation revealed staff served the resident hot tea with a lid on the cup. Further observation revealed at 9:01 AM, Nurse Aide C removed the lid from the plastic cup at the resident's request. The resident lifted the cup and drank the coffee with a steady hand grip. On 5/3/17 at 2:35 PM, Nurse E stated staff were directed to collect a urine sample for testing for fall prevention and staff performed 15 minute visual checks for 3 days following a fall, but verified staff do not perform visual checks on a consistent basis. Nurse E stated the visual checks do not prevent falls, but helps the staff to narrow down the length of time between when the resident was last seen verses the time of the fall. On 5/3/17 at 5:20 PM, Nurse Aide F reported staff assist the resident to the bathroom, when he/she gets up in the morning, again between 10:30 AM to 11:00 AM, and 1:00 PM to 1:30 PM on the day shift. Nurse Aide F stated the resident gets up on his/her own, without assistance at times, depending on the day, then explained the resident is fast and moves quickly. Nurse Aide F further reported the resident only used the call light at times, and was incontinent of both urine and bowel. He/she further stated the resident had cognitive difficulty, had shakes/tremors at times, but does not ask for hot drinks on the evening shift. Nurse Aide F stated 15 minute visual checks and frequent reminders to use the call light were the safety interventions used for the resident. On 5/4/17 at 10:35 AM, Nurse Aide H reported staff performed visual checks for a few days after each fall, staff encouraged the resident to use toileting times offered, as scheduled, to ensure the resident would not attempt to get up on his/her own, then added there were no other fall prevention interventions. The 5/4/17 at 11:02 AM, Maintenance Staff I reported the resident's fall on 4/25/17 from the toilet was caused when the toilet moved from its placement on the floor, and the resident lost his/her balance. The toilet was loose because of a faulty flange (a pipe fitting that mounts the toilet to the floor and connects the toilet drain to a drain pipe), which staff replaced. On 5/4/17 at 11:38 AM, Nurse J, reported the charge nurse investigated after each fall, and made a change to the care plan, based on the findings from his/her investigation. Nurse J reported the facility discussed root cause analysis at nursing meetings, although the facility did not provide specific training on root cause analysis. On 5/2/17 at 10:35 AM, Administrative Nurse K stated staff had not completed a hot liquid assessment for the resident and stated it should be done on admission, quarterly, with significant change, and annually. Administrative Nurse K verified the resident did not have a long term care plan intervention added after each fall. On 5/9/17 at 5:00 PM, Physician L stated any resident entering a long term care facility should be considered at risk for burns related to the individual's health history. Physician L verified assessment and care planning should be completed on that basis. Physician L stated the facility should implement new interventions to help prevent falls, in addition to visual checks. The facility's 9/12/16 Fall Reduction and management policy and procedure directed staff to complete an initial post fall assessment to identify injuries, then determine what happened. The charge nurse would make changes to the plan of care and the ADL worksheets for immediate action to decrease or prevent future occurrences. It is the responsibility of the facility to assure that all residents upon admission or re-admission, at least quarterly, and with significant change in status, be assessed for their risk for falls, manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. The 11/10/14 Bowel/Bladder Assessment documented the purpose of the policy was to provide a consistent procedure for monitoring and developing a toileting plan using the resident's toileting patterns. After the assessment time period is complete, the MDS Coordinator and/or licensed nurse will evaluate data obtained and develop or revise the resident's toileting plan. Upon request, the facility did not provide a policy and procedure for Hot Liquid Assessment. The facility failed to provide Resident #1 with adequate supervision and timely and effective interventions to prevent falls, assess for causative factors for multiple accidents including 6 falls, 1 resulting in a laceration to the head, and a burn from hot liquid. The resident required treatment in the emergency room to obtain staples to his/her head for the laceration.