Every finding on record at Delmar Gardens West

Based on interview and record review, the facility failed to immediately report an alleged violation of staff to resident abuse involving Resident #1 and Laundry Aide A to the Department of Health of Senior Services within the required two-hour time frame. The sample size was seven. The census was 196. Review of the facility's abuse, neglect, exploitation policy, dated 07/2022, showed:-Application: The Administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, not later than 2 hours after the allegation is made, to other officials in accordance with state law including to the state survey and certification agency. Review of Resident #1's annual minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/07/2026, showed:-Diagnoses included cognitive communication deficit, contracture (tightening of muscles) of the right hand, hemiplegia (total or partial paralysis) affecting the right dominant side;-Moderately impaired cognition. Review on 08/20/2026, of the facility's investigation, dated 08/13/2026, showed no documentation the allegation was reported to the state agency. Review on 08/20/2026, of the state survey agency database showed no self-reports from the facility regarding the allegation involving Resident #1 on 08/12/2026. During an interview on 08/20/2026 at 11:26 A.M., Activity Aide B said on 08/12/2026 he/she was walking down the 300 hallway and as he/she passed the resident's room, he/she saw Laundry Aide A bent over, standing in front of the resident, pulling up his/her pants. The resident was seated behind Laundry Aide A in his/her wheelchair. He/She said he/she could see the skin of the right side of Laundry Aide A's thigh and at the top of the his/her intergluteal cleft (groove between the buttocks). He/She confronted Laundry Aide A and asked what he/she was doing and that he/she was going to report what he/she saw. He/She said Laundry Aide A said he/she was not doing anything, and the resident liked to touch his/her bottom. He/She said he/she went and reported the event to his/her direct supervisor, Assistant Administrator, and the Administrator. He/She felt that something inappropriate could have been going on before he/she walked by. During an interview on 08/20/2026 at 12:14 P.M., the Administrator said he would expect the facility's policy to be followed, which would include reporting allegations of abuse within the required time frame. He did not feel this allegation should have been classified as abuse. He felt that the allegation was a concern of Resident #1's behaviors. He said the Resident had prior behaviors of pinching staff members on the bottom. 3167340

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to cover food and failed to ensure that expired thickened dairy products were discarded. The facility also failed to ensure kitchen equipment was kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temperature logs as well as chloride testing logs. Furthermore, the facility failed to follow the puree recipes for six of the seven purees observed and failed to ensure dishes were properly washed in between use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 181. 1. Observation of the kitchen walk in (left side) cooler on [DATE] at 11:12 A.M., [DATE] at 3:13 P.M. and [DATE] at 11:15 A.M., showed: -An opened box of turkey sausage links exposed to air; -An opened box of sausage patties exposed to air; -An opened box of bacon exposed to air. 2. Observation of the kitchen's large storage room on [DATE] at 11:12 A.M., [DATE] at 3:13 P.M. and [DATE] at 11:15 A.M., showed: -Six-gallon size containers of mustard, with best by dates of [DATE]; -Two boxes that contained several containers of Thick and Easy Thickened Dairy Drink, with best by date of [DATE]; -One box that contained several containers of Thick and Easy Thickened Dairy Drink, with best by date of [DATE]; -One box of Ready Care Apple Juice, with best by date of [DATE]. 3. Observation of the kitchen on [DATE] at 11:12 A.M. and [DATE] at 3:13 P.M. and [DATE] at 11:15 A.M., showed the following: -The stove: -Heavy caked-on stains on the stove burners; -Heavy caked-on stains along the front of the stove; -The double deep fryer: -Old grease in the fryers; -Baked on grease on strainers and along the inside of the fryers; -Heavy caked-on stains along the front and on the side in between the grill; -Stand-alone double oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, and sides of oven. 4. Review of the undated pureed food preparation policy, showed: -Guideline: Pureed foods will be prepared, using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value; -Procedure: -Each menu cycle will be reviewed to ensure there is a pureed recipe for each item to be served; -Standardized recipes will be used to prepare all pureed foods. The recipes will be adjusted according to the number of pureed diets needed, indicating seasoning and technique to ensure the highest quality; -Recipes will not use water to thin pureed foods. Only broth, milk, juice, gravy, margarine, or another appropriate condiment that preserves flavor shall be used. -Food thickener will be used only in accordance with a specific recipe or product instructions. Measure and add commercial thickener, stabilizer, or shaping/enhancing product as directed in the recipe and process until blended. -Serve with appropriate scoop number or divide equally to provide an equal number portions. All of the pureed foods must be used in order to deliver the correct nutrient density to each resident. The number of servants obtained from the puree recipe must be equal to the number of servings from which you started. For example, if ten servings of the regular recipe are to be pureed, follow the puree recipe for ten servings. The yield of the pureed recipe must give you ten equal pureed servings. If the recipe was altered, the scoop size may also need to be altered. Due to the nature of variance in foods, it is possible that slight alterations or not using all the liquid in a recipe will be required. Therefore, the division of an equal portion of final product to the starting number of servings insures equal nutritive value in each portion. Record this alteration information on the recipe with the date and your initials. Review altered pureed recipes with the facility Registered Dietitian. -Pureed foods will be the consistency of pudding or smooth, mashed potatoes. A food processor is preferred; however, a blender may be used to make pureed foods. -The flavor of pureed food will be assessed. The pureed food should have the same desirable flavor as the menu item. -Staff will be in-serviced on proper preparation of pureed foods. Observation on [DATE] at 7:18 A.M., showed Dietary [NAME] (DC) BB pureed eggs. During an interview at that time, DC BB said he/she was pureeing dishes for five residents. He/She used a jumbo-sized scoop that appeared to look like an ice scoop. He/She placed two full scoops, and two half sized scoops of unmeasured scrambled eggs into the food processor. DC BB poured an unmeasured amount of apple juice into the food processor and pureed the items for approximately ten seconds. He/She stopped and said the mixture needed more thickener and added three scoops of thickener at that time and added an additional unmeasured amount of apple juice and pureed the items for approximately ten more seconds. DC BB stopped the food processor and added an additional unmeasured amount of apple juice and pureed for another ten seconds. DC BB then stopped the food processor and stirred the mixture. DC BB placed the mixture into four small metal aluminum pans and covered the pans with the lids. The consistency was somewhat thick but with a fluffy texture. The mixture was not smooth. Further observation showed DC BB did not consult the recipe book during the preparation. Review of the pureed eggs recipe, showed the following for nine servings: -Ingredients: -Twelve #16 scoops of scrambled eggs (see recipe); -,d+[DATE] cup of milk; -Method: -Count out the number of prepared scrambled eggs according to yield desired. Place in food processor; -Add milk. Puree until smooth. Eggs will be thin cake batter consistency (will tighten up on steam table); -Portion into steam table pans according to each dining room count. Cover and place in oven or warmer until serving time. Temperature 165 degrees. Observation on [DATE] at 7:28 A.M., showed DC BB pureed bread. DC BB said sometimes he/she would use three or four loaves of bread so he/she would have enough. DC BB tore open the packaging and placed all the bread from four loaves of bread into the food processor. He/She then poured an unmeasured amount of apple juice into the food processor and pureed the items. As the items pureed, DC BB poured an additional unmeasured amount of apple juice through the opening in the lid and pureed the items for a total of approximately 20 seconds and then stopped the food processor. He/She poured an additional unmeasured amount of apple juice into the food processor and then blended the mixture for approximately 15 seconds and stopped the blender. DC BB got another box of apple juice and poured an unmeasured amount of apple juice into the food processor and pureed the items for approximately 15 seconds. DC BB stopped the food processor and then added an unmeasured amount of apple juice and pureed the items for an additional 20 seconds. The consistency was thick but smooth in consistency. Further observation showed DC BB did not consult the recipe book during the preparation. Review of the pureed bread recipe, showed the following for five servings: -Ingredients: -Five slices of bread; -,d+[DATE] cup plus two tablespoons of milk. Method: -Place bread in blender or food processor; -Gradually add milk; blend until smooth; chill until serving time. Serve chilled or reheat to 165 degrees; -Portion with number 16 scoop. Observation on [DATE] at 7:35 A.M., showed DC BB pureed ham. He/She rinsed out the bowl and rinsed off the lid of the food processor from the previous bread puree with water. There was still residue on the lid and batter on the inside on the sides of the bowl. DC BB placed 17 pieces chunks of ham inside the food processor and blended about ten seconds and stopped the food processor. He/She poured an unmeasured amount of apple juice inside the food processor. DC BB got another box of apple juice and poured an additional unmeasured amount of apple juice inside the food processor and blended for another 15 seconds. He/She stopped the blender and added an additional unmeasured amount of apple juice and pureed the mixture for an additional 20 seconds. He/She placed the mixture into four small aluminum metal pans and placed lids on top of them. The mixture was gritty in consistency. The mixture was not smooth. Further observation showed DC BB did not consult the recipe book during the preparation. Review of the pureed meat recipe, showed the following: -Ingredients: -Chicken, beef, liver, ham, pork, or fish; -Method: -Count out number of portions needed. Place in robot coupe; -Add complementary broth to reach desired consistency; -Should be between applesauce and mashed potato consistency; -Thickener may be added as needed to reach the appropriate consistency; - Reheat to 165. Observation on [DATE] at 11:17 A.M., showed DC CC pureed pineapple coleslaw. DC CC placed three scoops of thickener, eight scoops of coleslaw and an unmeasured amount of apple juice inside the food processor and pureed the items for approximately ten seconds. He/she stopped the food processor and placed three more scoops of slaw and an additional unmeasured amount of apple juice inside the blender and pureed the items for an additional 30 seconds. DC CC stopped the food processor and said he/she would eyeball the mixture to make sure it was correct and then he/she pureed the mixture for an additional 30 seconds. DC CC placed the mixture into four small aluminum metal pans and placed lids on top of them. The mixture was gritty but soupy in consistency. Further observation showed DC CC did not consult the recipe book during the preparation. Review of the pureed fruit recipe, showed the following: -Ingredients: -Canned fruit or fresh fruit; -Method: -Count out number of portions needed; -Drain canned fruit and place in blender. Fresh fruit in robot coupe; -Pureed until consistency of applesauce or thicker; -Juice or thickener may be added to reach consistency. Observation on [DATE] at 11:27 A.M., showed (DC) CC prepared pureed salami, turkey, and pepperoni. DC CC placed four scoops of thickener, nine scoops of salami, turkey, and pepperoni along with an unmeasured amount of beef broth inside the food processor inside the food processor and pureed the items for approximately 45 seconds. He/She stopped the food processor, looked at the mixture, and then poured an additional unmeasured amount of beef broth inside the food processor and stopped it. DC CC pureed the mixture for an additional 35 seconds. He/She stopped the food processor and poured the mixture inside of four small aluminum metal pans. Further observation showed DC CC did not consult the recipe book during the preparation. Review of the pureed meat recipe, showed the following: -Ingredients: -Chicken, beef, liver, ham, pork, or fish; -Method: -Count out number of portions needed. Place in robot coupe; -Add complementary broth to reach desired consistency; -Should be between applesauce and mashed potato consistency; -Thickener may be added as needed to reach the appropriate consistency; - Reheat to 165. Observation on [DATE] at 11:32 A.M., showed DC CC prepared pureed rolls. DC CC placed three scoops of thickener, a package of rolls, and an unmeasured amount of two percent milk inside the food processor and pureed the items for approximately 15 seconds. He/She stopped the food processor and added an unmeasured amount of two percent milk inside the food processor and pureed the items for another 20 seconds. DC CC stopped and said he/she probably needed to add a little more bread. He/She placed three hamburger buns inside the food processor and pureed the mixture for an additional 20 seconds. The mixture was smooth in consistency. Further observation showed DC CC did not consult the recipe book during the preparation. Review of the pureed bread recipe, showed the following for five servings: -Ingredients: -Five slices of bread; -,d+[DATE] cup plus two tablespoons of milk. -Method: -Place bread in blender or food processor; -Gradually add milk; blend until smooth; chill until serving time. Serve chilled or reheat to 165 degrees; -Portion with number 16 scoop. 5. Observation on [DATE] at 11:27 A.M., showed DC CC prepared pureed salami, turkey, and pepperoni. He/She rinsed out the bowl and the lid from the previous pureed onion ring puree. After (DC )CC rinsed the bowl and lid off, residue from the onion ring puree was on the lid and batter was along the inside of the bowl. (DC) CC proceeded to puree the salami, turkey, and pepperoni at that time. 6. Observation of the kitchen on [DATE] at 11:12 A.M., [DATE] at 3:13 P.M., [DATE] at 11:15 A.M. and [DATE] at 11:28 A.M., showed: -Incomplete temperature logs for [DATE]-11, 2025; -No temperature logs for February and [DATE]; -No logs for testing the chloride for February, March, and [DATE]. 7. During an interview on [DATE] at 11:28 A.M., the Dietary Manager (DM) said she expected all food and drinks to be properly labeled, dated and stored, and for all expired items to be discarded. She expected all kitchen equipment to be clean and in proper working order. General cleaning is done every day and deep cleaning of certain items is done daily and some are done weekly. During the dish cleaning cycle, the temperatures are taken and recorded. Staff should be running the machines twice to make sure everything is working properly. The temperatures should be taken at breakfast, lunch and dinner everyday and logged. The test strips to test the chloride in the water should be used as well and logged after every dish washing cleaning service. This is done to make sure that the dishes are being sanitized. This should be done regularly. This was her expectation. She expected proper infection control practices followed while preparing food as well as ensuring dishes are thoroughly cleaned in between use. The DM expected staff follow puree recipes. The recipes should be followed so the food had the right consistency and texture and the flavor should match the food. The texture is part of the consistency. She was not aware the staff used apple juice for a lot of the purees. She expected the puree recipe book to have been opened and used during the preparation of pureed meals. The staff who did the purees worked there for years so he/she knew how to do the purees. They should read the book to make sure nothing changed. She expected the dishes to have been properly cleaned. You don't want bread to taste like meat. She would want the food items to taste like what it is supposed to be.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, five errors occurred resulting in a 13.51% error rate (Residents #67, #112, #157 and #141). The census was 181. Review of the facility's Insulin Administration via Pen Devices policy, last reviewed 5/2021, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and facility recommendations; -Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual; -Remove the pen cap and cleanse the rubber stopper wit an alcohol wipe Attach pen needle to device; -Prime the pen immediately before injection. Priming is dialing up 2 units of insulin and pressing the button on the top of the pen to shoot some insulin into the air. You should see a drop of insulin at the end of the needle. More than one prime may be required for a new pen; -Dial up the dose on the pen as indicated on the order; -Verify that insulin is being given at the correct time in relation to meals; -For Humalog (short acting insulin) administer 15 minutes before a meal or immediately following. 1. Review of Resident # 67's medical record, showed: -Diagnoses included diabetes and dementia; -An order dated 4/07/25, for insulin Humalog (short acting insulin) administer 8 units subcutaneous (under the skin) three times a day with meals at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Observation on 4/08/25, at 7:26 A.M., showed Licensed Practical Nurse (LPN) D obtained a blood sugar result of 115. LPN D drew up 8 units of Humalog after priming 2 units. LPN D administered the insulin into the resident's left arm without pinching the skin to ensure the insulin was administered subcutaneous. He/she existed the room. Resident #67 was not brought to breakfast until 8:13 A.M., were he/she was observed holding his/her head. When asked what's wrong, he/she said, I feel sick to my stomach, and they bring me to lunch. At this time, no residents in the unit dining room were served breakfast. Staff served the resident breakfast at 8:34 A.M. (1 hour and 8 minutes after he/she received short acting insulin). 2. Review of Resident #112's medical record, showed: -Diagnoses included diabetes; -An order dated 4/2/25, for insulin aspart (short acting insulin) administer 18 units three times a day with meals; -An order dated 4/2/25, for Lantus Solostar (long-acting insulin), administer 30 units daily, scheduled administration time between 7:15 A.M. and 11:15 A.M. daily. Observation on 4/8/25 at 7:24 A.M., showed LPN E entered the resident's room and obtained a blood sugar result of 158. He/She obtained the resident's insulin aspart pen, placed the needle on the pen, and set the pen to administer 18 units. He/She administered the insulin into the resident's abdomen. The insulin pen was not primed prior to administration. LPN E said he/she would administer the resident's Lantus after he/she obtained a Lantus pen from stock. At 8:35 A.M., LPN E obtained the resident's Lantus pen, placed the needle on the pen, and set the pen to administer 30 units. He/She administered the insulin into the resident's abdomen. The insulin pen was not primed prior to administration. 3. Review of Resident #157's medical record, showed: -Diagnoses included diabetes; -An order dated 3/13/25, for Basaglar (long-acting insulin) pen, administer 10 units every 12 hours, scheduled at 8:00 A.M. and 8:00 P.M. Observation on 4/8/25 at 7:41 A.M., showed LPN E obtained a blood sugar level of 104. LPN E obtained the resident's Basaglar insulin pen, placed the needle on the pen, and set the pen to administer 10 units. He/She administered the insulin into the resident's left upper arm. The insulin pen was not primed prior to administration. 4. Review of Resident #141's medical record, showed: -Diagnoses included diabetes; -An order dated 8/7/24, for Humalog insulin pen, administer 7 units with meals; -An order dated 8/7/24, for Humalog sliding scale insulin, administer no additional insulin for a blood sugar below 200. Observation on 4/8/25 at 8:17 A.M., showed LPN E obtained a blood sugar level of 189. The resident said he/she already ate breakfast of cereal and an egg and sausage sandwich. LPN E obtained the resident's Humalog insulin pen, placed the needle on the pen, and set the pen to administer 7 units. He/She administered the insulin into the resident's upper arm. The insulin pen was not primed prior to administration. 5. During an interview on 4/10/15 at 1:50 P.M., with the Director of Nursing (DON) and Infection Preventionist, they said when administering insulin, staff should follow the facility policy on how close to mealtime the insulin should be administered. The risk of too much time going by between administration of a short acting insulin is hypoglycemia (low blood sugar level). Staff should follow facility policy on priming insulin pens. The standard is to prime with 2 units. Not priming the insulin pen could result in the wrong dose of insulin being administered. Blood sugar levels should be checked prior to the resident eating their meal. If a blood sugar level is obtained after the resident eats, the results would not be accurate, and they would get the wrong dose of sliding scale insulin.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified five medication rooms. Issues were found in two of the three medication rooms checked. Staff failed to double-lock the refrigerated controlled medications. The sample was 35. The census was 181. Review of the facility's Medications, Controlled Drugs policy, last revised 2/2023, showed: -All controlled medications must be stored in separately locked area that requires a different key; -Refrigerated Ativan (Lorezepam) liquid and injectable medications require a small lock box for the refrigerator. Review of the facility's Storage of Drugs policy, updated 12/21, showed compartments and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts and boxes. Observation and interview 4/8/25 at 10:20 A.M., showed a refrigerator with no lock system in the medication room of Hall 300. There was an unlocked black box inside the refrigerator which contained two unopened bottles of Lorazepam Oral Concentrate (used to treat anxiety), 2 milligrams per milliliters (mg/ml). Licensed Practical Nurse (LPN) W said they did not have a lock to the refrigerator or to the black box. He/She said they never had to lock the box since the medication room door was always locked. The nurses and Certified Medication Technicians (CMTs) had access to the medication room and refrigerator. Observation and interview 4/8/25 at 11:15 A.M., showed a refrigerator with no lock system in the medication room of Hall 500. The unlocked black box inside the refrigerator contained five Lorazepam Oral Concentrate bottles. Registered Nurse (RN) X said they never locked the black box. RN Y said those medications were to be discarded. The black box was always unlocked. They did not have a lock and key to the box. During an interview on 4/10/25 at 12:42 P.M., the Director of Nursing (DON) said the refrigerated controlled medications were to be stored in locked tackle boxes in each medication room. She expected the staff to double-lock the controlled medications. The nurses and CMTs should have the keys to the medication rooms and the tackle boxes.

Based on observation, interview and record review, the facility failed to follow acceptable infection control practice during care of residents. Staff failed to follow Centers for Disease Control and Prevention (CDC) guidance for Personal Protective Equipment (PPE) use for one resident with a contagious form of diarrhea and failed to ensure the facility policy for isolation was held to the same standard as the CDC guidance (Resident #424). Staff failed to ensure insulin pens were only for single resident use for one resident (Resident #67) when staff prepared to administer a different resident's insulin pen to the resident, prior to being stopped by the surveyor. Staff failed to follow proper enhanced barrier precaution (EBP, precautions used on residents with high risk of getting infections, who are not infectious themselves) for one resident who received personal care (Resident #22). Staff failed to cleanse the shared blood sugar machine with approved cleansing products between each resident use for four residents (Resident #112, #157, #32, and #141). Staff failed to follow proper infection control practices during medication administration for one resident (Resident #57) when staff administered a pill that had dropped on the medication cart, with their ungloved hands. In addition, staff failed to ensure resident laundry was covered when transported through the halls. The sample was 35. The census was 181. 1. Review of the facility's Clostridioides Difficile (C-diff., a very contagious bacterial infection that causes symptoms such as frequent watery diarrhea) Infection policy, dated 2/21, showed: -Policy: it is the policy of this facility to institute contact precautions for residents with known C-diff who are exhibiting diarrhea stools due to the infection in the following situations: when the resident is incontinent and soiling of the environment with stool is likely, when the resident is noncompliant with basic personal hygiene and hand washing, when contaminated stool cannot be contained, or when the resident is confused and cannot comply with appropriate hygiene measures; -Procedure: gowns should be worn if direct care (bathing or lifting) is provided. Review of the CDC.gov/c-diff/hcp/clinical overview, dated 3/5/24, showed, treatment and recovery, if C-Diff infection is confirmed, continue isolation and contact precautions. Review of Resident #424's medical record, showed: -Resident can make his/her needs known; -Diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke affecting left non-dominant side. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident had a deficit in functional ability with activities of daily living (ADLs, grooming, dressing, bathing and hygiene) for self-care and mobility related to recent stroke, weakness and required mechanical lift assistance; -Goal: will participate in ADL activities promoting maximum independence; -Interventions included: provide assistance with ADLs as needed or requested: bed mobility assist times one, toilet/incontinent care assist times one. Review of the resident's physician order sheet, showed an order, dated 4/3/25, for Vancomycin (antibiotic) 125 milligrams (mg) every six hours for nine days. Review of the resident's progress notes, dated 4/6/25 at 9:20 A.M., showed the resident continues antibiotic/vancomycin 125 mg for C-diff until 5/1/25. Resident had one episode of diarrhea prior to breakfast meal. Observation and interview on 4/8/25 at 8:20 A.M., showed the resident up in his/her wheelchair, in the dining room. Staff propelled the resident back to his/her room. There was an EBP magnet on the door frame. PPE hung on the bathroom door. Certified Medication Technician (CMT) Q and Certified Nurse Aide (CNA) R washed their hands in the resident's bathroom and put gloves on, then they attached the mechanical lift cloth to the mechanical lift and transferred the resident from his/her chair into bed. Staff assisted the resident to roll towards the window and staff tucked the mechanical lift pad under the resident. Staff then rolled the resident towards the door and the lift cloth was removed. CMT Q and CNA R removed their gloves, performed hand hygiene and put new gloves on. Staff unfastened the resident's brief and tucked it down between his/her legs. Staff then provided perineal care (peri-care, care to the surface area between the thighs, extending from the pubic bone to tail bone). CNA R said the resident was incontinent of bowel. Staff did not wear a gown during the transfer nor while providing direct resident care. Observation on 4/9/25 at 6:50 A.M., 4/10/25 at 7:50 A.M., and 4/11/25 at 7:20 A.M., showed the EBP magnet remained on the door frame. No isolation sign was posted. During an interview on 4/10/25 at 10:10 A.M., Licensed Practical Nurse (LPN) S said the resident was on EBP because he/she had C-diff. During an interview on 4/10/25 at 9:20 A.M., CNA T said residents who had wounds or Covid had an EBP magnet outside their door. Staff should wear gloves, N95 mask, face shield and gown every time they enter the resident's room. During an interview on 4/10/25 at 9:47 A.M., CNA U said residents who had wounds had an EBP magnet outside their door. He/She performed hand hygiene and wore gloves for all personal care. He/She did not know if any other PPE would be required or not. During an interview on 4/10/25 at 10:10 A.M., LPN S said residents who have catheters or infections had an EBP magnet on their door frame. Staff should wear gloves and gowns while providing care. During report, the CMT/CNAs are made aware of which residents require PPE. During an interview on 4/10/25 at 12:00 P.M., CNA R said he/she was made aware which residents required PPE during report. If the resident had an EBP magnet outside their door, that meant the resident had an infection and staff should wear gown and gloves and if there are face shields by the door, they should also wear it. The PPE should be worn every time staff enter the room. During an interview on 4/11/25 at 9:40 A.M., with the Director of Nursing (DON) and the Infection Preventionist (IP), the IP said she was responsible for putting the EBP magnets out. Residents who have wounds, intravenous lines (IV), catheters and gastric tubes would have a magnet placed outside their door. Staff should wear gown and gloves while providing direct patient care. If staff was transferring a resident with the mechanical lift and the resident was already dressed, the staff are not required to wear a gown. If staff was performing peri care on a resident, staff should wear a gown. If a resident had C-Diff and their BM was not contained, that resident would be placed on contact precautions, but if the BM was contained the resident was placed on EBP. If the resident is on contact precautions there would be a sign on the door, if the resident was on EBP they would have a magnet on the door frame. C-diff is highly contagious, staff should wear gown and gloves while providing direct patient care. If staff do not wear a gown there is potential for bacteria to get on their clothes or on their hands and they could spread it to other residents or staff. The IP said she would expect for staff to wear the proper PPE. 2. Review of the facility's Insulin Administration via Pen Devices policy, last reviewed 5/2021, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and facility recommendations; -Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual. Review of Resident #67's medical record, showed: -Diagnoses included diabetes; -An order, dated 4/7/25 for Humalog insulin (short acting insulin) 8 units subcutaneous (under the skin) scheduled administration at 8:00 A.M., 12:00 P.M., 5:00 P.M. Observation on 4/8/25 at 11:22 A.M., showed LPN D obtained the lunch blood sugar for the resident with a blood sugar result of 160. He/She obtained a Humalog insulin pen and set the pen to administer 8 units. Observation of the insulin pen, showed a different resident's name listed on the pen. Before he/she could administer the insulin, the observation was stopped by the surveyor to prevent cross contamination to Resident #67. LPN D acted surprised and confirmed he/she had the wrong resident's insulin pen. At this time, he/she had to pull a new insulin pen from the E-kit (medication stock) for the resident. LPN D then primed and then resumed to administer the resident's ordered insulin. During an interview on 4/10/25 at 1:50 P.M., the DON confirmed that facility policy is for insulin pens to be assigned to the resident and insulin pens should never be shared among other residents for any reason. During an interview on 4/10/25 at P.M., the IP said it is important to keep insulin pens designated to one resident as opposed to sharing. Sharing insulin pens could have potential harm for blood borne pathogens to spread from resident to resident. Staff were in-serviced last month, March 26 & 27 at their annual training, regarding safety hazards if an insulin pen was to be utilized as a community pen instead of a single resident use as designed. After the in-service each nursing staff were assigned a competency test to show compliance with the education provided. 3. Review of the facility's Enhanced Barrier Precautions policy, dated July 2022, showed: -Purpose: To reduce the spread of multi-drug resistant organisms (MDRO); -Residents with colonization of MDRO or with indwelling devices will be placed on EBP; -Signage will be placed outside of their rooms to alert staff that PPE is needed; -PPE should be worn during high-contact resident care activities: Dressing, bathing/showering/providing hygiene/changing briefs or assisting with toileting; -Resident status: Has a wound or indwelling medical device without secretions or excretions that are unable to be contained and are not know to be infected or colonized with any MDRO: Use EBP. Review of Resident #22's medical record, showed: -Diagnoses included quadriplegia (paralysis or lack of function in all four limbs); -A care plan, in use at the time of the survey, showed: -Problem start date 4/8/25: Category: Infection: Resident is at risk for contracting MDRO due to wound that requires the use of PPE during high contact activities; -Approach: Resident is on EBP. Staff must perform hand hygiene before and after providing care. Staff to wear gloves and gowns when providing high contact activities. Observation on 4/9/25 at 7:34 A.M., showed the resident in bed. CNA V stood at the resident's bedside and wore gloves with no gown on. CNA V assisted to lower the resident's pants and provided perineal care. The resident was incontinent of bowel. CNA V assisted the resident to roll to his/her left side and then the right. As he/she assisted the resident to roll, his/her clothing pressed up against the resident. A dressing intact to the resident's buttocks was visible. After providing care, CNA V assisted the resident to use a urinal and get dressed. No gown was worn during care. Observation in the resident's room, showed a PPE caddy with gowns available. Observation of a sign outside the resident's room, showed EBP, perform hand hygiene and wear a gown and gloves. During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said if a resident is on EBP, a gown should be worn during perineal care because staff are attempting to curb the spread of the infection. 4. Review of the facility's Blood Glucose Monitors (Equipment Cleaning) policy, last revised February 2021, showed: -Purpose: To prevent the spread of blood borne pathogens; -Equipment used to obtain blood glucose (sugar) results that are used for more than one resident will be cleaned before and after each use; -A container of Oxivir TB (disinfectant) will be stored in each treatment cart; -Before and after the testing procedure, the nurse will cleanse the monitor with the Oxivir TB. Review of Resident #112's medical record, showed: -Diagnoses included diabetes; -An order dated 4/2/25 for insulin aspart (short acting insulin) administer 18 units three times a day with meals. The medication administration record required a documented blood sugar before administration. Review of Resident #157's medical record, showed: -Diagnoses included diabetes; -An order dated 3/13/25, for blood sugar check every 12 hours, scheduled at 8:00 A.M. and 8:00 P.M. Review of Resident #32's medical record, showed: -Diagnoses included diabetes; -An order dated 1/22/25, for blood sugar check twice a day, scheduled between 7:15 A.M. through 11:15 A.M. and 7:15 P.M. through 11:00 P.M. Review of Resident #141's medical record, showed: -Diagnoses included diabetes; -An order dated 8/7/24, for Humalog (short acting insulin), administer 7 units with meals. The medication administration record required a documented blood sugar before administration. Observation on 4/8/25 at 7:23 A.M., showed LPN E obtained a blood sugar machine from the medication cart and obtained a blood sugar result from the resident. He/She then wiped off the blood sugar machine with an alcohol wipe and placed the machine back into the top drawer of the medication cart. At 7:41 A.M., LPN E propelled the medication cart to the room of Resident #157. He/She obtained the resident's blood sugar result and cleaned the machine with the approved disinfectant wipes located in the bottom drawer of the medication cart. At 7:53 A.M., LPN E went to the room of Resident #32 and obtained a blood sugar result from the resident. The blood sugar machine was placed directly on the medication cart after use while LPN E administered insulin to the resident. LPN E returned to the medication cart and cleaned the machine with an alcohol wipe. At 8:06 A.M., LPN E went to the room of Resident #141. He/She obtained the resident's blood sugar result and cleaned the machine with the approved disinfectant wipes located in the bottom drawer of the medication cart. LPN E said he/she is agency and really does not get any orientation when coming to the facility for the first time. He/She can ask the staff about care needs of the residents. During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said staff should use Oxivir wipes to cleanse the blood sugar machines between resident use. Machines are not to be cleaned with alcohol. 5. Review of Resident #57's electronic Medication Administration Record (eMAR), for April 2025, showed orders for: -Acetaminophen (Tylenol) tablet 500 mg, administer 1000 mg by mouth three times a day; -Bethanechol chloride (for urinary retention) tablet, administer 25 mg by mouth three times a day; -Bisacodyl (for constipation) tablet 5 mg, administer 2 tablets once a day, every other day; -Diltiazem HCl (for high blood pressure) tablet 120 mg, administer 1 tablet by mouth once a day; -Docusate sodium (for constipation) tablet 100 mg, administer by mouth once a day; -Eliquis (blood thinner) tablet 2.5 mg, administer by mouth twice a day; -Ergocalciferol (vitamin D2, for vitamin d deficiency) capsule by mouth, 1,250 micrograms (mcg) or 50,000 units, administer one capsule by mouth, once a day on Mondays; -Furosemide (for fluid retention) table 20 mg, administer 1 tablet by mouth once a day; -Magnesium oxide (for constipation) tablet 400 mg, administer 1 tablet by mouth once a day; -Montelukast (for asthma) tablet 10 mg, administer 1 tablet by mouth once a day. During a medication administration observation on 4/8/25 at 8:10 A.M., showed CMT P prepared the residents ordered medication. He/She dropped one of the resident's pills directly on the medication cart. CMT P picked up the pill with his/her bare hand and placed it back in the medication cup with the other pills, then administered them to the resident. The medication cart had some white laxative powder spills on top of the cart when the CMT dropped and picked up the pill. During an interview on 4/11/25 at 9:40 A.M., the DON said if a staff member dropped a pill, she expected him/her to discard the pill and obtain a new one. 6. Observation on 4/8/25 at 6:27 A.M., showed Laundry Attendant A propelled an uncovered laundry rack full of resident personal clothing, down the 400 halls. At 6:29 A.M., Laundry Attendant A said the facility does all their own laundry. They do not outsource any laundry. They do linen, towels, resident clothing, etc. they have staff on all shifts. Day, evening, and night. Observation of the laundry room on 4/9/25 at 10:36 A.M., showed two different types of personal laundry racks. One that had a cover and one that did not. Laundry Attendant B said resident personal clothes are transported to the halls using the hanging cart with a cover. The uncovered cart is for laundry room use only. During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said clean resident clothing should be covered when transported down the hall. If not covered, contamination could occur. 42247 45083 52419

Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not ensure one resident's (Resident #53's) shower drainage was properly maintained to allow water to flow unobstructed. The sample size was 35. The census was 181. Review of Resident #53's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed the following: -Diagnoses included dementia and chronic obstructive pulmonary disease (COPD, lung disease); -Shower/bathe self with Partial to moderate assistance. Review of the resident's care plan, dated 3/11/25, showed a deficit in mobility and activities of daily living (ADL) functions with COPD, dementia with cognitive impairment, and the need for occasional supervision and cueing with ADLs. Observation of the resident's shower on 4/7/25 at 2:39 P.M., showed the shower floor had a slight slope towards the drain which created a pool of water within 20 seconds during the water flow. Observation of the resident's shower on 4/8/25 at 1:55 P.M., showed the shower floor had a slight slope towards the drain which created a pool of water that measured 4 inches in dominator during the 1 minute and 2 second water flow duration. Observation of the resident's shower on 4/9/25 at 7:41 A.M., showed the shower floor had a slight slope towards the drain which created a pool of water that measured 10 inches in diameter during the 2 minute water flow duration. During an interview on 4/7/25 at 2:39 P.M., the resident said he/she had reported the issue to staff last week, but it was still not fixed. When he/she attempted to take a shower this morning, he/she could not wash his/her hair and only rinse off due to the amount of water that was backing up. During an interview on 4/9/25 at 10:15 A.M., Certified Nursing Assistant (CNA) K said the resident made him/her aware of the water backup in the shower a few days ago but he/she could not remember the exact day. He/She immediately told Maintenance L when he/she walked past him/her in the hallway. He/She had no knowledge if the problem was fixed. The process in which staff inform the maintenance department of any issues is when maintenance passes them in the hallway, they let them know. During an interview on 4/9/25 at 10:20 A.M., Maintenance L said he/she could not remember if he/she was made aware of the drain in the resident's shower, but he/she probably was and just forgot. He/She is generally made aware of any maintenance issues by the staff when he/she passes the staff in the hallway. Maintenance L is unaware of any maintenance log or any other type of maintenance request system to document maintenance needs. During an interview on 4/9/25 at 9:40 A.M., Receptionist M said when he/she gets maintenance or housekeeping requests, it is recorded in the carbon copy call-log book. He/She then gives the top copy to the appropriate department. Receptionist M was unsure if all the other receptionists do the same. During an interview on 4/10/25 at 8:45 A.M., the Maintenance Director said he was unaware there was an issue in the resident's shower. The facility does not have a process to document maintenance concerns. Staff will tell maintenance in passing if they have concerns. It was not uncommon for things to be forgotten when they are reported maintenance as they are walking by to complete another task. However, requests are also sometimes given to the receptionist. He expected for the shower drain to have been unclogged the same day they were made aware of the issue.

Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resident (Resident #67). Two Certified Nursing Assistants (CNAs) placed a gait belt around Resident #67's abdomen loosely, and both CNAs placed their arms directly up and under resident's arm pits to lift the resident. One CNA grabbed his/her waistband to pull him/her to a standing position. The sample was 35. The census was 181. Review of the facility's Gait belt policy, dated effective 7/2015, Reviewed 6/21, showed: -Wrap gait belt around resident's waist and pull the strap through the buckle to tighten; -4. Gait belt should be snug but not uncomfortable. Make sure you can slide your open flat hand between the belt and resident; -6. Face resident when assisting resident with mobility by pulling on belt; -9. Follow proper body mechanics when using gait belt and refer to transfer policy for proper transfer techniques. Review of Resident #67's diagnoses, showed dementia, mood disturbance, anxiety, high blood pressure, type 2 diabetes mellitus with diabetic neuropathy-Polyneuropathy (with a decrease in nerve sensation), cervical disc degeneration (degeneration of the spine in the neck area), urinary incontinence, age-related physical debility, and repeated falls. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/30/24, showed: -Cognitively intact; -Used a wheelchair; -Range of motion coded no impairment Review of the resident's physician orders, showed an order, dated 1/7/25, transfer order: x1 assist. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: At a risk for falls, due to dementia, high blood pressure and incontinence; -Goal: Decrease the risk of falls and/or injury should a fall occur; -Intervention: Assess for additional safety devices and ability to use call-light. Staff will also adjust environment low stimulation and free from clutter for increased confusion and poor vision; -The care plan updated as of April 1, 2025, to show the residents recent decline in mental and physical status. Observation on 4/8/25 at 8:04 A.M., showed CNA N entered the resident's room. CNA O also entered the resident's room. A CNA placed a gait belt above the resident's belly button but below the breast line loosely. His/Her wheelchair was positioned perpendicular to the bed. Both CNAs placed their forearms directly underneath his/her arm pits and lifted the resident to an upright stance. Resident # 67 was not given any warning, or verbal communication prior to the CNAs lifting him/her out of the wheelchair. Resident #67 had a tennis shoe on the right foot and a heel protective boot (heel float boot) on the left foot. During the transfer the resident's legs were in a locked position and the resident did not pivot his/her feet. When staff placed him/her in bed, his/her legs faced to the left, and his/her upper body leaned right in a twisted and unnatural body alignment. During an interview on 4/9/25 at 11:38 A.M., Physical Therapy Assistant (PTA) F said he/she was involved with the resident's therapeutic needs regarding range of motion (ROM). He/she has worked with the resident approximately 7 times since the beginning of 2025. He/She acknowledges the resident's ability to use a sliding board for self-transfer with a CNA present. He/She is unaware what medical change occurred, but noticed a mentation change that included decline in physical stamina along with personality and assumed a urinary tract infection (UTI). PTA F recalls the resident falling and it physically took 3 staff members and the PTA assist to help Resident #67 into a chair. After that encounter, PTA F believes Resident #67 was sent to local hospital for an evaluation. Since his/her return from a week long hospitalization , no new orders or physical assessment was completed. Resident #67 remains a x1 assist. During an interview on 4/8/25 at 10:30 A.M., the Director of Physical Therapy said she was unable to give specifics regarding Resident #67 and is unfamiliar with personalized care of residents at this time. On 4/9/25 at 11:30 A.M., the Director of Physical therapy said a resident who required a 2 person assist with a gait belt would present like this: a staff member would position the chair 45 degrees to one side of the bed. The gait belt would be positioned around the upper portion of the belly button but below the breast line. The safety device should appear snuggly, but not tightly. Both staff members need to be in ready motion, with a staff personnel standing in the front of the resident. Staff should have bent knees, providing verbal cues to the resident before the resident is in an upright stance. Personnel continues verbal commands to the resident until the transfer is completed. The resident's body would remain free from abnormal ligament, twisting motions or restricting devices limiting range of motions, which includes a heel float boot. During an interview on 4/10/25 at 1:50 P.M., the Director of Nursing (DON) said nursing staff should transfer residents according to facility policy. He/She confirmed the proper technique was to use a gait belt around the mid sections of the individual and have the belt snuggly, leaving enough space for the CNA's hand to slide comfortably between the resident and the belt. The belt is the only garment that should be held by the staff when transfers occur. Using an article of clothing, for example utilizing a fabric waist band, would be considered noncompliant with facility policy. Failure to follow policy could lead to harm to staff and ultimately the resident. It is essential for there to be verbal communication from staff to Resident #67 during the transfer. Failure to provide cues or step by step directions during the transfer can lead to confusion. A resident who is dependent on 2 staff assist is required to be able to pivot their own weight during the transfer. He/She could not see a safety concern with a resident being transferred with a heel protective boot on. The resident should be a mechanical lift if they cannot transfer themselves or a physical decline is noted. Resident #67 was noted to have a decline and is not fully back to baseline after readmission from the hospital.

Based on interview and record review, the facility failed to ensure intravenous (IV) services provided were consistent with professional standards of practice when a Licensed Practical Nurse (LPN) removed a peripherally inserted central catheter (PICC line, a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck that is used for IV medications and fluids) for one resident (Residents #142). The sample was 35. The census was 181. Review of the Rules of Department of Commerce and Insurance, Division 2200-State Board of Nursing, Chapter 6-Intravenous Infusion Treatment Administration, dated 5/31/24, showed: -Definitions: Administer: to carry out comprehensive activities involved in IV infusion treatment modalities that include, but are not limited to, the following: observing; performing; monitoring; discontinuing; maintaining; regulating; adjusting; documenting; assessing; diagnosing; planning; intervening and evaluating; -Central venous catheter: a catheter that is advanced through the internal jugular vein (vein in the neck), cephalic (a superficial vein in the arm) or basilic vein(vein in the upper arm) in the antecubital fossa (front of the elbow, between the arm and forearm) or subclavian vein (vein under the collarbone), with the catheter tip terminating in the superior vena cava (a large vein that carries deoxygenated blood from the head, neck, arms, and upper chest back to the heart). Central venous catheters may be used to administer prescribed IV infusion treatments modalities or to perform prescribed IV infusion diagnostic procedures and include but not limited to PICC (line); -Graduate practical nurses, IV-certified LPN, and LPN nurse who hold an active multistate license to practice under the nurse licensure compact shall not, under any condition, perform the following functions or duties: -Remove a mid-line catheter (a catheter that is inserted into a vein in the antecubital fossa and then advanced three to 12 inches into the proximal (near the center) upper arm) or any type of central venous catheter. Review of the facility's LPN Job Description, undated, showed: -IV certified LPNs may manage IVs within the restrictions of his/her certification. They may not administer IV push medications, may not add medication to IV fluids and may not access an implanted port; -See that all physician orders are carried out or appropriate arrangements made. Review of the facility's investigation, dated 1/29/25 through 1/30/25, showed: -On 1/29/25, nurse discontinued IV PICC line on 1/28/25; -On 1/28/25, Register Nurse (RN) placed call to Infectious Disease (ID) to obtain order to remove at 9:47 A.M.; -On 1/28/25, resident requested PICC line to be discontinued; -On 1/28/25, an order was obtained (LPN) at 9:51 P.M., -On 1/29/25, no adverse outcome, educated LPN on practice; -On 1/30/25, no adverse outcome. Review of the nursing schedule dated 1/28/25, showed, 2:30 P.M. through 11:00 P.M. there was two RNs scheduled and 10:30 P.M. through 7 A.M., there was one RN was scheduled. Review of LPN Z's employee file, showed: -LPN had an active license and was IV certified; -The Counseling Form dated 1/29/25, showed: -When performance or behavior issues arise, a counseling session is used to help employees focus on the area of concern. The issue that leads up to this counseling is: removed PICC line; -In order to achieve acceptable level of performance, the following change(s) must take place: you must practice within your scope. LPN may insert, remove IV lines that are three inches or less in length. You may administer medications and flush a PICC line; -As an employer, we will provide the following support, training and/or coaching to help you achieve this goal: if procedures come up or orders are obtained that are not within your scope of practice you must defer the procedure to an RN or report to the Director of Nursing (DON) so he/she can delegate; -Services we suffer when we do not follow proper procedures or behave in an acceptable manner. The consequence of this is: termination on any other practice completed by you that is outside your scope of practice; -The form was signed by the LPN Z, the DON and the Administrator on 1/30/25. Review of Resident #142's admission quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/25, showed: -Cognitively intact; -Diagnoses included: wound infection; -Had IV access while a resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: heart failure, high blood pressure, wound infection, anxiety and depression. Review of the care plan in use at the time of survey, showed: -Problem: Resident required IV medication; -Goal: Resident will not exhibit signs of complications from IV (localized infection,(infection in one part of the body), systemic infection (an infection that has spread throughout the body), electrolyte imbalance, air embolus (one or more air bubbles or gas bubbles enter a vein or artery and block it) dislodgement, infiltration (the leakage of IV fluids or medications into the surrounding tissue instead of the vein), extravasation (leakage of a solution that can cause tissue damage), phlebitis (inflammation of a vein), fluid overload (occurs when the body receives more fluid than the body can process), dehydration); -Interventions included: Discontinue IV at the first sign of infiltration or local inflammation. Created: 1/07/2025. Discipline: Nursing. Review of the progress notes dated 1/27/25 through 1/28/25, showed: -On 1/27/25 at 11:46 A.M., PICC line no signs and symptoms of adverse reaction noted, stop date for vancomycin (antibiotic) per pharmacy was 1/26/25; -On 1/28/25 at 9:47 A.M., call placed to ID office to find out about PICC line removal order or if need any lab draw or follow up appointment. Will be faxing new orders to the facility; -On 1/28/25 at 9:52 P.M., resident request the PICC line to be removed due to possible infiltration/line unable to be flushed and because line was dislodged and hanging from site barely intact. Call place to Medical Doctor (MD). New order, ok to remove PICC line until further orders received from infection control. Review of the Medication Administration Record (MAR) dated 1/1/25 through 1/31/25, showed: -A physician order to remove the PICC line; -Documentation showed on 1/28/25 at 10:00 P.M., the PICC line was removed by LPN Z. During an interview on 4/9/25 at 6:55 A.M., the resident said he/she did not recall any issues with his/her PICC line. The staff administered his/her medications and flushed it without any problems. The dressings were changed weekly. During an interview on 4/8/25 at 3:15 P.M., LPN Z said LPNs could administer medications and flush PICC lines. They could also change the dressings and remove them in an emergency. The resident had a PICC line in his/her left arm and he/she wanted it out. LPN Z went into the room to assess the resident. The PICC line was not intact, the line was exposed three to four inches and the dressing had come loose. Basically, the line came out, they were no longer stitching the PICC lines in place. LPN Z said in the moment he/she was concerned the resident could go septic (a severe and potentially life-threatening response to an infection, often triggered by bacteria) because the resident had Methicillin-Resistant Staphylococcus Aureus (MRSA, infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) on his/her skin. The nurse called the physician and obtained an order to discontinue the PICC line. He/She did not have to pull too much to remove the PICC line. The PICC line was discontinued on the night shift and there was no RN in the building. There was an on-call supervisor, but he/she did not call them. The DON was notified the next day, and she provided education on what LPNs could do and she clarified the difference between the IV lines. During an interview on 4/9/25 at 8:55 A.M. LPN AA said LPNs could flush and administer medications through the PICC line. LPNs could not discontinue them. During an interview on 4/10/25 at 10:10 A.M., LPN S said LPNs could not discontinue PICC lines. If he/she got an order to discontinue it, he/she would tell the Assistant Director of Nursing (ADON) or the DON. During an interview on 4/8/25 at 2:03 P.M. and at approximately at 4:00 P.M., and on 4/9/25 at 9:23 A.M., the DON said LPNs could administer medications and flush PICC lines. LPNs could not remove them. The resident wanted his/her PICC line out. The day nurse called the ID doctor and left a message. The evening nurse, LPN Z, called the primary care physician and obtained an order to remove the PICC line. Then, he/she went into the resident's room and removed it. As far as the DON knew, the PICC line was intact at the time it was removed. There was an RN in the building on both the evening and the night shift that day. LPN Z did not know he/she could not remove the PICC line and that it was out of his/her scope of practice. LPN Z was provided education on his/her scope of practice and the difference between the lines. If an LPN obtained an order to discontinue a PICC line and/or there was no RN in the facility, the DON would expect for the nurse to leave the line in place and notify a RN/nurse manager or the DON. The DON also expected staff to practice within their scope of practice. MO00250188

45083 Based on interview and record review, the facility failed to timely address the pharmacist recommendations from the Drug Regimen Review (DRR) for two residents (Residents #157 and #16). The sample was 35. The census was 181. Review of the facility's DRR policy, dated reviewed 5/21, showed: -Policy: the consultant pharmacist reviews the medications for each resident for any irregularities and to: verify appropriateness of the medications involved; evaluate disease state management; ensure appropriate medication monitoring to maximize safety and efficacy; and prioritize patient goals, safety, and quality of life; -Procedures: the consultant pharmacist reviews each resident chart to identify and address any irregularities: medication duration and medication monitoring; -The consultant pharmacist will review the chart of every resident each month and document the DRR as follows: the consultant pharmacist will utilize a current census or resident lists in the electronic medical record (EHR) to ensure that all active residents have been reviewed each month; -All recommendations (including no recommendations) will be printed each month (within 72 hours of completing all the DRR's in the facility) and sent to the corresponding Director of Nursing (DON) via a delivery company to distribute and get completed; - Pharmacy consults should be signed, completed, and acted on within 30 days of being sent to the facility; -The facility should write a description of their attempts to get the consult completed on the actual consult (or in response to the observation in EHR). For example, faxed to physician on these dates; put in physician mailbox on this date, etc.; -Each month the consultant pharmacist will follow up on previous consults, nursing consults will be repeated the following month if not completed; physician consults will be repeated 2 months later if not completed. 1. Review of Resident #157's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/3/25, showed: -Readmitted [DATE]; -Cognitively intact; -Highly impaired vision; -No behaviors or rejection of care; -Diagnoses included: stroke, high blood pressure, diabetes, anxiety and depression. Review of the physician order sheet, in use at the time of survey, showed a physician order for tobramycin 0.3%, instill one drop into left eye three times a day until healed and reassessed by the medical doctor (MD). Start date was 3/13/25. Review of the Pharmacist Recommendation to Prescriber, dated 10/18/24, showed: -Findings/recommendation: the resident has an order for tobramycin eye drops since 3/31/24 with special instructions of until healed and reassessed by the MD. The pharmacist could not find any notes if this had been assessed and if the tobramycin could be discontinued. The optometrist notes from 5/6/24 dose does not mention this medication. Please clarify with MD; -Prescribers comments: please contact ophthalmologist, dated 11/10/24. Review of the eye clinic notes, showed: -On 11/6/24, the note did not address the tobramycin; -On 3/7/25, the visit was cancelled. Patient said the light was too bright and wasn't able to keep his/her eyes open for exam. During an interview on 4/11/25 at 9:20 A.M., 9:40 A.M. and 12:24 P.M., the Assistant Director of Nursing (ADON) said the facility did not receive the recommendations the day the pharmacist reviewed the resident's chart. Sometimes it took a couple of weeks for the facility to receive the pharmacy recommendations. Once the recommendations were delivered, the DON divided the recommendations out by physician and put them in their folders to be reviewed during their next visit. Once the recommendations were reviewed, the MD or the nurse should put a note in the medical record. The eye clinic visited the facility twice a month, but the residents were only seen every six months. The ADON looked at the resident's medical record and did not see where the recommendation was addressed. The ADON said the nurse placed a call to the physician to ask about the recommendation. The physician said the resident could continue the eye drops. The ADON would have expected the pharmacy review to have been addressed before today. 2. Review of Resident #16's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included heart disease, high blood pressure, diabetes, and high cholesterol. Review of the resident's electronic pharmacist DRRs, dated 9/27/24, 12/13/24, and 2/3/25, showed: -Please take the following actions: Resident receives the following lipid-lowering medication(s): Atorvastatin 40 milligram (mg) tablet; -Package insert and clinical guidelines recommend periodic checks of fasting lipid panels to monitor therapy; -None in chart since 4/2023; -Check fasting lipid panel now and yearly going forward. Review of the resident's laboratory results, showed the most recent lipid panel was on 4/4/23. The facility did not provide laboratory results after 4/23. No hard copies of the pharmacist DRR sheets were provided on the review dates referenced in the pharmacy DRR recommendations. During an interview on 4/10/25 at 12:42 P.M., the DON said they would not address the pharmacist's DRR and/or recommendations until they received the actual hard copies which were provided by pharmacy staff a few days after the electronic versions were posted electronically. They then sort out the DRR sheets and distribute to corresponding providers. They scanned the DRR sheets into the electronic health records once the providers addressed the DRR. During an interview on 4/11/25 at 11:09 A.M., the Primary Care Physician (PCP) said he/she did not know how those three pharmacy DRR recommendations were missed. The PCP said if not scanned into the EHR, they would not be seen or addressed. He/She said the resident's previous lipid panels were good. He/She ordered to have the resident's lipid panel drawn and will be done for the 5/2/25 schedule. 3. During an interview on 4/11/25 at 11:59 A.M., the Pharmacy Consultant said all their DRR sheets were delivered to the facility a few days after being posted electronically. The providers may not be able to address the recommendations, depending on the timing of the visits, for up to three weeks. The pharmacy sends a monthly summary of all the residents reviewed, through email, in addition to the individual sheets provided. 4. During an interview on 4/11/25 at 11:43 A.M., the DON said she expected the staff to make sure the monthly Pharmacist DRRs were addressed timely and to follow the provider's orders.

See Event ID 0G6G12 Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180.

See Event ID 0G6G12 Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent roaches and gnats in the kitchen, where residents' food was prepared and served. The census was 181. Review of the facility's Pest Control Policy, revised 08/2024, showed: -Purpose: To ensure that the facility is free to exposure to pests to include, but not limited to insects, cockroaches, rats, mice, bed bugs, etc; -Procedure: -The Director of Environmental Services is the designated coordinator for this facility. This person acts as a liaison between the building occupants and the pest management provider; -Regular inspections will be performed by both the Director of Environment Service/designee and the contracted pest management professional. They will note situations that are conducive to pest populations and recommend repairs, sealing of pest entry points, clutter reduction, improved sanitation, and monitoring procedures; -Repairs will be performed as needed to prevent pest access to buildings or to hiding spaces in walls and equipment. Water leaks will be repaired, and standing water will be eliminated whenever possible; -Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests; -Proactive/preventative measures for roaches and other pest: The Environmental and Dining Services staff will regularly inspect and perform and/or request preventative maintenance to ensure areas are clean, dry and pest free; -Wet places: Water is the main draw for any pest, so inspect sinks (including under the lip), dishwashers, pipes, cooler and refrigerator doors, ice machine lids and other areas of water pooling and condensation. Include drains and wet floor mats; -Areas where food debris accumulates: Organic matter collects just about anywhere in a commercial kitchen. Look in the obvious areas - where food is stored, prepared, and served, and where trash is discarded - but also in less conspicuous places, i.e. under equipment; -Storage rooms: Remove all cardboard boxes and other clutter provide harborage for roaches, rodents, and ants; -Heat sources: Inspect all equipment that generates heat, pests will gravitate toward it; -Cracks and holes: Look for any structural weaknesses that might offer pests access to the kitchen. Also check for cracks in the floor tile or worn-away grout; -Drains and garbage disposal: Roaches are nocturnal, so it is important to block drains at night after pouring Consume Chemical (enzyme that removes food source) down each kitchen drain and garbage disposal (after ensuring disposal is clean and free of food/garbage). Run hot water down sink for a couple minutes prior to pouring Consume down disposal; -If a roach/pest infestation is found in kitchen or service area, proceed with the Night Kitchen Cleaning - Roach/Pest Control check list and immediately call provider. Review of the facility's Kitchen/Service Area/Dry Storage and Dish Room Night Cleaning/Checks - Roach/Pest Control form, showed: -Leave floor fans blowing at top speed in infested area(s); -Ensure no leaks or water sitting in areas; -Ensure all food is completely covered--NO FOOD SHOULD BE LEFT OUT AT NIGHT; -Ensure no open cracks/crevices in walls/floors; -Ensure that no produce boxes, paper bags or cardboard are left in area; -Ensure no dirty dishes are left on dish machine; -Cover all floor and sink drains with stopper and/or rubber mats every night. Review of the facility's Pest Control vendor binder, showed: Areas of concern: -9/29/23: Gnats entire dietary kitchen, office, dish room and janitor area; -10/28/23: Kitchen and doors to kitchen, roaches; -5/20/24: Human Resource/Public Relations office - roaches; -5/21/24: 500 Serving and hot cart - roaches; -8/19/24: Roaches in Recreation office; -The pest control binder concerns were written randomly, were not in chronological order, and did not include the concern for all entries. During an interview on 8/21/24 at 10:14 A.M., the Maintenance Director said he had gone around the facility to caulk cracks and holes, anywhere there were hiding spots. He measured all the drains and was in the process of getting covers for the drains. He thought keeping food put away and boxes off the floor would help because the boxes were just an extra place for the roaches to hide. He said the night staff in the kitchen was supposed to put baking soda and vinegar down the drains after dinner. He was Floor Technician D's supervisor, but he didn't know if he/she had sprayed or treated the kitchen in the evening with the chemical. Observation of the facility's main kitchen on 8/20/24 between 10:49 A.M. and 11:55 A.M., showed: -Bait traps filled with brown cockroaches; -Cockroaches crawled on multiple walls and on the floor in the kitchen; -There were dead cockroaches in the corners of the kitchen floor; -There was a dead cockroach on a prep table near two boxes of gloves; -Multiple cockroaches crawled on the silver platform where dishes were placed for washing after meal service; -Some cockroaches were dead on the platform in puddles of water; -There were three large white trash bags tied up on the floor near a large trash can in the kitchen; -There was one black fan in the kitchen near a door and was not running. During an interview on 8/20/24 at 10:49 A.M., the Dietitian said the Kitchen Manager was not in today. She said the pest control company came out two times a week. The pest control company left Maintenance some of the chemical used to treat the roaches in the kitchen. The Dietitian said staff sprayed the kitchen last night and thought that was why the roaches were so active today. During an interview on 8/20/24 at 11:15 A.M., a Dietary Aide A said the facility had a lot of roaches and gnats. He/She was told the facility was sprayed last week. He/She had seen the pest control person spray and take away old traps. He/She didn't know when the last time the roach bait traps had been replaced. He/She had seen roaches crawl on resident's plates, but he/she did not serve those plates to residents. Observation on 8/20/24 at 11:15 A.M., showed brown boxes in the walk-in cooler and one large brown box on the floor near a trash can in the kitchen. During an interview on 8/20/24 at 11:55 A.M., Dietary Aide C said bugs and roaches came out from time to time. He/She said a company sprayed every other week and Maintenance had sprayed before too. He/She was off yesterday but thought the last time the facility had been sprayed was four days ago. Observation on 8/20/24 at 11:55 A.M., showed boxes and other items on the floor and up against the wall in the office located in the kitchen area. During an interview on 8/21/24 at 10:28 A.M., Resident #3 said he/she had seen roaches in his/her room before but not many. He/She saw roaches on the dining room floor yesterday, but not in his/her food. During an interview on 8/21/24 at 2:17 P.M., Resident #2 said he/she had seen roaches in his/her room and the dining room. He/She said the facility tried to spray when they were told about the roaches. He/She saw roaches crawling on his/her friend's chair in the dining room at lunch today. Resident #2 said he/she had friends living in the facility, whose rooms were infested with roaches. He/She said the residents were moved to a different room and all their clothing was thrown away because of the roaches. He/She said the facility tried to blame the roaches on the residents, but they were clean people. He/She didn't think they were the reason for the roaches in their room. During an interview on 8/20/24 at 12:08 P.M., the Administrator said the pest control company came out last night, so he stayed late. Two guys came out last night and set traps and sprayed an aerosol and liquid spray. The Administrator said he didn't know if the pest control company changed the bait traps every time they came, but they sprayed the kitchen every two weeks. The pest control company left the facility some of the spray concentrate and a Maintenance Technician sprayed the kitchen with it a couple times a week. He said staff mopped the kitchen everyday but the owner of the pest company, who was there last night, said the pest control company told him not to mop the floors for at least twelve hours. The Administrator said before the owner told him that, staff mopped the floor after each meal. He said he had help to power spray the kitchen floor and found he was standing in water. The water wasn't going down the drain. He thinks the facility had the roaches on the run and were in pretty good shape. The Administrator said the pest control company didn't give him any written recommendations but said they were supposed to keep the standing water off the floor. During an interview on 8/20/24 at 1:51 P.M., a Pest Control Company Representative said on 8/19/24, the owner of the pest control company told him/her the roaches were from produce boxes and deliveries being brought into the facility. He/She said that's usually where the problem started. The Pest Control Company Representative said the owner also said the facility's cleaning needed to be stepped up and getting the boxes out of the facility would really help. He/She said getting the water off the floor would really help. When water was on the floor and the chemical was sprayed, it laid on top of the water and was washed away when the water was cleaned up or went down the drain. He/She said water rendered the chemical ineffective. He/She said keeping the floor dry and clean was all that was needed to be done. He/She didn't know if the problem was improving or not but was told it seemed to be improving. Observation and interview on 8/20/24 at 2:01 P.M., showed one black fan running in the kitchen. Dietary Aide A said the fan was on because the kitchen was hot. He/She said the Dishwasher/Pot Cleaner cleaned the floors. During an interview on 8/20/24 at 2:06 P.M., the [NAME] E said he/she cleaned the front line at the end of shift. The fan was on to help keep the kitchen cool. The building was old and had cracks for roaches to hide. He/She saw the pest control company before but didn't know how often they came. He/She said maybe every two weeks. During an interview on 8/21/24 at 9:42 A.M., the Administrator said staff knew what the cleaning procedure was, and they had been in-serviced. He said the exterminator said the more fans the facility had in the kitchen the better it would be. The Administrator was was told dietary staff said they used the fan to cool off the kitchen and not used as an intervention for the roaches to keep the floor dry. He said not all staff had been in-serviced on the purpose of the fan to deep the floor dry as an intervention for roaches. The checklist was just created last week. They would in-service everyone. The Administrator said they started taking the boxes out of the kitchen at night and put them in the storeroom they used to share with maintenance. Bugs like boxes and water, so taking the boxes out at night would give the kitchen a clean slate every morning. The Administrator said he spoke with the owner of the pest control company and was told to keep everything off the floor in the kitchen and to keep it dry. He said the owner of the pest control company suggested using bleach and water for the drains, but he thought that might be bad for the pipes, so he suggested baking soda and vinegar. The Administrator said the night shift dishwasher or floor technician was responsible to use the baking soda and vinegar. Dayshift had a cleaning schedule, but it was different from night shift's deep cleaning schedule. MO00240710 MO00240668

Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180. Review of the facility's Physician Orders, Following policy, dated 6/29/21, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts; -Procedure included: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -All physician or other healthcare professional's verbal, telephone or written orders will be immediately entered into the electronic health record (EHR) by the nurse obtaining the order. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed: -No cognitive impairment; -Diagnoses included: stroke, congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body). Review of the resident's care plan, last reviewed on 8/24/24, and in use during the survey, showed: -Problem: Resident receives daily diuretic therapy (any substance that promotes diuresis, the increased production of urine) related to diagnosis of CHF; -Goal: Resident will not exhibit signs/symptoms of hypokalemia (low potassium)/dehydration and will be monitored on an ongoing basis; -Interventions included obtain/record weight as ordered. Review of the physician order sheet (POS) , showed an order, dated 8/24/24,for daily weights. Call physician group if weight is up more than three pounds in one day or five pounds in a week. Review of the resident's medical record, showed a letter from the resident's cardiologist to the facility, dated 9/11/24. The letter included: Resident's cardiologist is requesting resident's daily weights to be sent to our office on a weekly basis starting on 9/11/24. Fax number provided. Review of the resident's medical record, showed: -A progress note, dated 9/12/24: New order entered to fax daily weights to resident's cardiologist on a weekly basis. This nurse entered order into EHR for every Monday; -A progress note, dated 9/12/24: This nurse faxed daily weights from 9/1/24 through 9/11/24 to resident's cardiologist; -No documentation staff faxed the resident's weight on the following two Mondays, 9/16 and 9/23/24; -A progress note, dated 9/26/24: Around 12:45 P.M. spoke with representative from resident's cardiologist's office. Informed weights for 9/1 through 9/11/24 were received and weights for 9/12 until now needed to be re-faxed, along with CHF form. Form completed and faxed as requested. Review of the POS, showed an order dated 9/27/24, daily weights to physician's office on a weekly basis starting on 9/11/24. Once a day on Mondays. Review of the resident's medical record, showed: -No documentation staff faxed the resident's weight on the following Monday, 9/30/24; -A progress note, dated 10/7/24: Weekly weights faxed to resident's cardiologist. During an interview on 10/9/24 at 12:21 P.M., LPN A said physician orders should be followed. Any nurse could have faxed the resident's weights to his/her cardiologist. He/She said the resident's family member was there last night asking about the weights. Yesterday, LPN A reviewed the resident's weights through 10/7/24 and faxed them to the cardiologist. LPN A said the nurse assigned to the resident on Mondays was responsible to fax the weekly weights to the cardiologist. LPN A said new orders pop up on the EHR screen to sign off on and when there was something to complete for the order. During an interview on 10/9/24 at 12:39 P.M., LPN D said physician orders should be followed and care plans should be followed as best as possible. During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said nurses knew when there were new orders through shift report and the new orders would pop up on their screen for them to sign off on. She said existing orders would pop up too on the nurse's screen if the order required the nurse to do something. They communicated the resident's weights over the phone with the cardiologist's office. She expected nurses to fax the weights every Monday between 7 A.M. and 3 P.M., as the physician order specified. The nurse responsible for faxing the resident's weights was the nurse assigned to the resident on that shift. The DON said nursing staff spoke to the cardiologist and the cardiologist's office said they received all the weights. She couldn't say what the impact of not receiving the weights would be because all residents were different. MO00242708

Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180. Review of the facility's Physician Orders, Following policy, dated 6/29/21, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts; -Procedure included: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -All physician or other healthcare professional's verbal, telephone or written orders will be immediately entered into the electronic health record (EHR) by the nurse obtaining the order. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed: -No cognitive impairment; -Diagnoses included: stroke, congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body). Review of the resident's care plan, last reviewed on 8/24/24, and in use during the survey, showed: -Problem: Resident receives daily diuretic therapy (any substance that promotes diuresis, the increased production of urine) related to diagnosis of CHF; -Goal: Resident will not exhibit signs/symptoms of hypokalemia (low potassium)/dehydration and will be monitored on an ongoing basis; -Interventions included obtain/record weight as ordered. Review of the physician order sheet (POS) , showed an order, dated 8/24/24,for daily weights. Call physician group if weight is up more than three pounds in one day or five pounds in a week. Review of the resident's medical record, showed a letter from the resident's cardiologist to the facility, dated 9/11/24. The letter included: Resident's cardiologist is requesting resident's daily weights to be sent to our office on a weekly basis starting on 9/11/24. Fax number provided. Review of the resident's medical record, showed: -A progress note, dated 9/12/24: New order entered to fax daily weights to resident's cardiologist on a weekly basis. This nurse entered order into EHR for every Monday; -A progress note, dated 9/12/24: This nurse faxed daily weights from 9/1/24 through 9/11/24 to resident's cardiologist; -No documentation staff faxed the resident's weight on the following two Mondays, 9/16 and 9/23/24; -A progress note, dated 9/26/24: Around 12:45 P.M. spoke with representative from resident's cardiologist's office. Informed weights for 9/1 through 9/11/24 were received and weights for 9/12 until now needed to be re-faxed, along with CHF form. Form completed and faxed as requested. Review of the POS, showed an order dated 9/27/24, daily weights to physician's office on a weekly basis starting on 9/11/24. Once a day on Mondays. Review of the resident's medical record, showed: -No documentation staff faxed the resident's weight on the following Monday, 9/30/24; -A progress note, dated 10/7/24: Weekly weights faxed to resident's cardiologist. During an interview on 10/9/24 at 12:21 P.M., LPN A said physician orders should be followed. Any nurse could have faxed the resident's weights to his/her cardiologist. He/She said the resident's family member was there last night asking about the weights. Yesterday, LPN A reviewed the resident's weights through 10/7/24 and faxed them to the cardiologist. LPN A said the nurse assigned to the resident on Mondays was responsible to fax the weekly weights to the cardiologist. LPN A said new orders pop up on the EHR screen to sign off on and when there was something to complete for the order. During an interview on 10/9/24 at 12:39 P.M., LPN D said physician orders should be followed and care plans should be followed as best as possible. During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said nurses knew when there were new orders through shift report and the new orders would pop up on their screen for them to sign off on. She said existing orders would pop up too on the nurse's screen if the order required the nurse to do something. They communicated the resident's weights over the phone with the cardiologist's office. She expected nurses to fax the weights every Monday between 7 A.M. and 3 P.M., as the physician order specified. The nurse responsible for faxing the resident's weights was the nurse assigned to the resident on that shift. The DON said nursing staff spoke to the cardiologist and the cardiologist's office said they received all the weights. She couldn't say what the impact of not receiving the weights would be because all residents were different. MO00242708

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180. Review of the facility's Transfer and Lift policy, reviewed 5/2021, showed: -Purpose: To provide communication to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safety of our residents including acknowledgement that this facility has adopted a NO LIFT policy (approach that aims to reduce or eliminate staff from the manual lifting of residents) by for residents requiring a mechanical means of transfer; -Upon admission each resident will be assessed by the inter-disciplinary team on the capability of how the resident transfers; this will be re-assessed with changes in condition and at the quarterly care plan; -The resident's transfer ability will be indicated in the resident's orders and included on the resident profile and care plan; -When using a mechanical lift to transfer residents, two employees are required to assist in the transfer, without exception. Review of Resident #1's medical record, showed a physician order, dated 6/22/24, for: Transfer status x 2 Hoyer lift. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed: -No cognitive impairment; -Chair/bed-to-chair transfer, Ability to transfer to and from a bed to a chair (wheelchair): Dependent, staff does all of the effort. Resident does none of the effort; -Diagnoses included: stroke, congestive heart failure (CHF), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body). Review of the resident's care plan, reviewed on 8/24/24 and in use during the survey, showed: -Problem: Resident experiences a deficit in mobility/Activities of Daily Living (ADLs, self-care) function related to hemiplegia, incontinence and the need for assistance with ADL care; -Goal: Resident will maintain current level of mobility; -Approaches included: Provide assistance for transferring. Uses the Hoyer lift with two person assist. Review of the resident's progress notes, showed on 10/9/24 at 9:38 A.M. Licensed Practical Nurse (LPN) A wrote: CNA called for nurse to come to resident's room due to him/her falling from the Hoyer lift during transfer to chair. Resident was on the floor in between the lift and bed, moaning and calling for help. Upon assessment, resident was complaining of neck and back pain with hip and knee pain. Primary doctor and family member notified. Family member requested resident be sent to the hospital for further evaluation. Ambulance transferred resident to the hospital at 9:40 A.M. During an interview on 10/9/24 at 12:21 P.M., LPN A said the resident had been taken to the hospital. This morning, CNA B went to weigh the resident alone. When he/she moved the resident away from the bed in the Hoyer lift, the resident slipped and fell underneath the lift. LPN A said it always took two people to operate the lift. He/She said all CNA B had to do was ask someone to help him/her because there was more than enough staff on the floor. LPN A would have helped if CNA B would have asked. He/She said CNA B was suspended after the incident. LPN A said the expectation for CNA B was for him/her to ask for help from a peer or the nurse when transferring the resident or any other resident who needed a mechanical lift. During an interview on 10/9/24 at 2:07 P.M., Certified Medication Technician (CMT) H said he/she knew the resident and had helped with transferring the resident in the past. CMT H said the resident was a Hoyer lift transfer and it took two people to work the lift always, no exception. He/She said there would never be a time when only one staff transferred a resident with a mechanical lift. Everyone knew that. He/She knew what type of transfer the resident was by a sign on his/her door, shift report, and by looking in the resident's chart. CMT H said he/she never transferred the resident or any other resident using a mechanical lift alone. He/She said CNA B did not ask him/her for help to transfer the resident. During an interview on 10/9/24 at 2:13 P.M., CNA I said he/she knew the resident and his/her transfer information was posted on the wall in the resident's room. He/She said the resident was a Hoyer lift transfer and he/she would know because a lift pad would be in the resident's chair. He/She said it took two people to work the Hoyer lift and there was never a time when only one person should use it to transfer a resident. He/She never transferred the resident or any other resident with a mechanical lift alone. CNA I had been educated on mechanical lifts. During an interview on 10/9/24 at 12:48 P.M., CNA E said it always took two people to operate a mechanical lift. He/She said one person should not use the lift to transfer a resident. During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said what happened to the resident today was bad. She helped the charge nurse with the assessment and there didn't appear to be any apparent injuries. She spoke with the hospital, and they told her the resident had no trauma or acute injury. The hospital was looking to discharge the resident back to the facility today. She expected nursing staff to follow the physician's orders. She expected CNA B to ask for help with transferring the resident using a Hoyer lift. She said they provided comprehensive education and reminded staff what the transfer policy was. She expected CNA B and all other staff to follow the transfer policy. MO00242708

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180. Review of the facility's Transfer and Lift policy, reviewed 5/2021, showed: -Purpose: To provide communication to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safety of our residents including acknowledgement that this facility has adopted a NO LIFT policy (approach that aims to reduce or eliminate staff from the manual lifting of residents) by for residents requiring a mechanical means of transfer; -Upon admission each resident will be assessed by the inter-disciplinary team on the capability of how the resident transfers; this will be re-assessed with changes in condition and at the quarterly care plan; -The resident's transfer ability will be indicated in the resident's orders and included on the resident profile and care plan; -When using a mechanical lift to transfer residents, two employees are required to assist in the transfer, without exception. Review of Resident #1's medical record, showed a physician order, dated 6/22/24, for: Transfer status x 2 Hoyer lift. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed: -No cognitive impairment; -Chair/bed-to-chair transfer, Ability to transfer to and from a bed to a chair (wheelchair): Dependent, staff does all of the effort. Resident does none of the effort; -Diagnoses included: stroke, congestive heart failure (CHF), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body). Review of the resident's care plan, reviewed on 8/24/24 and in use during the survey, showed: -Problem: Resident experiences a deficit in mobility/Activities of Daily Living (ADLs, self-care) function related to hemiplegia, incontinence and the need for assistance with ADL care; -Goal: Resident will maintain current level of mobility; -Approaches included: Provide assistance for transferring. Uses the Hoyer lift with two person assist. Review of the resident's progress notes, showed on 10/9/24 at 9:38 A.M. Licensed Practical Nurse (LPN) A wrote: CNA called for nurse to come to resident's room due to him/her falling from the Hoyer lift during transfer to chair. Resident was on the floor in between the lift and bed, moaning and calling for help. Upon assessment, resident was complaining of neck and back pain with hip and knee pain. Primary doctor and family member notified. Family member requested resident be sent to the hospital for further evaluation. Ambulance transferred resident to the hospital at 9:40 A.M. During an interview on 10/9/24 at 12:21 P.M., LPN A said the resident had been taken to the hospital. This morning, CNA B went to weigh the resident alone. When he/she moved the resident away from the bed in the Hoyer lift, the resident slipped and fell underneath the lift. LPN A said it always took two people to operate the lift. He/She said all CNA B had to do was ask someone to help him/her because there was more than enough staff on the floor. LPN A would have helped if CNA B would have asked. He/She said CNA B was suspended after the incident. LPN A said the expectation for CNA B was for him/her to ask for help from a peer or the nurse when transferring the resident or any other resident who needed a mechanical lift. During an interview on 10/9/24 at 2:07 P.M., Certified Medication Technician (CMT) H said he/she knew the resident and had helped with transferring the resident in the past. CMT H said the resident was a Hoyer lift transfer and it took two people to work the lift always, no exception. He/She said there would never be a time when only one staff transferred a resident with a mechanical lift. Everyone knew that. He/She knew what type of transfer the resident was by a sign on his/her door, shift report, and by looking in the resident's chart. CMT H said he/she never transferred the resident or any other resident using a mechanical lift alone. He/She said CNA B did not ask him/her for help to transfer the resident. During an interview on 10/9/24 at 2:13 P.M., CNA I said he/she knew the resident and his/her transfer information was posted on the wall in the resident's room. He/She said the resident was a Hoyer lift transfer and he/she would know because a lift pad would be in the resident's chair. He/She said it took two people to work the Hoyer lift and there was never a time when only one person should use it to transfer a resident. He/She never transferred the resident or any other resident with a mechanical lift alone. CNA I had been educated on mechanical lifts. During an interview on 10/9/24 at 12:48 P.M., CNA E said it always took two people to operate a mechanical lift. He/She said one person should not use the lift to transfer a resident. During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said what happened to the resident today was bad. She helped the charge nurse with the assessment and there didn't appear to be any apparent injuries. She spoke with the hospital, and they told her the resident had no trauma or acute injury. The hospital was looking to discharge the resident back to the facility today. She expected nursing staff to follow the physician's orders. She expected CNA B to ask for help with transferring the resident using a Hoyer lift. She said they provided comprehensive education and reminded staff what the transfer policy was. She expected CNA B and all other staff to follow the transfer policy. MO00242708

Based on observation, interview and record review, the facility failed to provide a homelike environment by failing to ensure three sampled residents on the 100 unit had sufficient hot water for at least three months (Residents #1, #4 and #6). This had the potential to affect all 17 residents who resided on the 100 unit. The census was 185. 1. Review of Resident #1's admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder and pain in right hip due to osteonecrosis (occurs when part of the bone does not get blood flow and dies). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/23, showed: -Cognitively intact; -Able to make self understood; -Able to understand others. During an interview on 4/24/24 at 11:50 A.M., the resident, with his/her family member on the phone, said: -There had been an issue with the water heater since he/she had been admitted ; -There had been no hot water in the seven months he/she had been in the facility; -The lack of hot water had limited the resident's ability to shower; -The resident would clean himself/herself up in the bathroom sink most days; -He/She was able to shower independently but did not get showers due to water being too cold for a shower. Observation on 4/25/24 at 11:28 A.M., showed the water temperature at the handwashing sink in the resident's room, was 86 degrees Fahrenheit (F), after the water was allowed to run for two minutes in that room. Observation on 4/29/24 at 10:13 A.M., showed the water temperature at the handwashing sink in the resident's room, was 97 degrees F, after the water was allowed to run for four minutes in that room. 2. Review of Resident #4's admission Face Sheet, showed the resident was admitted to the facility on [DATE] with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), left sided hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), and cognitive communication deficit (difficulty with thinking and how someone uses language). Observation on 4/29/24 at 2:40 P.M., showed the water temperature at the handwashing sink in the resident's room, was 98 degrees F, after the water was allowed to run for two and a half minutes in that room. 3. Review of Resident #6's admission Face Sheet, showed the resident was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder and cognitive communication deficit. Observation on 4/29/24 at 2:45 P.M., showed the water temperature at the handwashing sink in the resident's room, was 90 degrees F, after the water was allowed to run for four minutes in that room. 4. Review of the facility's 100 Unit Weekly Water Temperature Log, dated February 2024, showed: -Week one, 2/7/24: --room [ROOM NUMBER], temperature 111 degrees F; --room [ROOM NUMBER], temperature 102 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; -Week two, 2/14/24: --room [ROOM NUMBER], temperature 99 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 98 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 106 degrees F; -Week three, 2/21/24: --room [ROOM NUMBER], temperature 106 degrees F; --room [ROOM NUMBER], temperature 96 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 104 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; -Week four, 2/28/24: --room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 104 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 106 degrees F. Review of the facility's 100 Unit Weekly Water Temperature Log, dated March 2024, showed: -Week one, 3/6/24: --room [ROOM NUMBER], temperature 90 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 105 degrees F; --room [ROOM NUMBER], temperature 108 degrees F; -Week two, 3/13/24: --room [ROOM NUMBER], temperature 103 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 89 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; -Week three, 3/20/24: --room [ROOM NUMBER], temperature 96 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 105 degrees F; --room [ROOM NUMBER], temperature 110 degrees F; -Week four, 3/27/24: --room [ROOM NUMBER], temperature 111 degrees F; --room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F. Review of the facility's 100 Unit Weekly Water Temperature Log, dated April 2024, showed: -Week one, 4/3/24: --room [ROOM NUMBER], temperature 105 degrees F; --room [ROOM NUMBER], temperature 102 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 99 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; -Week two, 4/10/24: --room [ROOM NUMBER], temperature 112 degrees F; --room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 106 degrees F; -Week three, 4/17/24: --room [ROOM NUMBER], temperature 103 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 98 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; -Week four, 4/25/24: --room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 86 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F; --room [ROOM NUMBER], temperature 78 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F. 5. During an interview on 4/29/24 at 1:54 P.M., the Maintenance Director said: -He/She was the one who did the temperature testing of the water; -Water temperatures should be between 105 degrees F and 120 degrees F after running the water for two minutes; -There had been issues with water temperatures on the 100 division being low for a while now, but only on the 100 division; -It is not acceptable for the residents to go without hot water for so long; -No residents had complained of low water temperatures to him/her personally, but staff had complained to him/her about it; -The facility had plumbers come out in February for a couple of weeks to try and figure out the problem and spent thousands of dollars on it and still no definitive answers on what the problem it; -He/she had changed all the shower heads on the 100 unit and that did not fix the problem; -He/she is in the process of changing out all the balancing spools also. They only had 10 in stock and had to order the rest. MO00234143

Based on observation, interview and record review, the facility failed to ensure a resident who was issued a 30-day discharge and known to be homeless, with a diagnosis of major depression, did not receive access to behavioral health services as an option to process emotional stressors (Resident #1). The census was 185. Review of the trauma informed care and behavioral health management policy, revised 9/2022, showed: -Purpose: the facility will treat all residents with love, care and understanding. The facility believes all behaviors have meaning and is often a way of communication of a need. Assist in the early identification of residents past traumatic events/behaviors and to develop and implement interventions to manage or deescalate those behaviors. The community provides behavioral health services to residents requiring such services; -Definition: Behavioral health: a state of mental/emotional being and /or choices and actions that affect wellness; -Procedure: -Notification and necessary referrals will be sent to the resident's physician and/or psychiatrist; -Resident identified with or a history of trauma related disorders will have non-pharmacological interventions implemented; -The resident and/or resident representative are active participants in identifying triggers for behaviors and developing coping interventions; -Consult with psychiatry for additional interventions once medical and environmental reasons have been ruled out. Review of the PHQ-2 assessment (used to determine the frequency of depressed mood), dated 11/13/23, showed: -Should the resident mood interview be conducted: yes; -Little interest or pleasure in doing things over the last two weeks: no; -Over the last two weeks, felt down, depressed or hopeless: no; -Over the last two weeks, have trouble falling or staying asleep or sleeping to much: no; -Over the last two weeks, been bothered by feeling tired or having little energy: no; -Over the last two weeks, been bothered by overeating: no; -Over the last two weeks, feeling bad about self or that your a failure, let yourself or family down: no; -Over the last two weeks, have trouble concentrating on things, such as reading the paper or watching TV: no; -Over the last two weeks, been bothered by moving or speaking slowly that others have noticed or being fidgety or restless and moving more than usual: no; -Over the last two weeks, been bothered by thoughts of being better off dead, or harming self: no; -Severity score: 0. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/10/24, showed: -admitted : 8/11/23; -Able to make needs and wants known; -Does not refuse care, no mood problems; -Propels self in wheelchair; -Staff provide set up for care; -Diagnoses included heart disease, heart failure, anxiety, depression and lung disease; -Takes as needed pain medication; -Pain affects sleep occasionally; -Receives routine antidepressants and narcotic pain medication. Review of the resident's care plan, dated 2/22/24, showed: -Problem: Receives antidepressant medications related to depression; -Goal: Will not exhibit signs of drug related sedation; -Approach: assess/record effectiveness of the drug treatment, staff monitor and report changes. Monitor the resident's mood and response to medication. Review of the physician order sheet, showed an order, dated 4/16/24: Prozac (used to treat anxiety and depression) 20 milligram (mg). Take 40 mg once daily. During an interview on 4/24/24 at 11:50 A.M., the resident said he/she had lived at the facility since August 2023. He/She lived out in the community previously and admitted to the hospital for neck surgery. He/She had been notified in the hospital, he/she had become homeless and lost his/her apartment. He/She admitted to the facility for therapy services. He/She had a bill at the facility and was stressed on how to pay the bill. His/Her family did not agree with the billing, and he/she had been issued a 30-day discharge. He/She appealed the discharge and is awaiting the hearing. He/She was stressed and upset at the loss of his/her home, being discharged from the facility and additional stressors. He/She had anxiety and depression and took routine medication. The facility had not offered a therapist or counselor since his/her admission. He/She said he/she may like to speak to a counselor or therapist. During an interview on 4/24/24 at 1:50 P.M., the Compliance Officer (CO) said the resident admitted to the facility in August 2023. The resident had a diagnosis of depression and was notified in the hospital, he/she had been evicted from his/her apartment. The resident received routine medication for depression. The resident had been issued a 30-day discharge for failure to pay. The facility had offered different payment arrangements, the resident and family refused the alternative payment options. The resident had no orders for a psychiatric evaluation. During an observation and interview on 4/29/24 at 11:12 A.M., the resident was in his/her room. He/She appeared frustrated and stressed. The resident called his/her family and said he/she was anxious regarding scheduling orthopedic surgery. He/She was nervous about the upcoming discharge appeal hearing. The facility notified him/her of one other facility willing to accept him/her, but he/she did not want to move to that facility. During an interview on 4/29/24 at 12:30 P.M., the Social Worker (SW) said the resident admitted to the facility following neck surgery. The resident received therapy services. The resident is his/her own responsible party and the family is very involved in the resident's care. The resident has diagnoses of anxiety and depression and received routine medication. The resident had no history of trauma and staff had not reported any behaviors. The resident was issued a Notice of Medicare Non-Coverage (NOMNC) and the resident refused to apply for Medicaid. The resident had been evicted from his/her apartment during his/her hospital stay. The resident wanted to be discharged to the community and the SW offered contact information to long term stay hospitals. The resident became upset and told him/her that he/she would find a place to stay in the community himself/herself. The resident had been issued a 30-day discharge and appealed the discharge. The appeal hearing was upcoming. The resident had many stressors occurring. The SW conducted a cognitive assessment and depression assessment every 90 days. The resident has visitors frequently and attends physician appointments outside of the facility. Facility management had instructed the management staff to only speak with the resident with two management staff due to developing issues. The SW had not referred the resident to a counselor or therapist. She had backed off the resident. The resident had been accepted into other facilities, and she notified the facility management team of those facilities. She left the notification of acceptance to the facility management to tell the resident. During an interview on 4/29/24 at 2:21 P.M., the Admissions staff said he/she was present the day the resident came into the facility. He/She attempted to present and read the admission paperwork to the resident. The resident yelled at him/her and tore up the paperwork. He/She did not have any additional interaction with the resident. He/She had been told the resident had been evicted from his/her apartment while in the hospital. He/She did not know if the resident was seen by mental health services. Review of the PHQ-2 assessment, dated 4/30/23, showed: -Should the resident mood interview be conducted: yes; -Little interest or pleasure in doing things over the last two weeks: no; -Over the last two weeks, felt down, depressed or hopeless: yes; -How often bothered by this: 7-11 days; -Over the last two weeks, have trouble falling or staying asleep or sleeping to much: yes; -How often been bothered by this: 12-14 days; -Over the last two weeks, been bothered by feeling tired or having little energy: no; -Over the last two weeks, been bothered by poor appetite or overeating: yes; -How often have you been bothered by this: 2-6 days; -Over the last two weeks, feeling bad about self or that your a failure, let yourself or family down: no; -Over the last two weeks, have trouble concentrating on things, such as reading the paper or watching TV: no; -Over the last two weeks, been bothered by moving or speaking slowly that others have noticed or being fidgety or restless and moving more than usual: no; -Over the last two weeks, been bothered by thoughts of being better off dead, or harming self: no; -Severity score: 3; -Minor depressive syndrome is suggested if of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much or (3) feeling tired or having little energy are identified at the frequency of half or more of the days (7-11 days) during he assessment period; -The assessment is used to track changes in severity over time. The total score can be interpreted 1-4 minimal depression. MO00234143

Based on interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who had physician orders for CPR and was found by staff without a pulse (Resident #1). The resident expired. The census was 191. The Administrator was notified on [DATE], of the Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. The facility provided training and in-servicing for all staff regarding the facility's CPR policy and using proper definitions/verbiage when reporting on CPR/Death Reporting Form. The IJ was corrected on [DATE]. Review of the facility's CPR Initiation, When Indicated Policy, revised [DATE], showed: -Purpose: To assure we meet professional standards of quality and provide the necessary care and services to attain or maintain the highest practicable well-being of the residents according to their requests and/or as stated in their Advanced Directives; -Policy: All licensed nurses are to be CPR certified by a qualified instructor. CPR code status of each resident is to be established and documented by the physician. Code status should then be identified on the physician order sheet. If CPR is indicated, CPR should be performed properly and promptly until advanced medical treatment can be obtained. -The American Heart Association (AHA) guidelines reflect global resuscitation science and treatment recommendations and are recognized by the Centers for Medicare and Medicaid Services (CMS). AHA has established evidence-based decision-making guidelines for initiating CPR when cardiac arrest occurs in or out of the hospital. AHA urges all rescuers to initiate CPR unless: A valid Do Not Resuscitate (DNR) order is in place, obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection (body is split in two), or decomposition) are present, or initiating CPR could cause injury or peril to rescuer. -Dependent Lividity: Dependent lividity is a settling of the blood in the lower (dependent) portion of the body postmortem (after death), causing a purplish red discoloration of the skin. When the heart stops functioning and is no longer agitating the blood, heavy red blood cells sink through the serum by action of gravity. -Rigor Mortis: rigor mortis is the stiffening of muscles due to the absence of adenosine triphosphate (ATP) after death. Without ATP, the myosin and actin (myosin and actin are muscle proteins that work together for muscle contraction) bind together, and the muscle fibers to become rigid. This process begins one to three hours after death. Review of the resident's Physician's Orders Summary (POS), showed an order, start date [DATE], for Full Code: Administer CPR. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses of lung cancer, anxiety, and acute respiratory failure. Review of the resident's progress notes, showed on [DATE] at 11:27 P.M., Licensed Practical Nurse (LPN) A wrote: This nurse was doing rounds, upon arrival to room, no obvious signs of life, pupils fixed, mucus membranes dry, no rise and fall of chest, no bowel sounds upon auscultation (listening to the sounds of organs, usually with a stethoscope), no pulse obtainable, fingers and toes cyanotic (blue discoloration due to lack of oxygen). Death was pronounced by two nurses at 11:18 P.M. Hospice called to come in and complete end of life notifications, per hospice. Review of the facility's investigative summary, dated [DATE], showed: -There were obvious signs of death when LPN A identified the resident had passed away/expired. The obvious signs of death were cyanotic/purplish hands and feet as described by charge nurses LPN A and LPN B. LPN A followed policy and procedure for not administering CPR when there are obvious signs of death present when encountering a resident without vital signs. LPN A followed facility protocol by notifying hospice, family, physician, and medical examiner after death; -The written statement from LPN B showed: -On [DATE] at approximately 11:10 P.M., LPN B received call from LPN A who requested assistance with a death assessment. LPN B asked status, and LPN A said the resident was on hospice. -Upon arrival LPN B walked into the room behind LPN A. The resident showed no signs of life. The resident's pupils were fixed with no response to light, oral cavity was dry, mouth open, no rise/fall of chest, hands and feet dark blue, neither nurse able to find a pulse at any locations. Time of death pronounced at 11:18 P.M -The written statement from LPN B did not note the resident had rigor mortis or dependent lividity and the clinical definition of rigor mortis and/or dependent lividity was not described in the interview. During an interview on [DATE] at 11:05 A.M., Certified Nurse's Assistant (CNA) C said on [DATE] at 10:00 P.M. he/she completed a round on the resident, and he/she was breathing evenly. CNA C then left at the end of his/her shift. During an interview on [DATE] at 10:54 A.M., LPN A said on [DATE] at approximately 11:18 P.M., he/she was completing rounds and found the resident with no signs of life. He/She called LPN B from another hallway to assist. The resident's pupils were fixed, mucus membranes were dry, no rise and fall of resident's chest observed, no bowel sounds, no obtainable pulse, fingers and toes were cyanotic. Mottling (common symptom that occurs near end of life where red and purple spots appear on toes, feet, fingers and spread slowly up the arms and legs) present in hands and feet. Feet and hands were dark blue. LPN A said his/her hands are always cold, so when he/she checked the resident's body temperature by hand, the resident felt not hot and not cold, more lukewarm. When asked during the interview if dependent lividity or rigor mortis were present when examining the resident, LPNA said No. LPN A said he/she did not administer CPR because he/she felt the resident had obvious signs of death. During an interview on [DATE] at 3:00 P.M., LPN B said he/she received a call from LPN A to come assist with the resident, who had expired. The resident showed no signs of life, with fixed pupils unresponsive to light, dry oral cavity, no rise and fall of chest, hands and feet dark blue, legs mottled. Neither he/she nor LPN A could palpate a pulse at any location. When asked during the interview if dependent lividity or rigor mortis were present LPN B said No when examining the resident. LPN B said he/she did not administer CPR because there were obvious signs of death. The statements from LPN A and LPN B did not provide a description showing the clinical definition of rigor mortis and/or dependent lividity in their interviews. During an interview on [DATE] at 1:00 P.M., Physician D said even if a resident is full code and on hospice, he/she would expect the facility to administer CPR and send the resident out to the hospital. During an interview on [DATE] at 12:15 P.M., the Administrator said when reviewing LPN A's progress notes and LPN B's written statement, he thought both nurses described dependent lividity, not just mottling. He believed the word dependent lividity was not a word that the staff were use to using when charting. MO00229571

Based on observation, interview and record review, the facility failed to uphold residents' rights by turning off residents' call lights without helping the residents, resulting in residents having to wait long periods of time for help, including one sampled resident (Resident #11) and failed to provide a homelike environment when the residents were served meals on Styrofoam plates for an extended amount of time, including one sampled resident (Resident #182). The sample was 35. The census was 183. 1. Review of Resident #11's care plan, revised on 6/26/23, showed: -Problem: The resident is incontinent of bowel and bladder related to functional mobility deficit, wheelchair dependency and the need for staff assistance with care; -Goal: Staff will attempt to keep the resident dry and free of odors and infection through the next review; -Approach: Assist to toilet per scheduled plan. During an observation and interview on 11/14/23 at 7:57 A.M., the resident lay in bed on his/her back. The resident smelled of urine and said he/she was soiled. The resident pressed his/her call light. At approximately 7:59 A.M., Certified Nurse Aide (CNA) K entered the resident's room and asked what he/she needed. The resident said he/she was wet and needed to be changed. CNA K turned off the resident's call light and said, I am not your aide today and will not be able to change you. Your regular aide is assisting other residents and when (he/she) is done, (he/she) will change you. CNA K asked the resident what he/she wanted for breakfast. The resident said he/she was soiled and could not think of food while wet. CNA K said, When your aide comes to your room, you can tell (him/her) what you want for breakfast and walked out of the resident's room. The resident said staff will answer call lights, turn them off and won't return. The resident was upset and said he/she would not want to eat breakfast if he/she was wet. Observation on 11/14/23 at 8:57 A.M., showed CNA L walked into the resident's room after he/she pushed his/her call light. CNA asked the resident, What do you want? and turned the call light off. The resident asked to be changed. The CNA told the resident he/she would change him/her after he/she brought the resident's breakfast. The resident asked the CNA what his/her name was. The CNA replied with the first letter in his/her first name and walked out of the room. Observation on 11/14/23 at 9:07 A.M., showed the resident lay in bed. The surveyor requested to observe perineal care on the resident. CNA L and Nurse M performed perineal care on the resident. The resident's brief was heavily soiled. Nurse M confirmed the resident was soiled. During an interview on 11/14/23 at 9:28 A.M., Nurse M said if the resident needed to be changed, the CNA should have prioritized and cleaned the resident. During an interview on 11/17/23 at 10:38 A.M., the Administrator and Director of Nursing (DON) said residents should be treated with dignity and respect. The CNAs should have changed the resident when he/she told them he/she was soiled. 2 During a group interview on 11/16/23 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. Six out of six residents said sometimes they had to wait up until an hour and a half before call lights were answered. Staff would see their call lights going off and would enter the room, turn the call light off and didn't return. At times, staff won't ask the residents what it was they needed when they pressed the call light. 3. Review of Resident #182's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/23, showed: -Cognitively Intact; -Diagnoses of muscle weakness, epilepsy and chronic kidney disease; -Independent with eating. During an interview on 11/13/23 at 10:06 A.M., the resident said the facility has been giving residents food on Styrofoam plates and plastic silverware for the past two weeks. He/She said the plastic silverware was hard to use and he/she had difficulty cutting his/her food. 4. During a group interview on 11/16/23 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. Six out of six residents said staff served food on a Styrofoam plate and plastic utensils and did not feel this was homelike. Two residents said the food burned through the Styrofoam. The facility had been using Styrofoam for over two weeks. 5. During an interview on 11/17/23 at 7:50 A.M., the Dietary Manager said it is not homelike for residents to be eating on Styrofoam plates because the plates can start melting with warm food. She does not know why the facility decided to use Styrofoam plates instead of other options. 6. During an interview on 11/17/23 at 10:38 A.M., the Administrator said the dishwasher in the kitchen was broken and they were waiting on a part to arrive. Styrofoam plates were not considered homelike but was acceptable. MO00209198

Based on observation, interview, and record review, the facility failed to ensure one resident was free from physical abuse (Resident #2), when staff inflicted injury to a resident, bruising underneath the eye, and also caused the resident to be fearful. The sample was three residents. The census was 194. The Administrator was notified on 7/21/23 of the past-noncompliance which began on 7/10/23. The facility conducted an investigation and immediately in-serviced staff on 7/10/23 regarding combative residents, abuse/neglect/exploitation and body mechanics. The facility instituted corrective measures on 7/10/23, including suspension of Certified Nurse Aide (CNA) G. The violation was corrected on 7/10/23. Review of facility's Abuse, Neglect and Exploitation policy, revised 01/2022, showed: -Policy: It is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, and misappropriation of property; -Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -It is the responsibility and the law that every staff member, volunteer, contractor or consultant immediately report any suspected abuse or neglect of any type; -Definitions: --Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pin or mental anguish; Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; --Mistreatment - means inappropriate treatment or exploitation of a resident. 1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/23, showed: -Cognitively intact; -Diagnoses included Alzheimer's disease and polyneuropathy (nerve damage). Review of the resident's progress notes showed: -Received a call this morning 7/10/23, around 8:27 A.M. from facility educator notifying this writer that the patient reported being assaulted by CNA. Patient with facial ecchymoses and a blood shot eye per educator. Please refer to detailed notes by nursing staff. Writer gave orders for facial and skull x-ray, but to notify the power of attorney as a CT of the head may be warranted to rule out intracranial bleed and further follow-up; -7/10/23 at 8:30 A.M., patient seen and examined this evening with physician's progress note to follow. Patient reported that CNA G was talking mean to him/her and then at some point last night punched the patient in the face once. Patient noted to have surrounding ecchymoses (bruising) and swelling around OS (left eye) and noted a headache and pointed to his/her left forehead. Patient also noted that he/she did not want to go to the hospital; -7/11/23 at 07:14 P.M., facial bones x-ray from today did not reveal a grossly displace or depressed facial fracture. Of note, the palliative care nurse practitioner did speak to patient's power of attorney who was a lawyer and legal representative who wanted a complete workup just to rule out any underlying issues such as intracranial bleed. Patient did have slightly more confusion last night, however, this may be attributable to patient's facial ecchymoses; -7/12/23 at 11:13 A.M., check on resident bruising: bilateral facial bruising had improved slightly, swelling on the right was decreased as well. Bruise on right elbow no longer visible. Bruise on left elbow still visible more green in color. Same discoloration/bruising visible on left forearm. Review of the residnet's hospital Progress note, dated 07/11/23 at 9:28 P.M., showed per report, only superficial, visible echymosis was the only injury. No orbital fracture, cranial fracture, or brain bleed noted. No new orders provided. Review of the resident's Social Worker B's note, dated 7/12/23, showed staff documented when meeting with victim he/she appeared with swollen, black and purple and blood shot left eye. He/She also had a purple blackish swell on his/her right cheek below his/her right eye. He/She stated that he/she was sore and was OK. Victim reported that he/she was assaulted by a CNA by the name of CNA G when victim was laying in his/her bed in the process of being changed and dressed for the day. The perpetrator had been terminated since the incident. Victim with facial ecchymosis and blood shot eye per doctor's report. Resident reported going to the hospital. Review of the facility's documentation, submitted to the Department of Health and Senior Services (DHSS) on 7/10/23, showed: -Reporting category: Abuse; -Date and time of alleged incident: 7/10/23 at approximately 6:15 A.M. or before; -Resident involved: Resident #2; -Staff involved: CNA G; -Summary: CNA F was doing morning rounds, when he/she went into the resident's room and he/she noted a red area on the resident's left side of face near his/her eye. When asked what happened, the resident said CNA G caused it. CNA F asked the resident how did CNA G cause it. He/She said CNA G hit harder than a man. CNA F reported it to Nurse I. Nurse I asked CNA F if the red area was old and CNA F said no. Nurse I reported to Nurse D, who noted a red/purple bruise to the resident's left eye. Nurse D notified Nurse H and Nurse S. The physician, family, and Administrator were notified. MO DHSS notified. After interviewing all the staff, it was reported that the resident would often get upset, swinging his/her arms up and down and would sometimes hit himself/herself or throw himself/herself on the floor. Review of CNA F's statement, dated 7/10/23, showed: -Last night on 7/9/23, the resident cried for a while. When he/she got up and was still crying, CNA F asked him/her why. But when fear came over the resident, CNA F insisted in him/her telling what happened. The resident said CNA G did it and he/she also said as CNA G was punching him/her, he/she hit harder than a man. He/She immediately told Nurse I and told CNA G that he/she was reporting him/her. Nurse I asked CNA F if that was old, and CNA F told Nurse I, no. CNA F said this was about 6:20 A.M. to 6:30 A.M. He/She said he/she went into the room, because the resident was crying. Review of CNA E's statement, dated 7/9/23 and signed by CNA E on 7/10/23, showed: -He/She had rooms 211 through 200. He/She only went in the rooms that were given to him/her. He/She saw the nurse go in the room between 1 A.M. to 3 A.M., once. Then he/she saw the aide (CNA G) CNA E said CNA G come out the room. CNA E said the aide said he/she ain't getting him/her up. He/She fighting him/her. That was before 6:15 A.M. Review of CNA G's statement, dated 7/10/23, showed: -He/She was the resident's aide. He/She was combative, but that is normal for him/her. As of me doing my rounds, CNA G said he/she did not notice anything on him/her. Upon doing his/her last round, CNA F came and told him/her that he/she should leave, because the resident said he/she hit him/her. Come to find out he/she was making rounds, as he/she rolled the resident facing the wall, he/she had his/her hands on the wall and CNA G changed him/her. CNA G said he/she did not notice a black eye. There was no injury that he/she caused. He/She was unaware of how this could have possibly happened. A remote was underneath the resident. Review of Nurse D's statement, dated 7/10/23, showed: -Agency nurse came to him/her this morning asking him/her to look at a resident's face, saying the resident stated that CNA G hit/punched him/her. The resident had red/purple bruising to left eye and says it hurt. CNA G said that he/she didn't touch the resident. Nurse D called Nurse H to investigate until he/she was free to take care of what he/she needed to do. Nurse D gave the resident an ice pack for pain. Review of Nurse H's statement, dated 7/10/23, showed: -Night nurse called him/her stating the resident said the aide punched him/her in the face. He/She went and interviewed the resident. Nurse H said the resident stated CNA G punched him/her several times, once blacking his/her left eye. Left eye noted purple bruise and bruise noted to right side of face cheek bone area. Nurse H and other nurse manager did full skin assessment. Bruises noted to bilateral elbows, no other bruising besides face bruising noted above. Administrator made aware and resident resting in wheelchair with call light in reach. Review of Nurse S's statement, dated 7/10/23, showed: -He/She was asked on the morning of 7/10/23, towards the end of night shift to come to division 200, because the resident was claiming a CNA had hit him/her. When he/she arrived, the resident was tearful. When asked what happened, the resident stated CNA G punched him/her. Resident had visible bruising to the left eye and right cheek and under eye the right cheek was also swollen. When asked if there were other places, he/she had been hit, the resident stated, all over. A head to toe skin assessment was completed at this time. Bruising on left elbow was dark purple. Bruising on the right elbow was light gray. No other bruising was noted at this time. Resident stated he/she didn't feel safe with CNA G in the room. CNA G was removed from the assignment. Review of CNA M's statement, dated 7/8/23, showed: -He/She took care of the resident on Saturday and Sunday, day shift. The resident had no marks on his/her face. During observation and interview on 7/19/23 at 10:27 A.M., the resident said he/she did not want to talk about what happened at first. He/She looked away, looked down and his/her eyes became wide. The resident said he/she had been punched in the eye by CNA G. He/She had purplish bruising underneath his/her left eye, yellow-green discoloration at the top of left eyebrow, temple, and cheek. The left eyelid crease had a thin line of purple colored bruising across the length of the eye and the resident's right cheek had yellow-green discoloration. The resident said it was the weekend when it happened and there was a lot of different staff. He/She said CNA G brought his/her dinner with no problem. He/She was hoping to keep CNA G from doing anything. Before dinner, CNA G said to get up, sit up for dinner. The resident said that was unusual because dinner would not come for an hour. CNA G ordered him/her to get up but he/she did not. The resident sat up when it was dinner time and when CNA G came into the room and saw him/her sitting up, the resident said CNA G said something like good. He/she knew what pissed CNA G off. CNA G was loud and [NAME] for no reason. The resident said he/she had a bowel movement and it stank, so CNA G opened the window, left, and the door slammed. The resident said he/she did not like the door closed so he/she yelled for CNA G to open the door and close the window. CNA G closed the window. The resident showed how the CNA bawled up his/her fist and then took his/her fist to the left side of the cheek to show how CNA G hit him/her. The resident said when he/she told CNA G you hit me, he/she said CNA G said he/she did not. The resident said he/she said the weekend is almost over, can't you just get through it. CNA G came back into the room on Monday and he/she said, oh my God, wasn't (CNA G) supposed to be off. The resident thought CNA G hit him/her two times, because he/she felt pain later on. The resident said he/she was afraid of CNA G. Observation showed the resident's eyes got really big and wide when he/she said he/she was afraid of CNA G. CNA G was the kind of person you could not reason with. The resident said he/she went to the hospital but not the same day it happened. It happened on Sunday and he/she did not go to the hospital until Tuesday. The resident said he/she was convinced CNA G hit him/her on both sides of his/her face after CNA G protested that he/she did not hit him/her. He/She was convinced CNA G hit him/her on both sides of his/her face, but he/she dropped it because he/she did not want to make matters worse. He/She was afraid of CNA G because he/she wondered about the people CNA G knew who worked at the facility. He/She said this was the first time he/she had been punched. During an interview on 7/19/23 at 7:34 P.M., CNA G said the resident was being combative during his/her double shift on 7/9/23 and 7/10/23. He/She turned the resident to the wall. The resident had a sheet on his/her head and then when the sheet was removed was when he/she saw the bruises on the left and right side. CNA G said he/she reported it to the nurse Nurse I and the nurse said he/she knew about the bruises. That was not his/her regular assignment. The resident likes to fight and the resident was swinging. He/She rolled the resident over and turned towards the wall. He/She said he/she didn't think anything was wrong. He/She said when the resident rolled towards him/her, the resident started swinging. CNA G said when he/she left, there were no concerns. CNA G said he/she would not do that to anyone. He/She did not hit the resident. CNA G said the resident will hit himself/herself. CNA G never hit the resident and has no ill will for the resident. CNA G said he/she did report to the nurse around 5:30 A.M. or 5:50 A.M. He/She said the nurse said he/she knew, so CNA G said he/she wasn't going to make a big deal about it. He/She thinks the resident did it to himself/herself. During an interview on 7/19/23 at 6:48 P.M., CNA E said he/she heard CNA G say he/she wasn't getting the resident up, because he/she was fighting him/her in the early morning of 7/10/23. He/She said a few minutes later, the resident screamed. Other staff went in the room. He/She said the resident was petrified. CNA G kept talking to the nurse, saying the resident was violent, but the resident was not violent. He/She said CNA G did hit the resident. He/She did not see it, but could tell by the way CNA G was acting. CNA G never went back into the resident's room to check on him/her. If CNA G did go back into the resident's room, he/she went with another staff. The resident had been calm the whole shift. People think residents' don't know what's going on. He/She said CNA G said if the bruising happened the night before, it would have been reported already. CNA F was crying and distraught, because he/she knew CNA G hit the resident. During an interview on 7/19/23 at 2:30 P.M., CNA M said he/she got to work around 5 A.M. or 6 A.M. on 7/10/23. The bruising appeared sometime after that. The resident was yelling and screaming. He/She said it was like a bruise at first but as the day went on, the bruising got darker. The bruising was underneath the resident's eye. CNA M said CNA F came into the room and asked the resident what's wrong and what happened to him/her. CNA M said he/she left the room. CNA M did not report it because CNA F didn't give him/her a chance too. CNA F told the nurse that CNA G was supposed to get written up. CNA F told the nurse that if he/she did not write up CNA G, he/she was going to tell the Administrator. CNA M said he/she only went into the resident's room, because he/she was screaming. He/She told CNA G he/she could go and that he/she would get the resident up. CNA M said the resident was fully dressed. The resident did not look like himself/herself and the resident looked scared. The resident became calm after CNA G left. The resident said oh (CNA M), you're here, you're here. CNA M said he/she left the room when CNA F came. During an interview on 7/19/23 at 7:02 P.M., CNA F said when he/she came in to work at 10:42 P.M on 7/9/23, he/she let CNA G keep that assignment because he/she worked a double, but that was CNA F's normal assignment. CNA F said when he/she went to get flat sheets that morning, he/she could see in the resident's room and he/she was crying. If something had happened the night before, the resident would be over it. CNA F said he/she asked the resident what was wrong. The resident was scared, but he/she just kept asking what was wrong. The resident said CNA G punched him/her in the face. The resident said CNA G said, I hit harder than a man. CNA F asked CNA G what happened. CNA G said the resident was lying. CNA F told CNA G that he/she was lying and he/she told Nurse I. He/She said Nurse I asked if the bruising was old. CNA F told Nurse I the bruising was not old and resident had swelling. CNA F told Nurse I if he/she did not check the resident out, he/she was going to report him/her too. Whenever there are scratches or anything, it was supposed to be reported. The resident was not a malicious person and he/she did not lie. CNA F was pretty sad that happened to the resident and he/she believed the resident when he/she said CNA G punched him/her in the face. The resident was visibly upset and scared. CNA F said the resident's face was swollen and red. He/She said the bruising was not old, it was new. During an interview on 7/20/23 at 10:20 A.M., Nurse I said he/she started his/her shift at 10:30 P.M. on 7/9/23, and he/she received report from off going shift, but during the report, he/she was not told any resident had bruising. He/She said that was his/her first time working on division 200, but the resident had not been combative and did not seem to be combative. He/She said the resident was pretty with it. He/She heard from CNA F about the abuse. He/She said CNA F said he/she had to go into the resident's room to look at him/her. Nurse I asked the resident what happened and the resident said CNA G hit him/her, but he/she could not remember exactly. He/She said the resident looked shook and scared when he/she went into the resident's room. He/She said CNA G was not allowed back into the resident's room. Nurse I said it was a quiet night and CNA G did not tell him/her anything about the bruising before it was discovered that morning. When the morning staff came in, they said the resident was alert, knows peoples' names, and would not say stuff that was not true. Nurse I said CNA G's demeanor changed once he/she knew the event had been reported. CNA G was mad with CNA F for reporting the incident to the nurse. Another nurse came to separate CNA F and CNA G, because they were arguing back and forth about what happened to the resident. During an interview on 7/20/23 at 3:31 P.M., Nurse D said it was about 5 A.M. on 7/10/23 when Nurse I reported to him/her the resident was complaining that CNA G had hit him/her. Nurse D said he/she asked CNA G what happened. CNA G said he/she did not hit the resident. He/She said he/she looked to see if it could have been environmental, but he/she said there was nothing there. Nurse D said the resident could tell you what happened and said CNA G had punched him/her in the face. He/She got the resident an ice pack. The resident was shaken up and did not want to talk about it and was scared. Nurse D asked the resident if he/she fell and the resident said he/she did not fall and that CNA G hit him/her. Nurse G said the resident's face was red, not quite purple. The resident knew what he/she was talking about. CNA G was looking like he/she did not do it, shrugged his/her shoulders up and threw up his/her hands into the air. CNA G said the resident was lying on him/her. During interview on 07/20/23 at 9:58 A.M., Nurse H said he/she came into work between 6 A.M. and 6:30 A.M. on 7/10/23, and he/she and Nurse S went straight to the resident's room. The resident said CNA G punched him/her in the face. CNA M got the resident into his/her wheelchair. The resident seemed distracted and scared. The resident admitted he/she was afraid of CNA G. The resident's left eye was reddish-purple and the right cheek was a little swollen. Nurse H said the resident's elbows had dull bruising. During an interview on 7/20/23 at 2:01 P.M., Social Worker P said the resident answers question appropriately, knew a lot of things, and the resident may have a little dementia, but not much. He/She said the resident had never made false allegations against anyone and if someone had did something inappropriate to the resident, he/she would be able to say the person did it. Social Worker P said the resident had never been involved in anything like this before. No one had ever reported to him/her that the resident was aggressive or had combative behavior. At 3:09 P.M., Social Worker P said he/she did not think CNA G would have hauled off and hit the resident, but CNA G probably became really frustrated with the resident. He/She thought there was a big argument, with the resident pulling one way and CNA G pulling another way, causing the resident to hit himself/herself in the face. It was possible CNA G could have become frustrated and hit the resident. During an interview on 7/20/23 at 2:27 P.M. , Social Worker B said the resident was not combative at all and he/she had been seeing him/her for the past four months, weekly or about three times a month. Social Worker B said the resident explained to him/her an aide punched him/her in the face. He/She said the resident said he/she was supposed to be getting changed and dressed at the time. Social Worker B said the resident might struggle a little with orientation but the resident was cognizant and lucid. During an interview on 7/20/23 at 3:09 P.M., Hosptial Nurse C said the resident told him/her that CNA G got mad at him/her and hit him/her in the face. He/She asked the resident how many times did CNA G hit him/her but he/she could not remember. The resident had bruising to inner/outer left eye. During an interview on 7/19/23 at 11:34 A.M., Nurse K said he/she never saw the resident swinging his/her arms, hitting out at staff or hitting self. Nurse K said he/she had not seen any aggressive behavior from the resident and was not aware of the resident being aggressive towards others. During an interview on 7/19/23 at 11:40 A.M., CNA L said he/she never saw the resident hit himself/herself in the face or be abusive. During an interview on 7/19/23 at 2:05 P.M., CNA N said the resident seemed real [NAME] and he/she never saw the resident act out except at bath time. CNA N had not seen the resident be combative or aggressive and the resident wanted to be dry and clean for real. During an interview on 7/20/23 at 11:27 A.M., the Director of Nursing (DON) said the resident was pretty stable and had been the same for the past six years he/she had been working at the facility. At 2:30 P.M., the DON said he/she could not find anything that showed the resident had bruising in the past. He/She said the resident did not have a history of bruising. MO00221193 MO00221315 MO00221766

Based on interview and record review, the facility failed to prevent the development of pressure ulcers to one resident (Resident #1). The resident admitted to the facility from the hospital with intact skin. The facility failed to ensure documentation of weekly skin assessments after the resident admitted to the facility on [DATE] until the discovery of the wound on 6/30/21. In addition, the facility failed to implement a physician-ordered specialized mattress until after the wound developed and failed to notify the wound physician when the resident refused a recommended supplement. At the time of the initial discovery of the wound, staff documented the sacral wound as a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). Two residents were selected for review of pressure ulcers, and concerns were identified with one. The census was 184. Review of the facility's wound care protocol, revised 8/2016, showed: -Goals of assessment: -Provide uniform description;; -Facilitate communication among staff; -Assess the entire person, not just the ulcer; -Assess for pain and implement interventions to relieve; -How to assess and document: -Initially assess the ulcer(s) for location, stage, size, sinus tracts, undermining (eroded tissue around the wound), tunneling (when channels extend from the wound), exudate (drainage), necrotic (dead) tissue, the presence or absence of granulation (new, connective tissue) and epithelialization (part of the wound healing process); -Treatment should be determined based on the assessment; -Documentation of the initial and weekly assessment findings should be noted in the wound management section of the electronic health record (EHR) or on the weekly wound assessment form; -Consult wound care expert: -All stage III, IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mutinous) or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, maybe softer or harder than surrounding skin, may be present on some parts of the wound bed) or unstageable pressure ulcers, vascular and diabetic ulcers upon admission or at the first discovery; -Stage II (Partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) ulcers, and any other non-healing wound that show signs of deterioration or remain open after two weeks; -Other considerations: -Determine what medical conditions present may prevent or limit wound healing; -Assess the resident for complications; -Identify pre-existing signs such as a deep tissue injury (DTI, purple or very dark area, surrounded by redness or swelling) suggesting the injury has already occurred and additional deep tissue loss may occur; -Screen the resident for nutritional deficiencies. Ensure adequate nutrition to support healing. Provide high potency vitamin and mineral supplements, per the registered dietician (RD) recommendations; -Assess psychosocial needs relative to the resident's life activities which are limited or changed due to the development of the ulcer; -Pressure Ulcers/Injuries: -Definition: a pressure ulcer is localized damage to the skin and/or underlying soft tissue, usually over a bony area or related to a medical or other device. The injury occurs as a result of intense pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by climate, nutrition, perfusion, comorbidities and condition of the soft tissue; -Avoidable: means the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors, define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice, monitor and evaluate the impact of the interventions and revise the interventions as appropriate; -Unavoidable: means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical conditions and pressure ulcer risk factors, defined and implemented interventions that are consistent with the resident's needs, goals, and recognized standards of practice, monitored and evaluated the impact of the interventions and revised the approaches as appropriate; -Preventions and early intervention goal: -To identify residents at risk for pressure ulcers; -To create an environment to promote the prevention of pressure ulcers; -Stage III pressure ulcer: Full thickness skin loss; -Definition: full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epipole (rolled wound edges) are often present. Slough (dead tissue) and/or eschar (dry, dead tissue) may be visible. The depth of the tissue damage varies by anatomical location, areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia (tissue under the ski that covers underlying tissue), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar stops the extent of tissue loss this is an unstageable injury; -Pressure redistribution: -Adjust turning schedule to eliminate turning to compromised area; -Reduce friction and shearing forces; -Use positioning devices to avoid placing the resident on an ulcer or other at risk area prominences to maintain alignment and prevent touching of the prominences; -Frequent turning and repositioning; -Stage IV Pressure ulcer: -Definition: Full thickness skin and tissue loss with exposed or directly felt fascia, muscle, tendon, ligament or bone in the ulcer. Slough and/or eschar maybe visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location; Pressure reduction: -Adjust turning schedule to eliminate turning to compromised area; -Evaluate pressure reduction/pressure relief measures; -Reduce shearing forces; -Use positioning devices to avoid placing the resident on an ulcer or other risk area; -Place cushioning devices or pillows between legs/ankles and other bony prominences to maintain alignment and prevent touching of bony prominences; -Frequent turning and repositioning. Review of the facility's skin monitoring policy, reviewed on 5/2021, showed: -Purpose: To identify residents who are at risk for skin breakdown and to initiate immediate treatment when skin breakdown occurs; -Procedure: -The Braden scale (assesses for pressure ulcer risk) is included as part of the admission process and quarterly; -Based on the assessed risk, preventive measures are to be initiated and documented in the plan of care; -Bath skin reports are given to the nurse aides with their shower assignments and returned to the charge nurse as soon as they are completed; -The area of concern that are identified on the bath report are assessed by the charge nurse and documented and nursing administration notified; -The bath reports with any areas noted are forwarded to the Director of Nursing (DON) or designee; -All wounds are assessed during dressing changes by the nursing staff and any significant change is brought to the attention of the DON; -The weekly wound rounds are completed by the DON or designee. Wounds are measured and assessed for the appropriateness of the treatments and their status documented in the medical record; -The wound report is forwarded to the administrator, dietician, therapy and the regional nurse. Review of Resident #1's hospital's post-acute transfer report, dated 6/18/21, showed: Problem list: [CONDITION(S)] (irregular heartbeat), peripheral [CONDITION(S)] (numbness, loss of sensation in the feet), arthritis, anxiety, [CONDITION(S)] (tremors), Alzheimer's disease ([CONDITION(S)] neurological disorder), adult failure to thrive and moderate malnutrition; -Encourage supplements with regular diet; -Hospital Braden scale score: 16, or a mild risk to develop pressure injury; -Incontinent of urine; -Skin assessment: thin skinned, loss of fat around buttocks, skin is red but blanchable to the buttocks and skin is intact. Apply barrier cream to the area. Review of the admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 6/18/21 to apply alternating pressure mattress (APM, used to alternate air pressure to reduce pressure to prevent tissue breakdown) on the bed. Review of the progress notes, showed on 6/18/21 at 6:18 P.M., an admission note: Resident admitted to the facility. Weight is 122 pounds. Vital signs stable. Skin intact. His/her physician notified and medications verified. Review of the admission Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 6/21/21, showed: -admitted [DATE]; -Cognitively intact; -Does not resist care; -Extensive staff assistance needed for bed mobility, transfers, dressing, toileting and hygiene; -Frequently incontinent of bowel and bladder; -At risk to develop pressure ulcers: yes; -Unhealed pressure ulcers: no; -Skin and ulcer treatments: pressure-reducing device for bed and chair. Review of the treatment administration record (TAR), showed: -An order dated 6/21/21 to complete weekly nursing skin assessment at 3:00 P.M., to 11:00 P.M. On 6/22/21 a staff initials in parentheses (the notation of not completed). Review of the initial nutritional assessment, dated 6/21/21 at 11:42 A.M., showed: -Diet: regular; -Location of most meals: bedroom and divisional dining room; -Current weight: 122 pounds (lbs); -Body mass index (BMI): 23.8; -Ideal body weight range (IBWR): 102-124 lbs; -Weight status: no weight change; -Relevant conditions or Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Able to feed self; -Skin conditions: skin intact; -Notes: initial assessment completed. Appetite poor at meals and is particular on foods he/she will eat. He/she will drink Ensure (liquid meal replacement). Recommend Ensure Plus (provides concentrated calories and protein to aid with malnutrition and calorie deficits). Monitor intakes and weights. Review of the resident's physician initial visit history and physician, dated 6/21/21 at 2:48 P.M., showed: -Alert and oriented to self and place; -Skin is warm, dry and has no rash. Review of the resident's weekly weights, showed on 6/25/21 at 3:42 P.M., a weight of 116 lbs. No documentation of notification of the dietician regarding weight loss (4.9% in four days). Review of the bath skin report, dated 6/29/21, showed a hand written circled area to the tailbone image of the back of the body. No charge nurse signature documented on the form. Further review of the medical record from 6/18/21 through 6/29/21, showed no weekly skin assessments documented and no other shower/bath skin reports. Review of the progress notes, showed on 6/30/21 at 11:49 A.M., an open area noted to the tailbone (sacrum). Wound measurements and orders obtained. Therapy notified and ordered a different seat cushion. APM, placed on the bed. Further Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 6/30/21, to cleanse the wound with normal saline (NS), apply Santyl (used to remove dead skin and tissue from a wound bed) ointment 250 grams (gm) to the wound and cover with a foam dressing. Change daily, scheduled for 7:00 A.M. to 3:00 P.M., and as needed (PRN). Further review of the TAR, showed: -An order dated, 6/30/21 to clean wound with NS and apply Santyl, nickel thick, cover with a foam dressing. Change daily during the 7:00 A.M., to 3:00 P.M., shift and PRN. Documented as completed by the wound nurse on 6/30/21. Review of the wound documentation, dated 6/30/21 at 11:55 A.M., showed: -Length: 1.5 centimeters (cm); -Width: 1 cm; -Can depth be measured: yes; -Depth: 0.2 cm; -Exudate (drainage) amount: light; -Exudate color and consistency: serosanguineous (pale red to pink, thin and watery); -Odor: No; -Stage: III; -Undermining present: No; -Sinus (tract/tunneling): No; -Tissue type: Slough; -Percent of wound covered: 90 percent (%); -Percent of wound covered by slough tissue: 10%. Review of the facility wound report, dated 7/1/21, showed: -Type: Pressure ulcer: Stage IV; -Date/time identified 6/30/21 at 11:54 A.M.; -Location: Sacrum; -Present on admission: No. Further review of the TAR, showed: -An order dated, 6/30/21 to clean wound with NS and apply Santyl, nickel thick, cover with a foam dressing. Change daily during the 7:00 A.M., to 3:00 P.M., shift and PRN; -No documented treatment completed on 7/6/21. Review of the specialized wound management (SWM) initial evaluation, dated 7/6/21, showed: -Chief complaint: sacral pressure ulcer; -History of present illness: the resident seen for an evaluation of a stage III pressure ulcer discovered on 6/30/21. The ulcer is treated with Santyl daily and an APM; -Urinary and bowel incontinence; -Wound/Ulcer #1 Assessment: -Location: Sacrum; -Type: pressure ulcer/injury: Stage III -Wound bed description: 50% granulation (healing tissue) and 50% slough; -Measurements: length 2.1 cm x width 1.9 cm x depth 0.3 cm; -Peri-wound (tissue surrounding wound): normal; -Exudate: small; -Color: yellow; -Interventions: Followed by dietician, specialty mattress, specialty seat cushion and supplements as ordered; -Plan: Clean with normal saline, apply Santyl and foam dressing daily and as needed. Assist with turning and repositioning, provide incontinence care, staff educated on dressing changes, skin care and positioning. Juven (used to build and maintain body mass and promote wound healing) added today. Monitor intake and weights for wound healing; -Goal: Debride (surgically remove dead tissue) devitalized (dead) tissue, minimize risk for fecal/urinary contamination, promote healing and maintain skin integrity. Follow up in one week. Further Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated, 7/7/21 for SWM to evaluate and treat sacral wound; -An order dated, 7/7/21 for Juven powder packet, give one packet twice a day. Discontinue if resident refuses. Review of the MAR, dated 6/18/21 through 7/17/21, showed an order dated, 7/6/21 for Juven powder packet, give one packet twice a day. Scheduled for 7:15 A.M. to 11:15 A.M., and 3:15 P.M., to 6:45 P.M. Discontinue if the resident refuses. Out of 22 opportunities, three noted as administered and 19 noted as refused. Further review of the progress notes, showed no documentation for notification regarding the refusal of the Juven supplement to the wound care physician from 7/7/21 through 7/17/21. Further review of the TAR, showed: -An order dated, 6/30/21 to clean wound with NS and apply Santyl, nickel thick, cover with a foam dressing. Change daily during the 7:00 A.M., to 3:00 P.M., shift and PRN; -Staff initials on 7/8/21, showed the treatment was not completed, the resident up in his/her chair; -Staff initials on 7/11/21, showed the treatment was not completed, the resident was busy. Review of the SWM visit note, dated 7/13/21, showed: -Chief complaint: evaluation response for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -History of present illness: the resident is seen for a follow up evaluation of a stage III sacral pressure ulcer. The ulcer treated with Santyl daily and an APM. Healing complicated by multiple medical problems including incontinence, chronic pain, anxiety, [CONDITION(S)] and malnutrition; -Weight: 116 lbs; -Nutritional status: fair, getting Ensure Plus three times a day and Juven twice a day; -Musculoskeletal: has evidence of muscle wasting and weakness, non-ambulatory; -Wound #1: -Location: Sacrum; -Type: Pressure ulcer/injury stage III; -Wound bed: 70% granulation tissue, 30% slough; -Measurements: 2.0 cm x 1.5 cm x 1.5 cm; -Peri-wound: wound edges are macerated (wet, moist); -Exudate: moderate serosanguineous; -Interventions: followed by dietician, speciality mattress, speciality seat cushion and supplements; -Plan: clean with NS, apply Santyl, pack with Kerracel AG (used to absorb wound drainage), cover with foam dressing daily and PRN; -Additional notes: wound declined, added Kerracel AG; -Plan: The DON is going to move the bed away from the wall making it easier for staff to assist with repositioning. Recommend a bed wedge for positioning. Review of the significant change MDS, dated [DATE], showed: -Enrolled in hospice services on 9/29/21; -Severe cognitive impairment; -No behaviors; -Extensive staff assistance for bed mobility and dressing; -Total staff assistance needed for toileting and hygiene; -Has one or more unhealed pressure ulcer at stage I or higher; -Has one stage IV pressure ulcer; -Used pressure-reducing device on the bed and chair; -Nutrition and hydration to manage skin problems; -Received pressure ulcer care; -Application of non-surgical dressing other than to the feet; -Received hospice services. Review of the care plan, updated 10/21/21, showed: -Problem: The resident currently has a pressure injury to the sacrum. He/she is often non-compliant with positioning and dietary supplements; -Goal: The ulcer will heal without complications; -Interventions: Assess the pressure ulcer for stage, size (length, width and depth), presence/absence of granulation tissue and condition of surrounding skin every week. Document in the wound management record. Ensure treatments are in place every shift and change as needed. No more than one hour in the wheelchair for therapeutic activity for no more than three hours a day. Specialized wound management to follow the resident. During an interview on 11/2/21 at 2:13 P.M., the hospice registered nurse (RN) said the resident was admitted to hospice services on 9/29/21 and had a large sacral wound upon admission. The resident is seen weekly by the wound physician for wound care. The resident had very high anxiety for wound treatments and does not like to turn in the bed for wound care. During an interview on 11/3/21 at 12:20 P.M., the facility wound care nurse and the DON said he/she had been the wound care nurse since the end of 9/2021. When a resident admitted to the facility, the charge nurse would complete a full head to toe skin assessment and document the assessment into the medical record. If an area of concern is noted, the charge nurse should notify the wound care nurse for further assessment. The charge nurse is responsible to complete all ordered weekly skin assessments and treatments. All residents should receive a weekly skin assessment which is documented in the electronic medical record. During an interview on 11/4/21 at 9:32 A.M., the resident's family said the resident was admitted to the facility from the hospital with intact skin. A few weeks after the admission, he/she was notified the resident developed a large wound on his/her tailbone area. The resident had not been showered often and he/she questioned if the nurses looked at the resident's skin often enough. The resident admitted to hospice services in part because the wound had become worse. The resident has high anxiety, and does not like to turn in the bed. The resident was at a higher risk to develop skin problems when he/she admitted into the facility. During an interview on 11/4/21 at 2:20 P.M., the DON said the facility had a difficult time with maintaining adequate staff to ensure all residents were bathed twice a week. All residents should receive at least two showers a week. During an interview on 11/4/21 at 10:42 A.M., the resident's physician said the resident admitted in to the facility from the hospital with intact skin. The resident was compromised, thin-skinned and did not want to get out of bed related to anxiety. The resident had a poor appetite at times. The facility should conduct weekly skin assessments on a compromised resident. Compromised residents can develop wounds quickly and if weekly assessments are not completed, a wound could develop and decline quickly. If a resident is ordered supplements and refused, the staff should contact the provider and notify them. MO 880 MO 536 MO 010

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for one of three sampled residents when one staff member provided care to a resident who required the assistance of two staff for personal care. During care by one staff member, the resident rolled out of bed, fell and was hospitalized with a subarachnoid hemorrhage (severe head injury in which there is a pool of blood between the brain and the skull), large left frontal scalp hematoma (bruise), and acute fracture of his/her left clavicle (collarbone) (Resident #1). The census was 243. Review of the facility's nursing policy and procedure manual, revised (MONTH) 2019, titled Freedom From Neglect, showed: -It is the policy of the facility to maintain a work and living environment that is professional and residents are free from neglect; -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees and volunteers have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents makes ethical and professional behavior essential. -Definitions: -Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; -Mistreatment means inappropriate treatment or exploitation of a resident; -Adverse Event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Review of Resident #1's medical record, showed an admission date of [DATE]. His/her [DIAGNOSES REDACTED]. Review of the resident's care plan, showed: -Problem: Falls; -On 9/10/18, the resident lay on his/her side being cleaned by a Certified Nurse Aide (CNA) and got too close to the edge of the bed which caused him/her to be wedged between the wall and bed. The CNA supported the resident's head as he/she was lowered to the floor. No injuries noted, Approach: Staff to have two assist with care, if needed; -On 2/25/19, the resident was assisted with a bed bath and was rolled too far over which caused him/her to fall out of bed. Staff attempted to catch his/her fall, but the resident couldn't help due to a stroke which affected his/her right side. He/she sustained a hematoma (an abnormal collection of blood outside of a blood vessel) to his/her right forehead; -Approach: Bolster in place, staff to do all activities of daily living (ADLs) and care needs with two CNAs at all times to prevent falls from bed. Review of the resident's progress note, dated 7/9/19 at 1:13 A.M., showed a late entry at 1:24 A.M. Nurse A was called to the resident's room with a report the resident was on the floor after he/she rolled off the bed at the wall side. Visible 1 to 1.5 centimeter (cm) raised hematoma observed on the resident's left frontal temporal area, approximately 3.5 to 4 cm in diameter. Ice pack applied, neurological checks performed were within normal limits, and vital signs were taken. Decision made to transport to emergency room (ER) for evaluation of head trauma, family was notified, and ambulance was called for transport. Review of CNA B's post fall summary, dated 7/8/19, showed: -Time of fall: 9:15 to 9:30 P.M.; -What the resident was trying to do: Assist holding the bed as CNA B turned him/her; -Prior to the fall, time of care last provided: 7:00 P.M.; -Why resident fell : he/she kept rolling; -What could have been done differently to prevent the fall: More help, bed to the wall. During an interview on 8/1/19 at 10:35 A.M., CNA B said he/she was assigned to the resident on day shift, starting at 6:30 A.M., and worked a double shift into the evening that day. He/she knew the resident required the assistance of two staff for personal care and had help during prior rounds. The resident was the only one on CNA B's assignment that required a two person assist, and he/she saved the resident until last because of this. He/she looked for help and didn't see anybody. The resident had a special roll mattress, due to a previous fall from bed. The resident was wet with urine and soiled with feces. CNA B didn't want to leave the resident that way. He/she pulled the resident toward him/her, turned the resident, and the resident rolled onto the floor. When the resident fell , CNA B screamed out and staff responded to the resident's room. CNA B didn't know where the staff had been, but when he/she screamed, they came. CNA B felt if he/she left the resident dirty, it would've been better than the resident's fall with injury. CNA B didn't know what else he/she could've done. During an interview on 7/22/19 at 3:10 P.M., Nurse A verified his/her 7/9/19 nurse's note. It was probably around 10:00 P.M. on 7/8/19. He/she didn't take breaks and stayed on the hall. CNA B had dropped the resident once before. Months ago, the facility put a plan in place for the resident to be a two person assist. The incident was totally preventable. Nurse A instructed staff if they didn't find anyone else to help them, get Nurse A. CNA B knew the resident required a two person assist and didn't ask Nurse A to assist him/her. The resident required a Hoyer lift (a mechanical lift). Nurse A didn't think CNA B was malicious, but it was because he/she was in a hurry. CNA B neglected the resident because he/she knew, didn't provide proper assistance, and the resident was injured badly. The resident didn't deserve that. During an interview on 7/22/19 at 2:00 P.M., Certified Medication Technician (CMT) C said the resident was a stroke victim, very weak, and could not assist in turning. Staff needed to pull the resident to them, then turn him/her to a second staff member. If staff were alone, gravity would pull the resident. The resident's bed had a mattress with barrier sides to help prevent falls. CMT C knew the resident required two staff assistance and always had someone help him/her with the resident. CNA B had asked for help before with the resident, but not that evening. CMT C worked on the hall that evening and was in another resident's room. During an interview on 7/22/19 at 3:00 P.M., CNA D said the resident was normally assigned to CNA B. The resident was a two person assist, period. He/she required a Hoyer lift for transfers. If staff couldn't find help, they should wait and return to the resident with a second staff member. CNA B had asked CNA D for help in the past and he/she didn't know why CNA B didn't ask for help that evening. Review of the resident's hospital records, dated 7/8/19, showed the following: -Height, 4'11'', weight 176 pounds; -Presented with fall from bed while being cleaned at his/her skilled nursing facility. He/she reported hitting his/her head with pain afterward; -Found to have acute subarachnoid hemorrhage, large left frontal scalp hematoma, and acute fracture of left clavicle; -Evaluated by neurosurgery and trauma surgery, then admitted to the intensive care unit (ICU) for further management; -Upon arrival to the ICU, he/she was awake and alert, able to follow some commands to move his/her left upper extremity, answered questions with yes and no, and reported an ongoing headache. During an interview on 7/22/19 at 9:50 A.M., the administrator and Director of Nursing (DON) said CNA B made a terrible independent decision. The CNA initially said he/she couldn't find help, but staff responded after the resident's fall. They were confident CNA B knew the resident required a two person assist. During an interview on 7/22/19 at 11:00 A.M., the facility's medical director said the resident's aide didn't follow protocols for the facility or the individual resident. All falls could not be prevented, but the facility/staff must protect residents. During an interview on 7/22/19 at 5:05 P.M., the administrator, DON, Assistant Director of Nursing (ADON) and regional nurse said the resident had a tube feeding, required a Hoyer lift transfer, and was total care. The resident had a mattress overlay bolster with noodles on the edges. He/she required two person assistance while in bed. To keep the resident safe, CNA B should have had another employee with him/her. If staff look for help and no one is seen and/or available, staff should stop and wait for help. CNA B had no intent to abuse and/or neglect the resident. The resident loved CNA B, he/she was good at his/her job, and made a poor decision. CNA B acted independent of his/her training and education. Additional staff were on the hall and CNA B had all the tools to do the job correctly. Review of the facility's written statement, dated 7/24/19 and signed by the administrator, listed the following facts: -The facility collectively provided a structured environment with processes and safety interventions in place in the care of Resident #1; -The facility provided training and education regarding safety and fall prevention on a monthly basis from (MONTH) through (MONTH) 2019; -The provision of sufficient staffing and resources necessary to provide care were established; -This was not a purposeful, willful, intentional or disrespectful disregard to Resident #1 or his/her needs, but a decision made by CNA B to provide the care for the resident despite having previous education 1:1 on the needs of the resident; -Employees interviewed acknowledged and stated CNA B routinely requested assistance, as the facility would expect; -The facility understood a poor decision resulted in an unfortunate accidental outcome. Providing safety application and prevention for all residents was a priority. The facility screened CNA B prior to employment, he/she was oriented, trained, in-serviced and received ongoing education. MO 108 MO 147 MO 168

Based on interview and record review, facility staff failed to call emergency personnel and failed to provide basic life support, including cardiopulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped, for one of three sampled residents. (Resident #143) The census was 263. The administrator was notified on [DATE] at 3:30 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the administrator became aware of the violation of the facility CPR policy. The staff member was suspended pending investigation. The facility inserviced the staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. Review of the facility's CPR policy, dated (MONTH) (YEAR), showed the following: -Purpose: --To assure the facility meets professional standards of quality and provides the necessary care and services to attain or maintain the highest practicable well-being of the residents according to their request as stated in their Advanced Directives; -Policy: --Licensed nurses are to be CPR certified by a qualified instructor; --CPR code status of each resident is to be established and documented by the physician. Code status should then be identified on the physician order [REDACTED]. --If CPR is indicated, CPR should be performed properly and promptly until advanced medical treatment can be obtained; --If the resident does not have a code status identified on the physician order [REDACTED]. --If the code status indicates full code staff is expected to initiate CPR; --If the code status indicates DNR do not resuscitate, staff is expected to not perform CPR; -Procedure: --Confirm code status by checking the physician's orders [REDACTED].>--Call a STAT (immediately) to your location, call 911 and give a specific description of the resident's condition (e.g. pulse, breathing, color, temperature and location.); --Simultaneously, CPR should be initiated by certified staff arriving at the scene if resident is a full code or there is not a code status identified on the physician's orders [REDACTED].>--Follow Transfer to Hospital or Death Policy and Procedure. Review of Resident #143's end of therapy Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Re-admitted [DATE]; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 15 of 15 (cognition intact); -Extensive assistance of one to two persons with care; -Total dependence on two persons with transfers. Review of the resident's progress notes, showed the following nurse practitioner entries: -On [DATE] at 2:00 P.M., Pathways Palliative Care (care that is focused on providing relief from the symptoms and stress of a serious illness) admission. -On [DATE] at 1:45 P.M., Pathways Palliative Care follow up visit. Note to follow. Please notify of change in condition, uncontrolled symptoms or hospitalization . Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. vascular disease (disorder of circulatory system); -Code status: CPR (start date [DATE]); -Palliative Care (start date [DATE]). Review of the resident's nurse's notes, documented by Nurse H, dated [DATE] at 3:28 [NAME]M., showed the following: -On [DATE] at 1:00 [NAME]M., resident observed lying in bed, with Cheyne[NAME]respirations (abnormal pattern of breathing), and then breathing stopped; -Unresponsive with no pulse or respirations noted. Pupils dilated (widening in center of eye) and fixed (does not react to light); -Resident is DNR code status and a patient of Pathways Hospice; -Postmortem care done; -First responsible party notified and made aware, and will not be coming to the facility, but verified funeral home to release the remains; -At 3:43 [NAME]M., physician notified and made aware of resident's death, and gave [DIAGNOSES REDACTED]. -Medical examiner notified; -Pathways Hospice called with no response. During an interview on [DATE] at 10:50 [NAME]M., night shift Nurse H said the following: -He/she received orientation regarding the CPR clipboard located at the nurse's station; -The Director of Nursing (DON) said they put the CPR status sheet out there so staff would not have to check the resident's chart; -The resident took his/her last breath on [DATE] at 1:00 [NAME]M., and Nurse H went to get the crash cart; -Nurse H stopped at the nurse's desk, looked at the CPR clipboard and observed the resident was a full code; -Nurse H looked at the computer and observed the resident was on hospice; -Nurse H went back to the resident's room, checked his/her vital signs and concluded he/she was expired; -Nurse H made a poor decision; -The resident's advanced directive was not carried out; -Nurse H said he/she would do it differently next time. During an interview on [DATE] at 10:37 [NAME]M., night shift Certified Nursing Assistant (CNA) I said the following: -He/she last saw the resident between 12:30 [NAME]M. and 1:00 [NAME]M. on [DATE]; -The resident was sleeping, with no problems breathing; -,[DATE] minutes later, Nurse H said the resident took his/her last breath and died ; -CNA I cleaned the resident, which took about 30 to 40 minutes; -When CNA I left the resident's room, it was 1:37 [NAME]M. During an interview on [DATE] at 11:09 [NAME]M., night shift CNA J said the following: -At the beginning of the shift on [DATE], he/she was at the nurse's station; -Nurse H rushed to the nurse's station, said the resident passed away, looked in the computer and said the resident was on palliative care; -Nurse H went to get CNA J to get the resident cleaned up; -There was no STAT or code called. During an interview on [DATE] at 1:05 P.M., Nurse A said the following: -On [DATE] at 6:30 [NAME]M., Nurse H stated the resident passed away at 1:00 [NAME]M.; -Nurse H said he/she ran out of the resident's room and yelled What's his/her code; -Nurse H looked at the CPR board and observed the resident was a full code; -Nurse H went back to the resident's room and he/she was expired; -Nurse H thought he/she was going to have to do a full code, but he/she realized the resident was on palliative care, so CPR was not done; -Nurse A told Nurse H that he/she should have called a code and done CPR. During an interview on [DATE] at 8:00 [NAME]M., the administrator said the following: -Nurse H said he/she made a terrible mistake by not doing CPR on the resident; -When Nurse H found the resident, he/she checked the CPR clip board, which showed the resident was a full code; -Nurse H went to the resident's room with the crash cart; -Then Nurse H went to check the computer and saw the resident was on hospice; -The resident received palliative care and was a full code. During an interview on [DATE] at 12:30 P.M., the DON said the following: -Nurse H received orientation on the code status clipboard after he/she was hired on [DATE]; -Nurse H said he/she understood the correct procedure; -Nurse H was suspended pending investigation; -All CPR certified staff were inserviced regarding CPR, code status and the CPR clipboard used to identify the residents who are full code. During an interview on [DATE] at 4:00 P.M., the DON and administrator said the following: -Nurse H should have called a STAT and other nurses would have come right away to help him/her; -Nurse H should have done CPR on the resident and called 911; -The CPR clipboard is located at the nurse's station on each division; -A new CPR list is printed each shift. During an interview on [DATE] at 1:05 P.M., the resident's physician said the following: -The resident's condition declined a lot and he/she was a no code at the hospital; -The resident had bad cardiovascular disease (narrowed or blocked blood vessels that can lead to a [MEDICAL CONDITION]) and a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]); -After the resident came back from the hospital, the he/she wanted to be a full code; -The resident was on palliative care and not doing good; -The staff technically should have done CPR, but it would not have made a difference with the outcome of the resident. Review of Nurse H's employee counseling form, dated [DATE], showed the following: -Nurse H failed to initiate CPR for the resident; -Nurse H should have followed the resident's preferred code status; -The CPR clipboard was discussed with Nurse H; -Nurse H was suspended pending investigation. MO 395

Based on observation, interview and record review, facility staff failed to prevent a pressure ulcer for Resident #128 when they did not follow up on a hard and reddened area on the resident's right ischium (forms the lower and back part of the hip bone) until the Stage 3 pressure ulcer (full-thickness skin loss in which subcutaneous fat and granulation tissue may be visible) was found six days later, which later developed into a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone). In addition, nursing staff failed to complete weekly skin assessments as directed by the care plan for Resident #128 to assist in the prevention of additional pressure ulcers. Facility staff failed to provide the necessary treatment for [REDACTED]. The facility census was 258. 1. Review of the facility's Pressure Ulcer Care and Documentation Policy, revised December 2006, showed the following: - Staff were directed to observe daily for potential pressure ulcer signs and report accordingly; these signs included redness, a darker bruise-like color, heat, tenderness, pain, discomfort, cracks in the skin, excessive dryness, sores, cuts, abrasions. Staff were directed to report any changes of condition to the charge nurse; - Any time a Stage 1 (non-blanchable redness of intact skin; the presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes) or greater pressure ulcer is noticed on a resident, the Charge Nurse must fill out a Wound Assessment Form and forward it to the Director of Nurses (DON) or designee, notify the physician of pressure ulcer treatment orders and notify the responsible party. 2. Review of the Resident #128's Braden Scale (assessment used to predict a person's risk of developing a pressure ulcer) score, dated 11/21/16, showed staff assessed the resident was at mild risk of developing a pressure ulcer. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/23/2016, showed staff assessed the resident as follows: - Severe cognitive impairment; - Did not reject care; - Totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene; - Did not walk; - Always incontinent of bowel and bladder; - diagnosed with [REDACTED]. - At risk for developing pressure ulcers; - Did not have pressure ulcers. Review of the resident's care plan, dated 11/29/16, showed the resident was at risk for skin breakdown and staff were directed to do the following: - Nursing to conduct a systematic skin inspection at least weekly and CNA (Certified Nurse Aide) daily. Pay particular attention to the bony prominences; - Report any signs of skin breakdown (wore, tender, red, or broken areas); - Assist with bed mobility and repositioning; - User moisture barrier product to perineal area as ordered. Review of the resident's Bath Skin Report, dated 2/3/17, showed the resident had normal skin. Review of the resident's Bath Skin Report, dated 2/10/17, showed a CNA documented the resident had a hard and reddened area over the right ischium. Review showed the nurse documented that the area did blanch and he/she applied [MEDICATION NAME] (a topical medication that provides a barrier to prevent irritation from moisture). Review of a nurse's note, dated 2/16/17, showed staff documented It was brought to this nurse's attention that the resident has an open area on the bottom of the right buttock close to the hip. Open area has two spots that are about 1.0 cm long and 1.0 cm wide. In addition, staff documented the physician was notified and staff were awaiting a treatment order. Review of a Weekly Wound Assessment, dated 2/16/17, showed staff documented the resident had a new Stage 3 pressure ulcer on the right ischium that measured 1.0 cm long by 1.0 cm wide by 0.1 cm deep. Review showed the pressure ulcer wound bed was 75% red and 25% yellow. Review of the resident's chart showed the following: - Nursing staff did not document any follow up to the hard and reddened area on the right ischium identified on 2/10/17 until a Stage 3 pressure ulcer was identified on the right ischium on 2/16/17; - Nursing staff did not document they notified the resident's physician of the hard and reddened area on the right ischium identified on 2/10/17 until a Stage 3 pressure ulcer was identified on the right ischium on 2/16/17; - Nursing staff did not document any treatment of [REDACTED]. - The care plan showed staff did not document any information about or skin interventions for the hard and reddened area on the right ischium until a Stage 3 pressure ulcer was identified on the right ischium on 2/16/17. Review of wound assessments, dated 2/16/17 through 1/22/18, showed the resident continued to have a pressure ulcer to his/her right ischium. Review of the wound assessment, dated 1/22/18, showed staff documented the pressure ulcer is a Stage 4 that measures 3.5 cm long by 2.5 cm wide by 1.4 cm deep. Review of the resident's Treatment Record Nursing Observations and Comments, dated July 2017, showed nursing staff were directed to document a full body skin assessment for the resident every Friday. Staff did not document a skin assessment for 7/7/17, or any other day that week, as directed by the care plan to assist in the prevention of pressure ulcer development. Review of the resident's Treatment Record Nursing Observations and Comments, dated August 2017, showed nursing staff were directed to document a full body skin assessment for the resident every Friday. Staff did not document a skin assessment on 8/18/17 or 8/25/17, or any other days during those weeks, as directed by the care plan to assist in the prevention of pressure ulcer development. Review of the resident's Treatment Record Nursing Observations and Comments, dated October 2017, showed nursing staff were directed to document a full body skin assessment for the resident every Thursday. Staff did not document a skin assessment on 10/19/17 or 10/26/17, or any other days during those weeks, as directed by the care plan to assist in the prevention of pressure ulcer development. Review of the resident's Treatment Record Nursing Observations and Comments, dated November 2017, showed nursing staff were directed to document a full body skin assessment for the resident every Monday. Staff did not document a skin assessment on any date that month, as directed by the care plan to assist in the prevention of pressure ulcer development. Review of the resident's Treatment Record Nursing Observations and Comments, dated January 2018, showed nursing staff were directed to document a full body skin assessment for the resident every Thursday. Staff did not document a skin assessment on 1/16/18, or any other day that week, as directed by the care plan to assist in the prevention of pressure ulcer development. Observation on 1/11/18 showed the resident had a Stage 4 pressure ulcer to the right ischium that measured approximately 2.5 cm in diameter. During an interview on 1/18/18 at 1:30 P.M., DON said nurses document weekly skin assessments on the Treatment Record Nursing Observations and Comments form. During an interview on 1/18/18 at 1:30 P.M., the (Assistant Director of Nurses) ADON said the facility began using the Treatment Record Nursing Observations and Comments form in June 2017 or July 2017. During an interview on 1/18/18 at 1:30 P.M., the Corporate Nurse said prior to the Treatment Record Nursing Observations and Comments form, CNAs conducted the weekly skin assessments for residents. If the CNAs found any issues with a resident's skin, then they would notify the resident's nurse. The nurse would then do an assessment of the area. During an interview on 1/19/18 at 11:00 A.M., Registered Nurse (RN) A said nurses conduct weekly skin assessments and document them on the Treatment Record Nursing Observations and Comments form. Before the facility utilized this form, CNAs documented skin assessments on Bath Skin Reports. During an interview on 1/19/18 at 2:40 P.M., RN Q said the following: - He/she was the nurse who documented on the Bath Skin Report, dated 2/10/17. The area over the right ischium was hard and reddened, but did blanch; - He/she did not do a wound assessment for this area or notify the physician, because it blanched, so it was not considered a Stage 1 pressure ulcer; - He/she does not necessarily think the red and hardened area needed to be documented in the care plan or a nurse's note; - Staff monitor and assess a resident's skin every day; - He/she did not recall if he/she worked any other shifts that week as the resident's nurse. During an interview on 1/19/18 at 2:45 A.M., the DON said nursing staff are now directed to notify the wound nurse for any skin issues. She would expect staff to notify the wound nurse of a hard and reddened area even if it did blanch, so it could be monitored by the wound nurse. During an interview on 1/19/18 at 3:30 P.M., the DON said she expects staff to follow the care plan. 3. Review of the Resident #203's care plan, dated 6/9/17, showed staff documented the resident was at risk for unavoidable pressure ulcers and had a pressure ulcer on the sacrum (wedge shaped bone at the lower end of the spine that connects to the tailbone). The resident was diagnosed with [REDACTED]. The resident had a decreased level of consciousness that fluctuated, required extensive to total assistance from staff for most activities of daily living, preferred to be on bed rest, and was incontinent of bowel and bladder. Review showed staff were directed to have the mobile wound company recommend treatment and treat as ordered. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: - Moderate cognitive impairment, inattention, altered level of consciousness; - Did not reject care; - Totally dependent on staff for transfers, locomotion and toilet use; - Required extensive assistance from staff for bed mobility, dressing and personal hygiene; - Did not walk; - Always incontinent of bowel and bladder; - diagnosed with [REDACTED]. - Had a Stage 3 pressure ulcer that measured 0.4 cm long by 0.3 cm wide by 0.1 cm deep. Review of the Mobile Wound Company's Weekly Wound Assessments showed the following: - 11/6/17 - Stage 3 pressure ulcer to the sacrum not healed, improved, measured 1.0 cm by 0.2 cm by 0.2 cm deep. Continue with the current treatment order to clean with normal saline (a solution often used to clean wounds), apply Santyl (a topical medication used to help heal pressure ulcers by breaking up and removing dead tissue and skin), [MEDICATION NAME] (an antimicrobial dressing that maintains a moist environment at the wound surface to promote healing), and a foam dressing and change daily and as needed. Review of the Physician order [REDACTED]. Review of the resident's Treatment Administration Record (TAR), dated 11/1/17 through 11/30/17 showed an order that directed staff to clean the coccyx pressure ulcer with normal saline, apply Santyl, [MEDICATION NAME] and an [MEDICATION NAME] foam and change daily and as needed. Review showed staff did not document they completed the treatment for 11/6, 11/7, 11/9, 11/10, 11/11, 11/14, 11/22, 11/23, 11/24, 11/26 or 11/30/17 (a total of 11 days out of 30 days). Review of the POS [REDACTED] - An order that directed staff to clean the coccyx pressure ulcer with normal saline, apply Santyl, [MEDICATION NAME], and an [MEDICATION NAME] foam dressing and change daily and as needed; - An order, dated 12/11/17, to discontinue the current coccyx treatment and a new treatment order that directed staff to cleanse the coccyx pressure ulcer with normal saline, apply [MEDICATION NAME], Sensi-care protective ointment (acts as a barrier to skin irritants to protect skin; promotes healing of damaged skin) to the periwound (tissue surrounding a wound), cover with Polymem Silver (antimicrobial dressing that is water resistant), apply Skin Tac (adhesive barrier) to periwound, cover with 2 x 2 (gauze dressing) and Clearview (transparent film dressing) and change daily and as needed; - An order dated, 12/18/17, to discontinue the Sensi-care ointment to the periwound. Review of the resident's TAR, dated 12/1/17 through 12/31/17 showed the following: - An order that directed staff to clean the coccyx pressure ulcer with normal saline, apply Santyl, [MEDICATION NAME] and an [MEDICATION NAME] foam dressing and change daily and as needed. Review showed staff did not document they completed the treatment for 12/2, 12/3 or 12/4 (3 days out of 11). Staff did not discontinue this treatment order as directed on 12/11/17 and did not document the new order, to clean the coccyx pressure ulcer with normal saline, apply [MEDICATION NAME], Sensi-care protective ointment to the periwound, cover with Polymem Silver, apply Skin Tac to periwound, cover with 2 x 2 and Clearview and change daily and as needed. Staff did not document they provided the new treatment as ordered for the dates of 12/12 - 12/31/17 (the 20 remaining days that month). -Staff did not document any pressure ulcer treatment was performed for a total of 14 days out of 31 days that month. Review of the Mobile Wound Company's Weekly Wound Assessments showed the Nurse Practitioner documented the following: - 12/4/17 - Stage 3 pressure ulcer to the sacrum not healed, deteriorated, measured 0.8 cm by 0.3 cm by 0.2 cm deep. The coccyx ulcer is a little bit bigger today and I think the treatment is appropriate at this time so we will continue it for one more week and see how it looks then; - 12/11/17 - Stage 3 pressure ulcer to the sacrum not healed, deteriorated, measured 0.9 cm long by 0.4 cm wide by 0.2 cm deep. A new wound order to clean the wound with saline, apply [MEDICATION NAME], Sensi-care protective ointment to the periwound, cover with Polymem Silver, apply Skin Tac to periwound, cover with 2 x 2 and Clearview and change dressing daily and as needed; - 12/18/17 - Stage 3 pressure ulcer to the sacrum not healed, deteriorated, measured 1.2 cm long by 0.3 cm wide by 0.2 cm deep. A new wound order to discontinue the Sensi-care to periwound, but continue with the rest of the current wound treatment order; - 12/25/17 - Stage 3 pressure ulcer to the sacrum not healed, unchanged, measured 1.2 cm long by 0.3 cm wide by 0.2 cm deep. Continue current treatment order to clean the wound with normal saline, apply [MEDICATION NAME], cover with Polymem Sliver, Skin Tac to periwound, cover with 2 x 2 and Clearview and change daily and as needed; - 1/3/18 - Stage 3 pressure ulcer to the sacrum not healed, deteriorated, measured 2.5 cm long by 0.5 cm wide by 0.2 cm deep. New treatment order to clean wound with saline, apply [MEDICATION NAME] with foam and change daily and as needed. Observation on 11/16/18 at 4:30 P.M., showed the resident had a Stage 3 pressure ulcer that measured approximately 2.5 cm long by 0.5 cm wide. During an interview on 1/19/18 at 3:30 P.M., the DON said she expected staff to follow physician orders. She also said she expected staff to document treatments they provide on the TAR.

Based on observation, interview, and record review, facility staff failed to complete a safe transfer with the use of a gait belt, which resulted in a fall with a fracture for one resident (Resident #234) out of 35 sampled residents. Facility staff failed to ensure Resident #204 received adequate supervision and/or failed to transfer the resident in a manner to prevent five falls. Facility staff failed to ensure foot pedals were on four residents' (Resident #204, Resident #159, Resident #94 and Resident #20's) wheelchairs when they wheeled the residents in wheelchairs down the hallway putting the residents at risk for falls and/or injury; Resident #204 fell out of the wheelchair face first onto the floor and sustained facial injuries; Resident #159 put his/her feet down on the floor and came to an abrupt stop and jolted forward in the wheelchair while being pushed in the hall by staff; and Residents #94 and #26 dragged their feet on the floor as staff pushed their wheelchairs down the hallway. The facility census was 258. 1. Record review of Resident #234's comprehensive plan of care, dated 6/22/17, showed the resident was at risk for falls due to a history of falls, impaired balance, unsteady gait, muscle weakness, and [MEDICAL CONDITION], and staff were instructed to: -Provide assistance of one staff with ambulation with the use of a walker; -Provide assistance of one staff with transfers as needed for weakness, unsteadiness, etc.; -Encourage resident to ask for assistance as needed for feelings of unsteadiness, pain, etc. Record review of the resident's quarterly Minimum Data Set, a federally mandated assessment instrument, dated 12/12/17, showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance of one staff with bed mobility, dressing, and toilet use; -Required limited assistance of one staff with walking in his/her room; -Required supervision of one staff with transfers; -Frequently incontinent of bladder and occasionally incontinent of bowel; -Had one fall with injury (not major) since the last assessment. Record review of the resident's Physician order [REDACTED]. a [DIAGNOSES REDACTED]. During an interview on 1/9/18 at 01:37 P.M., the resident's roommate said the resident fell last night while the aide was ambulating the resident to the bathroom. The resident's roommate said he/she told the aide the resident was too sick and weak from pneumonia to walk, and the aide needed another person to help with ambulating the resident. The resident's roommate said the aide did not listen, and the resident ended up falling. Record review of the resident's active medical record showed staff did not document the resident had a fall on 1/8/18. Record review of the resident's Post-Fall Assessment, dated 1/10/18 at 7:45 P.M., showed staff documented a Certified Nurses Aide (CNA) attempted to transfer the resident, and when he/she went to the standing position his/her knees gave out, and the resident slid down the footrest of the resident's power lift recliner. Staff documented the resident complained of pain to right ankle. Record review of the resident's POS, dated 1/10/18 at 1:15 (A.M./P.M. not specified), showed the resident's physician directed staff to obtain an X-ray of the right tibia/fibula and ankle related to a fall and the resident feeling a pop along with complaints of pain. Record review of the resident's comprehensive plan of care, updated 1/10/18, showed staff documented the resident went to stand up with a CNA assisting, the resident's knees gave out and he/she slid to floor. Staff documented the resident has a history of ankle fractures and is currently being treated for [REDACTED]. Record review of the resident's X-ray results, dated 1/11/18 at 11:12 A.M., showed an acute-appearing slightly displaced oblique or spiral [MEDICAL CONDITION] right tibia. Record review of the resident's POS, dated 1/11/18 at 11:35 A.M., showed the resident's physician directed staff to send the resident out to the hospital related to a [MEDICAL CONDITION] tibia. During an interview on 1/12/18 at 9:51 A.M., the resident's roommate said Wednesday evening (1/10/18) one aide transferred the resident from the power lift recliner to a standing position. The resident and roommate told the aide he/she needed another aide to help, because the resident was still very weak from pneumonia. The resident's roommate said he/she told the aide to use a gait belt, but the aide transferred the resident without a gait belt and no other staff assistance. The resident's legs gave out and the resident slid down the recliner footrest and ended up with his/her feet underneath him/her. The resident said he/she heard a pop and was in a lot of pain. The resident's roommate said he/she is not sure if it was the same aide as the aide who dropped the resident on 1/8/18. The resident's roommate said the night of the first fall on 1/8/18, he/she had a hard time getting anyone to answer the call light. He/she said it had been a while, so he/she went out into the hall to find someone. He/she said two staff members slept while sitting in chairs in hallway that lead to the family room on the 300 hall. During an interview on 1/18/18 at 3:03 P.M., the Clinical Nurse Manager (CNM) said she was not aware the resident fell on [DATE] and was only aware of the fall on 1/10/18. During an interview on 1/18/18 at 3:18 P.M., the CNM said no other administrative staff were aware the resident fell on [DATE], but they were looking into it. During an interview on 1/18/18 at 3:28 P.M., CNA C said he/she did not work with the resident on 1/8/18, but he/she heard that someone dropped the resident that evening. He/she does not know who the staff person was, because he/she is fairly new (began working at the facility in October 2017) and does not know everyone yet. CNA C said she worked the evening of 1/10/18 and was assigned to the resident. CNA C said the resident had really bad diarrhea, so he/she assisted the resident with getting cleaned up. The resident stood between his/her power lift recliner and motorized wheelchair. The resident used the wheelchair for support with his/her hands on it. CNA C said he/she just put a new brief on the resident when the resident said his/her legs were giving out. CNA C pivoted the resident to his/her power lift recliner, which was in the lift position. CNA C had the resident lean back against the recliner while he/she continued to clean the resident's legs and the floor. CNA C said he/she may have had his/her back to the resident while cleaning the floor when the resident said he/she was slipping. CNA C said he/she immediately went over to the resident and tried to put gait belt on the resident, but it was not big enough for the resident. The resident slid down the footrest of the recliner with his/her legs underneath her. CNA C said he/she was not informed by anyone the resident was ill and needed extra assistance. CNA C said the resident was usually able to toilet him/herself and toileted him/herself earlier in the day, so CNA C thought the resident felt better. CNA C said he/she was trained to use a gait belt with all transfers. During an interview on 1/19/18 at 9:32 A.M., Licensed Practical Nurse (LPN) B said he/she expects staff to use a gait belt with all transfers (unless it is a mechanical lift transfer). LPN B said he/she does not know much about the resident's fall, because he/she was not the charge nurse for that side of the hall. LPN B said the resident was very weak due to having pneumonia. During an interview on 1/19/18 at 1:17 P.M., Registered Nurse (RN) A and CNM said staff are expected to use gait belts with all transfers. They said they are not sure sure if the CNA should have used a gait belt during this incident, even though the resident was ill and weak, because the resident was normally independent with transfers. During an interview on 1/19/18 at 1:20 P.M., the Director of Nursing (DON) said staff should use a gait belt with transfers and always ensure transfers are safe. The DON would not say whether the CNA should have used a gait belt during the incident on 1/10/18. The DON said she did an investigation regarding the resident's fall on 1/8/18. CNA D said the resident took him/herself to the toilet and turned on call light, because he/she needed assistance. CNA D put a gait belt on the resident and transferred him/her from the bathroom to the resident's motorized wheelchair. The resident became weak and could not step up on the platform of the wheelchair, so CNA D lowered the resident to the platform of the motorized wheelchair. CNA D got two other staff to assist him/her with getting the resident up. The charge nurse working that night did not identify this as a fall, because he/she is new. The DON said she inserviced the charge nurse and has started inservicing all staff on the fall policy. The DON said by definition this was a fall. 2. Review of the Resident # 204's care plan, dated 2/14/17, showed staff assessed the resident was at risk for falls due to mobility, cognition, a history of recent and numerous falls, recurrent falls, [MEDICAL CONDITION] drug use, bowel and bladder incontinence, hard of hearing and language barrier. Review showed staff were directed to do the following: - Check often and provide position changes and frequent toileting as needed; - If a fall occurs, evaluate the cause and make changes as needed; - Update from Occupational Therapy, dated 2/24/17, showed the resident was supposed to have elevated leg rests and a foot/calf board. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from staff for transfers, dressing, toilet use personal hygiene and locomotion off unit; - Required limited assistance from staff for locomotion on unit; - Did not walk; - Occasionally incontinent of bowel and bladder; - diagnosed with [REDACTED]. - Had two or more falls without injury since the last admission or prior assessment; - Had two or more falls with injury (not major) since the last admission or prior assessment. Review of a Post-Fall Assessment, dated 5/26/17, showed staff documented the following: - Resident was being pushed in wheelchair and put feet down and went head first into the carpet. The resident sustained [REDACTED]. - Staff will use foot pedals when transferring (the resident) in wheelchair. Review of the resident's care plan showed staff updated the care plan on 5/26/17 and documented the following: - The resident was being pushed in hallway and placed feet on carpet, causing the resident to fall out of wheelchair onto floor; - Abrasion/hematoma to forehead, abrasion to bridge of nose; - Staff will use foot pedals when transporting the resident in wheelchair. Review of a nurse's note, dated 9/3/17, showed staff documented Resident put on toilet by this nurse at start of shift. Was getting shift report when heard resident crying for help from toilet in spa. Found resident on floor sitting between toilet and wheelchair. Resident may have slipped on urine/water on floor near toilet while getting up. No apparent injury noted. Asked aide for help to put resident in wheelchair. Review of a Post-Fall Assessment, dated 9/3/17, showed staff documented the following: - Resident put on toilet by nurse; couple of minutes later heard resident yelling; slipped on urine on floor while getting up to transfer to wheelchair; - Stay with resident in bathroom until done. Review of the resident's care plan showed staff updated the care plan on 9/3/17 and documented Resident placed on toilet by staff and heard yelling, slipped on urine that was on floor. Do not leave resident in spa room unattended. Review of a nurse's note, dated 10/10/17, showed staff documented Resident was being given shower and was being transferred from toilet to shower chair. Resident was being assisted by aide and resident slipped to his/her bottom. Needed 4 aides/nurses to assist resident into shower chair. Floor slippery and resident had bare feet. Skin tear right shin. Review of a Post-Fall Assessment, dated 10/10/17, showed staff documented Transferring to toilet from shower chair. Slipped on wet floor in spa to floor. Review of the resident's care plan showed staff updated the care plan on 10/10/17 and documented Resident on toilet and was being transferred to shower chair, floor was wet causing the resident to slip and fall. Skin tear to right lower extremity. Staff to make sure floor is not wet before transfer. Review of a nurse's note, dated 10/23/17, showed staff documented Resident found on floor of spa toilet after this nurse put resident on the toilet at request of resident's family member. Was called away and aide heard resident yell out from floor. Helped resident to wheelchair. Review of a Post-Fall Assessment, dated 10/23/17, showed staff documented Resident taken to spa to toilet. Heard resident calling out 5 -10 minutes later on floor next to wheelchair. Review of the resident's care plan showed staff updated the care plan on 10/23/17 and documented Resident taken to spa toilet and left in spa unattended due to charge nurse being called away. Resident attempted to transfer self from toilet to wheelchair and fell to floor. Staff educated on making sure resident is not left unattended. Review of nurses notes showed staff documented the following: - 11/6/17 - Resident heard yelling from room and staff found the resident laying on the wheelchair between the bed with head touching floor. Staff lowered the resident to the floor and then assisted the resident to the wheelchair. The resident complained of left ankle pain and swelling and physician notified; - 11/7/17 - X-ray results back - indicated acute non-displaced lateral malleolar fracture. Review of the resident's MDS, dated [DATE], showed staff assessed the resident had two or more falls without injury and one fall with injury (not major) since the last admission or prior assessment. Review showed staff did not code the MDS to reflect the resident had a fall with major injury. Review of a nurse's note, dated 12/27/17, showed staff documented Resident found on floor of spa/bathroom after having been placed on toilet. Resident had been placed there 5 minutes or so earlier. Found face down. Assisted resident on turning around and aide helped to get resident in wheelchair. Noted small scrape abrasion med-back. Had left resident to assist another resident. Review of a Post-Fall Assessment, dated 12/27/17, showed staff documented Resident put in bath spa to toilet and got up to put him/herself in wheelchair and fell on floor. The resident sustained [REDACTED]. Review of the resident's care plan showed staff updated the care plan on 12/27/17 and documented Resident was on toilet and got up unassisted to transfer to wheel chair and lost balance. No injuries. Staff to stay with resident and keep close watch. During an interview on 1/19/17, CNA U said when the resident falls, it is usually in the bathroom, because the resident tries to toilet him/herself and is not safe doing so. If staff assist the resident to the toilet, they should stay in the bathroom with the resident, because the resident will try to transfer back to the wheelchair unassisted. During an interview on 1/19/17 at 3:00 P.M. RN Y said he/she left the resident on the toilet alone and the resident tried to transfer him/herself back to the wheelchair and fell . Normally, staff stay with the resident, but if he/she is busy or the only nurse on that hallway, then he/she leaves the resident in the bathroom alone to go check on other residents. The resident is very impulsive. 3. Review of the Resident #159's care plan, dated 2/20/17, showed staff documented the resident had a memory problem related to a [DIAGNOSES REDACTED]. Observation on 1/9/18 at 11:24 AM showed Resident #159 sat in a wheelchair. Foot pedals were not on the wheelchair and CNA W pushed the wheelchair quickly down the hallway towards the dining room. The resident dropped his/her feet on the floor and the resident came to an abrupt stop and jolted forward in the wheelchair. CNA W told the resident to pick his/her feet up and the CNA W continued to push the resident in the wheelchair without foot pedals down the hallway and into the dining room. 4. Review of Resident #94's MDS, dated [DATE], showed staff assessed the resident had severe cognitive impairment, [MEDICAL CONDITION] and was totally dependent on staff for locomotion. Observation on 1/9/18 at 9:01 A.M., showed the resident sat in a wheelchair. Foot pedals were not on the wheelchair and the resident's feet dragged the floor as an unknown CNA pushed the wheelchair out of the dining room. 5. Review of Resident #26's MDS, dated [DATE], showed staff assessed the resident had severe cognitive impairment and required limited assistance from staff for locomotion on the unit. Observation on 1/9/18 at 10:53 A.M., showed the resident sat in the wheelchair. Foot pedals were not on the wheelchair and the resident's feet dragged the floor as an unknown CNA pushed the wheelchair down the hall. 6. During an interview on 1/19/17, CNA U said if a resident does not have foot pedals attached to their wheelchair and staff transport the resident in the wheelchair then staff have the resident lift up their legs. CNA U said most residents without foot pedals use their feet to propel their own wheelchair and are not pushed by staff. MO 6

Based on observation, interview and record review the facility failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for five of 30 sampled residents. (Resident #12, #20, #8, #11 ). The facility staff failed to do skin assessments for Resident #12 to prevent the development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue making the ulcer unable to be staged) that developed osteo[DIAGNOSES REDACTED] (bone infection). The facility staff failed to do skin assessments for Resident #20 to prevent the development of a stage III pressure ulcer (full thickness tissue loss involving damage to or necrosis of the subcutaneous tissue). The census was 270. Record review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [REDACTED]. -A pressure ulcer is 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. A number of contributing factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated; -Stage I-intact skin with non-blanchable redness of a localized area usually over a bony prominence. Dark pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful,firm,soft,warmer or cooler as compared to adjacent tissue; -Stage II-partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. It may present as an intact or open/ruptured serum filled blister; -Stage III-full thickness skin loss. Subcutaneous fat may be visible but bone,tendon,or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling or undermining; -Stage IV- full thickness tissue loss with exposed bone,tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling; -Unstageable-depth unknown. Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and eschar (tan, brown, or black)in the wound bed. Until enough slough is removed to expose the base of the wound bed, the true depth and therefore stage can not be determined; -Suspected deep tissue injury (DTI) depth is unknown. A 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. The area may be preceded by tissue that is painful, firm, boggy, mushy, warmer or cooler as compared to adjacent tissue; -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. 1. Record review of the facility Wound Care Protocol dated 8/2016, showed the following: *Stage 0- Resident's identified at risk prevention: Braden scale upon admission, readmission, quarterly and with any significant change of condition; -Regardless of the residents risk score, the charge nurse is responsible to review each risk factor on the Braden scale and potential causes individually and provide interventions written on the care plan; -Frequent turning; -Evaluate pressure redistribution measures for bed and chair. Manage moisture, and shear; -Keep skin soft and supple. Recommendations/Treatment: -Use moisturizers/lubricating ointments after cleansing with mild soap and water; -Use absorbent pads and briefs that wick and hold moisture; -Offer routine toileting; -Offer hydration in conjunction with turning schedules; -Skin prep to soft heels every day with offloading heels while in bed; -Pain: Assess and address. *Stage III Pressure Ulcer Injury: Full thickness skin loss: -Adjust turning schedule to eliminate turning to compromised area; - Reduce friction and shearing forces; Use positioning devices to avoid placing resident on an injury or other at risk areas; -Place cushioning devices or pillows between legs/ankles and other bony prominence to maintain alignment and prevent touching of bony prominence's; Frequent turning and repositioning. *Unstageable Pressure Ulcer Injury: Obscure full thickness skin and tissue loss; -Adjust turning schedule to delaminate turning to compromised area; -Evaluate pressure reduction relief measure, i.e. mattress and chair cushion; -Reduce shearing forces; -Use positioning devices to avoid placing resident on an injury or other at risk areas; -Place cushioning devices or pillows between legs/ankles and other bony prominence's to maintain alignment and prevent touching of bony prominence's -Frequent turning or repositioning; *** Careful evaluation is needed for all eschar on lower extremities*** 2. Review of Resident #20's quarterly MDS, a federally mandated assessment tool, dated 7/11/16, showed staff assessed the resident as: - Moderate cognitive impairment; - One person physical assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; - Frequently incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - At risk for pressure ulcers. Review of Resident #20's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Moderate cognitive impairment; - One person physical assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; - Frequently incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - At risk for pressure ulcers; - Stage I or greater pressure ulcer; - One Stage II pressure ulcer; - One stage III pressure ulcer. Review of the resident's Braden scale (assessment used to predict a person's risk of developing a pressure ulcer), dated 10/18/2016, showed staff assessed the resident's score at 19 (high risk of developing a pressure ulcer). Review of the resident's plan of care, dated 4/18/16, showed staff are directed to provide the following interventions: - Barrier cream/ointment with incontinence care as directed by nurse; - Bilateral heels protectors on as ordered; - Body/skin audit by nurse weekly; - Pressure redistribution cushion on wheelchair; - Pressure redistribution mattress on bed; - Report red, bruised or open areas of skins. Further, review of the resident's care plan showed staff did not document any new pressure ulcer interventions when the resident developed a left heel blister on 8/23/16 and a Stage III on his/her right heel on 9/26/16. Review of the resident's Physician order [REDACTED]. - Apply skin prep (skin protectant) everyday; - Ace wraps bilaterally toes to knees everyday for swelling in lower extremities in the morning. Remove at bedtime; - Inspect feet weekly; - Pressure relieving boot to left foot at all times; - Right foot apply skin prep; - Float heels in bed; - 10/24/2016 discontinue treatment to left heel. Review of the resident's weekly wound assessments showed staff documented on: - 8/24/16: left heel intact blister. Apply skin prep everyday. No documentation of right heel; - 9/26/16: right heel, new wound, Stage III pressure ulcer. Measured 2.5 centimeters (cm) length by 2.0 cm wide by 0.2 cm depth, 75% pink and 25% yellow tissue. - 10/24/16: right heel wound, Stage III pressure ulcer. 1.0 cm length by 0.9 cm width by 0.1 cm depth. 10% pink tissue. Review of the resident's bath skin reports (done by the CNAs during the resident's bath or shower and signed by the charge nurse) showed staff documented on: - 8/23/16: Normal (no areas of concern noted); - 9/6/16: Normal; - 9/13/16: Normal, left foot circled and no other documentation; - 10/4/16: Normal; - 10/8/16: Normal; - 10/13/16: Normal; - 10/15/16: Normal; - 10/20/16: Normal; - 10/22/16: No documentation; - 10/25/16: Normal. Review of the resident's nurses notes showed staff documented the following on: - 8/23/16: Blister left heel; - 9/26/16: Stage III pressure ulcer right heel. Observation on 10/26/16 at 3:00 P.M., showed Licensed Practical Nurse (LPN) C removed the resident's right heel dressing. The resident's right heel pressure ulcer measured 1.2 cm length by 1.0 cm width by 0.1 cm depth. LPN C cleansed the wound and applied Santyl and a dressing. Observation showed the resident's left heel ulcer closed and LPN C applied skin prep to the left heel. During an interview on 10/27/16 at 9:00 A.M., Registered Nurse (RN) D and the Assistant Director Of Nursing (ADON) said the resident's heel pressure ulcers were facility acquired. The staff nurses check the resident's skin as necessary. The CNA's documented any areas of concerns on the resident's bath skin reports. The charge nurse would review and sign the bath skin reports. 3. Review of Resident #12's admission MDS, dated [DATE], showed staff assessed the resident as: - At risk for developing pressure ulcers; - No unhealed pressure ulcers. Review of Resident #12's significant change MDS, dated [DATE], showed staff assessed the resident as: - Cognitive; - One person assistance for transfers, dressing and personal hygiene; - Extensive assistance for toileting; - Incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - Pain; - Stage one or greater pressure ulcer; - At risk for pressure ulcers; - One unstageable pressure ulcer; - No pressure ulcer on prior assessment; - Pressure reducing device on chair and bed; - Pressure ulcer care; - Applications ointment or medication and dressings to feet. Review of the resident's plan of care for pressure ulcer, dated 5/27/16, in the division care plan binder at the nurses' station showed staff are directed to: - Barrier cream/ointment with incontinence care as directed by nurse; - Bilateral heels protectors on as ordered; - Body/skin audit by nurse weekly; - Pressure redistribution cushion on wheelchair; - Pressure redistribution mattress on bed; - Report red, bruised or open areas of skins. Review of Resident #12's significant change MDS, dated [DATE], showed staff assessed the resident as: - Cognitive; - Total dependence for bed mobility, transfers, dressing and personal hygiene; - Extensive assistance for toileting, and eating; - Incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - Pain; - Stage one or greater pressure ulcer; - At risk for pressure ulcers; - One unstageable pressure ulcer; - No pressure ulcer on prior assessment; - Pressure reducing device on chair and bed; - Pressure ulcer care; - Applications ointment or medication and dressings to feet. Review of the resident's POS, dated 9/19/16, showed: - [MEDICATION NAME] 1.0 milligram (mg) (antibiotic) IV every 12 hours; - [MEDICATION NAME] 2.0 gram (antibiotic) IV everyday; - [MEDICATION NAME] 500 mg (antibiotic) three times a day; - Inspect feet weekly once a day on Tuesday; - PICC line (indwelling central catheter used for long term antibiotics administration) change dressing weekly times six weeks on Thursday; - PICC line saline flush every shift; - Right heel ulcer - cleanse with Dakin's 0.25% (cleanser used to prevent skin infections), apply Santyl (ointment used to cleanse wounds), cover with Dakin's moistened gauze, then cover with dry dressing once a day. Review of the resident's POS, dated October 2016, showed: - [MEDICATION NAME] 1500 mg IV piggy back everyday at 8:30 A.M.; - [MEDICATION NAME] trough (monitors blood levels) 10/28/16 at 7:30 P.M.; - 10/24/16 cleanse right heel with Dakins 0.125%, apply Santyl, [MEDICATION NAME] and dry dressing everyday and as necessary; - No weight bearing; - Inspect skin weekly; - Pain assess every shift. Review of the resident's re-admission assessment, dated 8/1/216, showed staff assessed the resident at moderate risk for skin breakdown. Review of the resident's plan of care for his/her pressure ulcer, dated 5/27/16, (located in the Treatment Administration Record (TAR) and not accessible to unlicensed staff) showed staff are directed to: - Barrier cream/ointment with incontinence care as directed by nurse; - Bilateral heels protectors on as ordered; - Body/skin audit by nurse weekly; - Pressure redistribution cushion on wheelchair; - Pressure redistribution mattress on bed; - Report red, bruised or open areas of skins. Further, review showed staff documented on the TAR care plan on: - 8/12/16: Re-admit, right heel unstageable, follow doctor's orders, assess skin and infection; - 8/29/16: Right heel improved, debrided, new treatment, antibiotic, continue specialized wound management and boot on; - 9/6/16: Right heel improved, continue specialized wound management, continue antibiotic, new treatment noted and surgical consult; - 10/3/16: Right heel improved, continue treatment and continue intervention; - 10/10/16: Right heel improved, continue specialized wound management, interventions and graft scheduled for 10/11/16; - 10/24/16: Right heel not improved, new treatment noted, specialized wound management to follow, continue intravenous antibiotic per orders and continue all interventions. Review showed staff did not document any new or updated resident specific pressure interventions on the care plan after the resident developed the right heel unstageable pressure ulcer. Review of the resident's physician progress notes [REDACTED]. Review of the resident's weekly wound assessments (done by licensed nursing staff) showed staff documented: - 4/27/16: New facility acquired unstageable with blister intact pressure ulcer on right heel and acquired on 4/27/16. The pressure ulcer measured 4.5 cm length by 6.5 cm width. The current treatment was skin prep daily; - 5/2/16: Unstageable right heel pressure ulcer. Measured 6.5 cm length by 8.0 cm width. Blood blister. Wound status unchanged. Skin prep daily. - 5/9/16: Unstageable right heel pressure ulcer. Measured 4.0 cm length by 8.0 cm width. Wound status was improved and skin prep daily; - 5/16/16: Unstageable right heel pressure ulcer. Measured 4.0 cm length by 6.0 cm width. Wound status was improved and healing; - 5/23/16: Suspected deep tissue injury and pressure ulcer right heel. Measured 0.7 cm length by 0.3 cm width. Wound status was improved and healing; - 5/31/16: Suspected deep tissue injury and pressure ulcer right heel. Measured 0.5 cm length by 0.2 cm width. Wound status was improved and healing. Skin prep every shift; - 6/6/15: Stage II pressure ulcer on right heel. Measured 0.3 cm length by 0.3 cm width by 0.1 cm depth, 100% pink and granulation tissue not present. Wound status was improved and healing. Skin prep every shift; - 6/13/16: Right heel pressure ulcer healed. Will continue skin prep to both heels every shift; - 7/11/16: New unstageable right heel pressure ulcer acquired on 7/11/16. Measured 6.5 cm length by 6.0 cm width. Tissue was 5% black, 4% yellow and 1% red. Treatment was [MEDICATION NAME] and dry dressing every shift. Boots on; - 7/18/16: Unstageable right heel pressure ulcer. Necrotic tissue was 6% black, 3% yellow and 1% red, moist and granulation tissue not present. Deteriorating wound status. Cleanse, apply [MEDICATION NAME] with dry dressing daily. Heel boots on; - 7/25/16: Unstageable right heel pressure ulcer. Measured 3.0 cm length by 4.0 cm width. Wound status - improved. Continue same treatment; - 8/1/16: Unstageable right heel pressure ulcer. Measured 4.0 cm length by 5.0 cm width. Wound bed - 20% yellow and 80% black, yellow moderate drainage with a slight odor; - 8/15/16: Unstageable right heel pressure ulcer. Measured 5.0 cm length by 5.5 cm width. Wound bed - 100% dry, hard, black eschar and intact. Scant yellow drainage with no odor. Wound status - unchanged; - 8/22/16: Unstageable right heel pressure ulcer. Measured 5.5 cm length by 6.0 cm width. Wound bed - 10% yellow and 90% dry hard black eschar. Scant yellow drainage with an odor and surrounding skin red. Wound status - deteriorated; - 8/29/16: Unstageable right heel pressure ulcer. Measured 5.0 cm length by 5.0 cm width. Wound bed - 10% pink and 90% yellow. Moderate yellow drainage. Wound specialist debrided and started antibiotics; - 9/6/16: Unstageable right heel pressure ulcer. Measured 5.5 cm length by 6.5 cm width. Wound bed - 90% pink and 10% yellow. Moderate yellow drainage with odor and surrounding skin red. Wound status - deteriorated; - 9/26/16: Unstageable right heel pressure ulcer. Measured 5.5 cm length by 5.5 cm width. Wound bed - 50% pink and 50% yellow. Moderate yellow drainage with no odor and surrounding skin intact. Wound status - improved; - 10/3/16: Unstageable right heel pressure ulcer. Measured 5.0 cm length by 4.5 cm width. Wound bed - 50% pink and 50% yellow. Moderate yellow drainage with no odor and surrounding skin intact. Wound status - improved; - 10/10/16: Unstageable right heel pressure ulcer. Measured 5.0 cm length by 54.5 cm width. Wound bed - 90% pink and 10% yellow. Moderate yellow drainage with no odor and surrounding skin intact. Wound status - improved; - 10/17/16: Unstageable right heel pressure ulcer. Skin graft done. - 10/20/16: Stage IV right heel pressure ulcer. Measured 5.0 cm length by 5.0 cm width by 0.4 cm depth. Wound bed - 90% pink and 10% yellow, moderate thin watery bloody and yellow drainage; - 10/24/16: Unstageable right heel pressure ulcer. Measured 5.0 cm length by 5.0 cm width by 0.4 cm depth. Wound bed - 80% pale pink and 20% thin yellow necrosis around wound edges. Surrounding skin shows maceration (prolonged exposure to moisture). Wound status- deteriorated. Review of the resident's weekly wound/skin assessments made available showed no skin assessments for the weeks of 6/18/16, 6/25/16 and 7/2/16. Review of the resident's nurses' notes, dated 7/6/16, showed staff documented resident referred to wound care team for right heel. Looks ischemic, necrotic and has a foul smell now. Review of the resident's Bath Skin Report (completed by the CNA during the resident's shower and signed by the charge nurse) showed staff documented the following on: - 6/14/16: Skin normal; - 6/18/16: Skin normal; - No bath skin reports provided by facility from 6/19/16 to 7/7/16; - 7/7/16: Skin normal and no breakdown noted, no documentation of right heel breakdown; - 7/9/16: Skin abnormal and slight redness in groin area from brief. No documentation of right heel breakdown; - 7/18/16: Skin normal; - 8/20/16: Skin normal; - 8/27/16: Skin abnormal and open area on back of foot (left heel circled). Treatment ordered: - 9/12/16: Skin normal and right foot circled. No other documentation; - 9/16/16: Skin normal; - 10/17/16: Skin normal; - 10/20/16: Skin abnormal. Left foot circled; - 10/22/16: Skin normal. Right foot circled and documented dressing treatment ordered; - 10/25/16: Skin normal. Right heel circled. During an interview on 10/26/16 at 11:15 A.M., CNA H said that every time a resident has a shower CNAs are to fill out the shower sheet with any skin or other problems. The shower sheet is turned in to the charge nurse at the end of the shift. Review of the resident's active medical record showed staff documented different different dates that the resident's unstageable right heel pressure ulcer was first observed: - Weekly wound assessments showed facility acquired on 4/27/16, healed on 6/13/16 and found on 7/11/16. On 7/11/16 documented as a new unstageable pressure ulcer; - Nurses notes dated 7/6/16 showed refer to wound care; - Bath skin reports showed no documentation of the resident's right heel breakdown until 8/27/16. Review of the resident's contracted wound specialist notes showed on: - 8/29/16: Debridement of unstageable right heel pressure ulcer. Pre debridement measurements 5.0 cm by 5.0 cm. Clean wound with Dakin's 0.25% solution, apply Santyl, cover with Dakin's moistened gauze and dry dressing. Change daily and as necessary. Local infection present. Plan: Give [MEDICATION NAME] (antibiotic) for 14 days; - 9/6/16: Unstageable pressure ulcer right heel. Wound has deteriorated. Measured 5.5 cm length by 6.5 cm width, unable to determine depth. Local infection present. Surgical consult ordered; - 9/12/16: Unstageable pressure ulcer right heel. Measured 5.5 cm length by 5.0 cm width, unable to determine depth. Wound base - 10% yellow and 90% black. Local infection; 9/19/16: Unstageable right heel pressure ulcer. Surgically debrided one week ago. On [MEDICATION NAME] and [MEDICATION NAME] IV and [MEDICATION NAME] by mouth; - 9/26/16: Evaluation and debridement of right heel pressure ulcer. Wound type: Stage IV pressure ulcer. Diagnosis - [DIAGNOSES REDACTED]; - 10/3/16: Stage IV right heel pressure ulcer. Measured 5.0 cm length by 4.5 cm width; - 10/10/16: Stage IV right heel pressure ulcer. Measured 5.0 cm length by 5.5 cm width. Wound graft to be done tomorrow; - 10/17/16: Skin graft placed, dressing to stay on for 10 days. No visit today; - 10/20/16: Stage IV right heel pressure ulcer. Measured 5.0 cm length by 5.0 cm width by 0.4 cm depth. Staples removed, continue use of heel boot and no weight bearing; - 10/24/16: Stage IV right heel pressure ulcer. Measured 5.0 cm length by 5.0 cm width by 0.4 cm depth. Remains on IV antibiotics. Review of the wound specialist's progress notes, dated 9/26/16, showed the physician documented the resident had an approximately 8.0 cm in diameter stage IV pressure ulcer. Observation on 10/25/16 at 10:50 A.M., showed RN D and RN E removed the resident's right heel dressing. RN E cleansed the wound with Dakins solution 0.125%, applied Santyl, [MEDICATION NAME] and a dry dressing. The wound measured 5.0 cm length by 5.0 cm width by 0.4 cm depth. During an interview on 10/25/16 at 10:50 A.M., RN D said the right heel pressure ulcer was facility acquired. The resident had a graft to the pressure ulcer two weeks ago and the staples were removed five days ago. 4. During an interview on 10/26/16 at 10:45 A.M., RN D said bath sheets are done with the residents' showers three times a week by the CNAs. The CNAs look for any skin breakdown and write on bath sheets. RN D said licensed staff do not do any skin assessments on the residents and all residents' heels are floated in bed. 5. During an interview on 10/26/16 at 12:00 P.M., the Staff Development Coordinator said CNAs inspect residents' skin during showers by looking for skin tears, bruises and anything that shows injury. The CNAs turn the shower sheets into the charge nurse who signs the form. The CNAs do not do the weekly skin assessment that is to be done by the nurses. 6. During an interview on 10/27/16 at 11:30 A.M., the DON, ADON and Corporate Nurse said pressure ulcers are looked at everyday by the CNAs. The CNAs observe the residents' skin during daily care. The CNAs should notify the wound nurse of any change in wound status. The CNA fills the Bath Skin Report form out during the resident's bath and the charge nurse then signs the residents' Bath Skin Report form. The charge nurse is not required to observe the resident's skin before signing the Bath Skin Report. The licensed nurses are responsible for assessing the residents' skin weekly and documenting on the weekly wound assessment form. The DON said a change in how skin assessments were done happened around June. At that time staff did not document on the weekly skin assessment form consistently as it was duplicate paperwork. The DON said the pressure ulcer care plans are in the TAR. 7. Review of the facilities Skin Monitoring Policy and Procedure, undated, showed staff were to conduct skin monitoring to identify residents who are at risk for skin breakdown and to initiate immediate treatment when skin breakdown occurs. Review showed staff were directed to do the following: - Complete a Braden Scale assessment (used to predict a person's risk of developing a pressure ulcer) as part of the admission process and quarterly with the Minimum Data Set (MDS) (a federally mandated assessment instrument); - Based on the assessed risk, initiate preventive measures and document them in the Plan of Care; - Bath Skin Reports are given to the nurses aides with their shower assignments and returned to the charge nurse as soon as they are completed; - The areas of concern that are identified on the Bath Skin Report are assessed by the charge nurse and documented. Nursing administration is notified; - The Bath Skin Reports with any areas noted are forwarded to the Director of Nursing (DON) or designee; - All wounds are assessed during dressing changes by nursing staff and any significant change is brought to the attention of the DON or her designee; - The weekly wound rounds are completed by the DON or her designee. Wounds are measured and assessed for the appropriateness of the treatments and their status documented on the weekly wound report by the DON or her designee. Review of the Pressure Ulcer Prevention Policy and Procedure, undated, showed staff were directed to do the following: - Complete a skin pressure risk assessment on admission, quarterly with MDS and with significant change of condition; - Assist residents who are unable or require assistance with turning with repositioning at a minimum of every two hours; - Report any signs of skin irritation and pressure to the Charge Nurse immediately; - Document all skin observations on the Bath Skin Report. 8. Review of the State Operations Manual, Appendix PP, Tag F314 states it is important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers. 9. Facility staff failed to perform and/or appropriately document skin assessments for one resident (Resident #11) before and after the resident developed a facility acquired unstageable pressure ulcer. Review of the resident's care plan, dated 9/28/15, showed staff identified the resident was at risk for pressure ulcers related to limited mobility, [MEDICAL CONDITION], kidney disease, diabetes, [MEDICAL CONDITION] and spending a lot of time sitting in a wheelchair or in bed. In addition, review showed the following: - Staff were directed to turn and reposition resident every two hours and as needed; - Provide incontinence care after each incontinent episode; - Use pillows, wedges, etc., for pressure reduction when resident in bed; - Complete a weekly wound report. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Required extensive assistance from staff for bed mobility and dressing; - Totally dependent on staff for transfers, locomotion and toilet use; - Did not walk; - Always incontinent of bladder and bowel; - At risk for pressure ulcers; - Did not have any pressure ulcers; - diagnosed with [REDACTED]. the body). Review of the resident's Braden scale assessment dated [DATE], showed staff assessed the resident scored a 13 (at moderate risk for developing a pressure sore). Review of the resident's Standard to Maintain Skin Integrity form completed with the Braden scale assessment, dated June 2016, showed All residents will have a systematic skin inspection during baths/showers by the CNA's paying particular attention to the bony prominences. Results of skin inspection will be reviewed by the Charge Nurse and documented/interventions applied, as necessary, of any new areas of concern. Review of the Physician order [REDACTED]. Review of the resident's Treatment Administration Record (TAR), dated 7/1/16 through 7/31/16, showed staff were directed to conduct a skin assessment for the resident every Friday. Review showed a nurse signed off the skin assessment as completed for the resident for every Friday in July 2016 (7/1, 7/8, 7/15, 7/22 and 7/29). Review showed the resident's medical record did not include documentation of the skin assessments signed off by nurses on Fridays for the month of July 2016. Review of the resident's Bath Skin Reports (shower/bath sheets) dated 7/04/16 and 7/15/16 showed CNAs (Certified Nurse Aides) documented the residents skin was normal and nurses signed off on the report. Review of the resident's Bath Skin Report, dated 7/20/16, showed a CNA did not document any abnormal areas for the resident's feet and a nurse signed off on the report. Review of the nurses note, dated 7/20/16, showed a nurse documented the resident had a deep tissue injury to the left plantar foot that measured 2.2 cm by 4.0 cm and the depth was unable to be determined. Review of the resident's POS, dated 7/1/16 through 7/31/16, showed staff were directed to apply skin prep (a liquid that forms a protective film over skin) to the resident's left plantar foot daily. Review of the resident's Weekly Wound Assessment, date 7/20/16, showed staff documented the resident had a pressure ulcer and classified it as a Suspected Deep Tissue Injury (SDTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue; deep tissue injuries may sometimes indicate severe damage and have the potential for rapid deterioration) to the plantar portion of the left foot which measured 2.2 cm by 4.0 cm, depth was unable to be determined, and the wound bed was 100% black. Review of the care plan showed an update, dated 7/20/16, where staff documented the resident had a deep tissue injury to the plantar area of the left foot. Review showed staff were directed to follow treatment orders, maintain a boot on the resident at all times and notify the physician of any signs and/or symptoms of infection. Review of the resident's Monthly Summary, dated 7/21/16, showed a nurse documented the resident had black eschar (thick, leathery, frequently black or brown in color, necrotic (dead)) on left plantar foot - skin prep. Review of the resident's Weekly Wound Assessment, date 8/1/16, showed staff documented the resident had a Suspected Deep Tissue Injury pressure ulcer to the plantar portion of the left foot which measured 1.5 cm by 1.3 cm, depth was unable to be determined and the wound bed was 100% dry/hard/black eschar intact. Review of the resident's Bath Skin Reports, showed staff did not document any bath skin reports from 7/21/16 through 8/4/16 (for 15 days). Review of the Bath Skin report, dated 8/5/16, showed a CNA documented the resident's skin was normal and did not document the resident had a pressure ulcer on the left foot. Review showed a nurse signed off on the report and did not correct the inaccurate information. Review of the Bath Skin Report, dated 8/12/16, showed a CNA documented the resident's skin was normal and did not document the resident had a pressure ulcer on the left foot. Review showed a nurse signed off on the report and did not correct the inaccurate information. Review of the Bath Skin Report, dated 8/24/16, showed a CNA documented the resident

Based on interview and record review, the facility failed to provide the necessary physician-ordered wheelchair positioning devices for one of ten sampled residents. (Resident #37) The resident fell on [DATE], the facility also failed to adequately assess the resident for possible changes in condition. On [DATE], staff noted the resident as unresponsive and sent the resident to the hospital. The resident had cervical fractures. The census was 263. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed the following: -Severely impaired vision; -Ability to repeat but inability to recall three given words; -Inability to report correct day, month or year; -Extensive assistance required with transfers; -Required total dependence with locomotion; -Required limited assistance with eating; -[DIAGNOSES REDACTED]. -Received scheduled pain medication but no pain present upon interview; -No condition or chronic disease which would result in a life-expectancy less than six months; -No falls since prior assessment; -No swallowing disorder. Review of the resident's care plan, dated [DATE] with a review date of [DATE], showed the following problems: -Activities of daily living (ADLs)- the resident needed assistance with all ADLs. The resident could not see people or objects clearly; so he/she needed help transferring in and out of bed, standing, walking or propelling the wheelchair in uncommon areas. -Cognition- the resident's memory was poor, and he/she was forgetful, especially when anxious. The resident could not see well. -Falls- the resident had a history of [REDACTED]. The resident took medication for anxiety, depression and sleep, which could cause falls. The staff approaches included the following: -Follow fall intervention guidelines for high fall risk; -If fall occurred, evaluate the cause and make changes as needed; -Perimeter mattress on bed and wedge cushion in wheelchair. -Nutrition- the resident had a history of [REDACTED]. The resident ate in the division dining room related to poor vision and recent [DIAGNOSES REDACTED]. The staff approaches included: -Document intake of meal on consumption board or in nurse's notes; -Observe for and report aspiration as evidenced by increased shortness of breath, change in voice, productive cough; -Observe for and report sadness, anxiety, poor sleep or other mood changes which could result in loss of appetite. -Pain- the resident had knee and shoulder pain. The resident had arthritis and was at risk for breakthrough pain. The resident took routine pain medication. The staff approaches included: -Observe for and encourage him/her not to engage in unsafe behaviors; twisting back, leaning forward in chair and reaching outside of the line of the trunk. -Observe for and report if the resident did not get relief from pain. Review of the high risk for falls guidelines (no date), included the following: -Assist the resident with all transfers. Make sure the resident has shoes or non-skid slippers on for all transfers; -Toilet the patient frequently while awake. Offer fluids and comfort measures. Reposition in bed. Reorient to the environment frequently; -Place the call light within reach; -The resident should not be left alone on the toilet. Attempt to keep resident in common areas. Review of the occupational therapy (OT) evaluation, dated [DATE], listed the goal to increase posture in the wheelchair secondary to leaning leftward at the trunk. The resident leaned leftward at the trunk and head/neck. The resident's neck tilted at 45 degrees. The resident's safety awareness was poor. The resident was alert and oriented times one to two (person and place). Review of the OT discharge summary, dated [DATE], showed the resident demonstrated good sitting posture with right arm rolls and left lateral support for upper body and foot/calf board on elevated leg rests. The resident sat upright for meals, leisure and rest while in wheelchair. OT staff instructed charge nurses and certified nurse's assistants (CNAs) during the day and evening shifts regarding the application and use of the positioning devices. Review of the resident's care plan, updated [DATE], showed the following information: -Restorative nursing daily for passive range of motion to neck and upper extremity joints; -Wheelchair positioning with bilateral arm rolls, foam seat cushion, foot/calf board on elevated leg rests in 16 by 16 inch high-back reclining wheelchair. Review of a note from the OT department, dated [DATE], showed the following recommendations for the resident's high-back reclining wheelchair: -Blue arm rolls on armrests; -Black foam "camp" seat cushion; -Black foot/calf-board on leg rests. Review of the physician's progress note, dated [DATE], showed the resident's current issues included: urinary frequency, weight loss and [DIAGNOSES REDACTED] (brain disease which affects eye movement). Physician Y noted the resident was fairly stable. The resident continued to lose weight gradually, but staff said the resident ate well and were surprised at the weight loss. The resident's lungs were clear. The physician noted the resident was involuting (shrinking). Review of the resident's [DATE] physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Orders included: -Extra strength Tylenol 1000 milligrams (mg) every eight hours; -Tylenol 500 mg twice per day, as needed for fever; -[MEDICATION NAME] (pain medication) 50 mg four times per day, as needed for pain; -Apply [MEDICATION NAME] (pain medication), one patch to left rib every twelve hours as needed, please date on and off and site of patch; -Bilateral arm rolls, left lateral support foam seat cushion, foot/calf board on elevating leg rest in wheelchair; -Restorative therapy two times per week for bilateral upper extremity exercise with one pound therabar (an exercise tool for improving grip and upper extremity strength) in all planes, twenty repetitions times three sets, order dated [DATE]; -Restorative therapy two times per week for bilateral lower extremity exercise with two pound weights in all planes, twenty repetitions times three sets, order dated [DATE]; -Restorative therapy daily for passive range of motion to upper extremities/joints and neck in all planes, order dated [DATE]. Review of the POS [REDACTED].M., showed staff left the resident in his/her room to watch television. When staff checked on the resident, he/she was out of the wheelchair, on the floor, face down. The resident had a nosebleed and complained of right neck pain. The resident was forgetful and had poor safety awareness. Review of the [DATE] physician's orders [REDACTED]. During an interview on [DATE] at 2:30 P.M., CNA O said he/she had never been assigned to the resident's care prior to the shift when the resident fell . At approximately 5:15 A.M. on [DATE], the CNA assisted the resident into his/her wheelchair and left the resident in his/her room to watch television. Because it was the resident's scheduled shower day, the CNA left the resident in a gown. The CNA did not bring the resident to a common area because the resident only wore a gown. The resident had a high back wheelchair with padded armrests. The CNA did not remember if the wheelchair reclined or not. The CNA did not place the foot pedals on the wheelchair because he/she did not realize the resident's wheelchair had pedals. When the CNA returned to the resident's room, the resident lay on his/her stomach with his/her neck turned and right arm in back of him/her. The CNA did not see any injury, but the resident complained of neck pain. The nurse knew about the resident's neck pain. Two nurses moved the resident from the floor to the chair. The CNA did not assist with the resident's transfer to the chair because the nurses did not do range of motion or assess the resident prior to moving him/her. Prior to this incident, night shift staff did not receive assignment sheets regarding how to care for the residents. The CNA did not see the resident's foot pedals that morning because they were behind the resident's blankets. During an interview on [DATE] at 11:00 A.M., Nurse P said the charge nurse assigned to the resident called for his/her assistance when the resident fell on [DATE]. The resident lay face forward with both his/her arms back behind him/her. The resident's face was turned with his/her head on the floor. The nurses turned the resident over and did an assessment from "head to toe." The resident was conscious and his/her speech was normal. The nurses completed range of motion on the resident's extremities, and the resident did not complain of pain. The nurses lifted the resident to his/her wheelchair. Review of CNA Q's written statement (no date), showed at the beginning of day shift on [DATE], the resident lay in bed. Staff said the resident fell . The resident remained in bed for breakfast. Later, a family member visited. CNA Q and the family member both told the nurse the resident's neck hurt. During an interview on [DATE] at 11:16 A.M., Family Member (FM) Z said when he/she arrived at the facility on [DATE], the resident looked like he/she had fallen on his/her face. There was a bruise on the resident's hand and forehead. The resident said his/her neck was sore. When FM Z asked staff about x-rays, staff said they would call the physician. Another family member visited later, and the resident complained about neck pain again. Staff told the other family member they would not take an x-ray but monitor the resident. During an interview on [DATE] at 3:10 P.M., Nurse R said on [DATE] at the beginning of the day shift ([DATE]), he/she received report about the resident having a fall with no injuries. Staff monitored the resident every two hours. Neither the family member nor the CNA reported the resident's pain to the nurse. The family member came to the nurse's station and asked about the foot pedals for the resident's wheelchair. The nurse did not recall how much the resident ate that day. The nurse did not recall if the resident needed neurological (neuro) checks after this fall. After a resident fell , staff should complete incident follow-up, which included vital signs, neuro checks, and a pain assessment. Review of the nurse's notes, dated [DATE] at 2:00 P.M., showed the resident was on incident follow-up after a fall. The resident's temperature was 99.6 degrees Fahrenheit (F) (normal 97.8 to 99.1 degrees F), pulse was 80 (normal 60 to 80 beats per minute), respirations 20 (normal ,[DATE] breaths per minute), and blood pressure was ,[DATE] (normal ,[DATE] to ,[DATE] millimeters (mm) mercury (Hg)). Staff noted no signs of discomfort. Staff administered pain medication at 12:00 P.M. per the family member's request. The pain medication was effective. Review of the resident's record, showed no nurse's notes during the evening shift on [DATE]. Review of the nurse's notes on [DATE] at 12:00 A.M., showed the resident had a quiet night with no complaints of pain or discomfort. The resident's temperature was 97.2 degrees F, pulse was 72, respirations were 18 and blood pressure was ,[DATE]. During an interview on [DATE] at 2:45 P.M., CNA S said he/she worked with the resident during the night shift (,[DATE] through [DATE]) and knew the resident fell during the previous day. Every two hours, the resident was incontinent and required care. The resident complained of pain and said, "Aaaah." When the CNA asked if the resident was in pain, the resident said "yes." The CNA reported the resident's pain to the charge nurse after first rounds, approximately ,[DATE]:15 A.M. on [DATE]. The resident complained of pain every two hours when the CNA moved the resident during care. The resident had bruises on the left side of his/her body. During an interview on [DATE] at 6:30 A.M., Nurse T (assigned to the night shift ,[DATE] through [DATE]) said no one reported any problems or complaints of pain with the resident during the night shift. If staff reported concerns, the nurse would have documented it. During an interview on [DATE] at 10:45 A.M., CNA U (assigned to day shift on [DATE]) said the resident leaned his/her head to the side throughout the day, which was unusual for the resident. The resident also had cough and congestion. The resident ate only one bite of lunch, which the CNA reported to the charge nurse. A family member visited during the day. No one gave the CNA any special instructions regarding the resident's care that day. During an interview on [DATE] at 11:16 A.M., FM Z said on [DATE], the resident said his/her neck was sore. FM Z fed the resident his/her pureed lunch. The resident grimaced and was clearly in pain. FM Z asked staff about an x-ray, and staff said they did not do an x-ray. FM Z asked about pain medication, and staff administered Tylenol. Review of Nurse V's (assigned to day shift on [DATE]) written statement (no date), showed he/she did not recall anything special regarding this resident on this day. If there were anything out of the ordinary, the nurse would have documented it. Review of the resident's record, showed no nurse's notes during the day shift on [DATE]. During an interview on [DATE] at 2:00 P.M., CNA AA (assigned to evening shift on [DATE]) said the resident had a noticeable bruise on his/her face. Other staff said the resident previously fell . The resident asked to stay in bed because he/she did not feel good. The resident said he/she hurt all over, especially during turning and repositioning. No one told the CNA about any special way to turn the resident. The CNA told the charge nurse, who came in and assessed the resident. The Certified Medication Technician (CMT) administered pain medication. During an interview on [DATE] at 2:40 P.M., Nurse BB (assigned to evening shift on [DATE]) said the resident had a bruise on his/her right hand, which had some pain to the touch. The resident had no bruise on his/her face. The nurse did not recall how much the resident ate that evening. The nurse did not recall completing neuro checks for this resident. If he/she had recently fallen, staff would do incident follow-up charting, which included vital signs every shift. Review of the nurse's notes, dated [DATE] at 10:30 P.M., showed the resident's fall follow-up vital signs were as follows: temperature 99.8 degrees F, pulse was 68, respirations were 20, and blood pressure was ,[DATE]. During an interview on [DATE] at 10:20 A.M., Nurse CC (assigned to night shift ,[DATE] through [DATE]) said the resident usually stayed in bed all night, and night shift staff got the resident up in the morning prior to the end of their shift. The resident leaned to the right, and the resident had a right seat arm rest for support. The resident also had foot supports and a reclining wheelchair. Staff did not always recline the wheelchair. It depended on the resident's comfort. The resident did not speak much. In report, the nurse heard the resident had a fall with no injury. Staff did not say anything about watching for anything in particular. Staff did not report any problems to the nurse during the night. Review of the nurse's notes on [DATE] at 3:00 A.M., showed the resident's temperature was 98.6 degrees F, pulse was 74, respirations were 20, and blood pressure was ,[DATE]. Staff noted no signs/symptoms of pain or discomfort. Staff administered the resident's scheduled Tylenol at 6:00 A.M. During an interview on [DATE] at 2:30 P.M., CNA Q said he/she worked on the day shift of [DATE]), the resident was not him/herself. The resident had a bruise on the hand and the neck. The resident did not eat like usual. The CNA thought the resident was in severe pain because every time the CNA touched the resident's neck, like to brush his/her hair, the resident winced and pushed the CNA's hand away. Each time the resident complained of pain, the CNA reported it to the nurse. Review of the resident's record, showed no nurse's notes during the day shift on [DATE]. During an interview on [DATE] at 12:25 P.M., CNA DD (assigned to the evening shift on [DATE]) said the resident leaned to the left more than usual. The resident did not complain of pain, but he/she was "drained" and tired. The resident usually ate well, but did not want to eat that evening. During an interview on [DATE] at 8:20 A.M., Nurse EE (assigned to the evening shift on [DATE]) said he/she did not work at the facility often and had no recollection of the resident. If a resident is on incident follow-up after a fall, usually the nurse did the vital signs. The nurse knew no one reported anything unusual with the resident that shift because he/she would have investigated it if they had reported anything. Review of the resident's record, showed no nurse's notes during the evening shift on [DATE]. Review of the nurse's notes on [DATE] at 1:00 A.M., showed the resident's temperature was 100.5 degrees F, pulse was 90, respirations were 20 and blood pressure was ,[DATE]. The resident had no complaints of pain or discomfort. Staff administered as needed Tylenol for slight elevation of temperature. Review of CNA FF's (assigned to the night shift of ,[DATE] through [DATE]) written statement (no date), showed the resident said his/her neck hurt. The CNA told the charge nurse after assisting the resident into his/her chair. During an interview on [DATE] at 6:20 A.M., Nurse GG (assigned to the night shift of ,[DATE] through [DATE]) said the resident just finished with incident follow-up. Nothing occurred with the resident during the shift until the morning. The resident complained of some minor neck pain, and staff administered the resident's routine Tylenol. The nurse saw on the fall report that the resident complained of neck pain after his/her fall. Nurse GG assumed the resident still had some soreness. The resident was his/her normal self and could move his/her neck. Review of CNA Q's (assigned to the day shift of [DATE]) written statement (no date), showed he/she assisted the resident during breakfast, and the resident did not eat or drink much. The CNA wrote the resident did not look good that morning. The CNA asked the nurse about x-rays and if the nurse could check the resident's neck. The nurse checked the resident's neck. Later that morning, the resident's breathing was "hard." The CNA told the nurse who administered oxygen. At lunch time, the resident did not look any better, so the CNA took the resident to the desk. The Director of Nursing (DON) was at the desk at the time. During an interview on [DATE] at 2:15 P.M., Nurse HH (assigned to the day shift of [DATE]) said the resident complained of neck pain at breakfast. The nurse thought the resident ate well that morning, but the CNA said he/she did not eat well. At approximately 11:00 A.M., the resident began making a "grunting sound" and did not hold his/her head up. The nurse called the physician who ordered the resident's transfer to the hospital. Review of the nurse's notes, dated [DATE], showed the following: -At 11:15 A.M., the resident's oxygen saturation was 97% on room air (normal 94 to 100%), pulse was 104, temperature was 98.4 degrees F and blood pressure was ,[DATE]. -At 12:15 P.M., the resident became unresponsive, grunting while breathing. Staff transferred the resident to bed. The resident opened his/her eyes. The resident was alert to self, nodded his/her head appropriately but was unable to speak. The resident's temperature was 99.6 degrees F, pulse was 100, respirations 20, and blood pressure was ,[DATE]. -At 12:50 P.M., the resident's oxygen saturation was 99% on 3 liters/minute of oxygen. Staff called the physician who gave orders to send the resident to the hospital. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"as needed" Tylenol, [MEDICATION NAME] or [MEDICATION NAME] medication administered to the resident from [DATE] through [DATE]. Review of the resident's neurological assessment form, showed the following: -Neurochecks for head injuries should be completed as follows: -Every fifteen minutes during the first hour; -Every thirty minutes during the next two hours; -Every hour during the next four hours; -Every four hours during the next seventy-two hours. -Neurochecks for falls without head injury are to be completed every shift for seventy-two hours. -Staff conducted neurological checks on the resident at the following times: -[DATE] at 6:15 A.M.; -[DATE] at 6:30 A.M.; -[DATE] at 2:00 P.M.; -[DATE] (no time noted); -[DATE] at 3:00 A.M.; -[DATE] at 10:00 A.M.; -[DATE] at 6:00 P.M.; -[DATE] at 1:00 A.M. Review of faxed correspondence from Corporate Nurse W, dated [DATE], showed the facility could not locate the resident's consumption records for [DATE]. Review of the hospital record, showed the following: -The skin assessment, dated [DATE] at 2:20 P.M., showed the resident had bruised areas to the front of the head and the posterior (back) right hand. -The discharge summary, dated [DATE], showed the resident had mild distress from neck pain upon admission to the hospital. The resident had difficulty with swallowing as a continuation of his/her prior neurologic status, but also subacutely worsened with a cervical fracture. The resident was a poor candidate for surgery. As a result of both acute and chronic processes, the resident silently aspirated. The resident rapidly dwindled and expired on [DATE]. The resident's discharge [DIAGNOSES REDACTED]. -Aspiration pneumonia; -Dysphagia (difficulty swallowing) secondary to [DIAGNOSES REDACTED] exacerbated by a cervical fracture; -[DIAGNOSES REDACTED] (presence of an abnormal protein in the blood) previously diagnosed as [DIAGNOSES REDACTED] of undetermined significance (MGUS), possible transformation to [DIAGNOSES REDACTED] (cancer of plasma cells); -Urinary tract infection; -[DIAGNOSES REDACTED]; -Cervical fractures at C1 and C2 (the upper cervical vertebrae); -Dementia; -[MEDICAL CONDITION]; -[MEDICAL CONDITION] of chronic disease; -[MEDICAL CONDITION]; -[MEDICAL CONDITION]. During an interview on [DATE] at 2:15 P.M., Restorative Therapist (RT) II said he/she routinely did passive range of motion with the resident's upper and lower extremities. The restorative therapist did not do any type of daily restorative therapy with the resident. The therapist was off for the holiday week-end, and did not work with the resident at all after the resident's fall. During an interview on [DATE] at 12:55 P.M., the DON said there was no restorative therapy documentation for the resident in [DATE]. During an interview on [DATE] at 6:50 P.M., Occupational Therapist JJ said when he/she discharged the resident from therapy, all the positioning devices were in place, except the high-back wheelchair, which came within a week. When the therapist saw the resident after this in the dining room, his/her positioning looked fine. The arm rolls supported the resident's trunk for upright sitting and prevented leaning. The foam seat cushion had a saddle insert for the resident's legs. The resident's comfort level dictated how much staff should recline back the wheelchair, as long as ,[DATE] minutes had passed since a meal. The elevation of the leg rests depended on the resident's swelling and would be a nursing decision. The resident had a calf board so his/her feet would not fall between the foot rests. The arm rolls were more important to prevent forward leaning than the foot rests. The foot rests were more important to prevent or slow down sliding out of the wheelchair. During an interview on [DATE] at 11:16 A.M., FM Z said the hospital neurologist said there were two broken rings in the resident's neck from the fall. The neurologist said the resident could have a hard collar and a feeding tube, or a halo to support his/her neck. Prior to the fall, the resident planned to attend a family wedding the next week-end. The resident was not near death or in poor health. During an interview on [DATE] at 10:50 A.M., Physician Y said the resident's fall itself was not too surprising due to the resident's [MEDICAL CONDITION] symptoms. After a fall, staff should assess for range of motion, bleeding, and signs/symptoms of pain. If the resident hit his/her head, staff should complete neuro checks. At the time of the resident's fall, Physician Y was out of town. The physician told the facility to contact the nurse practitioner with any issues regarding his patients. Staff called Physician X, who is a [MEDICATION NAME]. Although Physician X was a qualified physician, the nurse practitioner might have been more familiar with nursing home protocols. If the resident had continued complaints of pain, staff should have contacted the physician again. Physician Y is the facility's medical director and reviewed this incident. The physician said it was difficult to determine how much pain the resident had during the time after the fall. The physician expected a resident to have some pain after a fall. If the resident's current medications controlled the pain, another physician contact might not have been warranted. Another factor in determining someone's pain level was his/her appetite. The physician did not expect staff to document the percentage of the resident's meals, but he expected staff to notify him of an overall decline of the resident's intake. The physician would like to have known about the resident's fracture sooner, but the resident's outcome was no different due to the delay in treatment. The resident was not a surgical candidate and the hard collar did not help control the resident's pain. Due to the resident's overall condition, the resident would have died of aspiration pneumonia and dysphagia over the next several weeks to months, however, the fracture accelerated the dying process. During an interview on [DATE] at 12:55 P.M., the DON said after a fall, staff should complete the post-fall assessment form and start the resident on incident follow-up, where staff take vital signs every shift. Staff should follow the guidelines for neuro checks as listed on the form. If there is a possibility the resident hit his/her head, staff should conduct neuro checks. The DON was not in the building and not aware the resident fell until [DATE]. When the DON saw the resident on [DATE], she could hear the resident's breathing difficulties without the use of a stethoscope. The DON said if the resident continued to complain of pain, the DON would have sent the resident to the hospital for additional tests. The DON was surprised the physician did not give orders to send the resident out right away or obtain x-rays. If the DON were aware of the situation, she would have "pushed" the physician. Review of the facility's incident/accident policy (no date), showed procedures included: -Examine the person for possible injury. Person should remain flat until assessment determines the person may be moved; -Residents are to be observed and condition documented as necessary, but at least every shift for 72 hours. The assessment should include the following: -Blood pressure; -Pulse; -Respirations; -Level of consciousness. -Residents sustaining a head injury with a fall should have vital signs, including neuro checks (per Neurological Assessment Policy) and condition documented every shift for 72 hours or as ordered by the physician. Review of the facility's Neurological Assessment policy (no date), showed staff should document date, time and results of all neurological assessments, including: -Level of consciousness; -Pupillary reaction; -Motor and sensory function; -Vital signs; -Description of all behaviors and responses; -All teaching done, if appropriate, and resident's level of understanding. MO 146