Every finding on record at Colby Operator, LLC

The facility had a census of 32 residents. The sample included 12 residents, of which five were reviewed for sufficient and competent nurse staffing. Based on the record review and interview, the facility failed to verify one of the five Certified Nurse Aides (CNA) had a current license prior to employing her and allowing her to work the floor providing resident care. Findings included: - Review of the CNA Kansas Department for Aging and Disability Services (KDADS) nurse aide registry confirmation notice revealed CNA P's nurse aide license had expired on [DATE]. Review of the facility's date of hire information revealed CNA P was hired on [DATE]. On [DATE] at 02:37 PM, Consultant Staff GG verified CNA P license was inactive on [DATE], and the verification was conducted today. Consultant Staff GG stated Administrative Staff B was responsible for verifying CNAs' licenses were current before hiring them. Consultant Staff GG verified CNA P was scheduled to work the evening shift today, and she would not be working. On [DATE] at 03:12 PM, Administrative Staff A verified the facility had hired CNA P on [DATE] with an expired license. Administrative Staff A stated the director of nursing (DON) and the business office manager were responsible for verifying nurse aids have a current license. Administrative Staff A verified CNA P had worked the floor providing care for residents for seven days with an expired license. On [DATE] 03:52 PM, Administrative Nurse D stated from what she understood both the DON and the Administrative Staff B thought the other one had conducted the license verification check, prior to CNA P being hired and thought CNA P had a current active license. The facility's Credentialing of Nursing Service Personnel Policy, revised 10/2024, documented nursing personnel requiring a license/certification would not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks had been completed. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the DON before or upon employment.

The facility had a census of 32 residents. The sample included 12 residents, with one reviewed for dignity and respect. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 3, who was left uncovered in bed with only an incontinence brief on. This placed R3 at risk for impaired dignity. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), diabetes mellitus (DM - when the body cannot use glucose, no enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperpiesia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had severely impaired cognition. R3 was dependent upon staff for toileting hygiene, showers, dressing, personal hygiene, mobility, and transfers. R3 was always incontinent of bowel and had a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). R3's Care Plan, dated 05/28/25, initiated on 02/09/21, documented R3 required two staff for bed mobility, and one staff for personal hygiene. The update, dated 03/24/23, documented R3 had a catheter and directed staff to check tubing for kinks often throughout every shift, monitor and document intake and output as per facility policy. On 06/10/25 at 08:15 AM, observation revealed Certified Nurse Aide (CNA) N removed R3's blanket off the bed and revealed R3 only had on an incontinence brief. CNA M wiped R3's face with a wet washcloth and swabbed his mouth. CNA M untaped R3's brief and noticed there were no wipes for her to perform catheter care. CNA M asked CNA N to go and get her some wipes so that she could do R3's catheter care. CNA M did not cover R3, and he laid in bed naked while CNA N left the room to get the wipes. R3 stated, You guys gonna cover me up? I'm freezing! CNA M did not cover up R3; she stood by his bed and waited for CNA N to bring more wipes. After CNA N brought in the wipes, CNA M performed catheter and other personal care. After they provided personal care, a clean attend was placed under him, and he asked that it not be fastened but left open. R3 was repositioned on his left side, and then he was covered up with a clean blanket. On 06/11/25 at 08:30 AM, CNA M stated she should have covered him up while waiting for the wipes. On 06/10/25 at 02:53 PM, Administrative Nurse D stated that R3 should not have been left uncovered while there were no cares being provided, and she would reeducate staff on dignity and respect for the resident. The facility's Resident Rights policy, dated 12/24, documented that the facility would make every effort to assist each resident in exercising his/her rights to ensure that the resident was always treated with kindness, respect, and dignity.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions for Activities of Daily Living (ADL) for one resident, resident (R) 25. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R25's Annual Minimum Data Set (MDS), dated [DATE], documented R25 had moderately impaired cognition. R25 required set-up assistance with oral hygiene, dressing, and personal hygiene. R25 was independent with mobility, transfers, and ambulation. R25 had no behaviors or rejection of care and felt it was very important to choose a bath, shower, or bed bath. The ADL Care Area Assessment (CAA), dated 09/02/24, documented R25 had a risk for potential alterations in his ADL function related to his diagnoses. The CAA further documented that staff would put interventions into place for his ADL status. R25's Quarterly MDS, dated 03/21/25, documented R25 had severely impaired cognition. R25 required supervision with showers, and independent with dressing, oral hygiene, mobility, transfers, and ambulation. R25 had no behaviors or rejection of care. R25's Care Plan, dated 03/12/25, lacked a care area with interventions for ADLs. The April 2025 Shower Sheets documented R25 had not received a shower during the following days: 04/01/25 - 04/12/25 (12 days) The April Shower Sheets documented R25 refused a shower on 04/09/25. The May and June 2025 Shower Sheets, documented R25 had not received a shower during the following days: 05/09/25 - 05/25/25 (17 days) 05/27/25 - 06/04/25 (9 days) The May Shower Sheets documented R25 refused a shower on 05/12/25. On 06/09/25 at 08:00 AM, the hair on the back of his head was disheveled, and he was unshaven. On 06/10/25 at 07:45 AM, R25 had his coat on and was unshaven. On 06/11/25 at 10:30 AM, R25 had on his coat, and he was unshaven. On 06/10/25 at 12:15 PM, Administrative Nurse F verified there was not a care plan with R25's ADLs and stated she would get it done right away. On 06/11/25 at 10:15 AM, Administrative Nurse D stated that all residents should have an ADL care plan. The facility's Comprehensive Care Plan policy, dated -3/25, documented that an individualized, comprehensive person-centered care plan was developed for each resident. The care plan would include measurable objectives and time frames that met the resident's medical, nursing, mental, cultural, and psychological needs. The care plan team was responsible for periodic review and updating the care plans.

The facility had a census of 32 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide consistent bathing and grooming for one resident, Resident (R) 25. This placed the resident at risk for complications related to poor hygiene and impaired dignity. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R25's Annual Minimum Data Set (MDS), dated [DATE], documented R25 had moderately impaired cognition. R25 required set-up assistance with oral hygiene, dressing, and personal hygiene. R25 was independent with mobility, transfers, and ambulation. R25 had no behaviors or rejection of care and felt it was very important to choose a bath, shower, or bed bath. The ADL Care Area Assessment (CAA), dated 09/02/24, documented R25 had a risk for potential alterations in his ADL function related to his diagnoses. The CAA further documented staff would put interventions into place for his ADL status. R25's Quarterly MDS, dated 03/21/25, documented R25 had severely impaired cognition. R25 required supervision with showers, and independent with dressing, oral hygiene, mobility, transfers, and ambulation. R25 had no behaviors or rejection of care. R25's Care Plan, dated 03/12/25, lacked a care area with interventions for ADLs or rejection of care. The April 2025 Shower Sheets documented R25 had not received a shower during the following days: 04/01/25 - 04/12/25 (12 days) The April Shower Sheets documented R25 refused a shower on 04/09/25. The May and June 2025 Shower Sheets documented R25 had not received a shower during the following days: 05/09/25 - 05/25/25 (17 days) 05/27/25 - 06/04/25 (9 days) The May Shower Sheets documented R25 refused a shower on 05/12/25. On 06/09/25 at 08:00 AM, the hair on the back of R25's head was disheveled, and he was unshaven. On 06/10/25 at 07:45 AM, R25 had his coat on and was unshaven. On 06/11/25 at 10:30 AM, R25 had his coat on and was unshaven. On 06/10/25 at 12:54 PM, Licensed Nurse (LN) G stated he refused his shower a lot of the time. Staff were to inform the nurse when that happened, and other staff members reapproach him at a later time. LN G stated that after seven days without a shower, then she tried harder to get him to take a shower by calling the family. On 06/11/25 at 10:15 AM, Administrative Nurse D stated staff reattempted, offered different alternatives than the shower, and should document in the EMR that the resident did not want a shower. On 06/11/25 at 10:30 AM, Certified Nurse Aide (CNA) N stated he refused his shower, and that they would try to reapproach later. CNA N further stated his family requested that staff shave him even if he refused his showers. On 06/11/25 at 10:45 AM, Certified Medication Aide (CMA) R stated he rarely took a shower, and staff just had to keep asking. The facility's Quality of Life-Activities of Daily Living policy, dated 04/25, documented that the community environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. If a resident refuses care and treatment that may contribute to a decline, they are to inform and/or educate the resident of the benefits and risks of not accepting such interventions. Staff are to document such in the record, including the interventions identified in the care plan and in place to minimize the functional loss that was refused. The policy further documents staff are to document substitute interventions that were tried with consent or refused.

The facility had a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician's ordered parameters for one resident, Resident (R) 3. This placed the resident at risk for adverse effects related to medication. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), diabetes mellitus (DM - when the body cannot use glucose, no enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperpiesia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition. R3 was dependent upon the staff for showers, toileting, transfers, and dressing. R3 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a class of medications used to treat mood disorders), and diuretic (medication used to promote the formation and excretion of urine) medications during the look-back period. The Quarterly MDS, dated 05/28/25, documented R3 had severely impaired cognition. R3 was dependent upon staff for toileting hygiene, showers, dressing, personal hygiene, mobility, and transfers. R3 received insulin, antidepressant, and diuretic medication during the look-back period. R3's Care Plan, dated 05/28/25, initiated on 03/02/20, directed staff to monitor blood glucose as ordered, administer diabetes medication as ordered by the doctor, and monitor for side effects and effectiveness. The update, dated 02/11/21, directed staff to obtain a fasting serum blood sugar (measures the level of glucose [sugar] in the blood after you've fasted [not eaten or drunk] for at least eight hours) as ordered by the physician. The update, dated 03/24/23, directed staff to monitor for compliance with diet and document any problems. The update, dated 03/27/23, directed staff to administer insulin as directed/ordered. The Physician's Order, dated 06/28/24, directed staff to administer insulin glargine (long-acting insulin), 17 Units (U), twice a day, for DM. Hold if glucose < (less than) 120 mg (milligrams) per deciliter (dl). R3's Medication Administration Record (MAR), dated April 2025, documented the following days R3 received his insulin when his blood sugar was out of the physician's ordered parameters: 04/06/25 at 06:00 PM - 102 mg/dl 04/14/25 at 09:00 AM - 112 mg/dl 04/20/25 at 09:00 AM - 108 mg/dl 04/21/25 at 09:00 AM - 103 mg/dl 04/21/25 at 06:00 PM - 112 mg/dl 04/22/25 at 09:00 AM - 112 mg/dl 04/22/25 at 06:00 PM - 114 mg/dl 04/23/25 at 09:00 AM - 104 mg/dl 04/28/25 at 09:00 AM - 101 mg/dl 04/28/25 at 06:00 PM - 114 mg/dl 04/29/25 at 06:00 PM - 114 mg/dl R3's MAR, dated May 2025, documented the following days R3 received his insulin when his blood sugar was out of the physician's ordered parameters: 05/14/25 at 09:00 AM - 96 mg/dl 05/24/25 at 09:00 AM - 82 mg/dl 05/25/25 at 09:00 AM - 100 mg/dl On 06/10/25 at 09:00 AM, Licensed Nurse (LN) G, gowned and gloved, rubbed an alcohol swab over R3's left pointer finger, and obtained his blood sugar. LN G stated his blood sugar was out of parameters and would not be administering R3's insulin. On 06/10/25 at 12:45 PM, LN G verified there were several days that R3 received his insulin when the out-of-physician ordered parameters. On 06/10/25 at 02:53 PM, Administrative Nurse D stated, staff were to follow the physician's orders. The facility's Obtaining a Fingerstick Glucose Level policy, dated 10/24, directed staff to verify that there was an order for the procedure. Staff were to document the results and follow facility policies and procedures for appropriate nursing interventions regards the blood sugar results.

The facility identified a census of 34 residents with three residents reviewed for pressure ulcers. The facility failed to identify and provide appropriate interventions consistent with the standards of care to prevent pressure ulcers from developing and worsening for Resident (R) 1. On 03/11/24, R1 developed two facility-acquired Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) 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) to her bilateral buttocks. On 05/16/24 the wound specialists identified diffuse pressure and redness to the entire intergluteal cleft (a deep groove that separates the buttocks and runs from the third or fourth sacral spine to the anus) area. The facility did not implement further preventative measures to address offloading or positioning until 07/11/2024. The facility further failed to assess R1's pressure wounds weekly to determine the effectiveness of treatments. On 08/07/24, R1 was transferred to an acute care hospital where they identified she arrived with an unstageable pressure ulcer (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) to her coccyx (area at the base of the spine) with necrosis (localized tissue death that occurred in a group of cells in response to disease or injury) and slough (dead tissue, usually cream or yellow) in the wound bed, a Stage 3 pressure ulcer (full thickness pressure injury extending through the skin into the tissue below) to her left buttock, a Stage 3 pressure ulcer to her right buttock, a deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right heel a DTI to the left trochanter (bony prominence on the upper part of the thigh bone) that serves as a site for muscle attachment. The facility's failure to identify and implement interventions consistent with standards of care to prevent the development of further pressure injuries and to promote healing of existing facility-acquired pressure ulcers placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of pressure ulcer of unspecified stage to unspecified buttock, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), morbid obesity, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R1 had no impairment of her upper or lower extremities. The MDS documented R1 was completely dependent on staff for assistance with toileting, dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 had no pressure ulcers, was at risk for pressure ulcer development, had a pressure-reducing device for her chair, had a pressure-reducing device for her bed, and was on a turning/repositioning program. The MDS documented R1 received nutrition interventions to manage skin problems, received pressure ulcer care, and application of dressings and ointments/medications. The Quarterly MDS, dated [DATE], documented R1 had a BIMS score of 15 which indicated intact cognition. The MDS documented R1 had impairment of her bilateral lower extremities. The MDS documented R1 was completely dependent on staff for assistance with toileting, dressing, personal hygiene, bed mobility, and transfer. The MDS documented R1 had two Stage 2 pressure ulcers that were not healed. The MDS recorded R1 was at risk for pressure ulcer development, had a pressure-reducing device for her chair, and was on a turning/repositioning program. R1 received nutrition interventions to manage skin problems and had application of ointments/medications. The Functional Abilities Care Area Assessment (CAA), dated 12/21/23, documented R1 was at risk for potential alterations in her activity of daily living (ADL) function, had several medical conditions that affected her ADL functions, and required supervision to dependent assistance from staff with her ADLs. The Pressure Ulcer Injury CAA, dated 12/21/23, documented R1 was at risk for pressure-related injuries/ulcers. R1's skin was intact and was being treated for moisture-associated skin damage (MASD). The CAA documented weekly skin assessments were performed and R1 had interventions in place to prevent skin breakdown. R1's Care Plan documented R1 was unable to ambulate and required a sit-to-stand lift for all transfers by two staff members. R1 required total assistance of two staff members for toileting, was dependent on two staff members to turn and reposition in bed and was totally dependent on two staff members for bathing, personal hygiene, and dressing. The care plan documented R1 had the potential for altered skin integrity related to DM, pain, anxiety, and immobility. The care plan directed staff to follow the facility policies and protocols for preventative/treatment of skin breakdown. The care plan documented R1 was to lay down in bed for sixty minutes every day, but R1 refused to comply and would sit in her recliner most of the time. The care plan documented R1 required a pressure relieving/reducing cushion to her wheelchair (03/22/24). The care plan documented R1 was being seen by the wound care clinic and staff were to follow their treatment plan. The Braden Scale for Predicting Pressure Injury Scale, dated 05/08/24, documented a score of 16, low risk for pressure ulcer development. The Braden Scale for Predicting Pressure Injury Scale, dated 08/06/24, documented a score of 10, high risk for pressure ulcer development. The Progress Note, dated 03/11/24, documented R1 had a bleeding wound on her buttocks bilaterally that was cleaned and had to be bandaged twice during the shift. A large amount of blood was noted during bathroom use and the first bandage was soaked through and replaced. The Weekly Skin Condition Report, dated 03/11/24, documented R1 had MASD on her right and left buttock. No measurements of the wounds were documented. The note documented a large amount of exudate (drainage). The surrounding skin had discoloration. The area pained R1. The comments documented R1 agreed to lie in bed for one hour daily as R1 typically stayed in her recliner and slept in her recliner. No specialty interventions were documented. The Progress Note, dated 03/13/24, documented R1 with a wound to her buttocks. R1 stated it hurt. Staff encouraged R1 to lie in bed and get off of her buttocks to aid in healing and decrease the pain. R1 stated she was not lying in bed and wanted the doctor called to get a stronger pain pill. The Progress Note, dated 03/14/24, documented R1 had multiple wounds on her buttocks, but it was likely due to the amount of time R1 spent up in her recliner. The note recorded staff attempted to ask R1 to lay in bed to relieve pressure off her sores and R1 denied this. Staff applied honey barrier cream liberally to R1's buttocks while she was up on the commode. R1 stated she could not tell if it was helping. The Progress Note, dated 03/15/24, documented staff encouraged R1 to lie in bed and get off of her bottom. R1 stated she could not lay in the bed as it kills her to lay in that bed. The Progress Note, dated 03/17/24, documented that the dressing on R1's buttocks was saturated that morning. The areas to the left and right buttocks remained open. Staff cleansed the wound, patted the area dry, and applied a new sacral foam dressing. R1 reported discomfort to the area. The Progress Note, dated 03/18/24, documented that a Certified Nurse's Aide (CNA) requested the nurse come to R1's room. R1 had a bowel movement, and the CNA was unsure if the dressing should be changed due to mild soiling. The old dressing was removed. The area to R1's buttocks remained open and small amounts of bloody drainage were noted. Staff cleansed the area with wound cleanser, patted the area dry, and applied a new dressing. R1 reported discomfort on her buttocks. R1 was repositioned in the recliner. The Secure Conversations Note, dated 03/18/24, documented the nurse asked R1's provider if R1 could have a wound consult with wound care so the facility could apply the right dressing. Administrative Nurse D responded the facility now had a wound care consultant in-house and the doctor could see R1 through telehealth and asked for orders for R1 to be seen. R1's provider responded he agreed with a wound consult and directed to keep him posted. The Weekly Skin Condition Report, dated 03/18/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. The report indicated there was no exudate noted, and the surrounding skin was reddened. No specialty interventions were documented. The Progress Note, dated 03/19/24, documented R1 refused to see wound care via telehealth and wanted to be seen in person. An appointment was made at the wound clinic for 03/21/24 at 09:00 AM. The Secure Conversation Note, dated 03/20/24, documented the nurse requested and order from R1's provider to start R1 on Arginaid (protein drink to aid in healing) twice a day and a multivitamin and vitamin C daily. R1's provider responded yes to start them. The Weekly Skin Condition Report, dated 03/26/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. The report indicated there was no exudate noted, and the surrounding skin was reddened. No specialty interventions were documented. The Weekly Skin Condition Report, dated 04/02/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The surrounding skin was normal. No specialty interventions were documented. Nutritional interventions were documented as vitamin therapy. The Wound Care Progress Note, dated 04/04/24, documented R1 presented to the wound care clinic for initial evaluation of pressure wounds to bilateral buttocks. R1 stated the wounds were painful. The wounds have been ongoing for at least one month. R1 stated they bled a lot. R1 stated she sat in a recliner most of the time as she felt her bed was not comfortable at all. R1 did not have a cushion for her recliner or her wheelchair. R1 stated she laid on her back in her bed only to sleep at night. The left buttock wound measured 6 cm by 8 cm by 0.1 cm and had copious amounts (a lot) of sanguineous (bloody drainage) drainage. The right buttock wound measured 6 cm by 8 cm by 0.1 cm and had copious amounts of sanguineous drainage also. There was a treatment ordered for staff to apply Triad paste (zinc-oxide based hydrophilic paste for light to moderate levels of wound exudates and helps to maintain an optimal wound healing environment to facilitate autolytic debridement), Maxsorb sheet (an alginate dressing that locks fluid away as a gel providing beneficial, moist wound environment), and bordered foam dressing. Change every two to three days and as needed if saturated. R1 needed a good cushion (preferably Roho [pressure relief cushion that is made of soft, flexible air cells]) in her recliner and wheelchair. The resident was to change position every two hours. Follow up with wound care in two weeks or sooner if needed. The Progress Note, dated 04/05/24, documented R1 had a wound care appointment the previous day on 04/04/24 and the facility received the following new orders: 1. Apply Triad paste, then Maxsorb sheet, then bordered foam dressing. Change every 2-3 days and as needed if saturated, soiled, or falling off. 2. Get a good cushion for R1's recliner and wheelchair preferably a Roho cushion. 3. Please be sure R1 is changing positions and shifting weight often as these wounds are due to constant pressure in this area. 4. Follow up in wound care in two weeks, sooner if needed. The Nutrition Note, dated 04/08/24, documented R1 had open wounds to her left and right buttocks. R1 refused her Juven/Argenaid for wound healing. The registered dietitian recommended discontinuing the Juven/Arginaid and giving R1 1 to 2 ounces of extra protein with all meals. R1 agreed with the recommendation. The Weekly Skin Condition Report, dated 04/09/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. A moderate amount of serosanguinous (semi-thick blood-tinged drainage) exudate was noted. The wound bed had dark pink/red tissue. The surrounding skin was reddened. No specialty interventions were documented. The nutritional intervention was vitamin therapy. The Weekly Skin Condition Report, dated 04/16/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The surrounding skin was normal for skin. No specialty interventions were documented. The Wound Care Progress Note, dated 04/18/24, documented wound care follow-up with R1 due to pressure wounds to the buttocks. R1 stated the pain was much improved. R1 stated she had a cushion in her recliner and her wheelchair. R1 stated the staff at the facility changed the dressing every other day. The left buttock wound measured 7.4 cm by 4 cm by 0.1 cm with a moderate amount of drainage. The right buttock wound measured 7.4 cm by 4 cm by 0.1 cm with a moderate amount of drainage. The resident received a treatment of Adaptic (a non-adhering wound contact layer made of knitted cellulose) folded in fourths on the right buttock and covered with bordered foam dressing and bordered foam dressing to the left buttock. No debridement. Wounds were much improved, with a small open area to the right buttock noted with bleeding upon initial evaluation. Follow up in one month or sooner if needed. The Nutrition Note, dated 04/18/24, documented R1 remained on treatment for pressure areas to her left and right buttocks. The wounds were reported to be improving. R1 was eating well, on 1-2 ounces of protein powder with meals for wound healing. The Progress Note, dated 04/19/24, documented new orders received from wound care on the dressing to R1's bottom. The note documented to continue with Triad paste and cover with a foam dressing and documented staff needed to try and get R1 off her bottom as much as possible. The dressing was to be changed every three days and as needed if soiled or falling off. The Weekly Skin Condition Report, dated 04/25/24, documented no skin issues. No measurements of the wounds were documented. No exudate was noted. The surrounding skin was normal for skin. A wheelchair/chair cushion was documented as a specialty intervention. The Weekly Skin Condition Report, dated 05/09/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The surrounding skin was normal for skin. No specialty interventions were documented. The Wound Care Clinic Progress Note, dated 05/16/24, documented wound care follow-up. R1 presented with pressure wounds to the bilateral buttocks. R1 stated her right buttock was painful when she was sitting. R1 stated she never laid in her bed as it was very uncomfortable. R1 had one bordered foam dressing to each buttock. The right buttock wound measured 4.5 cm by 3 cm by 0.1 cm and the left buttock wound measured 1.4 cm by 0.7 cm by 0.1 cm. No active bleeding was noted on the exam. R1 did have open wounds bilaterally and her entire buttocks/intergluteal cleft area was ecchymotic (bruised), evidence of pressure injury diffusely. R1 stated she refused to lay in bed as it was uncomfortable, and she had arthritis. The wound care provider would talk to R1's primary care provider to see if it was an option for the nursing home to get a Sizewise (specialty bariatric hospital-type bed with a larger surface area) bed. Discussed with R1 that unless she attempted to offload this area her wounds would not heal and would worsen. The Nutrition Note, dated 05/16/24, documented R1 continued to have open areas to her left and right buttocks with treatment in place. Continue current interventions for wound healing. Weight fluctuations were noted. The registered dietitian would continue to monitor monthly until R1's wounds were healed. The Weekly Skin Condition Report, dated 05/17/24, documented R1 had MASD on her right and left buttock. No measurements of the wounds were documented. No exudate was noted. The area pained R1. The wound bed was documented as pale pink tissue. The surrounding skin was reddened. No specialty interventions were documented. The nutritional intervention was vitamin therapy. The Weekly Skin Condition Report, dated 05/25/24, documented R1 had no type of wound documented to her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The wound bed had pink, pale tissue. The surrounding skin was normal for skin. No specialty interventions were documented. The Weekly Skin Evaluation Note, dated 05/29/24, documented R1's skin was intact. The Weekly Skin Condition Report, dated 06/01/24, documented R1 had no type of wound documented to her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The wound bed was normal for skin. The surrounding skin was normal for skin. No specialty interventions were documented. The Weekly Skin Evaluation Note, dated 06/08/24, documented R1's skin was intact. The Nutrition Note, dated 06/12/24, documented R1 had been eating well. R1 had an open area to her coccyx (tail bone) and redness to her right and left iliac crest (the curved, bony ridge that forms the upper border of the ilium the largest of the three bones that make up the hip bone). Recommended to continue current interventions for wound healing. The Wound Care Clinic Progress Note, dated 06/13/24, documented wound care follow-up for pressure wounds to the bilateral buttocks. R1 complained of increased bleeding to wounds. R1 stated she slept in her recliner every night and refused her bed as it was very uncomfortable. R1 also refused to shift her weight from side to side and stated she sat right in the center of her buttocks. No measurements were noted. Triad paste to bilateral buttocks. No active bleeding was noted. R1 had superficial open areas to her right buttock but nothing of depth. The note recorded the wound would not heal if R1 continued to sit directly on her buttocks all day and all night. The note recorded someone would see about ordering a Roho cushion for R1, however R1 stated it would not work in her recliner. The Weekly Skin Condition Report, dated 06/20/24, documented R1 had no type of wound documented to her right and left buttocks. No measurements of the wounds were documented. No exudate was noted. The wound bed was normal for skin. The surrounding skin was normal for skin. No specialty interventions were documented. The Progress Note, dated 06/21/24, documented a message was sent to R1's provider requesting an as-needed administration for Triad paste due to R1 not having any on that morning after toileting and the wound was bleeding. The Progress Note, dated 06/21/24, documented starting Triad past every other day. R1 tolerated well. The Progress Note, dated 06/23/24, documented a new order to receive Triad hydrophilic wound dress external paste to bilateral buttocks every other day remained in place. The Weekly Skin Evaluation Note, dated 06/25/24, documented a Stage 2 ulcer to R1's coccyx. The Secure Conversation Note, dated 06/26/24, documented the facility was having difficulty maintaining the Triad paste barrier with every other day application. Request for as-needed order to reapply when needed especially when the order date did not line up with R1's bath day. R1's provider said yes to the request. The Weekly Skin Condition Report, dated 06/27/24, documented R1 had pressure wounds on her right and left buttocks. No measurements of the wounds were documented. No other description of the wounds was documented. The area pained R1. No specialty interventions were documented. The nutritional intervention was documented as vitamin therapy. The report documented R1 was being seen at the wound care clinic and to see notes. The Weekly Skin Evaluation Note, 07/01/24, documented R1's skin was intact. The Weekly Skin Condition Report, dated 07/04/24, documented R1 had a Stage 2 pressure wound on her right buttock. No measurements of the wounds were documented; serous (thin, clear) exudate was noted. The wound bed had pink/pale tissue. The surrounding skin was reddened and macerated. The area pained R1. A wheelchair/chair cushion was noted as the specialty intervention. The nutritional intervention was vitamin therapy. The report documented R1 was being seen at the wound care clinic, see notes. The note documented the area had deteriorated. The Secure Conversation Note, dated 07/09/24, documented the facility thought it would be beneficial for R1 to have an order for a catheter (a tube inserted into the bladder to drain urine). The wound to R1's bottom was not improving. Triad past was being used on R1's wound. R1's provider asked if R1 was willing to consider the placement of a Foley catheter and if so, he would be willing to order it. The facility responded R1 was willing to try it. R1's provider responded to place a Foley catheter to dependent drainage and once the wound was healed, remove the catheter. The Wound Care Clinic Progress Note, dated 07/11/24, documented a wound care follow-up for pressure wounds to the bilateral buttocks. R1 had no concerns during the visit. The nursing home continued to use Triad paste to the buttocks. No measurements were noted for the right buttock wound. The left buttock wound measured 3 cm by 0.5 cm by 0.1 cm. The Rental Review Receipt, dated 07/11/24, documented the facility acquired a bariatric frame and a bariatric therapeutic support mattress for R1. The Weekly Skin Condition Report, dated 07/12/24, documented R1 had a Stage 2 pressure wound on her right and left buttock. No measurements of the wounds were documented. Serosanguinous exudate was noted. The wound bed had pink/pale tissue. The surrounding skin was normal for skin. The area pained R1. The nutritional intervention was vitamin therapy. No specialty interventions were documented. The Weekly Skin Condition Report, dated 07/18/24, documented R1 had a coccyx pressure wound. No measurements of the wound were documented. Serous exudate was noted. The wound bed had pink/pale tissue. The surrounding skin was reddened. A specialty bed was noted as the specialty intervention. The nutritional intervention was vitamin therapy. The Secure Conversation Note, dated 07/30/24, documented that Administrative Nurse D requested advice regarding R1. The note stated R1 utilized the bed but now R1 would not get up from the bed. R1 refused weights even though the full body lift with scale would be used. R1 refused to let staff reposition and refused staff to change incontinent products. R1 stated it hurt too much to move and complained of increased pain. The facility wanted to do what was best for R1. R1's wound to her buttocks showed no improvement. R1's provider responded he would see R1 the next day. The Physician Progress Note, dated 07/31/24, documented R1 complained of sacral (the region at the bottom of the spine between the fifth segment of the lumbar spine and the coccyx) pain secondary to a wound. R1 was started on an antibiotic for a urinary tract infection. R1 continued to see wound care for a sacral ulcer. The Infection Note, dated 08/01/24, documented R1 was alert and able to make needs known. Antibiotic therapy was in progress for a urinary tract infection. R1 had Bactrim-DS (antibiotic) for ten days. R1 had no complaints of discomfort post-void and was afebrile. Fluids were encouraged and accepted. Respirations were even and unlabored. No signs and symptoms of acute distress. The Weekly Skin Condition Report, dated 08/01/24, documented R1 had a coccyx pressure wound. No measurements of the wound were documented. No exudate was noted. The wound bed had pink/pale tissue. The surrounding skin was normal for skin. A specialty bed was noted as the specialty intervention. The nutritional intervention was identified as vitamin therapy. The Progress Note, dated 08/01/24, documented the facility received a phone call from R1's provider and he ordered a repeat urine sample and sensitivity as R1 had two bacteria in her urine. R1's provider at first ordered ceftriaxone one gram intramuscularly (IM-administered directly into the muscle) but then realized R1 was allergic to it, so ordered R1 to continue with the Bactrim-DS. The Infection Note, dated 08/03/24, documented R1 was in bed with her eyes opened, respirations even and unlabored, skin warm and dry to the touch; R1 was able to make her needs known, and confusion was noted. R1 continued antibiotic therapy. Fluids were encouraged and incontinent care was provided. Treatment of R1's coccyx was ongoing. The Progress Note, dated 08/04/24, documented R1 was alert and awake, respirations were even and unlabored, no acute distress was noted, and skin warm and dry to the touch. R1 transferred to the recliner per full lift. The Progress Note, dated 08/06/24, documented the nurse went to assess R1 after a phone call from R1's daughter. R1 was alert and oriented, lung sounds were clear, and R1 had times of confusion. The note documented R1's hands shook a lot more than they used to. The Communication with Physician Note, dated 08/06/24, documented the nurse called R1's provider to discuss R1's change of status. The nurse talked to R1's provider about R1's confusion, shaking hands, elevated blood pressure, and coccyx wound. R1's provider ordered lab work, vitals twice a day, and one-time blood sugar. R1's provider would round on R1 tomorrow. The Skin and Wound Evaluation, dated 08/06/24, documented a pressure wound to R1's coccyx which measured 4.64 cm by 1.42 cm, a pressure wound to R1's left buttock which measured 2.01cm by 1.66 cm, and a pressure wound to R1's right buttock which measured 9.3 cm by 2.09 cm. The evaluation documented that on 08/12/24 Administrative Nurse D changed the coccyx wound and the left buttock wound description to Kennedy terminal ulcers (KTU- a pressure-based injury that can develop quickly and is often a sign of terminal illness or impending death) in the wound description tab. The Progress Note, dated 08/07/24, documented the facility received a call from the lab reporting R1 had a critical value for a potassium level of 6.2 milliequivalents per liter. R1's provider was notified of the critical lab value, and he ordered R1 to be transferred to the hospital via ambulance. R1's responsible party was notified. R1 was diagnosed with acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). R1 would be transferred to a higher level of care but it was unknown where R1 would be sent. The ER Progress Notes, dated 08/07/24, documented R1 had a right heel pressure ulcer that was erythematous (redness) and eccymotic with an intact blister and seemed to be painful for R1. It also noted a pressure area to R1's coccyx. The notes did not include measurements or descriptions. The hospital's Wound Service Consult Note, dated 08/08/24, documented R1 presented to the higher level of care hospital with an unstageable pressure injury to her coccyx, a Stage 3 pressure injury with evolving DTI to her left buttock, a Stage 3 pressure injury with evolving DTI to her right buttock, a DTI to her right heel, and a DTI to her left trochanter (hip bone). The exam noted an unstageable pressure injury to R1's coccyx that was active with necrotic (pertaining to the death of tissue in response to disease or injury) tissue with the ability to probe through the fascia (band of thin, fibrous connective tissue)to the bone to the center point of injury which measured 4 cm by 2 cm by 2 cm. Adhered slough with necrosis to the wound edges with malodor. Bilateral buttocks pressure injuries were full-thickness tissue injuries at Stage 3 with superimposed DTI features. The wound edges were irregular indicative of continual friction and shearing forces adversely impacting condition epidermal stripping forces more prominent to the left buttock. The left buttock wound measured 4 cm by 2 cm by 0.2 cm and the right buttock injury measured 8 cm by 6 cm by 0.3 cm. The left trochanter DTI had an intact bulla with darkened purple discoloration to the wound bed and measured 7 cm by 3 cm. Generalized DTI formations were noted to the gluteal cleft and gluteal tissue. The right heel DTI with intact bulla with darkened purple discoloration to the wound bed and measured 4 cm by 4 cm. Evidence of neglect. Consider magnetic resonance imaging (MRI-medical imaging used to view soft tissue) for coccygeal pressure injury. The coccyx and bilateral buttock pressure injuries were cleansed with saline-moistened gauze, Medihoney (medical grade honey used to aid wound healing) gel applied to the wound beds, covered with Allevyn (brand of dressing) pink bordered heel dressing, ensure all three injuries are covered. Change every two days or as needed. To the right heel DTI and left trochanter DTI, maintain heel Allevyn to the right heel and a 6 X 6 Allevyn to the left trochanter. Change every 48 hours or when soiled, saturated, or dislodged. If the blisters pop, take a picture and send it to wound care. On 08/12/24 at 10:30 AM, observation revealed a wheelchair in the corner of R1's room that had a pressure relieving cushion (not a Roho cushion) in it. R1's recliner was in the center of the room covered with chucks. Observation of the bed revealed a regular mattress on a twin bed frame. On 08/12/24 at 11:00 AM, Certified Nurse Aide (CNA) M stated she did not ever remember R1 having a pressure-relieving cushion in her recliner. CNA M stated R1 sat in her recliner twenty-four hours a day, seven days a week because it was too painful for R1 to get into bed. On 08/12/24 at 11:15 AM, CNA N stated she took care of R1 all the time and there was never a pressure relieving cushion in R1's recliner. CNA M stated there were always chucks and maybe a turn sheet in R1's recliner but never a pressure relieving cushion. CNA N stated R1 would refuse to reposition at times because she was comfortable where she was and did not want the pain to start. CNA N stated aides were able to reposition R1 in her recliner using three aides, but it was difficult. CNA N stated aides would also change R1's briefs in the recliner. CNA N stated once R1 had an air mattress she was able to get into bed and not have pain. On 08/12/24 at 11:30 AM, Licensed Nurse (LN) G stated she never saw a pressure relieving cushion in R1's recliner. LN G stated when R1 got an air mattress, she finally got into bed. LN G said that prior to getting the air mattress, R1 constantly sat up in her recliner. On 08/12/24 at 12:15 PM, Administrative Nurse D stated the facility did not order a specialized mattress because R1 kept saying she would not use it and R1 had not paid her bill at the facility so the facility would then be out that much more money for the bed. Administrative Nurse D stated R1 was very non-compliant but unfortunately, that was not in the care plan until after she came down with the pressure ulcers to begin with. Administrative Nurse D stated she knew there was a cushion in R1's recliner. Administrative Nurse D stated she talked with the doctor, an [TRUNCATED]

The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 33 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for food borne illness. Findings included: - On 09/26/23 at 11:55 AM observation revealed the ceiling light fixtures above the stove, grill top, steam table, and three-compartment sink all had dead insect in them. The dining room ceiling light cover also contained dead insects. Further observation revealed the front sheath and blades of the fan attached to the wall and venting ducts over the area where clean dishes were stored had brown, fuzzy material hanging from them. Throughout multiple observations of the kitchen and dining room, a large number of flies were also noted landing on the food preparation tables in the kitchen, the dining room tables, and food on the plates which the residents had to wave away during the meal. On 09/26/23 at 02:09 PM Dietary Staff (DS) BB stated the ceiling lights in the kitchen and dining room and the fan and venting ducts were to be cleaned when she had returned to the facility after time off. DS BB verified numerous flies throughout the kitchen and dining room and said the pest control company came monthly and as needed. The facility Sanitation policy, dated 10/2022, documented all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The facility failed to store, prepare, and serve food under sanitary conditions for residents that resided in the facility and received meals from the kitchen, placing the residents at risk for food borne illness.

The facility had a census of 33 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit the information for Licensed Nurses (LN) 24 hour/day staffing as required. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2022 Quarter 4 and FY 2023 Quarters 1 through 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on over 75 dates. Review of the faciliyt provided staffign information revealed the facility had a licensed nurse 24 hours a day, seven days a week. On 09/28/23 at 08:30 AM, Administrative Staff B stated she started in October and was given a crash course on the PBJ reporting. She said she has since learned how to input it correctly, and felt that it was the agency nursing staff that had not been input correctly which caused the LN 24hours a day to trigegr. The facility's Payroll Based Journal policy, dated 11/17, documented the facility would submit payroll data in a uniform format to CMS, including staffing information for the community, agency, and contract staff. The facility would distinguish employees from agency and contract staff when reporting information about staffing. The facility failed to submit accurate information to CMS PBJ. This placed the residents at risk for unidentified and ongoing inadequate staffing.

- On 09/26/23 at 07:55 AM, observation revealed R27 in the dining room. His oxygen tubing and cannula laid on the dining room floor. On 09/26/23 at 08:58 AM, observation revealed R27 self propelled his wheelchair into the television area, his oxygen tubing and cannula was wound around the right wheel of his wheelchair. Further observation revealed Administrative Staff B asked Administrative Nurse E to get R27 a new set of tubing sine R27's touched the ground. Administrative Nurse E replaced the old tubing and assisted R27 with the new tubing. Continued observation revealed, the oxygen tank R27 was using was empty and Adminsitrative Nurse E brought R27 a new tank. Administrative Nurse E obtained R27's oxygen saturation (percentage of oxygen in the blood) which was in the 70 percentile (normal is 90-100 %). After Administrative Nurse E had R27 take deep breaths, he was able to get his saturations up into the 90 percentiles. Administrative Nurse E stated it was everyone's responsibility to make sure R27 had a full oxygen tank and to make sure he was wearing the nasal cannula correctly and it was not dragging on the floor. Upon request a policy for oxygen tubing storage was not provided. The facility failed provide infection control practices for F27, when his oxygen tubing and cannula dragged on the floor and not bagged. This placed the resident at risk for infection. - On 09/27/23 at 08:14 AM, Maintenance Staff U stated he had the testing material for the water management process but had not started yet. The facility's Water Management, Legionella Testing policy dated 10/22, documented the facility handled and maintained its water supply in accordance with recommendations of the CDC, the Healthcare Infection Control Practices Advisory Committee and the FDA (Food and Drug Administration) to minimize their risk of Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other opportunistic pathogens in the building water system through a documented water management. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who resided in the facility at risk of contracting Legionella pneumonia. 37450 The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to maintain acceptable infection control practices during Resident (R)15's feeding assistance, R24's bathing on enhanced precautions (infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares), R131's wound dressing change, and care of R27's oxygen tubing. The facility further implement the water management program to prevent Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations). These practices placed the residents at risk for transmission of infectious disease. Findings included: -On 09/26/23 at 12:18 PM, observation revealed R15 was assisted by Certified Nurse Aide (CNA) M with eating a sandwich in the dining room. CNA M handled the sandwich without the use of gloves while giving bites to the resident. On 09/26/23 at 01:48 PM, Dietary Staff (DS) BB verified sandwiches should not be handled without gloves while assisting the resident to eat. The facility's Paid Feeding Assistants policy dated 10/2022 documented the use of basic infection control practices related to food and feeding. The facility failed to provide standard infection control practice for R15 who was fed by staff with ungloved hands, which placed R15 at increased risk of illness and infection. - On 09/27/23 at 07:47 AM, observation revealed R24, who was on enhanced barrier precautions for infectious disease, in the bathing room. Certified Nurse Aide (CNA) M provided bathing activities without the use of gloves or gown. The signage outside R24's room instructed providers and staff to put on gloves and a gown. On 09/27/23 at 08:58 AM, Administrative Nurse D verified CNA M should have worn gloves and a gown during bathing activity for R24 who had enhanced barrier precautions. The facility's Initiating Transmission-Based Precautions (TBA), (Isolation), (Contact, Enhanced, Airborne, Droplet) policy, dated 05/2023, documented Transmission Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. When TBP are implemented, the following is recommended: protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions or be ware that they must first see a nurse to obtain additional information about the situation before entering the room. Put on gown, do not use cloth gowns more than once, and linens are to be placed in black trash can with clear sack labeled trash. The facility failed to ensure staff followed the enhanced barrier precautions while giving direct care to R24, which increased the risk of transmission of infectious disease. - On 09/27/23 at 10:45 AM observation revealed Administrative Nurse E remove a soiled dressing from R131's buttock wound. Administrative Nurse E used the same gloves to remove the soiled dressing, cleanse the wound with wound cleanser, and to apply a clean dressing to the wound. On 09/28/23 at 01:02 PM, Administrative Nurse E verified she should have changed gloves after cleansing the buttock wound and before placing a clean dressing to the site. The facility's Pressure Injury Treatment Guidelines policy, dated 03/2023, documented steps in treatment procedure to wash hands before treatment, apply disposable gloves, remove soiled dressing and gloves and place in open plastic bag, wash hands, apply disposable gloves, clean area and pat dry, apply dressing/treatment remove and discard soiled gloves. The facility failed to follow acceptable infection control measures during wound care for R131 by not changing soiled gloves before applying a clean dressing, which placed R131 at risk for wound infection.

The facility had a census of 33 residents. Based on observation and interview, the facility failed to maintain an effective pest control program for the 33 resident's residing in the facility. This placed the resident's at risk for illness and an uncomfortable environment. Findings included: - On 09/25/23 at 11:21 AM, observation revealed during the noon meal, R132 had flies land on her food. On 09/25/23 at 11:30 AM meal, R2 complained about all the flies that landed on his food and onto the table. On 09/25/23 at 12:50 PM, observation in R14's room revealed multiple flies landing on and around the resident as he was transferred by staff. On 09/26/23 at 10:00 AM, R2 stated the flies were terrible in his room. As he spoke, a fly landed on his nose. On 09/26/23 at 12:00 PM, observation revealed R2, in the television area, with a fly swatter in his hand as he tried to kill flies. On 09/27/23 at 02:00 PM, observation revealed several flies landed on R9 while she sat in her recliner. On 09/27/23 at 05:00 PM, observation revealed flies on R9 as she sat in the television area. On 09/27/23 at 08:30 AM, Maintenance U stated he was unsure what to do about all the flies and stated he would contact his pest control provider. The facility's Pest Control policy, dated 02/20, documented the community shall maintain an effective pest control program to ensure that the building was kept free of insects and rodents and maintenance services assist, when appropriate and necessary in providing pest control services. The facility failed to maintain an effective pest control program for the 33 residents related to flies in the building. This placed the resident's at increased risk for illness and an uncomfortable environment.

The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to adequately label and store insulin (hormone that lowers the level of glucose in the blood) for five residents in the facility's medication room. This placed the affected residents at risk for ineffective medication regimens. Findings included: - On 09/25/23 at 01:59 PM, observation of the medication room refrigerator had the follwoing insulin pens which were open, and in use which lacked a date when opened and/or discard date: Residents (R)1's Levemir (long acting insulin) and lispro (short acting insulin) was not labeled with opened or discard dates. R2's Levemir was not labeled with opened or discard date. R14's insulin glargine (long acting) was dated 07/23/23 but not specified if that was an open or discard date. R24's Levemir was dated 09/17/23 but notspecified if that was an open or discard date. R11's basaglar (long acting insulin) was not labeled with opened or discard date. On 09/25/23 at 02:05 PM, Licensed Nurse (LN) G stated she did not know what the insulin pen dating policy was for the facility's insulin use. On 09/26/23 at 08:02 AM, Administrative Nurse D stated the insulin pens should be dated to when it was opened and when it should be discarded. The facility's Identifying and Managing Medication Errors and Adverse Consequences policy, dated 09/2023, documented the staff and practitioner shall strive to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The policy further the staff to follow relevant clinical guidelines and manufacturers' specifications for use. The facility failed to label and store insulin pen with opened and expiration dates for R1, R2, R14, R24, and R11, which placed the affected residents at risk for ineffective medication regimens.

The facility had a census of 33 residents. The sample included 15 residents, with two reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 14 remained free from neglect when the facility failed to provide the necessary care and service as directed by the resident's plan of care, on more than one occasion, despite being aware of what care the resident required. This placed the resident at risk for congoing neglect and related complications. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following other cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left dominant side, muscle weakness, abnormalities of gait and mobility, and lack of coordination. The Admission Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting. R14 did not ambulate. The assessment further documented R14 had unsteady gait, upper and lower functional impairment on one side, and had no falls. The Fall Care Area Assessment (CAA), dated 02/27/23, documented R14 had unsteady, impaired gait and balance, and was at risk for falls. R14 used a wheelchair and was at risk for injuries from falls. The Quarterly MDS, dated [DATE], documented R14 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further documented R14 had unsteady gait, upper and lower functional impairment on both sides, and had two or more falls since prior assessment. The Fall Assessment, dated 02/22/23 documented R14 was a low risk for falls. The Fall Assessment, dated 05/26/23, 08/15/23, and 08/26/23 documented R14 was a high risk for falls. R14's Care Plan, dated 07/24/23, initiated on 03/21/23, directed staff to anticipate and meet his needs, be sure R14's call light was within reach and encourage him to use it for assistance as needed as R14 required prompt response to all requests for assistance. Encourage R14 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure R14 wore appropriate footwear and ensure he had a safe environment. Provide activities that minimized the potential for falls while providing a diversion and use a sit to stand lift for transfers with two staff. R14's Care Plan updated 09/08/23 documented R14 continued to self-transfer himself without assistance and directed staff to educate and reeducate him on using his call light to request assistance as needed. The update, dated 09/26/23, directed staff to use a full body lift for transfers. The Fall Investigation, dated 08/15/23, at 01:31 PM, documented a Certified Nurse Aide (CNA) attempted to transfer R14 off the toilet to his wheelchair. R14's left foot was unable to move as the CNA tried to pivot turn the resident, and the CNA had to assist R14 to the ground. The investigation further documented R14 did not sustain any injury. On 09/25/23 at 12:50 PM, observation revealed R14 sat in his wheelchair. CNA N and CNA O put the sit to stand sling around R14's waist, placed his feet upon the foot plate of the lift, and told R14 to hold onto the handles of the lift. R14 held onto the lift handle with his right hand but CNA O had to put R14's left hand onto the handle and hold onto it for him. CNA N used the lift controller to lift R14 and told him to stand up. As the lift rose, R14 started to lean to the left and his left foot fell off of the foot plate. R14 could not stand and continued to lean heavily to his left, tipping the wheelchair. CNA N kept telling R14 to stand up, and R14 told both CNA he could not. CNA N lowered the lift and tried to reposition and straighten R14. The CNA tried to get R14's left foot back onto the foot plate. CNA O put her left knee against R14's left leg to try to hold it into place as both CNA attempted to stand R14 once again. R14 continued to lean heavily to the left and R14 again stated that he could not stand as the CNA continued to attempt to stand R14 using the lift. As the lift was raised, R14 continued to lean left, and the wheelchair started to tip. R14 stated No wonder my left side hurts sometimes and CNA N stated she did not feel comfortable using the sit to stand lift with R14 and had CNA O go tell the nurse to come to the resident's room. Licensed Nurse (LN) G went to R14's room and directed staff to use the full body mechanical lift to transfer R14 to the toilet. LN G then left to try to find a toileting sling to use on the resident. Further observation revealed R14 already had a full lift sling in his room that he stated had been used on him by one of the night shift CNA. CNA N and CNA O placed the sling under R14 while he was in his wheelchair. Staff lifted R14 into the air and placed R14 in his bed. Observation revealed the sling was not the right size for the resident and the straps were tight and cut into R14's inner thighs and made his head lean forward. The staff removed R14's pants and brief then lifted R14 again using the lift. R14's genitals were smashed in between the leg straps of the sling and R14 stated he was uncomfortable. CNA O was unable to position the lift in order to get R14 seated comfortably onto the toilet and Administrative Nurse D was asked to assist the two CNA with the resident. Administrative Nurse D stated the sling was not the right size for R14 and said that she would request a physical therapy evaluation to determine the best option to transfer R14. On 09/26/23 at 04:09 PM, observation revealed R14 sat in the shower chair with a gait belt around his waist. CNA M was on R14's right side and CNA O on the left. R14 used his right hand to guide his left hand to the end of the whirlpool tub so that he could hold on while both CNA transferred him to his wheelchair. CNA N stated, Are you sure we can transfer him, ok? and CNA N answered, Yes. CNA started to stand R14. R14 started to bend at the waist and his head was over the whirlpool. R14 said If I fall in, you are going to have a hard time getting me out of the whirlpool. Both CNAs had difficulty holding R14 up and they had to sit him down in the shower chair because he could not stand long enough to complete the transfer. R14's left foot did not move and seemed to be stuck on the floor. Continued observation revealed the CNAs attempted to stand R14 again and were able to transfer him into his wheelchair. On 09/26/23 at 04:30 PM, CNA M stated R14 was stronger before his shower, CMA M said she transferred R14 from his wheelchair to the shower chair without any assistance. On 09/28/23 at 09:30 AM, LN H stated R14 had severe left side weakness and therapy had evaluated him. LN H said therapy would work with R14 to try to get him stronger and see which lift would be appropriate for him. LN H stated when a resident had a fall, she filled out fall paperwork but did not implement interventions for falls. LN H said she did not document interventions on the care plan. On 09/28/23 at 01:52 PM, Administrative Nurse D stated if staff felt unsafe or unsure of how to transfer the resident, staff needed to stop and ask questions. Administrative Nurse D further stated staff should provide whatever assistance was directed by the resident's' care plans. The facility's Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) policy, dated 08/22, documented neglect occurs when the facility were aware of, or should have been aware of good ad services that a resident required but the facility failed to provide them to the resident resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress. The facility failed to ensure R14 remained free from neglect when the facility failed to provide the necessary care and service as directed by the resident's plan of care, on more than one occasion, despite being aware of what care the resident required. This placed the resident at risk for congoing neglect and related complications.

The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R)16 and R18 for posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed R16 and R18 at risk for unmet care needs. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, mood {affective} disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord , and problems related to care provider dependency. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, required supervision and one person assist with activities of daily living, had primary diagnoses of non-traumatic brain dysfunction, and other diagnoses of anxiety disorder, depression, but not PTSD. The MDS further documented R16 took an antianxiety (class of medications that calm and relax people) , antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used for pain relief) daily. The Care Plan initiated 04/10/23, documented R16 had mood problems and directed staff to administer medications as ordered and monitor/document for side effects and effectiveness. The care plan further documented R16 needed encouragement, assistance, and support to maintain as much independence and control as possible. The plan directed staff to assist R16 to identify strengths, positive coping skills and reinforce these. The care plan lacked did not identify R16 had PTSD and interventions to prevent traumatization triggers. The Mental Health Consultation Progress Note dated 08/16/23 documented R16 reported nightmares that disturbed her and caused her to be upset; asome were about people that worked at the facility. The note recorded the mental health consultant ordered medication at bedtime for PTSD and nightmares. The Progress Note dated 09/14/23 at 02:58 PM, documented R16 was screaming and crying after being informed of the rules for pets in the facility. R16 appeared safe at that time, and was given time to calm down. R16 wrote a letter and gave it to the nurse to pass on to the mental health provider. On 09/26/23 at 08:25 AM, observation revealed R16 ambulated in the hallway with her walker. R16 reported she had better days than that particular time and day. On 09/28/23 at 09:24 AM, Certified Nurse Aide (CNA ) P stated she was not aware of R16's diagnosis of PTSD, nor the triggers associated with this. On 09/28/23 at 10:40 AM, Licensed Nurse (LN) H stated she was aware of R16's PTSD. LN H stated she was not aware of R16's triggers associated with the diagnosis. LN H stated that information would be helpful for the care of the resident. On 09/28/23 at 09:08 AM, Consultant HH verified R16 had PTSD on admission and the Social Service Admission Assessment, dated 09/21/21, documented R16 had PTSD and a triggers of people who downplay the trigger and those who snuck up on her. On 09/28/23 at 01:50 PM Administrative Nurse D verified R16's care plan lacked the identified concern or problem of PTSD. The facility's Comprehensive Care Plans policy, dated 09/2023, documented an individualized comprehensive person-centered care plan that includes measurable objective time frames to meet the resident's medical, nursing, mental, cultural and psychosocial need is developed for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care plan should describe the resident's nursing, medical, physical, mental and psychosocial preferences. Each resident's comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified concerns, aid in preventing or reducing declines in the resident's functional status ad or functional levels and enhance the optimal functioning of the resident. The facility failed to develop a comprehensive care plan to include R16's PTSD which placed the resident at risk for unmet care needs. - R18's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, chronic pain, acute and chronic respiratory failure, rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems) , dependence on supplemental oxygen, panic disorder, starvation, severe protein-calorie malnutrition, post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), need for assistance with personal care, and problems related to care provider dependency. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had intact cognition, and required limited assistance of one person for activities of daily living. R18 was not steady, was only able to stabilize with staff assistance, and used a walker and wheelchair. R18 had occasional incontinence of urine and used oxygen. The MDS further documented R18 had diagnoses of anxiety disorder, PTSD, and regularly took an antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used for pain relief). The Care Plan initiated on 05/03/23 documented R18 was at risk for a potential psychosocial well-being problem related to anxiety, pain, recent admission, repeated falls, shortness of air, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and depression. The care plan directed staff to allow R18 time to answer questions and verbalize feelings, perceptions, and fears as needed. The plan directed to assist, encourage, and support R18 to set realistic goals and to consult with pastoral care, social services, and psychiatric services. The care plan further directed staff to assist, supervise, and support R18 to identify causative and contributing factors. The care plan lacked direction regarding R18's PTSD diagnosis and interventions to prevent traumatization triggers. The Social Service Admission Note dated 04/18/23 at 03:49 PM documented R18 came to the facility due to failure to thrive living at home with family. R19 was on an antipsychotic, antidepressant, and antianxiety medications, and exhibited signs of depression and anxiety. The note further documented R18 did not have a history of trauma and/or PTSD. The Mental Health Consultation Progress Note, dated 04/19/23, documented R18's thought process associations were logical, attention span was normal throughout the interview, and concentration intact. R18 had not realized how depressed he was and what a terrible state he was in. R18 was not currently taking psychiatric medications, but had diagnoses of depression, anxiety and PTSD. The note further documented R18 needed therapy from a trauma informed perspective and intensive talk therapy to help in working through his grief and loss. The plan/recommendation to start and antianxiety medication for anxiety and panic attacks, and antidepressant for depression, and talk therapy for PTSD and trauma. On 09/26/23 at 12:30 PM, observation revealed R18 sat in an electric wheelchair in the dining room and had lunch at a table of male residents. On 09/28/23 at 09:24 AM, Certified Nurse Aide (CNA ) P stated she was not aware of R18's diagnosis of PTSD, nor the triggers associated with this. On 09/28/23 at 10:40 AM, Licensed Nurse (LN) H, stated she was not aware of R18's PTSD. LN H stated she was not aware of R18 triggers associated with the diagnosis. LN H stated this information would be helpful for the care of the resident. On 09/28/23 at 01:50 PM Administrative Nurse D verified R18's care plan lacked the identified concern or problem of PTSD. The facility's Comprehensive Care Plans policy, dated 09/2023, documented an individualized comprehensive person-centered care plan that includes measurable objective time frames to meet the resident's medical, nursing, mental, cultural and psychosocial need is developed for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care plan should describe the resident's nursing, medical, physical, mental and psychosocial preferences. Each resident's comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified concerns, aid in preventing or reducing declines in the resident's functional status ad or functional levels and enhance the optimal functioning of the resident. The facility failed to develop a comprehensive care plan to include R18's PTSD which placed the resident risk for unmet care needs.

The facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to revise Resident (R) 28's plan of care to reflect his current needs and use of a mechanical lift for transfers. This placed the residents at risk for preventable accidents and injury due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R28 documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), unsteadiness on feet, and abnormalities of gait and mobility. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and R28 did not ambulate. The assessment further documented R28 had unsteady balance, upper and lower functional impairment on one side, and had no falls. The Quarterly MDS, dated [DATE], documented R28 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and did not ambulate. The assessment further documented R28 had unsteady balance, had upper functional impairment on one side and lower functional impairment on both sides, and had one non-injury fall. The Fall Assessments, dated 01/12/23, 05/31/23, 07/06/23, documented R28 was a high risk for falls. The Care Plan, dated 09/08/23, initiated on 02/16/23, directed staff to anticipate and meet R28's needs, be sure he has his call light within reach, encourage him to use it for assistance as needed as R28 needed prompt response to all requests for assistance. The plan directed staff to follow facility fall protocol. R28 needed a safe environment, and physical therapy was to evaluate and treat as ordered or as needed. R28 required extensive assistance of two staff for all transfers. The Fall Investigation, dated 07/16/23 at 10:44 AM, documented a Certified Nurse Aide (CNA) notified the nurse that R28 was lowered to the ground and was kneeling on both knees in front of the bed and beside the wheelchair. The investigation further documented R28 became weak, could no longer stand, started to fall, and the CNA had to lower him to his knees. On 09/26/23 at 11:50 AM, observation revealed CNA N and CNA O placed to full body mechanical lift sling under R28, attached the straps to the lift, raised R28 up, then sat him down in his wheelchair. CNA N removed the sling from behind the resident, attached R28's foot pedals to the wheelchair, placed R28's feet on the pedals and took him to the dining room for lunch. On 09/26/23 at 11:50 AM, CNA stated physical therapy worked with R28 and staff used the full lift because R28 had a stroke. 09/28/23 at 09:30 AM, Licensed Nurse (LN) H stated R28 was a full lift for transfers and said she did not know of any falls R28 had. On 09/28/23 at 01:00 PM, Administrative Nurse D stated the nurse was responsible for implementing new interventions after falls and should document the new intervention on the care plan. Administrative Nurse D further stated, she will sometimes run the care plans, but not all the time as other staff members run the care plans also. Care plans are completed outside of the facility with the assistance of a corporate nurse who corresponds with her through phone calls and emails and stated that any assessment completed by staff was sent to her to build the care plan. Administrative Nurse D stated she did not know where to find any care plan conference documentation and hoped to hire someone soon to do the care plans. The facility's Comprehensive Care Plans policy, dated 08/22, documented an individualized person-centered care plan that included measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs was developed for each resident and the team would review and update the care plans. The facility failed to revise R28's care plan to reflect his need for a mechanical lift for transfers. This placed the resident at risk for accident or injury related to uncommunciated care needs.

The facility had a census of 33 residents. The sample included 15 residents. Based on record review, and interview, the facility failed to complete a discharge summary, a reconciliation (summary) of pre and post discharge medications, and post-discharge plan of care for Resident (R) 30, who discharged from the facility. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of fracture of neck of right femur (thigh bone), right artificial hip joint, major depressive disorder (major mood disorder which causes persistent feelings of sadness) , chronic kidney disease, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), fluid overload, severe protein malnutrition, weakness, and need for assistance with personal care. The EMR documented R30's admitted [DATE] and discharge date of [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], documented R30 had severe cognitive impairment, required limited assistance with activities of daily living, was not steady, and only able to stabilize with staff assistance. R30 used a walker and wheelchair. The MDS documented R30 had occasional incontinence of urine and bowel. The MDS further documented R30 had a surgical wound and received an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and antidepressant (class of medications used to treat mood disorders) daily. The Care Plan dated 05/17/23 documented R30 and her family wished for her to return home upon discharge. The care plan directed staff to encourage R30 to discuss feelings and concerns with impending discharge, to monitor for and address episodes of anxiety, fear and distrust. The care plan further directed staff to establish a pre-discharge plan with resident and family, plan with required community resources to support independence post-discharge, and R30 needed written instructions and visual aids, as required, to ensure care continuity post-discharge. R30's EMR lacked a physician order for discharge. The Progress Note dated 07/05/23 at 03:43 PM documented R30 was discharging to another facility closer to family. R30's EMR lacked further evidence of a summary or recapitulation of R30's stay, reconciliation of medications, the post-discharge plans and needs, and any services required. On 09/28/23 at 09:03 AM, Consultant HH verified there was no physician order for discharge to another facility, or a discharge summary to include a recapitulation and reconciliation of medications. The facility's Discharge Summary and Plan policy, dated 09/2023, documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The recapitulation will include, but not limited to: diagnoses, course of illness, treatment or therapy, pertinent lab, radiology and consultation results, reconciliation of all pre-discharge medications with the resident's post-discharge medications for prescribed and over the counter, and a final summary paragraph that may be released to any provider with the consent of the resident or representative. The facility failed to complete a discharge summary, a reconciliation of pre and post discharge medications, and post-discharge plan of care for R30. This placed the resident at risk for unmet care needs.

The facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to provide an environment free from preventable accidents and falls for Resident (R)9, R14, and R20. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), repeated falls, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The Quarterly Minimum Data Set, (MDS), dated [DATE], documented R9 had severely impaired cognition and required extensive assistance of two staff for bed mobility, dressing, toileting, personal hygiene, transfers, and extensive assistance of one staff for ambulation. The MDS further documented R9 had unsteady balance, lower functional impairment on one side, and had no falls. The Quarterly MDS, dated [DATE], documented R9 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and did not ambulate. The MDS further documented R9 had unsteady balance, no functional impairment, and had one non injury and one injury fall since prior admission. The Fall Assessments, dated 08/21/22, 11/21/22, 02/21/23, 03/27/23, 06/27/23, documented R9 was a high risk for falls. R9's Care Plan, dated 09/07/2023, initiated on 06/27/17, directed staff to lower R9's bed. The update, dated 05/13/20, directed staff to monitor for safety on nurse rounds every two hours. The update, dated 03/26/21, directed staff to monitor for R9 sleeping on the side of her bed and assist her to the middle of the bed if noted. R9 Care Plan recorded an update, dated 02/20/23, which directed staff to make sure R9's call light was within reach and encourage her to use it for assistance as needed, educate R9 and family about safety reminders and what to do if a fall occurs, encourage R9 to participate in activities, ensure R9 wore appropriate footwear when ambulating or mobilizing in her wheelchair, have a safe environment for R9, and provide activities that minimize the potential for falls that would provide distraction or diversion. R9 Care Plan recorded an update, dated, dated 06/10/23, which directed staff to make sure a pillow was placed under her right side no matter of position, ensure R9 was closer to the wall when in bed and ensure her bed was in the lowest position, ensure her fall mat was next to her bed when she was in bed, and ensure R9 was positioned closer to the wall due to her air mattress. The update, dated 08/14/23, directed staff to ensure bolsters were on the outer edge, right side of bed, when R9 was in bed. The Fall Investigation, dated 01/21/23 at 03:15 AM, documented R9 was observed on the floor on the right side, parallel to the bed, with her head slightly under the bed. Her legs were outstretched, and her right arm was beneath her. The investigation further documented staff lifted R9 off the floor with the use of a Hoyer (total body mechanical lift), and R9 did not have pain. The investigation documented R9 could not tell staff what happened, and staff felt R9 rolled out of bed while repositioning herself on her new air mattress. R9's record lacked evidence an intervention addressing the air mattress related fall was implemented at that time. The Fall Investigation, dated 01/31/23 at 05:00 AM, documented R9 was on the floor beside her bed and sustained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). R9 stated she was looking for her children. The investigation further documented R9 had impaired memory, hallucinations (sensing things while awake that appear to be real, but the mind created) and staff lifted her off the ground and placed her back into her bed. R9's record lacked evidence of interventions related to this fall at that time. The Fall Investigation, dated 04/16/23 at 06:15 PM, documented R9 laid on her right side on the floor, and did not sustain any injuries. The investigation further documented staff assisted R9 off the floor, placed her back into bed, positioned her with pillows, and set up her supper tray. R9's record lacked evidence of interventions related to this fall at that time. The Fall Investigation, dated 06/10/23 at 05:15 PM, documented R9 was lying on the floor next to her bed and stated she scooted a little bit then whop. The investigation further documented R9 sustained a hematoma to the right side of her forehead and her bed was not in the lowest position. R9 was assisted back onto her bed by three staff with a gait belt, then transferred to her wheelchair and taken down to supper. The Fall Investigation, dated 08/09/23 at 11:30 AM, documented staff found R9 on the floor parallel with her bed. There was a fall mat beside the bed. R9 had a moderate amount of blood beneath her head, and staff applied gentle direct pressure to a laceration (wound to the skin) at her temple. On 09/28/23 at 08:21 AM, observation revealed R9 laid in bed. There was a fall mat beside the bed, and a bolster under the mattress cover, but not visible. There were no pillows on R9's right side. On 09/26/23 at 02:30 PM, CNA N stated she was not aware R9 had any falls. CNA N said R9 worked with physical therapy, and staff used a sit to stand lift to transfer R9. On 09/28/23 at 09:30 AM, Licensed Nurse H stated R9 had a fall matt beside her bed, required frequent checks, and was a two-person transfer. Licensed Nurse H stated when a resident had a fall, she filled out fall paperwork but did not implement interventions for falls. Licensed Nurse H stated she did document interventions on the care plan. On 09/28/23 at 01:00 PM, Administrative Nurse D stated the nurse was responsible for implementing new interventions after falls and should document the new intervention on the care plan. The facility's Falls and Fall Risk, Managing policy, dated 10/22, documented based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The policy further documented, the team would attempt to identify appropriate interventions to reduce the risk of falls, If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. the staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falls, staff would continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. The facility failed to identify relevant interventions after falls to prevent further falls for cognitively impaired R9. The facility further failed to ensure staff implemented the plan of care related to fall prevention when staff failed to place pillows as directed by R9's plan of care. This placed the resident at risk for further falls and injury. - R14's Electronic Medical Record (EMR) documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following other cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left dominant side, muscle weakness, abnormalities of gait and mobility, and lack of coordination. The Admission Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting. R14 did not ambulate. The assessment further documented R14 had unsteady gait, upper and lower functional impairment on one side, and had no falls. The Fall Care Area Assessment (CAA), dated 02/27/23, documented R14 had unsteady, impaired gait and balance, and was at risk for falls. R14 used a wheelchair and was at risk for injuries from falls. The Quarterly MDS, dated [DATE], documented R14 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further documented R14 had unsteady gait, upper and lower functional impairment on both sides, and had two or more falls since prior assessment. The Fall Assessment, dated 02/22/23 documented R14 was a low risk for falls. The Fall Assessment, dated 05/26/23, 08/15/23, and 08/26/23 documented R14 was a high risk for falls. R14's Care Plan, dated 07/24/23, initiated on 03/21/23, directed staff to anticipate and meet his needs, be sure R14's call light was within reach and encourage him to use it for assistance as needed as R14 required prompt response to all requests for assistance. Encourage R14 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure R14 wore appropriate footwear and ensure he had a safe environment. Provide activities that minimized the potential for falls while providing a diversion and use a sit to stand lift for transfers with two staff. R14's Care Plan updated 09/08/23 documented R14 continued to self-transfer himself without assistance and directed staff to educate and reeducate him on using his call light to request assistance as needed. The update, dated 09/26/23, directed staff to use a full body lift for transfers. The Fall Investigation, dated 08/15/23, at 01:31 PM, documented a Certified Nurse Aide (CNA) attempted to transfer R14 off the toilet to his wheelchair. R14's left foot was unable to move as the CNA tried to pivot turn the resident, and the CNA had to assist R14 to the ground. The investigation further documented R14 did not sustain any injury. On 09/25/23 at 12:50 PM, observation revealed R14 sat in his wheelchair. CNA N and CNA O put the sit to stand sling around R14's waist, placed his feet upon the foot plate of the lift, and told R14 to hold onto the handles of the lift. R14 held onto the lift handle with his right hand but CNA O had to put R14's left hand onto the handle and hold onto it for him. CNA N used the lift controller to lift R14 and told him to stand up. As the lift rose, R14 started to lean to the left and his left foot fell off of the foot plate. R14 could not stand and continued to lean heavily to his left, tipping the wheelchair. CNA N kept telling R14 to stand up, and R14 told both CNA he could not. CNA N lowered the lift and tried to reposition and straighten R14. The CNA tried to get R14's left foot back onto the foot plate. CNA O put her left knee against R14's left leg to try to hold it into place as both CNA attempted to stand R14 once again. R14 continued to lean heavily to the left and R14 again stated that he could not stand as the CNA continued to attempt to stand R14 using the lift. As the lift was raised, R14 continued to lean left, and the wheelchair started to tip. R14 stated No wonder my left side hurts sometimes and CNA N stated she did not feel comfortable using the sit to stand lift with R14 and had CNA O go tell the nurse to come to the resident's room. Licensed Nurse (LN) G went to R14's room and directed staff to use the full body mechanical lift to transfer R14 to the toilet. LN G then left to try to find a toileting sling to use on the resident. Further observation revealed R14 already had a full lift sling in his room that he stated had been used on him by one of the night shift CNA. CNA N and CNA O placed the sling under R14 while he was in his wheelchair. Staff lifted R14 into the air and placed R14 in his bed. Observation revealed the sling was not the right size for the resident and the straps were tight and cut into R14's inner thighs and made his head lean forward. The staff removed R14's pants and brief then lifted R14 again using the lift. R14's genitals were smashed in between the leg straps of the sling and R14 stated he was uncomfortable. CNA O was unable to position the lift in order to get R14 seated comfortably onto the toilet and Administrative Nurse D was asked to assist the two CNA with the resident. Administrative Nurse D stated the sling was not the right size for R14 and said that she would request a physical therapy evaluation to determine the best option to transfer R14. On 09/26/23 at 04:09 PM, observation revealed R14 sat in the shower chair with a gait belt around his waist. CNA M was on R14's right side and CNA O on the left. R14 used his right hand to guide his left hand to the end of the whirlpool tub so that he could hold on while both CNA transferred him to his wheelchair. CNA N stated, Are you sure we can transfer him, ok? and CNA N answered, Yes. CNA started to stand R14. R14 started to bend at the waist and his head was over the whirlpool. R14 said If I fall in, you are going to have a hard time getting me out of the whirlpool. Both CNAs had difficulty holding R14 up and they had to sit him down in the shower chair because he could not stand long enough to complete the transfer. R14's left foot did not move and seemed to be stuck on the floor. Continued observation revealed the CNAs attempted to stand R14 again and were able to transfer him into his wheelchair. On 09/25/23 at 01:00 PM, CNA N stated R14 was impulsive and did not like to wait for help. On 09/26/23 at 04:30 PM, CNA M stated R14 was stronger before his shower. CMA M said she transferred R14 from his wheelchair to the shower chair without any assistance. On 09/28/23 at 09:30 AM, LN H stated R14 had severe left side weakness and therapy had evaluated him. LN H said therapy would work with R14 to try to get him stronger and see which lift would be appropriate for him. LN H stated when a resident had a fall, she filled out fall paperwork but did not implement interventions for falls. LN H said she did not document interventions on the care plan. On 09/28/23 at 11:30 AM, Consultant II stated he worked with R14 in the past and R14's cognition did not allow him to retain any safety awareness. Consultant II said he would be working with R14 again but felt R14 would continue to fall because the resident wanted to be independent and did not remember that he cannot transfer alone. On 09/28/23 at 01:52 PM, Administrative Nurse D stated if staff felt unsafe or unsure of how to transfer the resident, staff need to stop and ask questions. Administrative Nurse D further stated the nurse was responsible for implementing new interventions after falls and should document the new intervention on the care plan. The facility's Falls and Fall Risk, Managing policy, dated 10/22, documented based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The policy further documented, the team would attempt to identify appropriate interventions to reduce the risk of falls, If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. the staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falls, staff would continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. The facility failed to ensure an environment free from preventable accidents and hazards when staff performed unsafe transfers with R14 which resulted in an assisted fall. This placed R14 at increased risk for preventable falls and related injuries. - The Electronic Medical Record (EMR) for R20 documented diagnoses of lack of coordination, repeated falls, dementia with other behavior disturbance (progressive mental disorder characterized by failing memory, confusion), and difficulty walking. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and extensive assistance of one staff for ambulation, mobility, and personal hygiene. The assessment further documented R20 had unsteady balance, no functional impairment, and had one fall with injury. The Annual MDS, dated [DATE], documented R20 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment further documented R20 had unsteady balance, no functional impairment, and had one fall with injury. The Fall Assessments, dated 08/09/22, 08/19/22, 11/19/22, 02/19/23, 05/19/23, 08/21/23 recorded R20 was a high-risk for falls. R20's Care Plan, dated 09/07/23, initiated on 01/02/22, directed staff to have her call light within reach. keep frequently used items within reach, keep room door open when up in recliner, keep her walker near the resident, proper footwear and no slip socks. The update, dated 03/28/22, directed staff to refer to therapy post fall for screen. The update dated 07/07/22 documented R20 was a two person assist for ambulation and transfers. The Fall Investigation, dated 11/16/22 at 11:50 AM, documented one staff member assisted R20 to her recliner when R20 decided to sit down and missed the chair. The investigation further documented she sat down, her feet slipped, and she fell on to the floor. The investigation documented R20 did not sustain any injuries. On 09//26/23 at 02:00 PM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around R20's waist, stood her up. and ambulated R20 to her recliner. On 09/26/23 at 02:00 PM, CNA N stated R20 was assisted with ambulation by two staff if there were two staff available to help her. CNA N stated R20 had falls because she would often forget her walker. On 09/28/23 at 09:30 AM, Licensed Nurse (LN) H stated R10 required assistance of two staff with transfers and said she was unaware that R20 had any falls but she had only worked at the facility for a month. LN H stated when a resident had a fall, she filled out fall paperwork but did not implement interventions for falls. LN H said she did not document interventions on the care plan. On 09/28/23 at 01:52 PM, Administrative Nurse D stated, if staff felt unsafe or unsure of how to transfer the resident, staff need to stop and ask questions. Administrative Nurse D further stated the nurse was responsible for implementing new interventions after falls and should document the new intervention on the care plan. The facility's Falls and Fall Risk, Managing policy, dated 10/22, documented based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The policy further documented, the team would attempt to identify appropriate interventions to reduce the risk of falls, If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. the staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falls, staff would continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. The facility failed to provide the appropriate amount of assistance to prevent accidents and falls for R20. This placed the resident at risk for further falls and injury.

The facility had a census of 33 residents. The sample included 15 residents, with four reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27, who required continuous supplemental oxygen, received adequate respiratory care and services. This placed the resident at risk for physical decline. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and muscle weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented R27 had moderately impaired cognition and required supervision and one person assistance for toileting, personal hygiene, and supervision and set up assistance for all other activities of daily living. The MDS further documented R27 had shortness of breath with exertion, sitting, lying flat, and received oxygen. The Care Plan, dated 09/07/23, directed staff to monitor for signs and symptoms of respiratory distress, and provide oxygen therapy as ordered. The plan directed to keep the head of the bed elevated for optimal breathing, and maintain a clear airway by encouraging resident to clear own secretions with effective coughing. The plan directed R27 frequently takes off his oxygen, and forgot to put it back on; staff to remind and assist the resident as needed. The Physician's Order, dated 11/10/22, directed staff to ensure R27 received 4 liters (L) of oxygen continuous via nasal cannula. On 09/26/23 at 07:55 AM, observation revealed R27 sat in the dining room. His oxygen tubing and cannula laid on the dining room floor. On 09/26/23 at 08:58 AM, observation revealed R27 self propelled his wheelchair into the television area, his oxygen tubing and cannula was wound around the right wheel of his wheelchair. Further observation revealed Administrative Staff B asked Administrative Nurse E to get R27 a new set of tubing sine R27's touched the ground. Administrative Nurse E replaced the old tubing and assisted R27 with the new tubing. Continued observation revealed, the oxygen tank R27 was using was empty and Adminsitrative Nurse E brought R27 a new tank. Administrative Nurse E obtained R27's oxygen saturation (percentage of oxygen in the blood) which was in the 70 percentile (normal is 90-100 %). After Administrative Nurse E had R27 take deep breaths, he was able to get his saturations up into the 90 percentiles. Administrative Nurse E stated it was everyone's responsibility to make sure R27 had a full oxygen tank and to make sure he was wearing the nasal cannula correctly and it was not dragging on the floor. On 09/26/23 at 12:25 PM, observation revealed R27 fiddled with his oxygen tubing and oxygen tank. Closer observation revealed R27's oxygen tank was empty and he was having difficulty catching his breath. Administrative Nurse E was notified and retreived a new tank for R27. Adminsitrative Nurse E again checked R27's oxygen saturations again, which read in the 90 percentiles. Administrative Nurse E stated staff must not be turning off the tank when they switched R27 from the portable tank to his concentrator in his room. On 09/26/23 at 1:00 PM, Administrative Nurse D stated R27 often took his oxygen off and it would be found on the floor, or he would put it in his mouth. Administrative Nurse D further stated staff should make sure the oxygen tanks were full and assist R27 with his tubing. On 09/28/23 at 09:30 AM, Licensed Nurse (LN) H stated, R27 had an oxygen concentrator in the dining room instead of using the portable tanks due to staff not turning them off when they switched from the tank to the concentrator. On 09/28/23 at 10:40 AM, Certified Nurse Aide (CNA) P stated the staff were supposed to check R27's oxygen tank to make sure it has oxygen in it when the change him from the concentrator to the portable tank. CNA P stated R27's oxygen tank was empty again that morning and R27 now had a concentrator in the dining room. The facility's Oxygen Administration policy, dated 06/21, directed staff to check the tubing connected to the oxygen cylinder to assure that it is free of kinks, turn on the oxygen, place appropriate oxygen device on the resident, and adjust the oxygen delivery devices so that it is comfortable for the resident and the proper flow of oxygen was being administered. Check the mask, tank, to be sure they are in good working order and are securely fastened, and observe the resident upon setup and periodically thereafter to be sure oxygen was being tolerated, The facility failed to ensure R27, who required continuous supplemental oxygen, received proper respiratory care and services. This placed the resident at risk for physical decline.

The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16 and R18 received trauma informed care to eliminate or mitigate triggers that may care re-traumatization which placed the residents at risk for unmet behavioral health care needs and impaired psychosocial well-being. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, mood {affective} disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord , and problems related to care provider dependency. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, required supervision and one person assist with activities of daily living, had primary diagnoses of non-traumatic brain dysfunction, and other diagnoses of anxiety disorder, depression, but not PTSD. The MDS further documented R16 took an antianxiety (class of medications that calm and relax people) , antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used for pain relief) daily. The Care Plan initiated 04/10/23, documented R16 had mood problems and directed staff to administer medications as ordered and monitor/document for side effects and effectiveness. The care plan further documented R16 needed encouragement, assistance, and support to maintain as much independence and control as possible. The plan directed staff to assist R16 to identify strengths, positive coping skills and reinforce these. The care plan lacked did not identify R16 had PTSD and interventions to prevent traumatization triggers. The Mental Health Consultation Progress Note dated 08/16/23 documented R16 reported nightmares that disturbed her and caused her to be upset; and some were about people that worked at the facility. The note recorded the mental health consultant ordered medication at bedtime for PTSD and nightmares. The Progress Note dated 09/14/23 at 02:58 PM, documented R16 was screaming and crying after being informed of the rules for pets in the facility. R16 appeared safe at that time and was given time to calm down. R16 wrote a letter and gave it to the nurse to pass on to the mental health provider. On 09/26/23 at 08:25 AM, observation revealed R16 ambulated in the hallway with her walker. R16 reported she had better days than that particular time and day. On 09/28/23 at 09:24 AM, Certified Nurse Aide (CNA ) P stated she was not aware of R16's diagnosis of PTSD, nor the triggers associated with this. On 09/28/23 at 10:40 AM, Licensed Nurse (LN) H stated she was aware of R16's PTSD. LN H stated she was not aware of R16's triggers associated with the diagnosis. LN H stated that information would be helpful for the care of the resident. On 09/28/23 at 09:08 AM, Consultant HH verified R16 had PTSD on admission and the Social Service Admission Assessment, dated 09/21/21, documented R16 had PTSD and a triggers of people who downplay the trigger and those who snuck up on her. On 09/28/23 at 01:50 PM Administrative Nurse D verified R16's care plan lacked the identified concern or problem of PTSD. The facility's Trauma Informed Care policy, dated 09/2023, documented residents who are known trauma survivors, will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization's. The Interdisciplinary Team (IDT) will quarterly and as needed, monitor the care and services delivered to the resident with identified trauma. The facility failed to ensure R16 receive trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet emotional and psychosocial needs. - R18's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, chronic pain, acute and chronic respiratory failure, rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems) , dependence on supplemental oxygen, panic disorder, starvation, severe protein-calorie malnutrition, post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), need for assistance with personal care, and problems related to care provider dependency. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had intact cognition, and required limited assistance of one person for activities of daily living. R18 was not steady, was only able to stabilize with staff assistance, and used a walker and wheelchair. R18 had occasional incontinence of urine and used oxygen. The MDS further documented R18 had diagnoses of anxiety disorder, PTSD, and regularly took an antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used for pain relief). The Care Plan initiated on 05/03/23 documented R18 was at risk for a potential psychosocial well-being problem related to anxiety, pain, recent admission, repeated falls, shortness of air, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and depression. The care plan directed staff to allow R18 time to answer questions and verbalize feelings, perceptions, and fears as needed. The plan directed to assist, encourage, and support R18 to set realistic goals and to consult with pastoral care, social services, and psychiatric services. The care plan further directed staff to assist, supervise, and support R18 to identify causative and contributing factors. The care plan lacked direction regarding R18's PTSD diagnosis and interventions to prevent traumatization triggers. The Social Service Admission Note dated 04/18/23 at 03:49 PM documented R18 came to the facility due to failure to thrive living at home with family. R19 was on an antipsychotic, antidepressant, and antianxiety medications, and exhibited signs of depression and anxiety. The note further documented R18 did not have a history of trauma and/or PTSD. The Mental Health Consultation Progress Note, dated 04/19/23, documented R18's thought process associations were logical, attention span was normal throughout the interview, and concentration intact. R18 had not realized how depressed he was and what a terrible state he was in. R18 was not currently taking psychiatric medications, but had diagnoses of depression, anxiety and PTSD. The note further documented R18 needed therapy from a trauma informed perspective and intensive talk therapy to help in working through his grief and loss. The plan/recommendation to start and antianxiety medication for anxiety and panic attacks, and antidepressant for depression, and talk therapy for PTSD and trauma. On 09/26/23 at 12:30 PM, observation revealed R18 sat in an electric wheelchair in the dining room and had lunch at a table of male residents. On 09/28/23 at 09:24 AM, Certified Nurse Aide (CNA ) P stated she was not aware of R18's diagnosis of PTSD, nor the triggers associated with this. On 09/28/23 at 10:40 AM, Licensed Nurse (LN) H, stated she was not aware of R18's PTSD. LN H stated she was not aware of R18 triggers associated with the diagnosis. LN H stated this information would be helpful for the care of the resident. On 09/28/23 at 01:50 PM Administrative Nurse D verified R18's care plan lacked the identified concern or problem of PTSD. The facility's Trauma Informed Care policy, dated 09/2023, documented residents who are known trauma survivors, will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization's. The Interdisciplinary Team (IDT) will quarterly and as needed, monitor the care and services delivered to the resident with identified trauma. The facility failed to ensure R18 receive trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet emotional and psychosocial needs.

The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from significant medication errors when medication was not administered per physician orders for Resident (R) 81. This placed the resident at risk for decreased physical and mental well-being. Findings included: - The Electronic Medical Record (EMR) for R81 documented diagnoses of delusion (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R81 had intact cognition and was dependent upon two staff for toileting, personal hygiene. R81 required extensive assistance of two staff for bed mobility, transfers, and dressing. The MDS recroded R81 felt depressed, had thoughts about being better off dead never or one day, and had no behaviors. The MDS further documented R81 received antipsychotic (class of medications used to treat major mental conditions which 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. R81's Care Plan, dated 09/12/23, initiated on 03/28/23 documented R81 received antipsychotic medications and directed staff to administer medications as ordered, and monitor for side effects from medications. The Physician Encounter Note, dated 08/16/23, directed staff to add Abilify (antipsychotic medication) to R81's medications to help with his increased paranoia. The Physician's Order, dated 08/16/23, directed staff to administer Abilify, 2 milligrams (mg), one tablet, at bedtime. The August 2023 Medication Administration Record (MAR) lacked evidence R81 received the physician ordered Ability. The September 2023 Medication Administration Record (MAR) lacked evidence R81 received the physician ordered Ability. On 09/26/23 at 11:10 AM, observation revealed R81 laid in bed with his eyes closed. On 09/27/23 at 12:01 PM, Administrative Nurse D verified R81's Ability was missed and not given. The facility's Identifying and Managing Medication Errors and Adverse Consequences policy, dated 04/07, documented the staff and practioner should try to prevent medication errors and adverse medication consequences and should strive to identify and manage them appropriately when they occur. The facility failed to ensure residents remained free from significant medication errors when medication was not administered per physician orders for R81. This placed the resident at risk for decreased physical and mental well-being.

The facility had a census of 33 residents. The sample included 15 residents. Based on observation and interview, the facility failed to display current daily nursing staffing hours as required. Findings included: -During the survey on 09/25/23 and 09/26/23, observation revealed the nursing hours posted with a date of 09/05/23. On 09/28/23 at 04:00 PM, Consultant Staff HH verified the nursing hours posted were incorrect and she had corrected the posting. Upon request the facility did not provide a staff posting policy. The facility failed to display current daily nursing hours as required.

The facility identified a census of 28 residents, with three reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had foot pedals on his wheelchair when Certified Nurse Aide (CNA) M attempted to push R1 in his wheelchair to the nurse's station. As a result, R1 put his foot down on the ground and the wheelchair abruptly stopped, flipping R1 out of the wheelchair and forward onto his face, which resulted in a laceration to his right eyebrow. R1 had to be transported to the emergency room for sutures to be placed to his laceration. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Quarterly Minimum Data Set (MDS), dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated R1 was severely cognitively impaired. The MDS further documented R1required extensive assistance of one staff for bed mobility, transfer, toilet use, and bathing. The MDS documented R1 required limited assistance of one staff for ambulation, locomotion in wheelchair, and dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/19/22 documented R1 had diagnoses of Parkinson's disease and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and had cognitive deficit with behaviors. The CAA directed staff to monitor R1 for increased cognitive issues. The Activities of Daily Living (ADL) CAA, dated 06/19/22, documented R1 required supervision and cueing for ADL. R1 had behaviors that could interfere with his ability to perform his ADL. The CAA continued to document R1 had difficulty making safe decisions for his care and was at risk for falls and injuries. The Elopement Care Plan, dated 04/23/21, documented R1 would self-propel in his wheelchair up and down the halls and to the nurse's station frequently. The Fall Care Plan, dated 09/26/22, directed staff R1 had poor safety awareness, needed increased monitoring while awake, ensure R1 wore appropriate footwear, ensure R1 had a safe environment, and to follow the facility fall protocol. The Nurse's Note, dated 11/20/22 at 08:10 PM, documented R1 fell . Staff rolled R1 over and noted R1 had a laceration to his right eyebrow that needed sutures. The facility notified the provider of the fall and she said she would let the emergency department know R1 would be arriving to be seen. The Emergency Department Paperwork, dated 11/20/22 at 09:45 PM documented R1 was at the emergency department with a laceration to his right eyebrow from a fall and noted six sutures were placed to R1's right eyebrow. R1 was discharged back to the facility with new orders to keep the sutures clean and dry. The facility could wash the sutures once daily with soap and water. In five days, the sutures needed to be removed. The Nurse's Note, dated 11/20/22 at 10:11 PM, documented R1 arrived back at the facility from the emergency department. R1's vital signs were stable and R1 sat in the nurse's station and slept for two hours. The Nurse's Note, dated 11/21/22 at 04:35 AM, documented R1's laceration was cleansed, and lubricant applied. The Facility Incident Report, dated 11/23/22, documented R1 sat in the dining room when CNA M attempted to move R1 closer to the nurse's station. There were no foot pedals on R1's wheelchair and R1's foot hit the floor and R1 fell forward out of the wheelchair face first, which caused a laceration above R1's right eye. R1 was sent to the emergency room and R1 received four sutures and then returned to the facility. R1 was care planned to self-propel in his wheelchair. The investigation documented the standard of practice was to have foot pedals on the wheelchair when staff propelled R1. All nursing staff were re-educated on the use of foot pedals and daily monitoring by management staff would be completed for correct use of foot pedals on wheelchairs. On 12/12/22 at 12:30 PM, CMA R stated the facility had provided wheelchair safety education several days prior to the day the incident with R1 had occurred. On 12/12/22 at 01:30 PM, Administrative Nurse D stated she expected all of the facility staff to follow safe wheelchair practices to prevent any injury from occurring to the residents. On 12/12/22 at 02:30 PM, Administrative Staff A stated the facility trained staff regarding wheelchair safety five days prior to the incident. Administrative Staff A stated he expected all staff to follow safe wheelchair practices. The facility's Residence of Gramercy Ambulation Assistance Policy, revised October 2021, documented to assist a resident using a wheelchair be sure the resident is properly and securely seated in his/her wheelchair and if it is necessary to push a resident in a wheelchair staff need to walk at a normal pace and not rush and ensure that the foot pedals are down and the resident's feet are properly placed on the foot rests to avoid getting their feet caught underneath the wheelchair as the resident is propelled. The facility failed to ensure R1 had foot pedals on his wheelchair when R1 was being propelled by CNA M which resulted in an avoidable accident where R1 sustained a laceration that required emergent treatment and sutures. On 11/23/22 the facility completed the following corrective actions: The facility reported the incident to the State Agency. All staff received education to ensure staff placed foot pedals on the wheelchairs of all residents prior to any event when staff propelled residents in the wheelchairs. Facility management staff reviewed and audited daily to ensure staff followed the policy and training regarding the use of foot pedals. The deficient practice was cited at past-noncompliance.

The facility identified a census of 28 residents. The sample included seven residents reviewed for activities of daily living and skin issues. Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers (a 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) from developing for Resident (R) 1, who was at risk for pressure ulcers. R1 developed a facility-acquired unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to his right heel, a stage 3 (full thickness tissue loss where fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer to his sacrum (shield-shaped bony structure that is located at the base of the spine) and a stage 3 pressure ulcer to his left hip. Findings included: - The Electronic Medical Record (EMR) documented R1 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of two which indicated R1 had severely impaired cognition. The MDS documented R1 required extensive assistance of one to two staff for activities of daily living (ADLs) including bed mobility, transfer, ambulation, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS documented R1 did not have any pressure ulcers on admission, was at risk for acquiring pressure ulcers, and did not have any pressure reducing device for his chair or his bed, and was not on a turning/repositioning program. The Cognitive Loss Care Area Assessment (CAA), dated 06/03/22, documented R1 had orientation, memory and recall deficits due to dementia, change in mental status, and short- and long-term memory loss which placed R1 at risk for self-care deficit, falls and injuries, incontinence, skin breakdown, weight loss, and fluid imbalance. The Urinary Incontinence CAA, dated 06/03/22 documented R1 required assistance with toileting and had actual incontinence episodes placing R1 at risk for skin breakdown, falls, and recurrent urinary tract infections (infection of the urinary system). The Pressure Ulcer CAA, dated 06/03/22 documented R1 had the potential for acquiring pressure ulcers due to ADL/functional/mobility impairment and incontinence. The Admission Skin Assessment, dated 05/23/22, documented R1 admitted to the facility with a skin tear to his right third finger, bruising to his left arm, and a scab to this third toe. R1's Care Plan, dated 05/24/22 lacked any goals or interventions regarding activities of daily living. R1's Care Plan initiated on 06/13/22 and revised on 08/17/22 documented R1 was at nutritional risk due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention dated 08/17/22 directed recommendations sent to the healthcare provider (HCP) to start R1 on a two-ounce Med Pass (liquid nutritional supplement) with morning meal and evening medications to help with weight and wound healing. The Care Plan lacked evidence directives/interventions were in place to prevent pressure ulcer development. The Care Plan lacked wound treatment information or directives for monitoring and assessing. The Nurse Note' dated 06/10/22 recorded the night nurse (unidentified) noted a blister to the pad of R1's right great toe and an unstageable pressure sore to R1's right heel. The nurse applied an adhesive dressing to the right heel for prevention of future breakdown. The nurse noted staff continued to monitor per protocol. Staff notified R1's representative, who stayed in the room with R1 and R1's physician. The Skin Assessment, dated 06/13/22, documented R1 had intact skin. The Skin Assessment, dated 07/20/22, documented R1 had a skin tear to his left heel, two scabs on his left buttock, and an open wound to his right elbow. R1's clinical record lacked evidence the wound to R1's right elbow was measures, assessed and treatment initiated. A Wound Care Clinic Note, dated 07/21/22, documented R1 was seen for the first time at the appointment for a right heel pressure ulcer with a moderate amount of serous (clear) drainage, malodorous (bad smelling), and erythematous (swollen) per-wound. The right heel wound measured 2.41 centimeters (cm) in length by 2.81 cm in width and was covered with 1.95 cm of slough. The wound care specialist used sharp debridement (surgical removal of dead tissue from a wound). The wound care specialist ordered for a foam dressing change every three days and off-loading boots to be applied. The wound care specialist noted there were no other areas of concern regarding R1's skin . The Skin Assessment, dated 07/27/22, documented R1 had a scab to his right elbow and a skin tear to his right heel with the dressing clean, dry and intact. The Nurses Note, dated 07/28/22, documented R1 had a red sore over his left coccyx (tailbone) and nursing recognized the need to change R1's position every two hours to avoid pressure. The note documented the Certified Nurse Aides (CNAs) were informed to turn R1 every two hours. The Nurses Note, dated 07/31/22 at 04:07 AM recorded the nurse became aware of a large abrasion with blisters on R1's right inner buttocks. The area was cleansed with wound cleaner and covered with a dressing. The nurse instructed the CNAs to use precaution when repositioning R1. The note recorded R1's representative knew of the skin issue. The dressing on the right heel was dry and intact. The Nurses Note, dated 07/31/22 at 02:27 PM documented the dressing to R1's right heel was changed and serosanguinous (yellowish drainage with small amounts of blood) drainage was noted to the dressing. The off-loading boot was in place to R1's right foot. A large pressure ulcer was noted to R1's right buttock without any signs or symptoms of infection. The pressure ulcer to the right buttock was cleansed and covered with a dressing. The Nurses Note, dated 08/03/22, documented R1's dressing to his right heel was clean, dry and intact. The dressing to R1's coccyx was clean, dry and intact. A new dressing was applied to R1's left trochanter (hip) due to a stage 3 pressure sore. The Skin Assessment, dated 08/03/22, documented skin alterations to R1's right heel, sacrum, and left trochanter. The EMR lacked documentation regarding the status of the wound beds, measurements, or surrounding skin. The Wound Care Clinic Note, dated 08/04/22, documented R1 was in for a revisit regarding an unstageable ulcer to his right heel. The wound measured 1.45 cm in length by 1.84 cm in width with 0.89 cm of slough to the wound bed. Sharp debridement was performed to R1's right heel. The wound care specialist ordered to continue dressing changes every three days with a foam dressing and continue to use off-loading boots while non-weightbearing. The wound care specialist documented there were no new wound concerns noted by nursing home staff. The wound clinic documentation and clinical record lacked evidence R1's other wounds were reported to and evaluated by the wound clinic . The Nurses Note, dated 08/9/22 recorded the dressing to R1's right heel was changed as ordered that morning. The area was macerated (occurs when skin has been exposed to moisture for too long); skin- prep (liquid skin barrier) was applied to periwound (skin around the wound). R1 had two pressure ulcers on his to coccyx with slough (dead tissue) noted to the wound. The area was cleansed, and a dressing applied. The pressure ulcer to the left hip had a dark spot to the middle of the wound bed. The area was cleansed, and a dressing applied. The nurse notified the wound nurse of increased ulceration and discussed the possibility of an air mattress. The Skin Assessment, dated 08/10/22, documented pressure ulcers to R1's left hip, right buttock, and right heel with the dressings intact. The EMR lacked documentation regarding the status of the wound beds, measurements, or surrounding skin. The Nurse Note, dated 08/10/22 recorded R1's dressings to left hip, right buttock, and right heel remained clean, dry, and intact. R1's right heel continued with off-loading boot. The Nurses Note, dated 08/11/22, documented the dressing to R1's left hip was dislodged while bathing. A stage 2 pressure ulcer was noted with slough (yellow, tan, gray, green or brown dead skin cells) present in the wound bed. R1's dressing to his right buttock was dislodged during bathing. A stage 2 pressure ulcer was observed with slough to the wound bed. R1's dressing to his right heel was dislodged after bathing with surrounding skin noted to be red. The Nurses Note, dated 08/14/22, documented R1's dressings to his right heel, right buttock, and left hip were all changed due to the dressings being saturated. R1's right heel continued to be open with peri-wound (skin around the wound) macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods). The wound to R1's left hip had had darkened area and a 4 x 4 dressing was applied. R1's buttocks were noted to have 2 small pressure ulcers with slough in the wound bed and a sacral dressing was applied. The Nurses Note, dated 08/15/22, documented R1's dressing to his right buttock and left hip were intact. A new dressing was applied to R1's right heel. A moderate amount of drainage was noted on the old foam dressing and a slight odor noted to the wound. The Nurses Note, dated 08/18/22, documented R1 had seen the wound care specialist that morning and left with dressings to R1's left hip, right heel, and right buttock. New orders were received for R1 to start an antibiotic twice a day for ten days for the left hip wound. R1's left hip wound was cultured at his appointment at the wound care clinic. The Skin Assessment, dated 08/19/22, documented open wounds to R1's right heel, right buttock, and left iliac crest (hip bone). On 08/22/22 at 01:00 PM, observation revealed, R1 sat in his recliner. R1's uneaten lunch sat on the side table. R1 wore pressure relieving boots to his bilateral feet. R1 did not have a pressure relieving cushion in his seat. On 08/22/22 at 02:30 PM, Certified Nurse Aide (CNA) M stated prior to R1's acquired pressure ulcers, he had not worn any pressure relieving boots and was not on a repositioning schedule. CNA M stated the only way she knew R1 was on a repositioning schedule was by word of mouth during report. CNA M stated R1 had never had a pressure relieving cushion in his recliner or wheelchair. On 08/22/22 at 02:45 PM, Certified Medication Aide (CMA) R stated R1 was now on a repositioning schedule every two hours but before he developed the wounds, he had not been on a positioning schedule and did not have pressure relieving boots. On 08/22/22 at 03:30 PM, Licensed Nurse (LN) H stated she did not know what R1's care plan said about pressure ulcers and skin integrity. LN H knew R1 had pressure relieving boots to his feet and was on a repositioning schedule every two hours. LN H did not think R1 had a pressure relieving cushion in his recliner. On 08/22/22 Administrative Nurse D stated education and training were needed regarding implementing interventions needed to prevent pressure ulcers. Administrative Nurse D expected nurses to use critical thinking skills to place interventions for residents at risk for pressure ulcers. On 08/22/22 and 08/31/22 attempted to interview Consultant GG, however they did not return the calls. The facility's Pressure Injury/Skin Breakdown policy, dated June 2022, documented the facility nursing staff will, upon admission complete an evaluation of the resident's skin and resulting risk factors for d3eveloping pressure injuries; for example, immobility, recent weight loss, and a history of pressure injuries. The staff will examine the skin of a new admission and or re-admission for ulceration or indications of a Stage 1 pressure area that has not yet ulcerated at the surface. A standardized tool will be utilized weekly for four weeks after admission and/or re-admission and at least quarterly to determine risk for clinical breakdown. The nursing staff will complete an evaluation of the skin weekly. Based upon need and results of the evaluations the staff will implement interventions for the prevention and care of skin issues. The facility failed to implement pressure relieving interventions upon R1's admission to the facility to prevent pressure ulcers. The facility further failed in identify R1's increased risk once an unstageable pressure injury developed and failed to act immediately to implement pressure relieving devices resulting in a stage two and stage three pressure ulcer development.

The facility identified a census of 32 residents with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received the necessary protective oversight to prevent ongoing abuse and neglect when facility administrative staff failed to respond to an allegation of staff to resident abuse. On 03/19/22 at approximately 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. At 10:30 PM staff reported the abuse to Administrative Staff A. The facility failed to implement protective measures after Administrative Staff A learned of the abuse allegation. CNA M was allowed remain in the facility, providing direct care to R1 and the other residents for twelve hours after the alleged abuse occurred and for 7.5 hours after Administrative Staff A became aware of the allegation. This deficient practice placed R1 and the other residents in the facility in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, which indicated R1 had severe cognitive functioning. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living. The MDS further documented R1 had verbal behaviors directed towards others one to three days during the look back period and other behavioral symptoms not directed towards others for one to three days during the look back period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/21/21, documented R1 had decreased ability to make herself understood and to understand others. The CAA further documented R1 had confusion, disorientation, and forgetfulness. R1's Behavioral Care Plan, revised 08/19/21, directed staff to intervene before R1's agitation escalated, guide R1 away from sources of distress, and engage R1 calmly in conversation. It further directed if R1's response was aggressive, staff were to stay calm, ensure R1's safety, walk away calmly, and re-approach later. R1's Fall Care Plan, revised 03/21/22, directed staff to anticipate and meet R1's needs. If R1 was restless at night to assist R1 up and offer food or toilet, and to toilet R1 from 08:00 PM to 09:00 PM. The Nurses Note, dated 03/19/22 entered at 09:05 PM, documented R1 was found on the floor after a fall from her bed. R1 laid on the floor, on her left side, in her room. R1's blood pressure was elevated at 192/85 millimeters of mercury (mmHg). Staff notified R1's primary care physician who ordered administration of extra blood pressure medications. The Nurses Note, dated 03/20/22 at 02:29 AM, documented law enforcement officers arrived at the facility to perform a welfare check on R1 due to a police report regarding Certified Nurse Aide (CNA) M's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN H documented R1 was safe. LN H assessed R1 and did not note any bruising on R1's arms. On 03/22/22 at 02:26 PM the State Agency received report that on the 03/19/22 evening shift, LN G and CNA N observed CNA M abuse R1 when CNA M tried to reposition R1 on her side in bed. CNA M was rough, pulled on R1, and was being aggressive with R1. R1 screamed for help, stated, get her out of my room, and appeared to be panicking. At approximately 07:00 PM that same evening, CNA M asked CNA O for help getting R1 off the floor of her room. LN G, CNA N, and CNA O followed CNA M back to R1's room where R1 laid on the floor. The report indicated that all staff present told CNA M that LN H needed to assess R1 before getting R1 off the floor. CMA M argued with the other staff and pulled on R1's arm. CNA M was rough with R1 again and used a curse word in front of R1 . On 03/23/22 at 09:45 AM, observation revealed R1 sat in her wheelchair and watched television. On 03/23/22 at 02:30 PM, R1 visited with her representative in her room. R1's representative stated he was concerned about the incident and worried about R1's safety. On 03/23/22 at 09:30 AM, Administrative Staff A stated that she received a phone call from LN G and CNA N at approximately 10:30 PM on 03/19/22. LN G and CNA N stated they witnessed CNA M repositioning R1 in a rough manner while placing pillows behind R1 in bed. Administrative Staff A stated she asked LN G and CNA N if it was abuse and they stated they did not think it was abuse. Administrative Staff A stated she thought LN G and CNA N witnessed CNA M shoving pillows behind R1's back to keep her from rolling out of bed. Administrative Staff A stated she instructed LN G and CNA N to write the incident down on paper and put it under her office door. On 03/23/22 at 10:45 AM, CNA O stated he had not seen any abuse occur on 03/19/22 by CNA M. CNA O did state that he had concerns regarding CNA M treating residents in a rough manner and was also concerned that CNA M became agitated quickly with the residents. He stated he observed CNA M pull on R2's arm multiple times during transfers. CNA O stated he did not report those observations to Administrative Staff A. On 03/23/22 at 11:10 AM, in an interview LN G stated on 03/19/22 at approximately 06:00 PM LN G and CNA N heard R1 screaming from her room. LN G and CNA N went to R1's room and witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. Afterwards, R1 was inconsolable so staff had to just leave her alone in her room. LN G reported approximately an hour later, R1 fell in her room. LN G stated she reported the incident to Administrative Staff B at 10:02 PM, who instructed LN G to call Administrative Nurse D. LN G stated she called Administrative Nurse D at 10:10 PM to report the incident and was told by the Administrative Nurse D to call Administrative Staff A. She called Administrative Staff A at approximately 10:20 PM about the incident that occurred around 06:00 PM. LN G stated Administrative Staff A said, Abuse? That's a pretty big word. Are you sure it was abuse? LN G stated Administrative Staff A instructed her to write the incident down on a piece of paper and put it under her office door. LN G stated that she did not report the abuse to administrative staff until 4.5 hours after the incident occurred. She reported she did not tell LN H because LN H was present at the time and aware of the occurrence. On 03/23/22 at 01:30 PM, Administrative Staff A stated, in hindsight she should have come to the facility and investigated the situation and sent CNA M home pending the investigation. Administrative Staff A stated CNA M continued to work the remainder of her shift and was suspended from duty at the facility on 03/20/22. Review of the facility's working schedule reflected CNA M was removed from the schedule. On 03/23/22 at 01:30 PM, Administrative Nurse D stated that she expected all the staff at the facility to report any suspicions of abuse immediately to administration. Review of the facility's working schedule revealed CNA M continued to provide care for the remainder of the shift on the evening and night of 03/19/22 through the morning of 03/20/22. Administrative Nurse D confirmed CNA M stayed on duty and provided care to the residents who required assistance in the facility during her shift. The facility's Protection of Resident During Abuse Investigations, policy, revised May 2021, documented the community staff will strove to protect residents from harm during investigations of abuse allegations. The policy recorded the steps of the investigation included: immediate protection of the resident, assessment of the resident for injury including physical or psychosocial assessment, increased supervision for the alleged victim and other residents, room or staffing changes to protect from perpetrator, and protection from any type of retaliation. During abuse investigations residents were protected from harm by the following measures: employees accused of participating in the alleged abuse would be suspended immediately The facility failed to ensure R1 received the necessary protective oversight to prevent ongoing abuse and neglect when the facility failed to respond to an allegation of staff to resident abuse placing R1 in immediate jeopardy. On 03/24/22 the facility completed the following actions to remove the immediacy: Administrative Staff A was re-educated on protecting residents when an allegation is made. CNA M was suspended pending investigation. Administrative Staff A or designee completed an interview with current alert and oriented residents to determine that they have received the needed supervision for resident safety and to prevent episodes of staff to resident abuse and neglect. Re-education was completed by Administrative Staff A or designee to current staff on the abuse and neglect prevention policy and procedures. All staff would be educated on abuse and neglect policy prior to their next shift. The scope and severity remained at a E.

The facility identified a census of 32 residents, with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from abuse and neglect when the facility failed to prevent an episode of staff to resident abuse, mistreatment, and neglect. On 03/19/22 at approximately 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. As a result of this occurrence, R1 was inconsolable and was left alone in her room where she subsequently had a fall an hour later. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, which indicated R1 had severe cognitive functioning. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living. The MDS further documented R1 had verbal behaviors directed towards others one to three days during the look back period and other behavioral symptoms not directed towards others for one to three days during the look back period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/21/21, documented R1 had decreased ability to make herself understood and to understand others. The CAA further documented R1 had confusion, disorientation, and forgetfulness. R1's Behavioral Care Plan, revised 08/19/21, directed staff to intervene before R1's agitation escalated, guide R1 away from sources of distress, and engage R1 calmly in conversation. It further directed if R1's response was aggressive, staff were to stay calm, ensure R1's safety, walk away calmly, and re-approach later. R1's Fall Care Plan, revised 03/21/22, directed staff to anticipate and meet R1's needs. If R1 was restless at night to assist R1 up and offer food or toilet, and to toilet R1 from 08:00 PM to 09:00 PM. The Nurses Note, dated 03/19/22 entered at 09:05 PM, documented R1 was found on the floor after a fall from her bed. R1 laid on the floor, on her left side, in her room. R1's blood pressure was elevated at 192/85 millimeters of mercury (mmHg). Staff notified R1's primary care physician who ordered administration of extra blood pressure medications. The Nurses Note, dated 03/20/22 at 02:29 AM, documented law enforcement officers arrived at the facility to perform a welfare check on R1 due to a police report regarding Certified Nurse Aide (CNA) M's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN H documented R1 was safe. LN H assessed R1 and did not note any bruising on R1's arms. On 03/22/22 at 02:26 PM the State Agency received report that on the 03/19/22 evening shift, LN G and CNA N observed CNA M abuse R1 when CNA M tried to reposition R1 on her side in bed. CNA M was rough, pulled on R1, and was being aggressive with R1. R1 screamed for help, stated, get her out of my room And appeared to be panicking. At approximately 07:00 PM that same evening, CNA M asked CNA O for help getting R1 off the floor of her room. LN G, CNA N, and CNA O followed CNA M back to R1's room where R1 laid on the floor. The report indicated that all staff present told CNA M that LN H needed to assess R1 before getting R1 off the floor. CMA M argued with the other staff and pulled on R1's arm. CNA M was rough with R1 again and used a curse word in front of R1. On 03/23/22 at 09:45 AM, observation revealed R1 sat in her wheelchair and watched television . On 03/23/22 at 02:30 PM, R1 visited with her representative in her room. R1's representative stated he was concerned about the incident and worried about R1's safety. On 03/23/22 at 09:30 AM, Administrative Staff A stated that she received a phone call from LN G and CNA N at approximately 10:30 PM on 03/19/22. LN G and CNA N stated they witnessed CNA M repositioning R1 in a rough manner while placing pillows behind R1 in bed. Administrative Staff A stated she asked LN G and CNA N if it was abuse and they stated they did not think it was abuse. Administrative Staff A stated she thought LN G and CNA N witnessed CNA M shoving pillows behind R1's back to keep her from rolling out of bed. Administrative Staff A stated she instructed LN G and CNA N to write the incident down on paper and put it under her office door. On 03/23/22 at 10:45 AM, CNA O stated he had not seen any abuse occur on 03/19/22 by CNA M. CNA O did state that he had concerns regarding CNA M treating residents in a rough manner and was also concerned that CNA M became agitated quickly with the residents. He stated he observed CNA M pull on R2's arm multiple times during transfers. CNA O stated he did not report those observations to Administrative Staff A. On 03/23/22 at 10:55 AM, R2 stated CNA M was rough with her during transfers and yanked on her arms. R2 stated CNA M's actions made her feel like she was not worth being careful with. On 03/23/22 at 11:03 AM, R3 stated CNA M helped her into the bathroom and then told her she could get back to her chair by herself after she was done. CNA M left the room without assisting R3 back to her chair. R3 stated CNA M's actions caused her to feel helpless. On 03/23/22 at 11:10 AM, in an interview LN G stated on 03/19/22 at approximately 06:00 PM LN G and CNA N heard R1 screaming from her room. LN G and CNA N went to R1's room and witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. Afterwards, R1 was inconsolable so staff had to just leave her alone in her room. LN G reported approximately an hour later, R1 fell in her room. LN G stated she reported the incident to Administrative Staff B at 10:02 PM, who instructed LN G to call Administrative Nurse D. LN G stated she called Administrative Nurse D at 10:10 PM to report the incident and was told by the Administrative Nurse D to call Administrative Staff A. She called Administrative Staff A at approximately 10:20 PM about the incident that occurred around 06:00 PM. LN G stated Administrative Staff A said, Abuse? That's a pretty big word. Are you sure it was abuse? LN G stated Administrative Staff A instructed her to write the incident down on a piece of paper and put it under her office door. On 03/23/22 at 11:30 AM, R4 stated that CNA M had a bad attitude and left his room without helping him on multiple occasions. R4 stated CNA M's actions and treatment made him feel insignificant. On 03/23/22 at 11:45 AM, CNA M was unavailable for interview. On 03/23/22 at 11:45 AM, CNA G was unavailable for interview. On 03/23/22 at 11:50 AM, LN H was unavailable for interview. On 03/23/22 at 01:30 PM, Administrative Staff A stated, in hindsight she should have come to the facility and investigated the situation and sent CNA M home pending the investigation. On 03/23/22 at 01:30 PM, Administrative Nurse D stated that she expected all the staff at the facility to report any suspicions of abuse immediately to administration. The facility's policy Abuse Prevention Program approved 04/2021 recorded residents had the right to be free from abuse, neglect, corporal punishment and any physical or chemical restraint not required to treat the resident's medical conditions. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods and services that were necessary to attain or maintain physical, mental, or psychological well-being. The policy defined willful as deliberate actions, not that the individual must have intended to inflict injury or harm. The facility failed to ensure R1 remained free from abuse and neglect when the facility failed to prevent an episode of staff to resident abuse and neglect. This deficient practice placed R1 in immediate jeopardy. On 03/24/22 the facility completed the following actions to remove the immediacy: R1 was assessed for any physical and/or psychological injury. Administrative Staff A or designee completed an interview with current alert and oriented residents to determine that they have received the needed supervision for resident safety and to prevent episodes of staff to resident abuse and neglect. Re-education was completed by Administrative Staff A or designee to current staff on the abuse and neglect prevention policy and procedures. All staff would be educated on abuse and neglect policy prior to their next shift. The scope and severity remained at a D.

The facility identified a census of 32 residents, with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure staff identified and immediately reported an allegation involving abuse, neglect, or mistreatment. On 03/19/22 at 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N responded to cognitively impaired Resident (R) 1 screams for help. When LN G and CNA N entered R1's room, they witnessed CNA M roughly yanking on R1's arm and roughly repositioning R1 in bed while R1 screamed out for help and yelled to CNA M to get out of the room. LN G and CNA N failed to immediately report the witnessed abuse to Administrative Staff A until 4.5 hours after the event, at 10:30 PM. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, which indicated R1 had severe cognitive functioning. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living. The MDS further documented R1 had verbal behaviors directed towards others one to three days during the look back period and other behavioral symptoms not directed towards others for one to three days during the look back period. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/21/21, documented R1 had decreased ability to make herself understood and to understand others. The CAA further documented R1 had confusion, disorientation, and forgetfulness. R1's Behavioral Care Plan, revised 08/19/21, directed staff to intervene before R1's agitation escalated, guide R1 away from sources of distress, and engage R1 calmly in conversation. It further directed if R1's response was aggressive, staff were to stay calm, ensure R1's safety, walk away calmly, and re-approach later. R1's Fall Care Plan, revised 03/21/22, directed staff to anticipate and meet R1's needs. If R1 was restless at night to assist R1 up and offer food or toilet, and to toilet R1 from 08:00 PM to 09:00 PM. The Nurses Note, dated 03/19/22 entered at 09:05 PM, documented R1 was found on the floor after a fall from her bed. R1 laid on the floor, on her left side, in her room. R1's blood pressure was elevated at 192/85 millimeters of mercury (mmHg). Staff notified R1's primary care physician who ordered administration of extra blood pressure medications. The Nurses Note, dated 03/20/22 at 02:29 AM, documented law enforcement officers arrived at the facility to perform a welfare check on R1 due to a police report regarding Certified Nurse Aide (CNA) M's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN H documented R1 was safe. LN H assessed R1 and did not note any bruising on R1's arms. On 03/22/22 at 02:26 PM the State Agency received report that on the 03/19/22 evening shift, LN G and CNA N observed CNA M abuse R1 when CNA M tried to reposition R1 on her side in bed. CNA M was rough, pulled on R1, and was being aggressive with R1. R1 screamed for help, stated, get her out of my room, and appeared to be panicking. At approximately 07:00 PM that same evening, CNA M asked CNA O for help getting R1 off the floor of her room. LN G, CNA N, and CNA O followed CNA M back to R1's room where R1 laid on the floor. The report indicated that all staff present told CNA M that LN H needed to assess R1 before getting R1 off the floor. CMA M argued with the other staff and pulled on R1's arm. CNA M was rough with R1 again and used a curse word in front of R1. On 03/23/22 at 09:45 AM, observation revealed R1 sat in her wheelchair and watched television. On 03/23/22 at 02:30 PM, R1 visited with her representative in her room. R1's representative stated he was concerned about the incident and worried about R1's safety. On 03/23/22 at 09:30 AM, Administrative Staff A stated that she received a phone call from LN G and CNA N at approximately 10:30 PM on 03/19/22. LN G and CNA N stated they witnessed CNA M repositioning R1 in a rough manner while placing pillows behind R1 in bed. Administrative Staff A stated she asked LN G and CNA N if it was abuse and they stated they did not think it was abuse. Administrative Staff A stated she thought LN G and CNA N witnessed CNA M shoving pillows behind R1's back to keep her from rolling out of bed. Administrative Staff A stated she instructed LN G and CNA N to write the incident down on paper and put it under her office door. On 03/23/22 at 10:45 AM, CNA O stated he had not seen any abuse occur on 03/19/22 by CNA M. CNA O did state that he had concerns regarding CNA M treating residents in a rough manner and was also concerned that CNA M became agitated quickly with the residents. He stated he observed CNA M pull on R2's arm multiple times during transfers. CNA O stated he did not report those observations to Administrative Staff A. On 03/23/22 at 11:10 AM, in an interview LN G stated on 03/19/22 at approximately 06:00 PM LN G and CNA N heard R1 screaming from her room. LN G and CNA N went to R1's room and witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. Afterwards, R1 was inconsolable so staff had to just leave her alone in her room. LN G reported approximately an hour later, R1 fell in her room. LN G stated she reported the incident to Administrative Staff B at 10:02 PM, who instructed LN G to call Administrative Nurse D. LN G stated she called Administrative Nurse D at 10:10 PM to report the incident and was told by the Administrative Nurse D to call Administrative Staff A. She called Administrative Staff A at approximately 10:20 PM about the incident that occurred around 06:00 PM. LN G stated Administrative Staff A said, Abuse? That's a pretty big word. Are you sure it was abuse? LN G stated Administrative Staff A instructed her to write the incident down on a piece of paper and put it under her office door. LN G stated that she did not report the abuse to administrative staff until 4.5 hours after the incident occurred. She reported she did not tell LN H because LN H was present at the time and aware of the occurrence. On 03/23/22 at 11:45 AM, CNA M was unavailable for interview. On 03/23/22 at 11:45 AM, CNA G was unavailable for interview. On 03/23/22 at 11:50 AM, LN H was unavailable for interview. On 03/23/22 at 01:30 PM, Administrative Staff A stated, in hindsight she should have come to the facility and investigated the situation and sent CNA M home pending the investigation. Administrative Staff A stated CNA M continued to work the remainder of her shift and was suspended from duty at the facility on 03/20/22. Review of the facility's working schedule reflected CNA M was removed from the schedule. On 03/23/22 at 01:30 PM, Administrative Nurse D stated that she expected all of the staff at the facility to report any suspicions of abuse immediately to administration. Review of the facility's working schedule revealed CNA M continued to provide care for the remainder of the shift on the evening and night of 03/19/22 through the morning of 03/20/22. Administrative Nurse D confirmed CNA M stayed on duty and was assigned to provide care to all residents who required assistance in the facility during her shift. The facility's Reporting Abuse to Facility Management, revised May 2021, documented It is the responsibility of the employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect, exploitation, or resident abuse. Employees must immediately report any suspected abuse or incidents of abuse to their direct supervisor, abuse coordinator and/or administrator. Any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of the mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to ensure staff identified and immediately reported an allegation involving abuse, neglect, or mistreatment involving R1. This deficient practice placed R1 in immediate jeopardy. On 03/24/22 the facility completed the following actions to remove the immediacy: Administrative Staff A re-educated LN H on the importance of identifying and reporting abuse and neglect to the administrative team immediately. LN G resigned effective immediately. CNA N was an agency aide whose contract ended on the evening of 03/19/22. Administrative Staff A or designee completed an interview with current alert and oriented residents to determine that they have received the needed supervision for resident safety and to prevent episodes of staff to resident abuse and neglect. Re-education was completed by Administrative Staff A or designee to current staff on the abuse and neglect prevention policy and procedures. All staff would be educated on abuse and neglect policy prior to their next shift. The scope and severity remained at a D.

The facility had a census of 30 residents. The sample included 6 residents of which 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide interventions to prevent the development of 2 pressure ulcers and to promote healing for 1 of 3 sampled residents (#2) who developed 2 avoidable, unstageable facility acquired pressure ulcers and a stage 2 pressure ulcer. Findings included: - Resident #2's physician order [REDACTED]. The Admission (MDS) Minimum Data Set 3.0 assessment, dated 6/26/14, indicated the resident had moderately impaired cognition, with a (BIMS) Brief Interview for Mental Status score of 8, required extensive assistance of 2 staff with bed mobility and transfers, and extensive assistance of 1 staff with locomotion on and off the unit, dressing, personal hygiene and bathing. The MDS indicated the resident had limited range of motion of his/her lower extremity on 1 side and received as needed pain medication for frequent moderate pain rated at a 7 on a 1-10 scale. The MDS further indicated the resident was at risk of pressure ulcers, had pressure reducing devices for the bed and chair, was on a turning/repositioning program, and had no current pressure ulcers. The 6/26/14 pressure ulcer (CAA) Care Area Assessment stated the resident was dependent on staff for bed mobility, transfers and repositioning, and his/her [DIAGNOSES REDACTED]. The CAA revealed these risk factors placed the resident at possible risk for decline in skin integrity, bed mobility and activities. The 6/20/14 initial care plan directed the staff to check the resident every 1-2 hours for safety and positioning, provide a pressure relieving mattress to the bed and a pressure relieving cushion to his/her chair. The care plan directed the staff to do a weekly and as needed skin assessment. The care plan did not contain any interventions regarding the floating (raising something so pressure relieved) of the resident's heels when he/she was in bed as outlined in the facility policy. Further review of the care plan revealed on 7/23/14 the staff identified the resident's pressure ulcer on his/her left foot and added the following interventions to the care plan: apply a pressure relief device to the resident's left foot per physical therapy, no shoe on the resident's left foot in bed, place a heel protector on the left foot in the bed, and elevate heels off the mattress with a pillow under his/her lower legs when he/she was in bed. The 6/20/14 Braden Scale (a scale used to evaluate a resident's pressure ulcer risk) revealed a score of 15 which indicated the resident at risk for developing of pressure ulcers. The 7/14/14 weekly skin integrity tool indicated the resident had no open areas to his/her skin. The 7/23/14 (9 days later) weekly skin integrity tool indicated the resident had a reddish purple spot on his/her left heel that measured 3.5 (cm) centimeters x 4 cm and a 1 cm x 1 cm black spot to the left great toe. The weekly pressure ulcer record indicated the unstageable pressure ulcers on the resident's left heel and left great toe with the following measurements: Left Heel: 7/31/14 3.2 cm x 3 cm 8/5/14 2.5 cm x 2 .4 cm 8/12/14 3 cm x 3.7 cm Left great toe: 7/31/14 1.5 cm x 1.8 cm 8/5/14 1.4 cm x 1.7 cm 8/12/14 1 cm x 1 cm The 7/28/14 lab report revealed a total protein level of 6.7 (6 - 8.3 normal) and an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) level of 3.8 (3.5 - 5 normal). The 8/1/14 physician's orders [REDACTED]. The 8/4/14 registered dietician progress notes stated the resident's weight was down approximately 4 pounds since his/her admit weight however showed a > (greater than) 5% weight loss from his/her weight on 6/30/14. The registered dietician progress notes also stated the resident had black areas on his/her left toe and heel, and he/she received Med Pass 2 oz. ordered three times a day initiated on 8/1/14, and recommended 4 oz. nutritional supplement be provided between meals three times a day or a high calorie snack three times a day. The registered dietician progress notes stated if the resident took the 4 oz. nutritional supplement, to increase the nutritional supplement to 8 oz. three times a day. The August 2014 snack sheet indicated the resident received the 4 oz nutritional supplement three times a day with intake amounts varying from 25 - 100%. The August 2014 (MAR) Medication Administration Record [REDACTED]. (8/2, 8/3, 8/5, 8/6, 8/7, 8/8, 8/12, 8/13, 8/14) On 8/14/14 at 8:19 AM, observation revealed Nurse Aide B and F assisted the resident into his/her bed and positioned a pillow under the resident's knees. The resident's right heel rested directly on the bed and his/her left heel in a firm fleece lined pressure relief boot. On 8/14/14 at 3:28 PM, observation revealed the resident lying in his/her bed and his/her right foot rested on the bed and his/her left heel in a firm fleece lined pressure relief boot. On 8/15/14 at 10:08 AM, observation revealed Nurse A entered the resident's room and the resident was lying on a pressure relieving mattress in his/her bed with a firm fleece pressure relief boot on his/her left foot and a tennis shoe on his/her right foot. Nurse A unfastened the strap on the fleece boot on the left foot and revealed a nickel sized red area with an approximate 0.25 cm open area in the center of his/her shin under the strap and a nickel sized black area on the tip of the resident's great toe. Nurse A completely removed the resident's boot from the left foot, raised the resident's leg up and revealed the resident's left heel had a quarter size black area with dry skin around the black area approximately the size of a tennis ball, and 2 nickel size fluid filled spots on sides of the black area. Nurse A verified the black areas were both firm to touch and the nickel size areas on the resident's heel were filled with fluid. On 8/14/14 at 8:26 AM, Nurse Aide B stated before the resident developed the sore on his/her left foot, the staff had not floated his/her heels when he/she was in bed. On 8/14/14 at 11:17 AM, Physical Therapy Staff E stated he/she was not checking the resident's heels before nursing staff found the pressure ulcer, the resident's shoe had rubbed an area on the resident's left great toe and was now a black area, and he/she was not aware the resident was at risk for pressure ulcers before the resident's pressure ulcer was found. On 8/14/14 at 4:23 PM, Nurse Aide stated the staff removed the resident's pressure relief boot on his/her left foot in the morning and at night when the staff changed the resident's clothes. On 8/15/14 at 11:32 AM, Administrative Nurse C verified the resident had a new open area on his/her left shin under the velcro strap of the fleece boot. On 8/15/14 at 3:52 PM, Administrative Nurse C verified the staff should float the resident's heels when he/she was in bed and this intervention was not included in the plan of care until after the development of the resident's left heel pressure ulcer. Administrative Nurse C verified the August 2014 MAR indicated [REDACTED]. On 8/18/14 at 5:11 PM, Physician Assistant D verified the facility should have implemented preventative measures for Resident #2 to prevent pressure ulcers, the black area on the resident's left heel was a pressure ulcer, and all pressure ulcers were possibly avoidable. The facility's March 2005 Prevention of Pressure Ulcer policy, stated any resident with a pressure ulcer risk factor of immobility and in bed, every attempt should be made to "float heels" (keep heels off of the bed) by placing a pillow from the knee to the ankle, or with other devices as recommended by therapist and prescribed by the physician. The policy also stated to refer immobile residents for therapy evaluation and/or restorative nursing program. The facility failed to develop and implement effective interventions to prevent the development of pressure ulcers and administer the physician ordered supplement for cognitively impaired, dependent Resident #2, who developed 2 avoidable facility acquired unstageable pressure ulcers and 1 stage 2 facility acquired avoidable pressure ulcer.

The facility had a census of 31 residents and 3 hallways where the residents lived. The facility reported 10 residents ambulated independently with or without an assistive device. The sample included 3 residents reviewed for falls. Based on observation, interview, and record review, the facility failed to ensure the environment remained free of potential hazards when 10 independently ambulatory residents had access to hot water in excess of 140 degrees F (Fahrenheit) in the dining room, men's bathroom, and women's bathroom hand-washing sinks. This failure placed the 10 independently mobile residents in immediate jeopardy. The facility failed to ensure 1 of the 3 residents sampled for accidents received adequate supervision (safe transfer) to prevent accidents. (#18) The facility also failed to ensure the environment remained free of potential hazards when staff used toilet risers with unsafe, loose handrails in 1 of the 3 hallways. Findings included: - Initial tour of the facility on 2/4/14 at 8:06 a.m. revealed the facility had one hand-washing sink in 1 of 2 dining areas. The dining sink presented on a cabinet at a height difficult to reach from a wheelchair. Water temperature of the accessible hand sink measured 143.8 degrees F for approximately 30 seconds with steam present. Rechecks with different thermometers of the dining room water temperature measured 129.5 degrees F at 8:15 a.m. and 134.4 degrees F at 8:20 a.m. Maintenance staff was not on duty at the time of initial tour. 15 residents sat in the dining area near the hand sink at that time and licensed nursing staff O stood near a medication cart adjacent to the 2 dining rooms. Initial tour of the facility on 2/4/14 at 8:24 a.m. and revealed the facility had 3 hallways where the residents lived. The "B" hallway had two common bathrooms: one labeled "men" and one labeled "women". Observations revealed the men's bathroom door unlocked and accessible and the men's bathroom hand sink water temperature measured 132.4 degrees F. The women's bathroom door presented as locked during the initial tour. Observations revealed no residents near the men's and women's bathrooms. During an observation on 2/4/14 at 10:05 a.m., direct care staff N unlocked the women's bathroom with a key hanging adjacent to the men's bathroom accessible to residents that walked. The water temperature of the women's bathroom hand sink measured 124.5 degrees F. During an interview on 2/4/14 at 8:08 a.m., licensed nursing staff O reported that he/she had not seen any residents use the dining room sink. During an interview on 2/4/14 at approximately 10:45 a.m., administrative nursing staff B reported the facility had 10 residents that walked independently with or without an assistive device. During an interview on 2/4/14 at 11:44 a.m., resident #19 reported he/she had seen multiple residents use the dining room sink to wash their hands. Review of the water temperature check logs from November 2013 to February 2014 revealed that staff monitored 6 random water temperatures every week, including laundry, kitchen, shower room, and residents' rooms from each of the 3 hallways. The log lacked evidence that staff monitored the water temperature of the dining room, men's bathroom, and women's bathroom hand sinks. During an interview on 2/4/14 at 12:16 p.m., maintenance staff G reported the pressure valve on the boiler malfunctioned the night before and staff called in a plumber to fix it at the time. He/she reported that he/she checked the temperature of the dining room sink prior to leaving the facility at approximately 5:00 a.m. and found the temperature below 120 degrees F. He/she reported that no other staff checked temperatures since 5:00 a.m. that day. He/she reported that once a week he/she checked water temperatures of random residents' rooms, the men's and women's common bathrooms, and the dining room. Although he/she reported he/she checked the dining room and men's/women's bathroom, he/she confirmed that he/she failed to document the temperature of the dining room sink and men's/women's bathroom sinks. He/she confirmed that the dining room sink hot water exceeded 140 degrees and he/she turned off the hot water to the building moments before the interview. During an observation on 2/4/14 at 5:15 p.m., the hot water in the dining room hand-washing sink remained off and the men's/women's common bathroom doors remained locked with the key accessible to residents. During an observation on 2/5/14 at 7:35 a.m., a key remained next to the men's and women's bathrooms and each door presented as locked. The water temperature of the men's bathroom sink measured 160.1 degrees F by one thermometer and 159.8 degrees F by another thermometer for approximately 90 seconds with large amounts of steam present. At 7:38 a.m., the water temperature of the women's bathroom sink measured 155.8 degrees F with one thermometer and 155.8 degrees F with another thermometer for approximately 90 seconds with large amounts of steam present. At 7:40 a.m., the water temperature of the dining room sink measured 55 degrees F and the hot water remained turned off. Observation revealed no residents or staff near the men's and women's bathrooms at this time During an observation on 2/5/14 at 7:42 a.m., administrative staff A removed the key from the men's/women's bathroom and placed "out of order" signs on each door and notified a plumber who arrived at the facility at approximately 8:00 a.m. During observations on 2/5/14 at 6:36 p.m. and 2/6/14 at 8:08 a.m., the dining room hand washing sink hot water remained off and the men's/women's bathrooms remained locked with signs that indicated "out of order" on each door without an accessible key to residents. During an interview on 2/11/14 at 1:44 p.m., administrative staff A reported the men's and women's bathroom was meant for the public and residents who can reach the key, such as the 10 independently ambulatory residents. The facility's "Safety of Water Temperatures" policy, dated December 2009, instructed staff to set the water heater that serviced residents' rooms, bathrooms, common areas, and tub/shower rooms at no more than 119 degrees, maintenance staff held the responsibility to check and record the thermostats and temperature controls in the facility, and maintenance staff conducted and recorded periodic tap water temperature checks. The facility failed to ensure the environment remained free of potential hazards for 10 independently ambulatory residents with or without an assistive device who had access to hot water in excess of 140 degrees F in the dining room, men's bathroom, and women's bathroom hand sinks. This failure placed the 10 residents in immediate jeopardy. The facility abated the Immediate Jeopardy on 2/11/14 at 9:35 a.m. when they implemented the following measures: * contacted a plumber on 2/4/14, replaced a circulation pump on 2/5/14, and replaced a pressure relief valve on 2/6/14. The facility planned to order new mixing valves for the dining room sink and the men's and women's bathroom sinks and order a new thermostat. Meanwhile, the facility will keep the hot water off. * staff will monitor all sinks and water sources weekly twice a day rotating throughout the facility to ensure that water temperatures accessible to residents remain at acceptable levels. * all staff will be inserviced of the importance of keeping water temperatures within range. If staff find water temperature hot water out of range, staff will immediately shut off the hot water and immediately inform the administrator. * temperatures will be reviewed daily in the department head meeting and monitored at the monthly QAA (Quality Assurance and Assessment) committee meetings. After abatement, the deficient practice of the facility failure to ensure the resident environment remained free of potential hazards and each resident received adequate supervision and assistive devices to prevent accidents remained at a scope/severity of "E". - Resident #14's 12/4/13 physician's orders [REDACTED]. Resident #14's 12/5/13 Significant Change of Status MDS (Minimum Data Set) Assessment reported the resident usually understood others and made him/herself understood. The resident had short/long term memory problems with modified independent decision making skills and fluctuating inattention. The resident experienced delusions, displayed physical and verbal behaviors 1 to 3 days in the observation period, and rejected cares 4 to 6 days which staff documented as worse than the prior assessments. The resident needed total assistance of 2 staff for bed mobility, transfers, and toileting and was not steady between sitting and standing without staff assistance. He/she had limited function of both upper and lower extremities and needed total assistance of 1 staff for locomotion in the wheelchair. Resident #14's 12/12/13 Cognitive Loss CAA (Care Area Assessment) summary reported the resident had progressively declined in cognition over the past year prior to a hospitalization . The resident had dementia, had occasional leg pain due to left femur (the thigh bone) fracture (broken bone), and had a significant decline in ADLs (activities of daily living). His/her ADL CAA reported that he/she refused to do many things such as self propelling his/her wheelchair in which he/she was capable of doing and became combative with staff. The CAA reported that he/she stood in a sit-to-stand lift but refused to assist in transfers any other time. Review of the "Fall Assessment" form indicated that the resident scored "15" on 12/1/13, with indication that residents with scores of 10 or greater posed a high risk for falls. Resident #14's 9/9/10 care plan, last reviewed on 1/11/14, informed staff that the resident posed a risk for falling due to decreased cognition, impaired judgment, and decreased safety awareness. A 12/18/12 revision instructed staff to use a sit-to-stand lift for transfers with 1 - 2 staff as needed. Staff revised the care plan on 2/9/13 instructing staff they may transfer the resident with 1 - 2 staff but lacked mention of use of a gait belt. During an observation on 2/6/14 at 8:18 a.m., direct care staff D propelled resident #14 to his/her room. At 8:19 a.m., staff D locked the wheelchair brakes and placed a gait belt around resident #14's torso. Direct care staff D and E placed their arms under resident #14's arms and held the gait belt while supporting the resident's weight under the resident's arms. Staff D asked the resident if he/she was ready to stand and the resident did not respond. Staff D prompted the resident to stand but the resident did not move. Staff D and E leaned the resident forward out of the wheelchair and the resident did not support his/her own weight. Staff D and E physically lifted and swung the resident into the recliner while holding the resident under each arm. Staff D placed multiple pillows around the resident, covered him/her with a blanket, and placed a call light within the residents' reach. During an interview on 2/6/14 at 8:22 a.m., direct care staff D reported that staff could use the sit-to-stand lift with resident #14 but for the past 6 months, the resident had shown a decline in his/her cognition and had not held the lift handles safely. He/she reported that staff had been transferring the resident by holding up his/her whole body when the resident did not want to bear his/her weight. During an interview on 2/6/14 at 12:32 p.m., licensed nursing staff H reported that no direct care staff informed him/her that the resident did not bear his/her own weight during a transfer that morning. He/she reported that staff should have told him/her of the incident so that he/she could assess the resident for safe transfer. He/she stated that resident #14 should have been transferred with a total mechanical lift when he/she did not stand on his/her feet during transfers. During an interview on 2/10/14 at 2:59 p.m., administrative nursing staff B confirmed staff failed to safely transfer resident #14 when the resident did not bear his/her own weight during a transfer. The facility's "Safe Lifting and Movement of Residents" policy, dated October 2009, instructed staff that "manual lifting of residents shall be eliminated when feasible". The facility failed to provide adequate supervision to prevent accidents when staff failed to safely transfer resident #14 who did not bear his/her own weight during a transfer. - An observation on 2/4/14 at 12:15 p.m., revealed a toilet riser with unsafe loose handrails in a resident bathroom on hallway 100. During an interview on 2/10/14 at 11:59 a.m., maintenance staff G revealed that the facility did not check the toilet risers on a regular basis. Staff G revealed that the staff can put any issues concerning maintenance in a request book at the nurses ' station. Although requested the facility failed to provide documentation of checking toilet risers as part of their preventative maintenance program. The facility failed to keep the resident free of accident hazard by having toilet risers with unsafe/loose hand rails,