Every finding on record at Diversicare of Chanute

The facility identified a census of 57 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 received the necessary care, including his personalized physician ordered medication regimen, to alleviate terminal agitation and promote comfort as intended by the hospice provider resulting in increased anxiety/agitation, a fall with an injury and low back pain. Findings included:- R1's Electronic Medical Record (EMR) documented a diagnosis of unspecified visual loss, muscle weakness, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), altered mental status (a non-specific, change in brain function, resulting in confusion, decreased alertness, or behavioral changes), and unspecified vision loss. R1's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had lower extremity impairment on one side and had a limb prosthesis. He used a walker and a wheelchair. The MDS documented R1 was dependent on staff for toileting hygiene and required substantial to maximal assistance for bathing, lower body dressing, putting on or taking off footwear, and wheelchair mobility. R1 required partial or moderate assistance for shower or tub transfers, and transitioning between lying to sitting, and sitting to standing. The Functional Abilities Care Area Assessment (CAA), dated 02/10/26, documented the CAA triggered secondary to assistance required in activities of daily living (ADL), impaired balance, and functional impairment in activity. The CAA further documented contributing factors, including generalized weaknesses and decreased safety awareness. The CAA documented risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. The Psychotropic Drug Use CAA dated 02/10/26, documented the CAA triggered secondary to the use of psychotropic medications to manage a psychiatric illness or condition. The CAA documented contributing factors included current history of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (any major mental disorder characterized by a gross impairment of perception), and insomnia (inability to sleep). The CAA documented risk factors included increased falls, impaired balance, and potential for adverse effects of medication. The Psychosocial CAA dated 02/10/26, documented the CAA triggered secondary to feelings of sadness, lack of interest, and feeling bad about oneself. The CAA documented R1 stated he had little interest in normal favorite activities and stated he wished he were dead. The CAA documented contributing factors included diagnoses of depression, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), new placement in a facility, and living in a facility for an extended time. The CAA documented risk factors included decreased socialization, worsening depression, and anxiety. R1's 03/02/26 Care Plan documented R1was on hospice care related to end-of-life care for a terminal diagnosis of cerebral infarction. The plan included the following interventions dated 03/02/26:Staff were to coordinate the care plan with hospice.Staff were to notify hospice of any change in condition or medication changes.Staff were to provide emotional support to the patient and family during the dying process. R1's 03/02/26 Care Plan documented R1 had potential for drug-related complications associated with the use of psychotropic medications related to anti-anxiety medication. The plan included the following interventions dated 03/02/26:Staff were to provide medications as ordered by the physician and evaluate for effectiveness.Staff were to observe for side effects and report to the physician.Staff were to provide non-pharmaceutical interventions of offering fidget items to decrease target behaviors, anxiety, or depression.A psychotropic medication risk and benefit and reduction plan as recommended by the physician and pharmacist. A Durable Power of Attorney (DPOA) for Healthcare Decisions dated 10/21/21, documented Administrative Nurse E was R1's primary DPOA, and R1's Representative was recorded as R1's alternate DPOA. The document recorded R1's DPOAs were authorized to consent, refuse, or withdraw consent to any care, procedure, treatment, or service to diagnose, treat, or maintain a physical or mental condition, including artificial nutrition and hydration. R1's EMR recorded the following orders:Clonazepam (anti-anxiety medication) 0.5 milligrams (mg) two times a day for anxiety related to altered mental status, started 02/06/26 and discontinued on 02/24/26. Seroquel (antipsychotic - class of medications used to treat major mental conditions which cause a break from reality) 50 mg one time a day for dementia with distressing psychotic features that diminish quality of life and pose a risk to others, started 02/09/26. A Provider's Order dated 02/20/26, and signed by Consultant GG, documented the following orders:Ativan (anti-anxiety medication) 0.5 mg three times a day for 14 days for agitation and irritability.Admit to hospice. A General Notes dated 02/24/26 recorded R1 admitted to hospice services. All medications were discontinued except Tylenol 500 mg two tabs three times daily, clonazepam 0.5 mg twice daily, Lantus (long-acting insulin) 14 units daily, lorazepam 0.5 mg three times daily, Tramadol 50 mg every six hours as needed, and Seroquel 50 mg twice daily. A hospice Progress Report dated 02/24/26 documented an admit visit between hospice and R1's DPOA (Administrative Nurse E). A text message, reviewed and verified from Administrative Nurse D to Administrative Nurse E sent on 02/25/26 at 12:30 PM, documented Administrative Nurse D asked Administrative Nurse E why R1 had both scheduled Ativan and clonazepam and texted the resident did not need both. Administrative Nurse E responded that the medications were ordered by R1's primary care provider (PCP), Consultant GG. Administrative Nurse D replied and stated R1 cannot be on both and texted that Consultant GG would have to pick one or the other. Administrative Nurse D responded and said she required Administrative Nurse E to call Consultant GG because R1 could not have both, there was no monitoring entered, and no consents. A Provider's Order dated 02/25/26, and signed by Consultant GG, documented the following orders:Continue lorazepam (Ativan) 0.5mg three times a day for dementia and altered mental status.Continue Seroquel 50 mg twice a day.Discontinue clonazepam. LN G documented a General Notes dated 02/25/26 at 02:53 PM, noting new orders to discontinue R1's clonazepam. A General Notes marked as a late entry had a created date of 02/25/26 at 02:55 PM and an effective date of 02/25/26 at 03:17 PM, documented R1 came to the nurse's desk and asked to talk to his daughter (Administrative Nurse E). The note documented R1 wheeled himself over to the other side and wanted to talk with his daughter, Administrative Nurse E. The note documented that Administrative Nurse E told the nurse that Administrative Nurse E told R1 that she was working and that she would talk to R1 when she was able. The note documented that staff brought R1 back to the west side of the facility; R1 was upset. The note documented R1 became upset when asked to take his medications and stated he would not take the medications and said he thought staff was trying to poison him. The note documented R1 picked up a folding table, went down to the south door, and watched the traffic. Staff approached R1 several times and asked him to take his medication. R1 became agitated and yelled that he was going to throw the table through the door. The nurse asked R1 if they could put the table where it belonged, and R1 gave the table back to the staff and was pleasant at that moment. The note documented that R1 continued to refuse medications, was very agitated, and threatened staff. The note documented that the staff called Administrative Nurse E and then reapproached R1 about taking his medications. The note documented R1 took the medications and went back to his room. A General Notes dated 02/25/26 at 07:45 PM documented R1 yelled for help. Staff entered R1's room, and R1 was on the side of the bed trying to put on his prosthetic leg. R1 stated he needed to get some things out of the truck. The note further documented that R1 had knocked over the water pitcher, and snacks were also knocked to the floor. Staff assisted R1 back to bed and cleaned the area. A hospice Progress Report dated 02/26/26 documented R1 refused all care. A hospice Progress Report dated 02/27/26 documented the hospice nurse visited R1 in the facility. The resident was only alert to himself. The hospice nurse visited with LN G, who expressed no concerns. The hospice nurse then spoke with Administrative Nurse D, who informed the hospice nurse that R1 could not be on scheduled clonazepam and lorazepam and told the hospice nurse that she wanted R1's PCP notified that the orders needed to be changed. A General Notes dated 02/28/26 documented R1 was visibly upset, tearful, and filled with worries. The note documented R1 expressed that he was confused about where he was and that he was upset that he did not know where his daughter was. The note further documented R1 had delusions about the Air Force being in the facility to clean up. R1's face was filled with worry, and he had an expression that indicated he was fearful; he was grimacing. The note documented that staff administered R1 medication for lower back pain. A General Notes dated 03/01/26 documented R1 was standing up in his room, leaning against the refrigerator. The note documented R1 called out for help, and staff assisted him to his wheelchair and took him to lunch. R1 declined to eat lunch and instead drank two glasses of orange juice. R1 also declined snacks. A General Notes dated 03/01/26 at 04:39 PM documented R1 had an unwitnessed fall in the hallway; R1 reported to staff he was trying to go downstairs. R1 sustained a small skin tear to his right elbow and appeared to have discomfort, so staff administered pain medication. The note recorded staff were unable to complete a blood pressure measurement because R1 was unable to sit still. A hospice Progress Report dated 03/04/26 documented the hospice nurse visited R1. The nurse noted R1 had increased restlessness and agitation. A Physician's Progress Notes dated 03/04/26 documented a clarification medication order from the hospice provider. The document recorded orders for the following:Restart clonazepam 1 mg, three times a day for agitation related to altered mental status for 14 days.Discontinue the current scheduled lorazepam order and start lorazepam 0.5 mg every four hours as needed for anxiety or restlessness, or for 14 days. Review of R1's Medication Administration Record (MAR) for February 2026 and March 2026 revealed R1 received narcotic as-needed pain medication in addition to Tylenol six times (no more than once daily) over the 19-day period. between 02/04/26 and 02/247/26. After R1's clonazepam was discontinued on 02/24/26, R1 required as-needed narcotic pain medication daily until 03/03/26, when the as-needed pain medication was changed to Percocet 5 mg three times daily, scheduled. On 03/05/26 at 10:58 AM, R1 slept in a recliner in his room with no signs of distress observed. On 03/04/26 at 04:05 PM, LN G stated R1 was prescribed Ativan and clonazepam together initially. LN G stated she heard Administrative Nurse D tell Consultant HH that R1 could not be on both Ativan and clonazepam, and if R1's DPOA did not like that then she could take R1 home. LN G stated Administrative Nurse D said R1's DPOA would have to choose one or the other, as R1 could not be on both. LN G stated Administrative Nurse D made these comments at the desk in front of her and was speaking to Consultant HH at the time. LN G stated R1 had more agitation after the medication was discontinued. On 03/04/26 at 04:30 PM, Consultant HH stated R1 admitted to hospice services on 02/24/26, and upon his admission, they received signed orders from Consultant GG and all medications that were given in the facility. She stated this information was also placed in the hospice chart. Consultant HH stated on 02/27/26 a staff nurse told her the clonazepam had been stopped. She stated hospice never received an order from the PCP to stop that medication, and if that order was received at the facility, it was never communicated to hospice. Consultant HH stated she contacted the primary care doctor's office to ask about the discontinued medication, but was unable to reach anyone, so she left a message. Consultant HH stated she questioned facility staff and was told R1's clonazepam was no longer ordered, and he was no longer getting it. Consultant HH stated she had noticed some increased agitation and confusion from R1 after the medication was discontinued and said she was not certain that R1's increased behaviors and agitation were caused by discontinuing the medication, but confirmed his behaviors, anxiety, and agitation had increased t around the time the medication was stopped. Consultant HH stated R1 had a fall on 03/01/26, which was communicated to hospice. Consultant HH stated Administrative Nurse D stated it was dumb to have R1 on clonazepam, Ativan, and Seroquel at the same time. Consultant HH stated that Administrative Nurse D told her that if R1's PCP did not want to give the orders to discontinue one of the antianxiety medications as she requested, she would go above the PCP's head to the facility's medical director and have the medication discontinued that way. Consultant HH stated Administrative Nurse D told her R1 could not be on clonazepam and Ativan at the same time. She stated Administrative Nurse D told her either the anti-anxiety medication R1 stayed on would need to be increased, or the Seroquel would need to be increased, but R1 could not be on both anti-anxiety medications at the same time. Consultant HH stated when she was in the facility on 03/02/26 R1 was very confused and was not having a great day. She stated the hospice doctor gave a new order to restart the clonazepam at one mg three times a day and changed the Ativan to an as-needed medication which helped R1 be less anxious and more comfortable. On 03/05/26 at 11:05 AM, R1's DPOA stated R1 was on both clonazepam and Ativan to try and get ahead of the behaviors that he typically had in the late afternoon going into the evening. She stated R1 was more restless, fidgeted more in the evenings, and was not sleeping well since the clonazepam was discontinued. R1's DPOA confirmed that Administrative Nurse D told her R1 could not be on both Ativan and clonazepam and said she would have to pick one or the other, so R1's DPOA spoke to R1's PCP about the medications. She told R1's PCP that she was exhausted from the ongoing battle with Administrative Nurse D over R1's medications. R1's DPOA stated she felt as though she had no choice but to have one of the medications changed due to the pressure from Administrative Nurse D even though it was not in R1's best interest. R1's DPOA stated she was concerned about retaliation from the facility if she did not have one of the medications discontinued and was fearful R1 would be forced to leave the facility and Administrative Nurse D had told her if she refused to comply, Administrative Nurse D would just get the facility's medical director to discontinue R1's medications. R1's DPOA said she felt harassed and bullied to get R1's PCP to discontinue the clonazepam. R1's DPOA stated R1 did not deserve to be treated that way and said R1 had spent his whole life doing things for everyone else, and he did not deserve to be miserable. R1's DPOA stated she was happy with the results from R1's medication regimen that included the lower dose of Seroquel, clonazepam, and Ativan, and said this is the regimen that best helped R1 be comfortable and less anxious. R1's DPOA said it was not in R1's best interest to have the medications changed as it had a negative impact. On 03/05/26, Administrative Nurse D was unavailable for interviews. On 03/05/26 at 12:53 PM, Administrative Staff A stated Administrative Nurse D did not have authority to dictate what medications residents were allowed to take. Administrative Staff A stated he believed it was in the best interest of the residents to receive the medications the provider deemed appropriate to meet their needs. He said he felt there was room for conversation between the nurse and doctor regarding prescribed medications, but ultimately, the power resided with the prescribing authority. Administrative Staff A stated it would have been more appropriate for Administrative Nurse D to clarify if she had issues with the medication, instead of just saying R1 could not have the medication. On 03/05/26 at 05:05 PM, Consultant GG stated she was aware of the concurrent clonazepam and Ativan orders for R1. She stated R1 was on clonazepam prior to coming to the facility, and she changed it to twice a day and then later added the Ativan. Consultant GG stated she had planned on weaning R1 down over the course of a few weeks but stated she was unable to get to that point because she was told staff at the facility had an issue with R1 being on both clonazepam and Ativan. Consultant GG stated R1 was placed on hospice, and he could have been weaned down on clonazepam and changed to Ativan, and hospice usually uses that for residents receiving their services; however, she did not want to just stop the clonazepam abruptly, as there was worry of potential side effects. She stated she spoke to R1's DPOA about the medication situation and felt like someone at the facility was giving R1's DPOA a hard time about R1's medications. She stated that ideally, she would have kept R1 on both (clonazepam and Ativan) for another one to two weeks, weaned him down every week, and slowly increased the Ativan. She stated she felt like someone at the facility put pressure on R1's DPOA to put pressure on her, as the provider, to discontinue one of the medications. On 03/09/26 at 12:27 PM, R1's representative stated he went to meet with Administrative Staff A and Administrative Nurse D to discuss concerns he had related to R1's increased agitation and anxiety, resulting in a fall and increased pain for R1. R1's representative expressed concern regarding R1's medications and being told by the facility that R1 could not have both the Ativan and clonazepam. The facility's Use of Psychotropic Medications policy, dated February 2026, documented that it is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to, the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.

Based on record review and interview, the facility failed to ensure staff immediately reported an incident of resident-to-resident abuse allegation to the Administrator and further failed to report the incident to the State Agency (SA).Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), and abnormalities of gait and mobility.R1's Significant Change Minimum Data Set (MDS) dated 03/19/26 documented a Brief Interview for Mental Status (BIMS) score of three, which indicated significantly impaired cognition. R1 was dependent on staff for transfers, toileting hygiene, putting on and taking off footwear, and lower body dressing. R1 required partial to moderate assistance with upper body dressing and showering/bathing. The MDS documented R1's behaviors fluctuated; he had delusions and displayed physical behaviors directed towards others one to three days during the look-back period. R1's current behavior status, care rejections, or wandering was documented as worse compared to prior assessments. R1 used a manual wheelchair to propel in the facility.R1's Behavioral Symptoms Care Area Assessment (CAA) dated 03/19/26 triggered due to physical/verbal abusive behaviors towards staff and other residents. R1 was resistant to care, wandered, yelled, and cursed.R1's Little or No Awareness of Safety, or Boundaries Related to Others' Personal Space Care Plan, revised 02/26/25, documented in the afternoon, it was harder for R1 to remain satisfied in his living environment. The plan directed staff that it may help if staff kept him involved in activities.R1's Care Plan lacked any interventions related to physical or verbal behaviors towards other residents.The Behavior Charting Note dated 03/22/26 at 03:51 PM documented R1 approached R2 and pinched her. The note documented the incident was unprovoked, and R1 was removed from the area. R1 attempted to hit staff and called staff expletives. Staff educated R1 to not harm other residents or staff.R1's progress notes lacked further documentation related to this incident.R2's EMR revealed a Significant Change MDS dated 03/05/26 which noted she had a BIMS of four indicated she had severe cognitive impairment.R2's EMR, in a General Note dated 03/22/26 at 03:33 PM, documented she was pinched by another resident on the left forearm.R2's General Note dated 03/23/26 at 12:05 PM documented staff examined R2's left arm and there was no signs of bruising or redness and R2 had no verbalizations of pain at that time. R2's EMR lacked further documentation related to the event including evidence of follow-up for psychosocial impact related to the event.Review of the Investigation Template dated 03/23/26 revealed R1 pinched R2 at 03:21 PM on 03/22/26. The template noted the incident was not reported the residents' representatives. The investigation summary noted the nurse did not notify the provider, family. Administrative Nurse D, or Administrative Staff A.The facility was unable to provide witness statements or corrective actions associated with the incident.On 05/05/26 at 01:40 PM, Licensed Nurse (LN) G stated that R1 pinched R2 on the arm. LN G stated she immediately separated the residents and went to make sure that R2 was alright and check her arm for any injuries. LN G stated that Administrative Nurse D asked her to write a witness statement.On 05/05/26 at 01:43 PM, Administrative Nurse D stated that if one resident pinched another resident, it would only be reported if there was an actual injury. Administrative Nurse D further stated she was not aware that R1 had pinched another resident. Administrative Nurse D stated no one had told her about R1 pinching anyone.On 05/05/26 at 02:20 PM, Administrative Nurse D recanted her previous statement and said that she had known about the event and said she must have learned of it after reading through the progress notes. Administrative Nurse D stated she texted LN G about the event. Administrative Nurse D stated that R1 had a history of hallucinating and making a pinching motion, but had never actually pinched anyone. Administrative Nurse D stated that R2 had not said ouch or anything like that.On 05/05/26 at 02:22 PM, LN G stated that on 03/22/26, R2 sat next to the medication cart near the nurses' station where LN G sat. LN G observed R1 self-propelling in his wheelchair towards the doorway that was beside R2. R1 then reached out quickly and pinched R2's arm. LN G stated that R2 cried out, Ouch, he pinched me. LN G stated she immediately separated the two residents and looked over R2's arm. LN G stated that Administrative Nurse D reached out to her to ask about the incident where R1 pinched R2 but further said she thought she had mentioned it to Administrative Nurse D.On 05/05/26 at 02:47 PM, Administrative Staff A stated he remembered LN G coming in and writing a witness statement about the event and said he would go look for the witness statement.On 05/05/26 at 04:25 PM, Administrative Nurse D stated the facility did investigate the event, and she did have a file showing the investigation. With the investigation, Administrative Nurse D stated the staff were re-educated on the abuse and neglect policy and reporting immediately when something occurs.On 05/05/26 at 04:28 PM, Administrative Staff A stated he located an internal document regarding the resident to resident on 03/22/26 and said the incident was investigated. Administrative Staff A stated the incident was not reported to the SA because he did not think R1 had actually pinched R2 and if it did happen, there was no physical injury.The facility's Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, documented a resident-to-resident altercation would be reviewed as a potential situation of abuse. The policy documented ongoing assessment of residents with behaviors would be addressed with care planning and appropriate interventions. The policy documented behaviors that may provide a reaction and resident-to-resident events included: physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, or throwing objects.

The facility reported a census of 47 residents; the sample included 15 residents. Based on interviews, record review and observation, the facility failed to ensure a safe, clean home-like environment in the resident's rooms and facility common areas. Findings included: - Observed on 09/21/25 at 09:04 AM, Resident (R)1's room had trim-molding around the base of the wall peeled off and paint on the wall peeled off, exposing sheetrock; the inside of the room door had exposed wood and splintered areas.Observed on 09/21//25 at 09:48 AM, R17 and R8's bathroom door had multiple areas with paint missing and exposed wood, and the door frame to the bathroom had areas of peeled paint that exposed bare metal.Observed on 09/21/25 at 10:49 AM, in R9's room, the corner of the wall, by the floor, next to the door frame, trim-molding was missing and exposed a hole with loose sheetrock. The area where the wall met the ceiling above the windows had bubbled, missing, and peeling paint. The window blinds were bent in multiple places. The bathroom door had chipped paint and an area that was broken, approximately three inches by one inch, just above the lower door hinge, with exposed and splintered wood.Observed on 09/21/25 at 11:32 AM, R24's room had various areas where the walls meet the ceiling, and paint had separated, cracked, and peeled. One wall, next to the bead, paint had peeled away in several places and exposed sheetrock. The blinds on the windows were dusty, had broken and bent slats.Observed on 09/21/25 at 11:51 AM, the blinds on R46's windows had numerous bent slats, and the room door had multiple areas splintered and exposed wood.Observed on 09/22/25 at 01:25 PM, during the environmental tour with Administrative Staff A, Maintenance U, and Maintenance V, the four air conditioning (A/C) vents in the ceiling of the 200 hallway appeared to have dark black and gray spots covering them. Upon closer investigation, the dark spots appeared to have a fuzzy appearance and be of an unknown organic substance. Several areas of the ceiling, around the vents, appeared to have this same substance.Observed on 09/22/25 at 01:45 PM, while further performing the environmental tour with Administrative Staff B and Administrative Staff A, the A/C vent and the fire suppression sprinkler head in the ceiling of the facility lobby area appeared to have an unknown organic substance on, back, and gray in color with fuzzy appearance, and around them, to include the ceiling. Both Administrative Staff B and Administrative Staff A stated that they were unaware of the substance on the vents and ceiling, and further stated that it was a concern.Observed on 09/22/25 at 02:53 PM, two fluorescent lights in the 100 hallway were partially hanging down from the ceiling, and the four A/C vents in the 100 hallway ceiling appeared to have an unknown organic substance that was black and gray in color with a fuzzy appearance. This substance appeared on the ceiling around the vents, also.Observed on 09/23/25 at 7:27 AM, upon entering the facility, in the main lobby area, the A/C vent appeared to have been cleaned, and the ceiling around the sprinkler head and vent appeared to have been freshly painted, along with the eight vents and ceiling areas in the 100 and 200 hallways.Observed on 09/23/25 at 09:05, the ceiling in the main lobby area of the building, around the fire detection device, was a black and fuzzy appearing, unknown organic substance. Administrative Staff A stated that he was unaware of this spot in the ceiling and confirmed it appeared to be of an unknown organic substance.The contract, signed and dated on 05/01/13, documented that Diversicare of Chanute contracted housekeeping and laundry services to an outside group. The contract did not list the housekeeping duties that would be covered and performed by the contracted housekeeping staff.The Medical Director Services Agreement, signed by Administrative Staff C and Consultant GG and dated 06/23/16, documented that the medical director would help the facility provide a safe and caring environment and help promote employee health and safety.Review of records showed a facility Performance Improvement Project (PIP) that addressed the facility items that do not contribute to a homelike environment and was marked as ongoing.On 09/22/25 at 01:27 PM, Administrative Staff A stated that the substance on the vents and ceiling of the 200-hall did not appear to be dirt, dust, or rust, and further stated that the substance was concerning. Maintenance U verified that the substance did not appear to be dust or dirt and further stated that it was a concern.On 09/22/25 at 01:35 PM, Maintenance U stated that maintenance and environmental repairs are tracked through The Equipment Lifecycle System (TELS- a building and asset management platform for the long-term care and senior living industries) via work-order.On 09/22/25 at 02:55, Administrative Staff B stated that she was unaware of the lights that hung from the 100-hallway ceiling and was unaware of the substance in and around the ceiling and A/C vents in the 100-hallway. She further stated that the substance appeared organic. Administrative Staff B also stated that the facility had a PIP that identified homelike environmental concerns about the resident rooms that included doors, window blinds, wall and ceiling paint, but was unaware of the hole in the wall of R9's room. She also stated that the roof and main A/C units for the building had recently been repaired and replaced.On 09/22/25 at 03:10 PM, Administrative Staff B stated that she expected staff to be vigilant and identify and report any maintenance or environmental issues, and for the maintenance department to reduce and eliminate any hazards quickly and correctly.On 09/23/25 at 7:49 AM, Maintenance U stated that he removed the A/C vents in the hallways, and the internal ducts appeared to be clean, the evening of 09/22/25.On 09/23/25 at 08:31 AM, Administrative Staff A reported that the administrative and maintenance team decided that an outside contractor was not required to clean or identify the unknown organic substance in and around the ceiling A/C vents. He further stated that on the evening of 09/22/25, Maintenance U and Maintenance V removed the nine A/C vents that had the unknown organic substance, cleaned them, and cleaned the ceiling around the vents. He also reported that the residents were not in the hallway or immediate area when the vents and ceilings were cleaned, and the facility had started a working plan to correct and prevent further environmental concerns, and that an internal audit had been performed related to current respiratory illness for all residents, and none had been identified.On 09/23/25 at 10:04 AM, Maintenance V stated that the resident room Packaged Terminal Air Conditioners (PTAC) are maintained, at a minimum, monthly, and the main building A/C unit was included with this maintenance schedule, but that did not include cleaning the vents in the building. Maintenance U stated that housekeeping services were contracted out to a vendor, and that they were responsible for the cleaning of all vents. Administrative Staff A verified that housekeeping services were contracted out.On 09/23/25 at 10:48 AM, Housekeeping W stated that she did not know who was responsible for cleaning the building vents and did not know the last time they were cleaned.On 09/23/25 at 10:55 AM, Housekeeping X stated that housekeeping services were responsible for dusting the vents in the building, not cleaning them, and that high-surface dusting was performed monthly, and there was a calendar maintained to track that the high-surface dusting was performed. She further stated that she knew the vents were cleaned last week.On 09/23/25 at 11:30 AM, Administrative Staff A and B provided housekeeping records, with a cleaning checklist, that revealed the housekeeping staff performed daily cleaning duties for the resident rooms only. Administrative Staff B stated that there was no checklist or record maintained for the main building areas to be cleaned; there was only a calendar maintained that showed who was responsible for those duties on each day. The facility policy Resident's Rights and Quality of Life, dated 05/01/12, documented that residents had the right to receive services in a facility environment that is safe, clean, and comfortable.

The facility reported a census of 47 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses)) for one resident, Resident (R)3. Findings included:- R3's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness), and insomnia.R3's EMR documented the following physician's orders:Latuda (an antipsychotic medication), 40 milligrams (mg), by mouth (PO), every day (QD), for a diagnosis of MDD, ordered 07/28/25.Pristiq (an antidepressant medication), 100 mg, PO, QD, for a diagnosis of depression, ordered 07/28/25.Remeron (an antidepressant medication), 15 mg, PO, QD, for a diagnosis of insomnia, ordered 07/28/25.Xanax (an antianxiety medication), 0.25 mg, PO, twice daily for a diagnosis of anxiety, ordered 07/28/25.R3's EMR lacked documentation of informed consent for the medications.On 09/22/25 at 03:11 PM, Administrative Nurse D stated the expectation was for the nursing staff to complete a psychotropic informed consent with any dose change or before the initiation of a psychotropic medication.The facility policy for Resident's Rights and Quality of Life, effective 05/01/12, included: All residents in the facility have the right to be informed in advance about care and treatment and any changes in care or treatment.

The facility reported a census of 47 residents; the sample included 15 residents with one resident reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide nail care for the one sampled resident, Resident (R)5. Findings included:- R5's Electronic Medical Record (EMR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R5's Quarterly Minimum Data Set, dated [DATE], documented that the resident had a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. She required partial to moderate assistance with showering and setup assistance for personal hygiene.R5's Care Plan revised 08/14/25, instructed staff the resident had dementia and required assistance with all ADL.On 09/22/25 at 09:19 AM, R5 sat in her wheelchair in the doorway of the dining room. The resident had long, dirty fingernails.On 09/22/25 at 09:21 AM, Certified Nurse Aide (CNA) M stated that staff clean the residents' fingernails on their shower days.On 09/22/25 at 12:45 PM, Certified Medication Aide (CMA) R stated residents' fingernails were cleaned on their shower days.On 09/22/25 at 12:51 PM, Administrative Nurse E stated it was the expectation for staff to clean residents' fingernails on shower days.The facility policy for Resident's Rights and Quality of Life, effective 05/01/12, included: All residents in the facility have the right to a dignified existence.

The facility reported a census of 47 residents. Based on observation, record review and interview, the facility failed to display accurate, and identifiable staffing information, on a daily basis, for the 47 residents who resided in the facility.- Review of the facility's Daily Staffing sheets, 08/22/25 through 09/21/25, revealed that the actual hours worked per shift had not been completed on the daily staffing sheets. On 09/22/25 at 12:41 PM, Administrative Nurse D confirmed the Daily Staffing sheets lacked the actual hours worked per shift.The facility did not provide a policy.

The facility reported a census of 44 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide food that was nutritionally balanced, palatable, attractive, and at safe appetizing temperatures. This placed the residents at risk for inadequate nutrition and decreased quality of life. Findings included:- Observation on 07/29/25 at 3:25 PM revealed R3 in his room. R3 reported that the facility's food could be better. He stated he usually opted to eat in his room, and the food was not as hot as he would like. He stated that the staff offered to heat the food if he was not satisfied, but some things just do not taste right after it has been reheated, such as French fries. R3 stated he just makes do as he does not want to bother the staff. He reported he ordered boiled eggs and juice frequently, so if it was served cold, it was ok. R3 reported that if he wanted something else besides what was served at the facility, he had an account at a local restaurant where he could have food delivered. Observation on 07/29/25 at 4:24 PM R5 sat in bed doing crossword puzzles. She stated she always ate in her room by choice. She reported the food at the facility was nasty and cold. R5 stated when she tells staff the food is cold, they tell her it was hot when it left the kitchen. She stated she complained to the nursing and kitchen staff; she said she had not filed a written grievance, but said staff knew her concerns and nothing had changed. R5 said the staff told her there is not anything they can do to fix it because she is in her room and not the dining room. R5 said the nursing staff offered to warm up the food, but then it tasted worse. R5 said there are potatoes served at most every meal, and there were no alternatives except for peanut butter and jelly sandwiches. Observation on 07/29/25 at 4:45 PM revealed R4 sat in his recliner and reported he was waiting for his supper. R4 said the food at the facility was not the worst food he had eaten in his life. He stated he was a little spoiled because he had lived with a chef. R4 went on to say his mom taught him to eat what was set in front of him. R4 reported he chose to eat in his room, and the temperature of most meals was not totally cold, but not hot either. R4 stated staff heated the food up if asked. R4 stated he tried to choose and order foods that would not be a problem if it was served cold. Observation on 07/29/25 at 5:14 PM revealed that the [NAME] Unit room trays were delivered to the unit in an insulated meal cart. Observation on 07/29/25 at 05:21 PM revealed that staff delivered R4's room tray. R4 declined his meal and reported he was still full after eating lunch. R4's meal tray was selected to use as a test tray for food temperatures and palatability, as it was the last tray served from the cart. During an observation and interview on 07/29/25 at 05:37 PM, Dietary Staff BB tested the temperature immediately after the last tray was served on the delivery cart. The noted temperatures revealed the turkey and rice casserole temperature of 127 degrees Fahrenheit (F.), sugar snap pea pods of 119 degrees F., and strawberry swirl cake of 77 degrees F. The tray was then taste tested by the Dietary Staff BB, who reported the main course foods would be more palatable if they were hotter. Additionally, she stated the strawberry cake with white icing was made with milk and refrigerated after preparation, prior to putting it on the delivery cart. Dietary Staff BB confirmed the strawberry cake was a substitute for the chocolate cake with peanut butter icing listed on the menu. She verified the previously refrigerated strawberry cake with milk-based icing was now at room temperature and less palatable than if served chilled.Observation on 07/29/25 at 05:49 PM revealed that the East Hall room trays were delivered in an insulated meal cart.During an observation and interview on 07/29/25 at 05:51 PM, Dietary Staff BB noted the nursing staff were not present to deliver the meal trays delivered to East Hall. She left the food cart in the hallway to locate the staff. Upon her return, she stated the nursing staff were not available to pass meal trays in a timely manner due to being in the shower room providing direct care to a resident. Upon her return to the meal cart, she confirmed the meal trays remained on the cart and had not been served. On 07/29/25 at 05:55 PM, observation revealed Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N approached the meal delivery cart, pushed the cart to the middle of the hall, and started to deliver the meal trays to the residents. On 07/29/25 at 05:02 PM, LN H stated some residents complained about the food. LN H said the resident's meal ticket should have their likes and dislikes on there, and staff should offer an alternative if the resident did not like what they got. On 07/30/25 at 10:35 AM, Administrative Nurse D confirmed the dietary services were provided by a contracted service, and she was not aware of how the concerns related to dietary were communicated to the dietary staff. On 07/29/25 at 02:45 PM, Activity Staff Z stated she received complaints regarding dietary and food almost monthly since January 2025. Activity Staff Z said the residents' complaints included that food was not delivered in scheduled mealtimes; the residents sat at the table waiting for meals in the dining room, and sometimes did not get their meals until an hour after the scheduled times for meal service. Activity Staff Z said the residents complain about the temperature of the food, saying the food was not hot enough, and complain about the lack of options or alternatives. Activity Staff Z stated she did not know what was done to address the concerns, but they do not appear to be resolved. On 07/30/25 at 11:49 AM, Dietary Staff CC reported she relied on Dietary Staff BB and Administrative Nurse D to make her aware of the resident's concerns regarding the food. She reported the resident council concerns expressed about the food or dietary services should be shared with Administrative Staff A, Administrative Nurse D, and Dietary Staff BB for follow-up and resolution in a timely manner. She stated she visited with the residents who ate in the dining room, but she had not interviewed residents who dined in their rooms as she should have. Dietary Staff CC reported she identified a cook not doing a good job on 07/15/25 and transferred the staff member to another position within the organization. Dietary Staff CC reported that cake with icing that contained milk should be served at 41 degrees F. Dietary Staff CC said there was a list of food alternatives posted at the nurse's station and said available alternates included deli sandwiches, salad, fruit cups, grilled cheese, and soup of the day. She reported that the residents who ate in their rooms may not be aware of the alternate items available and said that room trays were always the house special meal unless the kitchen was made aware to offer an alternative to the residents who dined in their rooms. On inquiry, Dietary Staff CC reported all food substitutions should be signed off by the Dietitian and all food items substituted on the approved menu should then be documented on the Food Substitution Log, to ensure the facility provided a nutritional equivalent for the food substituted. She confirmed the strawberry cake served as a substitute on 07/29/25 had not been signed off or documented on the substitution log. On 07/30/25 at 12:15 PM, Administrative Nurse D reported there were ongoing issues with concerns related to dietary services, including food temperatures, lack of variety, and complaints of food quality, texture, and palatability. On 07/30/25 at 01:15 PM, Administrative Staff A acknowledged there were concerns regarding dietary services and resident satisfaction. The facility policy Food: Quality and Palatability, dated 01/2019, documentation included that food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.

The facility reported a census of 44 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide the residents of the facility with reasonable access to receive mail. Findings included:- During an observation and interview on 07/29/25 at 03:25 PM, R3 sat in his room. He stated he received a little mail at the facility, but the young lady who delivered the mail does not work on weekends, so he did not think the residents received mail on Saturdays.During an observation and interview on 07/29/25 at 04:24 PM, R5 was in bed doing crossword puzzles. She stated she got her mail at the facility Monday through Friday, but the residents did not get mail delivered to them on Saturdays. She stated she wished she had gotten her mail on Saturday, but the staff who deliver the mail do not work the weekend.During an observation and interview on 07/29/25 at 05:21 PM, R4 sat in his room awaiting his evening meal. On inquiry, he reported he did not receive mail in the facility; his mail was delivered to his house. He stated his house was near the facility, and he received mail on Saturdays at his house, so he expected mail would be delivered to the facility on Saturday as well.On 7/29/25 at 12:08 PM, Certified Medication Aide (CMA) R stated somebody should check for, and deliver the mail to the residents every day, Monday through Saturday. CMA R said she was not sure who delivered the mail anymore since the previous Activity Director (AD) used to check the mail, sort it, and deliver it to the residents. Monday through Friday. She stated she did not know who checked the mail and delivered it to the residents of the facility, but the AD does not work on Saturdays. CMA R, it was her understanding that AD Z did not check the mail like the previous AD. On 07/29/25 at 02:45 PM, Activity Staff Z stated that before the new business office manager (Administrative Staff C) started at the facility, the previous business office manager was responsible for the mail. She reported that when Administrative Staff C started, she checked the mailbox Monday through Friday, sorted the mail, and placed the residents' mail in Activity Staff Z's mailbox. Activity Staff Z stated she delivered the mail to the residents Monday through Friday and confirmed she did not work on Saturdays and did not know who checked the mail on Saturday because Administrative Staff C does not work the weekend either. Activity Staff Z stated that on Monday mornings, there are usually two bundles of mail for her to deliver to residents, so that might include the Saturday delivery. She stated that all mail delivered to the residents should be delivered sealed and not opened unless the resident requested assistance. On 07/29/25 at 5:02 PM, Licensed Nurse (LN) H reported she saw Activity Staff Z and the Administrative Staff A deliver mail to the residents during the week. Additionally, she stated she worked every other weekend but did not observe any mail being delivered on the weekends she worked. On 07/30/25 at 11:35 AM, Administrative Staff A confirmed the residents had a right to receive their mail delivered to the facility on Saturday, the same day the post office delivered their mail. The facility policy Rights of Nursing Facility Residents, dated 05/01/2012, documents that the elderly have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of the state and the United States. By law, every nursing facility resident has the right to send and receive mail. The policy lacked an address for the timely delivery of resident mail received on Saturdays.

The facility reported a census of 46 residents with four residents selected for review, including three residents reviewed for skin conditions. Based on observation, interview, and record review, the facility failed to ensure one of the three residents, Resident (R)1, had clean and dry dressings to his lower extremities. On 06/17/24, at an appointment, Consultant Staff GG discovered two maggots on R1's right lower extremity while removing urine and fluid-soaked dressings due to weeping from his right lower extremity. The dressings removed were dated 06/13/24, four days prior, when Consultant Staff GG applied the lymphedema wraps (compression wraps used to try and reduce swelling caused by accumulation of lymph). R1 reported concerns about his wraps to Licensed Nurse (LN) I on 06/16/24 between 10:00 PM to 11:00 PM, and LN I told R1 his wound appointment was scheduled for the next morning. R1's dressings remained in place until his appointment time on 06/17/24 at 01:00 PM, 14-15 hours after R1 voiced his concerns about his dressings. R1 lacked any additional orders to instruct the staff what to do should his dressings become soiled, wet, or loose. Findings included: - The Medical Diagnosis tab for R1 included diagnosis of lymphedema (swelling caused by accumulation of lymph), venous insufficiency (poor circulation), and cellulitis (skin infection caused by bacteria) of the right lower extremity. The Admission Minimum Data Set, dated dated dated [DATE], assessed R1 with a Brief Interview of Mental Status score of 15, which indicated he had intact cognition. R1 did not reject cares and was continent of urine. R1 had an infection of his foot, moisture associated skin damage (MASD). R1 had dressings applied to his feet, nonsurgical dressing applied other than to feet, and ointments/medications applied other than to feet. The Functional Abilities Care Area assessment dated [DATE], revealed R1 required assistance with his activities of daily living (ADL's), had increased weakness, and was at risk for skin breakdown, incontinence, and further ADL decline. The Dehydration/Fluid Maintenance CAA dated 03/25/24, revealed R1 admitted to the facility with cellulitis and prescribed two antibiotics to treat the cellulitis. R1 had a chronic wound on his right leg with Ace wraps (elastic bandage) daily and wound treatments to his wound. R1 had risk factors of impaired fluid balance and impaired skin integrity. The Pressure Ulcer/Injury CAA dated 03/25/24, revealed the staff were to notify R1's physician of any abnormal findings and treatment orders. The Care Plan dated 04/11/24 revealed R1 had cellulitis to his right lower extremity and the infection would resolve without complication. R1 was to have elastic bandage wraps applied to bilateral (both) lower extremities in the am and taken off at hour of sleep. The staff were to administer antibiotics as ordered and follow wound treatment orders. The Skin and Wound Evaluation revealed on 06/11/24, R1 had a blister to his front left lower leg and had areas of weeping to his right calf in three different areas that were not open. On 06/19/24, R1 had a new blister to his left calf. The Physician Orders tab included an order for R1, dated 06/14/24 to keep lymphedema wraps to his bilateral lower extremities clean, dry, and intact. Outpatient therapy were to change the dressings on Monday, Wednesday, and Friday. Staff were to monitor the wraps twice daily during the 06:00 AM to 06:00 PM shift and the 06:00 PM and the 06:00 AM shift. The Treatment Administration Record (TAR) dated June 2024, revealed the resident's wraps were clean, dry, and intact on 06/14/24 for the 06:00 PM shift, 06/15/24 for the 06:00 AM and PM shift, and on 06/16/24 for the PM shift. On 06/16/24 for the 06:00 AM shift, the staff documented a 7 indicating to Other/See Progress Note. The Progress Note dated 06/13/24 at 09:42 AM, revealed R1 returned from his appointment at the outpatient clinic with new orders, and his next appointment was on 06/17/24 at 01:00 PM. The Progress Note dated 06/16/24 at 10:42 AM, an order administration note for R1, lacked documentation for the reason on the TAR to be charted as Other/See Progress Notes as to why the wraps may not be clean/dry/intact. The Progress Note dated 06/17/24 at 01:11 PM, revealed R1 left the facility for his appointment at the wound clinic. The Progress Note dated 06/17/24 at 02:02 PM, revealed R1 returned from his appointment at the wound clinic with no new orders. The note lacked documentation regarding maggots. The Progress Note dated 06/22/24 at 01:39 PM, revealed R1 removed his wraps this morning due to them being soaked with urine, which was a frequent occurrence with him, saturating his wraps and pants with urine. On 06/24/24 at 07:55 AM, observed R1 in his room in a recliner. His feet rested on a folded-up towel which was directly on the floor. A tied-up plastic bag sat on the floor, and next to the towel, his feet were on a pile of wraps and gauze. R1's left leg had gauze wrapped around it from above his ankle to below his knee and his right leg had gauze wrapped from the base of his toes to below his knee and was loose at the top with abdominal gauze pads (ABD pads - highly absorbent dressing) in place. The gauze wraps on the right lower leg were almost entirely yellow in color from drainage. R1 had a flyswatter in his room and killed one live fly and two others were observed in the room and landed on the dressings piled directly on the floor. There was a prominent foul odor in his room. On 06/24/24 at 07:57 AM, R1 stated he was told by LN H not to leave wet soiled wrappings on his leg and R 1 removed them at 06:00 AM. He informed the off-going CNA M and CNA N, and CNA N placed a towel on the floor for R1 to rest his feet on. R1 stated while at the (outpatient clinic for wound management), two maggots were found under his dressing. R1 stated staff were to change his dressing daily, but the dressing did not get changed yesterday. R1 stated he wished LN H would have changed them yesterday and further stated he had staff ask her about it but she had already gone home. R1 stated last week there were four days the dressings did not get changed as Administrative Nurse D said not to change or touch the wraps. R1 stated he was finally able to get staff to remove the plastic thing off of the toilet (referred to device in bathroom with elevated seat and handles that sits over the toilet) as it was causing urine to run down and get in his wraps. On 06/24/24 at 08:20 AM, LN G stated she did not think she had to do anything with R1's wraps, as he was scheduled to go today to the wound clinic, and she had not seen his legs yet today for her shift. LN G stated in shift change report, she was told R1's wraps were getting changed at there (outpatient clinic for wound care), and she was not able to change those due to lack of certification to apply the lymphedema wraps. LN G stated the wraps were to be changed on Monday, Wednesday, and Friday by outpatient therapy and prior to that, the facility nurses changed the dressings daily. LN G stated R1 removed the wraps a lot because they would get wet. LN G looked at the pile of wraps on the floor and they were dated for 06/22/24 and initialed by LN H. LN G left the pile of wraps and gauze on the floor and exited the room. On 06/24/24 at 08:54 AM, LN G asked Administrative Nurse D what to do with R1's legs. Administrative Nurse D stated she needed to find R1's order sheet, as she thought the outpatient therapy center sent back instructions on what to do. The Progress Note dated 06/24/24 at 09:01 AM, revealed Administrative Nurse D spoke with outpatient therapy on what treatment needed done when R1's wraps became soiled and the staff stated, Leave them off today and we will talk to him about removing them himself and will send orders back for what to replace wraps with when they become soiled. The note revealed nursing staff were notified. On 06/24/24 at 09:09 AM, LN G picked up the wraps and dressings off the floor in R1's room and removed part of the gauze wraps from his legs then exited the room. On 06/24/24 at 09:11 AM, LN G stated there was not an order for R1 if his wraps were not clean/dry/intact and Administrative Nurse D was going to request one. LN G stated what had been on R1's legs on 06/22/24 was the treatment that was being done before, and R1 should have an order on what to do in between times if the wraps were not clean/dry/intact. LN G stated she would clean R1's legs after he finished eating, and she left the current drainage covered gauze wraps in place to his right lower extremity and the gauze wraps remained on his left lower extremity. On 06/24/24 at 10:16 AM, LN G stated she did not have a treatment order for R1's legs yet. On 06/24/24 at 10:34 AM, LN G stated she was going to take the rest of the wraps off of R1's legs and clean them and did not have an order yet for any dressings. R1 was sitting in his recliner in his room. LN G placed the packaged gauze directly on the nightstand along with tape cut in pieces to secure the gauze. After removing the dressings, LN G began to clean R1's legs with the same contaminated gloves used to remove the soiled dressings. When the surveyor questioned if a new pair of gloves should be in place, LN G stated, It's dirty too and removed the gloves and applied a new pair without performing hand hygiene. Then, LN G placed four by four-inch gauze pads directly on R1's overbed table and used a gloved hand to open the nightstand drawer and removed more four -inch gauze pads out of the drawer and placed them directly on the overbed table. These treatment supplies were used to wipe R1's legs after LN G sprayed them with wound cleanser. R1 had an ABD pad which was stuck to his left lower extremity and required LN G to spray wound cleanser on to loosen the ABD pad from his leg. There was a live fly observed in R1's room during the process. LN G stated she was going to check with Administrative Nurse E to see if she wanted to take pictures of R1's legs and exited the room. R1's legs were noted to have redness, scaling, and edema. The left leg had a small scab to shin area and was not able to visualize the back of his legs. On 06/24/24 at 10:55 AM, LN G stated Administrative Nurse E wanted to take pictures of R1's legs but was assisting another resident at the time. LN G stated Administrative E told her to wrap his legs with Kerlix (gauze rolls which can be used to absorb wound drainage and hold dressings in place) because they were weeping. On 06/24/24 at 11:24 AM, entered R1's room with LN G and observed an area of fluid on the floor next to the towel R1 had his feet on. LN G stated that was from R1's legs it just runs. LN G retrieved a roll of gauze from the drawer in R1's nightstand, not packaged, sprayed R1's legs with a wound cleanser, and used the gauze wrap to wipe R1's legs. LN G then removed her gloves and applied a new pair without performing hand hygiene. LN G moved the packaged gauze wraps and strips of tape to R1's bed along with scissors without a barrier. LN G moved a trash can on its side and used the towel under R1's feet that was on the floor and placed it on the trash can, then R1's right foot on top of the towel that had been on the floor. LN G then began using gauze rolls to wrap R1's legs and during that time drips of fluid were coming from the back of his right leg. Once LN G finished wrapping the right leg, she placed his left foot directly on the trash can and removed her gloves. LN G stated she would be right back she needed to get more gauze. LN G returned and applied gloves then stated she forgot to grab socks, so she exited R1's room while removing the gloves at 11:36 AM without disposing gloves or performing hand hygiene before exiting the room On 06/24/24 at 11:38 AM, LN G returned to R1's room with socks, applied gloves, and placed a sock on R1's right foot. LN G stated, It is leaking already and applied another layer of gauze to R1's right leg. LN G placed R1's left heel back on the trash can and applied one roll of gauze. While she went to grab another roll, the end of the applied roll fell down and touched the surface of the trash can. LN G reapplied the end of the gauze roll that touched the trash can and began wrapping R1's left leg with the second roll. After securing with gauze with tape and after she applied a sock to his left foot, LN G exited the room at 11:47 AM with her gloved hands, tied up the trash and the linen bag, scissors, wound cleanser, and the stool she [NAME] in to sit on while she performed dressing cares. On 06/24/24 at 12:36 PM, Housekeeping Staff U stated the only issues with flies she had seen in the facility was in R1's room, which she thought was due to his legs that leaked fluids which smelled like rotten eggs. Housekeeping Staff U stated when she was in there yesterday his bandages were soaked through. When asked what was done about the flies in R1's room Housekeeping Staff U stated, I don't have a fly swatter and she had not killed any in his room. On 06/24/24 at 12:46 PM, LN G stated she had not seen any maggots on R1's skin or dressings but received in report one day they were found at the center where his wraps were done. On 06/24/24 at 12:54 PM, LN H stated she heard R1 had maggots in his leg dressings from R1 and LN J on one of the days he went to the clinic. LN H stated on 06/22/25, R1 removed his wraps, and his legs were weeping fluid all over the floor, so she applied wraps. LN H stated R1 told her the clinic said to remove the wraps when they became soaking wet. LN H stated she re-wrapped his legs because they were open to air and fluid leaked all over the floor. LN H stated she was not aware of what the clinic advised as there was not any paperwork received from them. LN H stated on 06/23/24, R1 had some wetness by the ankle and up a little bit and did not do anything with the dressings and left them in place through the end of her shift at 06:00 PM. On 06/24/24 at 01:06 PM, LN J stated R1 told her that last week when returning from the clinic they (clinic staff) found maggots. She verified there have been flies in his room, and thought he had a fly swatter in his room. LN J stated she had not killed any flies in his room and seemed like that was the only room that had them. LN J stated the clinic (where wraps are done) usually does not send paperwork back from his appointments. LN J stated Administrative Nurse D kept tracks of resident wounds. On 06/24/21 at 01:11 PM, Administrative Nurse E stated R1 returned from the center where his wraps are done and reported maggots were found, so she called the center to clarify what he had said. Administrative Nurse E stated she was told by Consultant Staff GG on 06/17/24 of two maggots found and had not seen any on 06/14/24. Administrative Nurse E stated hand hygiene should be performed during dressing changes and before going in a resident's room, gloves should be removed after taking off dressings and hand hygiene should be performed before applying new gloves. Administrative Nurse E stated staff should place a barrier between the dressing supplies and the surface placed on. Administrative Nurse E stated a trash can should not be used to prop his foot/leg up on for the dressing change and if any part of the dressing touched the trash can surface, it should be disposed of. Administrative Nurse E stated if the dressings are loose, the nursing staff should address that as soon as they see it and should use a clean towel under his feet before doing his dressing changes. Gloved hands should not be used to gather supplies from the nightstand drawer. If R1's dressings were leaking, then the nursing staff should try to address it even if just reinforcing them and should call the doctor at any time to get an order, as he was the one that ordered the wraps. Administrative Staff A stated the staff should clean/sanitize the floor where the wraps were in contact with. On 06/24/24 at 02:00 PM, LN G stated during the weekend of 06/15/24 and 06/16/24, during her day shift (06:00 AM to 06:00 PM) R1's legs were not leaking, and she did not do any treatments to R1's legs. On 06/24/24 at 02:37 PM, Consultant Staff GG stated she had been doing the lymphedema wraps and when R 1 came in on 06/13/24, his wraps were soiled. When R1 came in on 06/17/24 his wraps were soiled with urine and his legs weep a lot. The dressings in place were dated 06/13/24 and were the ones she had placed on that day when she evaluated him. When she was unwrapping R1's right leg on 06/17/24, she observed a maggot toward the top of his leg and one on his ankle. Consultant Staff GG stated she told R1 to keep the bandages on unless soiled then to take them off. Consultant GG stated she did not call the facility right away regarding the maggots as she had another patient and Administrative Nurse E had called her and she gave Administrative Nurse E instructions on keeping the wraps on and clean unless they became soiled. Consultant Staff GG stated she would have expected R1 to arrive with cleaner dressings on than he did on 06/17/24 and not the ones from 06/13/24. Consultant Staff GG stated she had made contact with the facility almost every visit she had seen R1. On 06/24/24 at 02:59 PM, Administrative Nurse D stated R1 went for an evaluation on 06/13/24 and they received the treatment orders on 06/14/24 from the clinic. Administrative Nurse D stated the nurse should call if wraps were soiled to get a treatment order. On 06/24/24 at 04:17 PM, LN I stated he took care of R1 on 06/14/24, 06/15/24, and 06/16/24 during the 06:00 PM to 06:00 AM shift and R1 had an order for lymphedema wraps on Monday, Wednesday, and Friday for therapy to perform the dressing changes. LN I stated he was told not to apply new wraps as he was not trained to change the wraps. LN I stated he looked at the wraps and on 06/16/24 they were not clean/dry/intact. LN I stated R1 had brought that to his attention around 10:00 PM or 11:00 PM and LN I told R1 the wraps would get changed in the morning. LN I stated he was not aware of any other orders in place when not clean/dry/intact. On 06/24/24 at 04:56 PM, Administrative Staff A stated, when asked what the facility had done to address the issue of maggots being found on R1's skin, he stated he was not aware of maggots being found until today (06/24/24) from one of the nurses after the surveyor's arrival on site. The facility's policy for Hand Hygiene Audit undated, revealed hand washing should be done every time staff remove gloves, before and after each resident contact, every time moving from a dirty to a clean area, and sanitizer could be used instead of soap and water when hands are lightly soiled without visible debris on hand. The facility's undated policy for Clean Dressing Change revealed to create a clean field using a towel or paper towels, open dressings, and place on first pair of gloves, remove soiled dressing, dispose of gloves, wash hands, apply a second pair of gloves, cleanse wound, remove gloves, wash hands/sanitize, and re-glove. After applying prescribed medication/dressing secure per order, remove gloves, and wash hands. The facility's policy for Notification of Patient/Resident Change dated 11/01/16, revealed the facility will consult the resident's physician, nurse practitioner or physician assistant when there is a need to alter treatment significantly (i.e., need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The facility failed to ensure R1 had clean/dry/intact dressings/wraps to his lower extremities and failed to contact the physician for orders when dressing were wet/soiled, which resulted in R1 going 14 - 15 hours from 06/16/24 to 06/17/24 when he had his appointment with outpatient therapy for his lymphedema wraps. On 06/17/24 at outpatient therapy, maggots were found on R1's skin when therapy staff removed his wet and soiled wraps dated 06/13/24. Additionally, the facility failed to ensure wraps were clean/dry/intact on 06/24/24 when R1 alerted staff regarding their condition at 06:00 AM. The staff removed the rest of the soiled dressings from his legs on 06/24/24 at 10:34 AM, more than four hours later. The facility failed to ensure R1 had an order in place for treatment to R1's legs if the wraps were not clean/dry/intact, placing R1 at risk for further skin impairment and further presence of maggots to areas requiring treatment.

The facility reported a census of 46 residents with four residents selected for review including three residents reviewed for following physician wound care orders. Based on observation, interview, and record review, the facility failed to ensure one of the residents, Resident (R)4, had the appropriate wound treatment provided. Findings included: - The Medical Diagnosis tab for R4 included diagnoses of need for assistance with personal cares, muscle weakness, and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Significant Change Minimum Data Set (MDS) dated [DATE], assessed R4 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R4 had frequent incontinence of bowel and bladder, moisture associated skin damage (MASD) and application of nonsurgical dressings and ointments/medications other than to feet. The Pressure Ulcer/Injury Care Area assessment dated [DATE], revealed R4 had MASD to buttocks and received ointment, and was incontinent of bowel and bladder. The Quarterly MDS dated [DATE], revealed R4 continued with a BIMS score of 15, was frequently incontinent of bowel and bladder and had MASD. The staff applied nonsurgical dressings and ointments/medications other than to feet. The Care Plan dated 04/26/24 revealed R4 was at high risk for pressure ulcer development related to her history of ulcers, immobility, and presence of moisture and had MASD on her right and left medial (middle) thigh and coccyx. The staff were to complete wound treatments as ordered. The Skin and Wound Evaluation dated 06/18/24 revealed R4 had the right and left medial thigh. The Physician Orders tab for R4 revealed an order dated 06/08/24 to apply Dermafoam (highly absorbent waterproof foam dressing) to bilateral (both) upper back thigh wounds PRN [as needed] soiled, in the morning. The Progress Note dated 06/08/24 at 10:25 AM, revealed R4 wounds measured, and a new treatment to bilateral leg wounds for Dermafoam over wounds and change as needed when soiled. On 06/24/24 at 02:10 PM, observation revealed Licensed Nurse (LN) G apply Dermaseptin to the back of R3's left and right thigh LN G failed to follow orders and applied an ointment instead of a foam dressing. On 06/24/24 at 02:12 PM, LN G stated she had never put foam on her before and had never seen foam on those wounds. On 06/24/24 at 02:20 PM, Administrative Nurse E stated per physician orders, the LN should apply Dermafoam to R4's upper thighs. Administrative Nurse E stated the Dermafoam should be in place at all times and change if soiled, the dressing was not a PRN dressing. On 06/24/24 at 02:28 PM, R4 stated the foam had been off since last night, time unknown, did not know if the nursing staff was aware or not, and usually has foam in place. R4 stated if the areas are really bothering her, she will ask for foam to be put on, which is usually when she sits up for too long. On 06/24/24 at 02:59 PM, Administrative Nurse D stated the LN should check the orders before doing the treatment, they need to know the exact steps, like a medication. On 06/24/24 at 04:17 PM, LN I, who had worked the night shift, stated he was not aware of any open areas that R4 had, she had a cream for her bottom, and could not recall a treatment to her thighs. The facility lacked a policy regarding following physician orders. The facility failed to follow physician orders and apply the physician ordered treatment to R4's two thigh wounds.

The facility reported a census 46 with four residents selected for review including three residents reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to monitor bowel functioning for one Resident (R)3 for constipation (difficulty passing stools) and contact the physician for orders to treat the constipation. Findings included: - The Medical Diagnosis tab for R3 included diagnoses of fracture (broken bone) of the shaft of the right fibula (one of the two bones of the lower leg) and need for assistance with personal care. The Minimum Data Set (MDS) tab revealed R3 entered the facility on 06/18/24, and the Admission MDS was in progress. The Baseline Care Plan dated 06/18/24, for R3 lacked any information filled in by the facility. The Care Plan initiated on 06/24/24, revealed R3 had a self-care deficit problem related to her fractured right leg and recent surgery and lacked any information regarding bowel function. The Clinical and Order Alerts Report dated 05/25/24 through 06/23/24, revealed R3 lacked having a bowel movement documented in three days. Review of the Licensed Medication Administration Record and Medication Administration Record from 06/18/24 to 06/24/24, lacked any medication for R3 for constipation. R3 received Ultram (pain medication) and Bumex (medication used to remove excess fluid), which both can contribute to constipation. Review of the Bowel Elimination task revealed R3 had a bowel movement on 06/19/24 and on 06/25/24. R3 lacked having a bowel movement for five days from 06/20/24 through 06/24/24. Review of the Progress Notes from 06/18/24 through 06/24/24 for R3 lacked documentation regarding constipation. The Daily Skilled Nurses Note under the Evaluation tab for R3 revealed on 06/22/24 (three days after the last bowel movement) and 06/23/24 (four days after the last bowel movement) she did not have constipation. Both skilled notes revealed R3 was alert and oriented to person, place, and time. The Evaluation tab lacked a Daily Skilled Nurses Note for 06/24/24. On 06/25/24 at 10:58 AM, observation revealed R3 sitting up in her room in a wheelchair with her right leg in a cast and elevated with the footrest on the wheelchair. A mechanical lift sling was under R3 in the wheelchair. Certified Nurse Aide (CNA) O was in her room and had emptied the commode. On 06/25/24 at 11:00 AM, R3 stated she had a terrible time with constipation, which was not unusual for her to have that kind of trouble and stated she had not had a bowel movement since she had been in the facility, and she did not have one during the night. R3 stated at home she took Miralax (medication for constipation) and her bowel movements were more regular. R3 stated she did not know if the staff addressed her constipation but said they know about it. R3 stated she was not having any pain but a lot of gas. On 06/25/24 at 11:07 AM, Licensed Nurse (LN) G stated the process for bowel monitoring was the CNAs would report the bowel movement on their daily charting and the nurse would get a printout on the computer if the resident had not had a bowel movement in three days. LN G stated, people usually tell us if they need something. LN G stated by the third day if no bowel movement, then we give them something. LN G stated the facility has standing physician orders that can be activated if needed for constipation. LN G stated R3 had not been on the report for no bowel movement. LN G stated laxatives are given by the nurse who passes the medications and did not know if R3 received pain medication or not that could cause constipation. On 06/25/24 at 11:24 AM, Administrative Nurse D stated the process for bowel monitoring included the CNAs chart everyday whether a resident has had a bowel movement or not, then an alert is on the electronic charting if a resident has not had a bowel movement for three days, and the nurses are to address it. If a resident does not have an order for an as needed (PRN) medication for constipation, the staff were to contact the physician for orders, as the facility does not have standing orders. Administrative Nurse D stated the nurses were to address the no bowel movement alert before the end of their shift, and a lot of times night shift or herself would print out the list for the staff passing medications to administer a PRN for constipation. Administrative Nurse D recalled last Thursday (06/20/24) or Sunday (06/23/24) talking about her bowel function but was not aware if the doctor had been contacted or not. Administrative Nurse D stated anyone on pain medication should have a stool softener or something for their bowels. On 06/25/24 at 11:52 AM, CNA O stated she had assisted R3 at least three times with toileting and she had not had a bowel movement. CNA O stated R3 complained of constipation yesterday to her and she reported that to LN G. The facility policy Notification of Patient/Resident Change dated 11/01/16, revealed the center will consult the resident's physician, nurse practitioner or physician assistant when there is a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The facility failed to notify the physician when R3 went three days without having a bowel movement, resulting in five days from 06/20/24 through 06/24/24, without having a bowel movement.

The facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program with failure to perform appropriate hand hygiene and a clean dressing change procedure on 06/24/24, and to ensure Resident (R)1 had clean and dry dressings to his lower extremities. Findings included: - The Medical Diagnosis tab for R1 included diagnosis of lymphedema (swelling caused by accumulation of lymph), venous insufficiency (poor circulation), and cellulitis (skin infection caused by bacteria) of the right lower extremity. The Admission Minimum Data Set, dated dated dated [DATE], assessed R1 with a Brief Interview of Mental Status score of 15, which indicated he had intact cognition. R1 did not reject cares and was continent of urine. R1 had an infection of his foot, moisture associated skin damage (MASD). R1 had dressings applied to his feet, nonsurgical dressing applied other than to feet, and ointments/medications applied other than to feet. The Functional Abilities Care Area assessment dated [DATE], revealed R1 required assistance with his activities of daily living (ADL's), had increased weakness, and was at risk for skin breakdown, incontinence, and further ADL decline. The Dehydration/Fluid Maintenance CAA dated 03/25/24, revealed R1 admitted to the facility with cellulitis and prescribed two antibiotics to treat the cellulitis. R1 had a chronic wound on his right leg with Ace wraps (elastic bandage) daily and wound treatments to his wound. R1 had risk factors of impaired fluid balance and impaired skin integrity. The Pressure Ulcer/Injury CAA dated 03/25/24, revealed the staff were to notify R1's physician of any abnormal findings and treatment orders. The Care Plan dated 04/11/24 revealed R1 had cellulitis to his right lower extremity and the infection would resolve without complication. R1 was to have elastic bandage wraps applied to bilateral (both) lower extremities in the am and taken off at hour of sleep. The staff were to administer antibiotics as ordered and follow wound treatment orders. The Physician Orders tab included an order for R1, dated 06/14/24 to keep lymphedema wraps to his bilateral lower extremities clean, dry, and intact. Outpatient therapy were to change the dressings on Monday, Wednesday, and Friday. Staff were to monitor the wraps twice daily during the 06:00 AM to 06:00 PM shift and the 06:00 PM and the 06:00 AM shift. On 06/24/24 at 07:55 AM, observed R1 in his room in a recliner. His feet rested on a folded-up towel which was directly on the floor. A tied-up plastic bag sat on the floor, and next to the towel, his feet were on a pile of wraps and gauze. R1's left leg had gauze wrapped around it from above his ankle to below his knee and his right leg had gauze wrapped from the base of his toes to below his knee and was loose at the top with abdominal gauze pads (ABD pads - highly absorbent dressing) in place. The gauze wraps on the right lower leg were almost entirely yellow in color from drainage. R1 had a flyswatter in his room and killed one live fly and two others were observed in the room and landed on the dressings piled directly on the floor. There was a prominent foul odor in his room. On 06/24/24 at 08:20 AM, LN G looked at the pile of wraps on the floor and they were dated for 06/22/24 and initialed by LN H. LN G left the pile of wraps and gauze on the floor and exited the room. On 06/24/24 at 09:09 AM, LN G picked up the wraps and dressings off the floor in R1's room and removed part of the gauze wraps from his legs then exited the room. On 06/24/24 at 09:11 AM, LN G stated there was not an order for R1 if his wraps were not clean/dry/intact and Administrative Nurse D was going to request one. LN G stated what had been on R1's legs on 06/22/24 was the treatment that was being done before, and R1 should have an order on what to do in between times if the wraps were not clean/dry/intact. LN G stated she would clean R1's legs after he finished eating, and she left the current drainage covered gauze wraps in place to his right lower extremity and the gauze wraps remained on his left lower extremity. On 06/24/24 at 10:34 AM, LN G stated she was going to take the rest of the wraps off of R1's legs and clean them and did not have an order yet for any dressings. R1 was sitting in his recliner in his room. LN G placed the packaged gauze directly on the nightstand along with tape cut in pieces to secure the gauze. After removing the dressings, LN G began to clean R1's legs with the same contaminated gloves used to remove the soiled dressings. When the surveyor questioned if a new pair of gloves should be in place, LN G stated, It's dirty too and removed the gloves and applied a new pair without performing hand hygiene. Then, LN G placed four by four-inch gauze pads directly on R1's overbed table and used a gloved hand to open the nightstand drawer and removed more four -inch gauze pads out of the drawer and placed them directly on the overbed table. These treatment supplies were used to wipe R1's legs after LN G sprayed them with wound cleanser. R1 had an ABD pad which was stuck to his left lower extremity and required LN G to spray wound cleanser on to loosen the ABD pad from his leg. There was a live fly observed in R1's room during the process. LN G stated she was going to check with Administrative Nurse E to see if she wanted to take pictures of R1's legs and exited the room. R1's legs were noted to have redness, scaling, and edema. The left leg had a small scab to shin area and was not able to visualize the back of his legs. On 06/24/24 at 11:24 AM, entered R1's room with LN G and observed an area of fluid on the floor next to the towel R1 had his feet on. LN G stated that was from R1's legs it just runs. LN G retrieved a roll of gauze from the drawer in R1's nightstand, not packaged, sprayed R1's legs with a wound cleanser, and used the gauze wrap to wipe R1's legs. LN G then removed her gloves and applied a new pair without performing hand hygiene. LN G moved the packaged gauze wraps and strips of tape to R1's bed along with scissors without a barrier. LN G moved a trash can on its side and used the towel under R1's feet that was on the floor and placed it on the trash can, then R1's right foot on top of the towel that had been on the floor. LN G then began using gauze rolls to wrap R1's legs and during that time drips of fluid were coming from the back of his right leg. Once LN G finished wrapping the right leg, she placed his left foot directly on the trash can and removed her gloves. LN G stated she would be right back she needed to get more gauze. LN G returned and applied gloves then stated she forgot to grab socks, so she exited R1's room while removing the gloves at 11:36 AM without disposing gloves or performing hand hygiene before exiting the room On 06/24/24 at 11:38 AM, LN G returned to R1's room with socks, applied gloves, and placed a sock on R1's right foot. LN G stated, It is leaking already and applied another layer of gauze to R1's right leg. LN G placed R1's left heel back on the trash can and applied one roll of gauze. While she went to grab another roll, the end of the applied roll fell down and touched the surface of the trash can. LN G reapplied the end of the gauze roll that touched the trash can and began wrapping R1's left leg with the second roll. After securing with gauze with tape and after she applied a sock to his left foot, LN G exited the room at 11:47 AM with her gloved hands, tied up the trash and the linen bag, scissors, wound cleanser, and the stool she [NAME] in to sit on while she performed dressing cares. On 06/24/21 at 01:11 PM, Administrative Nurse E stated hand hygiene should be performed during dressing changes and before going in a resident's room, gloves should be removed after taking off dressings and hand hygiene should be performed before applying new gloves. Administrative Nurse E stated staff should place a barrier between the dressing supplies and the surface placed on. Administrative Nurse E stated a trash can should not be used to prop his foot/leg up on for the dressing change and if any part of the dressing touched the trash can surface, it should be disposed of. Administrative Nurse E stated if the dressings are loose, the nursing staff should address that as soon as they see it and should use a clean towel under his feet before doing his dressing changes. Gloved hands should not be used to gather supplies from the nightstand drawer. If R1's dressings were leaking, then the nursing staff should try to address it even if just reinforcing them and should call the doctor at any time to get an order, as he was the one that ordered the wraps. Administrative Staff A stated the staff should clean/sanitize the floor where the wraps were in contact with. The facility's policy for Hand Hygiene Audit undated, revealed hand washing should be done every time staff remove gloves, before and after each resident contact, every time moving from a dirty to a clean area, and sanitizer could be used instead of soap and water when hands are lightly soiled without visible debris on hand. The facility's undated policy for Clean Dressing Change revealed to create a clean field using a towel or paper towels, open dressings, and place on first pair of gloves, remove soiled dressing, dispose of gloves, wash hands, apply a second pair of gloves, cleanse wound, remove gloves, wash hands/sanitize, and re-glove. After applying prescribed medication/dressing secure per order, remove gloves, and wash hands. The facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection while providing a clean dressing change to R1's lower extremities.

The facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. On 06/17/24, Resident (R)1 had an appointment where Consultant Staff GG discovered two maggots on R1's right lower extremity while removing urine and fluid-soaked dressings due to weeping from his right lower extremity. Findings included: - The Progress Note dated 06/17/24 at 01:11 PM, revealed R1 left the facility for his appointment at the wound clinic. The Progress Note dated 06/17/24 at 02:02 PM, revealed R1 returned from his appointment at the wound clinic with no new orders. The note lacked documentation regarding maggots. On 06/24/24 at 07:55 AM, observed R1 in his room in a recliner. His feet rested on a folded-up towel which was directly on the floor. A tied-up plastic bag sat on the floor next to a pile of wraps and gauze which were next to a towel on the floor. R1 had a flyswatter in his room and killed one live fly and two others were observed in the room and landed on the dressings piled directly on the floor. There was a prominent foul odor in his room. On 06/24/24 at 07:57 AM, R1 stated while at the wound clinic, two maggots were found under his dressing. R1 was not able to recall for sure the exact date. On 06/24/24 at 10:34 AM, Licensed Nurse (LN) G stated she was going to take the rest of the wraps off of R1's legs and clean them and did not have an order yet for any dressings. R1 was sitting in his recliner in his room. There was a live fly observed in R1's room during the process of a dressing change performed by LN G. On 06/24/24 at 12:36 PM, Housekeeping Staff U stated the only issues with flies she had seen in the facility was in R1's room, which she thought was due to his legs that leaked fluids which smelled like rotten eggs. Housekeeping Staff U stated when she was in there yesterday his bandages were soaked through. When asked what was done about the flies in R1's room Housekeeping Staff U stated, I don't have a fly swatter and she had not killed any in his room. On 06/24/24 at 12:46 PM, LN G stated she had not seen any maggots on R1's skin or dressings but received in report one day they were found at the center where his wraps were done. On 06/24/24 at 12:54 PM, LN H stated she heard R1 had maggots in his leg dressings from R1 and LN J on one of the days he went to the clinic for wound treatment. On 06/24/24 at 01:06 PM, LN J stated R1 told her that last week when returning from the clinic they (clinic staff) found maggots. She verified there have been flies in his room, and thought he had a fly swatter in his room. LN J stated she had not killed any flies in his room and seemed like that was the only room that had them. On 06/24/21 at 01:11 PM, Administrative Nurse E stated R1 returned from the center where his wraps are done and reported maggots were found, so she called the center to clarify what he had said. Administrative Nurse E stated she was told by Consultant Staff GG on 06/17/24 of two maggots found and had not seen any on 06/14/24. On 06/24/24 at 02:37 PM, Consultant Staff GG stated she had been doing the lymphedema wraps and when R1 came in on 06/17/24 his wraps were soiled with urine and his legs weep a lot. The dressings in place were dated 06/13/24 and were the ones she had placed on that day when she evaluated him. When she was unwrapping R1's right leg on 06/17/24, she observed a maggot toward the top of his leg and one on his ankle. Consultant GG stated she did not call the facility right away regarding the maggots as she had another patient and Administrative Nurse E had called her and she gave Administrative Nurse E instructions on keeping the wraps on and clean unless they became soiled. On 04/24/24 at 04:30 PM, Maintenance Staff V stated he was not aware of any concerns about flies in the facility, a pest control company came out monthly, usually the first week of the month and had not been informed of any fly issues. Maintenance Staff V stated he was not aware of any residents having maggots found on their skin. Maintenance Staff V stated the staff will verbally tell him about any problems or put the concern in the TELS system (electronic communication system). Maintenance Staff V stated if he had been made aware, he could have had the pest control company come out to address. On 06/24/24 at 04:56 PM, Administrative Staff A stated, when asked what the facility had done to address the issue of maggots being found on R1's skin, he stated he was not aware of maggots being found until today (06/24/24) from one of the nurses after the surveyor's arrival on site. The facility policy Pest Control dated 09/01/14 revealed it was the policy of the center to maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building was kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services. The facility failed to ensure they maintained an effective pest control program resulting in R1 having maggots identified on his skin when Consultant Staff GG removed a dressing from his right leg at an appointment and observation of flies in R1's room.

The facility reported a census of 49 residents with five residents reviewed including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to administer the physician ordered amount of oxygen to Resident (R)5 and failed to ensure R1's oxygen tank did not run empty and/or was delivering oxygen as prescribed by the physician. Findings included: - The medical diagnosis tab for R5 included a diagnosis of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Significant Change Minimum Data Set, dated dated dated [DATE] assessed Resident (R)5 with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment and required oxygen while a resident. The Care Plan initiated on 12/15/23 revealed the staff were to administer oxygen to R5 as needed, per the physician order, and to observe the flow rate and response. The Physician Orders tab in the electronic medical record (EMR) included an order dated 01/03/24 for oxygen at three liters continuously via nasal cannula related to COPD. On 03/19/24 at 05:03 PM, observed R5 resting in bed, oxygen in place via a nasal cannula and connected to the oxygen concentrator, with the setting between 3.5 - 4.0 liters. On 03/21/24 at 10:16 AM, observed R5 sitting in her wheelchair in her room with oxygen in place via a nasal cannula and connected to the oxygen concentrator, with the setting between 3.5 to 4.0 liters. On 03/21/24 at 03:26 PM, R5 stated her oxygen usually was set at three liters but thought the day before yesterday it was moved to four because she felt low on air. On 03/21/24 at 03:27 PM, observed R5's oxygen setting to be between 3.5 - 4.0 liters via the oxygen concentrator while in her room. On 03/21/24 at 03:26 PM, Licensed Nurse (LN) H stated R5's oxygen was to be set at four liters, she has COPD and cannot hardly breathe at all. LN H stated she does not look at oxygen orders everyday unless there was a change and R5's oxygen order used to be at two to four liters. LN H stated she had not been told there was a change in R5's orders so she had not looked. LN H stated the other day, she increased the oxygen to four liters due to R5 feeling short of air. LN H looked up R5's orders in the EMR and stated R5 had orders for the oxygen to be at three liters per minute. On 03/21/24 at 04:39 PM, Administrative Nurse D stated the staff should follow physician orders for administering oxygen and if the oxygen needs increased the staff should get an order from the doctor if there is no order range to titrate. The facility policy Oxygen Guideline dated 01/01/22 revealed oxygen would be provided in accordance to a physician's order including the dose/rate of administration. The facility failed to provide oxygen as ordered for R5. - The Medical Diagnosis tab in the electronic health record (EMR) for Resident (R)1 included diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen) and heart failure. The Admission Minimum Data Set (MDS), dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of five, indicating severe cognitive impairment and did not require oxygen while a resident. The Quarterly MDS dated [DATE] assessed R1 with a BIMS score of eight, indicating moderate cognitive impairment and required oxygen while a resident. The Care Plan dated 12/21/23, revealed R1 had an alteration in his respiratory status due to congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and recent hospitalization for respiratory failure. The staff were to administer oxygen as needed per physician order and observe oxygen saturations (percentage of oxygen in the blood) on room air and/or oxygen and observe oxygen flow rate and response. The Physician Order tab in the electronic medical record (EMR) for R1 revealed an order dated 12/28/23 for oxygen at two liters per minute via a nasal cannula as needed to maintain oxygen saturation level above 90 percent, every shift, for respiratory failure. The cardiology physician Office Letter for R1's visit on 01/17/24 revealed upon arrival to the physician office, R1's oxygen tank was empty and R1's oxygen saturation level was 80 percent and R1 was a bit labored (trouble breathing). R1 complained of feeling very tired and weak. R1's oxygen saturation level was 80 percent upon arrival when the tank was empty. After R1 was on oxygen, he appeared more comfortable and was no longer hypoxic. The physician Office and Clinic Notes dated 03/15/24 revealed R1 had been wearing oxygen via a nasal cannula at three liters for some time secondary to hypoxia, when off oxygen, his oxygen saturation levels were below 86 percent on average. On 03/19/24 at 09:03 AM, observed R1 sitting up in his room in a wheelchair and had oxygen in place via the oxygen concentrator. R1's oxygen was set at 4.5 liters. On 03/19/24 at 09:05 AM, R1 stated he thought the oxygen was set on 3.5 liters. R1 stated the other day when he was in his room he had no air and the bottle was out of oxygen, it runs out a lot and that he was on the big one now so his oxygen was okay. R1 stated when he uses the bottle and it runs out, the staff does not get in in hurry to replace it. On 03/19/24 at 10:18 AM, R1's family member provided document which revealed he visited R1 nearly every day and nine times out of ten when arriving, there is no oxygen in the bottle. On 03/19/24 at 10:26 AM, R1's family member stated when talking to the facility about the oxygen bottle being empty, he was told there must be something wrong with the regulators. The family member stated R1 had a physician appointment on 03/15/24, and the oxygen bottle was empty when R1 arrived for the appointment, and the nurse had to hook him up to oxygen right away. On 03/19/24 at 12:13 PM, observed R1 sitting up in his wheelchair in the dining room feeding himself lunch. The oxygen in place per portable bottle at three liters. On 03/19/24 at 02:03 PM, Administrative Staff A stated on 03/16/24, R1's son voiced a concern of R1 being in his room and connected to the oxygen bottle, which was empty rather than the concentrator, and when at the doctor's office on 03/15/24, his oxygen ran out. Administrative Staff A stated on 03/15/24, transportation staff had called and said they needed a tank when they got back to the facility and when they pulled up to the facility, there was oxygen in the tank, the regulator was not turned all the way off, and you could hear the oxygen in it, the tank regulator showed the oxygen was low but not empty. Administrative Staff A stated he helped to change the oxygen bottle when R1 arrived back to the facility. On 03/19/24 at 02:18 PM, Licensed Nurse (LN) G stated on 03/16/24 after he took R1 to his room, his son who came in later came up to him and had said R1 had no oxygen and when he walked in to R1's room, the son told him he had taken care of it. LN G stated R1 was on the portable bottle, and he connected R1 to the oxygen concentrator. LN G stated R1 had the nasal cannula in his nose when he assisted him to his room and when he returned to the room. LN G stated R1 does have a habit of pulling the nasal cannula off to see if it was working. On 03/19/24 at 03:38 PM, Certified Medication Aide (CMA) R stated R1 often returned back from dialysis with an empty oxygen bottle, or the bottle would not be empty but needed the key to turn it on. CMA R stated the oxygen setting would be on, but the portable bottle was not turned on with the key so the oxygen could be delivered. CMA R stated at the time when he would return, she would go to shut the oxygen off, however, the oxygen was not turned on. CMA R stated at times, the piece that needed to be popped off before turning on, which would be in place on new oxygen bottles, would still be in place. On 03/21/24 at 11:16 AM, Consultant Staff HH stated she would have the office manager handle questions about R1's appointment on 03/15/24. On 03/21/24 at 11:39 AM, Consultant Staff GG stated she spoke with Consultant Staff HH who roomed R1 for his appointment on 03/15/24. When Consultant Staff HH was getting R1's vital signs, his oxygen saturation was low at 86 percent, and when looking at the oxygen bottle, the regulator showed it was in the red. Consultant Staff HH asked the family member that was there if the tank was on, and it was empty. After oxygen applied at three liters, R1's saturations increased to 93 percent. On 03/21/24 at 03:40 PM, Maintenance Staff U stated he took R1 to his appointment on 03/15/24 and stated he did not look at his oxygen bottle, he does not touch the oxygen, the aides get the resident ready and he takes them to the van. Maintenance Staff U stated R1's oxygen bottle regulator needle was in the red but not all the way. On 03/21/24 at 04:39 PM, Administrative Nurse D stated the staff should follow physician orders for oxygen. Administrative Nurse D stated the staff getting the resident ready for appointments should ensure the resident had enough oxygen and if the resident is leaving the building, they should have a new bottle. Administrative Nurse D stated the van should have an extra bottle of oxygen in there. The facility policy Oxygen Guidelines dated 01/01/22, revealed oxygen will be provided in accordance to a physician's order including dose/rate of administration. The facility failed to ensure R1 received oxygen per physician order.

The facility reported a census of 49 residents with five residents selected for review, including one reviewed for medication errors. Based on interview and record review, the facility failed to start a physician ordered medication for Resident (R)1, that resulted in 22 days without the ordered medication. Findings included: - The Medical Diagnosis tab in Resident (R)1's electronic medical record (EMR) included diagnoses of atrial fibrillation (rapid, irregular heartbeat) and dependence on renal (kidney) dialysis (procedure where impurities or wastes were removed from the blood). The Quarterly Minimum Data Set, dated dated dated [DATE] revealed R1 did not take an anticoagulant medication (medication used to thin the blood to prevent clot formation). The Cardio-Kidney Vascular Care Ellipsys [minimally invasive procedure creating a fistula for dialysis] Discharge Instructions dated 02/22/24, revealed R1 was to take regular medicine including the blood thinner. The instructions included the Procedure Room - Medication Reconciliation form which included an order for apixaban (Eliquis - anticoagulant medication), five milligrams (mg), oral tablet, twice a day. The instructions lacked the facility had noted the orders. The cardiologist Office Letter dated 01/17/24 revealed R1 was to be having a fistula placed and needed to start Eliquis after implantation. The physician requested to be contacted after the date of the fistula implantation would be done so the Eliquis could be initiated. The physician Office and Clinic Notes dated 03/15/24 revealed R1 was supposed to be on Eliquis, 2.5 mg, twice daily for cardiology in atrial fibrillation had stopped due to fistula formation, however, needs to be restarted. The Miscellaneous tab in the EMR under the physician order section revealed a physician written script dated 03/15/24 for Eliquis, 2.5 mg, twice daily, for atrial fibrillation. The Medication Administration Record (MAR) dated February 2024, lacked instructions for the staff to administer apixaban. The MAR dated March 2024 lacked instructions for the staff to administer apixaban until 03/15/24. The staff administered the medication on 03/16/24 (23 days after the initial order on 02/22/24). The Progress Notes dated 02/13/24 revealed R1 had an appointment on 02/22/24 at 01:30 PM for fistula placement for dialysis. The Progress Notes dated 02/22/24 revealed R1 left the facility for appointment and returned to facility the same day with a dressing to R1's right arm. The Progress Notes dated 02/13/24 through 03/14/24 lacked documentation the facility notified the cardiology physician regarding the fistula placement and restarting the Eliquis. On 03/19/24 at 10:26 AM, R1's family member stated after the fistula was placed, R1 was to start back on the Eliquis. R1's family member stated R1 had a follow up appointment on 03/05/24 and he received three phone calls questioning if the Eliquis had been restarted and he referred the caller to the facility. R1's family member stated when R1 had appointment with his physician on 03/15/24 the Eliquis was not on the medication list and the physician stated R1 was to be back on the Eliquis. The family member stated the facility started the Eliquis on 03/16/24. On 03/21/24 at 11:39 AM, Consultant Staff GG stated R1 did not have Eliquis on the medication list provided at the 03/15/24 appointment, and the dose ordered was according to the cardiologist office notes on 01/17/24. On 03/21/24 at 01:19 PM, Administrative Nurse D stated the facility did not have R1's appointment notes from 01/17/24 and had to request them. Administrative Nurse D stated she was not aware of the medication error with the Eliquis until 03/18/24 and R1 should have started the Eliquis after the fistula placement. Administrative Nurse D stated when a resident returns to the facility, the charge nurse at that time should take care of the orders, then medical records staff was to ensure the orders were noted before scanning in the EMR. The medical records staff was to bring any new orders to the morning meeting. Administrative Nurse D stated she did not recall seeing the orders from the procedure on 02/22/24, however, she had been working on the floor also and was not at every morning meeting. The facility lacked a policy for following physician orders. The facility failed to notify the cardiologist of the fistula appointment for instructions on restarting the Eliquis and failed to initiate the Eliquis ordered on 02/22/4 until 03/16/24, 23 days later after the initial order.

The facility reported a census of 50 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three of the three Certified Nurse Aides (CNA) reviewed, CNA M, CNA N and CNA O and failed to complete an annual performance review at least once every 12 months for two of the Certified Medication Aides (CMA) reviewed, CMA R and CMA S. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concern: Review of Certified Nurse Aide (CNA) M, hired 07/2019, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) N, hired 07/2022, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) O, hired 02/2023, lacked an annual performance review in her personnel file. Review of Certified Medication Aide (CMA) R, hired 01/2022, lacked an annual performance review in her personnel file. Review of Certified Medication Aide (CMA) S, hired 06/2022, lacked an annual performance review in her personnel file. On 02/29/24 at 08:47 AM, Administrative Nurse D stated the annual evaluations had not been completed, but the facility would work on catching them up. The facility policy for Performance Management, undated, included: Team members will have their performance appraisal at least one timer per year, on or around their anniversary date to discuss job tasks, identify and correct weaknesses, encourage and recognize strengths, and discuss positive purposeful approaches for meeting goals. The facility failed to complete an annual performance review for these five staff members, employed by the facility for greater than one year.

The facility reported a census of 50 residents. Based on observation and interview, the facility failed to maintain a two-inch air gap between the ice machine drainpipe and drain in the kitchen to prevent back up of contaminated water into the ice machine. Findings included: - Observation, on 02/28/24 at 09:37 AM, revealed the water drain in the kitchen was full of water with the drainpipe from the ice machine positioned directly in the water. Interview, on 02/28/24 at 09:57 AM with Maintenance Staff U, confirmed the lack of an air gap and the ice machine drainpipe positioned in the backed-up kitchen drainage plumbing. Staff turned the ice machine off on 02/27/24 at approximately 08:30 PM. The facility lacked a policy for maintaining a two-inch air gap between the ice machine drain and the kitchen drain. The facility failed to ensure a two-inch air gap between the ice machine drain and the kitchen drain to prevent contamination and food borne illness amongst the residents.

The facility reported a census of 50 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to weekend staffing, when the facility failed to accurately report weekend staffing during the third and fourth quarter of 2023. Findings Included: - Review of the 'Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) Quarter 3, 2023 (April 1-June 30) and Quarter 4 (July-September), 2023 revealed extremely low weekend staffing. Review of the Staffing Sheets from April 2023 through September 2023, revealed equal staffing on the weekends as during the week. Interview, on 03/04/24 at 08:22 AM, with Administrative Nurse D, revealed the facility's corporate office compiles the staff hours for the PBJ and transmits the data to CMS. Administrative Nurse D confirmed the inaccurate staff hours reported on the PBJ for Quarter 3, 2023 and Quarter 4, 2023. The facility lacked a policy for accuracy of the PBJ. The facility failed to accurately complete the PBJ to reflect actual staffing on weekends as required.

The facility reported a census of 50 residents. Based on observation and interview, the facility failed to ensure to maintain the environment in a safe, sanitary, and homelike manner to promote the well-being of the residents. Findings included: - Observation, on 02/27/24 at 08:30 AM, revealed the following areas of concern: 1. The beauty shop contained a floor mat which was torn across the entire surface. The floor in the beauty shop contained four stained tiles around the base of the heating/air conditioning unit. The vent on the ceiling contained an accumulation of dust. 2. The shower room on east hall contained 15 two by two tiles that were missing/loose around the drain. 3. Three resident rooms contained an unoccupied, unmade sanitized bed. 4. A resident room contained an unused commode bucket under the bed. 5. Three resident room hall doors contained broken/buckled plastic door guards. 6. Two resident rooms contained torn door molding. 7. One resident room contained wooden cupboards with scratches horizontally across the surface and the drawers to the wooden unit contained mismatched wood stain. 8. The community large bird cage contained streaks of white substances down the front windows. 9. The wooden doors between east and west hall contained multiple scratches in the wood horizontally. 10. The heating units on each side of the east and west hallway exit doors contained scratches in the paint along the entire horizontal surface. Observation, on 03/04/24 at 08:41 AM, during the environmental tour with Administrative Staff A, Maintenance Staff U and Housekeeping Staff V, observed and confirmed the above areas of concern that remained unchanged since first observed on 02/27/24. Maintenance Staff U stated he had fixed the tiles once before, but they became dislodged. Housekeeping Staff V stated the beauty shop floor needed cleaned and buffed, and the vent dusted. Administrative Staff A stated staff should make an unoccupied bed in a resident room and staff should keep the widows of the bird cage clean. The facility lacked a policy for maintenance and housekeeping of these areas. The facility failed to provide a safe, sanitary, and homelike environment for the residents of the facility to promote a sense of wellbeing for the residents.

The facility reported a census of 50 residents with 17 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for four of the residents sampled, including Resident (R)28 and R43, regarding fall interventions, and R 9 and R 19 regarding specific, individualized parameters for hypertensive medications (medications used to lower blood pressure-BP). Findings included: - Review of Resident (R)28's electronic medical record (EMR) included a diagnosis of weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She required substantial/maximal assistance of staff for toileting and was independent with supervision or touch assistance for sitting to standing, transferring from her bed to a chair or from her chair to a bed and transferring to the toilet. She used a walker and a wheelchair and had no falls since admission to the facility. The Falls Care Area Assessment (CAA), dated 12/19/23, documented the was at risk for falls. The falls care plan, dated 12/15/23, instructed staff the resident was at risk for falls due to a history of falls before admission. Staff were to educate the resident about safety reminders and ensure she had on appropriate footwear and/or non-skid socks when ambulating or mobilizing in her wheelchair. Staff were to keep the resident's wheelchair next to her bed so she could easily reach it when she needed. The resident was at times non-compliant with requesting assistance before attempting to ambulate. The care plan lacked new and appropriate interventions for falls which occurred on 01/28/24 and 02/01/24. Review of the resident's EMR revealed a fall assessment, dated 12/12/23, placed the resident at a high risk for falls. Review of a Post Fall Report, dated 01/28/24, and provided by the facility, revealed on 01/28/24 at 11:45 PM, the resident had an unwitnessed fall in her bathroom. The resident had no injury. The intervention for the fall was for the resident to wear non-skid socks, an intervention already in place following a previous fall. Review of a Post Fall Report, dated 02/01/24, and provided by the facility, revealed on 02/01/24 at 01:15 AM, the resident had an unwitnessed fall from her bed to the floor. The resident had no injury. The intervention for the fall was for the resident to wear non-skid socks, an intervention already in place following a previous fall. On 02/28/24 at 08:47 AM, Certified Nurse Aide (CNA) P stated the resident required more staff assistance some days than others. Staff are to visually check on her every 15 minutes to ensure she is safe and make sure she always had on non-skid socks or appropriate shoes. On 02/29/24 at 12:16 PM, Licensed Nurse (LN) G stated the vital signs and assessing for injuries are the fall interventions. Any type of intervention that would be included on the care plan would be initiated by Administrative Nurse D. On 03/04/24 at 09:47 AM, Administrative Nurse D stated the nurse on duty at the time of the fall would be responsible for initiating the new, appropriate fall intervention and putting it into the care plan. The facility policy for Care Plans, effective 10/2023, included: Care plans are developed by the interdisciplinary team (IDT) and revised as needed according to resident status or change. The facility failed to review and revise the care plan for this dependent resident following two non-injury falls. - Review of Resident (R)43's Physicians Order Sheet (POS), dated 02/19/24, revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She required partial to moderate staff assistance with toileting, transferring and ambulating 10 to 50 feet. She had two or more non-injury falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 01/30/24, documented the resident had a history of falls prior to her admission due to impaired balance, gait, strength, and muscle endurance. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She required partial to moderate staff assistance with toileting, transfers and ambulating 10-50 feet. She had two or more non-injury falls since her previous assessment. The care plan for falls, revised 02/19/24, instructed staff the resident was at risk for falls due to use of psychotropic medications (drug that affects behavior, mood, thoughts, or perception), decreased safety awareness and impaired cognition. Staff were to check on the resident every 15 minutes, toilet her upon rising, between meals, before bed and as needed (PRN), have her care for one of her baby dolls, ensure she had on non-skid socks, and ensure her call light was within reach of her. The care plan lacked new and appropriate interventions for falls which occurred on 10/07/23, 11/30/23 and 01/04/24. Review of her electronic medical record (EMR) revealed a fall assessment, dated 07/15/23, which placed the resident at risk for falls. Review of a Post Fall Report, dated 10/07/23, provided by the facility, revealed on 10/07/23 at 09:17 PM, the resident had a non-injury fall in her room when she attempted to stand up from her wheelchair. The intervention initiated was to re-educate the resident on using her call light when she needed assistance, an inappropriate intervention due to the resident having a BIMS of five, indicating severe cognitive impairment. Review of a Post Fall Report, dated 11/30/23, provided by the facility, revealed on 11/30/23 at 04:55 PM, the resident had a non-injury fall in the dining room when she attempted to stand up from her wheelchair. The facility lacked an intervention for the fall. Review of a Post Fall Report, dated 01/04/24, provided by the facility, revealed on 01/04/24 at 07:30 PM, the resident had a non-injury fall in her room. The facility lacked an intervention for the fall. On 02/28/24 at 04:02 PM, the resident sat in her wheelchair in the dining room watching a group activity. The resident's wheelchair had the anti-roll back brakes in place. On 02/29/24 at 02:25 PM, the resident propelled herself in her wheelchair around her hall. The resident wore appropriate footwear. On 02/29/24 at 12:16 PM, Licensed Nurse (LN) G stated the vital signs and assessing for injuries are the fall interventions. Any type of intervention that would be included on the care plan would be initiated by Administrative Nurse D. On 03/04/24 at 09:47 AM, Administrative Nurse D stated the nurse on duty at the time of the fall would be responsible for initiating the new, appropriate fall intervention and putting it into the care plan. The facility policy for Care Plans, effective 10/2023, included: Care plans are developed by the interdisciplinary team (IDT) and revised as needed according to resident status or change. The facility failed to review and revise the care plan for this dependent resident following three non-injury falls. - Review of Resident (R)9's Physician Order Sheet (POS), dated 12/27/23, documented the resident had a diagnosis of hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/23/23, documented the resident had anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Mood State CAA, dated 05/23/23, documented the resident had a diagnosis of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and would attempt to manipulate situations. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14. The care plan for congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), revised 02/19/24, instructed staff to give the resident's cardiac medications, as ordered, and to monitor her blood pressure (BP). The care plan lacked the resident's specific BP parameters for her hypertensive medications, as ordered by her physician. Review of the resident's electronic medical record (EMR) revealed the following physician's orders: Check BP every (Q) morning and hold BP medication if systolic (SBP-top number of the BP) BP was less than 120, ordered 12/18/23. Diltiazem (a medication used to lower BP) extended release (ER), 120 mg, oral (po) in the morning for HTN. Hold for SBP less than 110, ordered 02/26/24. Diltiazem ER, 120 mg, po in the morning for HTN. Hold for SBP less than 120, ordered 07/12/22. The order was discontinued (DC) on 02/26/24, and a new order for the same medication added. Review of the resident's February 2024 MAR, revealed the following dates and SBP when staff administered R9's Diltiazem ER 120 mg when the SBP was outside of the physician's ordered parameters: On 02/01/24, the resident's SBP was 113. On 02/02/24, the resident's SBP was 112. On 02/06/24, the resident's SBP was 108. On 02/16/24, the resident's SBP was 115. On 02/19/24, the resident's SBP was 110. On 02/20/24, the resident's SBP was 112. On 02/25/24, the resident's SBP was 109. On 02/28/24, the resident's SBP was 109. On 03/04/24 at 07:07 AM, Certified Medication Aide (CMA) S stated she will check each resident's BP before administering hypertensive medications. If the BP was outside of the parameters, she would notify the nurse on duty and hold the medication. On 03/04/24 at 07:09 AM, Licensed Nurse (LN) G stated if a resident's BP was outside of the ordered parameters, she would notify the physician if the resident was symptomatic. On 03/04/24 at 09:47 AM, Administrative Nurse D stated the care plan should have been updated to include the resident specific BP parameters ordered by the physician. The facility policy for Care Plans, effective 10/2023, included: Care plans are developed by the interdisciplinary team (IDT) and revised as needed according to resident status or change. The facility failed to review and revise the care plan for this resident with specific BP parameters for their BP medications. - The Physician Order Sheet (POS), dated 01/22/24, for Resident (R)19, documented the resident had a diagnosis of hypertension (HTN-elevated blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The Psychotropic Drug Use Care Area Assessment (CAA), dated 07/28/23, documented the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with a BIMS score of six. She required supervision with activities of daily living (ADL). The Modification of the Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. The nutritional care plan, revised 02/19/24, instructed staff the resident had a diagnosis of HTN. The care plan lacked the resident's specific BP parameters for her hypertensive medications, as ordered by her physician. Review of the resident's electronic medical record (EMR) revealed the following physician's orders: Check blood pressure (BP) every (Q) morning and hold BP medication if systolic (SBP-top number of the BP) BP was less than 120, ordered 11/09/23. Losartan (a medication used to decrease BP), 25 milligrams (mg), by mouth (po), in the morning for HTN. Hold if SBP was less than 120, ordered 09/02/23. Review of the resident's January 2024 Medication Administration Record (MAR), revealed the following dates and SBP when staff administered the Losartan 25 mg with the SBP outside of the physician's ordered parameters: On 01/02/24, the resident's SBP was 108. On 01/04/24, the resident's SBP was 119. Review of the resident's February 2024 Medication Administration Record (MAR), revealed the following date and SBP when staff administered the Losartan 25 mg with the SBP outside of the physician's ordered parameters: On 02/02/24, the resident's SBP was 111. On 03/04/24 at 07:07 AM, Certified Medication Aide (CMA) S stated she will check each resident's BP before administering hypertensive medications. If the BP was outside of the parameters, she would notify the nurse on duty and hold the medication. On 03/04/24 at 07:09 AM, Licensed Nurse (LN) G stated if a resident's BP was outside of the ordered parameters, she would notify the physician if the resident was symptomatic. On 03/04/24 at 09:47 AM, Administrative Nurse D stated the care plan should have been updated to include the resident specific BP parameters ordered by the physician. The facility policy for Care Plans, effective 10/2023, included: Care plans are developed by the interdisciplinary team (IDT) and revised as needed according to resident status or change. The facility failed to review and revise the care plan for this resident with specific BP parameters for their BP medications.

The facility reported a census of 53 residents, with one, Resident (R)1, reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure staff provided a safe environment as free of accidents as possible, when Certified Nurse Aide (CNA) M failed to apply the lap/shoulder belt on R1 prior to transport in the facility van to an appointment out of town. While traveling on the highway at approximately 67 miles per hour, CNA M looked in the rearview mirror, noted R1 to be dozing, and when CNA M looked back at the road, the vehicle in front of her had their brakes and left turn signal on. CNA M slammed on the brakes to avoid hitting the vehicle in front of the facility van, which caused R1 to fall out of the wheelchair and approximately three to four feet to the facility van floor. R1 landed on her face first and then onto her knees, hitting her upper body on the floor and her side on the handlebar between the passenger door and the van lift. R1 could recall hitting her knees, arms, and mouth during the incident and noted that her knees hurt afterwards. R1 required emergency medical transport to a local hospital for evaluation and then later emergency medical air transport to another hospital for further treatment, where she was diagnosed with a left distal radius (one of the bones going from the wrist to the elbow) fracture (broken bone), right flank (side of body between rib cage and hip) hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma), and acute blood loss anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). This deficient practice of failure to adequately secure the resident in the wheelchair prior to transporting her placed R1 in immediate jeopardy. Findings included: - The hospital Physician's Interagency Transfer Record and Admission Orders signed by the physician on 12/20/23 for R1 included diagnoses of right flank hematoma, acute blood loss anemia, end stage renal (kidney) disease, and left distal radius fracture. The Annual Minimum Data Set (MDS) dated [DATE], assessed R1 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had impairment of range of motion on one side of her upper extremities and she used a walker or wheelchair for locomotion. The Activities of Daily Living [ADL] Functional/Rehabilitation Care Area Assessment (CAA), dated 07/07/23 for R1 revealed she required assistance with her ADL's. The Quarterly MDS dated [DATE] revealed R1 continued to have a BIMS score of 15, had no range of motion impairment to her upper extremities, and continued to use a walker or wheelchair for locomotion. The Care Plan dated 10/04/23 revealed R1 was independent with her ADL's and used a wheelchair for mobility around the center. R1 required dialysis (procedure where impurities or wastes were removed from the blood) due to her end stage renal disease three times a week. The facility's Record of In-service dated 07/25/23, revealed Administrative Staff B provided education on van safety to CNA M, which included a return demonstration by CNA M on securing a resident with the wheelchair seat belt. The Nurse's Note dated 12/14/23 at 10:00 AM revealed Administrative Nurse D received a call from CNA M and reported R1 required an ambulance for transport to the local emergency department when CNA M had to make a sudden stop in the facility van and R1 was thrown out of the wheelchair. Administrative Nurse D called the hospital to check on the status of R1 and they reported they were getting x-rays. The hospital Emergency Department note dated 12/14/23, revealed R1 presented to the emergency room via emergency medical services (EMS) post motor vehicle accident with complaints of right hip/right knee pain and shortness of breath with increased oxygen consumption, which resolved after EMS applied oxygen per R1's request. R1 was riding to the hospital for a previously scheduled wound care appointment, in her wheelchair, and was not seat belted into her wheelchair. CNA M stated she was driving at 67 miles per hour and had to break very quickly, causing R1 to fall forward out of the wheelchair and hitting the right side of her body on a support pole/handrail. R1 stated she hit her lips on the back of the seat. At the time of the accident and time of arrival R1 rated her pain at a 10 out of 10 where a 10 is the worst amount of pain, mainly localized to the right hip, though she experienced pain to the right knee with palpation (examination of a body by touch). The report revealed R1 was unable to be moved into position for an x-ray of her hips and pelvis, so they performed a computed tomography (CT) scan of the pelvis. Upon R1's return from radiology, she became hypotensive (low blood pressure) with a blood pressure reading of 68/44 (normal range between 90/60 and 120/80). The decision was made to transfer her to another hospital due to her hypotension despite fluid administration, via emergency medical air transport. The CT Pelvis dated 12/14/23 for R1 revealed findings of a large heterogeneous (appearing irregular) hematoma involving the mid to lower extra-abdominal subcutaneous (beneath the skin) fat region on the right, and a heterogeneous hematoma involving the right posterior aspect of the abdomen and pelvis region, as well as significant fat stranding (change in density of fat around an inflamed structure) seen about the pelvis. The x-ray results of the Right Knee dated 12/14/23 revealed R1 had soft tissue swelling. The hospital CT Knee Right results without contrast dated 12/14/23, revealed the resident had a hematoma in the soft tissue of the medial right knee and diffuse soft tissue edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The hospital History and Physical dated 12/14/23 for R1, from the hospital where she was transferred to via emergency medical air transport, revealed R1 complained of right flank pain and left wrist pain. The resident had a large hematoma on the right flank, which extended down into the upper pelvis area, bruising to her left wrist, bruising to bilateral (both) knees, , and had dried blood on her lips. A left wrist x-ray revealed a distal radius fracture. The orthopedic physician splinted her left distal radius fracture while R1 was in the trauma bay. R1 admitted to the surgical intensive care unit. R1 received two units of blood at the outside facility and two units ordered for transfusion at this facility. The hospital x-ray results for the Left Knee dated 12/15/23 revealed extensive circumferential subcutaneous edema. The Nurse's Notes dated 12/15/23 at 07:41 AM revealed Administrative Nurse D received report from the hospital notifying her that R1 was sent to another hospital due to her low blood pressure, low hemoglobin (measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs), and required dialysis. The Nurse's Notes dated 12/15/23 at 07:55 AM revealed Administrative Nurse D spoke with a registered nurse (RN) at the second hospital who reported R1 received five units of blood so far and they were monitoring the abdominal hematoma for bleeding, her left knee had a hematoma, and her left wrist was currently in a splint. The facility investigation dated 12/19/23 revealed CNA M did not have the lap belt on R1 during transport to an appointment out of town. The Nurse's Note dated 12/21/23, revealed R1 returned to the facility at 01:30 PM. The Nurse's Note dated 12/21/23 at 10:35 PM by Licensed Nurse (LN) G revealed R1 had bruising to her right iliac crest (upper hip) and two scabs noted to area, bruising to bilateral knees, blister noted to left knee, bruising to left upper thigh, and a cast to left arm. The note lacked measurements of the areas. On 12/26/23 at 09:07 AM, observed R1 as she propelled herself down the hall in her wheelchair using her right hand and foot. R1 removed her jacket, and she had a splint in place from her left hand to her elbow. On 12/26/23 at 09:08 AM, R1 stated she was bummed up from a couple of weeks ago when the van wrecked, and she fell out of her wheelchair and fractured her wrist. On 12/26/23 at 09:27 AM, R1 stated on 12/14/23 she was going to [named location] for wound care, when someone stopped to turn, and CNA M slammed on the brakes to avoid hitting them. R1 stated the next thing she knew she was on the floor in the van. R1 stated the seat belt was not across her. R1 stated she remembered hitting her knees, then her arms, and mouth. R1 stated an ambulance came and they really had to work to get me out of the van and transported her to the hospital, then she was transported by life flight to another [named location] hospital. During the interview, R1 pulled up her left pant left leg, which revealed various faded purple bruising covering her left knee with an approximate 1.5 inch black scabbed area in the bruising, which R1 stated a blood blister had been there, as well as swelling noted to the left knee. On 12/26/23 at 11:53 AM, CNA M stated she received training by Administrative Staff B on getting a resident ready in the van which included putting the lap belt on prior to 12/14/23 before she started driving the van approximately four months ago. CNA M stated on 12/14/23 at approximately 08:45 AM, she transported R1 in the facility van in her wheelchair to an out-of-town appointment, however, she did not put the lap belt on R1 before transporting her. CNA M stated she had the cruise control set at about 67 miles per hour and looked in the rearview mirror at R1 and noted she was dozing and when she looked back down the vehicle in front of her had the brakes and left turn signal on. CNA M stated she slammed on the brakes and R1 came out of her chair and landed on the passenger side of the van all the way to the front where there was a fire extinguisher, and her head was next to it. CNA M stated prior to the incident she was sitting in the middle area of the van in the first spot a wheelchair could be strapped down to, however she was unsure of the distance from the chair to where R1 landed. CNA M stated she pulled over to the side of the road, put the van in park, and turned on the hazard lights. CNA M stated she checked on R1 who stated she needed an ambulance as she could not get the resident back up. CNA M stated she tried to get R1 up however, could not, and R1 was having pain on her right side above her hip. CNA M stated she had her phone in her hand getting ready to call for an ambulance and looked over and a cop was there who checked to see how we were and what was going on. CNA M stated an ambulance came to get R1 and took her to the hospital. CNA M stated she did not have contact with the vehicle in front of her and she went to the hospital after R1 had left in the ambulance. CNA M stated at the hospital R1 complained of lots of pain to her right side. On 12/26/23 at 12:31 PM R1 stated she had bruising to her right side, then lifted her shirt up, and noted large fading purple bruise, which had two scabs within the bruising approximately one inch in size. On 12/26/23 at 01:16 PM, Administrative Staff A stated he would have expected CNA M to fasten the lap/shoulder belt prior to transport. Administrative Staff A stated the facility van was currently in the shop. On 12/26/23 at 02:35 PM, Maintenance Staff U stated the lap/shoulder belt was to be in place prior to transporting a resident. Maintenance Staff U stated the approximate distance from the first spot in the van for a wheelchair to be for transport was approximately three to four feet from the driver's seat. The facility Driver Qualification Checklist for Vehicle Operation undated, referred to form VSP-05-E for the Q' Straint Wheelchair Securement System User Instructions. The QRT-1 Series User Instructions undated revealed after securing the wheelchair, attach lap belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. The instructions included to attach shoulder belt by extending the shoulder belt over the passenger's shoulder and across upper torso and fasten the pin connector onto the lap belt. Ensure belts were adjusted as firmly as possible, but consistent with user comfort. The facility failed to ensure staff provided a safe environment as free of accidents as possible, resulting in harm to R1 when CNA M failed to apply the lap/shoulder belt prior to transporting R1 in the facility van and which caused R1 to fall forward out of her wheelchair when CNA M slammed on the brakes during transport, which resulted in injuries and placed the resident in immediate jeopardy. On 12/26/23 at 04:33 PM Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facilities failure to provide a safe environment as free of accidents as possible when CNA M failed to apply the lap/shoulder belt prior to transporting R1 in her wheelchair in the facility van, which resulted in R1 falling forward out of her wheelchair when CNA M slammed on the brakes to avoid hitting the vehicle in front of them while traveling at 67 miles per hour down the highway. R1 required emergency medical transport for treatment following the fall on 12/14/23. The immediate jeopardy was determined to first exist on 12/14/23 and the surveyor verified onsite the facility identified and implemented corrective actions completed on 12/14/23 at 03:00 PM, when the facility completed the following: 1. On 12/14/23 at 09:38 AM, R1 assessed immediately for injury. 2. On 12/14/23 at 09:44 AM, called for EMS assessment and transport to the emergency room . 3. On 12/14/23 at 10:30 AM, R1's physician and family notified. 4 On 12/14/23 at 12:30 PM, CNA M placed on suspension pending investigation. 5. On 12/14/23 at 01:00 PM, all van drivers educated or prior to working on Abuse, Neglect, and Exploitation. 6. On 12/14/23 at 01:30 PM, education on the vehicle safety program guidelines for auto, van and passenger vehicles completed by transportation team members. 7. On 12/14/23 at 03:00 PM, education via online computer learning program training for driver safety completed by transportation team members. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J score and severity.

The facility reported a census of 54 residents with 17 residents sampled, including one resident reviewed for pressure ulcers (PU). Based on record review, interview, and observations, the facility failed to ensure appropriate treatment and services for the one Resident (R)4, with the failure to prevent the development of one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) PU. Findings included: - Review of Resident (R)4's electronic medical record (EMR), under the Med Diag[nosis] tab, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. The resident had no rejection of care. He required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. He needed extensive assistance of one staff for locomotion on the unit. He had no functional limitations in range of motion (ROM). He was at risk for the development of pressure ulcers (PU), with no unhealed PUs at the time of the assessment. He had a pressure reducing device for his bed and chair and was on a turning and repositioning schedule. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/24/22, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to monitor his need for cueing and reorientation. The Activities (ADL) Functional/Rehabilitation Potential CAA, dated 02/24/22, documented the resident transferred with a sit to stand lift (mechanical device designed to help residents who lack the specific strength or muscle control to rise to a standing position and quickly transfer) and required extensive assistance for most of his ADLs. The Pressure Ulcer CAA, dated 02/24/22, documented the resident required extensive assistance with bed mobility and transfers. The Baseline Care Plan, dated 02/18/22, stated the initial skin goal was to maintain the resident's skin integrity. Staff were to turn and reposition the resident. The base line care plan lacked staff instruction on the frequency of turning and repositioning the resident. The Cognition Care Plan, dated 02/28/22, instructed staff to cue and reorient the resident due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The ADL Care Plan, dated 02/28/22, instructed staff the resident required extensive assistance of two staff for bed mobility, dressing, and toileting. The PU Care Plan, dated 02/28/22, instructed staff the resident was at risk for the development of PUs. The revised Care Plan, dated 03/15/22, instructed staff the resident had a deep tissue pressure injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues, caused by pressure) to his right heel. Staff were to off load the resident's bilateral lower extremities (LE) and paint the right heel with an iodine swab (antiseptic used to clean wounds) twice daily (BID), until healed. Staff were to ensure the resident had a pressure reducing mattress on his bed and a pressure reducing cushion in his wheelchair. The revised Care Plan, dated 05/24/22, instructed staff the resident had an unstageable PU to his right heel. Review of the resident's EMR, under the Evaluations tab, included a Clinical Health Status Evaluation, dated 02/18/22, which documented the resident required assistance with bed mobility, dressing, and personal hygiene. The resident had no history of foot ulcers or deformities. Review of the resident's EMR, under the Evaluations tab, included a Braden Assessment (determines the risk of developing pressure ulcers), dated 02/18/22, which placed the resident at risk of developing a pressure ulcer. The EMR lacked any other Braden Assessments. Review of the resident's EMR, under the Evaluations tab, revealed Skin & Wound Evaluations, which included: On 03/15/22 the resident had a facility acquired PU DTI (deep tissue injury) to his right heel, which measured 4.3 cm (centimeters) in length (L) by 4.1 cm in width (W). The wound had no tunneling (a wound that goes deep in the body and snakes through layers of tissue), depth or undermining (occurs when the tissue under the wound edges becomes eroded). Documentation lacked further description of the wound bed. The wound showed no signs of infection and no exudate. The peri-wound (skin surrounding the wound) was normal in color for the resident. Additional care included a cushion, foam mattress, and heel suspension protective boots (boots designed to keep pressure off of the heels). The staff notified the resident's physician, responsible party, Registered Dietician (RD), and therapy of the new wound. Review of the resident's EMR, under the Orders tab, included liquid protein supplement (a dietary supplement which provides increased protein), 30 milliliters (ml) three times a day (TID), dated 03/22/22. The order lacked documentation of a diagnosis. Staff were to ensure the resident wore off-loading boots (boots to keep pressure off) to his bilateral LEs at all times, to maintain skin integrity, dated 03/15/22, and paint the wound with an iodine swab twice daily (BID) for wound care, dated 03/15/22. Review of the resident's EMR, under the Evaluations tab, revealed Skin & Wound Evaluations, which included: On 03/22/22, the resident's wound measured 3.5 cm L by 3.4 cm W. The wound assessment lacked further description of the wound bed, peri-wound and surrounding skin. The wound was stable, but slow to heal. On 03/29/22, the resident's wound measured 4.6 cm L by 3.5 cm W. The wound assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/05/22, the resident's wound measured 4.8 cm L by 3.0 cm W. The wound assessment lacked further description of the wound bed. The wound was slow to heal. On 04/12/22, the resident's wound measured 2.4 cm L by 2.5 cm W. The assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/19/22, the resident's wound measured 2.5 cm L by 2.2 cm W. The wound assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/26/22, the resident's wound measured 3.5 cm L by 1.8 cm W. The wound bed had 100 percent (%) eschar, with no evidence of infection. On 05/03/22, the resident's wound measured 2.0 cm L by 2.6 cm W. The wound bed had 100% eschar, with no evidence of infection. On 05/10/22, the resident's wound measured 2.8 cm L by 1.0 cm W. The wound bed had 100% eschar, with no evidence of infection. On 05/17/22, the resident's record lacked an assessment for the wound. Review of the resident's EMR, under the Prog[[NAME]] Notes tab, on 05/17/22, included a nurses' note which documented the staff visually assessed the resident's wound during treatment. No changes were noted from the previous week. Documentation lacked measurements of the wound. On 05/23/22, the facility received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/24/22, the resident's wound measured 3.2 cm L by 2.6 cm L. The wound bed had 10% slough (A layer or mass of dead tissue separated from surrounding living tissue, often yellow in color) and 80% eschar. The wound had evidence of infection with increased redness, inflammation, warmth, and a moderate amount of seropurulent (containing both serum and pus) exudate. On 05/24/22, the facility received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's EMR, under the Orders tab, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's EMR, under the Orders tab, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's EMR under the Prog Notes, included: On 05/22/22, a Progress Note documented the wound bed had dark brown necrotic tissue with yellow edges. Documentation revealed staff notified Administrative Nurse D of the decline in the resident's wound. On 05/24/22, a Progress Note documented the right heel wound was extremely macerated (skin has been exposed to moisture for too long) and edematous (swollen) with an extremely foul odor and copious amounts of dark brown, dark yellow drainage. The wound bed was black in color with the right side of the wound noted to be yellow and white in color with raised edges. On 05/22/22 at 08:57 AM, the resident sat in his high back wheelchair with bilateral (both sides) air boots (boots made to off-load PUs on the heels) on. On 05/22/22 at 12:35 PM, Certified Medication Aide (CMA) S and Certified Nurse Aide (CNA) N used the mechanical lift (full body lift) to transfer the resident from his wheelchair to bed. Upon placing the resident in his bed, his heels rested directly on the mattress. On 05/23/22 at 10:11 AM, Licensed Nurse (LN) I entered the resident's room to perform care to the resident's right heel. The wound to the resident's right heel had black eschar, surrounded by maceration. The area was cleansed with normal saline (NS) and patted dry. LN I applied skin prep, covered the wound with a bordered dressing. No exudate noted at that time. On 05/23/22 at 01:30 PM, CMA S and CNA O transferred the resident from his wheelchair to his bed with the mechanical lift. CMA S cupped the resident's bilateral heels in her hands during the transfer, placing pressure directly onto the resident's heels through the air boots. On 05/24/22 at 07:47 AM, CMA T entered the resident's room to get him up for the day. The resident's heels, without air boots, rested directly on the mattress. There was a moderate amount of tannish, clear exudate (drainage) on the mattress beneath where the resident's heel rested. On 05/24/22 at 09:27 AM, the resident sat in the commons area. The air boot to his right heel moved slightly to one side, causing approximately 50% of the wound to be partially inside of the air boot, causing pressure to the wound. On 05/24/22 at 07:47 AM, the resident stated he was unable to move his legs much at all. On 05/23/22 at 01:30 PM, CNA O stated, the resident wore the boots due to a wound on his right heel. When staff put the resident to bed, they will prop his legs with a pillow in order to keep his heels off the bed. CNA O stated the resident was able to help staff with repositioning some, but was not able to keep his heels elevated on his own. On 05/24/22 at 07:47 AM, CMA T stated, the staff would elevate the resident's legs with a pillow to keep his heels off the bed. Staff turned and repositioned the resident every two hours. CMA T confirmed the resident's heels were resting directly on the mattress. On 05/24/22 at 07:50 AM, CNA Q stated, the resident's heels were to be elevated while in bed. CNA Q confirmed the resident's heels were resting directly on the mattress. On 05/24/22 at 07:50 AM, CNA O stated, the staff were to ensure the resident's heels were kept off the mattress. CNA O confirmed the resident's heels were resting directly on the mattress. CNA O confirmed there was a moderate amount of drainage on the sheet from the resident's right heel. On 05/24/22 at 02:58 PM, CNA M stated, staff needed to ensure the resident's heels were floating when he was in bed On 05/23/22 at 10:11 AM, Licensed Nurse (LN) I stated she had not seen the resident's wound in quite awhile. The last time she saw the resident's wound, it was closed, but the wound was now open. LN I stated she would notify Administrative Nurse D of the change in the resident's wound. On 05/24/22 at 12:30 PM, Administrative Nurse D stated, consultant staff HH had been consulted to see the resident, regarding the wound to his right heel. On 05/24/22 at 01:09 PM, consultant staff HH stated, she observed a photo of the resident's wound and ordered cultures and Santyl for the wound. Consultant staff HH stated she would look at the wound next week while doing rounds in the facility. On 05/25/22 at 03:30 PM, Administrative Nurse D stated, when the wound healing stalled on 05/03/22, the doctor should have been notified and a treatment change requested. The instrument used to measure the wound was not working on 05/17/22, so no measurements were taken. Administrative Nurse D stated she did not recall being notified of the decline in the wound of 05/22/22. Administrative Nurse D confirmed the area worsened and the wound nurse would not be able to see the wound until the following week, however, the wound nurse put in new orders. The facility policy for Skin Care Guideline, dated July 2018, included: The wound bed color and type of tissue will be documented weekly. If there was any deterioration of the wound status the staff would initiate comprehensive re-evaluation and notify the resident's physician and representative. The facility failed to ensure appropriate services to prevent the development and promote healing of this unstageable PU to this dependent R4's right heel.

The facility reported a census of 50 residents with 17 residents sampled, including three residents reviewed for pressure ulcers (PU). Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for two of the three sampled residents, including Residents (R)44, for failure to prevent the development of four stage II PUs, and R19 regarding the worsening of a PU. Findings included: - The Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for bed mobility. She was at risk for the development of pressure ulcers (PU), but had no unhealed PUs at the time of the assessment . She had a pressure reducing device for her chair and bed and was on a turning and repositioning program. She had limited range of motion (ROM) on both sides of her lower extremities. The Care Area Assessment for Pressure Ulcers, dated 01/24/20, documented the resident required total assistance with all cares and had a [DIAGNOSES REDACTED]. Staff were to turn and reposition the resident every two hours and as needed (PRN). The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for bed mobility and personal hygiene. She was at risk for the development of PU, but had no unhealed PUs at the time of the assessment . She had a pressure reducing device for her chair and bed and was on a turning and repositioning program. She had limited range of motion (ROM) on both sides of her lower extremities. The Pressure Ulcer Care Plan, dated 08/25/20, instructed staff to have the resident wear the gray multi-podus boots (boots used to help prevent the development of PUs) while she was in the wheelchair and the air boots while she was in bed. Review of the Evaluations tab in Point Click Care (PCC), an electronic documentation system, revealed Braden assessments (assessments used to determine the risk of skin breakdown) which revealed assessments completed on 12/11/19, 03/11/20, and 04/12/20, which placed the resident at a high risk for skin breakdown and an assessment completed on 08/27/20, which placed the resident at a severe risk for skin breakdown. Review of Skin and Wound Evaluation in PCC included the following documentation: On 8/28/20, Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) PU to the second toe of the right foot, measured 1.3 cm (centimeters) in length (L) by 0.8 cm in width and acquired in-house. Documentation lacked description of the wound bed, exudate (drainage), odor, and periwound (surrounding wound tissue). On 09/01/20, documentation revealed the Stage II PU to the second toe of the right foot, which measured 1.86 cm by 1.29 cm. The form also identified another new Stage II PU to the third toe of the right foot, which measured 0.9 cm by 0.7 cm, and developed in-house. The area had no exudate or odor and the periwound was discolored black/blue. Documentation lacked description of the wound bed. On 09/01/20, documentation revealed the Stage II PU to the third toe of the right foot, measured 0.96 cm by 0.64 cm . The form identified another new area, Stage II PU to the fourth toe of the right foot, which measured 1.2 cm by 0.8 cm, and developed in-house. The wound had no exudate or odor. The periwound was blanchable (when a patient's skin loses redness with pressure). Documentation lacked description of the wound bed. On 09/01/20 documentation revealed the Stage II PU to the fourth toe of the right foot, measured 0.79 cm by 0.59 cm. Stage II PU to the fifth toe of the right foot, measured 0.9 cm by 0.4 cm, acquired in-house. No exudate or odor. Periwound discolored black/blue. Documentation lacked description of the wound bed. On 09/01/20 documentation revealed the Stage II PU to the fifth toe of the right foot, measured 0.99 X 0.54 cm . Treatment orders, dated 08/27/20, instructed staff to cleanse the areas to the toes on the right foot with normal saline (NS) and apply a generous amount of [MEDICATION NAME] (antiseptic)., Leave open to air twice daily (BID) and every one hour, as needed (PRN), for blisters. Staff were also to administer Proheal (medical food developed for the dietary management of wounds and conditions requiring supplemental protein) 30 ml (millimeters), by mouth (po), BID; Vitamin C 500 mg (milligrams), po every day (QD); Multivitamin po, QD; and Zinc 220 mg, po QD. On 08/27/20 at 11:25 AM, the resident rested in bed bare footed. The resident had four open areas to the tops of her 2nd, 3rd, 4th, and 5th toes of her right foot. The open areas were dry and dark red. Physician SS came into the room to see the resident and stated, The areas are certainly pressure . On 08/31/20 at 07:10 AM, the resident rested in bed on the air mattress. The resident had on bunny boots (pillow cushioning boot with toes open) to her bilateral feet. The resident's right foot was partially out of the boot with the open areas of her toes/feet pushing up against the foot area of the boot. On 08/31/20 at 02:57 PM, Licensed Nurse (LN) G entered the resident's room to do a treatment for [REDACTED]. Staff G washed her hands with soap and water and applied gloves, cleaned the resident's wounds on the right foot with normal saline and patted dry with a guaze pad. Staff G then removed her gloves, washed her hands with soap and water, put on new gloves and then applied [MEDICATION NAME] to all four open areas, as ordered. On 08/31/20 at 04:30 PM, the resident rested in bed. The blankets covering the resident rested directly on the open areas of her toes. On 09/01/20 at 10:54 AM, Administrative Staff D, entered the resident's room to measure the areas on the resident's toes. The resident's right foot had come partially out of the boot with the open areas of her feet pushing up against the foot area of the boot . On 09/01/20 at 02:59 PM, the resident rested in bed. Her right foot was partially out of the boot with the open areas of her feet up against the foot area of the boot. On 08/31/20 at 007:13 AM, Certified Nurse Aide (CNA) M stated, staff attempted to keep the resident's toes open to air due to the pressure ulcers (PU) on her toes. The resident curled her toes so the boot did not stay in place on her foot and her toes would come to rest directly against the boot. On 08/31/20 at 02:03 PM, CNA O stated, the resident had PUs on her toes, but staff did not know how they occurred. She wore bunny boots while in bed with socks and the bed linens/blanket would rest directly on her toes. On 08/31/20 at 04:30 PM, CNA P stated she had been instructed to not put the resident's bunny boots or socks on her anymore while she was in bed. CNA P confirmed the blanket would rest directly on the open areas of the resident's toes. On 08/31/20 at 04:00 PM, LN G stated, the resident currently had four new PUs to the top sides of her toes. Staff were unsure of what caused the PUs to develop. On 09/01/20 at 10:15 AM, Administrative Nurse D stated, the resident had four new stage II PUs to her toes which developed on Thursday. Staff D stated the reason for the development of the PUs was due to the resident curling her toes when her socks were on. The intervention was to remove the resident's socks when she was in bed at night and the air boots were removed from the resident's room. Staff would continue to use the bunny boots while the resident was in bed. The facility planned to put a cradle (wire lifted device to keep bed linens/pressure off of the resident) on the resident's bed to prevent the blankets from touching the resident's toes, but therapy had not been notified about this yet . The facility policy for Skin Care Guidelines, dated July 2018, included: The facility will have a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care in disruption of skin integrity. The facility failed to ensure appropriate services to prevent the development of four stage II PUs on the tops of this dependent resident's toes. - The signed Physician order [REDACTED]. The Significant Change Minimum Data Set, dated dated [DATE], documented R19's cognitive status as moderately impaired. She was independent with bed mobility and transfer, had occasional pain, and did not have pressure ulcers. The Pressure Ulcer/Injury Care Area Assessment, completed 06/29/2020, documented R19 was at risk for pressure injury. The pressure ulcer care plan, revised 08/26/2020, instructed staff to perform weekly pressure ulcer monitoring and measurement. A physician's orders [REDACTED]. dressing was in place, every day. The Treatment Administration Record, (TAR) dated 08/01/2020 to 08/31/2020, lacked documentation of treatment to R19's coccyx on 08/26/2020. The TAR lacked documentation regarding monitoring of the coccyx dressing. The Progress Notes documented staff monitored the coccyx dressing on 08/08/2020 and on 08/15/2020. (R)19's Skin & Wound Evaluation dated 08/30/2020, documented a dressing was in place however, lacked the location of the wound. On 08/27/2020 at 03:21 PM, Licensed Nurse (LN) H uncovered R19 to check on the coccyx pressure ulcer. The coccyx pressure ulcer lacked a dressing. At the surveyor's request, LN H obtained measurements. The pressure ulcer measured 3.5 by 3.0 centimeters (cm). The surrounding tissue was without irritation or redness. On 08/31/2020 at 01:14 PM, LN G removed R19's coccyx dressing, dated 08/27/2020. Staff measured the redness around the open pressure ulcer and the redness measured 5.4 cm long by 8.0 cm wide. The redness above the wound remained completely red when LN G pressed on the surrounding tissue. Administrative Nurse D observed the area at this time. On 08/31/2020 at 04:40 PM, Administrative Nurse D verified staff lacked monitoring of the pressure ulcer since 08/01/2020, and reported staff should monitor the resident's skin ulcer weekly. Furthermore, the physician's orders [REDACTED]. The Treatment Administration Record, dated 08/01/2020 to 08/31/2020, documented staff provided treatment to R19's left elbow pressure ulcer up through and including 08/26/2020. On 08/27/2020 at 03:35 PM, R19's left elbow's dressing dated 08/26/2020. LN H stated the pressure ulcer was healed and the dressing was a protective barrier. On 08/31/2020 at 01:20 PM, upon request, LN G removed the dressing on R19's left elbow, dated 08/26/2020 (a total of four days later). LN G, and Administrative D, verified they thought the area was Healed. LN G measured the left elbow pressure ulcer as 0.9 cm by 1.0 cm wide. On 08/31/2020 at 04:40 PM Administrative Nurse D verified the resident's left elbow pressure ulcer had not been measured since 08/21/2020. She verified staff failed to monitor R19's pressure ulcers weekly, for improvement or worsening of the pressure ulcers. The facility's policy titled, Skin Care Guideline, dated July 2018, instructed staff to assess pressure ulcers weekly. The facility failed to appropriately assess and treat the resident's pressure ulcers on her coccyx and left elbow, to promote healing, and prevent further pressure ulcer development.

The facility reported a census of 50 residents with 17 residents sampled, including three residents reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for three sampled Residents (R)44, R 32 and R 6, to maintain or prevent decline in range of motion (ROM) ability. The facility failed to provide R44 with the planned restorative services for at least 10 months. R44's arms became tighter with contractures, with increased difficulty to dress, and the need for increased muscle relaxant medication from the physician. Findings included: - The Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for dressing and total assistance of one staff for personal hygiene. She had no impairment in functional range of motion (ROM) of the upper extremities and bilateral impairment in ROM of the lower extremities. She received passive range of motion (PROM) one day of the assessment period. The Care Area Assessment for Activities of Daily Living (ADL), dated 01/24/20, did not trigger for further review. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for dressing and personal hygiene. She had no impairment in functional range of motion (ROM) of the upper extremities and bilateral impairment in ROM of the lower extremities. She did not receive any restorative services during the assessment period. The Restorative Care Plan, dated 12/16/19 and revised 08/25/20, instructed the staff to perform PROM. review of the resident's medical record revealed [REDACTED]. The facility lacked documentation evidence of restorative services completed. Review of the resident's medical record in Point Click Care (PCC), an electronic documentation system, under the Progress Notes tab, revealed the following nursing documentation, dated 08/19/20: The resident was found to have redness to her axillaries (arm pits) with a foul odor, redness, and moisture. Staff were unable to fully assess due to the resident's rigidity and limited ROM. Review of the resident's medical record in PCC under the Progress Notes tab, revealed the following nursing documentation, dated 08/20/20: Staff observed the resident as appearing to be tensed up and rigid mostly in her upper extremities. Staff reported her rigidity was causing difficulty with all activities of daily living (ADLS), especially dressing and undressing. It was also difficult for staff to get her blood pressure due to the resident being tense. Nurse updated the daughter regarding the resident's status and the daughter would like to have the resident evaluated for therapy. Message sent to the resident's physician inquiring about further orders. Currently awaiting response from the physician. Review of the resident's medical record chart, behind the physician's orders [REDACTED]. Staff have difficulty dressing her and obtaining her blood pressure (BP). She was receiving [MEDICATION NAME] (a muscle relaxer medication) 4 mg (milligrams) twice daily (BID), as needed (PRN), but this does not seem to help. The physician responded on 08/21/20 with a new order for [MEDICATION NAME] 2 mg (milligrams) three times a day (TID), for rigidity and tight muscles. Review of the resident's medical record in PCC under the Progress Notes tab, revealed the following nursing documentation, dated 08/22/20: Contacted on call APRN (Advanced Practice Registered Nurse) and requested an order for [REDACTED]. APRN responded with a new order for [MEDICATION NAME] 150 mg, one time. On 08/26/20 at 08:51 AM, the resident sat in her geri-chair (high back specialized wheelchair). The resident's bilateral shoulders pulled up with her elbows and wrists contracted (abnormal permanent fixation of a joint). On 08/27/20 at 11:20 AM, Certified Nurse Aide (CNA) TT and CNA N positioned the resident in the bed. Staff have a difficult time straightening the resident's shirt due to her arms being held tightly against her torso and her elbows being difficult to open. On 08/31/20 at 07:13 AM, CNA M and Q dressed the resident for the day. Staff explained they have a difficult time getting the resident's shirt on due to her upper extremities being tight. On 08/31/20 at 09:53 AM, CNA M and Q lay the resident down following breakfast. Staff have a difficult time situating the resident's shirt due to her contracted upper extremities. On 08/31/20 at 07:13 AM, CNA M stated, the facility does not currently have a restorative aide. No restorative was being done with the residents. The resident had contractures in her shoulders and she had an odor in her arm pits. Staff were not able to get her arms moved out far enough to clean well in the resident's arm pits. The resident did not refuse cares. On 08/31/20 at 09:53 AM, CNA N stated the resident had contractures to her arms for a long time, however, her arms at the elbows have become much stiffer than they were before. Staff have a difficult time getting her shirt on and off and the resident had reddened areas in the crease of her elbow. The resident had become stiffer due to not receiving restorative care for at least 10 months, according to staff N. On 08/31/20 at 02:03 PM, CNA O stated, the resident has contractures which make it difficult for staff to get her shirts on and off. It takes two staff to get her dressed because of the contractures. Lately, she has been keeping her arms tucked in more tightly. Currently, no staff are doing restorative care. On 08/31/20 at 04:30 PM, CNA P stated, the resident was a lot stiffer lately in her arms and shoulders. It's difficult to get her arm pits and elbow areas clean. The resident did not refuse cares. On 09/01/20 at 07:30 AM, CNA Q stated, the resident's arms are tight which makes it difficult to get them pulled out far enough to get her shirt on. CNA Q stated she does not do ROM with the resident. On 09/01/20 at 02:55 PM, CNA MM stated, the resident was stiff and it was hard to get her clothes on and off. The resident did not refuse cares. On 08/31/20 at 04:00 PM, Licensed Nurse (LN) G stated she was not sure if restorative care was being done with residents or not. On 09/01/20 at 07:47 AM, Administrative Nurse E stated, currently there was no restorative taking place in the facility. Some residents have programs in place, including this resident, but nobody was working as a restorative aide at this time. Staff E was unsure of an exact date that restorative services were completed. On 09/01/20 at 01:53 PM, therapy staff NN stated, the resident received occupational therapy from 04/27/20 until 05/23/20 for bed and wheelchair positioning. When she came off of therapy, she was put onto a restorative program which was to include hip abduction, hip and knee flexion, ankle rotation, toe flexion and extension, hamstring stretch, finger and wrist flexion and extension, thumb flexion and extension, elbow flexion and extension, shoulder flexion and extension, neck rotation, and neck flexion. Staff were to complete these exercises at a minimum of three times a week by the restorative aide. On 09/01/20 at 10:15 AM, Administrative Nurse D stated, she did not believe the resident was becoming stiffer, but some of the staff thought she was getting stiffer. The facility had not had anybody doing restorative for at least 10 months. A message was left with the physician SS on 09/02/20, with no return call to date. The facility policy for Restorative Guidelines, dated 2019, included: Restorative services are used to assist the resident in reaching her highest level and then maintain the function. Measurable objectives and interventions must be documented in the care plan. The facility failed to provide restorative services as planned for at least 10 months for this dependent resident, causing her to decline in her range of motion ability, with increase difficulty in dressing, and the need for an increase in her muscle relaxant medication ordered from the physician. - The signed Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], revealed R32 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she had intact cognition. She had occasional mild pain. She used opioid (narcotic pain medication) four on the seven days on the look back period. The Pain Care Area Assessment, dated 12/19/12 did not trigger. The Quarterly MDS, dated [DATE], documented the resident had occasional mild pain and used opioid medication four days of the seven day look back period. The care plan, dated 08/19/2020, instructed staff that R32 was in the restorative nursing program for active range of motion to restore or maintain her level of function in both shoulders. Review of restorative electronic medical records revealed staff administered services for seven of the 31 days. On 08/26/2020 at 12:59 PM, the resident reported she had occasional pain in her shoulder and should have received exercises to help with the pain. It really gets stiff at times. I have not had anyone work on my shoulder for a long time. On 08/27/2020 at 08:06 AM, direct care staff QQ stated the resident does have stiffness in her shoulder. She verified staff failed to provide the resident exercise or restorative. On 09/01/2020 at 07:47 AM, Administrative Nurse E, stated there was no restorative services for the residents in the facility. There have been programs in place, but nobody is carrying out the plans currently. The restorative aide was not doing restorative as she was needed to work the floor as direct care staff. Administrative Nurse D are aware that there is no restorative services. On 09/01/2020 at 10:15 AM, Administrative Nurse D, stated the restorative aide is working the floor, instead of providing restorative services. The policy Restorative Guideline dated 2020, instructed restorative services was to assist the resident in reaching his/her highest level, and then maintain that function. Measurable, objectives and interventions must be documented in the care plan. The facility failed to provide appropriate restorative services to increase or maintain range of motion, for this resident who had shoulder pain, to prevent a decline in range of motion ability. - The signed Physician order [REDACTED]. functions, including blood pressure, heart rate, bladder function, and digestion), muscle contracture, muscle wasting, and generalized [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). The annual Minimum Data Set, dated dated [DATE], documented (R)6 was cognitively intact and had functional limitation in all his extremities. He required staff to feed, dress, toilet, transfer, and bathe him, as well as to perform his personal hygiene and move him in bed . The ADL (Activity of Daily Living) Functional /Rehabilitation Potential Care Area Assessment (CAA), dated 06/05/2020, revealed (R)6 was quadriplegic and required total dependence of staff for all his cares. The current Care Plan instructed staff to perform Passive Range of Motion (PROM (amount of motion at a given joint when the joint is moved by an external force) for his Restorative program. The care plan lacked guidance for the resident's individual range of motion program. A Progress Note, located in the electronic medical record (EMR), dated 04/22/2019, documented a Passive Range of Motion Program that required staff to exercise his arms and legs for 15 minutes a day, for three to six days, each week. On 08/31/2020 at 07:58 AM, Certified Nurse Aide (CNA)N reported the facility lacked a restorative aide since October 2019 ( a total of 10 months), related to the restorative aide was Pulled to work the floor as a CNA. On 09/01/2020 at 07:47 AM, Administrative Nurse E reported the facility lacked restorative services for the residents of the facility. There were programs in place previously, however nobody (staff) carried out the restorative programs. The restorative aide was unable to perform restorative as restorative staff were Needed to work on the floor as a CNA. On 09/01/2020 at 10:15 AM, Administrative Nurse D verified the facility failed to have residents participate in a restorative program. On 09/01/2020 at 01:53 PM Consultant NN explained that (R)6 required staff to perform exercises to his hips, knees, ankles, toes, shoulders, elbows, wrists, fingers, thumbs, and neck. (R)6 was unable to feel ort move himself due to his spinal cord injury, he was at risk for contractures (abnormal permanent fixation of a joint) and required the exercises to help with his blood flow as well as to maintain his skin integrity. The facility policy for Restorative Guidelines, dated 2019, included: Restorative services are used to assist the resident in reaching her highest level and then maintain the function. Measurable objectives and interventions must be documented in the care plan. The facility failed to provide appropriate restorative treatment and services to maintain range of motion, for this dependent resident who had no movement to his extremities, to prevent further contractures.

The facility reported a census of 54 residents. Based on observation, record review, and interview, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of Coronavirus (COVID-19). The facility failed to perform appropriate staff screening that included temperature screening on 42 occasions, including staff that worked facility wide. In addition, staff entered the building and worked on four occasions with staff temperatures 100.0-degree Fahrenheit or greater, from 03/16/2020 to 06/11/2020. The failure to perform appropriate staff screening increased the risk of transmission of the pandemic Coronavirus (COVID-19) to the vulnerable residents of the facility, placing the residents in immediate jeopardy. Findings included: - Review of the facility's Coronavirus (COVID-19) Essential Visit (Facility) Team Member Log, from 03/16/2020 to 06/11/2020, revealed the following areas of concern: From 03/16/2020 - 03/31/2020, staff lacked temperature screening on 17 occasions, that included nursing, maintenance, and administrative staff. In April 2020, staff lacked temperature screening on four occasions, which included nursing and housekeeping staff. Furthermore, on 04/03/2020, one staff member had a documented body temperature of 100.0-degree Fahrenheit (F). On 04/16/2020, one staff member had a documented body temperature of 100.0-degree F. On 04/21/2020, one staff member had a documented body temperature of 100.2-degree F. Review of the daily staffing revealed these three staff members remained in the building and worked with the above temperatures. From 05/01/2020 - 05/16/2020, nursing staff lacked any temperature screening on 22 occasions. In addition, on 05/19/2020, one staff member had a documented body temperature of 100.4-degree F, and the daily staffing revealed the staff member remained in the building and worked the shift. Observation on 06/15/2020 at 08:37 AM, revealed Licensed Nurse (LN) G arrived at the front entrance, entered the building after another staff member opened the door for her, and LN G filled out her questionnaire, self-obtained her temperature, and documented the screening onto the Essential Visit-(Facility) Team Member Log. The Coronavirus (COVID-19) Essential Visit-(Facility) Team Member Log, contained areas for entry date, time, name, contact with COVID-19, respiratory illness, international travel in previous 14 days, traveled on cruise ships within last 14 days, temperature, symptoms of cough, shortness of breath, sore throat, and if staff completed handwashing. On 06/15/2020 at 03:00 PM, Administrative Nurse G, identified herself as the infection control nurse. Administrative Nurse G reported the staff should complete the Coronavirus (COVID-19) Essential Visit-(Facility) Team Member Log, screening tool before starting on their shift. She randomly monitored the screening log for omissions in documentation. On 06/15/2020 at 02:38 PM, Administrative Nursing Staff D, stated staff enter the healthcare facility, answer the questionnaire, and obtain their own temperatures prior to their shift. She stated every staff member received training on Coronavirus (COVID-19) Essential Visit-(Facility) Team Member Log, screening and verified she randomly reviewed the questionnaire. She verified the log lacked temperature monitoring as identified above. Staff that had a temperature of 100.0-degree F or greater should not be allowed to enter the building to work. She verified maintenance, housekeeping and administrative staff worked facility wide, and every staff member should self-screen and document the questionnaire before their shift starts. The facility's policy for COVID-19 Education, Prevention, and Response Guide, dated May 2020, documented in alignment with CDC's Interim guidance . included team members should continue to be screened at the start of their shift and report temperature and absence of symptoms prior each day to starting work. Healthcare workers included the facility's team members, agency healthcare workers, other healthcare practitioners such as hospice providers, surveyors, Emergency Medical Staff (EMS) personnel . Screen temperature and document. Staff that had a temperature above 100-degree Fahrenheit would not be permitted to enter. For team members, actively screen the individual for cough or shortness of breath, or at least two symptoms of fever, repeated shaking with chills, headache, new loss of taste or smell, diarrhea, chills, muscle pain, sore throat, and/or vomiting The facility failed to perform appropriate staff screening that included lack of body temperature screenings on 42 occasions, including staff that worked facility wide. In addition, staff entered the building and worked on four occasions with staff temperatures 100.0-degree F or greater, from 03/16/2020 to 06/11/2020. On 06/16/2020 at 11:30 AM, Administrative staff A and Administrative Nurse D were informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to perform appropriate staff screenings that included lack of body temperature screenings on 42 occasions, including staff that worked facility wide. In addition, staff entered the building and worked on four occasions with staff temperatures of 100.0-degree F or greater, from 03/16/2020 to 06/ 0. The facility provided an acceptable plan of removal of the immediate jeopardy on 06/16/2020 at 10:05 PM. The plan included: 1. All team members currently in the building screen was completed on 06/16/2020 prior to working. 2. Team members educated on infection control, handwashing and donning and doffing on PPE on 06/16/2020. at 10:05 PM. 3. Team members educated on appropriate screening and inability to work if temperatures at or above 100.0 degrees F and essential visitor screening on 06/16/2020,or prior to working at 10:05 PM. 4. Remaining staff would be educated on infection control, handwashing, donning and doffing, screening process prior to returning to work. Systematic Education Completed: 1. Team member will be assigned to door and responsible for screening during their assigned times. 2. Designated nursing staff (DNS) or designee would review screening logs daily to ensure they were completed and met the entry guideline. 3. Results of audits will be discussed in daily start up and then in QAPI (Quality Assurance & Performance Improvement) with follow up as needed. QAPI: 1. A focused QAPI meeting addressing the finding was initiated and completed on 06/16/2020 at 05:15 PM with the attendance of the Administrator, DNS and Medical Director. 2. Ongoing audits will be performed on staff screening. The survey team validated the immediate jeopardy removal on 06/17/2020 at 11:18 AM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of an F.

The facility reported a census of 58 residents, with 3 sampled for accidents. Based on observation, interview and record review, the facility failed to provide safe facility van transportation for 1 (#01) of the 3 sampled residents that utilized the facility van. During a transport for resident #01, the driver forcefully applied the brakes, to prevent a collision. The resident's lap and shoulder restraint belt on the wheelchair, became unhooked from the floor track, which allowed the resident to fall forward out of the wheelchair and hit the floor of the van head first. The resident sustained [REDACTED]. Findings included: - The medical record evidenced the facility readmitted resident #01 on 12/3/18. The resident's primary care physician listed [DIAGNOSES REDACTED]. The 1/23/19 annual MDS (minimum data set) assessment scored the resident with 15/15 on the brief interview for mental status, demonstrating cognition intact. The resident required supervision and limited assist with all activities of daily living. The resident had not experienced any falls since admission. The CAA (care area assessment), dated 12/10/18 for activities of daily living included, readmitted into facility for [MEDICAL CONDITION]. He/she required assist with his/her ADLs (activities of daily living) and will stay long term care at this time. He/she uses a wheelchair for his/her primary mode of locomotion and was able to wheel around the facility with supervision. The 4/15/19 plan of care included, the resident was primarily mobile per wheelchair and could propel it by his/herself. The facility self-investigation documentation included, on 4/22/19, administrative staff A was transporting resident #01 to a doctor's appointment in the company van. Prior to leaving the facility parking lot, staff A secured the passenger facing forward in the van with wheelchair anchors to the floor on each side and with a shoulder and lap seat belt attached in the floor track. Seventy miles into the transport, on a busy highway, administrative staff A had to apply the brakes due/to an oncoming, tractor/trailer in the van's lane. At that time, the seat belt became unhooked and the resident fell out of the wheelchair onto the floor of the van. The driver immediately pulled over and called 911 for assistance. The EMS (emergency medical service) arrived and assessed the resident. It was determined the resident needed some stitches and the resident declined the EMS transport. Staff A transported the resident back to the facility in the van. Upon post-accident investigation, the facility determined that the van floor debris caused the anchor to not fully click into the floor track to secure the should/lap belts. Facility nurse B assessed the resident and noted left shoulder pain and facial pain; with a laceration above the right eye brow 2 cm (centimeter) x 1.5 cm.; a skin abrasion to the right cheek, 4 cm x 2.5 cm along with bruising; a laceration 1 cm x 0.1 cm by the right nostril; abrasion to the right knee, 1 cm x 1 cm; and a skin tear to the right hand between the index and middle finger, 0.5 cm x 1 cm. The resident transported to the hospital by ambulance. The resident returned to the facility, with [DIAGNOSES REDACTED].M. On 5/2/19 at 10:30 A.M., administrative staff A provided a copy of the facility Vehicle Safety Program Guidelines for Vans and all passenger vehicles, dated 6/19/13. However, the administrator failed to provide any documentation of van maintenance including cleaning of the floors and checking for debris in the safety tracks and inspections. The CT (compound tomography) scans, dated 4/22/19 report included: 1). Slightly depressed fracture involving the anterior wall of the right maxillary sinus with slightly depressed fractures of the posterior lateral walls of the right maxillary sinus. Hemorrhage within the right maxillary sinus is seen. Soft tissue swelling within the periorbital region on the right as well as the facial soft tissues, on the right. On 5/2/19 at 9:15 A.M., Administrative staff A commented that it must have been dust or debris in the floor hook track that caused the shoulder/lap seat belt anchor to dislodge from the floor track. He/she verified each driver was to clean out the van after each transport. On 5/2/19 at 1:15 P.M., vehicle dealership maintenance supervisor C reported the shop staff evaluated the facility van on 4/22/19 at 4:08 P.M. The inspection of the front and rear seat belts and tracks all passed inspection at that time and there was no mechanical failure related to the actual van equipment itself. On 5/2/19 at 9:00 A.M., the resident self-propelled his/her wheelchair in the hallway of the facility. He/she reported being positioned in his/her wheelchair, with the seat and shoulder belt in place, behind the van driver and being sleepy, during the transport to his/her doctor's appointment on 4/22/19. The next thing he/she knew, was being on the floor of the van. He/she verified telling everyone at that time, I'm fine. The resident verified they took him/her to the hospital when x-rays were taken and a few stitches were put in his/her forehead. The resident's forehead displayed stitches in place and with some bruising on the right side of the forehead. The facility van policy and procedure, dated 6/19/13, included administrative issues, driver selection, driver education and training, operation of all company vehicles, vehicle maintenance and vehicle accidents. The plan also addressed visual pre-trip inspections to include cleanliness in the floor tracks to secure the shoulder/lap seat belts. The facility failed to ensure no build-up of debris, in the tracks to secure the wheelchair residents' shoulder/lap belt, remained intact, and the resident's shoulder/lap belt became unhooked, the resident fell to the floor, and experienced, bruises, skin tears and lacerations to the face which required sutures to close. The facility was cited as past non-compliance, as of 4/22/19 at midnight, after the facility took immediate action including: 1). The facility took the van out of service for a safety check. Staff cleaned out the floor tracks of the interior of the van to prevent potential securing issues. 2). QAPI meeting was held on 4/22/19 at 3:30 P.M., including the medical director. 3). Transportation team members were re-educated regarding vehicle safety program guidelines for van and passenger vehicles. Team members were observed during hands on competency training of securement for transports. Pre-trip inspections and check list were implemented to include cleanliness of the floor tracks. 4). Administrator or designee to observe transportation team member properly secure wheelchair for transport twice monthly for three months, including checking the cleanliness of the floor tracks. 5). All staff were re-trained regarding abuse, neglect and exploitation on 4/22/19. Those unable to be contacted would be trained before they returned to duty in the facility.

The facility reported a census of 56 residents. The 20 residents selected for sample review included 2 reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure the 2 of 2 sampled residents (#44 and #209) received adequate supervision and assistive devices to prevent accidents. Resident (#209), on 2/26/19, received 3 fractured ribs, and a compression [MEDICAL CONDITION] (spine/back area) related to the facility failure to maintain the resident's bed in the lowest position, as planned, and the lack of effective assistive devices to prevent the resident's falls from the bed. Findings included: - Resident #209's, signed physician orders, dated 3/6/19, documented the resident readmitted on [DATE], with the following Diagnoses: [REDACTED]. failing memory, confusion) without behavioral disturbances, [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. The quarterly MDS (minimum data set), dated 1/17/19, revealed the resident had a BIMS (brief interview for mental status) score of 3, indicating severely impaired cognition. The resident had fluctuating inattention and disorganized thinking. The resident required extensive staff assistance for bed mobility, transfers, and toilet use. The resident's balance was not stable, and was unable to stabilize balance without staff assistance, moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers. The resident without functional limitations in range of motion and required a wheelchair for mobility. The resident had 1 non-injury fall. The significant change MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderately impaired cognition. The resident had fluctuating inattention. The resident required total staff assistance for bed mobility, transfers, locomotion, and toilet use. The resident with functional limitation in range of motion to both lower extremities and required a wheelchair for mobility. The CAA (care area assessment), dated 2/7/19, for falls advised the resident would not have any injuries from a fall. The resident's fall assessments, dated to 10/24/18, scored 16, and dated 3/4/19, scored 14, with a score of 10 or more, indicating at high risk for falls. The care plan last reviewed on 1/7/19, identified the resident at a moderate risk for falls related to confusion, and gait/balance problems. The following interventions were in place: Ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. On 12/26/18: Toilet seat riser placed, transfer pole in bathroom, PT/OT (physical therapy/occupational therapy) to evaluate and treat. Orthostatic blood pressure obtained for 48 hours. Further care plan additions included: On 2/7/19: Use a wheelchair for mobility and propelled by staff. Bed mobility: The resident was totally dependent on 2 staff for repositioning and turning in bed every 2 hours and as necessary. The resident required transfers with a Hoyer (mechanical) lift with 2 staff for assistance. On 2/8/19: Anti-roll bars on the wheelchair for safety. Keep bed in the lowest position. On 2/26/19 actual fall: Upon return from the hospital: place a regular mattress on the floor at bedside. PT/OT to evaluate and treat as indicated. Bed to be in the in low position. Date Initiated on 3/8/19. (However, the care plan initially added the intervention to keep the resident's bed in the lowest position on 2/8/19, then repeated the same intervention for the bed to be in the low position, after the 2/26/19 fall. At the time of the resident's fall on 2/26/19, the resident's bed was not in the lowest position, per record review of the facility investigation, fall huddle worksheet, and staff interviews as follows.) The progress note, dated 2/26/19 at 9:00 AM, documented at 6:00 AM, this nurse heard the resident holler out, upon entering the resident's room, the resident was lying on his/her stomach next to the bed on the floor with his/her head at the foot of bed. The resident was unable to state what happened. This nurse along with the prior shift nurse log rolled (rolled as one unit together) the resident over onto his/her back. The resident without contusions (injury to tissue, or bruising) to his/her face. The resident complained of severe back and face pain. Neuro checks initiated, and the resident with bilateral hand grasps, and sluggish pupil response. Staff obtained the resident's vital signs and the resident had a blood pressure of 170/140 (very elevated, norm 120/80). Staff called 911 and the resident transferred to the hospital emergency via EMS (emergency medical services) at 6:10 AM. The intervention for the fall was as follows: fall mat beside the bed, and staff education to keep the bed in the lowest position. The nurse progress note, dated 2/26/19 at 9:41 AM, documented the hospital called and reported the resident admitted to the hospital for pneumonia, UTI (urinary tract infection), L1 (back/spine fracture) fracture, and left rib fracture. The result of a CT (X-ray image made using a form of tomography) of [MEDICATION NAME] spine (upper/midback of spine) dated 2/26/19, documented the resident had a compression [MEDICAL CONDITION] (back) of unknown age. There was also a non-displaced rib [MEDICAL CONDITION] sixth rib. The result of the CT of the resident's head or brain without contrast, dated 2/26/19, documented no acute abnormality. However, the result of a Chest X-ray dated 3/1/19, documented visualization of displacement of rib fractures on the left, with 2 additional rib fractures (7th and 8th) not seen on the previous CT [MEDICATION NAME] spine study. The resident's fall huddle worksheet (completed by staff following the resident's fall), dated 2/26/19, documented the bed was not in the lowest position; the bed height was not correct, the floor strips next to the bed utilized; and the resident had on non-skid socks. The intervention was for a fall mat at the bedside and to educate the staff to have the bed in the lowest position. The facility investigation, dated 2/26/19, provided by the facility staff, revealed an immediate intervention to replace the air mattress with a regular mattress, reminded staff that the bed was to remain in the low position, the bed replaced with a high/low bed, and continue with the fall mat next to the bed upon return from the hospital. This investigation did not include anything about the height of the resident's bed when the staff found the resident on the floor. Interview, on 3/13/19 at 3:20 PM, administrative nursing staff B stated staff notified him/her of the resident's fall on 2/26/19. It was his/her understanding administrative staff A came into the facility within 1-1 1/2 hours and measured the height of the bed. Staff A told staff B the resident's bed was maybe 1-2 inches from being in the lowest position. Staff B confirmed the investigation did not reflect this information and he/she was not aware of where staff documented the information. On 3/13/19 at 3:35 PM, administrative staff A explained he/she came to the facility 1 to 1 ½ hours following the resident's fall on 2/26/19 and measured the bed and it was maybe 1 to 2 inches from being in the lowest position. He/she verified the failure to document these findings in the facility investigation. And asked for the facility investigation back and in approximately 1 and ½ hours later returned the investigation. The facility investigation summary, at that time, documented in the summary, which lacked a date of or time of when the staff measured the bed or the update to the investigation. It did lack the information that the resident had an air mattress at the time of the fall from the bed. On 3/13/19 at 2:12 PM, direct care staff J stated the care guide informed the staff what care the resident required, was located at the nurses' desk, and updated routinely. The resident had moments of confusion and was a fall risk. The resident required 1 staff to transfer and fed himself/herself. Then the resident declined using a Hoyer lift due to his/her foot (directed by physical therapy) before he/she (fell ) and went to the hospital. Direct care staff J was not sure if the resident had a fall mat before the fall (on 2/26/19), however he/she had a fall mat or mattress after the fall (2/26/19) After the fall (2/26/19) the resident required total care assistance from staff. The bed rail was to be up, and the bed was to be kept in the lowest position. Then an added intervention was the resident was to be the first one up. On 3/13/18 at 2:39 PM, direct care staff X stated before the fall the resident did have periods of confusion. The resident was a 1 to 2 person transfer at the most, then the resident became a Hoyer lift due to an area on his/her heel. The resident was a fall risk, he/she had falls before. The bed was usually in the low position, but staff X did not know if it was the lowest position (on 2/26/19). After the resident fell (on 2/26/19) and he/she came back from the hospital, confused, and with a decline. The resident fell out of the bed a couple of times since then. The resident now had a scoop mattress, a fall mat (not a regular mattress as care planned), and side rails. He/she would inform the staff of any intervention, place interventions in the fall book, on the care guide and on the care plan. On 3/14/19 at 11:02 AM, direct care staff K explained the day of the resident's fall, on 2/26/19, he/she checked on the resident and found the resident asleep around 5:30 AM. The resident had a low air loss mattress, side rails, and an older style crank bed. The bed was not in the lowest position but was left up high enough, so staff could get the Hoyer lift under the bed. The resident before the fall was more alert, but now he/she could not focus, and the resident declined since the fall. On 3/14/19 at 10:34 AM, licensed nursing staff E stated when he/she worked the staffing was usually 1 nurse, 1 direct care staff, and a direct care staff who would float, however that night (2/26/19) it was himself/herself and 1 direct care staff. He/she was at the desk that morning and he/she went down the hall and found the resident on the floor, face down. There was not a fall mat beside the bed. That night was relatively busy. The last time he/she went by the resident's room (approximately 4:30 AM), the bed was not in the lowest position. On 3/14/19 at 11:18 AM, licensed nursing staff F stated when he/she came to work the morning (of 2/26/19), he/she heard the resident hollering out. Went to the resident's room and found the resident lying face down next to the bed, his/her head was at the head of the bed. The resident's bed was not in the lowest position, it was approximately waist high (approximately 36 inches). The resident had declined since he/she came back (3/4/19) from the hospitalization from the fall. The progress note, dated 3/4/19 at 8:03 PM, documented the resident arrived via facility vehicle and readmitted at 10:25 AM. The resident [DIAGNOSES REDACTED]. The resident required staff assistance of 2, for transfers with a Hoyer lift, and PT/OT were to evaluate and treat the resident. Staff placed a fall mat next to the resident's bed which was in the lowest position. Furthermore, a progress note, dated 3/5/19 at 9:56 AM, documented that at 6:40 AM, direct care staff notified the nurse the resident fell . Upon entering the room, the resident was lying on the mattress next to his/her bed. The resident's head was hanging off the mattress between the mattress and bedside table. The staff repositioned the resident from the mattress onto the floor, with 3 staff assistance. The staff assessed the resident without injuries. The resident called out 1 time when log rolled onto his/her left side. After returning the resident to his/her back, the resident stopped hollering out. Staff dressed the resident and transferred him/her to a wheelchair with the 3 staff assistance and the Hoyer lift. The progress note, dated 3/5/19 at 1:15 PM, documented the resident continued with skilled charting for PT and OT. The resident had continual confusion, grabbing at the air and calling out different peoples' names. When the resident asked what he/she was grabbing at, the resident was unable to communicate to this nurse. The resident responded to name but did not answer any other questions. Further care plan additions included: On 3/5/19 actual fall: 1/4 side rails, scooped mattress, PT/OT to evaluate and treat. Date Initiated on 3/6/19. (However, PT/OT to evaluate and treat was already initiated following the fall on 2/26/19, to initiate on 3/8/19.) The fall intervention update book, dated 3/5/19, documented the resident was getting out of bed unassisted, and the new intervention instructed the staff to prevent further falls to use a scoop mattress and quarter side rails. In addition, a progress note, dated 3/6/19 at 1:57 PM, documented that at 7:10 AM, the direct care staff notified the nurse the resident was lying on the mattress next to the bed. Upon entering the resident's room, the resident was lying on a mattress on the floor with his/her head by the east wall and was lying on his/her right side. The resident tinkered with the bed control cord. The resident wore an incontinent brief, gown, and non-skid socks. The resident lacked facial grimacing or moaning and was found without injury. Three staff transferred the resident with a Hoyer lift to a shower chair for a shower. The resident did not exhibit any signs or symptoms of pain or discomfort during the transfer. The fall intervention update book, dated 3/6/19, identified the resident was attempting to get out of bed unassisted and the intervention instructed the staff that the resident was to be the first resident up in the AM and staff requested (diagnostic) labs. The resident's care plan added, on 3/6/19 actual fall: The resident to be the first up in the morning. The care giver information sheet (small care plan for direct care staff), dated 3/13/19, advised the staff the resident was currently totally dependent on the staff for ADL's (activities of daily living); required staff to reposition him/her every 2 hours; a cushion in the wheelchair; incontinent and to check and change him/her every 2 hours. The resident was a fall risk; used anti-roll bars to the wheelchair, a low bed, and a fall mat beside the resident's bed. The progress note dated 3/8/19 at 2:18 PM, documented facility staff received the following orders from the physician for the resident's reported increase in confusion, and inability to communicate with staff; CBC (a complete blood count), CMP (complete metabolic panel), due to the change in the resident's mental status. The physician also documented the confusion was most likely due to the resident's narcotics which he/she now took for pain, which was causing the increased confusion on top of the resident's already severe dementia. Observation on 3/13/19 at 9:01 AM, revealed direct care staff L with the Hoyer lift in place and waiting for another staff member for assistance. The resident had drool from his/her left side of the mouth and making nonsensical noises. Direct care staff I and staff L transferred the resident from the wheelchair to the bed. The resident's bed contained a scoop mattress. The staff removed the lift sling and repositioned the resident to the left side, with 2 pillows placed behind his/her back. The floor beside the bed had non-skid strips. The resident's eyes opened during the transfer and positioning. The head of the bed slightly elevated and the staff then lowered the bed to the lowest position, put the side rail in the up position, and placed a fall mat on the floor instead of a regular bed mattress as care planned. (The facility added the intervention of a scooped mattress after the resident with fractures). On 3/13/19 at 1:51 PM, the resident was resting quietly in the bed with eyes closed on his/her back with the bed in the lowest position, and a fall mat (not a regular bed mattress) was beside the bed on the floor. The side rail was up on the left side of the resident's bed. On 3/13/19 at 3:49 PM, direct care M and staff P went into the resident's room. The resident rested in the bed with noted left side facial drooping. Staff checked the resident for urinary incontinence and provided peri care provided for the resident. At 4:04 PM, staff M and P provided the resident with oral care and then lowered the bed to the lowest position, and placed the fall mat (not a regular bed mattress) beside the bed, then the staff exited the resident's room. On 3/14/19 at 1:15 PM, the resident rested quietly in the bed with eyes closed. The bed was in the lowest position but at that time, a regular bed mattress was on the floor beside the bed. The side rails were in the up position, and a scoop mattress on the bed. The resident's sheet was half off his/her legs with his/her left leg over the right knee. Direct care staff X stated the resident did not get out of bed today. Staff X further explained the regular mattress on the floor beside the bed supposed to be a regular mattress and not a fall mat as he/she was previously told. Interview, on 3/13/19 at 10:03 AM, direct care staff I stated the resident would talk and joke around with staff. When the resident came back from the hospital (on 3/4/19) the resident was maybe a little more alert than what he/she was now. On 3/13/19 at 1:53 PM, licensed nursing staff C stated the resident previously to the fall (on 2/26/19) would propel himself/herself in a wheelchair. The resident's mental state was different than what it was now. The doctor thought it was dementia and the [MEDICATION NAME] medication (pain narcotic medication) because he/she did not have pain medication before that fall. The resident was having a slow decline, staff could understand what he/she was saying before the fall. The resident was on a low air loss mattress. After the fall (on 2/26/19) the resident had confusion and restlessness, with fractured ribs and lumbar 1 compression fracture. The staff called and asked for some labs due to mental changes and the doctor said it was most likely due to dementia and [MEDICATION NAME] use. The facility fall policy, dated 4/17, documented to establish a process that identified risk and established intervention to mitigate the occurrence of falls. The IDT (interdisciplinary team) reviewed post fall investigation and summarized the team recommendations. If there are multiple falls, staff routinely monitored for implementation of interventions. The facility failed to provide adequate supervision and assistive devices to prevent falls for this resident, when the facility failed to ensure the resident's bed remained in the lowest position as planned. The cognitively impaired dependent resident fell from the bed, on 2/26/19, and sustained fractures to his/her L1, and fractured 3 ribs. Furthermore, the facility failed to implement effective fall interventions and the resident experienced 2 more falls on 3/5/19 and 3/6/19. - Resident #44's, signed physician orders, dated 3/8/19, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 1/3/19, revealed the resident had a BIMS (brief interview for mental status) score of 8, indicating moderately impaired cognition. The resident with a mood score of 4, which indicated minimal mood and/or depression. The resident required extensive staff assistance for bed mobility, transfers, locomotion, and toileting ; limited staff assistance for walk in room. The resident's balance not steady and only able to stabilize with staff assistance for moving from a seated to standing position, walking, moving on and off the toilet, and surface-to-surface transfer; and the resident required a wheelchair for mobility. The resident frequently incontinent of bowel and bladder. The resident without pain; with shortness of breath or trouble breathing with exertion and when lying flat. The resident with a non-injury fall since admission. The resident received occupational therapy (OT) for 205 minutes for 5 days, with a start date of 12/28/18; physical therapy (PT) for 175 minutes for 4 days with a start date of 12/28/18. The CAA (care area assessment), dated 1/9/19, for falls documented the resident was weak, unsafe during transfers, and does not cognitively remember he/she was not safe, and would attempt to transfer himself/herself without assistance and fall. The quarterly MDS, dated [DATE], revealed the following changes from the admission MDS, dated [DATE] only: the resident had a BIMS score of 13, indicating intact cognition. The resident did not walk in room; and required extensive staff assistance for locomotion. The resident's balance was not steady, only able to stabilize with staff assistance moving from seated to standing position. The resident with vomiting, and with 1 non-injury fall since last assessment. The Fall Assessment, dated 12/27/18, with a score of 17, a score of 10 or more, represents the resident was high risk for falls. The 12/28/19, baseline care plan documented the resident had been living at home, and planned to discharge to home. The resident for safety issues advised the resident with a history of falls, with an initial goal to remain free of falls. The resident required a wheelchair for mobility, and received OT/PT services. The base line care plan on the EMR (electronic medical record) was still in progress. The care plan for falls initiated on 3/13/19, documented the following: The resident was at risk for falls related to the resident fell in the past 30 days, with a history of falls, and required staff assistance of 1 for transfers with the following interventions: * On 2/22/19: Actual fall. The resident found sitting beside his/her bed, the wheelchair was not locked. Date Initiated: 03/13/2019 * On 2/22/19: staff and resident reminded to lock wheelchair brakes, offered a snack and with recent orders for PT/OT. Date Initiated: 03/13/2019 * Appropriate footwear: shoes or non-slip socks to be worn. Date Initiated: 03/13/2019 * Staff to assist the resident into recliner when the resident in the living room/lobby. Date Initiated: 03/13/2019 * The resident transfers with staff assist of 1. Date Initiated 3/13/19. The comprehensive care plan not completed in the 21 days required. The CNA (certified nurses aide) care guide dated 3/13/19, advised the resident was a fall risk and to assist the resident to the recliner when noted to be in the living room/lobby area. Ensure the resident was wearing the proper foot wear and the call light was within reach. The resident required limited to extensive staff assistance of 1-2, and stood best when using a walker to help. The resident was occasionally incontinent and used a urinal. The resident wore a incontinent brief and would call for staff assistance as needed. The resident was a check and change every 2 hours during the night and prn. The progress note, dated 12/28/18 at 6:11 PM, documented a fall without any apparent injury. The resident was attempting to transfer himself/herself without staff assistance. The resident was a recent admission to the facility. This nurse was at nurse's desk when he/she heard a small commotion in lounge/lobby area, and looked up in time to see the resident slide to floor. The resident was attempting to transfer from his/her wheelchair to a recliner without staff assistance. The resident's wheelchair parked with the wheels locked, placed to the left of the recliner, but when the resident went to transfer he/she turned all the way around, then slid down recline. The resident was fully dressed in personal clothing with non-skid socks on. The resident denied any pain, and without injury. The resident did not hit his/her head. The resident was alert at the time, and able to explain what he/she was trying to do. The resident reminded to ask for help prior to any transfers, and expressed understanding. The fall intervention update book, dated 12/28/18, identified the resident was transferring himself/herself to the recliner in the living room without staff assistance, and misjudged the distance. The new intervention to prevent further falls was staff educated to assist the resident to the recliner when noted to be in the lobby. The resident educated to ask for assistance with transfers. The progress note, dated 1/14/19 at 8:51 AM, documented at 8:20 AM, direct care staff alerted this nurse that the resident fell . The fall was unwitnessed by the staff. The resident was lying on his/her back on the floor in the lobby area, with his/her head up against a recliner in the living room, and his/her feet in front of the toward the north. The resident's glasses were observed approximately a foot away, and the wheelchair was observed approximately 3 feet from recliner by resident's feet. The resident wore appropriately fitting clothing, and shoes. The resident stated he/she was transferring himself/herself from the wheelchair to a recliner when the wheelchair tipped over and he/she fell to his/her left side. The wheelchair was observed in an upright position. The resident denied pain or discomfort, and transferred with 2 staff assistance to the recliner. The intervention was for anti-roll bars to the wheelchair, and educate staff to assist resident to bathroom and recliner after meals. The fall intervention update book, dated 1/14/19, identified the resident transferred himself/herself from the wheelchair to the recliner. The new intervention to prevent further falls was anti-roll bars on the wheelchair, educate the staff to toilet the resident and transfer him/her to the recliner after meals. The progress note, dated 2/22/19 at 6:40 AM, documented direct care staff alerted this nurse that the resident fell . Upon entering the room the resident observed sitting on the floor near the foot of the bed with his/her back against the corner of the bed. The resident wore non-skid socks, and clothing that fit well. The resident toileted and assisted back into bed about 30 minutes prior to the fall. The resident without injuries. The resident without pain and range of motion was intact. The resident assisted back into bed by 2 staff members. The fall intervention: visual checks each time staff go by the resident's room. Anti-roll bars in place to back of chair. The fall intervention update book, dated 2/22/19, identified the resident was trying to transfer himself/herself into the wheelchair, and the new intervention to prevent further falls was visual checks and an anti-roll bar to the wheelchair. On 3/13/19 at 8:56 AM, the resident's recliner he/she usually sat in the lounge/lobby area with the non-skid strips noted on the floor. The resident assisted to transfer from the recliner to his/her wheelchair by administrative staff D without a gait belt. The resident took a few steps to his/her wheelchair and then sat down. The staff member told the resident to ask the girls on the way to his/her room for help. The resident propelled himself/herself to his/her bathroom. The resident transferred himself/herself to the toilet with the use of the grab bar beside the toilet. The resident toileted himself/herself, then stood with assistance of the grab bar and transferred to his/her wheelchair without locking the wheelchair brakes. The wheelchair rolled backwards when the resident sat down and the resident stated whoa. The resident then propelled his/her wheelchair with use of his/her feet to the lobby/lounge area and administrative staff W transferred the resident to a recliner without a gait belt. The wheelchair without anti-roll bar. On 3/13/19 at 4:25 PM, direct care staff M transferred the resident from the recliner to the wheelchair without use of a gait belt. The resident's wheelchair without anti-roll bar. On 3/14/19 at 11:00 AM, the resident's wheelchair lacked anti-roll bar. On 2/11/19 2:12 PM, direct care staff J stated the resident was very impatient. The resident required 1-2 staff assistance for transfers, and used a walker to assist with the transfer. The resident would propel himself/herself with his/her feet. The resident does not have anti-roll bar on his/her wheelchair. The resident was not supposed to transfer himself/herself. On 3/13/18 at 2:39 PM, direct care staff X stated the resident was a fall risk, and required 1-2 staff assistance for transfers. He/she thought the resident was to have the anti-roll bar on his/her wheelchair, but did not think he/she does. Staff were to check the fall book every shift. The nurses were pretty good at letting the staff know of the new interventions. On 3/13/19 at 10:53 AM, stated administrative staff D stated he/she was trying to put the care plans in the new computer program, but he/she was not able too. The baseline care plan was done, it is in the computer, and verified the baseline care plan was still in progress, and lacked a summary or the family review The resident should have a care plan for falls using the form called a problem list in the care plan book at the desk. When staff reviewed the care plan book, he/she verified there was not a problem list form for the resident. Review of the facility electronic care plan revealed the resident with a care plan in place for falls, with a initiated date of 3/13/19. Staff was unaware of the falls care plan. On 3/13/19 at 4:00 PM, licensed nursing staff C stated the resident was a fall risk. The resident was to transfer with 1-2 staff assistance with the use of his/her walker. The resident was not to transfer himself/herself without staff assistance. Staff was not aware the resident transferred himself/herself from the wheelchair to the toilet earlier. The resident would try to transfer himself/herself without staff assistance. Staff stated the resident's cognition varies throughout the day, he/she was alert and oriented with periods of confusion. Place a new intervention in the fall intervention update book, and on the care plan in the care plan book, and update the care giver guide. He/she would then let the direct care staff know of the new intervention. On 3/14/19 at 12:37 PM, licensed nursing staff H stated the resident was a fall risk, if the resident would fall, then put an intervention on the care plan, and on the the care guide. The resident was suppose to have a anti-roll bar on the wheelchair and was not suppose to transfer himself/herself. On 3/14/19 at 9:30 AM, administrative staff B stated the resident was to have anti-roll bar on the wheelchair. Staff B was not aware of the resident did not have anti-role brakes his/her wheelchair. The facility policy for falls dated 3/17, documented the staff to complete routine monitoring for implementation of interventions. The facility failed to provide adequate supervision and assistive devices to prevent accidents. The resident experienced 3 falls from 12/28/18, 1/14/19, and 2/22/19. In addition, on 3/13/19 the residents wheelchair lacked and anti-roll bar.

The facility reported a census of 67 residents, with 2 reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to implement effective interventions to prevent the worsening of the stage 3(full thickness tissue loss) and stage (full thickness tissue loss with exposed bone tendon or muscle) pressure and a stage 4 (full thickness tissue loss with exposed bone tendon or muscle)pressure ulcers (on the resident's left hip, which the resident admitted with) and the development of an unstageable(not stageable due to coverage of a wound bed by slough or eschar) pressure ulcer on the resident's right heel and a stage 2 pressure ulcer on the resident's right ischium (lower portion of the hip bone which became an unstageable pressure ulcer) for 1 (#54) of the two residents reviewed for pressure ulcers. Findings included: - Review of resident #54's physician order [REDACTED]. The admission MDS (minimum data set), dated 2-26-18, assessed the resident with a BIMS (brief interview for mental status) score of 12 (indicated normal cognitive status), required extensive assistance of 2 persons for bed mobility, impairment in range of motion in lower extremities on both sides, had an indwelling urinary catheter and an ostomy (for stool collection). The resident was at risk for pressure ulcer development, had a pressure relieving device in his/her bed and chair, and was on a turn and reposition schedule. The resident had one stage 4 and one stage 3 present on admission with the measurements of the stage 3 pressure ulcer as: length 4.1 cm (centimeter), width 3.4 cm, and depth 0.4 cm (centimeter). The CAA (care area assessment), dated 2-26-18, for pressure ulcers, assessed the facility admitted the resident with a cast to his/her right lower extremity due to fracture. The resident lived at home alone with home health assistance, had [MEDICAL CONDITION] with no feeling from the waist down, a BIMS of 12 used a trapeze (a device attached to the bed frame allowing the resident to grasp and pull up his/her upper body), and used a Hoyer lift (a device use to lift the resident) for transfers. The resident admitted with a stage 3 and 4 pressure ulcers to his/her left buttock, had an air mattress in place and vitamins for wound healing. The resident was seen by consulting wound specialist for pressure ulcer care. The resident required extensive assistance of 2 staff for bed mobility. The Braden assessment score (a method of assessing a resident's risk for pressure ulcer development), dated 2-19-18, revealed a score of 16, indicating mild risk for pressure ulcer development. Staff updated the Braden assessment weekly, and continued to assess the resident score of 16. The pressure ulcer care plan, updated 3-20-18, advised staff the resident had poor skin integrity related to [MEDICAL CONDITION] and needed assistance with repositioning to assist with wound healing. The care plan advised staff the resident used a trapeze to assist with self-repositioning, had an air mattress on the bed and pressure reducing cushion to his/her wheelchair. The care plan advised staff advised to encourage and assist the resident to weight shift while sitting up in a chair and to encourage the resident to maintain the head of bed at an angle less than 30 degrees. The resident required a mechanical lift for transfers to avoid skin friction/shearing (rubbing). The plan of care lacked instruction to staff as to how often the staff should turn and reposition the resident. The wound clinic notes documented the Stage 4 left ischium (lower portion of the hip bone) pressure ulcer measurements as follows: 2-19-18 length 2.5 cm (centimeter), width 2.20 cm, depth 1.3 cm. 2-27-18 length 2.1 cm, width 2.0 cm, depth 0.8 cm. 3-27-18 length 1.9 cm, width 1.5 cm, depth 0.9 cm. 4-03-18 length 1.3 cm, width 1.5 cm, depth 0.8 cm. 4-10-18 length 1.9 cm, width 2.1 cm, depth 1.0 cm (wound measures larger). 4-17-18 length 2.0 cm, width 2.5 cm, depth 1.0 cm (wound measures larger). 4-24-18 length 2.3 cm width 1.9 cm, depth 0.8 cm (wound measures larger). The wound clinic notes documented the Stage 3 left posterior buttocks pressure ulcer measurements as: 2-19-18 length 4.10 cm, width 3.4 cm, depth 0.40 cm. 2-27-18 length 3.9 cm, width 2.5 cm, depth 0.4 cm. 3-27-18 length 2.2 cm, width 1.8 cm, depth 0.3 cm. 4-03-18 length 2.1 cm, width 1.5 cm, depth 0.3 cm. 4-10-18 length 2.4 cm, width 1.7 cm, depth 0.7 cm (wound measures larger). 4-17-18 length 4.1 cm, width 4.2 cm, depth 0.7 cm now stage 4 (wound measures larger). 4-24-18 length 3.2 cm, width 4.3 cm, depth 0.9 cm wound measures slightly larger but does not appear to have been exposed to increased pressure. The wound clinic notes documented the shearing injury stage 2 right ischium: 4-3-18 length 3.0 cm, width 2.0 cm, depth 0.1 cm wound base 80% red, 20% dark color. 4-10-18 length 0.1 cm, width 0.1 cm, depth 0.1 cm. 4-17-18 no measurement stage 2 closed. 4-24-18 length 3.0 cm, width 1.0 cm now suspected deep tissue injury. The wound clinic notes documented the pressure/shear (two surfaces rubbing against each other) injury medial (towards center) to the right ischium stage 2: 4-3-18 length 0.5 cm, width 0.5 cm, depth 0.1 cm. 4-10-18 stage 2 closed, no wound measurements. 4-17-18 no measurement, stage 2 closed. 4-24-18 no measurement, stage 2 closed. The wound clinic notes documented the right heel suspected deep tissue injury: 4-3-18 The resident's cast removed today (right tibia fracture). 4-6-18 no measurements, a physician order, dated 4-6-18, instructed staff to cleanse the right heel with normal saline and apply a protective dressing, secure with Kerlix (a gauze wrap) to check every shift and change as needed. 4-24-18 length 1.2 cm, width 4.8 cm note documents the resident had a blue bootie over the foot and it looks as though this may have slipped out of place and created pressure. Staff advised to keep the heels off-loaded with pillows (instead of the blue booties). A physician order, dated 2-20-18, instructed staff to cleanse the stage 3 and 4 pressure ulcers with normal saline, apply alginate ((a material that is used to absorb wound drainage and form a gel-like barrier against bacteria) to the wound bed and cover with an ABD (thick gauze dressing) pad. A physician order, dated 3-2-18, instructed staff to administer Bactrim DS (an antibiotic),by mouth, every 12 hours, for 10 days [MEDICAL CONDITION] ([MEDICAL CONDITION] resistance [DIAGNOSES REDACTED] aurous a bacterium resistant to many antibiotics) in wounds. A physician order, dated 3-27-18, advised staff to cleanse the stage 3 pressure ulcer with normal saline, apply [MEDICATION NAME] (a wound care product with bacteria and healing properties) moistened with tap water, cover with a bordered foam dressing and change daily. If the wound drains discontinue the bordered foam dressing and use ABD (a thick gauze dressing) pads. The order instructed staff to cleanse the stage 4 pressure ulcers with normal saline, fill the tunnel (erosion under the skin) with [MEDICATION NAME] and cover the visible wound with alginate, and cover with bordered foam dressing three times a week. If the drainage was not contained with the foam dressing, may use ABD dressing and change daily. The physician order [REDACTED]. A physician order, dated 4-17-18, instructed staff to administer Bactrim DS, by mouth, twice a day, for 10 days, for wound infection. (second round of antibiotics) The physician order, dated 4-20-18, instructed staff to provide the following: Cleanse left hip stage 3 pressure ulcer with normal saline, dry, apply alginate (a material that is used to absorb wound drainage and form a gel-like barrier against bacteria) to the wound bed and cover with an ABD (a thick gauze dressing), secure with tape, daily and prn (as needed). Staff instructed to cleanse the stage 4 left ischial pressure ulcer, with normal saline, dry, apply alginate to the wound bed, cover with ABD pad, and secure with tape, daily and prn. A physician order, dated 4-24-18, instructed staff to float the resident's heels on pillows not to apply the heel boots. Staff instructed to cleanse the resident's right ischium with normal saline, apply a waterproof foam dressing 3 times weekly for suspected DTI (deep tissue injury). Staff instructed to apply a foam dressing to the resident's right heel, cover with a foam heal protector, secure with Keflex and change 3 times, weekly and prn for suspected DTI (deep tissue injury). Interview, on 4-25-18 at 03:08 pm, with licensed nursing staff V, revealed the resident used the trapeze bar to reposition his/her upper body. Staff V stated he/she thought that because the resident repositioned him/herself, his/her lower extremities moved also and this contributed to the pressure ulcer formations on the right ischium and right heel. (the resident upper body movements were not adequate to reposition his/her lower extremities to prevent development/decline in pressure ulcers.) Staff V stated the resident repositioned him/herself to watch tv, so the facility moved him/her to the present room and staff moved the bed around depending on the position of the resident to minimize pressure. Observation, on 4-26-18 at 9:00 am, revealed the resident sat up in bed eating breakfast. Observation continued 9:15 am, 9:30 am, 9:45 am, and 10:00 am, revealed the resident finished with breakfast and remained sitting up in bed, watching television. Interview, on 4-26-18 at 10:15 am, with the resident, revealed he/she used the trapeze bar to move his/her upper body, and was unable to move from T 4 down. The resident stated he/she had been getting up for meals and therapy, but staff now recommended he/she stay in bed in his/her room. He/she stated staff moved him/her to the present room to be able to watch TV in different positions. The resident stated a couple of weeks ago, he/she sat up in a wheelchair that was too small for him/her, and he/she remained up in the wheelchair for approximately 7 hours as staff could not get to him/her to lay him/her down. The resident stated his/her feet often touched the bottom footboard so he/she pulled himself up with the trapeze. Observation, on 4-26-18 at 10:20 am, revealed the resident turned on his/her call light. Direct care staff bb (who was passing medications) answered the resident light. The resident requested a positioning change. Direct care staff bb exited the room, without assisting the resident and informed direct care staff X that the resident requested positioning. Observation at 10:30 am revealed the resident remained sitting upright in bed. Observation continued at 10:45 am, 11:00 am and at 11:15 am and the resident lowered his/her head of the bed and pulled him/her self-up with the trapeze. Interview, on 4-26-18 at 11:16 am with direct care staff W, revealed the resident had not been repositioned since 9:00 am, as far as he/she knew, and staff would reposition him/her after providing incontinence care to 2 other residents. Staff W stated the resident should be repositioned every 2 hours. Observation, on 4-26-18 at 11:30 am, revealed no staff entered the resident room and the resident sat positioned in bed with the head of his/her bed elevated at approximately 30 degrees. Observation, on 4-26-18 at 11:33 am, revealed the resident turned the call light on (for the second time). Observation, on 4-26-18 at 11:40 am, revealed direct care staff W and licensed staff S answered the resident call light and repositioned the resident onto his/her left side (2 hours and 40 minutes in a sitting position in bed). The resident assisted with positioning using his/her trapeze. The dressings were intact to the right and left hips and right foot. The resident's right hip area was red in color with an approximate 6 cm by 1 cm dark red non-blanching (obstruction of blood flow) area present (as observed on 4-25-18). The resident stated he/she would eat lunch in this position. Interview, on 4-26-18 at 2:30 pm, with licensed nursing staff I, revealed the dressings were changed by the evening shift, and he/she checked the dressings for excess drainage and would change them if the drainage came through on the outer layer. Staff I thought the resident could position him/herself with his/her trapeze but would need assistance with pillow placement. Interview, on 4-26-18 at 2:30 pm, with direct care staff X, revealed staff used a Hoyer lift to transfer the resident and had a regular sized wheelchair to transfer the resident into prior to the isolation for a wound infection. Staff X stated the resident voiced being uncomfortable in the chair due to the position of the arm rests. Staff X stated eventually the resident's family brought his/her electric scooter in and he/she was more comfortable. Staff X stated the resident should be repositioned every 2 hours, but staff was providing incontinence care to 2 other residents earlier in the morning, and could not assist the resident when he/she put his/her call light on. Interview, on 4-26-18 at 3:15 pm, with consulting therapy staff Y, revealed the resident received therapy for upper body strengthening, and since removal of the cast from his/her leg, the resident could utilize the trapeze better, but still required staff assistance with positioning in bed and pillow placement to prevent pressure areas. Staff Y stated the resident previously (prior to isolation [MEDICAL CONDITION] in the wound) came to therapy in a regular sized wheelchair. Interview, on 4-30-18 at 12:45 pm, with administrative staff E, revealed he/she thought the resident could position him/herself with the use of the trapeze and side rails, but needed assistance with transfers since he/she had the cast on his/her leg. Staff E confirmed the care plan did not indicate a turning and repositioning schedule. Interview, on 4-30-18 at 1:49 pm, with consulting wound staff T, revealed the resident could reposition his/her upper body, but needed staff assistance with positioning pillows and lower extremities. Staff T stated he/she advised staff the resident should not remain in a sitting position longer than necessary, and staff should reposition the resident on a schedule to reduce pressure to the compromised areas. Staff T stated the resident reported an incident when he/she sat in his/her chair for an extended period of time and this contributed to the worsening of the left ischial and lower buttock pressure ulcers and development of the unstageable pressure ulcers on the resident's right ischium. Staff T felt the unstageable right heel ulcer could be due to misplacement/shifting of the blue heel bootie. Interview, on 4-30-18 at 4:30 pm with administrative staff B, revealed the resident admitted with the stage 3 and 4 pressure ulcers and was at risk for development of pressure ulcers due to previous pressure ulcers and multiple surgeries to these areas. Staff B stated he/she thought the resident improved with self-positioning and he/she used the trapeze. Observation, on 5-1-18 at 11:15 am, revealed consulting staff T provided wound care to the resident. The stage 4 left ischium pressure ulcer measured: length 1.7 cm, width 1.5 cm, and depth 0.8 cm with tunneling at 12:00 o'clock position of 1.4 cm. The wound was circular and had medium red tissue present and no drainage. The stage 3-4 left posterior hip wound contained yellow [MEDICATION NAME] tissue, and measured length 1.7 cm by 1.5 cm by 0.8 cm with the tunnel length at 1.4 cm. The right ischium pressure ulcer contained a pink colored open area measuring 1 cm by 0.3 cm 0.3. The right heel contained a crescent shaped purple area measuring length 1 cm by 2.5 cm in width. Staff T stated the 6 cm by .5 cm area of redness on the resident's proximal hip area was new, and at this point in time did have minimal blanching present. Staff T stated this could be caused from the elastic of the incontinent brief or wrinkles in the bed linen. The facility policy for skin care, dated 2/2017, advised staff if a resident has a decline in skin integrity, staff should review pressure redistribution surfaces initiate a positioning schedule as necessary to meet individual resident needs. Goals and interventions should be directed toward prevention of pressure ulcers and those at risk. The facility failed to ensure timely and effective interventions were in place for this dependent resident at risk for pressure ulcers to prevent the development of new pressure ulcers (an unstageable area on the resident's right heel and right hip) and worsening of existing pressure ulcers (stage 3 pressure ulcer on the resident's left posterior hip became a stage 4 and the stage 4 left ischial pressure ulcer increased in length and width after the resident sat in a chair for an extended period of time).

The facility reported a census of 69 residents. Based on observation, interview and record review, the facility failed to honor 1(#1) of 69 resident's wishes regarding code status (the level of medical intervention a resident wishes to have started if their heart or breathing stops). Facility staff found resident #1 non-responsive and without vital signs; staff failed to begin CPR (cardiac-pulmonary resuscitation), for resident #1, who designated a full code status (use of all medical interventions to restart breathing and heart beat). This practice placed the resident in immediate jeopardy. The facility also failed to maintain an accurate system to ensure staff were aware of the code status of 10 of 69 residents of the facility, including residents # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. Findings included: - Resident #1, admitted to the facility on [DATE], per the physician's orders [REDACTED]. The initial care plan, dated [DATE] lacked inclusion of the resident's code status. Review of the resident's medical chart lacked evidence of a designated code status, at the front of the chart. Review of the H&P (history and physical), dated [DATE], from the hospital included a code status of Full code. This information was in the hard (physical) chart, under the history and physical tab. Review of physician's orders [REDACTED].>[DATE] -- Contact EMS (emergency medical services) to verify death. [DATE] -- Release body to funeral home. A nursing note, on [DATE] at 12:31 AM noted that at 12:10 AM, the CNA (certified nurse aide) contacted the nurse regarding being unable to arouse the resident at bed-check. The writer (of the nursing note) checked on the resident, and found the resident without breath sounds or pulse. The resident was non-responsive to a sternal rub (a painful stimuli). The writer called the ER (emergency room ) for physician intervention. The staff informed the physician of the measures implemented; the physician gave orders for EMS to verify the death. Staff notified 911 and administrative staff A. During an interview on [DATE] at 8:46 AM, licensed nursing staff C reported the resident seemed stable on the evening of [DATE]. During the staff's assessment of the resident, the resident attempted to arise from the wheelchair, unassisted and staff reminded the resident to not get up without assistance. Around 10:00 PM the direct care staff completed rounds and the resident was fine. Around 12:10 AM direct care staff F rushed to the desk and reported the resident was not responding. Staff C went to the resident's room, at that time, to check on the resident, and noted the resident lying flat in the bed, with cyanotic (bluish colored) lips and non-responsive to a sternal rub or other stimuli. The staff checked for a pulse, breath sounds, and then checked for blood pressure and respirations; however, staff reported the resident lacked all vital signs. Staff noted the resident's arms remained warm, however, his/her face was cool to touch, and his/her fingertips were cyanotic. A blanket covered the resident's arms, legs and torso which were and warm to touch, and all skin exposed was cool to touch. The staff requested a direct care staff to contact the nurse on the other side of the building to come to the resident's room, while staff C continued to attempt to obtain a response from the resident. When the other nurse came over, staff C reported to the other staff, that he/she believed the resident expired and left the room to call the physician. Upon checking the chart, staff C noted in the history and physical section, the resident was a full code. Staff C relayed this information and the lack of any vital signs to the physician, a few minutes prior to 12:31 AM (noted as the time the staff began charting.) The physician ordered for EMS to verify the resident's death and release the body to the funeral home. When asked why the staff did not perform CPR (cardiopulmonary resuscitation) as the resident was a full code, staff C stated, he/she believed the resident was too far gone, at the time he/she was found non-responsive. On [DATE] at 9:36 AM, licensed nursing staff D, verified that he/she worked on the night the resident passed away, however, was working on the opposite hall from the resident. Staff D reported that a direct care staff member requested staff D come to the other hall. Upon arriving to the resident's room, staff D reported he/she checked the resident for a pulse and observed a lack of respirations and the resident's skin color was whitish/gray in color. The staff reported it was obvious the resident was too far gone for reviving and CPR was not mentioned. Staff C and D went to the nursing desk to contact the on-call physician, and staff C advised the physician of a lack of vital signs; the physician inquired about the code status of the resident and staff C and D looked through the chart and found the code status was Full Code. The physician then instructed staff to contact EMS for verification of death. The physician did not instruct staff C and D to begin CPR or inquire if staff started CPR. Staff C then called 911; upon the arrival of EMS they checked for an EKG (electrocardiograph (a measurement of the heart activity)) and determined the resident lacked any cardiac activity. Nurse D reported staff were instructed of the code status for all residents in the front of the resident's chart, with an orange sheet indicating DNR (do not resuscitate) and a white sheet indicating to conduct a full code. Neither of those pages was found in the front of the resident's chart. On [DATE] at 10:59 AM, direct care staff E reported the resident seemed fine at the 10:00 PM bed-check. Around midnight, direct care staff F and E went into the resident's room. Staff E went to check on the roommate, when staff F called out that the resident was not responding. Staff F left to get the nurse and staff E stayed with the resident. At that time, the resident appeared pale in color, with warm skin. The nurse returned, performed an assessment of the resident, stating the resident was gone and instructed staff E and F to clean the resident up. On [DATE] at 12:33 PM, direct care staff F reported he/she came on duty at 10:00 PM and stated the other shift just completed bed-check. Around midnight, direct care staff E and F started a bed-check. Staff F reported finding the resident in the bed, positioned side lying, facing away from staff F. Staff F reported he/she told the resident he/she was going to reposition and check the resident's brief and then removed the pillow at the resident's back. The resident's body then rolled back towards the staff, who then noticed the change in the resident's coloring and that the resident was not responsive. Staff F asked staff E to stay with the resident so he/she could get the nurse. The resident was not responsive at all and no one ever mentioned anything about CPR or the resident's code status. Nurse C reported to staff E and F the resident was gone and instructed the staff to begin cleaning the resident up. The staff verified code status is available in the front of the resident's clinical record. Social Services/Activity staff G reported, on [DATE] at 1:20 PM, that staff G was responsible for placement of the Code Status on the resident's chart upon admission to the facility. The staff reported that he/she may have overlooked placing the information in the resident's chart. On [DATE] at 12:05 PM, administrative nursing staff B reported he/she expected the nursing staff to initiate CPR for a resident identified as a Full Code. Staff B reported that when the nurse finds a resident non-responsive and without a heart beat the code status would be checked immediately (in the front of the chart) with CPR started and continued until EMS arrived. Staff B reported the nurse in charge would be expected to delegate tasks, as needed, to other staff to ensure the resident received the care needed. Furthermore, staff B reported the social services department staff were in charge of ensuring the placement of the resident's advance directives, including the code status, in the front of the resident's chart. The facility policy, dated [DATE], instructed staff to initiate CPR when [MEDICAL CONDITION] occurred for residents who requested CPR as part of the resident's advance directives, or for resident's who lacked a valid DNR order or lacked completion of advance directives. The facility procedure for code status, undated, included the resident's code status would be found in the front of the chart, utilizing an orange sheet indicating DNR, a white sheet indicating full code and in the absence of a sheet, assume the resident was full code and begin CPR. The facility failed to initiate CPR for resident (#1) when staff found the resident unresponsive. The staff failed to check the code status until after notification to the physician of the resident being absent of vital signs, and the physician inquired as to the code status of the resident. This practice placed this resident in immediate jeopardy. The investigation revealed the facility was in past-noncompliance as of [DATE] at 6:30 PM as the facility: 1.) Education was provided to all staff regarding knowledge of code status in the chart. 2.) All staff education on abuse, neglect and exploitation. 3.) All staff education on finding a resident unresponsive with the lack of vital signs. 4.) All staff education on CPR policy. 5.) Staff training/discipline on ensuring placement of Advance Directives on the chart. 6.) Completion of a comprehensive chart audit for Code Status. Code status auditing will continue monthly and submitted to QAPI. 7.) Review of CPR certification and scheduled training for staff not trained in CPR. 8.) Mock code drills will be conducted weekly for four (4) weeks, then monthly for three (3) months, and continue quarterly. 9. Review of all new admissions in daily start up meeting for code status. 10. Education to all newly hired licensed staff team members with completion of a posttest to validate the team member's comprehension of full code situation. 11. A focused QAPI meeting addressing the event was completed on [DATE] with the attendance including the administrator, director of nursing service, director of clinical operations and the medical director. - The facility failed to ensure the code status (the level of medical intervention a resident wishes to have started if their heart or breathing stops) of all residents of the facility were fully documented and readily accessible to the staff when 10 charts reviewed, lacked inclusion of the resident's code status. This deficient practice affected 10 residents of the 69 admitted to the facility, including residents #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. On [DATE] at 12:05 PM, administrative nursing staff B reported the social services department were in charge of ensuring the placement of the resident's advance directives, including the code status, in the front of the resident's chart. The staff member further indicated a review of all the resident's charts, conducted on [DATE] identified 10 records with incomplete advance directives related to CPR (cardiopulmonary resuscitation (an intervention to attempt to restart the beating of a stopped heart)) and DNR (do not resuscitate) status. Social Services/Activity staff G reported, on [DATE] at 1:20 PM, that staff G was responsible for placement of the Code Status on the resident's chart upon admission to the facility. The staff reported that he/she may have overlooked placing the information in the resident's chart. The facility failed to ensure the staff maintained the clinical record to reflect the resident's preference of advance directives when 10 of 69 resident's charts failed to identify the resident's choice of CPR or DNR.

The facility reported a census of 75 residents. The sample of 9 residents included 3 reviewed for falls. Based on observation, interview and record review, the facility failed to provide appropriate interventions for 2 of the 3 sampled residents including; (#7) whose cognition varied and revealed a decline on 1/27/16 through 1/30/16, when the resident fell and sustained a fracture hip; and (#9) whose physical ability declined, and then the resident fell , sustaining a fractured hip. Findings included: - The signed physician orders, dated 2/5/16 of resident # 7, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED].), mood disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain ) of the knee, and neuritis (inflammation of one or more nerves). The admission MDS (minimum data set), dated 1/6/16, revealed the resident had a BIMS (brief interview for mental status) score of 11, indicating moderately impaired cognition. The resident mood interview revealed the resident had trouble concentrating. The resident required extensive assistance of one staff with bed mobility, transfer, ambulation, locomotion, toileting, and personal hygiene. The resident was unsteady and only able to stabilize with staff assistance with balance during transitions. The resident used a walker and a wheelchair for mobility. The 30 day MDS, dated [DATE], revealed the resident had a BIMS score of 9, indicating moderately impaired cognition. The resident had hallucinations and delusions and required extensive assistance with bed mobility, transfer, and toileting and limited assistance with walking, locomotion, and personal hygiene. The medical record revealed the resident admitted to the hospital on [DATE] and returned to the facility on [DATE]. The significant change MDS, dated [DATE], revealed the resident with BIMS of 7, indicating severely impaired cognition. The resident had signs and symptoms of delirium that fluctuated with inattention and disorganized thinking. The resident wandered on 1 to 3 days during the assessment that placed the resident at a significant risk of getting into a potentially dangerous place. The resident required extensive assistance of 2 staff with bed mobility, transfer, walk, locomotion, dressing, toileting, and personal hygiene. The 14 day MDS, dated [DATE] with BIMS score of 13, indicated cognitively intact. The resident required extensive assistance of 2 staff for bed mobility, transfer, toileting, and personal hygiene, and the resident required extensive assistance of 1 staff for ambulation and locomotion. The resident's balance was unsteady, and the resident was only able to stabilize with staff assistance with moving from seated, walking, turning around, moving on/off toilet, and surface to surface. The resident utilized a walker and a wheelchair for mobility. The 30 day MDS, dated [DATE], revealed the resident with BIMS of 15. The resident required the assistance of 2 staff for bed mobility, toilet, and personal hygiene, and extensive assistance of 1 staff for transfer and ambulation. The CAA (care area assessment) completed on 2/9/16, for cognitive loss/dementia, revealed the BIMS was 7, which revealed severely impaired cognition. The ADL (activity of daily function) functional /rehabilitation CAA revealed the resident was able to ambulate with the use of a walker and the assistance of 1 staff. The resident used a wheelchair for mobility. The falls CAA revealed the resident was a fall risk and required the assistance of the staff for transfer and ambulation. The care plan evidenced : On 1/18/16, guided staff to assist the resident with stand by assistance for all ambulation; remind the resident to ask for assistance for all ambulation; and to observe the resident for changes in his/her condition that would warrant increased supervision and assistance. The staff were to keep the bed in the lowest position; encourage the resident to wear non -skid shoes/ socks when out of the bed; side rails; and lock the wheelchair at the bedside while the resident was in the bed. On 2/24/16 it guided the staff to assist the resident with decision making, and provide the resident with verbal cues and reminders when the resident could not remember. The staff were to continue to educate the resident not to transfer him/herself, but the resident refused to call for staff assistance. The care plan, updated on 3/3/16, guided the staff to re-educate the resident to ask for assistance prior to standing. On 3/4/16, guidance to the staff to assess the blood pressure lying, sitting, and standing twice a day for 3 days and then report the results to the physician. The care plan guided the staff to check on the resident frequently to ensure the safety of the resident was met; place a commode at the bedside at night; and a transfer pole placed at the head of the bed. The admission clinical health status, dated 12/20/15, identified the resident as a fall risk. The resident had an abnormal gait and memory loss. The resident ambulated with a shuffled gait, and the fall risk factors included impairment in the resident's gait or balance, and lower extremity strength. Review of the nurse's notes from 1/27/16 to 1/30/16, evidenced the resident had increased confusion. On 1/29/16, the resident was restless, and would get up by him/herself without the walker or the wheelchair. The resident stood in the hallway pushing his/her wheelchair, and the resident was re-educated to not stand and attempt to ambulate without asking for assistance. On 1/30/16, the resident stood at the bedside, and several times ambulated without any staff assistance. The resident was given education to ask for staff assistance. The post fall/ trauma report, dated 1/30/16, revealed the resident had a fall at 10:30 pm in the hallway while ambulating without staff assistance. The staff identified the resident with impaired safety/judgement. The staff transferred the resident to the hospital with a fractured left hip. The resident returned from the hospital on [DATE], with a post surgical repair of the left hip fracture. The report documented the post fall intervention was the Call before you Fall program. However, further multiple staff interviews revealed the staff lacked knowledge of what this program actually was and most had not heard of it before being questioned. Furthermore, this review of the resident's fall failed to identify the root cause of the fall to ensure appropriate prevention of a repeated fall. Review of the clinical health status, dated 2/2/16, revealed the resident had diminished awareness of safety, and the resident was identified as a fall risk. Review of the nurse's notes from 2/8/16 to 2/11/16, revealed the resident required assistance of 1 staff with transfers and ADL's. The resident attempted several times to self - transfer, and had an episode of night time restlessness. The staff educated the resident on the importance of waiting for assistance. Review of the post fall /trauma report, dated 2/11/16, revealed the resident had a fall in his/her room on 2/10/16 at 8:30 pm, and the resident was identified with a history of falls and impaired safety awareness. The resident had recently been toileted, and the resident attempted to self-transfer to the bed. The resident had localized pain of the knees, and was anxious and irritable. The post fall intervention guided the staff to toilet the resident before laying down in the bed, and encouraged the staff to provide activity outside of the room until bedtime. Review of the nurse's notes, from 2/29/16 to 3/6/16, revealed the resident self- transferred without assistance. On 3/3/16, the staff identified the resident with increased confusion with hallucinations. The resident forgot that he/she had a fractured hip and attempted to ambulate or transfer him/herself. Review of the post fall/trauma report, dated 3/3/16, revealed the resident fell at 1:00 pm in his/her room after the resident ambulated without assistance. The resident had impaired safety awareness, and transferred to the emergency room due to loss of consciousness at the time of the fall. The intervention for the fall revealed staff were to educate the resident not to stand unassisted. (The resident identified with varying degrees of cognition.) The interdisciplinary team reviewed the fall and assessment of orthostatic (a form of low blood pressure that occurs when standing after sitting or lying down) blood pressure for 3 days and to report to the physician. Review of the nurse's notes post fall, dated 3/3/16, revealed the resident returned from the emergency room , and attempted to get up many times during the night. Review of the post fall/trauma, dated 3/5/16, revealed the resident fell on [DATE] at 10:15 pm in his/her room. He/she had responded to toilet urgency, and attempted to self-toilet, and fell . The post fall guided staff to change the resident's footwear, use the Call before you Fall program, place a transfer pole at the bedside, have the bed in the low position, place the call light within the resident's reach, and a bedside commode to be used at night. (The resident required extensive assistance of 1 staff for transfers.) Review of the nurse's notes revealed the following: on 3/5/16, the lying blood pressure of 140/77, sitting at 134/72, and standing 94/62. The resident complained of dizziness on standing. On 3/6/16, the lying blood pressure of 142/74, sitting of 118/72, standing of 90/58. The resident was educated on the importance of requiring assistance due to the resident being unsteady. Review of the nurse's notes revealed that on 3/7/16, the resident had confusion at times, and attempted to transfer without assistance. The resident was educated on asking for assistance on transfer. (The staff used the same intervention after the resident's falls on 1/30/16, 3/3/16, and 3/5/16.) On 3/7/16, 3 days post fall, the facility placed a transfer pole at the resident's bedside and the staff were instructed to watch the resident closely if the resident was in the room by him/herself due to attempts to self -transfer. On 3/8/16, the resident transferred self without assistance. Review of the CNA (certified nurse aide) care card revealed the resident required a quarter side rail, and a transfer pole. On 3/3/16, the care card guided staff to provide education for the resident to ask for assistance prior to standing, and the use of a bedside commode. On 3/17/16 at 9:40 am, direct care staff H, reported he/she had put the resident on the toilet and came to get the surveyor for observation of a transfer off of the toilet and to the wheelchair. Upon entering into the resident's bathroom, the resident had stood up holding onto the arms of the wheelchair, with his/her disposable briefs and pants pulled down to his/her knees. After incontinence care was provided to the resident, the resident pulled up his/her briefs and pants, and observation of tremors to both hands occurred when the resident pulled up his/her briefs and pants. The resident pivoted from the toilet to the wheelchair and the resident required 7 shuffled, rigid, pivoted steps to turn him/herself around and sit in the wheelchair. On 3/16/16 at 4:21 pm, the resident stated sometimes he/she would get dizzy, and the last 2 falls were a result from dizziness and the resident reported the fall resulted in the loss of consciousness after his/her head struck the floor. On 3/16/16 at 5:00 pm, direct care staff I, stated this resident required to be watched closely because he/she no longer had any pressure alarms, and the resident would get up frequently. The resident had poor balance, and at times, was weak. The resident was more confused when he/she first woke up, and the staff attempted to educate the resident not to get up without assistance. The resident preferred to not wear socks at night. The wheelchair was kept by the bedside when the resident was in bed. On 3/17/16 at 9:45 am, administrative nursing staff B, stated the, Call before you Fall program was just something the nurses say, and staff B was unaware the program was on the electronic records as a choice of interventions after a fall. Administrative nursing staff B, explained being unaware if the staff knew what the, Call before you Fall program, was and verified he/she did not know what it was. The administrative nursing staff verified the facility lacked a policy for the, Call before you Fall program. On 3/17/16 at 9:50 am, direct care staff J, stated he/she was unaware of what the, Call before you Fall. program was. On 3/17/16 at 9:51 am, administrative nursing staff F, stated the resident had confusion on some days, and struggled when he/she was tired. Administrative nursing staff F, explained the resident could be forgetful, and his/her cognition varied. The resident had occasional periods of hallucinations, and education or cueing would not keep the resident safe when the resident was confused. On 3/17/16 at 11:39 am, direct care staff H, stated the resident was a significant fall risk, and walked with a sticky step. The resident was encouraged to transfer with set up assistance, but staff observed the resident self-transferring often. Direct care staff H, stated the staff were required to read the care plan book daily, and review the care card for instructions on how to care for this resident. Direct care staff H, stated when the resident was transferred to the bed, he/she did not place the commode by the bedside, but would place the wheelchair by the bed, especially since the resident had a transfer pole and self-transferred. (The resident identified as requiring staff assistance for transfers.) Direct care staff H, stated the resident became more confused in the evenings. When the resident's fall resulted in a fracture, staff H stated the resident should have asked for assistance, and stated the staff instructed the resident to utilize the call light frequently. Direct care staff H further explained the resident's bed was not a low bed, and had always remained at the same level that was a comfortable height for the resident to get out of. On 3/17/16 at 1:43 pm, administrative nursing staff B, stated when a resident had a fall, the nurse would figure out how they fell , and complete a fall worksheet after they assessed and treated the person, and initiated the neurological assessments, if applicable. The nurses were expected to have a new intervention after each fall, and the interdisciplinary team would review the post fall report for appropriate interventions. Administrative nursing staff H, stated this resident was a high fall risk, and after the resident's fall that resulted in a fractured hip, the resident's intervention was a, Call before you Fall program, and staff B then verified the intervention was inappropriate because the resident ambulated without assistance. Administrative nursing staff H, then stated the resident's cognition fluctuated, and sometimes the resident was really confused. An intervention was to have activities outside of the room, but staff H was unaware what activities were to be provided to the resident at those time. The staff were also to ensure the staff toileted the resident before going to bed. Administrative nursing staff H, stated the 3rd fall was the one they sent him /her to the emergency room , and stated the immediate intervention for this fall was for the resident to be educated to call for assistance, (The resident's cognition varies.) and verified the intervention was not appropriate. Staff initiated orthostatic blood pressures because the resident lost consciousness. The administrative nursing staff H agreed this was an assessment, and the facility lacked an intervention for the fall. Administrative nursing staff H, stated the following day, the resident fell after attempting to self toilet, and the intervention was to have a bedside commode at the bedside. Staff H reported being unaware if the resident utilized the commode or transfer pole as he/she did not follow- up to see if the intervention was appropriate for this resident. On 3/17/16 at 2:52 pm, licensed nursing staff E, stated the resident was a high risk for falls, and the staff attempted to anticipate the resident's needs. On 3/17/16 at 3:09 pm, direct care staff K, stated the resident was reminded to ask for assistance. The resident enjoyed reading or card playing in his/her bedroom, and was unaware the resident was to be encouraged to do activities outside of the bedroom. Direct care staff K stated the resident was unsteady, did not wear socks to bed, and would walk bare foot to the toilet at times. Direct care staff K verified the resident had a commode in the bedroom, but stated the resident did not use the commode. The facility lacked a policy for accident/falls. The facility failed to provide appropriate interventions for this resident whose cognition varied and revealed a decline on 1/27/16 through 1/30/16, when the resident fell and sustained a fracture hip. Furthermore, the facility failed to ensure adequate supervision and/or assistive devices to prevent further repeated falls after the hip fracture. - The POS (physician order [REDACTED].#9, dated and signed on 02/17/2016, documented the following [DIAGNOSES REDACTED]. The Significant Change MDS (minimum data set), dated 07/31/2015, documented a BIMS (brief interview for mental status) score of 00, indicating severely impaired cognition. The resident required supervision with walking, and limited assistance with bed mobility, transfers, dressing, and toilet use. The Cognitive loss/dementia CAA (care area assessment), dated 08/14/2015, documented the resident completed a BIMS score with the social worker, and provided recall information correctly with cueing. The Falls CAA, dated 08/14/2015, documented, the resident wandered about the facility daily, with an active [DIAGNOSES REDACTED]. The resident needed staff assistance of one with transfers at times, noted to be stable with a walker and ambulated independently throughout the facility. The resident was a fall risk related to a history of falls and the use of some medications. The 10/16/15 Quarterly MDS, documented no change in cognition, with the resident having a fall with injury (not major) since the prior assessment. The resident now had range of motion limitation in one side lower extremity, used a wheelchair/walker, and was unsteady but able to stabilize on his/her own. The resident's care plan, dated 07/30/2014, directed the staff to remind the resident to ask for assistance for all ambulation. (The resident had severe cognitive impairment.) If feeling weak or unsteady staff should refer for PT (physical therapy) evaluation. To observe for changes in condition that may warrant increased supervision/assistance and notify the physician. To keep the resident's call light in reach and to keep the room/area free of clutter. Ensure the resident was wearing non-skid shoes/socks when out of the bed and the bed was in the lowest position, with nonskid strips at the bedside. The staff were to check the resident and environment every two hours, to prompt the resident to void as needed. To keep the fall mat by the bed per family request on both sides of bed. Use of a bed alarm to alert staff when the resident got up at night. However, this was discontinued on 01/29/2016. To keep the walker within reach at all times, which was discontinued on 02/18/2016. Staff to keep the wheelchair with anti-roll bars, within reach at the bedside, which was discontinued on 02/23/2016. The SBAR note (a type of notification to the physician with a change in condition), dated 01/02/2016, documented the resident had increased confusion and increase pain which effected ADLs (activities of daily living). The resident had been having issues walking and performing ADLs this shift due to lower back pain. The confused resident was starting to have agitation due to not being able to perform ADLs. The resident rated the lower back pain as a 9 on a scale of 0/10, with 10 being worse. The Admission Clinical Health Status report, dated 01/29/2015, documented a history of falling. The resident was alert, but confused with memory problems, oriented to person, content pleasant, and wandered. The resident required assist of 1 staff for bed mobility, wheelchair and with side rails in use. The fall risk factors documented the resident had an impairment in gait strength and balance, history of falls, and an impairment in the lower extremity. The resident had diminished safety awareness, restless, wandering and resistive to cares. The fall risk factors indicated the resident was a fall risk. However, with the resident's impairment in cognition and the new decline in physical ability, the facility failed to identify/implement any new interventions at this time, to prevent further falls for this resident. The post fall/trauma report, dated 02/13/2016, documented an event occurred on 02/13/2016 at 2:00 AM, in the resident's room. The resident explained trying to get to the bathroom, but there was nothing to hang onto and fell . The resident had a history of [REDACTED]. The resident has had multiple falls due to his/her mental state. The resident was often confused and believed that he/she could walk without any help. The resident does need supervision to stand by assist at least with walking and does not use the call light to alert staff that he/she needed to be toileted. The staff are to ensure all resident needs are met. The recommendations/interventions documented included, Call before you fall program, keep the assistive device within reach, the bed in the low position, safety cues and reinforcement, give reminders, and keep the call light within reach. The IDT (inter department team) reviewed and recommended staff to toilet the resident every two hours at night, apply antiroll bars to the wheelchair and keep the wheelchair at the bedside at night. The nursing note, dated 02/13/2016 at 4:24 AM, documented to see the post fall assessment. This nursing note contained no assessment for injury from the time of the fall at 2:00 am. The record contained no further nursing notes until the next morning, 2/13/16 at 8:56 am. The Resident Fall Analysis worksheet, for the 2/13/16, 2:00 am fall, documented the resident was trying to go to the bathroom, no clutter or call light on, the equipment was away from the bed, bed height was correct, the floor was not wet, but there was urine on the floor. The floor mats and landing strips were utilized. The resident was in bare feet and was walking unassisted. There were no staff in the area when the resident fell and staff last had contact with the resident in the last couple of hours when he/she was resting in the bed. The outcome of the review documented the resident was confused and did not use call light to ask for assistance. The intervention was for staff to check on the resident more frequently to ensure safety, ensure resident has non-skid socks on, ensure bed in lowest position, ensure wheelchair close to the bed and wheels are locked for safety. The nursing note, dated 02/13/2016 at 8:56 AM, documented the staff may transfer the resident to the emergency room for evaluation as was reported the resident had a non injury fall during the night. CNA(certified nursing assistant) advised this nurse and reported the resident was having severe pain to the right shoulder. Went to assess and the resident's right shoulder was a slight bit swollen and the resident would grimace and holler out in pain when trying to move the shoulder. The resident was able to move the shoulder 25% on own. The resident's right wrist was also bruised and swollen and the resident voiced having pain in the wrist also. The staff received an order from the physician to send the resident to the emergency room to be evaluated. The nursing note, dated 02/13/2016 at 1:06 PM, documented the resident returned from the emergency room , with a new order to ice the right wrist and increase fluids by 3 to 4 glasses extra today. The resident was in a moderate amount of pain when returning. Administered scheduled pain medications upon when return. This writer talked to the family about possibly moving the resident room so he/she would be closer to the nurses station and that the staff would start toileting the resident every 2 hours around the clock. The nursing note, dated 02/14/2016 at 10:27 AM, documented the staff were to monitor the resident for falls. The resident required assistance of 2 staff for all transfers today, due to extreme amount of pain. The resident was attempting to get out of bed on his/her own this morning. The resident was unable to hold his/her right leg/foot up to assist with locomotion. The weekly nursing note, dated 02/14/2016, documented the resident needed 2 person assist, had partial weight bearing ability, short and long term memory problems, severely impaired cognition, and never/rarely made decisions. The resident had frequent sharp pain rated at 8, (scale of 0 to 10 with 10 being worst) pain in the right extremities. The resident received PRN (as needed) and scheduled pain medication for pain control. The resident's pain was controlled for approximately 2 hours after receiving the medications. Nursing note on 02/15/2016 at 10:12 AM, documented the resident continued to complain of severe pain. PRN (as needed)medications were given as ordered. Repositioning the resident for comfort. The facility staff were trying to get an appointment with the resident's primary care provider physician today, at some point, to be re-evaluated. The nursing note on 02/16/16 at 09:59 AM, documented the resident continued to complain of right shoulder pain, right wrist, hip, and leg pain mostly on the right side. A physician appointment was made with the primary care provider for 10:30 AM this morning, to see about possibly getting reevaluated from post fall injury. The nursing note on 02/16/2016 at 12:43 PM, documented the resident had not returned from appointment with PCP, and was obtaining another x-ray at the hospital prior to return to the facility. Further notes at 1:08 PM, documented the x-ray from the hospital revealed a displayed fractured hip and the resident was being admitted to the hospital for the fractured hip. There were no observations of the resident during the investigation visit, as the resident's record had been closed with discharge from the facility. On 3/16/16 at 5:19 am, Direct care staff O, reported the resident was a fall risk. Before the resident's fall/fracture, he/she used a bed alarm and chair alarm, and would turn it off. If the staff heard it go off, they would go down to check the resident. He/She took the alarms off and would let you have it. The bed alarm scared him/her, and he/she would pull the chair alarm. All of the alarms were removed and he/she would have days where he/she could walk on his/her own, other days the resident was guided, and on other days he/she couldn't do anything. On 03/16/2016 at 5:22 PM, License nursing staff C, reported when someone falls, the staff obtain vital signs and assess the resident for any injury. The staff check to see if the resident hit their head, find out what they were doing at time of fall, do neurological checks if he/she hit their head or it was unwitnessed. The staff do the paper notifications of the doctor family and send the resident out to the hospital if injured. This resident was a frequent faller especially at night. He/She had already had several falls before she fell and fractured his/her hip. The charge nurse documented new interventions to prevent further falls on the care plan. On 03/17/2016 at 9:45 AM, Administrative nursing staff B, explained the staff use the, Call before you Fall, this was to remind the resident to call before a fall, and it was to have the resident remember you need to call before you fall. Staff B further explained not being sure if all of the staff knew what the, Call before you Fall, was. On 03/17/2016 at 9:47 AM, Direct care staff L, advised he/she did not know what the, Call before you Fall, meant. On 03/17/2016 at 9:47 AM, License nursing staff D, advised he/she did not know what the, Call before you Fall, meant, but would assume it would be about the call light and remind the resident to use them. However, staff D had not ever heard this phrase used before. On 03/17/2016 at 9:47 AM, Direct care staff M, advised he/she did not know what the phrase, Call Before you Fall, meant. On 03/17/2016 at 9:48 AM, Direct care staff N, advised he/she did not know what the phrase, Call before you Fall meant. He/She further reported he/she had worked here a long time and assumed it had to be about reminding the residents to use the call light, but he/she had not heard that phrase used or remember using the phrase here in the past. On 03/17/2016 at 10:02 AM, Administrative nursing staff B, advised the staff do not do a fall investigation but use the post fall assessment. The, Call before you Fall, was just a phrase the nurses may or may not use, and did not know it was on the assessment. The nurse would document or see the post fall assessment in the nursing note and that was where the details were. The nurse would have the staff do statements, but further explained those are usually not much, because most staff would say they were elsewhere or did not see the fall. On 03/17/2016 at 1:11 PM, License nursing staff D advised, in general before the fall/fracture, the resident was confused and would try to walk. He/she could walk independently at times, but not safely. In report staff D was told the resident had a non-injury fall that night. At that point, when the shift changed at 2:00 pm, the resident was in pain with any movement. The family wanted him/her to be seen by his/her physician and he/she got into see him/her that Tuesday. (3 days after the fall). On 03/17/2016 at 2;24 PM, Direct care staff M explained that before the fall the resident was independent, but needed help getting dressed and out of bed, but could walk independently with the walker until fall. After the fall he/she tried to use the walker. but couldn't and we used the wheelchair. The facility lacked a policy for accidents/falls. The facility failed to develop and implement appropriate interventions to prevent repeated falls for this confused resident, after a decline in ADL ability with back pain in January, 2016. The resident fell [DATE] and sustained a fractured hip.

The facility reported a census of 73 residents with 4 residents sampled. Based on observation, interview and record review, the facility failed to maintain adequate levels of hydration for the 3 resident ' s sampled for hydration, #1 who had to go to the hospital for dehydration (a state when the body loses more fluid than it takes in), #3 a resident with quadraparesis (weakness of all four limbs to the point of being limp) and dependent of staff for drinking, and #4, a resident with repeated urinary tract infections (UTIs). Findings included: - The physicians order sheet, dated 7/8/15, documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set, dated dated [DATE], documented the resident ' s Brief Interview for Mental Status score of 14, indicating cognitively intact, and required extensive assist of 1 staff for eating. The resident was frequently incontinent of bladder with no toileting program. The resident had a UTI in last 30 days and used a diuretic (medication to promote the formation and excretion of urine) on 5 out of 7 days. The admission nursing assessment, dated 6/24/15, documented the resident as confused, lethargic (extreme fatigue or drowsiness and a sign of dehydration) and was dependent on 2 staff for toileting. The resident ' s diet included regular liquids with use of sipper cup adaptive equipment and was incontinent of bladder. The record lacked a temporary care plan directing staff to provide the resident ' s care. Review of the nurse ' s notes, from 6/24/15 to 6/29/15, revealed the resident admitted with good skin turgor (skin on the back of the hand is pulled up for a few seconds and does not return to its original state, a decrease in skin turgor is a sign of dehydration), and declined to poor skin turgor within a few days. The nurse ' s notes also revealed consistent low blood pressure, ranging from 82/52 to 98/64 (normal range 120/80 to 140/90), a sign of dehydration. The nurse ' s note, on 6/27/15 at 8:48 AM, documented the resident's family requested the resident be sent to the hospital for evaluation due to the resident not acting normal. The vital signs prior to leaving for the hospital included a blood pressure of 98/54. The nurse's note, on 6/27/15 at 1:23 PM, documented the resident returned from the hospital with 1 liter of fluid given intravenously for dehydration. The hospital labs, dated 6/24/15 (the day the resident admitted to the facility), revealed normal BUN (Blood Urea Nitrogen) level of 15 (normal range is 7-18) and normal Creatinine level of 0.83 (normal range is 0.6-1.0). The resident's vital signs on discharge from the hospital, on 6/24/15 at 7:38 AM, documented a normal blood pressure of 110/73 . The hospital lab, dated 6/27/15, revealed a high BUN level of 25, and a high Creatinine level of 1.08, both indications of dehydration. The hospital discharge instructions, dated 6/27/15, documented the resident had dehydration, and directed the resident for the next 24 hours to drink lots of clear fluids, recommended 3 liters (3000 cubic centimeters) of fluid per day, drank frequently, every 15-20 minutes, in small amounts of 1 -2 ounces (1 ounce = 0.033 cubic centimeters). The nurse ' s note, dated 7/1/15 at 1:38 PM, documented a late entry for 6/29/15 as follows: at 12:30 PM the resident with slow speech, blood pressure of 61/43 and oxygen saturation low at 85% on room air (all signs of dehydration). The resident was sent to the hospital again by ambulance. The hospital History and Physical, dated 06/29/15, documented the resident admitted for [MEDICAL CONDITION] with probable low-grade continued mild volume deficit with the plan to administer IV (intraveneous) hydration. The progress note, dated 06/30/15, doucmented the resident's [DIAGNOSES REDACTED]. The fluid intake report documented the following, an average fluid intake of 217 cc (cubic centimeters) per day: 6/24/15 intake of 120 cc 6/25/15 intake of 460 cc 6/26/15 intake of 480 cc 6/27/15 intake of 240 cc No intake documented on 6/28/15 or 6/29/15. On 7/29/15 at 10:49 AM, Direct Care Staff J reported he/she provided care for the resident on 3 out of the 5 days the resident was in the facility. The resident would say he/she needed to void, then when placed on the bed pan, he/she would say they could not go. The resident really never urinated when staff toileted him/her. The resident also wore an incontinence brief, and when it staff changed the brief, it was almost always dry. Staff also pushed fluids using a sipper cup with a straw, but the resident had to have help with drinking. If staff handed the resident the cup, he/she really could not drink independently. The resident did not drink much at all between meals, even when staff offered fluids. Staff J reported the resident drank 60 cc between meals in a day, at the very most and received a glass of ice tea (240 cc) with every meal. The cup the resident used held approximately 240 cc, and the resident never drank it all in a full day, maybe 1/4 of it. Staff stated he/she was taught lethargy, confusion, a dry mouth, little amounts or no voiding, strong urine, and not drinking well were signs to report to the nurse as concerns of dehydration. The resident definitely had some of those signs, like not voiding enough and not drinking much. Staff J stated he/she did say something to the charge nurse about being concerned about those things, but the nurse told staff J the resident was just getting over a UTI. That was the same day the resident went out to the hospital for dehydration. On 7/29/15 at 11:28 AM, Licensed Nursing Staff F stated he/she was not aware there were hospital discharge recommendations in the resident ' s chart to push fluids. Staff reviewed the chart, confirming the recommendations, and stated there was not enough time to read all the papers that were on a resident from the hospital. Staff stated the recommendation should have been reported to the physician, written as a nursing order, and placed on the care plan for staff to follow. Staff confirmed this was not done. On 7/29/15 at 8:50 AM, Administrative Nursing Staff B reported the fluid intake charting documented fluid intake with meals, and does not include what the resident received with medication administration or what he/she received in between meals. Staff stated that adequate fluid intake per day would be 1500 cc minimum total. Staff B further stated he/she did not really know how much the resident drank between meals, so was unable to say if the resident received adequate amounts of fluid. Staff B was not aware of the signs of dehydration the nurse ' s had documented, and after reviewing the record stated the turgor declined from good to poor, lethargy and low blood pressures should have been identified by the nurses as a sign of dehydration and reported to the physician. The physician was unable to be reached for interview on 07/30/15 and 08/03/15. The facility provided policy for hydration, dated 8/1/12, documented each resident will be provided with sufficient fluid intake through dietary and nursing interventions to maintain proper hydration. Upon admission and throughout the resident ' s stay, facility staff assesses the resident for signs of adequate hydration and will be [MEDICAL CONDITION] of signs of dehydration or possible insufficient fluid intake (e.g., dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, and fever). Staff is to also be [MEDICAL CONDITION] for abnormal laboratory values. The facility recognizes that the resident may become at risk for dehydration due to various conditions, but not limited to fluid loss, functional impairments that make it difficult to obtain fluids independently and dementia where a resident forgets to drink or is unable to locate water. If staff recognizes that the resident is at risk for possible dehydration a problem shall be immediately noted on the care plan with approaches designed and implemented to promote and ensure adequate hydration. Approaches shall include at a minimum, notification of the physician, consultation with the resident or family, placement on intake and output monitoring, and notification of dietary for their enlistment in assistance with fluid provision as necessary. The facility failed to provide adequate fluid intake for this resident, with a history of UTIs, to prevent dehydration, which resulted in a hospitalization and administration of intravenous fluids to treat the dehydration. - The physician's order [REDACTED].#3 admitted to the facility with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set, dated dated [DATE], lacked an assessment of the resident ' s cognition and documented the resident required dependence of staff for eating. Staff identified the resident as quadriplegic (paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) and always incontinent of bladder. The record lacked a temporary care plan directing staff regarding activities of daily living (ADLs) care, including hydration needs or thickened liquids. The nurse's admission note, dated 7/21/15 at 1:10 AM, documented the resident admitted yesterday from the hospital with quadraparesis and spinal stenosis (a [MEDICAL CONDITION] condition of the spine that can cause weakness and loss of use of the extremities) and awaiting decompression surgery on the spine when spinal swelling decreased. The resident was blind, non-verbal, could not feed self, and required assist of 2 staff for all cares. The fluid intake report, from 7/21/15 to 7/29/15, documented an average of 722 cc (cubic centimeters) of fluid intake per day. (The recommended fluid intake for geriatric's is 1500 cc per day). On 7/28/15 at 10:50 AM, the resident lying in bed with head elevated to an upright position, mouth and lips appear dry with a white substance visible in the mouth. There was no water or drinks on the bedside table, or in the resident ' s room. Attempted to interview the resident, who showed no sign of understanding or communicating. On 7/28/15 at 10:54 AM, Direct Care Staff M and N entered the resident ' s room to provide care. The residents brief was changed and was visibly wet with urine. As both staff exited the resident ' s room, Staff N stated, I don ' t know where the resident ' s water is. Continuous observation of the resident ' s room for additional 30 minutes, until 11:30 AM, revealed no staff returned during that time with any water or fluids for the resident. On 7/28/15 at 12:05 PM, a small glass (approximately 4 ounce) containing a red thickened liquid sat on the resident ' s bedside table with a straw in it and was approximately 1/3 full. At 12:42 PM, there was no change in the level of the drink on the bedside table and the resident was breathing heavily through an open mouth. The resident's oral cavity, lips and tongue were visibly dry with a white substance coating the tongue and interior of the lips. On 7/28/15 at 1:15 PM, the red thickened drink remained on the bedside table, with no change in the level of the drink from the 12:05 PM observation. Also on the table were the following: a full glass covered in plastic wrap, approximately 4 ounces, containing a dark red fluid; a full glass with a straw in it, approximately 8 ounces, containing thickened red fluid; and a full glass covered in plastic wrap, approximately 8 ounces, with nectar 7/27 written on the plastic wrap. There was no staff present in the room. At 1:22 PM, 1:29 PM, 1:37 PM, 1:42 PM, 1:56 PM, 2:08 PM, 2:14 PM, and 2:34 PM, there was no change in the level of the drinks on the bedside table next to the resident. On 7/28/15 at 2:35 PM, a staff member brought the ice and water cart to the end of the hall, entered rooms on both sides of the resident's room and across the hall, but passed the resident's room without entering to check on the resident or to offer the resident assistance with the 4 drinks that remained on the bedside table, at that time. At 3:13 PM, there remained no change in the level of the drinks on the bedside table. The resident was observed open mouth breathing at that time, with no visible change in the oral cavity. On 7/28/15 at 3:15 PM, Direct Care Staff O and H entered the resident ' s room to provide care. Staff changed a visibly soiled and wet brief on the resident, gathered the trash, washed their hands and left the resident ' s room. Staff failed to offer drinks to the resident, at that time. On 7/28/15 at 3:25 PM, Direct Care Staff H reported the resident required total care for everything, was totally limp, could only move his/her head a little, was blind, cannot call for help or talk to staff to tell staff what he/she needs. Staff are supposed to stop in and check on the resident whenever they pass the room. Staff are to give the resident drinks, which are nectar thickened liquids, and are supposed to offer fluids every time staff are in the room. Staff H stated the resident loved water, hated orange juice, and had to have a straw in the cup to drink. Staff H confirmed that no fluids were offered to the resident when staff H and O provided care for the resident and when asked to look at the drinks on the table, staff H stated it did not appear that any of the drinks had been opened or drank from, except one, which was still about 1/3 full. Staff H was told in report today the resident did not eat any lunch and the drinks on the table were left over from the lunch. On 7/28/15 at 4:28 PM, the four drinks were gone from the resident's bedside table. At that time, there was now a large mug which was ½ full of ice and resting in the mug was a small, approximately 6 ounce, glass. The glass was full with a clear thickened liquid and covered with plastic wrap, dated 7/27 . There was no straw in the drink or on the table. On 7/29/15 at 7:09 AM, the resident was lying in the bed, open mouth breathing with the oral cavity visibly dry. The large mug, observed the night before, remained on the bedside table, now ½ full of water (melted ice), with an empty glass floating in the water. The glass remained covered with the plastic wrap dated 7/27 , and had a straw poked through the plastic. On 7/29/15 at 8:10 AM, Direct Care Staff K reported staff had provided toileting care for the resident around 7:20 AM, but did not offer the resident any fluids to drink, because the cup that was in the room was empty. On 7/29/15 at 9:29 AM, Direct Care Staff K assisted the resident with eating breakfast, which included 240 cc of orange juice, which the resident drank 100%, and 360 cc of water, which the resident only took a few sips of. Staff did not offer the resident more orange juice at that time. On 7/29/15 at 9:34 AM, Direct Care Staff K reported the resident was dependent on staff for all activities of daily living and drank about 700-800 cc of fluids per day, including with meals and between meals. On 7/29/15 at 2:16 PM, Licensed Nursing Staff D reported staff are expected to offer drinks to the resident every time they are in the resident ' s room. At 2:48 PM, staff D provided a visual observation of the resident, stating the resident appeared very dehydrated, with a dry oral cavity and the resident's skin, overall, had a very dry appearance. On 7/29/15 at 4:26 PM, Administrative Nursing Staff B reported fluids should be offered to all residents at snack time and any time staff are in a room providing care and drinks should be offered to all residents during the snack pass. The facility provided policy for Hydration, dated 8/1/12, documented each resident will be provided with sufficient fluid intake through dietary and nursing interventions to maintain proper hydration. Upon admission and throughout the resident ' s stay, facility staff assesses the resident for signs of adequate hydration and will be [MEDICAL CONDITION] of signs of dehydration or possible insufficient fluid intake (e.g., dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, and fever). Staff is to also be [MEDICAL CONDITION] for abnormal laboratory values. The facility recognizes that the resident may become at risk for dehydration due to various conditions, but not limited to fluid loss, functional impairments that make it difficult to obtain fluids independently and dementia where a resident forgets to drink or is unable to locate water. If staff recognizes that the resident is at risk for possible dehydration a problem shall be immediately noted on the care plan with approaches designed and implemented to promote and ensure adequate hydration. Approaches shall include at a minimum, notification of the physician, consultation with the resident or family, placement on intake and output monitoring, and notification of dietary for their enlistment in assistance with fluid provision as necessary. The facility failed to provide adequate fluid intake for this resident, dependent of staff for all care, to prevent dehydration. - The physician order [REDACTED].#4 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status score of 15, indicating cognitively intact, and required supervision of 1 staff for eating, extensive assist of 2 staff for bed mobility and toileting, total dependence of 2 staff for transfers, and extensive assist of 1 staff for locomotion using a wheelchair. The care plan, dated 7/7/15, directed staff to evaluate fluid intake and hydration status, and encourage the resident to drink fluids. The fluid intake report, from 7/1/15 to 7/29/15, documented a total of 21,462 cc fluid intake, or an average of 740 cc per day. Review of the laboratory tests revealed the resident with UTIs on 4/14/15 and 6/24/15. The most recent CMP (complete metabolic panel), dated 7/6/15, revealed a high BUN (Blood Urea Nitrogen) of 26 (normal range is 7-21), an indication of dehydration. On 7/28/15 at 12:03 PM, the resident, heard from approximately 20 feet down the hall from the resident's room, yelling out, Water please (pause), somebody get me some water (pause), water please. This was audible from the hallway. The yelling and moaning for help continued, Please, please help me, I need water, please. At 12:12 PM, Direct Care Staff K observed passing by the resident's room while the resident was yelling for help and entered the room next to the resident's, helped that resident, and walked back by the resident ' s open door without going in to help. A different staff member, Staff L, also walked by the open door without helping, while the resident could be heard yelling and moaning from the hallway. The resident appeared as morbidly obese, having difficulty to maneuver in the bed independently, lying on his/her back with the bed flat. The call light was tied to the upper part of the side rail on the right side of the bed above the resident ' s head and out of reach of the resident. There was no bedside table visible in the room and no drink or fluids within reach of the resident. At 12:18 PM, Direct Care Staff K entered the resident ' s room, told the resident to please be patient and someone would come back to help the resident soon. The resident apologized to the staff, who left the room without offering a drink, giving the resident the call light, or asking what the resident needed. Staff K returned to the resident ' s room at 12:32 PM (29 minutes after the resident was first heard yelling for help). The resident stated he/she needed water, when staff saw there was no cup in the room for water, staff left and returned with a cup of water, placing it on a bedside table. The resident reported, on 7/28/15 at 12:47 PM, he/she had to yell out for help for over an hour for something to drink earlier before lunch because he/she could not quite reach the call light and staff had not brought any water yet today. The resident stated staff often does not bring anything to drink and he/she has to beg for it. Staff also leave the call light where it cannot be reached so the resident has to holler out for help, and hates to do that because the staff tell him/her that he/she is not to yell for help, but the resident had no choice when the light was not where it could be reached. On 7/28/15 at 2:04 PM, the resident sat in the wheel chair in the middle of the room, with the water mug on the bedside table in front of the resident, and could be heard in the hallway hollering out loud for help. The resident's call light was still attached to the side rail on the bed and out of reach of the resident. At 2:17 PM, two staff entered the resident's room and asked if the resident needed assistance. The resident stated he/she wanted to lay down. Staff then used the hoyer mechanical lift to transfer the resident from the wheelchair to the bed. Staff began to change the resident ' s brief, but said they would leave it since it was dry. Staff asked if the resident wanted anything else, who stated, Water, please get me water. Staff checked the mug, which was empty and left with it to refill it. Staff returned a short time later, and placed the mug within the resident's reach. On 7/29/15 at 7:14 AM, the resident was lying in bed resting, the bedside table was towards the foot of the bed and pushed away from the bed approximately 2 feet, out of reach of the resident. A mug was on the table, ½ full of water. On 7/29/15 at 8:43 AM, Direct Care Staff K and L entered the resident ' s room to provide care, left the room, and did not move the water within reach of the resident. At 9:34 AM, no change. At 9:51 AM, the bedside table with water on it had been moved next to the resident ' s bed, but the water mug was on the far side of the table, on the corner towards the head of the bed. The resident was repeatedly observed reaching for the mug, but unable to reach it. The resident stated he/she was very dry and thirsty. Staff L entered the resident's room, saw him/her reaching for the mug and handed it to the resident. On 7/29/15 at 10:12 AM, Direct care staff L stated the resident yells out for help so often it is just a behavior. Usually, the resident does not really need anything when staff go in to check. Staff L stated the call light and drink should always be left in the resident ' s reach when staff leave the room. Staff confirmed the resident was not able to reach the call light when it is tied high on the side rail of the bed, which is where it was usually left, and that the drink was out of the resident's reach when staff entered the room. On 7/28/15 at 3:25 PM, Direct Care Staff H stated the resident had lots of anxiety and was demanding, if staff does not respond in 2 seconds, the resident screams at staff. Staff try to keep the resident happy. The resident required total lift and 2 person assist for activities of daily living (ADLs), is incontinent, will use call light, and often screams out for help, because he/she was confused. On 7/29/15 at 2:16 PM, Licensed Nursing Staff D reported the resident yells, Help, help, help constantly and had anxiety that is extremely high. The resident frequently gets UTI's, is incontinent of bladder, and is very weak. On 7/29/15 at 4:26 PM, Administrative Nursing Staff B reported fluids should be offered to all residents at snack time and any time staff are in a room providing care. The facility provided policy for Hydration, dated 8/1/12, documented each resident will be provided with sufficient fluid intake through dietary and nursing interventions to maintain proper hydration. Upon admission and throughout the resident ' s stay, facility staff assesses the resident for signs of adequate hydration and will be [MEDICAL CONDITION] of signs of dehydration or possible insufficient fluid intake (e.g., dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, and fever). Staff is to also be [MEDICAL CONDITION] for abnormal laboratory values. The facility recognizes that the resident may become at risk for dehydration due to various conditions, but not limited to fluid loss, functional impairments that make it difficult to obtain fluids independently and dementia where a resident forgets to drink or is unable to locate water. If staff recognizes that the resident is at risk for possible dehydration a problem shall be immediately noted on the care plan with approaches designed and implemented to promote and ensure adequate hydration. Approaches shall include at a minimum, notification of the physician, consultation with the resident or family, placement on intake and output monitoring, and notification of dietary for their enlistment in assistance with fluid provision as necessary. The facility failed to provide adequate fluid intake for this resident, with frequent UTIs and dependent on staff for all care, to prevent dehydration.