Every finding on record at Ecumen North Branch

Based on observation, interview and document review, the facility failed to store food preparation items in a sanitary manner. This had the potential to affect all residents who resided in the facility. Findings include:During observation and interview on 7/22/25 at 11:15 a.m., a tour of the kitchen was completed with the director of culinary services. During the tour, was a stack of 9 large steam table pans on a storage rack to be used for food preparation. The director of culinary services stated those pans were clean and ready to use for food preparation. Upon examining the stack of steam table pans, 5 of 9 steam table pans were stored with visible moisture on the pans. The director of culinary services stated all dishes in the kitchen are to be completely dry before being stored and it looked like these pans were not completely dry. Once the dishes are washed and air dried, they should have been checked to ensure they are dry before placing them on the storage shelf. When dishes are stored wet there is increased risk for germs and bacteria to grow that cause illness. During an interview on 7/23/25 at 3:08 p.m., the administrator discussed the policy regarding storage of dishes.The facility's Ware Washing policy dated August 2023, identified dishes must be air dried on the dish racks or established drying racks and be inspected for dryness before putting dishes away.

Based on interview and record review the facility failed to ensure damp laundry was not left in overnight in the washing machines used for resident clothing. This deficient infection prevention practice had the potential to impact all 44 residents who resided at the facility. Findings include: During an observation and interview on 07/22/25 at 11:08 a.m., laundry staff (LS-A) stated bed linen and other laundry was sent out to a service, the facility staff only washed resident clothing and mop heads and cleaning cloths at the facility. LSA stated part of the laundry duties included starting a load of mop hands and cleaning rags in the washing machine before leaving for the day. Staff the next morning were responsible for putting the items in the dryer.During an interview on 7/23/25 at 1:15 p.m., with the DON and the infection prevention nurse, both reviewed the facility policy and did not find cleaning supplies specifically addressed in the laundry policy. Both indicated it was possible for bacteria to grow when things were left damp for a prolonged period of time.During an interview on 7/24/25 at 10:05 a.m., the laundry environmental services manager and administrator confirmed it was practice for laundry staff to start the washing machine load of cleaning cloths and mop heads at the end of their shift for the morning staff to put in the dryer the following day. Both indicated if it was an infection prevention concern, it would be easy for them to adjust their washing practice so the items could go directly into the dryer after the wash cycle.The facility policy Departmental (Environmental Services) - Laundry and Linen dated 1/2014, instructed do not leave damp linen in washing machines overnight. When washing machine is not in use, leave doors open.

Based on observation, interview, and document review, the facility failed to ensure the previous year's survey results were available to residents and visitors. This had the potential to affect all residents and/or visitors that wished to review the information.Findings include: During observation on 7/23/25 at 9:24 a.m., the facility survey results were located in a green three ring binder at the front desk. The survey results in the binder were results from a survey dated 9/27/23. No other survey results were in the binder. In review of survey results for facility, the last recertification survey was conducted on 8/9/24. Two complaint surveys were conducted on 9/17/24 and 2/13/25. During interview on 7/24/25 at 10:45 a.m., administrator stated he was responsible for maintaining the survey results binder. Administrator confirmed the last recertification survey, and two complaint surveys were not in the binder. Administrator stated he would update the survey binder.

Based on observation, interview, and record review the facility failed to adhere to the Centers for Disease Control (CDC) recommendations for testing and cohorting during a COVID-19 outbreak for 4 of 5 residents (R7, R31, R36, R39). In addition, the facility failed to ensure staff followed posted transmission-based precaution signs for 2 of 5 residents (R7, R9) reviewed for infection control. These practices had the potential to affect all residents, employees, and visitors of the facility. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified for the purposes of this guidance, higher-risk exposures are classified as Healthcare Personal (HCP) who had prolonged close contact with a patient, visitor, or HCP with confirmed SARS-CoV-2 infection and: -HCP was not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask). -HCP was not wearing eye protection if the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask. -HCP was not wearing all recommended PPE (i.e., gown, gloves, eye protection, respirator) while present in the room for an aerosol-generating procedure. Additionally, an exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period. However, the presence of extenuating factors (e.g., exposure in a confined space, performance of aerosol-generating procedure) could warrant more aggressive actions even if the cumulative duration is less than 15 minutes. The CDC's Infection Control Guidance: SARS-COV-2 updated 6/24/24, identified to place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Additionally, if additional (positive) cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition and diagnoses of metabolic encephalopathy, chronic kidney disease, and congestive heart failure (CHF). R7 needed staff assistance for all activities of daily living (ADLs). R7's care plan dated 7/31/24, identified R7 had a COVID-19 infection confirmed with testing on 7/31/24 and included instructions to place resident in a private room or to cohort with a resident with the same symptoms or COVID-19 positive test confirmation. The care plan further instructs caregivers to apply full-coverage eyewear or face shield with PPE. R7's electronic health record (EHR) contained a form titled, COVID-19 Testing V2 dated 7/31/24, identified a test was administered and found positive using a point of care (POC) testing device on that date. The door to R7's room contained signage for enhanced respiratory precautions with instructions to keep the door to the room closed, to wear a gown, facemask or N95 respirator, eye protection and gloves. There were also directions for the correct sequence for donning and doffing PPE. R9 R9's quarterly MDS dated [DATE], identified moderately intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis of the right side following a cerebral vascular accident (CVA). R9 needed staff assistance for all ADLs. R9's care plan dated 7/28/24, identified R7 had a COVID-19 infection confirmed with testing on 7/28/24 and included instructions to quarantine resident until 8/7/24, and able to leave his room on 8/8/24. The care plan further instructs caregivers to apply full-coverage eyewear or face shield with PPE. R9's EHR contained a form titled, COVID-19 Testing V2 dated 7/28/24, identified a test was administered and found positive using a POC testing device on that date. The door to R9's room contained signage for enhanced respiratory precautions with instructions to keep the door to the room closed, to wear a gown, facemask or N95 respirator, eye protection and gloves. There were also directions for the correct sequence for donning and doffing PPE. R31 R31's quarterly MDS dated [DATE], identified intact cognition and diagnoses of spinal stenosis, non-traumatic brain dysfunction, atrial fibrillation, and hypertension. R31 needed staff assistance for all ADLs. R31's EHR contained forms titled, COVID-19 Testing V2 dated 7/31, 8/2, 8/5, and 8/7/24, identified POC tests were all negative. R31 resided in a shared room with R7. R36 R36's significant change MDS dated [DATE], identified severely impaired cognition and diagnoses of Alzheimer's dementia, traumatic brain injury, renal disease, coronary artery disease and anemia. R36 needed staff assistance for all ADLs. R36's EHR contained a form titled, COVID-19 Testing V2 dated 8/5/24, identified a test was administered and found negative using a POC testing device on that date. R36 resided in a shared room with R39. R39 R39's significant change MDS dated [DATE], identified severely impaired cognition and diagnoses of dementia, diabetes, and renal disease. R39 needed staff assistance for all ADLs. R39's EHR contained a form titled, COVID-19 Testing V2 dated 8/5/24, identified a test was administered and found positive using a POC testing device on that date. The door to R39's room contained signage for enhanced respiratory precautions with instructions to keep the door to the room closed, to wear a gown, facemask or N95 respirator, eye protection and gloves. There were also directions for the correct sequence for donning and doffing PPE. During an observation on 8/6/24 at 2:05 p.m., nursing assistant (NA)-A was observed walking out of a resident at the far end of the 170s hallway wearing an isolation gown, gloves, and carrying a lift battery up the length of the hall to the corner of the common area and then all the way down the 160s hall to a stored mechanical lift where she swapped out the batteries. NA-A then walked all the way back to the far end of the 170s hallway and into a resident room. During an interview on 8/6/24 at 2:07 p.m., NA-A stated she forgot to remove her gown and gloves before she went out into the hallway from a resident room. NA-A stated she should have removed it and her gloves, then cleaned her hands before going out into the hallway from an enhanced barrier precautions room. During interview on 8/6/24 at 2:47 p.m., the director of nursing (DON) identified from 7/26/24 to 8/5/24 six staff members and three residents have tested positive for COVID-19 as follows: -7/26/24 assistant director of nursing (ADON) who worked in unit B. -7/28/24 licensed practical nurse (LPN)-A who had no resident or staff contact. -7/28/24 R9 on unit B. This case triggered broad based testing for unit B residents. -7/29/24 NA-C worked on unit B. -7/30/24 culinary director (CD) worked both units. -7/31/24 R7 on unit B and shares a split room with R31. -7/31/24 NA-D worked on unit B. -8/2/24 housekeeping (H)-B worked on unit A. This case triggered broad based testing for unit A residents. -8/5/24 R39 unit B and shares a split room with R36. The DON further stated residents were being broad-based tested , but staff were not. Staff were being tested if they had symptoms or had a high-risk exposure. The DON defined a high-risk exposure as being within 6 feet of a COVID positive individual for more than 15 minutes. The DON confirmed some staff worked on both units and residents from both units continued to intermingle during group activities. The DON confirmed two of the residents who tested positive for COVID were sharing a split room (room with shared entry area where entry to each room was divided by a curtain) with residents who tested negative for COVID. The DON stated the residents in those rooms were more than six feet apart, but she would move the COVID negative residents to a separate room if one was available. During interview on 8/6/24 at 6:51 p.m., DON identified the facility was in COVID outbreak and was following current Centers for Disease Control (CDC) guidance for COVID recommendations. During interview on 8/7/24 at 11:22 a.m., the administrator stated he was unaware of COVID positive and negative residents sharing split rooms and was uncertain if staff were being broad-base tested . The administrator states the facility intended to follow current CDC guidance for COVID recommendations. During an observation on 8/7/24 at 12:29 p.m., R9's room door was standing wide open. R9 was sitting in his wheelchair in the middle of the room. During an interview on 8/7/24 at 12:53 p.m., licensed practical nurse (LPN)-A confirmed R9's door was open but should be shut. LPN-A was not sure why it was open and proceeded to shut the door. During interview on 8/7/24 at 1:08 p.m., the administrator stated he had consulted with the DON and current CDC recommendations. As a result, staff would be broad-base tested and residents who were COVID negative sharing a split room with a resident who was COVID positive would be moved to a single room, pending family approval. During an interview on 8/7/24 at 2:19 p.m., LPN-A stated the reason R9's door was open was because it needed to be open when he was eating because he needed to be supervised during meals and maybe it just didn't get shut again. During an observation and interview on 8/8/24 at 9:04 a.m., NA-B came out of R7's room, wearing only a surgical mask and carrying a plate cover. NA-B stated this was her first day back after being gone for a week and she wasn't sure what she should be doing. NA-B acknowledged the signs indicating an N95, gown and gloves were needed to enter the room and a STOP sign instructing visitors to see the nurse before entering. NA-B stated she had gotten training for enhanced barrier precautions, but not for this precaution yet. During an observation and interview on 8/8/24 at 10:04 a.m., housekeeper (HK)-A was seen entering and exiting R7's room wearing only a surgical mask. HK-A explained the precautions were for when you were giving close-contact care and she was a housekeeper who did not give cares, so she did not need the PPE. During an interview on 8/9/24 at 9:18 a.m., the assistant director of nurses (ADON) stated rooms with enhanced respiratory precautions should have the door shut if the resident could have their door shut. The ADON would expect all staff to wear the PPE if the door is posted and would not expect staff to wear PPE out of a resident room and into the hallway. During an interview on 8/9/24 at 9:26 a.m., the administrator stated it was his expectation that all staff have infection control training, it was part of their training program for housekeeping, and would follow posted signage for PPE. The administrator stated this was important to care for the residents and keep them safe and infection prevention was a critical part of that. A facility policy COVID-19 undated, identified residents and staff will be tested , quarantined, and isolated based on the most up-to-date CDC guidance.

Based on observation, interview, and record review the facility failed to ensure residents were comprehensively assessed for self-administration of medications (SAM) for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of respiratory failure with hypoxia and hemiplegia and hemiparesis of the left side following a cerebral vascular accident (CVA). The MDS also identified R26 needed set up and clean up assistance for eating and oral hygiene. R26's provider orders dated 7/25/24, identified an order for albuterol sulfate solution to be inhaled via nebulizer treatment three times per day and as needed for shortness of breath and wheezing, an order for oxygen via nasal cannula at one to four liters per minute, but did not contain an order to self-administer medication. R26's care plan dated 7/31/24, didn't identify a plan for self-administration of medications. R26's medical record didn't contain an assessment for self-administration of medications. During an observation on 8/7/24 at 2:17 p.m., R26 was in his room in a recliner chair, eyes closed, head bent forward and to the right with a nebulizer mask strapped to his face and head. The machine could be heard running and vapor was escaping out of the mask. During an observation on 8/7/24 at 2:35 p.m., R26 could be heard hollering out in a muffled way from his room and there were no staff nearby. Licensed practical nurse (LPN)-A was summoned by surveyor to R26's room. LPN-A removed the mask and R26 said he wanted his socks off. LPN-A assisted R26 with his socks, disassembled and rinsed out the nebulizer mask and chamber. During an interview on 8/7/24 at 3:06 p.m., LPN-A confirmed R26 did not self-administer medications. LPN-A explained that was why they set up the nebulizer treatment and put it on R26 and then came back later to take it off. During an interview no 8/8/24 at 1:49 p.m., LPN-B stated R26 did not have a SAM order because he was not someone you could leave alone with the nebulizer mask on. LPN-B explained leaving the resident alone with the mask on would be considered self-administration. During an interview on 8/9/24 at 9:17 a.m., the assistant director of nursing (ADON) stated the nurse should be within eyesight of the resident with the nebulizer running for the safety of the resident and to make sure it is being used properly. A policy from 2001 Med Pass dated February 2021, identified part of the comprehensive assessment was for the interdisciplinary team to assess each resident cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident. If the team determines a resident cannot safely self-administer medications, the nursing staff administer the resident's medications.

Based on interview and document review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours as required to address the individualized needs for 1 of 1 resident (R198) reviewed for recent admission. Findings include: R198's admission orders dated 7/31/24, identified R198 was admitted to the facility from a hospital on 7/31/24, with a primary diagnosis of acute on chronic diastolic (congestive) heart failure. Admission orders further identified R198 was on two liters of oxygen via nasal cannula. On 8/7/24 at 2:58 p.m., R198's baseline care plan was found to be blank and lacked any information related to R198's care requirements including but not limited to transfer status, activities of daily living performance, assistive device use, impairments, or special treatments such as use of oxygen. During interview on 8/7/24 at 3:24 p.m., registered nurse (RN)-A verified R198's baseline care plan was blank and was not completed within 48 hours of R198's admission. RN-A stated she was aware baseline care plans should be completed within 48 hours and was unsure why R198's care plan had not been completed. During interview on 8/8/24 at 3:37 p.m., director of nursing (DON) verified R198's baseline care plan had not been completed within 48 hours of R198's admission. DON stated her expectation was for baseline care plans to be completed within 48 hours of admission and it was important to develop baseline care plans timely to ensure staff were aware of how to properly care for the residents. A policy on baseline care plans was requested, but not provided.

Based on observation, interview, and record review the facility failed to review and revise the care plan with current interventions for the care and prevention of pressure ulcers for 1 of 2 residents (R26) reviewed for pressure ulcer care. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of hypertension, chronic kidney disease, dementia, respiratory failure with hypoxia, peripheral vascular disease (PVD), and hemiplegia and hemiparesis of the left side following a cerebral vascular accident (CVA). The MDS also identified R26 was dependent on staff for assistance with bed mobility, transfers, toilet hygiene, was at risk for and currently had pressure ulcers. R26's provider orders dated 5/23/24, identified orders to care for wounds on the left and right feet, weekly skin checks, weekly wound rounds, shoes only when transferring, and must have Prevalon boots (brand name for padded boots designed to reduce pressure on the heels) on at all times. R26's care plan dated 7/31/24, identified a problem statement regarding skin impairment and interventions to offload and reposition R26 approximately every two hours, licensed nurse skin inspection weekly, lotion to lower extremities, observe for and report signs or symptoms of infection, Prevalon boots at all times, shoes for transfers and therapy only, and weekly wound documentation. During an observation on 8/5/24 at 2:35 p.m., R26 was sitting in his room in a recliner chair with the footrest up. R26 was wearing slipper-shoes with no socks. There were Prevalon boots laying on a chair. During an observation on 8/7/24 at 2:17 p.m., R26 was in his room sitting in a recliner with the footrest up and a pillow underneath his feet. R26's heels were not floating and there were no Prevalon boots in place. During an interview on 8/7/24 at 3:06 p.m., LPN-A stated R26 refused the Prevalon boots every day, he is supposed to wear them all day, every day except when transferring. But they had to fight with R26 every day about it. During an observation on 8/8/24 at 8:36 a.m., R26 was up having breakfast in the dining room, wearing slipper-shoes with no socks. During an interview on 8/8/24 at 1:49 p.m., LPN-B confirmed R26 refused stockings, socks and Prevalon boots on most days. LPN-B stated the nurses should put a note in the chart regarding refusals. During an interview on 8/8/24 at 2:59 p.m., the assistant director of nursing (ADON) stated the interventions for R26 were to elevate his heels with a pillow or the Prevalon boots. The ADON was aware of R26's refusals of the boots and explained when his wounds were worse, he wasn't as mobile, but now that he was more mobile the boots got in the way of propelling the wheelchair. The ADON would expect staff to chart a resident's refusal of an intervention. The ADON stated they try to update care plans in real time, or with the MDS process quarterly, annually and with significant changes. Real time updates were important, so the resident was getting the right care. A policy titled, Care Plans, Comprehensive Person-Centered and dated March 2022, identified a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and will be developed and implemented for each resident. The team will review and revise the care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, and at least quarterly in conjunction with the MDS assessments.

Based on observation, interview, and record review the facility failed to follow provider orders for weekly skin assessments for 1 of 2 residents (R26) reviewed for pressure ulcer care. The facility also failed to follow provider orders for an as-needed medication to be administered in response to clinical weight monitoring for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's significant change Minimum Data Set, dated dated dated [DATE], identified severely impaired cognition and diagnoses of hypertensive heart and chronic kidney disease with heart failure, chronic heart failure (CHF), hypertension, chronic kidney disease, peripheral vascular disease, and pressure wounds to left and right feet. Provider orders for R26 dated 6/25/24, identified orders for: - furosemide (a medication to help remove extra fluid) 20 milligrams (mg) two times per day, and an additional as-needed (PRN) 20 mg dose for weight gain of two pounds or more in a day. - daily weight monitoring with parameters as noted above. - weekly skin assessment every Saturday evening. R26's care plan dated 7/30/24, identified: - interventions to observe for signs of increased edema, or increased weight related to fluid retention, document, and update provider as necessary. -interventions for licensed staff to inspect skin weekly on bath day. R26's electronic health record identified: -a weight gain of 4.4 pounds (lbs.) on 7/13/24 and a gain of three lbs. on 7/31/24. Weight monitoring was not done on 7/18/24 and 8/1/24. R26's medication record reflected PRN furosemide doses were not given on the dates with weight gains of over two pounds. -Lapses in skin assessments from 4/13 to 4/28/24, from 5/25 to 6/15/24, from 6/15 to 7/6/24, and from 7/6 to 7/27/24. During an interview on 8/8/24 at 3:03 p.m., the assistant director of nursing (ADON) stated her expectation would be that weekly skin checks would be completed whether the resident had their bath that day. The ADON confirmed R26 didn't get the ordered PRN doses of furosemide on 7/13 or 7/31/24 and there were lapses in the skin checks, which she felt may be due to the amount of licensed agency staff, and a trained medication aid (TMA) they had working at the time, but that it was not an excuse. The expectation would be that orders are followed. The process for the TMA would be to report to the licensed nurse a finding such as weight gain. Policies regarding following orders with parameters and weekly skin checks were requested but not received.

Based on interview and document review the facility failed to have appropriate documentation and physician review for an as needed (PRN) opioid medication ordered for 1 of 5 residents (R11) reviewed for unnecessary medications. Findings included R11's quarterly minimum data set (MDS) dated [DATE], identified R11 was cognitively intact. Diagnoses included paraplegia, anxiety, and depression. R11 was on a scheduled pain mediation regimen and had not received any PRN pain medication or non-medication interventions for pain. R11's provider visit notes from 2/6/24 and 2/16/24, lacked documentation as to why PRN Oxycodone would potentially be needed for severe pain. There were no provider notes for a visit performed on 2/23/24 provided when requested. R11's provider orders dated 8/9/24, identified on 2/23/24, Oxycodone 5 mg by mouth twice daily as needed for severe pain was started and still active. R11's pain score charting was reviewed from 2/1/24 to 8/8/24, was reviewed and pain was frequently rated at a zero out of ten when asked, except for an occasional 1-4 rating. R11's electronic medication administration record (EMAR) from 2/23/24 to 8/8/24, was reviewed and indicated R11 had not taken PRN Oxycodone since the order was placed. R11's Consultant Pharmacist's Medication Review dated 7/2/24, indicated a request for Oxycodone to be reviewed and discontinue if not needed as it had not been taken since 2/24. The request was denied by the provider because patient wants available if needed. During an interview on 8/5/24 at 3:18 p.m., R11 stated she did not have any pain except for an occasional mild pain that would never be higher than a 3 on the pain scale. During an interview on 8/9/24 at 9:22 a.m., registered nurse (RN)-B stated medication lists were always monitored to see if there were any unnecessary medications on the residents medications lists. The review included PRN pain medication like Oxycodone (an Opioid medication). If there are medications present that are not used or needed then nursing would discuss with the provider to get the unnecessary medication discontinued. RN-B reviewed R11's medical record and acknowledged the PRN Oxycodone order and there was no clinical documentation for the need of PRN medication. RN-B also stated she had not talked with the provider about the medication. During an interview on 8/9/24 at 9:39 a.m., pharmacy consultant (PC) stated there was a recommendation to review and discontinue the Oxycodone in July, as it was not being utilized. PC stated there was no documentation for the need of the medication when it was ordered on 2/23/24 and has been no documentation for the need since that time. PC also stated there needed to be a numeric pain scale to show what was considered severe pain. The expected rate would be 7-10 on the pain scale. The PC stated based on the documentation there was no need to keep this medication order active. By keeping the medication active there would be an increased risk of addiction and diversion of the medication by somebody. The PC stated he had not received the response from the provider and would follow up with the medical director to address the Oxycodone order. During an interview on 8/9/24 at 10:14 a.m. the assistant director of nursing (ADON) stated nursing staff would review resident medication lists to see which medications were not used and have them discontinued. If a resident wanted to keep the medication active, even though not utilized, then the staff and the provider needed to figure a way to justify the medication or work on a different intervention that would assist the resident in comfort. Facility policy Medication Regimen Reviews last revised 5/19, identified reviews were performed by the PC on a monthly basis and included a review for medications ordered in excessive doses or without clinical indication.

Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with regulations for food safety. The facility failed to label and date resident food, and to remove expired food from unit refrigerators. These practices had the potential to affect any residents storing food at the facility. Findings include: During observation on [DATE] at 9:15 a.m., [NAME] unit refrigerator was reviewed. One resident meal labeled with name and dated [DATE] found in fridge. During observation on [DATE] at 9:44 a.m., Wild River unit refrigerator was reviewed. The following items were found in fridge: -plastic container of blueberries, initials 'JK' on sticker, no open date. -hard plastic container of leftover green beans, with resident name and date of ',d+[DATE]' on sticker. During observation and interview with culinary director (CD) on [DATE] at 8:39 a.m., [NAME] unit fridge was reviewed. CD noted resident meal in plastic bag dated [DATE]. CD stated 'it could still be good' but noted 'two weeks is too long' to store leftover food. CD further stated he would normally check the unit fridges himself, however he had been out from work for a week and 'no one else does it.' During observation and interview with CD on [DATE] at 8:41 a.m., Wild River unit fridge was reviewed. CD noted container of blueberries had initials 'JK' but no open date. CD further noted container of green beans labeled and dated ',d+[DATE].' CD stated resident food needed an open date to know if it was still ok to eat. CD stated policy was to throw out leftover resident food after three days. CD further stated this was important to prevent food-borne illness in residents. During interview on [DATE] at 9:14 a.m., administrator stated the facility policy on storing leftover resident food was to label the food with resident's initials and the date of opening the food. Administrator further stated the CD was in charge of checking unit fridges for expired food. Administrator stated labeling and dating food helps prevent food-borne illness. Administrator further stated staff should be checking dates on food even when CD is not at the facility. Food from Outside Sources policy, last revised [DATE], identified staff will place personal food items in a 'designated resident space, labeled with the resident's name and dated and placed in impervious container with a lid. The Ecumen location will dispose of food per manufacturer's date of the original container or 3 days after the food was marked.' Policy further identified 'personal items brought in that are not properly packaged, labeled or dated, will be discarded to maintain the residents' food safety and to minimize the risk of food borne illness.'

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate fall interventions were provided for 1 of 3 residents (R2) reviewed for resident safety. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had impaired cognition, was always continent of bladder and bowel, and had a fall prior to entry. R2's diagnoses included dementia and history of falling. R2's nursing assistant Care Sheet undated indicted R2 was at high risk for falls, but the Care Sheet lacked fall interventions. R2's care plan dated 6/10/24 lacked information related to R2's fall risk and fall interventions. A health status note dated 6/12/24 at 10:16 p.m. indicated R2 was found around 5:15 p.m. sitting on his bathroom floor covered in bowel movement. On 6/14/2024 at 11:58 a.m., nurse practitioner (NP)-A stated all residents should have documented fall interventions. All residents are a fall risk based on previous falls, their current health condition, and/or anxiety related to living in a different environment. If a resident falls, they could sustain a serious injury. On 6/14/2024 at 12:18 p.m., licensed practical nurse (LPN)-A stated she would look in the resident's care plan and on the nursing assistant care sheet to know resident specific fall interventions. On 6/14/2024 at 3:30 p.m., registered nurse (RN)-A stated R2's fall risk assessment indicated high risk for falls. Resident specific fall interventions would be found in the resident's care plan. RN-A confirmed R2's care plan did not include risk for falls or fall interventions. On 6/17/2024 at 2:06 p.m., R2 stated he doesn't not know why he falls, but he does not like falling because he has increased pain after a fall. On 6/17/2024 at 2:40 p.m., LPN-B stated she would look in a resident's care plan for fall risk and fall interventions. LPN-B stated R2 was not a fall risk because he did not have a care plan addressing falls. On 6/17/2024 at 4:30 p.m., RN-B stated a resident's care plan would be updated with a new intervention after a resident fall. It would be hard to know if the care plan was being followed if there is no care plan created. Lack of fall interventions could lead to a resident fall and possible injury. On 6/17/2024 at 3:09 p.m., assistant director of nursing (ADON) stated resident specific fall risk and fall interventions would be found in a resident's fall care plan and on nursing assistant care sheets. Every resident needs a fall care plan with interventions specific to the resident. After a fall, the resident's care plan should be updated with the new fall intervention. A resident could fall and sustain an injury if the care plan interventions are not followed. ADON confirmed R2 did not have a fall risk or fall interventions included on the care plan and no fall interventions on the nursing assistant care sheet. The undated Managing Falls and Fall Risk policy directed staff to implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview and document review the facility failed to ensure shared glucometers were sanitized after use for 2 of 8 residents (R6, R79) reviewed for glucometer use; failed to ensure staff completed hand hygiene during medication pass for 2 of 6 residents (R4,R21) observed during medication pass; failed to perform hand hygeine during wound care for 1 of 1 (R15) residents observed for wound care; and failed to display appropirate signage for 1 of 1 resident (R15) who was on contact precautions. Findings include: BLOOD GLUCOSE MONITORING: R79's undated, Admission Record identified R79 had a diagnosis of diabetes mellitus with hyperglycemia (elevated blood sugars). R79's undated, Order Summary Report directed to assist R79 with blood sugar checks every day and evening with a start date of 9/19/23. During an observation on 9/26/23 at 11:46 a.m., licensed practical nurse (LPN)-C assisted R79 with checking her blood sugar, LPN-C performed hand hygiene put on gloves, cleaned a tray and then set up supplies for R79. When R79 was done LPN-C placed a wipe pulled from a purple top container and wrapped the wipe around the glucometer and placed the glucometer in the drawer of the medication cart. During an interview on 9/26/23 at 11:52 a.m. LPN-C stated she wraped the glucometer in the wipe and put the glucometer back in the drawer and then would place the second glucometer on top of it. LPN-C stated some staff would wipe the glucometer for one minute before putting it away. 48109 R6's annual MDS dated [DATE], indentified intact cognition and a diagnosis of diabetes mellitus. R6's undated provider orders, indicated blood glucose testing four times per day. On 9/26/23 at 9:20 a.m., licensed practical nurse (LPN)-C was folding a Super Sani-Cloth (a germicidal wipe used to sanitize hard non-pouros surfaces) around a glucometer. LPN-C explained the used glucometer was wrapped in a wipe and placed in the top drawer of the medication cart. There was a second glucometer that had already been sanitized and was ready to use. On 9/26/23 at 11:22 a.m., RN-A donned gloves without first performing hand hygiene, and proceded to collect a blood sample from R6's finger. After obtaining a blood glucose result, RN-A removed her gloves, picked up an ice pack to show R6 and then wheeled R6 to the dining room. Once back at the medication cart, RN-A took out a Super Sani-Cloth and wrapped it around the glucometer. RN-A confirmed she did not perform hand hygiene before or after the gloves. During an interview on 9/27/23 at 12:08 p.m., the director of nursing (DON) stated the facility did not have a step-by-step process for cleaning and sanitizing a glucometer. Without using friction with the sanitizing wipe she wouldn't consider the glucometer sanitized, and that sanitizing was important to prevent the spread of infection. A facility document Obtaining a Fingerstick Glucose Level dated 10/2011, identified to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The document did not detail how to clean and disinfect the equipment. An undated, insert for the Assure Platinum blood glucometer identified a list of acceptable disinfectant brand names for use on this glucometer. Super Sani-Cloth was on the list. The instructions referred the reader to a website for the most up-to-date cleaning and disinfecting procedures for Arkray blood glucose meters. An undated, General Guidelines For Use, provided directions for Super Sani-Cloth wipes which indicated to unfold a clean wipe and thoroughly wet the surface and to remain wet for two minutes and then let air dry. HAND HYGIENE: R4's admission MDS, dated [DATE], indicated severe cognitive impairment and a diagnosis of congestive heart failure (CHF) and chronic kidney disease. R4's undated provider orders indicated orders for oxycodone with acetaminophen 5/325 mg, give one tab three times per day; buprion 100 mg one tab daily; citalopram 10 mg daily; furosemide 20 mg one tab daily, losartan 100 mg one tab daily. R21's quarterly (MDS) dated [DATE], identified severly impaired cognition and a diagnosis of familial dysautonomia (a disorder of the autonomic nervous system). R21's undated provider orders, indicated an order for Senna Plus (a stool softener with stimulant), two tabs two times per day. During an observation on 9/26/23 at 8:21 a.m., registered nurse (RN)-A prepared R21's medication at the medication cart by checking the medication administration record against the medication bottle label and shook two tabs out of the container into a souffle cup, and did not perform hand hygiene prior to the set up. RN-A locked the medication cart and computer screen, walked to R21 and greeted him. After confirming R21 was ready to take the medications, RN-A spooned them into his mouth and ensured he had swallowed them. RN-A failed to perform hand hygeine after the medication pass. During an observation on 9/26/23 at 8:26 a.m., RN-A prepared R4's medication at the medication cart by checking the medication administration record against the medication cards and labels, and did not perform hand hygiene prior to the set up. RN-A brought the medications in a suffle cup to R4 and asked if she was ready for her medications. R4 indicated she was and RN-A spooned the medication to R4's mouth. R4 drank some juice and reported they went down. RN-A failed to perform hand hygeine after the medication pass. During an interview on 9/26/23 at 8:39 a.m., RN-A confirmed she didn't perform hand hygiene between preparing and administering medications for R4 and R21. RN-A stated hand hygiene was important for not spreading germs. 48299 R15's quarterly MDS dated [DATE], indicated R15 was cognitively intact, had no rejection of care, and required extensive to total assistance with most activities of daily living which included bed mobility, transfers, and toilet use. R2 had a stage two pressure ulcer and an unstageable wound. R15 received hospice care. R15's care plan dated 9/5/23, indicated R15 had potential for impairment to skin integrity and risk for pressure injury with actual impairment to bilateral feet. Intervention included wound/skin treatments as ordered. During observation on 9/26/23 at 2:54 p.m., RN-A donned foot covers, gown, gloves, and mask to enter R15's room. RN-A assisted R15 with wound care to the first left toe and lateral right foot. RN-A removed the adhesive dressing from the first left toe, cleared the old Aquacel AG advantage dressing from the wound, cleansed the wound with dermal wound cleanser, used scissors to cut a small square of the Aquacel AG dressing and placed on the wound. RN-A used skin prep around the first left toe wound and then took their gloves off and placed new gloves; however, failed to complete hand hygiene after removing the contaminated gloves and placing on new gloves. RN-A proceeded to the lateral right foot wound and took the adhesive bandage off, cleansed the area with dermal wound cleanser, and used skin prep around the same area. RN-A initialed and dated two adhesive dressings and placed one on each wound. RN-A threw garbage away from wound care, took off gloves and other PPE upon exit of room, and performed hand hygiene. During interview on 9/26/23 at 3:16 p.m., RN-A stated in general they perform hand hygiene between gloves changes but RN-A did not during wound care. RN-A verified they did not change their gloves between taking dirty dressing off, cleansing, and placing clean dressing on. Drainage of wound and soilage of gloves were not present, and RN-A did not like to use dirty gloves to handle clean dressings. There was a risk of infection and spreading germs by not following proper hand hygiene and glove change procedures. During interview on 9/27/23 at 1:18 p.m., DON, who was also the infection preventionist (IP) stated glove changes should occur when going from a dirty task to a clean task and hand hygiene should occur between glove changes. The DON stated staff places a resident at risk for infection when introducing dirty into clean areas. The facility policy Handwashing/Hand Hygiene dated August 2019, directed staff to perform hand hygiene before and after direct contact with residents, after contact with blood or bodily fluids, after handling used dressings and contaminated equipment, after removing gloves. The policy also indicated the use of gloves does not replace hand washing/hand hygiene. CONTACT PRECAUTIONS NOTIFICATION: R15's care plan dated 9/5/23, indicated R15 was frequently incontinent of bowel and did not identfiy R15 was on contact enteric precautions. R15's undated current provider orders included contact precautions for Clostridioides difficile (a germ that causes diarrhea and inflammation of the colon; also known as C. difficile) every shift with start date of 9/19/23. During observation on 9/25/23 at 3:29 p.m., R15 had a plastic bin with personal protective equipment supplies (PPE) outside their door, but there was no sign on the door to indicate which type of isolation was required. During observation on 9/26/23 at 11:32 a.m., R15's door continued to not have a sign to indicate which type of isolation was required. During observation on 9/26/23 at 12:40 p.m., nursing assistant (NA-A) put on foot covers, isolation gown, and gloves prior to entering R15's room. During interview on 9/26/23 at 12:55 p.m., NA-A stated R15 was on precautions because they were on an antibiotic had loose bowel movements, so the facility placed R15 on precautions for C. difficile. Staff knew a resident was on precautions when they saw a bin of PPE outside a resident's room. During interview on 9/26/23 at 1:39 p.m., RN-A stated R15 was on hospice services and was on an antibiotic for a wound infection. After R15 developed loose bowel movements, R15 was prescribed the vancomycin and placed on contact precautions. RN-A did not think R15 had C. difficile, but R15 was on precautions because of loose stools to be extra safe. During interview on 9/26/23 at 3:16 p.m., RN-A stated staff and others knew a resident was on isolation precautions when there was a sign on their door and a bin with PPE and the nurses also went over precaution information during report. RN-A verified there was no sign on R15's door. R15 needed a sign on their door because staff and visitors were at risk of going into R15's room without proper PPE. During observation on 9/26/23 at 3:34 p.m., R15's door had a sign which specified contact enteric precautions and instructed staff and others to use soap and water upon exiting room. During interview on 9/27/23 at 1:18 p.m., DON stated precaution signs should be placed on a resident's door when a resident is placed on specific isolation precautions. The DON stated without the proper signage, people were at risk of going into the room without proper PPE. The facility's Isolation - Initiating Transmission-Based Precautions policy dated August 2019, directed the IP or designee to determine the appropriate notification on the room entrance door so that personnel and visitors are aware of the need for and type of precautions. Signage was to include the type of CDC (Centers for Disease Control and Prevention) precaution, instructions for use of PPE, and/or instructions to see a nurse before entering the room.

Based on observation, interview, and document review, the facility failed to maintain oxygen equipment according to their own policy to help prevent infection by routinely changing a nasal cannula for 1 of 2 residents (R12) reviewed for respiratory care. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and included a diagnosis of congestive heart failure (CHF). R12 was independent with transfers, dressing, eating, toileting and personal hygiene. R12's undated, Medication Review Report identified an order for oxygen at two liters per minute with a start date of 6/15/23; and to change oxygen tubing weekly on Sundays with a start date of 6/18/23 On 9/25/23 at 3:50 p.m., R12's oxygen tubing was dated 9/4/23 and R12 used the oxygen every night. During an interview on 9/27/23 at 11:17 a.m., licensed practical nurse (LPN)-A stated the oxygen tubing was changed out every Sunday. LPN-A confirmed the tubing on R12's oxygen was dated 9/4/23. During an interview on 9/27/23 at 12:03 p.m., the director of nursing (DON) stated the expectation would be the oxygen tubing gets changed weekly and as needed as this was important to prevent infection and assure the equipment was working properly. An untitled and undated document received from the facility directed replacement of the cannula or mask each week to reduce the risk of infections.

Based on observation, interview, and record review, the facility failed to utilize antibiotic use protocols to avoid unnecessary or inappropriate antibiotic use for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's care plan dated 9/5/23, indicated R15 was frequently incontinent of bowel and did not mention Clostridioides difficile (a germ that causes diarrhea and inflammation of the colon; also known as C. difficile) nor antibiotic use. R15's undated, current provider orders included vancomycin HCL (antibiotic) oral capsule 125 mg by mouth every 6 hours for C. difficile for ten days with start date of 9/20/23 and end date of 9/29/23. R15's orders indicated contact precautions for C. difficile every shift with start date of 9/19/23 . R15's health status note by licensed practical nurse (LPN)-B on 9/19/23 at 4:15 p.m., indicated labs were not collected. During interview on 9/26/23 at 1:39 p.m., registered nurse (RN)-A stated R15 was on hospice services and was on an antibiotic for a wound infection. After R15 developed loose bowel movements, R15 was prescribed the vancomycin and placed on contact precautions. Normally the facility would test a stool sample for C. difficile but did not think they did because R15 was on hospice services. RN-A did not think R15 had C. difficile, but R15 was on precautions because of loose stools to be extra safe. During interview on 9/27/23 at 11:03 a.m., a hospice licensed practical nurse (HLPN) stated for residents with increased loose stools, they would look at the residents' medication list and see if any medications needed to be held. Hospice had their own set of standards and orders and would contact the provider. They would still want to obtain a stool sample for suspected C. difficile and follow all the appropriate precautions for a resident on hospice services. They would want to follow provider's orders based on what was best for the resident on hospice and the resident's wishes. A resident could be placed at risk for further infection and developing antibiotic resistance by being placed on an antibiotic if they do not have C. difficile. During interview on 9/27/23 at 11:50 a.m., LPN-A stated the appropriate process for a resident on hospice services and loose stools would be to assess the resident and ask staff for information about resident's bowel movements, contact the hospice triage to update the hospice nurse, and then the hospice nurse would contact the hospice provider and call the facility nurse back with a plan. R15's C. difficile was suspected and did not see any tests or stool samples for the loose bowel movements. Developing super bugs was a risk of being on an antibiotic without testing. During interview on 9/27/23 at 1:18 p.m., the director of nursing (DON), who was also the infection preventionist stated R15's loose stools were not C. difficile like stools and the hospice provider choose not to obtain a stool sample to test for C. difficile and prescribed the vancomycin based off R15's symptoms. R15 started Lasix (diuretic) around the same time as the loose stools started, so the Lasix was discontinued and then R15's bowel consistency started to improve. When the swelling increased and Lasix started again, R15 stools became more loose again. Prescribing an antibiotic without testing could cause a resident to be treated unnecessarily. During interview on 9/27/23 at 1:58 p.m., LPN-B stated R15's bowel baseline was continent, soft stools and did not believe R15 had a history of C. difficile. Orders reviewed by LPN-B showed Keflex (antibiotic) was discontinued and bowel medications held on 9/15/23. Vancomycin started, contact precautions initiated, and Lasix held on 9/19/23, after R15's loose stools continued. The hospice nurse reviewed to continue the vancomycin and contact precautions as ordered and restarted R15's Lasix related to edema on 9/22/23. R15's last day of vancomycin was set for 9/29/23 and the need for isolation would be reevaluated at that time. No labs were ordered and believed R15's bowel continence was improving The facility's policy Ecumen North Branch Nursing Home Antibiotic Stewardship Policy dated 6/28/18, directed the facility to utilize the McGeer's Criteria when assessing residents suspected of having an infection and considering initiation of antibiotics. The criteria for C. difficile included needing criteria one and two to be present. Criteria one included presence of diarrhea or presence of toxic megacolon (abnormal dilation of the large bowel, documented radiologically). Criteria two included a stool sample yields a positive laboratory result for C. difficile toxin A or B, or a toxin-producing C. difficile organism identified from a stool sample culture or by a molecular diagnostic test such as PCR; or pseudomembranous colitis is identified during endoscopic examination or surgery or in histopathologic examination of a biopsy specimen.

Based on interview and document review, the facility failed to ensure their system of red and green dots for identifying code status matched the resident's Provider Order for Life Sustaining Treatment (POLST) for 1 of 1 residents (R14) reviewed for advance directives. Findings include: R14's Admission Record printed on [DATE], indicated R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's care plan revised on [DATE], indicated R14's wishes were for do not resuscitate (DNR) and would be reviewed with resident and family as needed. R14's Active Order Status dated [DATE], identified DNR and comfort cares as of [DATE]. On [DATE], at 4:25 p.m. nursing assistant (NA)-A stated the green dots on the name plate outside each resident's room meant the resident wanted to have cardiopulmonary resuscitation (CPR). On [DATE], at 4:30 p.m. R14's name plate outside his room had a green dot under his name. On [DATE], at 5:31 p.m. registered nurse (RN)-A stated the red and green dots were meant to be a quick look for CPR. RN-A went on to state the staff knew R14 was on hospice. RN-A stated she would look in the computer for code status and would check the POLST in the hard chart and not rely solely on the dots. RN-A verified there was a green dot on R14's door. RN-A stated that's not right, she stated R14 recently decided to go into hospice care and the dot on the door had not been updated. On [DATE], at 5:35 p.m. licensed practical nurse (LPN)-A stated she did not know what the red and green dots on the door meant. RN-B was standing nearby and volunteered the following information about the red and green dots; the doors were not up to date but were meant to signify if the resident wanted to have CPR or not. LPN-A then pulled out a chart and stated staff needed to physically look at the POLST in the chart. Both nurses stated the POLST was the place to look for code status, not the residents' doors. On [DATE], at 5:44 p.m. LPN-B stated the red and green dots were meant to help guide staff to CPR or DNR, but she would check the POLST in the hard chart. LPN-B went to look at R14's door and the dot had been changed to red. On [DATE], at 7:47 a.m. R14's door no longer had any dots. On [DATE], at 12:32 p.m. RN-B stated the policy had been reviewed and the dots were not part of the policy so all the name plates were changed to remove all dots. RN-B stated the policy had always been to check POLST no matter what color dot was on the door. On [DATE], at 2:24 p.m. the administrator stated they had changed the system because of the error that was found (the dot didn't reflect the updated POLST). The facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation revised ,d+[DATE], did not address the use of red and/or green dots on the resident's name plate outside their door.

Based on observation, interview, and document review, the facility failed to clean and maintain sheepskin coverings on resident equipment for 1 of 3 residents (R19) reviewed for sheepskin covers on equipment. Findings include: R19's Admission Record printed on 6/23/22, indicated R19's diagnoses included [CONDITION(S)] (paralysis of one side of the body) affecting the left non-dominant side, abnormal posture, low back pain, dementia, and history of [CONDITION(S)]. R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 was moderately cognitively intact and required extensive assistance with activities of daily living. In addition, R19's MDS indicated he was at risk for pressure ulcers. R19's care plan last reviewed on 7/11/21, did not address the sheepskin covers for his wheelchair arms. R19's skin assessment dated [DATE], indicated R19 had scattered bruises to bilateral arms, wrists, and top of hands. R19's Order Summary Report printed 6/23/22, indicated R19 was on [MEDICATION(S)] (a blood thinner medication used to prevent [CONDITION(S)] or stroke). The medication had the potential to cause bruising if R19 bumped his arm. On 6/21/22, at 1:38 p.m. R19's sheepskin on the arms of his wheelchair looked gray, was matted down, and attached to the arms of his wheelchair with Kerlix (bandage roll). R19 stated they looked dirty to him and added, they never change them. On 6/23/22, at 10:00 a.m. R19's sheepskin on the arms of his wheelchairs remained unchanged. R19 stated the sheepskin no longer gave him any padding, should be changed, and added they never changed or washed them. On 6/23/22, at 10:04 a.m. nursing assistant (NA)-B stated she was not aware of any process to ensure the sheepskins would get cleaned or replaced. NA-B looked at the sheepskin on the arms of R19's wheelchair and verified they were secured with Kerlix. NA-B stated, they're kind of grimy and should have been replaced. On 6/23/22, at 10:09 a.m. NA-C stated she was unsure how sheepskin padding was cleaned. NA-C looked at R19's sheepskin padding on the arms of his wheelchair and said, they look dingy, they should be replaced. On 6/23/22, at 10:20 a.m. licensed practical nurse (LPN)-C stated the nurse managers generally put the orders in the computer for sheepskin padding. The sheepskin padding should have been in the computer as an order to be changed on bath days. LPN-C looked at the sheepskin padding on the arms of his wheelchair arms and noted they were attached by using Kerlix and were matted and gray. LPN-C verified they were dirty and stated he needed them to prevent bruises as he tended to bump his arms and was on a blood thinner. LPN-C verified there were no orders in the computer and there was nothing in his care plan to direct staff to change or wash the sheepskin padding. On 6/23/22, at 10:29 a.m. registered nurse (RN)-B and the director of nursing (DON) verified the sheepskin on R19's wheelchair arms needed to be replaced as they were gray, matted, worn, and attached with Kerlix. A policy on care of sheepskin was requested but not provided.

Based on observation, interview, and document review the facility failed to ensure implementation of care planned fall interventions for 1 of 2 residents (R4) reviewed for accidents. Findings include: R4's Admission Record printed on 6/22/22, indicated R4's diagnoses included Alzheimer's disease, dementia, age-related [CONDITION(S)] (a condition in which bones become weak and brittle), moderate protein-calorie malnutrition, chronic pain syndrome, schizophreniform disorder (psychotic disorder that affects how a person acts, thinks, and relates to others), history of falling, and [CONDITION(S)] (a group of eye conditions that can cause [CONDITION(S)]). R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired. R4's MDS indicated she had moderate hearing difficulty and did not wear hearing aides and was able to understand and be understood. R4's MDS indicated she required extensive assistance with activities of daily living. R4's care plan revised on 10/30/20, indicated R4 was at risk for falls related to pain, weakness, impaired cognition, impaired mobility, antidepressant medication, and history of delusions and hallucinations. R4's interventions included spending time in the common area in a recliner, routine checks, anticipate needs, follow the facility fall protocol, be sure the resident's call light was within reach and encourage the resident to use it, and keep the bed in low locked position. On 6/21/22, at 1:21 p.m. R4 was in bed, the bed was in the high position (at about waist level for staff standing next to the bed). No staff were in the room. On 6/22/22, at 7:20 a.m. R4 was in bed, the bed was in the high position, the lights were off, the blinds were shut, she was talking out loud but no one was in the room. On 6/22/22, at 9:00 a.m. R4 was in bed eating her breakfast her overbed table was across the bed and in front of her. R4's bed was in the high position. Nursing Assistant (NA)-D was in the room and removed the breakfast tray. Outside of the room NA-D was asked about the bed being in the high position; NA-D stated R4 messes with her bed all day and concluded by stating the bed was sometimes in the high position. NA-D did not go back into the room and lower the bed. On 6/22/22, at 9:48 a.m. R4 was in bed, the bed was in the high position, lights off, shades pulled. On 6/22/22, at 10:42 a.m. R4 was in bed, the bed remained in the high position. On 6/22/22, at 12:30 p.m. R4 was in bed, the bed was in the high position, lights off, shades pulled, and overbed table in front of her. On 6/22/22, at 1:00 p.m. R4 was in bed, an unidentified staff member brought in a snack, the bed was in the high position, the staff member did not lower the bed. On 6/22/22, at 1:12 p.m. NA-D stated to prevent residents from falls staff should keep the call light within reach, timely toileting, and round frequently. NA-D stated R4 kept putting the bed up high, she went on to say R4 was not a fall risk as she never got out of bed, didn't roll side to side, but maybe she would sometimes put her feet out a little. On 6/22/22, at 1:19 p.m. NA-A stated to prevent falls staff needed to keep the bed low, keep the call light and items within reach. NA-A stated she had not noticed R4's bed up high and stated she was not aware of any care planned interventions to keep R4's bed in the high position. On 6/22/22, at 1:25 p.m. NA-E stated to prevent falls staff needed to make sure residents wear non-skid shoes, coach them with standing, use the right lift, and stated those residents with a fall risk should have their bed all the way to the floor. NA-E stated R4 was very particular and she wanted her bed up high. R4 went on to say there was a risk for injury if a resident would fall out of bed from high up. NA-E asked her if she could lower the bed and R4 said she was alright. On 6/22/22, at 1:58 p.m. licensed practical nurse (LPN)-C stated R4 plays with the remote so the bed would get into the high position. LPN-C went on to state she is not a fall risk, LPN-C stated she doesn't get out of bed. LPN-C stated a fall out of bed in the high position would put R4 at risk for a serious injury. On 6/22/22, at 2:03 p.m. registered nurse (RN)-C verified R4's bed was in the high position. RN-C stated R4's bed should be at a comfortable height for getting in and out of bed. RN-C stated R4 had not had any falls over the past two years. RN-C lowered R4's bed and she stated if R4 fell out of bed when it was in the high position there would be a risk for a significant injury. On 6/22/22, at 2:11 p.m. the director of nursing (DON) stated she would expect staff to prevent falls by keeping the floor free of clutter, having them wear non-skid footwear, keeping the call light in reach, and following the care plan. The DON verified there was a risk for serious injury from a fall out of a bed in the high position. The DON was not sure if there was a way to lock R4's bed into the low position. The facility Falls-Clinical Protocol revised 3/2018, directed staff to identify individuals for falls and risk factors for falling. The facility Falls and Fall Risk, Managing revised 3/2018, directed staff would identify interventions related to specific risks and causes to try to prevent the resident from falling. Some of the risk factors identified in the policy were incorrect bed height, poor lighting, pain, visual deficits, and cognitive impairment.

Based on observation, interview, and document review, the facility failed to ensure sufficient staff was available in order to meet the needs of the residents. Findings include: See F677: The facility failed to ensure facial hair was removed and oral cares were completed for 4 of 4 residents (R10, R17, R194, and R26) who required assistance with hygiene, and were reviewed for activities of daily living. In addition, the facility failed to ensure bathing was completed for 1 of 2 residents (R26) reviewed with bathing concerns. See F688: The facility failed to ensure functional maintenance programs were implemented as directed by the care plan for 5 of 5 residents (R194, R2, R15, R26, and R24). On 2/8/21, at approximately 3:00 p.m. R39 was interviewed. R39 was asked about care at the facility, and stated things were, Not too good. R39 stated service was slow, there was not enough help, and how long he waited for help depended on the day. On 2/8/21, at 5:15 p.m. R24 was interviewed. R24 stated she was on a walking program, but wasn't getting walked consistently. R24 stated she walked sometimes, but it was now harder to walk. -at 6:18 p.m. R26 was interviewed and stated sometimes the facility was so short staffed she did not always get her showers or baths done. R26 stated she had complained to the facility about that. R26 stated she was in her room on quarantine for 24 days, and only got one bed bath during that time. R26 said there was only one staff on during the evening today. R26 also stated she had not gotten her leg exercises done as she was supposed to, and she could not remember the last time staff had helped her to get them done. -at 7:17 p.m. R21 was interviewed and stated she did not always get her showers completed due to not having enough staff, and said there was only one staff on duty in the evenings. R21 stated sometimes she has to wait up to an hour when she puts on her call light, and there are times she is in the bathroom during those times, and needs staff assistance. On 2/9/21, at 9:40 a.m. R4 was interviewed and stated she had to wait a long time for staff to answer her call light. She was unsure of how long. Staff Concerns: On 2/10/21, at 10:10 a.m. nursing assistant (NA)-C was interviewed. NA-C stated resident cares were not being done, because there have not been enough staff. NA-C stated residents who were scheduled to be repositioned every two to three hours had not been repositioned on time. NA-C stated R2 had not been walked because they don't have time. NA-C stated residents were not being toileted or checked and changed on time, and skin breakdown had become more of a problem. NA-C stated baths and showers were not being done according to resident care plans. NA-C stated residents have complained that their care is not being done, and they have to wait long to have their call light answered. NA-C stated there were 16 open positions as of 2/10/21. -at 1:47 p.m. NA-D was interviewed. NA-D stated they used to have four NAs for their wing, now typically have two NAs. NA-D stated the personal things don't get done for the residents anymore. NA-D stated today with the nurse manager and medication nurse helping them, they were able to get all of the residents repositioned and checked and changed timely. NA-D stated she often has to stay overtime to complete documentation. - at 2:00 p.m. NA-E was interviewed. NA-E stated staffing on the day shift is best, but the afternoon and night shifts are struggling. NA-E stated on most day shifts they can get all residents checked and changed and repositioned as ordered, but today they would not have been able to accomplish this if the nurse manager and medication nurse wouldn't have helped them. -at 2:20 p.m. NA-B was interviewed. NA-B stated due to poor staffing, they have had to rush residents with cares. NA-B stated sometimes the cares are not completed such as baths, showers, shaving, and walks with residents. NA-B stated residents have long waits after putting on the call light. -at 2:24 p.m. NA-G was interviewed. NA-G stated tonight she is the only NA for 14 residents. Two residents require turning every three hours, the rest are on an every two hour turning schedule. Two residents will need to be transferred in/out of bed using a mechanical lift which requires two staff. NA-G stated the medication nurse's main job was to pass medications, but she would help as she is able. NA-G stated three residents need to be assisted with eating, another needs to be coaxed to eat, one resident doesn't eat but is lonely, and he likes her to sit and visit with him. NA-G stated all she can give him for visiting is 10 minutes. NA-G stated she has two baths tonight which will likely not get done, so will need to do bed baths instead. NA-G stated she would not be able to turn and check and change the residents timely. NA-G stated there was another NA floating between all three units who may be available to help. -at 2: 44 p.m. registered nurse (RN)-E was interviewed. RN-E stated she would be working with another RN caring for 12 residents. RN-E stated baths and showers don't always get done for the residents. -at 2:55 p.m. NA-H was interviewed. NA-H stated, Last night was rough. NA-H stated she would not have gotten through the evening meal without the help of physical therapy (PT) staff who stayed through the evening meal. NA-H stated she had two bath/showers to give last night, but was not able to get them done. NA-H stated she had three bath/showers tonight, and would likely not get them done. On 2/11/21, at 10:40 a.m. RN-A was interviewed. RN-A stated she had no control over the staffing. RN-A stated sometimes staff let her know when they can't complete all of the resident cares. RN-A stated she couldn't say how often this occurred over the past month. RN-A stated maybe staff have quit coming to tell her about not being able to get their work done. -at 11:05 a.m. a certified occupational therapy aide (COTA)-C was interviewed. COTA-C stated occupational (OT) and PT staff design restorative therapy programs for residents. Once a program was designed, instruction sheets were created and placed in resident rooms. The NA's assist residents in performing restorative therapy exercises. COTA-C stated restorative therapy was not being consistently done, and residents have not been assisted with ambulation or exercise programs. COTA-C stated PT and OT staff have tried to help nursing staff with basic cares when staffing is deficient. COTA-C stated, I try to help with feeding and basic cares when I can. It is frustrating to see staffing so inadequate. It is frustrating to see the residents not receiving restorative care. -at 4:32 p.m. the director of nursing (DON) and the administrator were interviewed. The administrator stated ideal staffing for all three houses would be six NAs on the day shift, six NAs on evenings, and three NAs on nights. The administrator stated ideally there would be one RN for each unit on the day shift and evening shift, and two RNs for the night shift. The administrator stated there was always a nurse on call. The DON stated staffing had been hard so day nurses will stay through the evening meal to help with the meal, and also help with any admissions, deaths, and evening cares. The DON stated when they were short staffed, staff have to re-prioritize the work. The administrator stated they closed one unit related to insufficient staff, and identified they are in a staffing crisis. The administrator stated prior to the COVID-19 outbreak they had ebbs and flows with staffing, but they have lost staff related to COVID-19 and fear. When asked specifically about restorative programs, ambulation and range of motion programs, the DON stated that it was not up to standard, and when residents refused, the staff often moved on, as there was not time to go back and re-approach. The daily staff posting for 2/8/21, for a census of 44 was as follows: Night: RN 2, NA 1 Day: RN 3, RN managers 2, NA 5 Evening: RN 3, LPN 1, NA 2 2/9/21, posted staffing; Night: RN 2, NA 2 Day: RN 3, RN lead 1, RN managers 2, NA 6 Evening: RN 3, LPN 1, NA 3 2/10/21, posted staffing; Night: LPN 2, NA 2 Day: RN 3, RN lead 1, RN managers 3, NA 6 Evening: RN 4, NA 3 The Centers for Medicare and Medicaid (CMS) form 672 indicated the facility had eight residents dependent on staff for bathing, and 36 residents who required the assistance of two for bathing. Twelve residents were dependent on staff for toilet use, and 30 residents who required the assistance of two staff for toilet use. Three residents were dependent on staff for assistance with eating, and eight residents who required some assitance with eating. Ten residents had unplanned significant weight loss/gain. Nine residents had pressure ulcers, and of that number only one had a pressure ulcer on admission. Twenty-five residents were receiving preventative skin care. The Facility Assessment reviewed 2/11/21, indicated the facility's staffing was based on case mix and 2018 Resource Utilization Group scores. The facility assessment addendum H was a staffing guideline current as of 2018. The guideline had a staffing pattern for a census 67-49. On 2/10/21, at 9:46 a.m. NA-C stated staffing had been bad. NA-C stated she was unable to complete all cares due to staffing levels. NA-C stated there was usually only one NA on for the afternoon shift on that unit, so some things would most likely not get done. NA-C stated R26's range of motion (ROM) was most likely not getting done, as it was to be done on the afternoon/evening shift, and there was only one NA scheduled during that shift, and it took a long time to do R26's ROM. NA-C stated staff did not have time to do the ROM. NA-C stated she was surprised to see R24 walked that morning, and said it had been so long since she had seen her walk. On 2/10/21, at 3:00 p.m. RN-C stated she worked as an NA some shifts, usually four to five of her seven scheduled shifts per pay period, due to being short-staffed. RN-C stated staff were not able to do all the restorative programs and get showers or baths done, due to being short-handed. RN-C stated they have gotten a small bonus for overtime, but were losing staff. RN-C stated they were unable to get repositioning done within the time frames. RN-C stated they tried to get the dependent residents done first. RN-C stated she does not have time to complete her document every shift, and gets behind. RN-C stated she would stay over and get her documentation done when working as a nurse. RN-C stated when working as a nurse, she helps the NA's out, but then gets behind with her responsibilities. RN-C stated she tried to do some of R26's ROM program, though is unable to complete it all. RN-C stated therapy staff will sometimes stay over and help them out on the afternoon shift, too. RN-C stated they try to get it all done the best they can for the residents. On 2/11/21, at 10:17 a.m. RN-B stated staff were supposed to communicate to the nurses if they were unable to get baths done. RN-B verified R26 was to receive a regular bath or shower twice weekly, but it had not been documented as being done the past two weeks. RN-B stated the NAs had not documented restorative programs recently, but felt it was due to a lack of documentation rather than not doing the restorative program. RN-B stated the NA's had not reported they were not able to get them done.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed and oral cares were completed for 4 of 4 residents (R10, R17, R194, and R26) who required assistance with hygiene, and were reviewed for activities of daily living. In addition, the facility failed to ensure bathing was completed for 1 of 2 residents (R26) reviewed with bathing concerns. Findings include: R10's Admission Record dated 4/16/20, indicated R10's [DIAGNOSES REDACTED]. R10's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R10 had intact cognition, and required supervision with hygiene. R10's care plan revised 8/24/20, identified R10 had a self-care deficit which required R10 to have her facial hair removed every Wednesday and Saturday, during showers. On 2/8/21, at 6:22 p.m. R10 was observed to have several long white chin hairs which were approximately 1 centimeter (cm.) long. R10 stated she did not like having chin hairs, and preferred to have her chin hairs cut with scissors. On 2/10/21, at 9:38 a.m. R10 was observed to have several white chin hairs approximately 1 cm long. On 2/11/21, at 8:15 a.m. R10 was observed to have several white chin hairs approximately 1 cm. long. During interview, R10 stated she received a shower the night before, but staff was in a hurry and didn't trim her chin hairs. On 2/11/21, at 8:26 a.m. nursing assistant (NA)-A verified R10 had facial hair. NA-A stated the overnight shift assisted R10 get ready for the day earlier that morning. On 2/11/21, at 8:38 a.m. registered nurse (RN)-A stated R10 wanted her chin hairs trimmed with a scissor. RN-A stated staff should trim R10's facial hairs when they noticed them. RN-A verified R10's care plan directed facial hair needed be groomed on shower days, which was the night before, but there was no documentation that verified the shower. On 2/11/21, at 8:47 a.m. the director of nursing (DON) stated staff should offer or assist residents with activities of daily living (ADLs). The DON stated if a resident refused. the nurse needed to be notified. The facility policy Shaving the Resident revised 10/10, directed the purpose of the procedure is to promote cleanliness and to provide skin care. The policy further directed the following information should be recorded in the resident's medical record: date and time that the procedure was performed. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure and if the resident refused the treatment, the reason(s) why and the interventions taken. R17's Admission Record printed 2/11/21, indicated R17's [DIAGNOSES REDACTED]. R17's admission MDS dated [DATE], indicated R17 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use. In addition R17's MDS indicated she was severely cognitively impaired. R17's Care Area Assessment (CAA) for ADLs dated 12/15/20, indicated she was weak and required increased assistance to complete ADLs. Staff were directed to anticipate her needs and assist with completion of ADLs. R17's care plan dated 1/11/21, indicated R17 had an ADL self-care deficit. R17's care plan directed staff to set R17 up for oral cares and grooming. On 2/10/21, at 7:49 a.m. R17's morning cares were observed with NA-D. NA-D assisted R17 with washing up, brushed her hair, then brought R17 out of her room. R17 was not brought to the sink and/or set up for oral care. The facility's Documentation Survey Report printed on 2/11/21, for 1/1/21, through 2/11/21, indicated R17 was to have oral care twice a day. R17 had one refusal documented, 35 times she accepted oral care, and 48 times she was not offered oral care. On 2/11/21, at 9:53 a.m. R17 was interviewed. R17 stated she had not had the opportunity to brush her teeth yet. She stated it was bothering her. R17's documentation indicated she had received oral care at 1:27 p.m. on 2/11/21. - at 10:21 a.m. RN-A was interviewed. RN-A verified R17 should be set up for oral care. RN-A stated it might not be getting done, because staff were rushing to get everyone up for the day, and ready for breakfast. R194's Admission Record printed on 2/11/21, indicated R194's [DIAGNOSES REDACTED]. R194's quarterly MDS dated [DATE], indicated R194 was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. R194's MDS further indicated he was severely cognitively impaired. R194's care plan reviewed 1/7/21, identified R194 had an ADL self-care performance deficit. Staff were directed to assist with upper and lower body washing, oral cares, and grooming. It was noted he would decline shaving frequently, but staff were to offer shaving daily. On 2/9/21, at 10:43 a.m. R194 stated he didn't get his teeth brushed yet today. R194 was observed with orange and red stains around his mouth and lips. R194 stated he had orange and cranberry juice with breakfast. R194 had white stubble on his cheeks, chin, and neck. R194 stated he preferred to be clean shaven. On 2/10/21, at 7:29 a.m. R194's morning cares were observed. NA-D cleansed R194's lower body and dressed R194, combed his hair, and then brought him to the dining room. R194 was not offered oral care, shaving, or hand and face washing. R194's Documentation Survey Report printed on 2/11/21, for 1/1/21, through 2/11/21, indicated R194 was to be offered oral care twice a day. There were 11 times R194 accepted oral care, 25 times he refused oral care, 1 not applicable, and 46 times he was not offered oral care. On 2/10/21, at 1:41 p.m. NA-D was interviewed. NA-D verified she did not offer oral care or shaving stating, He won't let anyone do it. On 2/11/21, at 10:10 a.m. RN-A was interviewed. RN-A verified oral care should be offered even if the staff think the resident will refuse. RN-A was aware that R194 prefers to be clean shaven, but would often refuse. RN-A stated staff should be trying at least weekly to shave him. -at 5:10 p.m. the DON was interviewed. The DON verified staff need to offer/try to get residents to perform oral care and shaving, even if they think the resident will refuse. The facility policy Teeth, Brushing dated 10/10, indicated the purpose of oral care is to clean and freshen the resident's mouth, to prevent infection of the mouth, to maintain the teeth and gums in a healthy condition, to stimulate the gums, and to remove food particles from between the teeth. The policy directed staff to document the time a.m. or p.m., to document refusals, the reason, and the intervention take. The policy further indicated staff were to report to the supervisor if the resident refuses the procedure. R26's Admission Record dated 2/11/21, indicated R26's [DIAGNOSES REDACTED]. R26's annual MDS dated [DATE], indicated R26 was cognitively intact, and required extensive assistance with bed mobility, dressing, and personal hygiene, required physical help in part of bathing activity, and had limited functional ROM of both lower extremities. R26's care plan for ADLs initiated 2/23/20, indicated R26 had an ADL self-care performance deficit, preferred a bath twice weekly on Wednesday and Saturday evenings, and required extensive assistance by one staff for bathing. R26's care plan directed staff to provide a sponge bath when a full bath or shower could not be tolerated. R26's undated caresheet directed staff to give R26 a tub bath on Wednesday and Saturday evening shifts. R26's Documentation Survey Report of tasks for January 2021, indicated R26 received a shower on 1/2/21, 1/16/21, and 1/20/21. R26's report indicated no baths were provided 6 of the 9 scheduled bath days for January 2021. R26's Documentation Survey Report of tasks for February 2021, indicated R26 had not received either of the 2 scheduled baths or showers between 2/1/20 and 2/9/20, so had not received a bath or shower since 1/20/21. On 2/8/21, at 6:18 p.m. R26 stated the staff was so short staffed, they couldn't always do her baths or showers. R26 stated she had complained about that. R26 stated she had only one bed bath while quarantined for 24 days, and there was only one staff that knew how to give a proper bed bath. R26 stated she preferred to sit in the bathtub. R26 stated there was only one nursing assistant (NA) on in the evening. On 2/10/21, at 9:46 a.m. NA-C stated she was unable to complete all cares due to staffing levels. NA-C stated there was usually only one NA on for the afternoon shift on that unit, so some things would most likely not get done. On 2/10/21, at 3:00 p.m. RN-C stated she works as an NA some shifts, and stated they could not always get showers done due to staffing. On 2/11/21, at 10:17 a.m. RN-B stated staff communicate to the nurses if they were unable to get baths done. RN-B verified R26 was to receive a regular bath or shower twice weekly, but it had not been documented as being done the previous couple of weeks.

Based on observation, interview, and document review, the facility failed to ensure functional maintenance programs were implemented as directed by the care plan for 5 of 5 residents (R194, R2, R15, R26, and R24). Findings include: R194's Admission Record printed on 2/11/21, indicated R194's [DIAGNOSES REDACTED]. R194's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R194 had an impairment of one upper extremity, and had not received restorative nursing care programs for range of motion (ROM) or splinting. R194's care plan reviewed 1/7/21, directed a functional maintenance program (FMP) that included complete gentle prolonged stretch of fingers into extension, note do not force. Staff were directed to cue resident to relax fingers and open hand. After ROM apply blue foam roll in palm of his hand. On 9/7/20, occupational therapy (OT) notes indicated R194 was placed on an FMP. The goal was for nursing staff to follow the FMP, resident will report decreased pain in right hand to moderate in order to perform passive ROM (PROM), and reduce contracture related skin breakdown. R194's nursing assistant care sheets directed complete gentle prolonged stretch of fingers into extension, do not force. Cue patient to relax fingers and open hand. Splint placed to hand on a.m. cares off at bedtime. Apply washcloth or pillow case to wick moisture. Document in progress notes. Please place hand splint daily. Documentation Survey Report printed on 2/11/21, for 1/1/21, through 2/11/21, indicated R194 was to have ROM and splint documented twice a day. The documention indicated R194 was not offered ROM or splint 58 times, refused 29 times, and documented as not applicable 6 times. On 2/10/21, at 7:29 a.m. R194's morning cares were observed. R194 was dressed, and transferred into his wheelchair. Nursing assistant (NA)-D combed R194's hair. There was no offer of of oral care, shaving, face and hand washing, or PROM and splint placement. R194's hand splint was visible on his dresser, but was not placed on his right hand. R194 was wheeled to the dining room. -at 10:10 a.m. registered nurse (RN)-A was interviewed. RN-A stated it was difficult to get R194 to cooperate with PROM and wearing his split. RN-A stated, He just won't wear it, won't do the stretching. RN-A stated it bothered R194 to wear the splint, and it might possibly be a time factor for staff to attempt. -12:58 p.m. R194 was seated in the dining room, there was no splint on his right hand. -1:41 p.m. NA-D was interviewed and stated she followed the care sheets for knowing how to care for residents. On 2/11/21, at 10:05 a.m. R194 was in his room. There was no splint on his right hand. R194 stated he stated he couldn't open his right hand, but that was usual. -at 12:43 NA-D was interviewed. NA-D stated she had never seen R194 wear his splint, so that was why she didn't try to put it on. NA-D stated if they do try to put it on, he cries out and resists. -at 1:19 p.m. occupational therapist (OT)-C was interviewed. OT-C stated R194 did not like to wear the splint related to pain. OT-C stated R194 could be verbally and physically abusive. OT-C stated when staff was able to get R194's hand open, it was odorous. -at 2:01 p.m. NA-E and NA-F were interviewed. Both NA-E and NA-F stated they no longer try to perform PROM or put R194's splint on his right hand. They stated they report his refusal to the nurse. -at 5:10 p.m. the director of nursing (DON) was interviewed. The DON stated it was her expectation that staff would follow the care plan and perform PROM and the use of splints. R2's Face Sheet printed 2/11/21, indicated [DIAGNOSES REDACTED]. R2's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R2 had moderate cognitive impairment. R2's care plan dated/revised 2/11/21, indicated R2 needed one or two persons to assist him with walking. R2's plan of care included ambulation to and from all meals, and to other activities with a step walker. R2's Plan of Care Response History was reviewed and indicated R2's ambulation was not conducted at all on the following dates: January 19, 22, 23, 29, 30, 31, and February 1, 2, 4, 6, 7, or 9. Ambulation was reported as not applicable on 1/16/21, and 1/17/21. R2 refused to ambulate on 1/26/21. R15's Face Sheet printed 2/11/21, included [DIAGNOSES REDACTED]. R15's quarterly MDS dated [DATE], indicated R15 was cognitively intact. R15's FMP dated 5/3/19, indicated staff was to perform right lower extremity PROM exercises twice a day, and massage right foot, ankle, twice a day. R15's treatment record for January 2021, listed prescribed restorative therapies to be done every shift. Therapies included the following restorative cares: dorsiflexion, inversion and eversion, plantar flexion, hip abduction, adduction, hip rotation, flexion/extension left lower extremity (LLE). Active range of motion LLE, PROM right lower extremity (RLE). Gentle massage/stroking to RLE while times when doing PROM. Directions on closet door. For the month of January, 62 opportunities to perform these interventions existed. Interventions were performed 37 times. On 2/09/21, at 1:59 p.m. R15 was interviewed and stated she was able to do her exercises without assistance most of the time. This included moving her arms while using one pound weights and changing position in bed. R15 stated she could not move her right leg without assistance. On 2/10/21, at 7:35 a.m. NA-B stated PROM was not done on R15's right side. NA-B stated, She is paralyzed on that side. You don't do range of motion on the paralyzed side. There is no point. When asked for clarification NA-B stated, The paralyzed side does not receive passive range of motion because that side is paralyzed. On 2/11/21, at 10:40 a.m. R15 stated staff offered to help with exercises only once or twice a week, if that. They are too busy. On 2/11/21, at 11:05 a.m. certified occupational therapy assistant (COTA)-C stated R15 had been taught various exercise regimes to help increase her mobility and decrease pain. PROM and massage was prescribed to decrease right leg and foot pain, and R15 needed assistance with massage and PROM. COTA-C stated upper body strengthening exercises were prescribed to increase her mobility and stamina. COTA-C stated R15 had hand weights and has done exercises independently while in bed. On 2/11/21, at 4:15 p.m. the DON stated PROM should be performed as care planned. R26's Admission Record printed 2/11/21, indicated R26's [DIAGNOSES REDACTED]. R26's annual MDS dated [DATE], indicated R26 was cognitively intact, and had limited ROM to both of her lower extremities. R26's MDS indicated R26 did not participate in a restorative program during the assessment period. R26's care plan initiated 2/23/20, identified R26 had limited physical mobility. R26's goal was to remain free from complications related to immobility which included contractures, formation of blood clots, and skin breakdown. R26's interventions included an FMP and active ROM, and strengthening exercises of her upper extremities which included completing two sets, 10 repetitions each, three times weekly. R26's care plan further directed R26 was to have ROM completed with a.m. and p.m. care daily. R26's undated caresheet, directed staff to provide R26's FMP three times weekly, according to Tasks in the electronic medical record (EMR). The caresheet further directed staff to provide bilateral lower extremity passive ROM, twice daily, according to the posted pictures. R26's FMP dated 11/5/20, directed staff to perform bilateral lower extremity passive ROM, twice daily, to maintain bilateral lower extremity ROM. R26's program indicated R26 was able to perform upper extremity and neck ROM independently. Exercises were posted on the door for staff and resident to refer to. R26's physical therapy progress and discharge summary dated 11/18/20, indicated R26 was able to complete a home exercise program for upper extremities independently. R26 required assistance with her lower extremity FMP. Discharge instructions included a FMP for a ROM program. R26's January 2021, Documentation Survey Report directed R26 was to have a functional ROM program of 2 sets, of 10 repetitions, completed three times a week on the afternoon/evening shift. R26's report indicated R26's ROM program was documented as completed once on 1/20/21. The report further directed staff to perform bilateral lower extremity passive ROM (performed by staff), twice daily, and ensure R26 was performing upper extremity and neck ROM independently on day shift and afternoon/evening shift. R26's report indicated R26's ROM programs were completed 7 of 62 opportunities, and potentially offered 15 of 62 possible opportunities. R26's February 2021, Documentation Survey Report directed R26 was to have a functional ROM program of 2 sets, of 10 repetitions, completed three times a week on the afternoon/evening shift. R26's report indicated R26's ROM program was documented as completed once on 2/5/21, between 2/1/21 and 2/10/21. The report further directed staff to perform bilateral lower extremity passive ROM, twice daily, and ensure R26 was performing upper extremity and neck ROM independently on day shift and afternoon/evening shift. R26's report indicated R26's ROM programs were completed 1 of 19 opportunities, and potentially offered 5 of 19 possible opportunities through 2/10/21. On 2/8/21, at 6:40 p.m. R26 stated she was supposed to get exercises for her legs, but no one did them. R26 stated she was unable remember the last time her exercises were done. R26 pointed towards exercises which were posted on her bathroom door. R24's Admission Record dated 2/11/21, indicated R24's [DIAGNOSES REDACTED]. R24's quarterly MDS dated [DATE], indicated R24 was cognitively intact, and did not participate in a restorative program. R24's care plan initiated 5/13/20, directed staff to ambulate R24 in her room, bed-to-door and back, twice daily. Staff were also permitted to walk with R24 in the hallway. R24's undated caresheet, directed staff to ambulate R24 in her room, from bed-to-door and back, twice daily. The caresheet also indicated staff could walk R24 in the hallway with a wheelchair following. R24's caresheet further directed staff to document, under the Tasks section of the EMR, every time R24 walked. R24's Therapist Progress & Discharge Summary dated 5/15/20, indicated R24 was able to walk 20 feet safely with a front wheeled walker, and contact guard assist, on even surfaces. A home exercise program for ambulation and lower extremity strengthening was initiated. R24's FMP dated 5/20/20, directed staff to ambulate R24 in her room twice daily, from bed-to-door and back, with a walker and assist of one. Additional comments on R24's FMP indicated R24 was slow and needed extra time. R24 could also walk in the hallway as distance increased. R24's FMP dated 7/15/20, directed R24 was to ambulate twice daily with staff and a 4-wheeled walker. R24's Documentation Survey Report for December 2020, indicated R24 walked in her room, from bed-to-door and back, or hallway, 5 of 62 opportunities. R24's refused 14 times; was documented not completed/not applicable/not available 5 of 62 opportunities; and, was blank 38 times. R24 walked either in her room, or hallway, an additional 5 times. R24's Documentation Survey Report for January 2020, indicated R24 walked in her room, from bed-to-door and back, or hallway, 4 of 62 opportunities; R24's refused 7 times; was documented as not applicable/not available 3 times; and, was blank 47 times. R24 walked either in her room, or hallway, an additional 6 times. R24's Documentation Survey Report for February 2020, indicated R24 walked in her room, from bed-to-door and back, or hallway, 0 of 20 opportunities between 2/1/20, and 2/10/20. R24's refused 2 times; was documented as not applicable/not available 1 time; and was blank 17 shifts. R24 walked either in her room, or hallway, 1 time. R24's Treatment Administration Record (TAR) for December 2020, indicated R24 had ambulated 9 of 33 possible shifts. R24's TAR indicated R24's ambulation was on hold from 12/17/20, afternoon shift through the end of the month. R24's TAR for January 2021, indicated R24 had not ambulated, and her ambulation was on hold from 1/1/21 through 1/28/21, p.m. shift. Though R24's Documentation Survey Report indicated R24 had ambulated during the time it was on hold. R24'S TAR for February 2021, indicated R24 ambulated 2 of 20 opportunities. On 2/8/21, at 5:15 p.m. R24 stated she was on a walking program, but wasn't getting walked during Coronavirus 2019. R24 stated she walked sometimes now, but it was now harder to walk since she wasn't previously walked. On 2/10/21, at approximately 8:45 a.m. R24 was observed walking in the hallway using a 4-wheeled walker and a wheelchair followed. One staff assisted her. On 2/10/21, at 9:46 a.m. NA-C stated restorative programs were not getting done. NA-C stated R26's ROM was most likely not getting done, as it was to be done on the afternoon/evening shift, and there was only one NA scheduled for all residents during that shift. NA-C stated R26's ROM took a long time to do, and staff did not have time. NA-C stated she was surprised R24 walked that morning, and it had been so long since she had seen R24 walk. On 2/10/21, at 3:00 p.m. RN-C stated staff was not able to do all the restorative programs due to being short-handed. RN-C stated R26's restorative program does not always get done, but staff tried to do part of the program, when able. On 2/11/21, at 10:17 a.m. RN-B stated R26 had ROM programs, and was to do the upper extremity exercises herself. RN-B stated NA's had not documented restorative programs recently and felt it was a lack of documentation. RN-B stated the nurse also assured the ROM was getting done and documented it on the TAR, or the nurse was doing the restorative program. RN-B stated NA's had not reported they were not able to get them done. On 2/11/21, at 2:39 p.m. LPN-A and RN-D stated therapy gave them a restorative programs and they entered them into the TAR. LPN-A and RN-D stated the NA's told them if a resident refused restorative cares, and then they would re-approach the resident. Both LPN-A and RN-B stated if a NA did not say anything to them, they would assume the restorative program was done, and they documented it as being done in the TAR. On 2/11/21, at 4:32 p.m. the DON stated documentation was not up to par, and when a resident refused, they were to encourage and find alternatives. The facility policy Range of Motion Exercises, revised 10/10, directed staff to ensure the resident had an order, check the resident's care plan for special needs, and how to perform range of motion. The facility policy and procedure directed staff what to document in the resident's medical record regarding the ROM exercises performed, and directed staff to notify the supervisor if the resident refused ROM. The facility policy Rehabilitative Nursing Care, revised 7/13, directed the rehabilitative nursing care program is to assist each resident to achieve and maintain their optimal level of self-care and independence, and was to be performed daily for those residents who required the service.

Based on interview and document review, the facility failed to offer timely toileting assistance, in accordance with the care plan, for 1 of 3 residents (R3) reviewed for falls. This deficient practice resulted in actual harm for R3, who self-transferred to the bathroom, had a fall, and was subsequently diagnosed with [REDACTED]. Findings include: R3's Admission Record printed 7/30/20, indicated R3's [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 had moderately impaired cognition. The MDS further identified R3 required extensive assistance with transfers and toileting. R3 was assessed to be not steady moving on and off a toilet. R3 was occasionally incontinent of bladder and always continent of bowel. R3's care plan dated 4/11/17, indicted R3 was at risk for falls with fracture related to [MEDICAL CONDITION], and generalized weakness. The care plan further indicated R3 had a history of [REDACTED]. Interventions included anticipating and meeting the resident's needs. R3's care plan dated 4/17/17, also identified R3 had activity of daily living self-care deficits related to impaired balance and directed R3 was to be toileted every two hours and as needed. A progress note dated 1/18/20, at 10:20 p.m. indicated R3 was found lying on the floor of her bathroom. R3 was noted to be lying on her right side. R3 informed staff she was unable to remember if she was going to the toilet or coming from the toilet. R3 then informed staff she had used the toilet and was coming out of the bathroom. Staff observed toilet paper in the toilet. R3 reported right knee pain, with movement, and was unable to bear weight on her right leg. R3 was transferred to the hospital. An interdisciplinary team (IDT) progress note dated 2/6/20, at 11:40 p.m. indicated R3 had an unwitnessed fall on 1/18/20, at 9:00 p.m. in her bathroom. The IDT progress note identified R3 had a history of [REDACTED]. Staff was to offer R3 toileting every two hours and as needed. The IDT progress note revealed R3 was last offered toileting at 6:15 p.m. on 2/6/20. R3's history and physical (H&P) dated 1/19/20, indicated R3 had a history of [REDACTED]. The H&P further indicated R3 had an unwitnessed fall in her bathroom, and it was presumed R3 fell when she was getting up from the toilet to use her walker. The H&P revealed R3 was diagnosed with [REDACTED]. A document titled Ecumen North Branch Investigation Guidelines dated 1/18/20, indicated R3 was toileted at 4:15 p.m., declined to be toileted at 6:15 p.m., and was visualized in her room seated in a wheelchair at 8:00 p.m. on 8/19/20. Immediate interventions put in-place included every two hour toileting was to be followed. A document titled QAPI (quality assurance process improvement) Action Plan: Fall with Fracture 1/18/20, dated 1/22/20, revealed a root cause analysis was conducted and determined R3 fell attempting to self-transfer due to not being toileted on time. On 8/6/20, at 2:00 p.m. an interview was conducted with registered nurse (RN)-A. RN-A stated R3 was a quiet and content resident who would not go out of her way to burden anyone. RN-A stated R3 was able to use her call light, but didn't always do so. RN-A stated R3 was forgetful, was known to self-transfer to the bathroom, and was to be offered toileting every two hours. RN-A stated she was unable to remember the details of R3's fall on 1/18/20. RN-A recalled a nursing assistant (NA), who was new to long-term care, was assigned to care for R3 on the evening of the fall. RN-A confirmed it was determined R3 was not toileted timely in accordance to the care plan and R3 suffered a fracture from the fall. RN-A stated the fall was caused by time management issue. RN-A stated the facility completed audits and education after the occurrence On 8/6/20, at 2:51 p.m. an interview was conducted with the assistant director of nursing (ADON). The ADON stated she received a call from a facility nurse on 1/18/20, after R3 was found on the floor of her bathroom. The ADON stated R3 was noted to be fully clothed and had a dry incontinence product. The ADON stated staff noted toilet paper was in R3's toilet. The ADON stated she inquired when R3 was last toileted, and the nurse responded they were unsure if the resident's care plan was followed. The ADON stated R3 initially verbalized she was unable to recall what had happened, however, R3 later stated she tried to use the toilet. The ADON stated after the fall, R3 had trouble bearing weight and complained of pain. The ADON confirmed R3 was found on the floor at 9:00 p.m. and stated R3 was last toileted at 4:15 p.m. on 1/18/20. The ADON stated R3 was offered and refused toileting at 6:15 p.m. The ADON confirmed R3 was not offered toileting again after 6:15 p.m., and stated R3 was supposed to be toileted every two hours. The ADON confirmed R3's fall on 1/18/20, resulted in a pelvic fracture. The ADON stated staff were expected to re-approach a resident if toileting was refused. The ADON stated if a resident still refused assistance a nurse needed to be notified. On 8/7/20, at 11:03 a.m. an interview was conducted with the director of nursing (DON). The DON confirmed R3 was not toileted in accordance with the care plan on 1/18/20. The DON confirmed R3 was toileted at 4:15 p.m., refused toileting at 6:15 p.m., and was not offered toileting again prior to the fall on 1/18/20. The DON stated the facility standard was to notify a nurse and re-approach a resident if care was refused. The DON stated if staff were unable to be timely with cares they were expected to call for help. The DON stated the facility learned R3 suffered a fracture when the hospital was called during the night. The DON stated after the incident, all staff were educated to follow resident care plans and how to call for assistance. The DON stated education was included in orientation packets, for new hires, and was ongoing. The DON stated residents at risk for falls were reviewed and audits were completed. The DON stated staffing patterns and call light usage were also reviewed, and it was determined staffing did not contribute to the fall. The facility policy Falls - Clinical Protocol dated 9/12, directed, If interventions have been successful in preventing falling, the staff will continue with current approaches . R3 had a fall which resulted in a pelvic fracture, after a self-initiated transfer to the bathroom, as staff failed to provide toileting in accordance with the care plan. However, by 2/21/20, the facility had implemented corrective action to prevent recurrence which included a quality assurance action plan, staff education, audits, review of staffing patterns, and reviewed residents who fell frequently or were at high risk for falls.

Based on observation, interview and document review the facility failed to ensure proper procedures were implemented for sling placement and staff presence with use of a hoyer (full body mechanical lift) for 1 of 1 resident (R1) who fell from the hoyer lift. This deficient practice resulted in an immediate jeopardy for R1, who fell from the Hoyer lift, sustained a lump on left side of head, two bruised ankles, hip pain and the facility failed to re-educate staff on the appropriate use of the lift and sling. In addition, the facility failed to implement facility policy related to staff presence with hoyer lift use for 2 of 3 residents (R12, R20) observed during transfers and placed 10 of 60 residents (R1, R5, R6, R7 ,R8, R9, R10, R11, R12, R20) who currently reside in the facility at risk for injury/ death who currently utilized a Hoyer lift for transfers. The immediate jeopardy began on 10/6/19, at 6:45 a.m. when R1 fell from a Hoyer lift while staff were not following facility protocol for staff presence during a lift and had improper sling placement and was identified on 10/18/19. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 10:22 a.m. on 10/18/19. The immediate jeopardy was removed on 10/20/19, at 5:39 p.m., but noncompliance remained at the lower level of scope and severity level of D isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had [DIAGNOSES REDACTED]. The MDS listed R1 required total assistance for all areas of daily living (ADL) including transfer and did not walk. The annual Care Area Assessment (CAA), dated 1/31/19, listed R1 had [DIAGNOSES REDACTED]. The CAA also indicated R1 had advanced Alzheimers disease with inability to participate in ADL and mobility tasks and was non verbal and dependent on staff for all needs. R1's care plan revised 10/9/19, identified R1 had impaired vision, communication and memory, had mental illness and limited mobility, required assistance of two staff with the Hoyer lift for transfers. The care plan further identified R1 had bruising surrounding the right and left ankle which extended upwards towards the shins, noted to be consistent with fall and feet landing first. The nursing assistant Care Sheet, updated 10/11/19, indicated R1 had impaired cognition and vision, and required assistance of two staff for transfer with the Hoyer lift. Review of R1's Incident report dated 10/6/19, indicated the nurse had entered R1's room and found her lying on her back with her head resting on a nursing assistant (NA) lap and another NA kneeling on her left side. NA's stated R1 had slipped out of the hoyer sling and fell on to her left hip, but did not hit her head. No injuries observed. The report indicated the hoyer sling had not been positioned correctly. Review of R1's progress notes from 10/6/19 to 10/17/19 revealed the following: -10/6/19, R1 was on her back on the floor with her head on a nursing assistant's lap. A second nursing assistant was kneeling on the floor on R1's left side. The nursing assistants reported R1 had slipped out of the Hoyer sling and fell on to her left side hitting her hip and denied that R1 had hit her head. The note indicated education would be provided to NARs on the use of the hoyer lifts. -10/9/19, right ankle is black and blue and slightly swollen, believed to be from fall on 10/6/19. Ice and elevation done. -10/10/19, bruise to right ankle is purple and greenish in color, another small red bruise on left inner ankle, ice applied, and R1 was noted to grimace when being turned for cares. -10/14/19, R1's fall from the Hoyer lift was reviewed, noted staff did not follow 2 person protocol at the time of the transfer. Staff education and follow up provided, incident isolated to this one transfer. Staff to have wheelchair in close proximity to the hoyer before resident is lifted from bed, staff to ensure proper sling placement. X-ray negative and bruises to ankles and shins evaluated by nurse practioner. Small lump on head resolved. Hourglass sling order due to posture and contractures, R1 leaning and shifting to the left at times. Staff to continue to monitor for non-verbal indicators of pain. Review of the facility's investigation notes for R1's fall on 10/6/19, indicated the second NA was not in proximity to lift during lifting as she was retrieving R1's wheelchair and R1 slipped from the hoyer sling during the transfer. At that time the 2 NAs were observed during hoyer transfer, educated on proper technique including wheelchair being in proper proximity to the lift and proper start to finish technique of transfer including sling placement. The notes indicated on 10/11/19, both NA's were given corrective action for not following facility policy for safe transfers to position chair and ensure wheels are locked, position lift over chair and make sure resident is positioned over the seat of the chair and provided a copy of the Lifting Machine policy. On 10/17/19, at 8:30 a.m. via telephone interview, NA-E stated she had been present when R1 fell from the lift. She stated she had placed the sling under R1, secured the loops onto the hooks of the hoyer and proceeded to lift R1 up from the bed. She then pulled the lift away from the bed, while the second NA was near the bathroom, to bring R1's wheelchair into the room. NA-E indicated R1 usually leaned to the left and felt R1 possibly fell because the sling was not pulled up enough to support R1 on the left side. On 10/17/19 at 11:23 a.m. registered nurse (RN)-A confirmed she had been the on call nurse the weekend R1 fell from the Hoyer lift and had spoken to the staff involved via telephone that evening. RN-A indicated she gathered the following information: R1 did not move independently; RN-B had reported R1 was observed to have the sling underneath her on the floor when the emergency call light was answered; NA-E had reported R1 slid out the left side of the sling; NA-D had reported when she returned from getting the wheelchair, she reported R1 had fallen from the lift feet first; Staff reported R1 did not hit her head but had a bump on the left side of her head. RN-A indicated LPN-A reviewed the Hoyer and sling used and found nothing wrong. RN-A identified she had then requested RN-B provide education for use of the Hoyer lift to the two nursing assistants involved. In a follow up interview on 10/17/19, at 4:22 p.m., RN-A confirmed NA-E had stated she believed everything had been done right, but RN-A felt because the resident slid out of the sling possibly it wasn't on correctly. On 10/17/19 at 3:12 p.m. during a follow up interview, NA-E stated she felt R1 had fallen out of the Hoyer lift because R1 had leaned to the left side and the sling had not been pulled up high enough on R1's left shoulder. NA-E indicated she informed RN-A the sling had not been properly placed at the time R1 had fell . The facility provided a list of residents currently residing in the facility with R1, R5, R6, R7 ,R8, R9, R10, R11, R12, and R20's names highlighted to indicate they currently utilized a full body lift for transfers On 10/17/19, at 3:36 p.m. director of nursing (DON) stated the report of R1's fall had inconsistencies from various staff. She indicated the nursing assistants reported R1 fell out of the lift sling and the nurses reported of the lift sling was found under R1 when they entered the room. DON indicated staff had reported R1 had not settled into the sling and stated she was not aware of what that meant. DON confirmed no further investigation or audits of cares had been done after R1's fall. DON stated because the reason R1 fell out of the hoyer was not established, the two staff involved in the incident received education on all aspects of the Hoyer lift and she felt if R1's wheelchair had been in place, the resident would not have fallen. The DON confirmed only the two staff involved with R1's fall from the Hoyer lift received re-education on the Hoyer lift, rather than all staff who use the Hoyer lift and no audits were completed on any staff following the incident. In a follow up interview on 10/17/19, at 5:05 p.m., DON stated she had believed the nurses findings of the incident, because she felt they had more training on making a judgement of the incident than she did. She confirmed no other staff were re-trained with use of the hoyer lift nor were any staff audits completed for lift use following the incident. DON stated she would expect staff to follow the facility policy for lift use. On 10/18/19, at 8:11 a.m. during a telephone interview, nurse practitioner (NP)-A indicated she was aware R1 had fallen from the lift in the recent past. NP-A indicated her understanding was that staff did not have the straps correct on R1 when in the lift, which allowed her to slide out of the sling. NP-A indicated she was aware the facility had provided some education to staff; however, did not the specifics. On 10/18/19, at 8:22 a.m. during a telephone interview with E-Z Way Lift representative (EZR)-A, she indicated resident falls from lifts were not common, but it can happen. EZR-A indicated although she was unaware of the fall in question, typically a fall occurs due to operator error. On 10/18/19, at 9:12 a.m. RN-B stated when R1 fell from the Hoyer lift he had been alerted by the emergency call light in the room. RN-A stated upon entering the room: R1 was on the floor on her back slightly turned to the left; NA-E was on her knees with R1's head in her lap; NE-D was on her knees to the left of R1; the hoyer sling was underneath R1; the lift was off to the left side of the room. RN-B indicated NA-E informed him R1 had leaned to the left while in the Hoyer sling and fell out. RN-B stated he did not understand how the lift sling was observed under R1 after the fall, and did not ask the nursing assistants. RN-B indicated he had provided education to both NA-D and NA-E regarding wheelchair placement, two staff to be within arms length of the resident during use, followed by the nursing assistants demonstration of lift use on another resident. RN-B identified he reported the incident and observations to the DON but did not identify how the fall occurred. RN-B stated, I don't know how you fall out of the sling. R12 R12's quarterly MDS dated [DATE], identified R12 had [DIAGNOSES REDACTED]. The MDS listed R12 had moderate cognitive impairment and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and total assistance for locomotion. R12's care plan reviewed 10/15/19, identified R12 had an ADL deficit related to impaired mobility, [MEDICAL CONDITION], weakness and contractures and directed two staff at all times, for cares which included mobility, grooming and transfer with a Hoyer lift. On 10/17/19, at 10:07 a.m. nursing assistant (NA)-F and NA-G assisted R12 with personal cares and then placed a mesh hourglass sling underneath R12. NA-F and NA-G raised R12 from the bed with the Hoyer lift, checked that the loops were correctly attached and with R12 suspended in the air, moved him away from the bed over the floor. NA-F immediately walked away from R12,and entered the bathroom to obtain the wheelchair and returned with the wheelchair. She proceeded to position the wheelchair under R12 who remained suspended in the lift over the floor. On 10/17/19, at 10:22 a.m. NA-G indicated the usual facility protocol for Hoyer lift use was 2 staff to place the resident in the middle of the sling, raise the resident off the bed, check for correct loop placement while the resident was over the bed, then one staff to pull the lift straight back and the second staff to get the wheelchair and place it under the resident on the lift. NA-G indicated due to room size and space, the wheelchairs were stored in the bathrooms until placed under the resident on the lift. On 10/17/19, at 10:28 a.m. NA-F indicated her usual practice for use of the Hoyer lift to transfer R12 included to obtain and position the wheelchair after R12 was suspended in the lift, over the floor. R20 R20's quarterly MDS dated [DATE], identified R20 had [DIAGNOSES REDACTED]. The MDS listed R20 had moderate cognitive impairment and required extensive assistance for bed mobility, dressing,eating, toilet use and personal hygiene, and total assistance to transfer, for locomotion and did not walk. R20's care plan revised 10/15/19, identified R20 had an ADL deficit due to [MEDICAL CONDITION], contractures, and impaired cognition. The care plan directed R20's care needs be provided by staff, including assistance with eating, dressing, mobility and use of a Hoyer lift for transfers with assistance of two staff. On 10/17/19, at 11:48 a.m. R20 was observed in bed in his room with NA-A and NA-C present in the room. NA-C and NA-A rolled R20 from side to side and placed the mesh sling under R20. The sling was then placed between R20's legs and the four sling loops were placed onto the hooks of the metal bar of the mechanical lift. NA-C operated the lift and raised R20 up off of the bed. NA-A then guided R20, in the sling, away from the bed over the floor. NA-A proceeded to walk away from R20, who was suspended in the air by the hoyer lift, and walked and entered the bathroom to obtain the wheelchair. On 10/17/19, at approximately 11:55 a.m., NA-A confirmed R20's wheelchair should have been positioned closer to R20 during the transfer and indicated R20 should not have been left elevated in the hoyer sling without two staff in close proximity. NA-A stated it was not always possible to have the wheelchair in close proximity to the Hoyer lift due to the configuration of the room, size of the room and the amount of furniture in the resident's room. Review of the facility policy titled Lifting Machine, Using a Portable, revised 12/13, directed the use of 2 staff, and listed the first step was to position the chair and ir it was a wheelchair, be sure to lock the wheels. The policy included several steps in the process and directed to position the sling, attach the hooks to the sling and proceed to lift the resident. Further, the policy directed to position the lift over the chair, and make sure the resident was positioned over the seat of the chair. The facility form titled Falls-Clinical Protocol revised (MONTH) 2012, identified 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. The immediate jeopardy that began on 10/6/19, was removed on 10/20/19, when the facility thoroughly investigated R1's fall, all staff who transfer residents with full body lifts received an information packet on hoyer lift operation/sling placement, were re-educated, competency tested , and audited with use of a full body lift, but the noncompliance remained at the lower scope and severity level of D, isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to ensure the care and services were provided for 2 of 3 residents (R12, R127) to prevent the development and promote the healing of pressure ulcers. This resulted in actual harm to R12 and R127. Findings include: R12 had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) on his coccyx. R12 sustained actual harm with increased undermining/tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) between 11/28/12, and 12/6/12. On 11/28/12, the coccyx ulcer measured 2.4 cm x 2.5 cm with undermining/tunneling of 0.8 cm at 12 o'clock and 1.4 cm at 3 o'clock, and minimal purulent serous drainage and slough. On 12/6/12 at 7:29 a.m., LPN-B was observed to measure R12's coccyx pressure ulcer as 2.6 centimeters (cm) long and 2.5 cm wide with tunneling 2 cm deep at 9 o'clock position and 3.4 cm at 3 o'clock position. R12's pressure relieving gel wheelchair cushion was not evaluated as directed by the wound care physician. Every 2 hour offloading (remove pressure from the affected area) was not provided as directed by the care plan, and R12 was not assisted to remain lying on his side while in bed with the head of the bed up less than 30 degrees. In addition, assessments were not consistently documented. R12 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE], identified R12 as cognitively intact, requiring extensive assistance with bed mobility, transfers and toileting. The MDS also noted a stage 4 pressure ulcer and a history of healed pressure ulcers. The Care Area Assessment (CAA) completed on 12/18/11, identified R12 was cognitively intact, was incontinent of stool, had an indwelling urinary catheter, and required extensive assistance with bed mobility, transfers and toileting. Also, the CAA identified R12 had an unhealed pressure ulcer, was at risk for developing pressure ulcers, had a pressure relieving device in bed and chair, and was on a turn and repositioning program. The CAA referred to the skin assessment for further information. The current plan of care dated 10/4/12, directed turn and reposition every 2 hours and prn (as needed), side to side, keep off bottom. Off load for full 2 minutes every 2 hours if sitting in chair for extended period of time. The Temporary Care Plan for Skin Risk/Problems dated 11/27/12, directed staff to turn and reposition every 2 hours while in bed and off-load at least 1 minute, turn and reposition while in chair (frequency not indicated), and off load at least 1 minute. It also directed licensed staff weekly skin audit. Lastly, it directed no more than 30 degrees side lying position or head of bed elevated. The plan of care did not direct leaving the mechanical lift sling underneath R12 in the wheelchair. The nursing assistant assignment sheet stated, "May leave sling under resident when up in chair or layed down for treatments." The nursing assistant assignment sheet also directed, "Must use extreme caution with transfers, bed mobility and cares as you are dislodging his wound dressing..." "Do not wipe from front to back with BM (bowel movements) as you are rolling up the dressing and ruining it!..." "Offload for 2 mins q (every) 2 hrs while in w/c (wheelchair) or electric scooter d/t (due to) pressure sore on sacrum/coccyx." During observation of morning cares for R12 on 12/5/12 at 7:21 a.m., the nursing assistant (NA)-C cleansed the peri-anal area and there was no stool or urine present. The pressure ulcer dressing was intact. The licensed practical nurse (LPN)-B was observed to provide wound care on 12/5/12 at 7:45 a.m. When the coccyx ulcer dressing was removed, there was a quarter sized piece of formed stool under the dressing. LPN-B cleaned the stool out of the wound bed, and without changing gloves or washing hands, reached in the tub of supplies and grabbed wound cleanser spray and sprayed the wound. LPN-B then wiped the wound and massaged [MEDICATION NAME] cream around the wound bed. Still wearing the soiled gloves, LPN-B applied skin prep (for sensitive skin) around the wound and bloody drainage noted on wipes. LPN-B changed gloves, but did not wash hands before placing absorbent gauze in the wound bed and applying an Opsite dressing. During interview on 12/5/12, at 7:59 a.m., LPN-B verified the lack of glove changes or hand hygiene during the dressing change. R12 was assisted into the wheelchair with a mechanical lift at 7:55 a.m. on 12/5/12. The cloth mechanical lift sling was left between R12's body and the pressure reduction cushion. During continuous observation on 12/5/12, from 7:55 am. to 9:58 a.m., R12 was observed sitting in his wheelchair, in the dining room until he wheeled himself back to his room at 9:08 a.m. At 9:20 a.m., R12 wheeled himself to the dining room to obtain a glass of water and returned to his room at 9:23 a.m. R12 was met by his guest when he returned to his room. At 9:25 a.m., NA-D offered to get R12 out of the wheelchair. NA-D stated R12 refused repositioning. NA-D stated that R12 said, "No, it's still morning." R12 remained sitting on the lift sling in the wheelchair, without repositioning, in his room until observation ended at 9:58 a.m.. On 12/6/12 at 7:29 a.m., LPN-B was observed to measure R12's coccyx pressure ulcer as 2.6 centimeters (cm) long and 2.5 cm wide with tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) 2 cm deep at 9 o'clock position and 3.4 cm at 3 o'clock position. R12's wheelchair gel cushion was noted to be flat and bottomed towards the back of the wheelchair. LPN-B, asked to evaluate R12's gel cushion, stated, "It's cracked, he needs a new one." The gel cushion was duct taped several times in the back, gel was falling out and noted to be scattered all over inside the cushion cover. LPN-B stated R12 brought the gel cushion from home. R12 was seen at wound clinic on 10/4/12, with recommendations for a wheelchair cushion evaluation since the gel part seemed to bottom out; however, there was no follow-up to obtain the evaluation. During interview on 12/6/12, at 9:31 a.m. the interim director of nursing (IDON) looked at the gel wheelchair cushion and stated, "That doesn't look good." "We should assess his tissue tolerance with the cushion under him in the wheelchair." A new gel cushion ([MEDICATION NAME] Spectrum) was placed in the wheelchair. During observation on 12/6/12 at 11:26 a.m., RN-B provided coccyx pressure ulcer care. R12 was observed to be lying flat on his back with head of bed elevated to 90 degrees. RN-B assessed an "erosion" on R12's penis where the urinary catheter sits. The penis "erosion" measured 0.5 cm x 4.5 cm with 20% eschar and some granulation. RN-B stated the "erosion" was stage 2, through the skin. The care plan dated 10/20/12, indicated an open area superficial between foreskin and penis. Goal: superficial open area will be healed within 30 days. The care plan and goal was updated 10/20/12. RN-B stated the coccyx pressure ulcer was unstageable with no slough and measured 3.8 cm x 3.5 cm., depth of tunneling at 3 o'clock position was 2.5 cm and the 12 o'clock position tunnel was closed. On 12/6/12, at 1:19 p.m., R12 was sitting on a cloth mechanical lift sling in his wheelchair. The Worksheet for Skin Checks Over Bony Prominence-Sitting dated 9/13/12, indicated the presence of a "wound" on the coccyx with some redness, zero open blanchable on cheeks/thighs after 2 hours. The assessment did not indicate the presence of pressure reduction cushioning during the observation. The Skin assessment dated [DATE], indicated R12 had multiple risk factors for contributing to increased risk for skin breakdown. Weekly full assessments of the sacral/coccyx pressure ulcer were to be completed weekly; however, there was no evidence to indicate assessment was provided between 10/18/12 and 10/31/12, or between 10/31/12 and 11/20/12. On 11/28/12, the coccyx ulcer measured 2.4 cm x 2.5 cm with undermining/tunneling of 0.8 cm at 12 o'clock and 1.4 cm at 3 o'clock, and minimal purulent serous drainage and slough. Nursing documentation dated 10/31/12, indicated "Encourage resident to stay on his side/side positioning no supine d/t (due to) wound. Resident states he will do what he wants to do. Explain risk slowed healing/outcome non compliance. Agreed he understood, but just shook his head. Cont (continue) to monitor and encourage." R12 was interviewed on 12/6/12, at 1:19 p.m., and when asked if staff had ever explained the risks of sitting in his chair and not offloading and repositioning every 2 hours, he shook his head no. No other information was provided from R12. The national sales manager for E/Z Weigh (lift manufacturer) was interviewed by phone on 12/6/12, at 4:27 p.m., and stated that it was recommended to use a mesh sling for anyone with a pressure ulcer. The sling was easily removed and the only time the sling should be underneath the resident is during the transfer. The canvas material does not allow air flow and moisture could build up between the sling and the resident. If the resident is using a gel cushion, the sling should not be left underneath the resident while they are the chair because it may impede the purpose of the cushion. R127 had intact skin on admission, but sustained actual harm with development of a Stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both) on the left heel. R127 was admitted with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], indicated R127 was cognitively intact, required assistance of two staff with bed mobility and transfers, did not ambulate, and required assistance of one staff for wheelchair mobility, dressing, toileting and personal hygiene. The MDS further identified R127 was at risk for the development of pressure ulcers. The Care Area Assessment (CAA) dated 10/23/12, identified R127 at risk for skin breakdown. On 10/10/12, the facility completed a Braden scale for predicting pressure sore risk with a score of 18, identifying R127 at risk for development of pressure ulcers. Braden scales were also completed on 10/19/12, and 10/30/12, with scores of 20 on both assessments (indicated low risk for the development of pressure ulcers). The Braden scale data on 10/19/12, and 10/30/12, conflicted with the MDS indicating R127, "walks occasionally during the day but for very short distances, with or without assistance." A tissue perfusion check was completed on 10/11/12, with no areas of concern identified after sitting and lying down for two hours. The skin assessment completed on 10/18/12, indicated R127 had risk factors for skin breakdown including friction/shearing potential; and the only skin issue identified was the site where a previous intravenous line had been placed. The assessment also directed repositioning every two hours, and to offload every two hours when sitting. The skin deficit care plan dated 11/12/12, indicated R127 was at risk for skin breakdown due to bowel incontinence, Foley catheter use, and the need for assist with bed mobility. The care plan did not identify or have interventions related prevention of pressure ulcers. The care plan directed skin checks to be done weekly, the nurse to assess weekly and report any areas of redness, dryness or potential breakdown to the nurse. The interdisciplinary progress notes (IPN) were reviewed from 10/10/12, through 12/3/12. There was no documented weekly skin monitoring, skin assessments, measurement or staging of the pressure ulcer. On 11/19/12, a physical therapy assistant note identified a full thickness wound on left lateral calcaneous (heel) measuring 1.2 centimeters (cm) wide x 1.0 cm in length. On 11/19/12, the nurse practitioner ordered heel protectors on at bedtime and a daily dressing change with [MEDICATION NAME] 2% ointment and a foam dressing secured with gauze roll and [MEDICATION NAME]. Physician documentation dated 11/30/12, indicated the open wound to the left heel was found by the nurse practitioner when she was trimming R127's toenails; however, the note did not include a description of the pressure ulcer. Nurse practitioner documentation on 11/27/12, indicated R127 had a wound with a small amount of drainage on the left heel and the base of the heel was boggy and whitish/yellowish in color. Nurse practitioner documentation on 12/3/12, indicated the left heel ulcer had no discharge but the heel was was boggy and whitish/yellowing in color. Nurse practitioner documentation did not include measurements or staging of the left heel pressure ulcer. The registered nurse (RN)-B, interviewed on 12/3/12, at 6:52 p.m., stated R127 developed a stage 2 pressure ulcer on the left heel after admission to the facility. On 12/5/12, at 12:03 p.m., RN-B verified the lack of weekly skin checks or assessments; and stated the pressure ulcer was not measured or staged since it developed. The director of nursing (DON) was interviewed on 12/6/12, at 7:35 a.m. and stated she would expect weekly skin checks and skin assessments to be completed. At 8:45 a.m., the DON stated she was unable to find documentation of weekly skin checks or weekly skin assessments. Observation of the pressure ulcer on 12/5/12, at 10:58 a.m. with RN-B and licensed practical nurse (LPN)-D revealed a 2.5 cm x 1.4 cm stage 2 pressure ulcer to the left lateral heel, an increase in size from the initial measurement. The dietary manager (DM)-C was interviewed on 12/6/12, at 1:32 p.m., and stated she would add nutritional interventions to aid healing if she was notified of a resident pressure ulcer. The DM stated she had not been notified and nutritional interventions were not initiated. The DON, interviewed on 12/6/12, at 2:26 p.m., stated nursing staff were expected to inform the dietary department of any pressure ulcers, either through a phone call or an email. The facility policy and procedure on Skin Care/Pressure Ulcer Care revised 5/11, directed a registered nurse to oversee each resident's skin care in accordance with the comprehensive assessment and care plan.

Based on observation, interview and document review, the facility failed to monitor skin integrity and provide the necessary care and services to prevent the development of a pressure ulcer for 2 of 3 residents (R11 and R130) in the sample reviewed for pressure ulcers. This resulted in actual harm for R11. Findings include: R11 was admitted with a scabbed area on the left [MEDICAL CONDITION] site that healed, however subsequent recurrent pressure ulcers developed. The left stump area was not assessed upon admission so individualized interventions were not developed. R11 did not receive the necessary treatment and services to heal and prevent recurrence. This resulted in harm for R11. R11 was admitted on [DATE], with [DIAGNOSES REDACTED]. The comprehensive minimum data set ((MDS) dated [DATE], indicated R11 was cognitively intact, and required extensive assistance of 2 staff with bed mobility, transfers, toileting and bathing, and required extensive assistance of 1 staff with dressing and personal hygiene. The MDS further identified R11 to be at risk for the development of a pressure ulcer. The care area assessment (CAA) dated 12/30/11, indicated R11 was at risk for developing pressure ulcers related to insulin dependent diabetes mellitus, a [MEDICAL CONDITION] of the left leg, the need for [MEDICAL TREATMENT], and a current stage IV pressure ulcer on the sacrum (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Per interview with the interim director of nursing (DON-B) on 3/8/12, at 9:27 a.m. R11 was admitted to the facility with scabbed areas to his left stump. She reported that the scabs came off during therapy. She stated the areas healed on 10/25/11. DON-B acknowledged the scabbed areas were not assessed upon admission and interventions were not implemented to assist with healing and prevent recurrence. The resident's admission/readmission information dated 9/23/11, lacked indication of skin issues to R11's left stump. The Braden scale for predicting pressure sore risk dated 9/23/11, indicated R11 was at risk for the development of pressure ulcers and interventions should be implemented. Based on the scoring, the Braden form specifically directed staff to implement interventions to reduce friction and shear, and address mobility, activity level and moisture. The care plan identifies a start date of 10/21/11 for interventions of mobility, activity level and moisture. The friction and shearing interventions did not begin until 3/12. The interdisciplinary progress notes (IPN) dated 9/23/11, failed to indicate scabbed areas on the left stump. The skin assessment dated [DATE], indicated R11 was at risk for the development of pressure ulcers, had a pressure ulcer on the sacrum, but failed to identify a pressure ulcer on the left stump. The IPN dated 9/30/11 identified a superficial open area on the left superior knee measuring 0.3 centimeters (cm) by .04 cm. The note stated the open area was surrounded by a 1.8 cm x 1.1 cm red, blanchable area with no warmth. The tissue perfusion worksheet dated 9/30/11, identified the same area on R11's left superior knee ([MEDICAL CONDITION]) after removing the prosthetic. The tissue perfusion worksheet dated 10/1/11, identified "sacral area reddened but blanchable. No other problems noted," even though the open area on the resident's stump had been identified on 9/30/11. The treatment record for 9/11, directed staff to check the left stump every week as he was treated for [REDACTED]. On 9/30/11, the treatment record directed staff to cleanse the open areas on the left superior knee with wound cleanser, apply skin prep and apply opsite (a transparent dressing). The treatment record also instructed that the opsite dressing be checked every shift and changed every 3-5 days and PRN (as needed). The dressing order was changed on 10/3/11, to apply a small amount of antibacterial ointment to the wound on the resident's stump, cover the area with a Band-Aid, and change the dressing every other day. The treatment was documented as "resolved" in the treatment record on 10/25/11. The IPN lacked documentation that the pressure ulcer had healed. A review of the skin assessments, Braden risk assessments, weekly skin audits, and tissue perfusion worksheets from 10/19/11, through 2/21/12, continued to identify R11 as being at risk for the development of a pressure ulcer. There was no further issue with the stump during this period of time. On 3/3/12, the IPN identified a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) on R11's left stump distal area. The pressure ulcer measured 1.0 cm x 1.0 cm with 0.2 cm depth. The IPN indicated "resident states that NARs (nursing assistants) are not putting the prosthesis on correctly. Writer has instructed NARs to leave prosthesis off until further notice." The physician was notified and a skin change form was filled out, indicating that the pressure ulcer was cleansed with wound cleanser and a [MEDICATION NAME] dressing was applied. The skin change form also included the information that the resident had reported the NARs were not putting the prosthesis on correctly. On 3/6/12, the skin ulcer data and assessment worksheet indicated the pressure ulcer continued to be a stage III, measured 1.0 cm x 1.6 cm, and was 2.25 cm deep, had a moderate amount of serous drainage, and the wound bed had 20% granulation (healthy) tissue and 80% slough (unhealthy tissue). The pressure ulcer had tunneling of 1.5 cm at 12 o'clock, 0.8 cm at 3 o'clock, 2 cm at 6 o'clock, and 2.25 cm at 9 o'clock and was surrounded by 2 cm redness. A wound culture was obtained. R11 was started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics), and a new intervention of placing a pillow under the left stump to suspend the stump off of the mattress was initiated. The care plan was updated on 3/6/12, directing staff to keep the prosthesis off until the left stump was healed and to place a pillow under the resident's left knee while in bed to suspend the stump off of the mattress. On 3/7/12, at 11:11 a.m. during observation of the pressure area, the wound was observed to be round, and over the bony prominence on his stump. During the observation, R130 frequently attempted to push himself up in bed, utilizing his stump to push with which created a significant shearing/friction force to his stump. R130 was also observed to rub his stump back and forth on the sheets creating friction. DON-B stated the pressure ulcer had a moderate amount of slough removed and was now a stage IV pressure ulcer, worsening from a stage III since 3/6/12. On 3/8/12, at 9:27 a.m. when asked about the scabbed areas that healed in October, the DON verified the prosthetic leg had not been checked to see if it was the cause of the pressure. She stated that the nursing assistants applied and removed the prosthesis. She further stated the nursing assistants had been taught how to apply the prosthesis. When given the opportunity, the DON was unable to provide documentation of the education. The DON stated interventions to reduce the risk of pressure ulcer development included an alternating pressure mattress, and weekly skin checks by licensed nurses on Tuesday afternoons and Wednesday nights. At 1:24 p.m. the DON verified no new interventions had been put into place following the pressure ulcer that healed on 10/25/11. On 3/8/12, at 12:45 p.m. R11 was interviewed and when asked if the NAs were putting the prosthesis on correctly, R11 stated, "I don't know." On 3/8/12, at 1:16 p.m. the geriatric nurse practitioner (GNP-F) was interviewed and stated R11 used the stump to reposition in bed, and has had pressure ulcers on the stump in the past. GNP-F further stated the area was vulnerable for recurring pressure ulcers due to the history of pressure ulcers. The facility policy and procedure on skin assessment and care dated 5/11, identified that assessments would be completed "upon admission, on a routine basis, and as needed. The policy further indicated the comprehensive assessments would be utilized to develop appropriate individualized interventions. R130 did not receive services to promote the healing and prevent infection of pressure ulcers. R130 was admitted from the hospital on [DATE], with a pressure ulcer on the coccyx that had not healed. The 3/12 admission/re-admission assessment identified R130 as alert and oriented. R130 had multiple [DIAGNOSES REDACTED]. R130 was dependent on staff for positioning needs due to fractures. The facility's Skin Assessment and Care policy revised 5/11, indicated that an assessment of potential skin problems would be completed upon admission, on a routine basis and as needed. A risk determination would be made by a RN prior to admission. The review of resident skin condition and risk for skin problems would also be completed with in 2 hours of admission if possible. The policy indicated that a skin care plan to prevent and or to treat skin problems would be initiated if needed upon admission. The Resident Admission Information form dated 3/3/12, indicated that R130 had a skin tear on the coccyx area. There was no further description of the open area on the admission form. The Skin Ulcer Data Collection and Assessment form dated 3/3/12, indicated that R130 had a stage two pressure ulcer which measured 1.6 cm long and 1.0 cm wide on the coccyx. There was no drainage or pain identified. The assessment form identified pressure ulcer risk prevention as the use of a Mepiplex dressing and staff off loading the resident every 2 hours for one to two minutes. A Braden score (pressure ulcer risk evaluation) was done on 3/3/12 and R130 scored 16. The form indicated a score of 18 or below required immediate implementation of pressure relieving devices in the chair/bed and a weekly skin review by a nurse would need to be completed. The short term plan of care documented on 3/4/12, indicated that R130 had a stage two pressure ulcer on the coccyx and needed to be turned and repositioned every two hours and as needed. The undated nursing assistants (NA)'s Care Sheet, directed staff to turn and reposition R130 every two hours and to offload for 1-2 minutes every two hours while sitting. R130 was observed on 3/8/12, at 9:50 a.m. seated in her wheelchair with her left foot elevated on a pillow and a small tray table on the left wheelchair arm. Interview with the resident on 3/8/12, at 10:00 a.m. indicated she did not know that she had a repositioning schedule. At 10:45 a.m. R130 verified that no one had offered to reposition her or take her to the bathroom. At 11:10 a.m. NA-A asked R130 if she was doing OK and told her she would come back and take her to lunch in 15 minutes. Interview with the resident at that time confirmed that NA-A did not offer to assist her in standing, repositioning, or toileting. NA-A returned to R130 and asked her if she was ready to go to the dining room. R130 requested that NA-A remove the tray table and put her wheelchair foot rest down. R130 remained in the dining room from 11:20 a.m. to 12:50 p.m. without an offer of or assistance with repositioning or toileting. At 12:55 p.m. R130 was toileted and repositioned by NA-B. Interview with NA-B after the cares were provided indicated that she was unsure about R130's repositioning needs. Interview with NA-A at 1:00 p.m. confirmed she had not repositioned R130 on the morning of 3/8/12. Interview with the interim director of nursing (DON) on 3/8/12, at approximately 1:30 p.m. confirmed that R130 should have been repositioned every two hours. She confirmed R130 had a pressure ulcer on admission and had been assessed as needing repositioning every two hours or more often if necessary .