Every finding on record at Diversicare of Larned

The facility reported a census of 44. Based on observation, interview and record review the facility failed to provide adequate infection control practices related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), hand hygiene and sanitizing shared equipment. Findings included:- Initial tour of the facility on 01/06/26 at 08:00 AM revealed a lack of visible signage to identify residents who required EBP. The facility had no visible setup for personal protective equipment (PPE) readily accessible to staff to apply before entering residents' rooms to provide direct care. During an observation 01/07/26 at10:16 AM, Licensed Nurse (LN) J and LN G entered the Resident (R) 2's room to provide catheter (tube inserted directly into the body to drain urine) care. The room lacked signage to indicate R2 required EBP. R2's room lacked the required EBP personal protective equipment (PPE) (gowns). There were gloves available in the room. R2's catheter bag laid on the floor. LN J picked up the catheter bag from the floor and hung it on the low bedrail, where it remained in direct contact with the floor. She washed her hands, applied gloves, and proceeded to provide catheter care. She cleaned the resident's catheter insertion site with gauze. The gauze was soaked with saline in a cup. LN J reached into the cup for saline-soaked gauze three times, wearing the same soiled gloves, each time continuing to use the gauze to clean the catheter insertion site. During an observation on 01/07/26 at 09:44 AM, Certified Nurse Aide (CNA) P and CNA M assisted R31 to bed with a mechanical lift. CNA M undressed R31's lower half and reported to CNA P that R31 was incontinent. CNA P opened a drawer with her gloved hands and got items out of the drawer, then proceeded to provide incontinent care to R31. Wearing the same gloves, CNA P sprayed peri wash directly on R31's perineum, then wiped with a wet wipe from a container while R31 remained on the soiled wet brief. Staff assisted R31 onto her left side. CNA P removed her gloves, then took another pair out of her pocket and applied them, without performing hand hygiene. CNA P cleaned R31 with a wet wipe, then applied a new brief and removed her gloves. Without performing hand hygiene, CNA P assisted R31 with positioning in bed and then used hand sanitizer. CNA P then picked up the bag of trash and took the trash as well as the mechanical lift out of the room. CNA P placed the lift in the hallway but did not sanitize it. CNA M finished placing the fall mat next to R31's bed, lowered the bed, then washed her hands and left the room. In an interview on 01/07/26 at 10:10 AM, CNA Q reported the staff probably did not always sanitize the mechanical lifts as they should. He reported the sanitizing wipes were stored in the biohazard rooms or clean rooms. During an interview on 01/08/26 at 07:55 AM with CNA P and CNA M, CNA P reported she would normally wash her hands when she changed her gloves and said she should have changed her gloves when she gathered supplies. CNA M reported they normally do not wipe off the lift after use. On 01/07/26 at 10:36 AM, LN I confirmed she did not remove her gloves and wash her hands before reapplying gloves. She said R2's catheter bag was directly on the floor and should have been changed to prevent cross-contamination and infection. LN I confirmed R2's room lacked signage to indicate EBP were required, and said none of the residents in the facility were set up for EBP. On 01/08/26 at 10:24 AM, Administrative Nurse D confirmed the catheter bags should not be placed directly on the floor, and if the bag and/or tubing come in direct contact with the floor, it should be replaced to prevent cross-contamination and infection. Administrative Nurse D confirmed none of the residents were identified as requiring EBP at the initiation of the survey. She reported four residents with indwelling catheters and one with wounds which should have EBP with readily accessible PPE and signage on the door to make staff aware. She stated staff should sanitize the lifts between resident use and perform appropriate hand hygiene to prevent cross-contamination and infection. The facility's Infection Control Guide dated 2025 included EBP referred to the expanded use of PPE and use of gown and gloves during high contact resident care activities which provide opportunities for transmission of multiple drug-resistant organisms (MDRO) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during high-contact care activities. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization of MDRO. Laminated signs should be placed on the resident's door to remind visitors and healthcare workers of needed precautions.

The facility reported a census of 44 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care and facial hair removal for Resident (R) 31. Findings included:- R31 's Electronic Medical Record (EMR) revealed diagnoses of 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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and dementia (a progressive mental disorder characterized by failing memory and confusion). R31's 05/13/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R31's MDS documented she had an impairment in her upper and lower extremities on one side. R31's MDS documented she required total assistance with all ADL, except she required setup for eating. R31's 05/14/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R31 triggered related to assistance required with ADLs. R31's 11/07/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. R31's MDS documented an impairment in her upper and lower extremities on one side. R31's MDS documented she required total assistance with all ADLs, except she required setup for eating. R31's 01/06/26 Care Plan lacked any care plan regarding facial hair and nail care. Review of R31's Bath and Shower Report sheets dated from 11/05/25 through 12/31/25 revealed facial hair removal was checked off as no, indicating it was done on all 13 shower report sheets. Additionally, R31's fingernails short/trimmed was checked off yes on 11/05/25 and checked off no for the remaining 12 shower reports. The facility lacked the shower reports for January 2026. During an observation on 01/06/26 at 11:30 AM, R31 sat in her wheelchair in the facility lounge. She had visible black and white colored facial hair approximately one-quarter inch in length above her upper lip. R31's fingernails were long on her right hand, and she had visible brown colored residue under most of her fingernails. During an observation on 01/07/26 at 08:05 AM, R31 sat in her wheelchair in the facility lounge. She had visible black and white colored facial hair approximately one-quarter inch in length above her upper lip. R31's fingernails were long on her right hand, and she continued to have visible brown colored residue under most of her fingernails. During an observation on 01/08/26 at 07:45 AM, R31 sat in her wheelchair in the facility lounge. R31's facial hair and nails were unchanged from the 01/06/25 and 01/07/25 observations. During an interview on 01/07/26 at 09:52 AM, Certified Nurse Aide (CNA) M reported she would assist R31 with ADLs around 06:15 AM every day. During an interview on 01/07/26 at 03:54 PM, CNA N reported the staff would complete nail care and facial hair removal on bath days or as needed. CNA N reported R31 received a shower on Wednesday and Saturday afternoon shifts. During an interview on 01/08/26 at 10:26 AM, Licensed Nurse (LN) I stated she expected the CNAs to shave and complete nail care for the residents who required assistance. During an interview on 01/08/26 at 11:12 AM, Administrative Nurse D revealed she expected the staff to shave and complete nail care for residents every shower day or as needed. The facility did not provide a policy for ADL care for a dependent resident.

The facility identified a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 1's antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medication and R31's activities of daily living (ADLs) for a dependent resident. Findings included:- R1's Electronic Medical Record (EMR) revealed diagnoses of bipolar disorder (a major mental illness which causes people to have episodes of severe high and low moods) and depression (a mood disorder which causes a persistent feeling of sadness and loss of interest). R1's 05/09/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, which indicated intact cognition. R1's MDS documented no behaviors and minimal depression. R1's MDS recorded R1 received an antianxiety (a class of medications which calm and relax people) and an antidepressant (a class of medications used to treat mood disorders) in the look-back period. R1's 05/12/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R1 triggered related to use of psychotropic medications to manage psychiatric condition. A care plan will be developed and/or reviewed to monitor the effectiveness of psychotropic medications. R1's 10/24/25 Quarterly MDS documented a BIMS score of 15, which indicated intact cognition. R1's MDS revealed R1 received an antianxiety and antidepressant medication in the look-back period. R1's 01/06/26 Care Plan lacked documentation for an antipsychotic medication. R1's Physician's Orders documented Seroquel (antipsychotic medication) 50 milligrams (mg), give one tablet, by mouth, daily for bipolar, date ordered 11/20/25, date discontinued 12/04/25. R1's Physician's Orders documented risperidone (antipsychotic medication) 0.25 mg, give one tablet twice a day for behaviors, date ordered 12/04/25. R1's Progress Notes, documented 11/20/25 at 11:53 AM, noted R1 was assessed by the provider who gave new orders to increase the Seroquel to 50 mg at bedtime. R1's Physician Notes on 12/04/25 documented R1 had been having aggressive behaviors and a lot of anger recently. She did have a history of bipolar disorder and anxiety. She was started on Seroquel previously, but the staff stated this had not made a difference in her behavior. R1 reported she was pushing her walker and pushing other things because she was mad. Staff reported she was very angry and said mean things to others. During an observation and interview on 01/06/26 at 09:33 AM, R1 ambulated independently down the hallway with her walker. R1 reported she was quite anxious about a surgery which had to be rescheduled from 01/08/25 to 01/29/25. R1 had a flat affect at first and refused an interview, but then she said she would interview. R1 reported she can get very angry quickly for no reason. She reported she really had no one here to talk to her about her feelings. During an observation on 01/07/26 at 08:08 AM, R1 was seated in her chair in the dining room, drinking coffee and socializing with other peers. During an interview on 01/08/26 at 10:26 AM, Licensed Nurse (LN) I reported care plans were developed and updated by Administrative Nurse D. During an interview on 01/08/26 at 10:52 AM, Administrative Nurse D reported R1's antipsychotic medications should have been documented on the care plan within twenty-four hours. The facility did not provide a policy for care plan development. - R31 's Electronic Medical Record (EMR) revealed diagnoses of 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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and dementia (a progressive mental disorder characterized by failing memory and confusion). R31's 05/13/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R31's MDS documented she had an impairment in her upper and lower extremities on one side. R31's MDS documented she required total assistance with all activities of daily living (ADL) and needed setup for eating. R31's 05/14/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R31 triggered related to assistance required with ADLs. R31's 11/07/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. R31's MDS documented impairment in her upper and lower extremities on one side. R31's MDS documented she required total assistance with all ADLs except she needed setup for eating. R31's 01/06/26 Care Plan lacked any care plan regarding facial hair and nail care. During an observation on 01/06/26 at 11:30 AM, R31 sat in her wheelchair in the facility lounge. She had visible black and white colored facial hair approximately one-quarter inch in length above her upper lip. R31's fingernails were long on her right hand, and she had visible brown colored residue under most of her fingernails. During an observation on 01/07/26 at 08:05 AM, R31 sat in her wheelchair in the facility lounge. She had visible black and white colored facial hair approximately one-quarter inch in length above her upper lip. R31's fingernails were long on her right hand, and she continued to have visible brown colored residue under most of her fingernails. During an observation on 01/08/26 at 07:45 AM, R31 sat in her wheelchair in the facility lounge. R31's facial hair and nails were unchanged from the 01/06/25 and 01/07/25 observations. During an interview on 01/07/26 at 03:54 PM, Certified Nurse Aide (CNA) N reported she would read the resident's care plan to know what care was required for a resident. During an interview on 01/08/2026 at 10:26 AM, Licensed Nurse (LN) I reported care plans are developed and updated by Administrative Nurse D. During an interview on 01/08/26 at 10:52 AM, Administrative Nurse D reported R31's Care Plan did not address any personal hygiene staff needed to provide. Administrative Nurse D reported she expected the care plans to be accurate so care would be provided to the residents. The facility did not provide a policy for care plan development.

The facility reported a census of 45 residents. The sample included 12 residents with two residents reviewed for facility discharge. Based on interview and record review e facility failed to complete a recapitulation of Resident (R) 47's stay in the facility. Findings included:- R47's Electronic Medical Record (EMR) revealed the following diagnoses: atherosclerotic heart disease (heart disease) and type two diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). R47's 10/02/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The MDS recorded R47 required supervision or touching assistance with toileting, and substantial/maximal assistance with bathing. R47's Care Plan identified a self-care deficit related to recent surgery. R47's endurance was low from the surgery; R47 had difficulty with ambulation over long distances and directed staff to offer a wheelchair and assist the resident to the dining room if needed. Staff were to provide supervision and touching assistance with the following tasks: toileting, showers, lower/upper dressing, footwear, sit-to-stand transfers, and ambulation with a front-wheeled walker. R47's Progress Note on 11/23/25 at 4:47 PM indicated R47 left the facility with a family member at approximately 4:45 PM with his four-wheeled walker, personal belongings, and medication. R47 ambulated independently with a walker out of the facility. R47's clinical record lacked evidence of a completed recapitulation outlining the course of his facility. On 01/08/26 at 08:00 AM, Social Services X revealed she sends out the monthly fax to the Ombudsman with discharges from the facility or hospitalization of our residents. On 01/08/26 at 08:27 AM, Administrative Staff D revealed the facility does not have a discharge summary system and verified the facility did not fill out the discharge summary or recapitulation of R47's stay. The facility failed to provide a policy on discharge.

The facility had a census of 44 residents. The sample included 12 residents with one reviewed for missing personal property. Based on observation, record review, and interview, the facility staff failed to document and promptly resolve Resident (R) 7's grievance when she reported to staff she had missing clothing items. Findings included:- R7's Electronic Medical Record (EMR) documented R7 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and depression (a mood disorder which causes a persistent feeling of sadness and loss of interest). R7's Significant Change in Status Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R7 was dependent and required substantial/maximal assistance for activities of daily living (ADLs). A review of the Resident Grievance/Complaint Log from 10/1/25 to present, provided by Social Services X, lacked documentation of R7's grievance regarding missing clothing items. There were three concerns of missing items, and two had been resolved favorably. An interview on 01/06/26 at 02:30 PM, R7's representative stated R7 had two brand new sweaters given to her as a Christmas gift, with the price tags still on them. R7's representative stated she informed an (unnamed) nurse aide and Administrative Staff A in December as soon as she discovered both sweaters were missing from R7's closet, though she was unsure of the exact date. On 01/08/26 at 10:26 AM, Administrative Staff A stated he was aware of the missing sweaters but said it probably was not documented anywhere. He said the issue was discussed with R7's representative multiple times. Administrative Staff A stated the situation remained unresolved and said despite the ongoing nature of the situation and the lack of documentation, the facility had full intentions of resolving the situation. On 01/08/26 at 10:35 AM, Social Services X verified she was notified of R7's missing sweaters at the Christmas party. Social Services X said staff were alerted to look for the sweaters at the time, though they were not found. Social Services X said the staff found a similar sweater and placed it into the resident's closet, but the staff did not notify the resident's representative. Social Services X stated she did not realize the missing sweaters were an ongoing issue. Social Services X verified an official grievance had not been logged regarding the situation. On 01/08/26 at 11:02 AM, Housekeeping/Maintenance U verified she was notified about R7's missing sweaters at the Christmas party. She said she looked in the laundry and other residents' closets but was unable to find them. Housekeeping/Maintenance U stated she found a black and maroon sweater, not exactly fitting the description of the missing sweaters with R7's name written on the tags, so they were put in the resident's closet. She stated she thought the issue was resolved. The facility's policy Customer Concern/Grievance Policy dated July 2018, states the resident (or representative) will have a prompt response, with follow-up communication within 48 hours, after the Administrator conducts a full investigation and composes a plan of action completed (with the customer) and have the plan documented, which involves a resolution.

The facility reported a census of 44 residents. Based on observation, interview and record review the facility failed to provide a safe, functional, and sanitary environment in the laundry area. Findings included:- The laundry tour on 01/08/2026 10:54 AM, with Laundry Staff U, Consultant GG, revealed the following concerns:A large yellow trash bin full of trash, without a cover, sat next to the washing machine.The laundry room ceiling had a brown discolored area adjacent to peeling paint and a strip of unfinished plaster without paint, approximately four feet by 10 inches above the dump tank.The folding room ceiling had a brown water stain approximately two feet by two inches along the junction of the ceiling to the wall over the folding table.On 01/08/2026 at 11:10 AM, Maintenance Staff V confirmed the above findings and reported the stains had occurred when the pipes froze. He stated he did not have a plan to repair the areas noted above.The facility policy Infection Control, dated 5/2025, documentation included the center's infection control policies and practices, which are intended to facilitate maintaining a safe, sanitary, and comfortable environment for team members.

The facility reported a census of 46 residents. The sample included 16 residents, which included four residents sampled for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate to identify causal factors of falls and/or initiate/implement immediate, appropriate interventions to prevent further falls for three sampled dependent residents, including Resident (R)15, related to a lack of wheelchair pedals for support while staff propelled the resident; R27, who experienced a fall with an inappropriate intervention; and for the multiple falls experienced by cognitively impaired R2, with the most recent fall resulting in major injury with two fractured (broken bone) vertebrae (bones of the spine). Findings included: - Review of R2's Physician Orders, dated 12/13/23, included diagnoses of fractured thoracic (middle section of the spine) vertebra, repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), need for assistance with personal care, lack of coordination, cognitive communication deficit, unsteadiness of feet, urinary incontinence, peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hypertension (high blood pressure), overactive bladder, and gait (manner or style of walking) and balance abnormalities. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The resident required substantial/maximal assistance of staff for bed mobility, transfers, and toileting. She had no functional limitations in range of motion of the upper or lower extremities. She was always incontinent of bowel, occasionally incontinent of urine, and did not have a toileting program. She experienced two or more non-injury falls and one fall with major injury. The resident received Occupational Therapy (OT) for four days and Physical Therapy (PT) for four days of the look back period. The Discharge Return Anticipated MDS dated [DATE], documented the resident transferred to an acute care hospital on 11/27/23. The Entry MDS dated [DATE], documented the resident returned to the facility on [DATE]. The Cognitive Loss/ Dementia, Communication, and Falls Care Area Assessments (CAA), dated 09/15/23, documented the resident lacked orientation with memory and recall deficits related to dementia, change in mental status, and short term/long term memory loss. She had a history of falls prior to admission, weakness, and physical performance limitations that affected balance, gait, strength, and muscle endurance. The Care Plan dated 12/22/23, included the following interventions: On 05/21/19, staff were to remind the resident to lock the brakes on the wheelchair before transfers. On 08/13/19, R2 experienced episodes of incontinence due to an overactive bladder if not toileted timely . (The care plan lacked any instruction staff on when to toilet the resident.) On 11/07/22, therapy was to screen, and staff would initiate a bladder diary to determine a toileting schedule. On 01/26/23, staff were to know the resident had a diagnosis of dementia and exhibited some restlessness and anxiety prior to a fall. R2 wandered into the wrong room and attempted to transfer to a bed unassisted. Nursing staff were to monitor the resident for behaviors every shift. If R2 was restless or anxious, staff were to report to the nurse to assess and treat. Staff would repeat urinalysis (UA). In addition, staff were to adjust the resident's bed height to a lower position for improved transfers. On 01/28/23, therapy assessed the resident's wheelchair, R2's positioning in the wheelchair, and therapy adjusted the wheelchair. Staff were to remind her to call for assistance for bathroom use. On 08/16/23, the facility asked R2's family to take Crocs (rubberized slip-on shoes) home. Staff were to encourage the resident to wear her tennis shoes. Staff would know the resident liked to wear her Crocs and remind her that they were not the safest footwear. Staff should remind the resident she cannot get up on her own and would know she may forget and may need reminders. On 09/19/23, nursing staff were to encourage the resident to utilize the grab bar in the shower room and ensure the wheelchair brakes locked before transferring the resident to the shower chair. On 09/20/23, R2 moved around the facility by self-propelling her wheelchair and would take assistance from staff if offered. The resident used bed rails to reposition and to get in and out of bed. The resident no longer used her walker for locomotion, but occasionally used the walker for transfers. The resident required two staff for transfers using a transfer belt and/or a mechanical lift as needed. Staff were to know the resident was forgetful and did not remember she needed assistance transferring. Staff were to keep pathways clear and decrease clutter to minimize the risk of falls. Staff were to keep the resident's wheelchair beside the bed. Staff were to ensure the resident wore secure footwear when out of bed. She sometimes lost her gripper socks and/or placed unsafe slippers over the gripper socks. Staff were to assist the resident in putting gripper socks back on. On 10/09/23, staff were to obtain a UA for the resident. On 11/14/23, staff were to lay R2 down after meals to prevent confusion and ensure safety. Review of the Progress Notes and Fall Investigation Reports revealed the following concerns related to falls experienced by R2: On 07/03/23 at 06:45 AM, the resident adjusted herself in the wheelchair and started to fall forward. Staff were able to catch the resident and assist her to the floor on her buttocks. The fall investigation report failed to identify causal factors to determine an immediate and appropriate intervention to prevent further falls. On 08/13/23 at 07:33 AM, two unidentified residents reported R2 got up from her wheelchair and fell . The intervention was to have family take R2's Crocs home and utilize sneakers. On 08/15/23 at 01:30 PM, an unidentified CNA reported R2 had an unwitnessed fall from the toilet, resulting in a goose egg sized, raised area to the back of the resident's head. The documentation noted the casual factor of the fall as the resident was impulsive and sometimes confused and should not be left on the toilet by herself. She had uneven balance and did not have her walker at the time of the fall. The facility educated the unidentified CNA regarding the importance of staying with a dependent, cognitively impaired resident while the resident was on the toilet and to provide supervision, to prevent falls. On 09/16/23 at 08:10 PM, R2 reported she attempted to transfer from the sofa to the wheelchair and fell to the floor. The fall was not witnessed, and the resident was noted to have severe cognitive impairment. The investigation lacked a causal factor and immediate appropriate intervention to prevent further falls. The facility placed an intervention to provide the unidentified CNA education. On 09/19/23 at 09:05 PM, an unidentified CNA reported they found R2 on the floor wearing a gown and socks. The resident reported she started to sit down, missed the chair, and landed on the floor. On 10/08/23 at 11:15 PM, staff found the resident sitting on the floor in front of the bathroom. The investigation report failed to provide an immediate intervention to prevent further falls. On 11/16/23 at 03:00 PM, the resident attempted to toilet herself and fell to the floor landing on her backside. She hit her head, causing a goose egg, which measured approximately two centimeters around, to the back of her head. The facility placed an intervention to prevent further falls, which included instructions to staff to remind the resident to use her call light for assistance for transfers and to ensure the resident used non-slip footwear. Review of the resident's care plan revealed both interventions were already implemented following previous falls. The Investigation Report, lacked a new immediate intervention to prevent further falls. The Progress Note dated 11/27/23 at 01:30 PM, revealed R2 was in her wheelchair when an unidentified Certified Nursing Assistant (CNA) served the resident's meal at 01:00 PM and left the room. Approximately five minutes later, an unidentified CNA heard a crash and found the resident on the floor with the bedside table on top of her. The nurse assessed the resident and called 911 for transport to the emergency room (ER). The Progress notes dated 11/27/23 at 05:30 PM, documented the nurse received a call from the ER with a resident status update. She had fractures of thoracic spine. The Hospital Discharge Summary dated 11/30/23, documentation included the resident sustained a fracture of the 10th and 11th vertebra of the thoracic (bones of the spine (mid back) following a fall on 11/27/23 at the nursing facility. Review of the R2's Electronic Medical Record, (EMR) from 07/01/23 through 01/10/24, revealed the resident had a history of falls and experienced eight falls in the five months prior to the fall on 11/27/23 at 01:05 PM, which resulted in two fractured thoracic vertebrae. Observation on 01/10/24 at 11:03 AM, revealed the resident sat in the wheelchair in the commons area. She wore multicolored Crocs, with her feet on the pedals of the wheelchair. A brace was visible beneath her shirt, that covered her chest wall. On 01/11/24 at 09:30 AM, observed Certified Nurse Aides (CNA) P, CNA MM, and CNA NN transferred and provided toileting to R2. The staff transferred the resident to the toilet with a gait belt. R2 wore Crocs on her feet. The staff reported she wore her crocs all the time. On 01/11/24 at 09:30 AM, CNA P reported the resident was at risk for falls and had several falls. The resident used to walk, and the staff could walk her back and forth to the bathroom but stated R2 had not walked in almost a year. CNA P said when a resident fell , the nurse should put an immediate intervention in place to prevent further falls. CNA P said the new interventions should be added to the care plan, and staff have access to the care plan for directions on caring for the resident. On 01/17/24 at 10:13 AM, Licensed Nurse (LN) I stated when a resident fell , the charge nurse should do an assessment, which included vital signs, range of motion, and a head-to-toe skin assessment. If the fall was not witnessed or the resident hit their head, staff should complete a neurological assessment. The nurse should notify the physician, the resident representative, and the Director of Nursing. The charge nurse should initiate an investigation at the time of the fall to determine the cause. An immediate new and appropriate intervention should be put in place and communicated to the staff. LN I stated a resident with dementia was not a reliable reporter for the cause of the fall and it would not be appropriate for a resident with dementia to use an intervention to remind the resident to use a call light. A resident that required assistance with transfers to the toilet and was cognitively impaired should not be left unattended in the bathroom. Staff should use the resident's care plan for guidance for fall interventions. New staff were not familiar with long term care and the system to put new appropriate interventions on the resident's care plan immediately to prevent further falls. On 01/17/24 at 01:15 PM, Administrative Nurse D stated on 11/27/23, R2 had an unwitnessed fall. The investigation revealed the probable cause was due to the resident reached for the wheeled end table and she fell . Administrative Nurse D stated the resident had a diagnosis of dementia and a history of multiple falls due to her poor impulse control where she would try to stand, transfer, and toilet herself without staff assistance. Staff had R2 transported to the hospital for an evaluation and R2 was admitted due to fractured vertebras. She was sent back to the facility with a brace to stabilize her fractured vertebrae. Staff removed the wheeled table from the resident's room and replaced it with a stationary table. The charge nurse should initiate a new immediate and appropriate fall intervention to prevent further falls. The resident's BIMS score should be 13 or higher for resident education to be an appropriate intervention. R2's interventions were not appropriate, and no new interventions were put in place to prevent further falls prior to the resident falling on 11/27/23, which resulted in fractures. The 02/2017 facility's policy for Clinical Care Systems Guidelines for Falls did not address initiating a new, immediate, and appropriate intervention based on causal factors of each fall experienced by a resident, in order to prevent further falls. The facility failed to thoroughly investigate to identify causal factors of the fall and/or initiate/implement, new immediate, appropriate interventions to prevent further falls for cognitively impaired R2, who had multiple falls, one of which resulted in two fractured vertebrae. 28560 - Review of Resident (R)15's Physician Order Sheet dated 12/13/23, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). . The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired decision making. The resident was rarely/never understood. The resident the resident was able to wheel herself in her wheelchair and was dependent on staff for transfers. The resident had no impairment in the upper or lower extremities. The Cognitive Loss Care Area Assessment (CAA), dated 10/27/23, assessed the resident was unable to always make her needs known. Staff assist the resident with all cares and the resident self-propelled herself to/from the dining room. The Falls CAA, dated 10/27/23, triggered secondary to impaired gait and mobility and level of assistance required with transfers. Contributing factors includes history of falls prior to admission, weakness and physical performance limitations affecting balance, gait, strength, and muscle endurance. The Care Plan reviewed 11/02/23, instructed staff the resident propelled herself in her wheelchair but did need assistance with direction. The resident was at high risk for falls, had weakness and poor understanding of safety issues. Observation, on 01/10/24 at 12:25 PM, revealed Certified Nurse Aide (CNA)Z propelled the resident in her wheelchair which lacked foot pedals, to the dining room. The resident thighs were slouched forward from the seat bottom. her knees were bent under the wheelchair, and her feet skimmed along directly touching on the floor. Observation, on 01/17/24 at 11:25 AM, revealed the resident seated in her wheelchair with her thighs slouched forward from the seat bottom of the wheelchair and she attempted to propel herself about in the common living area. Administrator A at that time, propelled the resident to the dining room without foot pedals on the chair and her feet skimmed along directly touching on the floor. Administrative Staff A obtained foot pedals for the resident's wheelchair, but the resident was unable to keep her feet on the pedals due to posture. Interview with Administrative Staff A revealed the resident needed a wheelchair seating evaluation as the resident usually propelled herself and took the pedals off the chair stating staff should guide the resident to the dining room while she propelled herself. Administrative Staff A stated when staff propel her, her feet should be on wheelchair pedals. Interview, on 01/17/24 at 11:28 AM, with Consulting Staff GG, confirmed the need for a wheelchair evaluation. Observation, on 01/17/24 at 11:32 AM, revealed CNA Q propelled the resident to the dining room in her wheelchair without foot pedals. The resident could not hold her feet up off the floor consistently and her feet skimmed the floor. Interview at that time with CNA Q revealed the resident slouched in her wheelchair, and thought the resident needed a different wheelchair. CNA Q stated the resident could propel herself, but often became confused and could not follow directions. The facility did not provide a policy for use of wheelchair pedals. The facility failed to ensure proper wheelchair seating seating/positioning/foot pedals to prevent accidents for this resident when staff aided with propelling to avoid injury as the resident's feet skimmed along directly touching on the floor under the wheelchair. 34056 - The Physician Order Sheet (POS), dated 01/02/24, for Resident (R)27, documented a diagnosis of weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair. He had no limitations in his range of motion (ROM) and no falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 08/02/23, documented the resident had a history of falls due to weakness and had impaired gait and mobility which required him to have staff assistance with transfers. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair and had no limitation in his ROM. He had one fall with injury (except major) since his prior assessment. The falls care plan, revised 01/08/24, instructed staff that the resident would forget he was unable to stand on his own, creating possible safety risks. Staff were to help remind him of safety issues. He had anti-tip brakes applied to his wheelchair to prevent the wheelchair from rolling backwards if he did attempt to stand up on his own. Staff were to keep the resident in the front commons area between meals. The resident received physical therapy (PT) following a prior fall. Review of the resident's EMR revealed Fall Assessments which placed the resident at a high risk for falls, dated: 06/11/23, 09/11/23 and 10/30/23. Review of a Fall Report, dated 12/23/23 and provided by the facility, revealed the resident had a witnessed fall on 12/23/23 in the front commons room when he attempted to stand up from his wheelchair, took a couple of steps and fell to the floor, landing on his right side. The resident had a decrease in his ROM on his right upper extremity and was transported to the ER for evaluation, where it was found he had a re-fracture of his right clavicle (collar bone). Staff were following all fall interventions at the time of the fall. The new intervention for the fall was to obtain a urine sample for a urinalysis (UA-lab analysis of urine) to check for a urinary tract infection (UTI-an infection in any part of the urinary system). Review of the resident's EMR lacked a lab result for the UA which had been ordered on 12/23/23. On 01/17/24 at 01:15 PM, Administrative Nurse E stated the facility had failed to obtain a UA to send to the lab for analysis at the time of the fall. Administrative Nurse E stated that had been an inappropriate fall intervention. The facility policy for Falls, dated February 2017, included: The interdisciplinary team (IDT) will review the post fall investigation and summarizes the team recommendations for interventions. The facility failed to initiate an appropriate fall intervention following an injury fall for this dependent resident to prevent further falls.

The facility reported a census of 46 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, 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 licensed nursing staff coverage 24 hours a day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the third quarter of fiscal year (FY) 2023, (04/01/23-06/30/23), revealed the lack of a License Nurse (LN) for 24 hours/seven days a week (24/7) on 04/01 Saturday (SA); 04/09 Sunday (SU); 04/15 (SA); 04/29 (SA); 04/30 (SU); 05/13 (SA); 05/14 (SU); 05/20 (SA); 05/27 (SA); 05/28 (SU); 06/04 (SU); 06/18 (SU); 06/24 (SA); and 06/25 (SU). Review of the facility's time sheets for licensed nursing staff on the above dates, revealed the facility had the required licensed nursing staff 24 hours each day, as required. However, the facility reported inaccurate staffing data, as required, on seven days of the above quarter. Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) 2023, for the fourth quarter of 2023, (07/01/23-09/30/23), revealed the lack of a License Nurse (LN) for 24 hours/seven days a week 24/7) on 07/02 (SU); 07/08 (SA); 07/15 (SA); 07/29 (SA); 08/12 (SA); 08/19 (SA); 08/27 (SU); 09/02 (SA); and 09/03 (SU). Review of the facility's time sheets for licensed nursing staff on the above dates revealed the facility had the required licensed nursing staff 24 hours each day, as required. However, the facility reported inaccurate staffing data, as required, on these 9 days of the above quarter. On 01/16/24 at 02:58 PM, Administrative Staff A confirmed the facility PBJ reporting to Centers for Medicare Services CMS lacked accurate data to reflect direct care provided by administrative nursing staff (RN) when providing direct care. He stated the facility did have 24-hours of a LN on duty each day. The above dates on the PBJ which did not reflect LN staffing was not accurate. Further explanation revealed the facility corporate pulled data from the time clock and should notify the facility of irregularities such as if the shift is covered by the Director of Nursing Services DNS (census less than 60). The facility lacked a policy to address the submission of accurate PBJ staffing report to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for 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 licensed nursing staff 24/7.

The facility reported a census of 46 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 01/11/24 at 08:01 AM, the following areas of concern were noted. 1. The stationary can opener had a build-up of dried on food substance on the cutting tip of the opener. 2. Six cutting boards were heavily grooved making the surfaces unsanitizable. 3. The inside of the microwave had dried on food on the top, sides and bottom. 4. A plastic container holding the roll of clear food wrap had a build-up of food substances and dust. 5. The two-door reach-in refrigerator had spilled, dried chocolate milk in several places on the inside. 6. The ice machine vents had a heavy build-up of dust. On 01/16/24 at 03:49 PM, Dietary staff BB confirmed the above areas needed to be cleaned. The facility policy for Kitchen Cleanliness, undated, documented the Certified Dietary Manager would oversee ensuring the kitchen was always kept clean. The facility failed to prepare and serve food to the resident sof the facility under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria.

The facility reported a census of 46 residents with 16 residents sampled. Based on observation, record review and interview the facility failed to review and revise the care plan for three sampled Residents (R)27 regarding revising the care plan to include an intervention following one fall, R 33 regarding revising the care plan to include staff instruction for verbalizations of suicidal tendencies, and R 2 regarding revising the care plan to include interventions following multiple falls. Findings included: - Review of Resident (R)33 electronic medical record (EMR) included the following diagnoses: insomnia (the inability to sleep) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. He had verbal behavioral symptoms directed towards others on one to three days of the assessment period with no impact on the resident or others. He received an antidepressant (medication used to treat depression) medication. The Behavioral Symptoms Care Area Assessment (CAA), dated 10/11/23, documented the resident had physical and verbal abusive behaviors towards staff with risk factors which included injuring himself and others. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14, indicating intact cognition. Delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) were present. He had verbal behavioral symptoms directed towards others, one to three days of the assessment period, with no impact to the resident or others. He received an antidepressant medication. The care plan, revised 01/02/24, lacked staff instruction for verbalizations of suicidal tendencies, identified on the 10/11/23 behavior CAA. Review of the EMR revealed the following physician's order: Celexa (an antidepressant medication), 10 milligrams (mg), by mouth (po), every day (QD), for depression, ordered 12/27/23. Review of the resident's EMR from 12/18/23 through 01/15/24, revealed the resident had multiple behaviors documented. Review of the resident's EMR on 12/27/23, revealed the resident requested for the staff to bring him a gun so he could shoot himself. Staff notified the resident's physician and an antidepressant medication was ordered on that date. The resident later told staff he had been frustrated and had no tendencies of suicide. On 01/16/24 at 01:52 PM, Certified Nurse Aide (CNA) N stated the resident would make comments regarding wanting to kill himself. When the resident would say this, CNA N stated she would let the nurse know and she would talk with the resident until he felt better. On 01/17/24 at 09:22 AM, Administrative Nurse E stated the resident would make comments about wanting to kill himself, but he would then say that he was only expression frustration. He was started on an antidepressant medication. Administrative Nurse E confirmed staff instruction for the resident's suicidal tendencies should be care planned. The facility policy for Care Plans, effective October 2023, included: Care plans will be developed for all residents based upon the RAI manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident status or change. The facility failed to include preventative care plan interventions regarding this dependent resident's suicidal tendencies. - The Physician Order Sheet (POS), dated 01/02/24, for Resident (R)27, documented a diagnosis of weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair. He had no limitations in his range of motion (ROM) and no falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 08/02/23, documented the resident had a history of falls due to weakness and had impaired gait and mobility which required him to have staff assistance with transfers. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers and extensive assistance of one staff for locomotion on the unit with the use of a wheelchair and had no limitation in his ROM. He had one fall with injury (except major) since his prior assessment. The falls care plan, revised 01/08/24, instructed staff that the resident would forget he was unable to stand on his own, creating possible safety risks. Staff were to help remind him of safety issues. He had anti-tip brakes applied to his wheelchair to prevent the wheelchair from rolling backwards if he did attempt to stand up on his own. Staff were to keep the resident in the front commons area between meals. The resident received physical therapy (PT) following a prior fall. The care plan lacked staff instruction on obtaining a UA for this resident following his fall on 12/23/23. Review of the resident's EMR revealed Fall Assessments which placed the resident at a high risk for falls, dated: 06/11/23, 09/11/23 and 10/30/23. Review of a Fall Report, dated 12/23/23 and provided by the facility, revealed the resident had a witnessed fall on 12/23/23 in the front commons room when he attempted to stand up from his wheelchair, took a couple of steps and fell to the floor, landing on his right side. The resident had a decrease in his ROM on his right upper extremity and was transported to the ER for evaluation, where it was found he had a re-fracture of his right clavicle (collar bone). Staff were following all fall interventions at the time of the fall. The new intervention for the fall was to obtain a urine sample for a urinalysis (UA-lab analysis of urine) to check for a urinary tract infection (UTI-an infection in any part of the urinary system). Review of the resident's EMR lacked a lab result for the UA which had been ordered on 12/23/23. On 01/17/24 at 01:15 PM, Administrative Nurse E stated all new fall interventions are to be added to the care plan at the time they are initiated. The facility policy for Care Plans, effective October 2023, included: Care plans will be developed for all residents based upon the RAI manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident status or change. The facility failed to review and revise the care plan for this dependent resident who experienced a fall to prevent further falls. 36881 - Review of R2's Physician Orders, dated 12/13/23, included diagnoses of fractured thoracic (middle section of the spine) vertebra, repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), need for assistance with personal care, lack of coordination, cognitive communication deficit, unsteadiness of feet, urinary incontinence, peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hypertension (high blood pressure), overactive bladder, and gait (manner or style of walking) and balance abnormalities. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The resident required substantial/maximal assistance of staff for bed mobility, transfers, and toileting. She had no functional limitations in range of motion of the upper or lower extremities. She was always incontinent of bowel, occasionally incontinent of urine, and did not have a toileting program. She experienced two or more non-injury falls and one fall with major injury. The resident received Occupational Therapy (OT) for four days and Physical Therapy (PT) for four days of the look back period. The Discharge Return Anticipated MDS dated [DATE], documented the resident transferred to an acute care hospital on 11/27/23. The Entry MDS dated [DATE], documented the resident returned to the facility on [DATE]. The Cognitive Loss/ Dementia, Communication, and Falls Care Area Assessments (CAA), dated 09/15/23, documented the resident lacked orientation with memory and recall deficits related to dementia, change in mental status, and short term/long term memory loss. She had a history of falls prior to admission, weakness, and physical performance limitations that affected balance, gait, strength, and muscle endurance. The Care Plan dated 12/22/23, included the following interventions: On 05/21/19, staff were to remind the resident to lock the brakes on the wheelchair before transfers. On 08/13/19, R2 experienced episodes of incontinence due to an overactive bladder if not toileted timely . (The care plan lacked any instruction staff on when to toilet the resident.) On 11/07/22, therapy was to screen, and staff would initiate a bladder diary to determine a toileting schedule. On 01/26/23, staff were to know the resident had a diagnosis of dementia and exhibited some restlessness and anxiety prior to a fall. R2 wandered into the wrong room and attempted to transfer to a bed unassisted. Nursing staff were to monitor the resident for behaviors every shift. If R2 was restless or anxious, staff were to report to the nurse to assess and treat. Staff would repeat urinalysis (UA). In addition, staff were to adjust the resident's bed height to a lower position for improved transfers. On 01/28/23, therapy assessed the resident's wheelchair, R2's positioning in the wheelchair, and therapy adjusted the wheelchair. Staff were to remind her to call for assistance for bathroom use. On 08/16/23, the facility asked R2's family to take Crocs (rubberized slip-on shoes) home. Staff were to encourage the resident to wear her tennis shoes. Staff would know the resident liked to wear her Crocs and remind her that they were not the safest footwear. Staff should remind the resident she cannot get up on her own and would know she may forget and may need reminders. On 09/19/23, nursing staff were to encourage the resident to utilize the grab bar in the shower room and ensure the wheelchair brakes locked before transferring the resident to the shower chair. On 09/20/23, R2 moved around the facility by self-propelling her wheelchair and would take assistance from staff if offered. The resident used bed rails to reposition and to get in and out of bed. The resident no longer used her walker for locomotion, but occasionally used the walker for transfers. The resident required two staff for transfers using a transfer belt and/or a mechanical lift as needed. Staff were to know the resident was forgetful and did not remember she needed assistance transferring. Staff were to keep pathways clear and decrease clutter to minimize the risk of falls. Staff were to keep the resident's wheelchair beside the bed. Staff were to ensure the resident wore secure footwear when out of bed. She sometimes lost her gripper socks and/or placed unsafe slippers over the gripper socks. Staff were to assist the resident in putting gripper socks back on. On 10/09/23, staff were to obtain a UA for the resident. On 11/14/23, staff were to lay R2 down after meals to prevent confusion and ensure safety. Review of the Progress Notes and Fall Investigation Reports revealed the following concerns related to falls experienced by R2: On 07/03/23 at 06:45 AM, the resident adjusted herself in the wheelchair and started to fall forward. Staff were able to catch the resident and assist her to the floor on her buttocks. The fall investigation report failed to identify causal factors to determine an immediate and appropriate intervention to prevent further falls. On 08/13/23 at 07:33AM, two unidentified residents reported R2 got up from her wheelchair and fell . The intervention was to have family take R2's Crocs home and utilize sneakers. On 08/15/23 at 01:30 PM, an unidentified CNA reported R2 had an unwitnessed fall from the toilet, resulting in a goose egg sized, raised area to the back of the resident's head. The documentation noted the casual factor of the fall as the resident was impulsive and sometimes confused and should not be left on the toilet by herself. She had uneven balance and did not have her walker at the time of the fall. The facility educated the unidentified CNA regarding the importance of staying with a dependent, cognitively impaired resident while the resident was on the toilet and to provide supervision, to prevent falls. On 09/16/23 at 08:10 PM, R2 reported she attempted to transfer from the sofa to the wheelchair and fell to the floor. The fall was not witnessed, and the resident was noted to have severe cognitive impairment. The investigation lacked a causal factor and immediate appropriate intervention to prevent further falls. The facility placed an intervention to provide the unidentified CNA education. On 09/19/23 at 09:05 PM, a n unidentified CNA reported they found R2 on the floor wearing a gown and socks. The resident reported she started to sit down, missed the chair, and landed on the floor. On 10/08/23 at 11:15 PM, staff found the resident sitting on the floor in front of the bathroom. The investigation report failed to provide an immediate intervention to prevent further falls. On 11/16/23 at 03:00 PM, the resident attempted to toilet herself and fell to the floor landing on her backside. She hit her head, causing a goose egg, which measured approximately two centimeters around, to the back of her head. The facility placed an intervention to prevent further falls, which included instructions to staff to remind the resident to use her call light for assistance for transfers and to ensure the resident used non-slip footwear. Review of the resident's care plan revealed both interventions were already implemented following previous falls. The Investigation Report, lacked a new immediate intervention to prevent further falls. The Progress Note dated 11/27/23 at 01:30 PM, revealed R2 was in her wheelchair when an unidentified C ertified Nursing Assistant (CNA) served the resident's meal at 01:00 PM and left the room. Approximately five minutes later, an unidentified CNA heard a crash and found the resident on the floor with the bedside table on top of her. The nurse assessed the resident and called 911 for transport to the emergency room (ER). The Progress notes dated 11/27/23 at 05:30 PM, documented the nurse received a call from the ER with a resident status update. She had fractures of thoracic spine. The Hospital Discharge Summary dated 11/30/23, documentation included the resident sustained a fracture of the 10th and 11th vertebra of the thoracic (bones of the spine (mid back) following a fall on 11/27/23 at the nursing facility. Review of the R2's Electronic Medical Record, (EMR) from 07/01/23 through 01/10/24, revealed the resident had a history of falls and experienced eight falls in the five months prior to the fall on 11/27/23 at 01:05 PM, which resulted in two fractured thoracic vertebrae. Observation on 01/10/24 at 11:03 AM, revealed the resident sat in the wheelchair in the commons area. She wore multicolored Crocs, with her feet on the pedals of the wheelchair. A brace was visible beneath her shirt, that covered her chest wall. On 01/11/24 at 09:30 AM, observed Certified Nurse Aides (CNA) P, CNA MM, and CNA NN transferred and provided toileting to R2. The staff transferred the resident to the toilet with a gait belt. R2 wore Crocs on her feet. The staff reported she wore her crocs all the time. On 01/11/24 at 09:30 AM, CNA P reported the resident was at risk for falls and had several falls. The resident used to walk, and the staff could walk her back and forth to the bathroom but stated R2 had not walked in almost a year. CNA P said when a resident fell , the nurse should put an immediate intervention in place to prevent further falls. CNA P said tthe new interventions should be added to the care plan, and staff have access to the care plan for directions on caring for the resident. On 01/17/24 at 10:13 AM, Licensed Nurse (LN) I stated when a resident fell , the charge nurse should do an assessment, which included vital signs, range of motion, and a head-to-toe skin assessment. If the fall was not witnessed or the resident hit their head, staff should complete a neurological assessment. The nurse should notify the physician, the resident representative, and the Director of Nursing. The charge nurse should initiate an investigation at the time of the fall to determine the cause. An immediate new and appropriate intervention should be put in place and communicated to the staff. LN I stated a resident with dementia was not a reliable reporter for the cause of the fall and it would not be appropriate for a resident with dementia to use an intervention to remind the resident to use a call light. A resident that required assistance with transfers to the toilet and was cognitively impaired should not be left unattended in the bathroom. Staff should use the resident's care plan for guidance for fall interventions. New staff were not familiar with long term care and the system to put new appropriate interventions on the resident's care plan immediately to prevent further falls. On 01/17/24 at 01:15 PM, Administrative Nurse D stated on 11/27/23, R2 had an unwitnessed fall. The investigation revealed the probable cause was due to the resident reached for the wheeled end table and she fell . Administrative Nurse D stated the resident had a diagnosis of dementia and a history of multiple falls due to her poor impulse control where she would try to stand, transfer, and toilet herself without staff assistance. Staff had R2 transported to the hospital for an evaluation and R2 was admitted due to fractured vertebras. She was sent back to the facility with a brace to stabilize her fractured vertebrae. Staff removed the wheeled table from the resident's room and replaced it with a stationary table. The charge nurse should initiate a new immediate and appropriate fall intervention to prevent further falls. The resident's BIMS score should be 13 or higher for resident education to be an appropriate intervention. R2's interventions were not appropriate, and no new interventions were put in place to prevent further falls prior to the resident falling on 11/27/23, which resulted in fractures. The 02/2017 facility's policy for Clinical Care Systems Guidelines for Falls did not address initiating a new, immediate, and appropriate intervention based on causal factors of each fall experienced by a resident, in order to prevent further falls. The facility failed to iniate/implement, new immediate, appropriate interventions on the residents care plan to prevent further falls for cognitively impaired R2, who had multiple falls.

The facility reported a census of 46 residents with 16 selected for review which included five residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to follow up on pharmacy recommendations in a timely manner for two Residents (R)2 and R29, of the five sampled residents, and failed to ensure pharmacy reviews for October 2023 and November 2023 for the five sampled residents R15, R23, R2, R29 and R27 . Findings included: - Review of Resident (R)23's electronic medical record (EMR), revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain hypothyroidism (condition characterized by decreased activity of the thyroid gland), dementia (progressive mental disorder characterized by failing memory, confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six which indicated severe cognitive impairment. The resident received scheduled pain medications. The resident received antipsychotics (class of medications used to treat major mental conditions which cause a break from reality) on a routine basis and received diuretic (medication to promote the formation and excretion of urine), antidepressant (class of medications used to treat mood disorders), and opioid (narcotic) medications. The Psychotropic (a medication used to alter mood or thought) Drug Use Care Area Assessment (CAA), dated 12/08/23, assessed the resident received psychotropic medications. The Care Plan reviewed 11/27/23, instructed staff to monitor, document and report any adverse reactions to psychotropic medications and to consult with the pharmacy and the medical doctor to consider dose reduction. On 10/05/21 the physician instructed staff to administer Milk of Magnesia, 30 milliliters, every 24 hours as needed for constipation (difficulty passing stools) On 08/10/23 the physician instructed staff to administer Abilify (an antipsychotic medication 2 milligrams (mg) daily for dementia with behaviors. On 12/19/23 the physician instructed staff to administer mirtazapine 7.5 milligrams at night for insomnia (inability to sleep). On 01/03/24 the physician instructed staff to administer levothyroxine, 125 micrograms, every morning for hypothyroidism. On 01/09/24, the physician instructed staff to administer Metformin, 500 milligrams twice a day for diabetes. Review of the resident's EMR revealed it lacked a pharmacy consultant review for the months of September and October 2023. Interview, on 01/16/24 at 01:20 PM, with Certified Nurse Aide (CNA) M, revealed the resident had several falls that caused the bruise on her face. On 01/17/24 at 12:54 PM, Administrative Nurse D stated she did not know what the prior director of nursing (DON) system was for the pharmacy consultant recommendations so not all the recommendations from June 2023 to present could be found. The facility policy for Medication Regimen Review, effective 11/28/16, included: The facility shall provide the resident's attending physician, Medical Director, and the Director of Nursing Services with copies of the Medication Regimen Review. The facility shall encourage the physician to act upon the recommendations in a timely manner. The facility failed to follow-up on pharmacy recommendations to ensure this resident did not experience adverse effects of medications. - Review of Resident (R)15's Physician Order Sheet dated 12/13/23, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). . The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired decision making. The resident was rarely/never understood. The resident received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (class of medications used to treat mood disorders) medications. The resident received antipsychotics on a routine basis. The Psychotropic (a medication that alters mood or thought) Drug Use Care Area Assessment (CAA) dated 10/27/23, triggered secondary to use of psychotropic med to manage psychiatric illness/condition. A licensed nurse monitors for side effects every shift, and the physician was to be notified of any abnormal findings. A pharmacist consultant will review medications monthly and the PCP (Primary Care Physician) will review medications with each visit. Contributing factors include 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 perception)/insomnia (inability to sleep). The Cognitive Loss CAA, dated 10/27/23, assessed the resident was unable to always make her needs known. Staff assist the resident with all cares. The Care Plan reviewed 11/02/23, instructed staff to monitor for bowel movement each shift and offer the as needed (PRN) laxative for constipation and monitor for effectiveness when given. On 11/20/20, the physician instructed staff to administer bupropion hydrochloride, 150 mg, every 12 hours daily for depression. On 03/03/22, the physician instructed staff to administer Milk of Magnesia Suspension (a laxative), 30 milliliters, every 24 hours as needed for constipation per standing order. On 03/24/23 the physician instructed staff to administer ibuprofen, 200 mg, two, tablets, every six hours, for dental pain. On 10/31/23 the physician instructed staff to administer olanzapine 2.5 mg, every other day for dementia with behaviors. On 12/28/23 the physician instructed staff to administer lorazepam 0.5 milligrams (mg) three times a day for anxiety (class of medications that calm and relax people). Review of the resident's EMR lacked a pharmacy consultant review for the months of September and October 2023. On 01/17/24 at 12:54 PM, Administrative Nurse D stated she did not know what the prior director of nursing (DON) system was for the pharmacy consultant recommendations so not all the recommendations from June 2023 to present could be found. The facility policy for Medication Regimen Review, effective 11/28/16, included: The facility shall provide the resident's attending physician, Medical Director, and the Director of Nursing Services with copies of the Medication Regimen Review. The facility shall encourage the physician to act upon the recommendations in a timely manner. The facility failed to follow-up on pharmacy recommendations to ensure this resident did not experience adverse effects of medications. 34056 - The Physician Order Sheet (POS), dated 01/02/24, for Resident (R)27, documented the following diagnoses: major depressive disorder (MDD-major mood disorder which causes persistent feelings pf sadness), hypothyroidism (condition characterized by decreased activity of the thyroid gland) and hypertension (HTN-elevated blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The resident received an antidepressant (medication to treat depression), an anticoagulant (a medication which thins the blood) and an opioid (medications used to treat pain) seven out of seven days of the look back assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/02/23, documented the resident received psychotropic medications to manage his psychiatric conditions. A pharmacist consultant would review his medications monthly and make needed recommendations. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. He received antidepressant, anticoagulant and opioid medications during the lookback assessment period. The care plan for medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration), revised 01/08/24, instructed staff the resident took medications with BBWs and to monitor for side effects of the medications. Review of the resident's electronic medical record (EMR) revealed the following physician's orders: Tramadol (an opioid pain medication) 50 milligrams (mg), by mouth (po) every (Q) eight hours, for pain, ordered 03/07/23. Eliquis (an anticoagulant medication) 2.5 mg, po twice daily (BID), for deep vein thrombosis (DVT - potentially life-threatening blood clot, usually in the legs), ordered 02/25/23. Lexapro (an antidepressant medication) 10 mg, po BID, for depression, ordered 02/24/23. Review of the resident's EMR revealed it lacked a pharmacy consultant review for the months of September and October 2023. On 01/17/24 at 12:54 PM, Administrative Nurse D stated she did not know what the prior director of nursings (DON) system was for the pharmacy consultant recommendations so not all the recommendations from June 2023 to present could be found. The facility policy for Medication Regimen Review, effective 11/28/16, included: The facility shall provide the resident's attending physician, Medical Director and the Director of Nursing Services with copies of the Medication Regimen Review. The facility shall encourage the physician to act upon the recommendations in a timely manner. The facility failed to follow up with pharmacy recommendations to ensure this resident did not experience adverse effects of medications. 36881 - Review of Resident (R)2's Physician Orders, dated 12/13/23 included diagnoses of fractured vertebrae (Fx-broken bones of the back) repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), iron deficient anemia, congestive heart failure (fluid around the heart which impairs the heart's ability to pump), traumatic subdural hemorrhage (bleeding of the brain) without loss of consciousness, lack of coordination, cognitive communication deficit, unsteadiness of feet, major depression disorder (major mood disorder which causes persistent feelings pf sadness), edema (swelling resulting from an excessive accumulation of fluid in the body tissues , psychotic mood disorder(any major mental disorder characterized by a gross impairment in reality perception), constipation, pain, peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hypertension, hypothyroidism, obstructive apnea, overactive bladder, asthma (disorder of narrowed airways that caused wheezing and shortness of breath), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), gait and balance abnormalities, and history of falling. The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. The resident received medications which included insulin injections for six days of the look back period. She had six insulin order changes during the look back period. The staff reported the resident demonstrated indicators of pain on one to two days of the look back period. The Quarterly MDS, dated [DATE], documented changes which included the resident received medication antianxiety, antidepressant, anticoagulants and opioid, antiplatelets for seven days of the look back period. She reported frequent pain that did not interfere with her sleep. The resident was not able to rate her level of pain. She received prn (as needed) pain medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) and Psychosocial Wellbeing CAA, dated 09/15/23, documented the resident had orientation, memory, and recall deficits. It included factors with dementia, change in mental status, and short term/long term memory loss. The Care Plan dated 12/23/23 directed staff to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the pharmacist's Monthly Medication Regimen Review, (MMRR) dated 06/17/23 through 12/04/23, revealed the following concerns: 1. (MMRR) dated 07/18/23, for discontinuation of Singular was not followed-up by the physician or the facility until 08/31/23 (31 days) after the recommendation was made. The physician discontinued the medication. 2. (MMRR) dated 08/2023 identified the facility lack of follow-up to the Pharmacy Medication Regimen Review, dated 07/18/23. 3. The resident lacked a (MMRR) for 09/2023. 4. The resident lacked a (MMRR) for 10/2023. On 01/17/24 at 07:57 AM, Administrative Nurse E confirmed the above findings and stated the pharmacist should review the resident's medication regimen monthly and report any irregularities such as side effects medication interactions and gradual dose reductions. The pharmacist's recommendations should be acted upon in a timely manner within 10 days of receiving the recommendations. On 01/17/24 at 02:30 PM, the pharmacist was not available for interview. The facility policy for Medication Regimen Review, effective 11/28/16, included: The facility shall provide the resident's attending physician, Medical Director, and the Director of Nursing Services with copies of the Medication Regimen Review. The facility shall encourage the physician to act upon the recommendations in a timely manner. The facility failed to act upon the identified irregularities by the consulting pharmacist on 07/18/23 in a timely manner. Additionally, the facility failed to ensure the resident received a MMRR by the pharmacist as required to monitor for any medication irregularities. - Review of Resident (R)29's Physician Orders, dated 12/13/23 included diagnoses cirrhosis (chronic degenerative disease of the liver), gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), urinary tract infection, arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement), cerebrovascular accident (CVA/stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia(paralysis of one side of the body)/hemiparesis(muscular weakness of one half of the body), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intact. The resident received medications which included prn (as needed) pain medication during the look back period. The Quarterly MDS, dated [DATE], documented changes which included the resident received medication of antianxiety, antidepressant, diuretics, and antiplatelets during the look back period. She reported frequent pain that did not interfere with her sleep. The resident was not able to rate her level of pain. She received prn pain medication. She reported occasional pain rated at 02/10. The Care Plan dated 11/15/23, directed staff to administer medications as ordered. Monitor/document for side effects and effectiveness of the resident's medications. Review of the pharmacist's Monthly Medication Regimen Review, (MMRR) dated 06/17/23 through 12/04/23, revealed the following concerns: 1. The resident lacked a (MMRR) for 09/2023. 2. The resident lacked a (MMRR) for 10/2023. On 01/17/24 at 07:57 AM, Administrative Nurse E confirmed the above findings and stated the pharmacist should review the resident's medication regimen monthly and report any irregularities such as side effects medication interactions and gradual dose reductions. The pharmacist's recommendations should be acted upon in a timely manner within 10 days of receiving the recommendations. On 01/17/24 at 02:30 PM, the pharmacist was not available for interview. The facility policy for Medication Regimen Review, effective 11/28/16, included: The facility shall provide the resident's attending physician, Medical Director, and the Director of Nursing Services with copies of the Medication Regimen Review. The facility shall encourage the physician to act upon the recommendations in a timely manner. The facility failed to ensure the resident received a MMRR by the pharmacist as required to monitor for any medication irregularities.

The facility reported a census of 46 residents which included 16 residents sampled with one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure the dignity/privacy of the one sampled resident (R)9, with a catheter/urine collection bag, with the lack of a cover for the urine collection bag to prevent full visualization of the resident's urine. Findings included: - Review of resident (R)9's Physician Orders, documentation included diagnoses of retention of urine, injury of kidney unspecified, and need for assistance with personal care. The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documentation included the resident with the Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Her continence was not rated due to ostomy and indwelling catheter. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) for urinary incontinence/indwelling catheter, dated 01/03/24, documented the resident used a urinary indwelling catheter. The care plan (CP) for indwelling catheter, dated 12/04/23, directed the staff to provide a privacy bag for the catheter and to position the catheter bag and tubing away from the entrance of the door. On 01/10/24 at 01:12 PM, the resident sat in her recliner. Her trash can, beside her recliner, held her uncovered catheter collection bag which hung on the outside of the trash can with her urine visible in the collection bag from the doorway. The resident stated that was where the staff always placed the urine collection bag. She stated there was a catheter cover on her wheelchair (W/C) which she liked to prevent others from seeing her urine. She did not know why one was not used while in her room. On 01/10/24 at 01:12 PM Certified Nurse Aide (CNA) MM confirmed the above finding and stated the resident's catheter bag should be covered with a bag to ensure the resident's privacy/dignity. On 01/17/24 at 10:13 AM, Licensed Nurse (LN) I, stated the resident's catheter bag should be covered to ensure the resident's privacy/dignity. On 01/17/24 at 12:49 PM, Administrative Nurse D stated the staff should cover the resident's catheter bag to prevent the urine from being seen from the doorway of her room and to ensure the resident's privacy and dignity. The facility lacked a policy regarding providing full visual privacy for a resident's urine collection bags. The facility failed to ensure the dignity/privacy of the resident with the lack of a catheter/urine collection bag cover, to prevent full visualization of the resident's urine to anyone passing or entering her room.

The facility reported a census of 46 residents with 16 selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one resident (R)15, of the five residents reviewed, received laxatives for lack of bowel movement as ordered by the physician. Findings included: - Review of Resident (R)15's Physician Order Sheet dated 12/13/23, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired decision making. The resident was rarely/never understood. The resident received antipsychotic, antianxiety, and antidepressant medications. The resident was on antipsychotics on a routine basis. The Psychotropic Drug Use Care Area Assessment (CAA) dated 10/27/23, triggered secondary to use of psychotropic med to manage psychiatric illness/condition. A licensed nurse monitors for side effects every shift, and the physician is to be notified of any abnormal findings. A pharmacist consultant will review medications monthly and the PCP (Primary Care Physician) will review medications with each visit. Contributing factors include current history of depression/psychosis/insomnia. The Cognitive Loss CAA, dated 10/27/23, assessed the resident was unable to always make her needs known. Staff assist the resident with all cares. The Care Plan reviewed 11/02/23, instructed staff to monitor for bowel movement each shift and offer the as needed (PRN) laxative for constipation and monitor for effectiveness when given. On 03/03/22, the physician instructed staff to administer Milk of Magnesia Suspension (a laxative), 30 milliliters, every 24 hours as needed for constipation per standing order. Review of the electronic medical record task for bowel movement documentation, revealed the resident did not have a bowel pattern of lack of bowel movement for four to five days, and the record documented the resident had a lack of bowel movement from 01/10/24 through 01/17/24, for seven days. Observation, on 01/11/24 at 09:35 AM, revealed Certified Nurse Aide (CNA) Q and Z transferred the resident from her wheelchair to bed. The resident smiled and laughed but did not answer questions. CNA Q stated the resident did not speak but did laugh to communicate to staff. Interview, on 01/17/24 at 03:00 PM, with Administrative Nurse E, confirmed the lack of bowel movement from 01/10/24 through 01/17/24, but wound question the Certified Staff to confirm this. Interview on 01/17/24 at 3:20 PM, with Administrative Nurse E, revealed she did a bowel assessment on the resident and found active bowel sounds, and would administer the Milk of Magnesia. Administrative Nurse E stated the resident usually had a bowel movement on shower days, but staff could not confirm the resident had a bowel movement for the past nine days. Interview, on 01/17/24 at 03:30 PM, with Consulting Staff GG, stated the facility followed the physician orders and standing orders for administering laxatives. The facility lacked a policy for administering laxatives. The facility failed to monitor this resident's bowel movements for constipation patterns and administer laxatives as ordered by the physician to ensure optimal bowel hygiene.

The facility reported a census of 46 residents which included 16 residents. The facility failed to maintain an effective infection control program to prevent cross contamination and the prevention infection related to urinary catheter care and services provided to one sampled Resident (R )9 with a urinary catheter/urine collection bag. Findings included: - Review of resident (R)9's undated Physician Orders, documentation included diagnoses of retention of urine, injury of a kidney unspecified, and the need for assistance with personal cares. The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented the resident with the Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. She used an indwelling urinary catheter. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 01/03/24, included the resident used an indwelling urinary catheter. The care plan for indwelling catheter, dated 12/04/23, directed the staff to position the catheter bag and tubing away from the entrance of the door. On 01/10/24 at 01:12 PM, the resident sat in her recliner. Her trash can, which was beside her recliner, had her urinary catheter bag hanging on the outside of the trash can with the urine collection bag in direct contact with the floor. On 01/10/24 at 01:12 PM Certified Nurse Aide (CNA) MM confirmed the above finding and stated the resident's catheter bags should be positioned off the floor to prevent cross contamination and prevent infection. On 01/17/24 at 10:13 AM, Licensed Nurse (LN) I, stated the resident's catheter bags should be positioned off the floor to prevent cross contamination and prevent infection. On 01/17/24 at 12:49 PM, Administrative Nurse D stated the staff should position the resident's urinary catheter collection bag off the floor to prevent cross contamination and prevent infection. The facility lacked a policy regarding positioning a urine collection bags off the floor to prevent cross contamination and prevent infection. The facility failed to maintain an effective infection control program with the failure to ensure the resident's urinary catheter bag remained without direct contact with the floor to prevent cross contamination and infections.

The facility census totaled 47 residents with all residents receiving meals from one main kitchen. Based on observation, interview, and record review the facility failed to prepare and serve food in a sanitary manner by the failure to change gloves when handling ready to eat food items and the failure to maintain clean cooking equipment that worked properly to prepare meals. Findings included: - On 03/09/22 at 11:20 AM observation of the facility kitchen revealed a large pan with sweet potato soufflé and a pan of pumpkin bars baking in the upright oven. Several checks of the food items in the oven by Dietary Staff E revealed the food was not done cooking. At 12:00 PM Dietary Staff E removed the pan of pumpkin bars from the oven though they could not be served due to not setting up or baked fully, and the staff served an alternate of ice cream. At 12:10 PM Dietary Staff E removed the sweet potator souffle from the oven. The middle of the soufflé was not set up. The soufflé had a temperature of 160 degrees Fahrenheith (F), but the center was runny. Dietary Staff E just stirred it all together and served it for the lunch meal. On 03/09/22 at 12:10 PM Dietary Staff E reported sometimes the oven worked fine and other times it won't cook the food. She stated she had it turned up to 500 degrees F and still it was not cooking the food. On 03/09/22 at 12:20 PM Dietary Staff D reported maintenance had looked at the oven and the corporation knew of the oven not working properly. Dietary Staff D hoped the oven would be replaced sometime soon. The undated facility policy titled Equipment revealed all food service equipment would be clean, sanitary, and in proper working condition. The facility failed to have cooking equipment in good, working condition when preparing food for the lunch meal. - Observation on 03/09/22 at 12:20 PM revealed Dietary Staff (DS) E made sandwiches. Dietary Staff E put clean gloves on and reached into a bag of bread to make one sandwich. She then used tongs for the meat and cheese. While wearing the same gloves, DS E took the sandwich plate to the serving line, put a food item on the plate, and handed it off to be served. DS E then handled several meal tickets. Aftewards and while wearing the same gloves, DS E reached into the bread bag and retrieved two pieces of bread for the second sandwich, and used tongs for the meat and cheese. Dietary Staff E wore the same pair of gloves throughout the observation of making both sandwiches. On 03/09/22 at 12:35 PM DS E reported she thought she used tongs to make the sandwiches. When reminded she wore gloves to handle the bread, she agreed she wore the same gloves without changing the gloves to handle the bread for making both sandwiches. On 03/09/22 at 12:40 PM CDM D reported she would do an education session with DS E on gloving and food handling. The facility's 11/01/17 policy Dietary Sanitary Practices revealed dietary staff would use utensils or wear disposable gloves to handle food. The facility failed to prepare and serve food in a sanitary manner when dietary staff did not change gloves between the handling of ready to eat food items. - Observation on 03/09/22 at 12:30 PM of the upright oven, being used for the noon meal, had thick burned debris in the oven with burned spilled food in the bottom of the oven. The oven also observed with thick, black, burnt buildup of food on the grates. The Kitchen Cleaning Schedule for January, February, and March of 2022 revealed the place to initial for cleaning of the oven was blank on all three months of the schedule. On 03/09/22 at 12:30 PM Certified Dietary Manager (CDM) D reviewed the cleaning schedules and agreed the oven was dirty and based on the schedules it had not been cleaned in at least three months. The undated facility policy titled Equipment revealed all food service equipment would be clean, sanitary, and in proper working condition. The facility failed to have the kitchen upright over in clean, sanitary condition.

The facility reported a census of 47 residents with 13 sampled, including two for hospitalization . Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 47. Findings Include: - Review of R47's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 02/22/22 and returned to the facility on [DATE]. Review of R47's Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge to R47's Office of the State Long-Term Care Ombudsman. On 03/07/22 at 04:09 PM R47 sat in his room in his recliner with his legs elevated, his walker next to his chair and all needed items within reach. On 03/08/22 at 11:35 AM Administrative Staff A confirmed the facility must notify the Office of the State Long Term Care Ombudsman at the time of discharge to the hospital. On 03/08/22 at 03:12 PM Administrative Nurse B confirmed that the Ombudsman should be notified, but they missed the notification because she and her Assistant Director of Nursing (ADON) were covering for the Social Services Designee (SSD) and Minimal Data Set Coordinator (MDS) positions. On 03/09/22 at 09:30 AM SSD C confirmed she did not send a notice to the Office of the State Long Term Care Ombudsman when a resident discharged to the hospital. The facility failed to send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman when R47 transferred to the hospital.

The facility reported a census of 47 residents with 13 sampled, which included two for hospitalization . Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Residents (R) 47 and R34 or their representative when they transferred out of the facility to the hospital. Findings Included: - Review of R47's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 02/22/22 and returned to the facility on [DATE]. Review of R47's Medical Record lacked evidence of written notification of the facility-initiated transfer to the hospital, which included a bed hold given to R47 or his representative. On 03/07/22 at 02:09 PM R47 ambulated with his walker to the bathroom with staff assistance. On 03/08/22 at 03:12 PM Administrative Nurse B stated the facility went over the bed-hold policy on admission, but they would not send a policy with a resident when they went to the hospital. On 03/09/22 at 11:29 AM Licensed Nurse (LN) F stated she did not send a bed-hold policy with the residents when they discharged to the hospital. On 03/09/22 at 12:26 PM Social Service Designee (SSD C stated she had not covered bed hold policy yet and that she was unsure who would do that, or when. The Bed-Hold Policy revised 11/01/16 documented before the center transferred a resident to a hospital the center would provide the resident or his resident representative the bed hold policy. The facility failed to provide a copy of the facility bed hold policy to R47 or his representative, when he transferred to the hospital on 02/22/22. - The Nurses Notes for R34 indicated the resident left the faciity on [DATE] at 05:20 AM for a heart catheterization. On 03/02/22 at 09:10 PM the nursing staff were informed the resident would be in the hospital until the weekend due to having stents placed in her heart. R34 did not return to the facility until 03/08/22 at 05:08 PM. The Nurses Notes from 03/01/22-03/08/22 lacked documentation the resident or residents representative received notification of the bed hold policy within 24 hours after R34 admitted to the hospital. Interview with Administrative Staff C on 03/09/22 at 12:26 PM indicated the facility had not completed training involving the bed hold policy and they did know know who would be responsible. The Bed Hold Policy dated 11/01/16 indicated the facility will hold a resident's bed during a temporary hospitalization or therapeutic leave allow the resident to return to the facility subject to the terms of this bed hold policy. The facility failed to provide R34 and or the resident's representative with the facility's bed hold policy within 24 hours after admission to the hospital.

The facility reported a census of 47 residents, with 13 in the sample, and Resident (R) 18 reviewed for Preadmission Screening and Resident Review (PASARR). Based on observation, interviews, and record review the facility failed to obtain a Care Assessment Screening for R18 upon admission. Findings include: - R18's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition and no behaviors exhibited. The Annual MDS dated [DATE] documented R18 could not complete the BIMS assessment, staff assessed cognition and noted to short/long term memory problems. R18 could not recall staff names and faces, current season, or location of his room. R18's cognitive skills for daily decision making were moderately impaired. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/06/22 documented R18 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavioral Symptoms CAA documented due to his dementia the resident resisted care. The Care Plan dated 02/11/21 indicated R18 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease (aggressive mental disorder characterized by failing memory, confusion) impaired memory, and loss of independence. The staff should monitor/document/report any changes in cognitive function specifically changes in decision making ability, memory recall, and general awareness. The Electronic Medical Record (EMR) lacked documentation of a completed PASARR upon admission for R18. Observation on 03/08/22 at 01:05 PM revealed the resident sat in his wheel chair as an unidentified staff member propelled him to his room. R18 exhibited no negative behaviors. Interview with Administrative Staff A on 03/07/22 at 01:48 PM verified R18's EMR lacked documentation of a completed PASARR and stated it was not done when he admitted . Interview with Administrative Staff C on 03/09/22 at 08:53 AM confirmed the PASARR was not competed on this resident when admitted on [DATE]. The undated PASARR Requirements policy stated the health management coordinator would obtain a complete record, all residents must have the a pre-admission screening prior to or immediately upon admission. The PASARR should be completed to determine provision of appropriate and needed service to individuals who have been diagnosed with mental illness/mental [CONDITION(S)] (MI/MR). The facility failed to obtain a Care Assessment assessment screening PASARR for R18 upon admission.

The facility reported a census of 47 residents with 13 selected for review, which included one resident reviewed for discharge. Based on interview and record review the facility failed to document a recapitulation of the resident's stay upon discharge for Resident (R) 52. Findings included: - Review of the R52's Physicians Order Sheet dated 01/06/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The resident required limited assistance of two staff for activities of daily living (ADL). The Activities of Daily Living Care Area Assessment (CAA) dated 01/12/22 indicated the resident required assistance in ADL due to impaired balance and transition during transfers, and functional impairment in activity. The Nurse's Notes dated 01/25/22 documented the resident discharged from the facility at 01:03 PM with a list of medications. No other information provided to R52. The Nurse's Notes from 01/25/22 lacked evidence of a recapitulation of stay or discharge summary given to R52 upon discharge. Interview on 03/09/22 at 01:10 PM with Administrative Nurse B confirmed the staff did not compete a discharge summary. Interview on 03/09/22 at 02:30 PM with Administrative Staff C confirmed all departments have a section to fill out on the discharge summary. The undated facility policy titled Discharge Summary Requirements included staff were to provide a summary of patient service provided during a length of stay, and to include applicable continuum of care instruction to the patient and/or next care provider. The facility failed to document a discharge summary including a recapitulation of this resident's stay at the facility, upon discharge of R52.

The facility reported a census of 49 residents. Based on record review and interview the facility failed to complete the required nurse aide performance reviews (at least once every 12 months) for three of the five Certified Nurse Aides (CNA) reviewed in order to provide in-service education based on the outcome of the reviews. Findings Include: - Review of five Certified Nurse Aides (CNA) records (with employment for the facility documented as more than one year) revealed lack of documentation of performance reviews for three of the five CNAs reviewed. (CNA P, CNA Q, CNA R) On 03/03/20 at 01:29 PM Administrative Nurse D stated she knew the facility did not have evaluations completed, knew they needed them, and they were working on them. On 03/03/20 at 03:23 PM Administrative Staff A stated he knew that the employee yearly evaluations were behind and stated they were starting with a new form and said they would be all caught up in March. The facility failed to provide a policy for performance reviews as requested on 03/04/20. The facility failed to complete performance reviews on three of the five CNAs reviewed, to ensure adequate cares provided to the residents of the facility.

The facility had a census of 50 residents. Based on observation, interview, and record review the facility failed to have a system in place to protect all residents following an allegation of staff to resident sexual abuse. Resident (R) 1 told two certified nurse aides (CNA) that a male CNA inserted his fingers into her vagina during care. The CNAs reported the allegation to the charge nurse. The charge nurse failed to notify the Administrator of the allegation and instead wrote the allegation on a piece of paper and slid it under the Administrator's office door where it was not discovered until approximately 15 hours later. During 12 of those 15 hours, the alleged perpetrator (AP) continued to provide care and have access to all 50 facility residents. The facility failed to have systems in place to ensure staff reported an abuse allegation timely, which led to a failure to protect residents from the AP during an ongoing investigation. This failure placed all 50 facility residents in immediate jeopardy. Findings included: - R1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 11/11/19 Quarterly Minimum Data Set (MDS) identified R1 with no cognitive impairment (Brief Interview for Mental Status score of 14) and the need for extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the 08/22/19 Mood State Care Area Assessment (CAAs) noted R1 reported feelings of depression because of health issues and she feels down most of the time. R1 also reported problems sleeping because of worry and having too many things on my mind. The CAA further noted R1's depression made it hard for her to focus and she felt like she lived in a fog. The 11/20/18 Care Plan directed staff to provide assistance of one or two staff for dressing, showering, toileting, and ambulation. On 11/18/19, staff added the intervention prefers female caregivers only. The facility provided an investigation of an allegation of staff to resident sexual abuse which involved Certified Nurse Aide (CNA) M and R1. According to the investigation, on 11/17/19 at approximately 05:00 PM, R1 told two CNAs that CNA M inserted his fingers into her vagina while providing care. The CNAs immediately told Licensed Nurse (LN) M of the allegation. LN M failed to immediately notify the Administrator of the allegation of staff to resident sexual abuse. CNA M continued to work for an approximate 12 hour time period immediately following the allegation, during which time he provided care to residents on all hallways and had access to all 50 facility residents. According to the investigation, Administrative Staff A learned of the allegation at approximately 08:00 AM on 11/18/19, approximately 15 hours after R1 made the allegation. Review of time clock entries for AP CNA M included a clock in time of 05:56 PM on 11/17/19, the day R1 alleged the sexual abuse, and a clock out time of 06:00 AM on 11/18/19. A Grievance Log entry dated 11/17/19 included, (R1) says that when (CNA M) dresses her for bed or in the morning that he has put his fingers in her vagina. She said it happened 2-3 times. During an interview on 11/19/19 at 04:30 PM, Administrative Staff A confirmed R1 told staff on 11/17/19 at approximately 05:00 PM that CNA M put his fingers inside her vagina. Administrative Staff A also confirmed LN G failed to notify him of the allegation. CNA M worked an approximate 12 hour shift after R1 told staff about the allegation of sexual abuse. During a later interview on 11/20/19 at 08:20 AM, Administrative Staff A reported he first learned of the allegation on 11/18/19 at approximately 08:00 AM, 15 hours after R1 reported the incident to staff. Administrative Staff A learned of the allegation when he arrived at work on 11/18/19 and found a note slipped under his door. During an interview on 11/19/19 at 04:55 PM, R1 was alert and oriented and had the ability to verbalize her needs. The resident described an incident which occurred on an unknown date a few days ago in which CNA M assisted her with care. R1 could not recall specifically the type of care CNA M provided at that time. According to R1, I don't know what he was doing or how he was helping me. I don't remember that but all of a sudden he had his fingers in my vagina. I was so shocked and scared and I told him he better get out of here and leave me alone . I was really scared. I kept hearing (CNA M) out in the hallway that night but he didn't come back into my room. I was terrified he was going to come back in here . R1 reported she decided to tell another staff person about what happened because I didn't want it to happen to me again or to anyone else. R1 could not remember who she told or the date/time she told them of the allegation of sexual abuse. During an interview on 11/20/19 at 10:30 AM, LN G confirmed she worked as a charge nurse on 11/17/19 on the 6 AM - 6 PM shift. LN G also confirmed she learned of R1's allegation of sexual abuse just before supper on 11/17/19. LN G reported she attempted to notify the on call nurse of the incident but that nurse failed to answer the phone. LN G reported she then filled out a grievance form which described R1's allegation and left copies for Administrative Nurse D and Administrative Staff [NAME] According to LN G, she slid Administrative Staff A's notification beneath the door of his office and knew he would see it the next day. LN G denied knowledge such an allegation required immediate notification of Administration. LN G also denied knowledge of specific requirements related to protection of all residents following such an allegation. LN G reported CNA M arrived for work at the beginning of the 6 PM - 6 AM shift as she was ending her shift. During an interview on 11/20/19 at 11:00 AM, Administrative Nurse D reported she expected LN G to call both the on call nurse and the Administrator immediately upon learning of R1's allegation of sexual abuse. During an interview on 11/20/19 at 03:40 PM, CNA M, the AP in this allegation of sexual abuse, confirmed he worked the 6 PM - 6 AM shift on 11/17/19. During that shift, CNA M reported he provided care to residents throughout the facility and had access to all 50 facility residents. CNA M reported he was placed on administrative leave the afternoon of 11/18/19. The facility's (MONTH) 2019 Abuse, Neglect, Misappropriation, Exploitation policy defined sexual abuse as nonconsensual sexual contact of any type with a resident/patient. The policy also directed staff to report all allegations to the Administrator or his/her designee immediately. The policy also included, If the suspected perpetrator is a team member, the Administrator/Director of Nursing or designee shall place the team member on immediate administrative suspension while completing the investigation. The facility failed to have a system in place to protect all residents following an allegation of staff to resident sexual abuse. This failure placed all 50 facility residents in immediate jeopardy. The deficient practice was cited as past non-compliance when the facility implemented a four step corrective action plan on 11/18/19 as follows: Step One: The facility staff comforted and assessed the resident for injury. The resident's NP/MD were notified. The facility requested a psych consultation for the resident. The facility notified local law enforcement. The facility put the AP on administrative leave. The facility held an emergency QAPI meeting with the resident's physician. Step Two: The facility interviewed other residents to ensure no further concerns regarding their care. The facility conducted safety surveys with residents. The facility initiated abuse and neglect and reporting training for all staff members (no staff members would be allowed to work until they completed the retraining on ANE and reporting requirements). The facility held a resident council meeting. Step Three: The facility continued training staff. Step Four: All actions were/and will be reviewed in QAPI for any follow-up. The deficient practice remained at a scope and severity of [MI]

The facility census totaled 55 residents and the sample included 29 residents with 4 sampled for review of accidents. Based on observation, interview and record review the facility failed to determine causal factors of multiple falls, and failed to develop and implement effective and appropriate interventions to prevent further falls for 1 of 4 residents (#29). Resident #29 had multiple falls and on 10/23/17 he/she fell resulting in a head injury with laceration requiring stitches and hospitalization . The resident fell 7 times between admission 9/29/17 and 10/26/17. Findings included: - Review of the physician's history and physical dated 10/23/17 revealed the following [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 5, which indicated severe cognitive impairment. He/she did not reject care but wandered 1-3 days of the 7 day observation period. The resident required limited assist of one person for bed mobility, walking in room/corridor, locomotion on/off of unit and extensive assist of one person for transfers. The resident was not steady and only able to stabilize with human assistance for balance during transitions and walking. The resident fell in the last month and 2-6 months prior to admission. The resident had a fracture related to a fall in the 6 months prior to admission. The cognition care area assessment (CAA) dated 10/12/17 indicated the resident had some memory problems, was alert and oriented to self and able to make his/her needs known. He/she exhibited intermittent confusion and disorientation, was forgetful and needed extensive assist of at least one staff for bed mobility, transfers, and toileting. The activity of daily living (ADLs) CAA dated 10/12/17 indicated the resident fell at home and as a result needed his/her left arm in an immobilizer. He/she had a bed alarm and chair alarm in place related to his/her fall risk and need for extensive assistance with most ADLs. He/she could ambulate with contact guard (one or 2 handed contact to help stabilize) or stand-by assistance of staff due to unsteadiness and arm immobilization. The urinary incontinence CAA dated 10/12/17 indicated the resident had the cognitive ability to recognize the need to toilet and he/she needed to wait on staff assistance to go to the bathroom. He/she required assistance with clothing and if he/she waited too long he/she may become incontinent of bladder. The fall CAA dated 10/12/17 identified the resident as a fall risk related to his/her left arm being in an immobilizer due to a fracture from a fall at home. The facility placed an alarm (did not specify if bed, chair or both were alarmed) to remind him/her to wait for staff assistance and to alert staff of the resident trying to get up. Review of the current care plan revealed a problem with ADLs dated 9/29/17 which directed staff to provide extensive assistance of 1 staff for bed mobility related to left arm immobilizer. He/she could move around in bed and get out of bed but not safely. He/she needed 1 staff assist for transfers related to poor balance due to the left arm immobilizer. Staff should encourage the resident to allow and assist the resident with contact guard assistance (CGA - 1-2 hands in contact with the body to help stabilize) or stand-by assistance (SBA) for ambulation in his/her room and hallways. The bowel and bladder care plan dated 9/29/17 included for staff to offer/assist the resident with toileting around 7:30-8:00 AM, 11:00 AM, 1:00 PM, 5:00 PM, 8:00 PM, 11:00 PM and as needed (PRN) during the night when awake. Assist him/her with clothing and personal hygiene. The mobility care plan dated 9/29/17 indicated the resident had a fall risk related to a fall at home with a fractured left arm. Staff should assist the resident with CGA - SBA for safety with ambulation. On 10/8/17 staff added physical therapy (PT) for therapeutic exercises/activities, neuromuscular re-education and gait training with occupational therapy (OT) included the same interventions and planned to address his/her edema. The fall/safety care plan dated 9/29/17 included; he/she had a brief interview for mental status (BIMS) score of 6 indicating severe cognitive impairment. He/she had a high fall risk related a fall prior to admission with a fractured left arm. The interventions included the above PT and OT directions. Staff added on 10/8/17 the resident could ambulate with a cane and 1 staff assistance with a transfer belt (a safety device secured around the waist and held by staff to provide support). Review of the facility's fall investigation dated 10/11/17 at 8:00 PM revealed the resident stood up from a chair which had an alarm in place (the investigation did not indicate if the alarm sounded) and started walking down 300 hall with his/her cane, got weak and his/her legs gave out and he/she fell back onto his/her sacrum. The fall was witnessed by staff. Nurse assessment revealed no injuries and staff assisted the resident off the floor and back into a chair. The investigation indicated the resident was restless, anxious and ambulating without assistance prior to the fall but did not identify the source of the restlessness, why he/she stood up, where he/she wanted to go, or basic needs of toileting or food/fluids were provided in a reasonable time frame prior to the fall. The facility listed causal factors of: needs assist with ambulation, restless, struggling to use his/her cane with the opposite hand. Staff updated the care plan on 10/11/17 with when the resident ambulated without assistance staff should make sure he/she had a cane, place a transfer belt on him/her and ambulate with him/her. When staff saw him/her walking down the wrong hall he/she was usually looking for the dining room, the bathroom or his/her room. Staff should place a transfer belt on him/her and assist him/her to where he/she wanted to go. Review of the fall investigation dated 10/13/17 at 8:30 PM indicated the resident fell in the middle of the hall and sat on his/her bottom. He/she had shoes on and walked with his/her cane. The investigation did not indicate which hand the resident had the cane in or if the left arm remained in an immobilizer. The resident had been restless and not easily redirected. The facility's causal factors were similar to 10/11/17 fall and included: needs assistance to ambulate safely, struggling using his/her cane with the right arm, restless, non-compliant and easily frustrated. The investigation lacked a reason for the restlessness, why the resident got up and where he/she wanted to go. The investigation did not indicate when he/she was last toileted or had food/fluids to ensure his/her basic needs were being met. The investigation indicated post fall interventions included staff asked the resident if he/she needed to use the bathroom, offered food/drink which the resident refused all so staff assisted him/her back to the chair in the living room for staff to observe him/her. Staff updated the care plan on 10/13/17 with make sure he/she had the cane when up (this investigation indicated he/she did have the cane) and he/she held the cane with his/her right hand now due to a fractured left arm from a fall at home. Review of the fall investigation dated 10/15/17 at 1:31 PM indicated the resident ambulated unassisted with his/her cane in the lounge area when he/she lost his/her balance and fell landing on his/her buttocks outside of the nourishment room. He/she hit his/her right forearm on the hand rail which caused a skin tear measuring 2 centimeters (cm) by 3 cm with the skin flap torn and missing. The nurse cleansed the wound, applied triple antibiotic ointment and covered the skin tear. The investigation indicated a chair alarm was in place but did not indicate if the alarm sounded, or if staff were present and/or responding. The investigation did not include the last time the resident was toileted, when he/she last had food/fluids or what he/she wanted to do that motivated him/her to get up. The facility listed causal factors as ambulating without assist, not used to using his/her cane in the right hand, unsteady, newly required assistance due to immobilizer and listed an intervention of staff assist with a transfer belt. Staff added to the care plan on 10/15/17 he/she had a bed alarm and an alarm in his/her recliner to alert staff when he/she attempted to get up. Staff should make sure the alarms were in place, on and out of his/her reach because he/she would turn the alarm off. He/she needed to have non-skid footwear on when he/she ambulated (the investigation indicated the resident wore shoes and used his/her cane and had a chair alarm in place). Review of the fall investigation dated 10/16/17 at 4:15 PM indicated the resident walked with a family member out the front entrance when his/her legs gave out, he/she was weak and dizzy. The investigation included possible dehydration or syncope (fainting or passing out). Interventions included push fluids, monitor for signs and symptoms of syncope, remind/encourage him/her to rise slowly from a lying position and check for orthostatic hypotension (blood pressure dropping with change of position). The investigation included a blood pressure reading of 132/89 (normal range 120/80) but did not include the orthostatic hypotension evaluation. Staff added to the care plan interventions with a date of 10/16/17 but did not include a time so unknown if the update went with this fall or the fall later on the same day. Review of the fall investigation dated 10/16/17 at 7:06 PM revealed the resident ambulated with 2 staff from lounge chair when he/she became pale and had a syncope episode so staff assisted the resident to the floor (the investigation did not indicate if a transfer belt was in use by staff). The nurse assessment showed the resident's blood pressure dropped from 154/90 to 100/70 when standing. Staff notified the physician and the resident went to emergency care for evaluation of orthostatic hypotension. Staff added to the care plan on 10/16/17 without a time (he/she had 2 falls on 10/16/17) keep his/her frequently used items close to him/her when in the bed or recliner, he/she was usually up and down throughout the night, keep a night light on at night, keep glasses within reach, keep cane at bedside and his/her shoes on the floor beside the bed where he/she can easily reach them. Keep his/her shoes and cane within reach when he/she was in his/her room because he/she would usually put his/her shoes on before getting up (same as another intervention with same date). Staff indicated he/she was having a hard time finding his/her room, bathroom and the dining room and frequently needed staff assistance to help him/her find a specific location (this was same intervention as 10/11/17 fall). Keep his/her call light secure and in reach, remind/encourage him/her to call for assistance before getting up (BIMS score of 6 indicating severely impaired cognition). Staff should cue the resident to get up slowly from a lying position and to sit on the side of the bed for a couple of minutes before standing. The care plan indicated the fall was a syncope episode - sent to the emergency room (ER) with medications reviewed by pharmacy. Keep room free of clutter and his/her pathway clear to decrease risk of falls. Syncope episodes - monitor for signs/symptoms of syncope and check for orthostatic hypotension as needed. Review of the fall investigation dated 10/23/17 at 7:36 PM indicated licensed nurse HH was down the resident's hallway when he/she heard the resident call out for help. The nurse found the resident on the floor against his/her bed with a copious (abundant supply) amount of blood noted on the floor and the resident bled from the left side of his/her head with a wound noted to the temple region. The nurse applied pressure until emergency medical services arrived and transported the resident to the ER for evaluation. The investigation indicated the resident got up without staff assistance, unsteady, needed assist to be safe, did not have his/her cane, non-compliant and restless. The investigation did not indicate if the planned bed alarm was in place and whether it sounded, did not indicate when the resident was last toileted or had food/fluids and did not indicate why he/she attempted to get out of bed and or what measures were in place to address the restlessness which had been a factor since admission and all previous falls. The investigation indicated the resident required 8 stitches to close the head wound, received a unit of blood and normal saline and admitted to the acute care unit of the hospital. Staff updated the care plan on 10/23/17 with the resident had a non-skid mat in front of his/her recliner and a mat in front of the toilet. He/she frequently got up without assistance and forgot his/her glasses and/or hearing aids with directions for staff to assist him/her with glasses and hearing aids as needed. Staff to assist the resident to the bathroom after meals as needed; needed help with pulling pants up and down, with the belt, buttons and zippers (the care plan for bowel and bladder included times for toileting and the need for assistance by staff). Staff updated the care plan on 10/24/17 (after the fall with injury on 10/23/17) to include interventions for restlessness which included staff to encourage the resident to go to activities, look at a magazine or newspaper, sit in commons area to listen to music, watch TV and/or interact with others. When the resident was restless or wandering staff should offer him/her a newspaper or magazine to read, offer something to eat or drink and assist him/her to the commons area and show him/her where he/she could sit down because if not shown he/she would take off walking again. When he/she was restless, wandering, frequently getting up walking without assistance, ask if he/she needed to use the bathroom. Staff to make sure he/she had hearing aids in place and could hear what was asked because he/she would answer no even if he/she did not know what was asked. The resident's bathroom had grab bars to assist him/her with transferring on/off the toilet. Staff should encourage the resident to use them when staff assisted him/her as needed. Review of the facility fall investigation dated 10/26/17 at 8:20 AM revealed staff found the resident on the floor. The investigation indicated the resident's family member left without alerting staff and closed the room door. The facility identified causal factors of need for more frequent observations, non-skid socks/shoes, he/she needed to use the bathroom and the alarm was not working. The investigation did not include when the resident was last toileted, interviews with staff about alarm placement or when the function of the alarm was last checked. Staff updated the care plan on 10/26/17 with room change to a room closer to the nurses' station. Review of the nursing notes between 9/29/17 and 11/22/17 revealed the following: 9/29/17 at 4:29 PM resident self- transferred and ambulated independently several times. Pressure alarm placed in lounge chair in room and also on the bed. 10/10/17 at 11:20 PM resident is completely noncompliant with treatment, protocol, advice, and assistance that facility tries to give resident. He/she lashes out hitting and yelling when you try to assist him/her with walking and other ADLs. Alarms are always in place resident gets up and out of bed or chair without help yells at staff and tries to hit when staff tried to assist him/her. The resident refused to follow facility and staff protocol, refused to use call light and refused to act in a civil manner. Subsequent notes through next 24 hours did not address interventions of psychosocial adjustment to the facility and what social service or the facility implemented to help the resident with his/her restlessness. The notes included the same general information as the above fall investigations with no notes regarding what the facility did for the resident in regards to restlessness or anxiousness until 10/30/17 when staff faxed the physician notifying him/her of the resident not sleeping up and down all night and requested an order for [REDACTED]. Observation on 11/15/17 at 1:12 PM the resident rested in bed with his/her eyes closed and no movement. An alarm box was visible and attached to the bed frame. At 1:15 PM the resident began to sit up, the alarm sounded and direct care staff NN responded, attempted to find out what the resident wanted to do and he/she could not tell staff NN. He/she then asked the resident if he/she wanted to lie back down since most of the other residents were and he/she said okay then staff NN assisted the resident to lay back down. At 1:28 PM the alarm sounded again, direct care staff R and direct care staff V responded within 30 seconds and observation revealed the resident was already out of the bed and in the nearby wheelchair. Interview on 11/15/17 at 1:30 PM with direct care staff R revealed the resident had a high risk for falls, had the bed alarm and chair alarm and he/she responded as soon as possible. He/she indicated knowing how to care for the resident and what safety precautions were needed from the electronic record care plan. Interview on 11/19/17 at 2:15 PM with licensed nurse K revealed the resident was doing much better and seemed to have settled in. He/she still did not use the call light and tried to get up without assistance because he/she did not remember. Nurse K said the resident's last fall was almost a month prior. When a resident fell the nurse should assess the resident for injury, complete an incident report, try to figure out what happened and put an intervention in place to prevent another fall, make a nursing note, and notify the physician and family. Interview with administrative nurse A on 11/17/17 at 2:10 PM revealed the resident had confusion, disorientation, was a new resident, had the immobilizer and had to use a cane in the non-dominant hand was the reasons for the falls. He/she said the interdisciplinary team reviewed each fall and tried many different things. Staff walked with the resident, the family came and spent time with the resident, facility staff found out he/she was having trouble hearing and he/she would remove the alarm or shut it off. Administrative nurse A confirmed the investigations did not include when the resident was last toileted, had food/fluids or what the facility did to address the resident's restlessness. He/she reported the resident would get up from the common area and walk down the 100 hall (where he/she resided until 10/25/17) which was not as visible to staff. The facility policy titled falls and dated 4/2017 directed staff to assess the resident for fall risk upon admission and when a risk factor was identified a corresponding intervention which addressed the risk factor should be developed and documented on the care plan and caregiver guide. Post fall staff should have a fall huddle to help investigate circumstances around the fall and help to determine immediate interventions. The tools portion of the policy directed staff to evaluate the following for a cognitively impaired resident: toileting program/schedule, ask family for assist in ideas for an activity basket, memory book or photo albums, restorative programs-exercises/ambulation, appropriate footwear and evaluate pain issues. The policy further directed staff if the resident had multiple falls the trending for time of day, reason for fall, location of fall and such should be reviewed. Consider room change to move to a more observed area, keep resident in view during high risk times if possible, discuss reason for the falls with the direct care givers, involve recreation for activity interventions, assess medical conditions/medications as possible causal factors, special activity group to diffuse energy and keep occupied during high risk times. The facility failed to determine causal factors then develop and implement effective and appropriate interventions to prevent further falls for this resident. The resident had multiple falls and on 10/23/17 he/she fell and sustained a head injury with laceration requiring stitches and hospitalization .

The facility had a census of 44 residents, with 5 residents selected for sample. Three sampled residents experienced falls within that past three months. Based on observation, interview and record review, the facility failed to ensure two of three residents who sustained falls received adequate supervision and assistive devices to prevent falls (Residents #1, #2). Staff failed to provide care as directed by the care plan for residents #1 and #2. Both residents fell and sustained fractures as a result of their falls. The facility also failed to provide appropriate assistive devices (foot pedals for wheelchairs) for resident #2 and the resident fell from the wheelchair while pushed by staff. Findings included: - Resident #1's clinical record included a 1/9/12 Quarterly MDS (Minimum Data Set) which identified the resident with no cognitive impairment, the need for extensive assistance of two staff for transfers, total dependence on staff for bathing, balance issues which results in an inability to stabilize without human assistance, use of a walker and wheelchair, a weight of 220 lbs (pounds), and no falls since the previous assessment. Resident #1's 1/18/12 Care Plan included, "I get around the facility in a WC (wheelchair). I am at risk for falls. I have fallen in the past. I am able to ambulate with staff assist and a walker...Use 2 staff with maxi-lift for all transfers....I need 2 staff with a gait belt for all transfers...I have a transfer pole in my room for assistance with transfers and mobility." A 1/9/12 "Transfer Assessment" noted resident #1 required a maxi-lift for transfers. Nurses Notes for Resident #1 included the following entries: o 3/8/12: "Resident fell in shower room at 2040 (8:40 p.m). R (right) leg inverted. Resident c/o (complains of) pain in outer aspect of left knee...order to transfer to ER (emergency room ) for Xray of right leg/knee..." o 3/9/12 at 12:15 p.m.: (Hospital) called to notify that resident has a fx (fracture) of the right distal femur..." o 3/9/12 at 9:25 a.m.: "Late entry 3/8/12 at 2130 (9:30 p.m.): CNA (certified nurse aide) reported that resident told (him/her) was allowed to use grab bar in shower to stand. Since care plan stated (he/she) could use transfer pole in room to transfer, CNA stated (he/she) allowed resident to hold and stand by grab bar in shower, but as CNA reached for WC (wheelchair) resident was unable to keep self standing and holding bar and fell to the floor." As requested, the facility provided their investigation of resident #1's fall on 3/8/12. A, "Supervisory Adverse Action Notice" dated 3/12/12 included: (Direct Care Staff D) transferred a 2-staff with gait belt resident by (him/herself). Resident fell and had injury..." During an interview on 5/21/12 at 10:00 a.m., Administrative Nurse B confirmed resident #1 fell in the shower on 3/8/12 and sustained a femur fracture in that fall. According to Nurse B, Direct Care Staff D failed to follow the care plan that directed staff to use 2 staff and a gait belt for transfers or a maxi-lift. Staff D attempted to transfer resident #1 by him/herself, and the resident fell . During an interview on 5/21/12 at 3:00 p.m., Resident #1 reported staff, "did not do what they were supposed to do and that's why I ended up like this...with a busted up leg." According to resident #1, staff typically transferred him/her to the shower chair with a mechanical lift or two staff, but on 3/8/12 Direct Care Staff D attempted the transfer without staff assistance. Resident #1 reported the problems started after the shower when Staff D directed him/her to hold onto the grab bars mounted to the wall while he/she (staff member) grabbed the wheelchair. According to Resident #1, his/her fingers/hands slipped on the bar and that's what caused the fall. Resident #1 expressed fear that he/she might not ever be able to walk again as a result of the fracture During an interview on 5/21/12 at 4:40 p.m., Direct Care Staff D confirmed he/she gave resident #1 a shower on the evening of 3/8/12, and instead of waiting for assistance from other staff, attempted to transfer the resident back to the wheelchair by him/herself. According to Staff D, resident #1's hands slipped from the grab bar and the resident fell to the floor. Staff D also confirmed resident #1 sustained a fractured leg as a result of that fall. Staff D also reported he/she knew the care plan directed staff to use two for all transfers. Attempts to contact resident #1's physician were unsuccessful on 5/23/12. During an observation on 5/21/12 at 4:00 p.m., resident #1 sat in a recliner in his/her room with both feet elevated. The resident wore a long leg brace/splint on the right leg. In summary, the facility failed to provide resident #1 with adequate supervision and assistive devices to prevent accidents. Staff failed to provide transfers as directed by the care plan, and resident #1 fell and sustained a femur (leg) fracture. - Resident #2's clinical record included a 2/27/12 Annual MDS (Minimum Data Set) which identified the resident with severe cognitive impairment, the need for assistance of two for transfers, unsteadiness in balance and only able to balance with human assistance when moving from seated to standing, no range of motion limitations, use of a walker and/or wheelchair, one fall since admission or the prior assessment and no falls with injury. CAAs (Care Area Assessments) completed on 3/1/12 noted no documented falls for resident #2 within the past 6 months, and the need for assistance of 1-2 staff for all transfers. Resident #2's 3/8/12 Care Plan included, "I get around the facility in my WC (wheelchair) propelled with my feet. I do have the ability to walk short distances. Generally I walk around my room and use my WC to get around the facility. I am at risk for falls. I have a fall risk of 9 which indicates I am at moderate risk of falling. I will allow 1-2 staff with a gaitbelt to assist me with all transfers....I need 1-2 staff and a gaitbelt to assist me with toileting and I need one staff to stay with me while I am on the toilet." The 3/8/12 care plan did not address the use of foot pedals on the wheelchair. A, "Fall Risk Assessment" completed on 2/29/12 identified resident #2 as a moderate risk for falls. Nurses Notes for resident #2 included the following entries: o 4/10/12 at 7:30 a.m.: "While propelling pt. (patient) to dining room pt. put (his/her) feet down, then fell out of WC (wheelchair). o 4/11/12 at 1:35 p.m.: "....redness to forehead, abraded areas to forearm and face with bruising noted around the eye" as follow up fall documentation. o 4/29/12 at 3:45 p.m.: "Res. (resident) coming out of (his/her) room to get into WC (wheelchair) and fell before anyone could reach (him/her)...fell hitting L (left) forehead on the carpet. Noted a 2 cm (centimeter) by 3 cm. purple bruise on L (left) frontal region of head. No other injuries noted...... A chair alarm was placed on resident and transferred to bed when (he/she) is in bed. Bed in low position." o 5/7/12 at 12:20 p.m.: "At approximately 1145 CNA (certified nurse aide) informed me resident was on floor. Resident was sitting on bottom with right leg at 90 degree angle under the left leg. Voiced pain in R (right) knee and back. Upon trying to straighten it, resident began crying and pushing staff away... EMS (Emergency Medical Services) notified and arrived at approximately 1200." o 5/7/12 at 3:25 p.m.: "Took call from RN (registered nurse} at (Hospital) stating resident had broken R knee and would be transported to (Hospital) trauma unit..." A 5/15/12 Transfer Form from the hospital back to the facility noted resident #2 had a surgical repair of a femur (leg) fracture while hospitalized . During an interview on 5/21/12 at 10:20 a.m., Administrative Nurse B confirmed resident #2 experienced falls on 4/10/12, 4/29/12 and 5/7/12 as described in the Nurses Notes. According to Nurse B, staff pushed resident #2 down the hallway in the wheelchair on 4/10/12 and did not have foot pedals on the wheelchair. Resident #2 dropped his/her feet to the floor while being pushed and that resulted in the resident's ejection from the wheelchair onto the floor. Nurse B reported staff decided to place a "drop seat" in the resident's wheelchair after the 4/10/12 incident in order to prevent further falls from the wheelchair. According to Nurse B, resident #2 still does not have foot pedals on the wheelchair. During an interview on 5/21/12 at 2:30 p.m., Administrative Nurse B reported resident #2 fell from the toilet to the floor on 5/7/12 when staff left the resident unattended in the bathroom. Upon review of the resident's 3/8/12 Care Plan, Nurse B confirmed the care plan directed staff to not leave resident #2 unattended in the bathroom. According to Nurse B, he/she did not know the care plan included that directive, and the "pocket" care plans provided to direct care staff did not include that information. Nurse B also confirmed resident #2 sustained a fracture to the leg during the 5/7/12 fall. During an interview on 5/21/12 at 9:00 a.m., Direct Care Staff C reported he/she left resident #2 on the toilet in the bathroom on 5/7/12 while he/she went to provide care to other residents. According to Direct Staff C, staff frequently left the resident alone in the bathroom and then checked on him/her occasionally because the resident was not on the, "Stay with" list (a list of residents who should not be left alone in the bathroom). When he/she went back to check on resident #2 on 5/7/12, the resident lay on the bathroom floor and complained of pain to the leg and back. During a later interview on 5/22/12 at 9:30 a.m., Direct Care Staff C reported resident #2 was never on the "Stay With" list in the entire 9 years he/she worked at the facility. According to Staff C, the pocket care plans used by nurse aides did not direct staff to stay with resident #2 while on the toilet. Attempts to contact resident #1's physician were unsuccessful on 5/23/12. During an observation on 5/21/12 at 9:00 a.m., resident #2 required assistance of two staff for a transfer from the wheelchair to the recliner. The resident wore a long leg brace/splint to the right leg. The resident had cognitive impairment and did not initiate conversation. During an observation on 5/21/12 at 11:40 a.m., an unknown staff member pushed resident #2 in the wheelchair to the dining room for lunch. The resident's wheelchair did not have foot pedals in place, and resident #2's feet dragged along the floor during the observation. The facility failed to provide resident #2 with adequate supervision and assistive devices (foot pedals on the wheelchair) to prevent falls. Staff failed to use foot pedals on the wheelchair and resident #2's feet caught on the floor while staff pushed the resident in the wheelchair, which resulted in the resident's ejection from the chair onto the floor. The facility also failed to provide care as directed by the care plan when staff left resident #2 unattended on the toilet. The resident fell from the toilet and sustained a fracture of the leg.

The facility reported a census of 49 residents and identified 2 with pressure ulcers. The 19 residents selected for review included the 2 with pressure ulcers. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services for 1 (#21) of the 2 residents with pressure ulcers, to promote healing, prevent infection, and prevent the development of a new pressure ulcer. Furthermore, the facility failed to provide timely assistance to reposition 2 (#3 and #6) selected residents who required repositioning assistance to prevent pressure ulcers. Findings included: - Resident #21 last readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 3/7/11 and 5/23/11, quarterly MDS, (minimum data set assessments) documented the resident at risk for pressure ulcers, none current, and no history. The facility documented the use of a pressure reducing device to the resident's bed and chair, with the 5/23/11, assessment addition of a turning and repositioning program. The 8/15/11, annual MDS documented a cognitive level of severely impaired with a score of 1 on the BIMS (brief interview mental status). The resident required extensive assistance of 2 staff for all bed mobility, transfers, and toileting needs. The resident required limited assistance of 1 staff for dressing and hygiene needs. The resident experienced pain, with non verbal sounds of crying, moaning, or groaning being present. The 8/24/11 CAAS (care area assessment summary), did not identify the resident with a pressure ulcer so the area did not trigger to further investigate. The 8/24/11 plan of care, included; "Apply barrier cream as needed. I have a pressure relief cushion on my wheelchair and on my bed. Use wedge for positioning while in bed. I am on the last one up first down list. I have an air flow mattress on my bed to help reduce pressure, please check to see if it is on. I am totally dependent on staff to complete my ADLs (activities of daily living needs). " The resident's weekly wound assessment records began with 9/7/11, with documentation of a stage 1 pressure ulcer on the resident's coccyx area, with measurements of 1.8 by 0.3 by 0.1 cm (centimeters) with 100% of granulation tissue present. These weekly wound assessments continued on 9/14/11, 9/21/11, 9/28/11, 10/5/11, and 10/12/11. The weekly wound assessment progress note, dated 9/28/11 at 1:40 PM, documented, "Wound to coccyx re-assessed today. Initially wound was assessed as skin tear, linear laceration upon initial presence back in May, 2011. Wound today presents as pressure in appearance and no longer linear in shape, but circular. Wound bed shows 100% red granulation tissue, moist without drainage, odor, or pain. (Physician) present and assessed wound at this RN's (registered nurse's) request. New treatment orders received. Continue to remove pressure to area when possible. Request therapy to assess current pressure reducing cushion in wheelchair." The assessment dated [DATE], documented increased measurements of 1.5 by 0.7 by 0.2 cm. The weekly wound assessment progress notes, also dated 10/12/11, documented, "Stage 2 ulcer, 1.5 by 0.7 by 0.2 cm. Wound bed moist, 100% pink granulation. No signs of infection. No signs of pain. The weekly wound assessments continued documentation on 10/19/11, of continued increasing measurements, 1.7 by 0.7 by 0.4 cm. without pain. The weekly wound assessment, 10/26/11, documented measurements of 2 by 0.5 by 0.7 cm, and 60% granulation with 40% slough, at this time the resident began with complaints of pain. Observation on 11/1/11 at 11:30 AM, revealed CNA's I and K just completed personal hygiene following incontinence, and transferred the resident with a mechanical lift into the wheelchair. The resident yelled out loudly and complained of pain on the buttock area during movements off and on. CNA I explained the resident with a sore on the bottom and that is why the resident complains more now of pain. CNA I assisted the resident in the wheelchair to the medication staff to obtain pain medication prior to the noon meal service. Further observation of the wheelchair, at the resident's upper leg region, revealed the resident on a foam type cushion, with a plaid cloth cover. The resident's bed contained a special air mattress overlay attached to an air pump. On 11/2/11 at 8:10 AM, the resident awakened CNA K brought the mechanical lift to the resident's room. At 8:15 AM, licensed nurse U entered the resident's room with treatment supplies for the resident's coccyx pressure ulcer treatment. The nurse placed the treatment supplies directly on the top of the bedside nightstand, which held a glass of thickened juice and various resident personal items. CNAs K and H assisted the nurse to position the resident onto the side for treatment of [REDACTED]. The resident's brief and buttocks area contained loose incontinent bowel movement with the urine and the nurse used periwipes to cleanse the area around the pressure ulcer. The nurse then measured the area and reported the pressure ulcer as now larger at 2 by 1 by 1 cm deep. Licensed nurse U then washed their hands and applied new gloves that lay directly on the nightstand top. The nurse used the gloved hands to open two different packets with a normal saline wipes that lay directly on the nightstand top, and cleansed through the pressure ulcer area. The nurse then washed their hands and applied another set of new gloves from directly on the nightstand top without barrier. The nurse used the gloved hands to open another packet, from the nightstand top, with an iodine soaked gauze type dressing, tore the gauze in half and inserted it into the wound bed with the gloved finger. The nurse opened another packet, from the nightstand top, with dry gauze, folded it in half and placed it over the pressure ulcer area. The nurse attempted to cover the dressing with a special tape, from the nightstand top, but the tape failed to stick to the resident's skin to keep the dressing in place. The nurse applied a thick barrier cream to the resident's buttocks around the taped dressing area prior to application of the new incontinent brief. CNAs H and K then placed a full size lift sling under the resident for the mechanical lift. The resident yelled out several times in pain and said, "It hurts, it hurts." When questioned where it hurts, the resident attempted to reach the pressure ulcer area of the coccyx and said, "Right here." Prior to transfer of the resident into the wheelchair, closer observation of the resident's wheelchair seat cushion revealed the back edge contained a V cut out in the center approximately 5 inches across the back. The cushion sat directly on top of a flat hard tan plastic device placed in the wheelchair to hold the seat up. However, the cut out section, of the cushion, allowed the resident's pressure ulcer area to sit and press directly down on this hard plastic. Licensed nurse U reported the therapy staff placed the resident on the cushion with the back cut out to attempt to relieve pressure to the resident's coccyx area. However, the staff failed to realize the cushion sat directly on the hard plastic directly under the pressure ulcer area. Licensed nurse U verified the seat cushion not appropriate and would actually cause increase pressure to the ulcer area. At this time, CNAs K and H reported the resident's bed contained the special air mattress for over a year and the wheelchair contained the same cushion for, "Quite awhile now." Licensed nurse U placed a bed pillow in the resident's wheelchair seat and instructed the CNAs to place the resident on this until after the morning meal and the therapy could find another appropriate seat cushion then. When the resident sat on the pillow seat, the resident reported the sore bottom felt better now. The facility's undated policy and procedure for, Dressing-Non Sterile, included; "... 8.) Prepare a clean dry work area at bedside..." On 11/7/11 at 3:00 PM, licensed nurse V verified the facility staff should place some type of protective clean barrier on the table to place treatment supplies on during a treatment of [REDACTED]. On 11/2/11 at 12:05 PM, CNAs K and X assisted the resident with incontinence hygiene following incontinence of bowel movement and urine. The resident's dressing fell off with soiling and the staff called the nurse to change the dressing. Licensed nurse U entered the room with treatment dressing supplied and again placed the items directly on the nightstand top without any type of clean barrier field. The iodine gauze packing remained in the ulcer cavity. Nurse U cleansed the area around the ulcer with periwipes and to the buttocks/rectal area. Licensed nurse U then continued and used the same gloves after cleaning the incontinent bowel movement to pick up a folded gauze 4 by 4 and placed it over the packed iodine inside, and covered the dressing with the tape. Following the treatment and new brief application, the CNAs used the mechanical lift and assisted the resident into the wheelchair. The wheelchair seat now contained a "Roho" type of pressure relieving seat cushion. The resident reported the new cushion felt better. On 11/3/11 at 8:40 AM, CNA J reported assisting the resident from the bed this morning. The staff changed the resident's incontinent brief due to wetness, and the resident's dressing came off of the resident's bottom. The nurse told the CNAs to leave the resident in bed but then came back and told the CNAs to get the resident up and to leave the dressing off because the doctor was coming and the nurse wanted the doctor to see the area. CNA J reported they used the mechanical lift to place the resident into the wheelchair and to go to the dining room. On 11/3/11 at 10:30 AM, physician A came to the facility to see residents including this resident. The physician reported the resident's pressure ulcer continued to enlarge and the staff attempted to find out why the area did not show healing. Following informing of the facility use of a seat cushion with the V cut out and the resident actually sitting the area directly on the hard flat plastic, the physician stated, "No wonder we are having trouble with it." At 11:45 AM, physician A followed licensed nurse U into the resident's room to assess the resident's pressure ulcer. Physician A verified the area as enlarged. Nurse U brought treatment dressing supplies to the room and placed the items on a clean white towel barrier on the nightstand top. The facility staff failed to provide pressure reducing devices to the resident's wheelchair seat and actually sat the resident's pressure ulcer area directly on a hard plastic surface of the chair. Furthermore, the staff failed to ensure appropriate treatment dressing changes to prevent further infection or decline in the resident's pressure ulcer. - The facility admitted resident #6 on 7/27/11. [DIAGNOSES REDACTED]. The 9/26/11, minimum data set assessment, documented the resident with cognitive impairment, incontinence of bowel and bladder and in need of assistance with all activities of daily living. The 10/4/11 plan of care included, 1-2 assist with all ADL's (activities of daily living) except eating. Use sara lift for transfers. On 11/2/11 at 7:00 A.M., licensed staff V pushed the resident, in the wheelchair to the dining room. The resident remained in the wheelchair in the dining room for breakfast. At 9:00 A.M., the resident sat in the wheelchair beside the the bed. At 9:40 A.M. the resident rolled to the doorway and stated, "Want to go to bed." At that time the resident smelled of bowel and bladder incontinence. Observation, at 10:00 A.M. (3 hrs. later), revealed direct care X and Y utilized a sara lift and placed the resident in bed. At that time, staff X and Y verified the resident remained in the wheelchair since gotten up before 7:00 A.M.. Observation, on 11/3/11, revealed the resident remained in the wheelchair until 9:50 A.M. At that time, direct care staff J and H transferred the resident to the shower chair with the sara lift. Observation revealed the resident's brief wet and soiled. On 11/3/11 at 10:10 A.M., direct care staff J reported staff got the resident up at 6:30 A.M., Observation revealed the resident in the wheelchair at 6:45 A.M. The resident remained in the wheelchair in the dining room for breakfast. Facility staff pushed the resident back to nurses station/TV area and he/she remained in wheelchair. The resident remained in the wheelchair without assistance to reposition for 3 hours and 20 minutes The facility positioning policy, dated 7/1/2008, included, "Reposition/turn every 2 hours or more often as needed depending upon the resident's condition and tolerance of the tissue load (pressure)." The nursing staff failed to reposition this dependent resident per their facility policy, at least every 2 hours. They placed this dependent resident at risk for altered skin integrity. - The facility readmitted resident # 3 on 10/20/10. [DIAGNOSES REDACTED]. The 9/26/11, minimum data set assessment identified the resident with cognitive impairment, memory problems and moderate impaired decision making. The resident's functional status included the need for 1-2 assists with all activities of daily living. The 10/4/11 plan of care included, "I need 2 staff with gait belt for all transfers." On 11/3/11 at 6:50 A.M. the resident sat in a wheelchair with oxygen on, at the beginning of hall 5. At 7:30 A.M., the resident remained in the wheelchair while fed in the dining room by staff. At 9:25 A.M., direct care H and J transferred the resident to a shower chair with a gait belt. At that time direct care J reported they assisted the resident up from the bed at 6:30 A.M. The resident remained in the wheelchair for 2 hours and 55 minutes without staff assistance to reposition. Facility staff failed to reposition this resident, with potential for altered skin integrity, in a timely manner as planned.