Every finding on record at Evansville Care Center

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to careplans which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 24 residents residing in the facility. Findings include:During an interview on 1/21/2026 at 5:12 p.m., administrator confirmed last survey's plan of correction (POC) and indicated the POC had been discussed at QAPI but was not a current QAPI project. Administrator stated after a recertification survey is completed, the results and POC are reviewed. The administrator further stated once the audits were completed meeting the POC's timeline, it would be considered completed. The administrator revealed the facility did not use past survey results for current QAPI projects. The administrator further revealed the facilities projects were generated from the [NAME] report and additional reports the facility had ran. The administrators stated it would be important to use the past survey results for QAPI projects and that is something the facility will look at in the future. The QAPI meeting minutes dated 10/9/25, current performance improvement projects were food enjoyment and relationship. QAPI meeting minutes further identified no changes were going to be made. Next meeting would be scheduled for 1/15/26. Facility policy titled QAPI policy undated, the purpose of QAPI in our organization is to take a proactive approach to improving the comprehensive range of care and services provided by our facility including clinical care, quality of life and resident choice and safety. We will continually be improving our facility in line with our vision to be the premier choice for care while exceeding expectations.

Based on interview, document review, and observation, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 2 of 12 (R21, R20) residents reviewed for comprehensive care plan. R20 R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 was cognitively intact and had diagnoses which included heart failure, arthritis, and seizure disorder. Indicated R20 was independent with activities of daily living (ADLs). R20s quarterly care area assessment (CAA) dated [DATE], had cognitive lose/dementia, behavioral issues, and issues with psychosocial wellbeing. R20's care plan dated [DATE], indicated resident had the potential for social emotional disturbances related to a diagnosis of cognitive communication deficit. Further indicated resident had target behaviors of refusal of cares, rude demeaning remarks to staff and abrasive behaviors. R20s care plan interventions stated daily monitoring of resident's target behaviors, interventions and outcomes to be documented on the POC. Review and adjust target interventions based on residents' response. Education provided to staff on mental health diagnosis including memory impairment. Care plan lacked evidence of planned interventions staff were to complete if resident was having target behaviors. Review of R20's behaviors displayed during shift report dated [DATE] to [DATE], lacked documentation for interventions staff were to follow if R20 was having behaviors. During an interview with R20 on [DATE] at 5:03 p.m., R20 stated she wanted to leave the facility. R20 stated that it would be a better place if certain political figures were deceased and groups of color were to leave. During an interview in on [DATE] at 3:28 p.m., nursing assistant (NA)-A stated R20 had a lot of behaviors. NA-A stated that staff talk to R20 in a calm voice and come back to R20s room after a while and reapproach R20 when staff are unable to help her at the time. NA-A stated she was unaware of any specific behavior interventions for R20. During an interview on [DATE] at 3:42 p.m., licensed practical nurse (LPN)-A indicated R20 requires a lot of reapproaching and reeducating. LPN-A further indicated R20 has a medical background and is very set in her ways. LPN-A stated R20 has behaviors that come and go and R20 can become very angry at times. LPN-A revealed R20 required a lot of education and redirection. LPN-A stated she was unaware of any specific interventions for R20 when her behaviors had arisen. During an interview on [DATE] at 3:44 p.m., minimum data set (MDS) coordinator (MDSC), stated resident is very resistant to any interventions. MDSC further stated the facility would need to include every intervention because the facility is not sure what intervention would work for R20. During an interview on [DATE] at 3:55 p.m., director of nursing designee (DOND) indicated R20 confirmed there were no interventions on R20s careplan to dear with R20s behaviors. During an interview on [DATE] 4:05 p.m., social services designee (SWD) indicated R20 had not been addressed by SWD for additional psychosocial services. SWD further indicated if staff felt a resident needed to be seen by psychological services SWD would be notified. SWD stated SWD does not do anything with the care plan and does not edit anything. During an interview on [DATE] at 5:03 p.m., DON and administrator confirmed R20s careplan lacked interventions for behavior. DON and administrator indicated it was important to have intervention to ensure R20 was receiving the best care possible. R21 R21 admission Minimum Data Set (MDS), dated [DATE], indicated R21 was admitted to the facility on [DATE], and had moderate cognitive impairment. R21 was dependent on staff for toileting and needed maximal assistance for dressing and transferring. R21 had a diagnosis of diabetes, hypertension, hip fracture, Parkinson's disease (movement disorder of the nervous system), malnutrition, and depression. R21 was taking medications, including antidepressants and opioids (medication for severe pain). R21 care area assessment (CAA) dated [DATE], triggered for cognitive loss, visual function, ADL functional rehabilitation, urinary incontinence, psychosocial wellbeing, behavioral symptoms, activities, falls, nutritional status, dehydration, dental care, pressure ulcer, psychotropic drug use, and pain. R21's care plan initiated on [DATE], identified R21 at risk for dependence with activities of daily living (ADLs) related to activity intolerance, cognitive impairment, physical impairment, decreased muscle strength, imposed restrictions of movement, pain or discomfort, and reliance on an assistive device. R21 care plan lacked evidence of the following areas being identified in the care plan after being identified in the CAA: cognitive loss, visual function, urinary incontinence, psychosocial, wellbeing, behavioral symptoms, activities, falls, nutritional status, dehydration, dental care, pressure ulcer, psychotropic drug use, and pain. During an interview on [DATE] at 11:44 a.m., dietary manager (DM)-A confirmed R21 had a weight loss. DM-A indicated R21's weight was 148 pounds (lbs.) before being admitted to the hospital, and had a weight of 129 lbs. after returning from the hospital. R21 was started on a magic cup (supplement for weight loss) every day and a mighty sake (supplement for weight loss) once a day to help with the weight loss. DM-A confirmed it is important to have information regarding diet located in the care plan to inform staff in order to resident to receive appropriate diet recommendations. DM-A expectation would be for R21's care plan to be updated with the current changes. DM-A verified R21 care plan was not up to date. During an interview on [DATE] at 2:12 p.m., activity staff (AS)-A indicated R21 participated in one-to-one visits with staff in R21's room, but has not been participating in other activities out of his room and was unaware of other activities R21 would enjoy. During an interview on [DATE] at [DATE] at 2:14p.m., nursing assistant (NA)-A indicated all staff had access to the care plan, but NA-A had not viewed R21's care plan. NA-A was not aware R21 had depression or aware of interventions on how to assist R21 when experiencing depression symptoms. During an interview on [DATE] at 2:23 p.m., NA-B indicated she was unaware of R21 having a diagnosis of depression or interventions on how to assist R21 when having depression symptoms. NA-B indicated staff used a care sheet that identified how to care for each resident. NA-B pulled the care sheet out of her pocket, which identified R21 needed assistance with ADLs. NA-B indicated the care sheets had a category titled other/notes, if R21 was depressed or had special interventions, it would be listed there. The care sheet, other/notes did not identify R21 of having depression or interventions to help manage depression symptoms. During an interview on [DATE] at 12:08 p.m., MDS coordinator indicated the process was to write a comprehensive care plan after the initial MDS was completed. MDS coordinator confirmed the initial MDS was completed. MDS coordinator confirmed the comprehensive care plan was not completed and should have been completed. During an interview on [DATE] at 4:48 p.m., director of nursing designee confirmed R21's comprehensive care plan should have been completed per regulations. The director of nursing designee expected care plans to be completed on time for staff to know how to adequately care for residents. Requested policy on care plans however, did not receive one.

Based on interview and document review, the facility failed to ensure the required Notice of Medicare Non-coverage (NOMNC) form-10123 was provided 48 hours prior to discharge for 2 of 3 residents (R22 and R78), and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form-10055 was provided timely to 1 of 3 residents (R17) reviewed for liability notices and resident rights. Findings include: Review of R22's Physical Therapy (PT) discharge summary and Occupational Therapy (OT) discharge summary dated 5/21/24, indicated R22 no longer required PT and OT services. R22's NOMNC indicated R22's last covered day for Medicare Part A was 5/29/24, and the form-10123 was signed 5/28/24. Review of R78's Therapy Discharge Notification dated 9/4/24, indicated R78's last covered day was 9/4/24. R78's NOMNC indicated R78's last covered day for Medicare Part A was 9/3/24, and the form-10123 was signed 9/3/24. Review of R17's Therapy Discharge Notification dated 11/11/24, indicated R17's last covered day was 11/13/24. R17's SNFABN indicated R17 may be responsible to pay for services beginning 11/14/24, however R17 dated the form-10055 11/24/24. During an interview on 11/18/24 on 3:19 p.m., Minimum Data Set (MDS) coordinator confirmed the above findings and indicated she was responsible for completing both forms. MDS coordinator stated once a resident received a discharge notification from PT/OT, she would complete the forms. MDS coordinator indicated she was aware the forms needed to be provided at least 48 hours prior to the residents being discharged . MDS coordinator stated R17 put the wrong date on the form and it was supposed to be signed 11/11/24. MDS coordinator confirmed the signed date was incorrect, I actually just caught that too, I didn't realize it was signed incorrectly. MDS coordinator was not able to locate any documentation in R22 or R78's electronic health record that identified the forms were provided 48 hours prior to discharge. During an interview on 11/19/24 at 11:52 a.m., administrator confirmed the above findings and confirmed the MDS coordinator was responsible for providing the forms to the residents who were being discharged from therapy. The administrator stated his expectation were the forms would be provided at least 48 hours in advance so residents had enough time to complete an appeal if they decided to. The administrator indicated progress notes should been placed in the residents file in addition to confirm proper notice had been provided. Review of facility policy titled Medicare Denial Notice Policy undated, identified the facility would meet the requirements of the centers for Medicare and Medicaid services (CMS) for residents to be notified.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed for 2 of 2 residents (R21, R17) reviewed for care planning. Findings include: R21 R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition with diagnoses which consisted of atrial fibrillation, osteoarthritis, coronary artery disease. Identified R21 required limited assistance with bed mobility, transfers, and toilet use. R21's admission Care Area Assessment (CAA) dated 10/28/24, identified R21 required limited assistance with transfers, toilet use and dressing. R21's electronic health record (EHR) lacked a comprehensive care plan. R21's admission record, undated, identified R21 admitted to the facility on [DATE]. During an interview on 11/20/24 at 9:34 a.m., nursing assistant (NA)-A stated R21 required assistance with dressing and setup help with personal hygiene. NA-A stated she would ask a nurse if the care sheet did not provide direction on resident cares. During an interview on 11/20/24 at 2:14 p.m., licensed practical nurse (LPN)-A stated a registered nurse (RN) could update a care plan. LPN-A stated a resident's care plan would be circulated with the staff near care conference time to review and provide changes. 48583 R17 R17's significant change MDS dated [DATE], identified R17 was moderately cognitively impaired and had diagnoses which included a recent hip fracture, diabetes, and anxiety. Indicated R17 required extensive assistance with activities of daily living (ADLs). R17's significant change CAA dated 10/14/24, indicated R17 had a hip fracture, cognitive impairment, and anxiety. Identified R17 had pain, a recent surgical procedure, and poor nutrition. R17's care plan dated 10/29/24, lacked updated recommendations from occupational therapy and dietary. Review of R17's progress notes from 9/17/24 to 11/20/24, revealed the following: -10/7/2024, occupational therapy (OT) recommended R17 to have no bending at the hips past 90 degrees, no crossing legs, no twisting, and no lifting. -10/18/24, dietary manager indicated R17 would be offered high calorie snacks R17 preferred. R17 was to receive ice cream at every meal and toppings could be added if R17 requested them. Additionally, R17 was to receive a 120 cubic centimeters (cc) mighty shake. -9/17/2024, dietary manager indicated staff were to promote fluids with calories at all meals and increase supplement of choice to 120cc's two times a day. During an observation on 1/19/24 at 6:21 p.m., R17 was laying back in her recliner with her legs crossed. During an observation on 11/20/24 at 12:04 p.m., R17 was sitting in her recliner in her room eating lunch. R17 did not have ice cream as ordered on her lunch tray. During an interview on 11/20/24 at 12:27 p.m., registered dietician (RD) confirmed the above findings and indicated R17 was to have a high calorie shake, high calorie foods and high calorie snacks. RD indicated R17's high calorie shake was increased to two times a day (BID). RD stated R17 was to have ice cream with every meal and she was not made aware R17 was not receiving ice cream every meal. During an interview on 11/20/24 at 1:44 p.m., dietary manager (DM) indicated R17 was to have high calorie shakes and ice cream with every meal. During an interview on 11/20/24 at 3:06 p.m., Minimum Data Set Coordinator (MDSC) confirmed the above findings and indicated R17's care plan did not include the recommendations from OT or RD. MDSC stated it was important care plans contained the most up to date recommendations to facilitate person-center care. MDSC indicated it was important that care plans reflected the needs of the residents. During a follow-up interview on 11/20/24 at 3:14 p.m., MDSC verified after review of the EHR that R21 did not have a care plan. MDSC stated R21 was not on her list for a care plan review and that she did not have an audit system to ensure resident care plans were completed as required. During an interview on 11/20/24 at 4:15 p.m., director of nursing (DON) confirmed the above findings and stated her expectations were care plans were completed as required and contained the most up to date recommendations for residents. A facility policy on care plans was requested and one was not provided.

Based on observation, interview and document review, the facility failed to ensure accurate coding to reflect resident status on the Minimum Data Set (MDS) for 1 of 1 residents (R17) reviewed for assessments. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 10/23, identified Section J: Health Conditions was to be completed with the intent to document health conditions, such as falls, that impact a resident's functional status and quality of life. The manual indicated Previous falls, especially recurrent falls and falls with injury, are the most important predictor of future falls and injurious falls. Further, the manual provided several assessment steps including: Review all available sources for any fall since the last assessment . Include medical records generated in any health care setting since last assessment and It is important to ensure the accuracy of the level of injury resulting from a fall. R17's significant change Minimum Data Set (MDS) dated [DATE], identified R17 was moderately cognitively impaired and had diagnoses which included a recent hip fracture, diabetes, and anxiety. Indicated R17 required extensive assistance with activities of daily living (ADLs). R17's MDS Section J: Health Conditions dated 10/14/24, indicated the following: -Did the resident have a fall any time in the last month prior to admission/entry or reentry, checked no. -Did the resident have a fall anytime in the last 2-6 months prior to admission/entry or reentry, checked no. -Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry, checked no. -Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent, checked no. -Number of falls since Admission or Prior assessment - No Injury, checked none. -Number of falls since Admission or Prior assessment - Injury (except major), checked none. -Number of falls since Admission or Prior assessment - Major injury, checked none. R17's significant change Care Area Assessment (CAA) for falls dated 10/14/24, was not triggered for falls and was left blank. R17's care plan dated 8/28/24, indicated R17 had decreased physical mobility with potential for falls related to unsteadiness and pain. R17 had interventions to provide the assistance of one and front wheeled walker for transfers. R17 was to wear proper and non slip footwear. Review of facility incident reports revealed the following: -8/15/24, R17 rang her pendant and was found laying on her left side in front of her recliner. R17 stated she was trying to take herself to the bathroom. R17 further stated she raised her recliner a small amount, tried to grab her walker to stand and slid from the recliner to the floor. -8/30/24, R17 rang her pendent and stated she was on the floor. R17 was sitting barefoot with her back against the wall and her legs extended in front of her. R17's walker was to the left side of her. R17 stated she fell backwards while taking herself to the bathroom. -10/3/24, R17 rang her pendant and was found laying on the floor beside her bed. R17's four wheeled walker was tipped over beside her. R17 stated she was getting her pajamas off when she fell and landed on her left hip. R17 further stated she was unable to more her left leg. R17 was transported to the emergency room for evaluation. Review of R17's provider progress notes revealed the following: -10/3/24, R17 had been seen in the emergency room post fall on 10/3/24. R17's xray report indicated R17 had a left hip fracture and was admitted to the hospital. -10/4/24, R17 continued to be hospitalized and was scheduled for surgery on 10/5/24, to repair R17's left hip fracture. During an interview on 11/19/24 at 6:21 p.m., R17 stated she recently received a left hip fracture when she slipped and fell . R17 indicated she was standing at the head of the bed when she slipped and fell . During an interview on 11/19/24 at 6:28 p.m., family member (FM) stated R17 had fallen at the facility and sustained a left hip fracture. FM indicated R17 was planning to return home when she fell and now R17 would remain at the facility long term. During an interview on 11/20/24 at 3:32 p.m., RN-A reviewed R17's fall assessment dated [DATE], and confirmed in was completed incorrectly by RN-A. RN-A stated the assessments should been completed accurately. During an interview on 11/20/24 at 4:15 p.m., director of nursing (DON) confirmed the above findings and indicated she was not aware the assessment had been completed inaccurately. DON stated her expectation was assessments were completed correctly as required. Requested facility policy on completing assessments however, DON confirmed the facility did not have a policy on completing assessments.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R3 and R13) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations dated 3/15/2023, revealed older adults who received Pneumococcal conjugate vaccine (PCV13) at any age and Pneumococcal polysaccharide vaccine (PPSV23) before age [AGE] years, the CDC recommended they receive one dose of PCV20 or PPSV23. Review of R3's facesheet identified R3, age 79 was admitted to the facility on [DATE]. Review of R3's Minnesota Immunization Information Connection (MIIC) undated, identified R3 had received the PPSV23 on 11/01/1998, and 11/2/2006, and the PCV13 on 11/7/2016. R3's medical record lacked documentation R3 had been offered or received the PCV20 vaccine or an additional dose of PPSV23. Review of R13's facesheet identified R13, age 78 was admitted to the facility on [DATE]. Review of R13's MIIC undated, identified R13 had received the PPSV23 on 10/24/2002, and on 10/2/2009, and the PCV13 on 7/27/2016. R13's medical record lacked documentation R13 had been offered or received the PCV20 vaccine or an additional dose of PPSV23. During an interview on 12/19/23 at 8:34 a.m., infection preventionist (IP) confirmed R3 and R13 had not been offered or received the pneumococcal vaccines as recommended by the CDC. IP indicated she was aware of the new CDC guidelines from 3/23, however misunderstood the guidelines for those residents who had previously received both the PCV13 and PPSV23 vaccine. IP stated her expectation was the facility would offer and administer all vaccinations per CDC recommendations. During an interview on 12/19/23 at 8:45 a.m., director of nursing (DON) stated she was aware of the CDC guidelines from 3/23, and would review the guidelines again to assure she understood them. Review of a facility policy titled SNF Vaccination of residents-Influenza, pneumococcal, revised 10/26/23, indicated pneumococcal vaccinations would be offered and administered to all eligible residents as appropriate.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 3 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 12/18/23 at 11:07 a.m., in the north hallway, social services housekeeping manager (SS)-A exited the laundry room with the laundry cart uncovered and pushed the laundry cart down the west hallway. SS-A proceeded to R21's room, removed laundry from the uncovered cart, placed the laundry in R21's closet, exited R21's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R1's closet, exited R1's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R8's closet, exited R8's room with empty hangers and hung the hangers in the cart. SS-A pushed the uncovered cart down the hallway, removed laundry from the uncovered cart, placed the laundry in R4's closet, exited R4's room with empty hangers and hung the hangers in the cart. SS-A proceeded to R10's room, removed laundry from the uncovered cart, placed the laundry in R10's closet, exited R10's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R12's closet, exited R12's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R18's closet, exited R18's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R14's closet, exited R14's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R15's closet, exited R15's room with empty hangers and hung the hangers in the cart. SS-A removed laundry from the uncovered cart, placed the laundry in R15's closet, exited R15's room with empty hangers and hung the hangers in the cart. SS-A removed more laundry from the cart and placed in R15's closet. SS-A pushed the cart past the exercise group in the lounge area and returned it to the laundry room. SS-A did not sanitize her hands and the laundry cart remained uncovered during the entire observation. During an interview on 12/18/23 at 3:13 p.m., SS-A verified she removed clothes from the uncovered cart, placed them in the residents' closets, took back any hangers to the uncovered cart and did not sanitize her hands. SS-A verified the expectation of staff would be to sanitize hands on the way out of rooms or in the hallway and to keep the laundry cart covered. SS-A stated the purpose of keeping the cart covered and for completing hand hygiene was to prevent the spread of infection between residents. During an interview on 12/18/23 at 3:19 p.m., the director of nursing (DON) verified the expectation of staff delivering laundry was to keep the laundry cart covered during delivery and to complete hand hygiene in between. DON stated these practices were important to prevent contamination from the environment and cross contamination of surfaces. Review of a facility policy titled Laundry Washing/Deliver Policy dated 10/26/23, indicated laundry should be packaged, transported and stored in a manner that ensured cleanliness and protected the laundry from dust and soil. Clothing would be taken out of cart and covered again while unattended in the hallways. Laundry staff would sanitize hands on the way out of the resident room.

Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 2 residents( R11) reviewed for activities of daily living (ADL)'s. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had moderate cognitive impairment and had diagnosis which included hypertension (elevated blood pressure), Diabetes Mellitus (DM), and hemiplegia (paralysis of one side of the body). Identified R11 required extensive assistance with ADL's which included bed mobility, transfers, and personal hygiene. R11's current care plan revised 7/24/23, indicated R11 was dependent with ADL's which included dressing, bathing, and grooming. Indicated staff were to assist R11 with grooming daily. R11's resident care sheet revised 12/17/23, indicated R11 required staff assistance with hygiene. R11's comprehensive Care Area Assessment (CAA) dated 6/8/23, identified R11 required staff assistance with ADL's. During an observation on 12/17/23 at 10:57 a.m., R11 was seated in a recliner in his room and had several gray 1/2 inch long facial hairs present on his cheeks, chin and above his lips. During an interview on 12/17/23 at 11:03 a.m., R11 stated he required assistance from staff to shave. R11 stated he preferred to be shaved every day or when facial hair was present. R11 indicated he had not been shaved since last week. During an observation on 12/17/23 at 6:09 p.m., R11 was seated in a recliner in his room and continued to have several gray 1/2 inch long facial hairs present on his cheeks, chin, and above his lips. During an observation on 12/18/23 at 8:28 a.m., R11 was seated in the dining room and continued to have several gray 1/2 inch long facial hairs present on his cheeks, chin, and above his lips. During an interview on 12/18/23 at 9:07 a.m., nursing assistant (NA)-A stated R11 required staff assistance to shave facial hair. NA-A stated she had had not offered to assist R11 with shaving and was unsure the last time R11 had been shaved. During an interview on 12/18/23 at 9:11 a.m., licensed practical nurse (LPN)-A stated R11 required staff assistance to shave his facial hair. RN-A verified R11 had several long facial hairs and was unsure when the last time R11 had been shaved. LPN-A stated her expectation was R11 would have been shaved daily or when facial hair was present. During an interview on 12/18/23 at 1:10 p.m., director of nursing (DON) indicated R11 required staff assistance with shaving. DON stated her expectation was R11 would have been shaved daily or when facial hair was present. A policy for activities of daily living (ADL's) was requested however, one was not provided.

Based on interview and document review, the facility failed to ensure routine COVID-19 testing occurred for unvaccinated staff according to the community positivity rates identified in CMS (Centers for Medicare and Medicaid Services) guidelines. In addition, the facility failed to identify if any individuals providing services under arrangement or volunteers who were not up to date with COVID vaccinations were also routinely tested per CMS guidelines. This deficient practice had the potential to affect all 24 residents residing in the facility. Findings Include: CMS's Quality, Safety and Oversite Group (QSO) memo 20-38 for nursing homes dated 3/10/22, identified the long term care (LTC) facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. The memo indicated the facility must have procedures for addressing staff, including individuals providing services under arrangement and volunteers, who refuse testing or were unable to be tested . The QSO memo identified Facility staff included employees, consultants, contractors, volunteers, and caregivers who provided care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. For the purpose of testing individuals providing services under arrangement and volunteers, facilities should prioritize those individuals who were regularly in the facility (e.g., weekly) and had contact with residents. The memo instructed facilities to use their community transmission level as the trigger for staff testing frequency. The facility was expected to test all staff, who were not up-to-date, at the frequency prescribed in the Routine Testing table based on the level of community transmission. The Center for Disease Control and Prevention (CDC) identified the [NAME] county community transmission rate was substantial from 4/19/22, to 4/25/22. Review of the employee COVID-19 vaccination log, untitled, undated, identified the facility had a total of 41 staff. Nine of the 41 staff were not up to date and eight staff had religious exemptions. Review of the facility Staff Testing log from 2/3/22, to 5/2/22, identified the following: -nursing assistant (NA)-A was marked as no show for testing scheduled 2/7/22. -NA-B was marked as no show for testing scheduled 2/24/22. -licensed practical nurse (LPN)-A was marked as no show for testing scheduled 4/21/22. -NA-C was marked as no show for testing scheduled 4/18/22. The testing log lacked identification if facility staff were tested prior to working when they were marked no show for the scheduled dates for routing testing. In addition, the facility lacked documentation which identified any individuals providing services under arrangement in the facility who were not up to date for COVID vaccinations were routinely tested based on the community transmission level. Review of the facility Daily Assignment Sheets from 2/3/22, to 5/2/22, identified the following: -NA-A worked 2/10/22, three days after marked no show for testing scheduled 2/7/22. -NA-B worked 2/25/22, one day after marked no show for testing scheduled 2/24/22. -LPN-A worked 4/21/22, after marked no show for testing scheduled 4/21/22. -NA-C worked 4/20/22, two days after marked no show for testing scheduled 4/18/22. NA-A's COVID-19 vaccination records identified Pfizer vaccination was administered 6/4/21, and 6/25/21. NA-A's form titled Employee Declination Of COVID Booster Vaccination identified NA-A declined the COVID-19 booster vaccination on 11/3/21. NA-B's COVID-19 vaccination records identified Pfizer vaccination was administered 1/13/22. No second vaccination or booster vaccination records were received. On 5/5/22, Administrator confirmed by email NA-B had not received her second vaccination or the booster. LPN-A's Religious Accommodation Request Form dated 11/21/22, identified NA-B's request for exemption was signed 11/18/21, no approval signature or date identified. NA-C's COVID-19 vaccination records identified Moderna vaccination was administered 1/7/21, and 2/4/21. NA-C's form titled Employee Declination Of COVID Booster Vaccination identified NA-C declined the COVID-19 booster vaccination on 2/15/22. During an interview on 5/4/22, at 11:36 a.m. social service designee (SSD)-A stated she completed the staff testing logs. SSD-A confirmed she recorded staff testing performed on the scheduled testing days and verified when staff were tested by placing an X on the log. SSD-A indicated she did not keep track if staff worked after they missed the scheduled testing date. SSD-D stated she was not aware if staff were tested prior to working their next shift if they missed a testing date. During a follow-up interview on 5/4/22, at 12:57 p.m. SSD-A confirmed the facility only tracked testing for facility employees and therapists. SSD-A verified the facility did not track vaccination status or testing of any other contracted staff who were in the facility providing services. On 5/4/22, at 1:52 p.m. director of nursing (DON) confirmed SSD-A was responsible for ensuring all staff were tested for COVID-19 as required. DON indicated the facility's routine COVID-19 testing was completed based on the level of community transmission and the facility had been performing routine testing twice a week for the past two weeks. DON stated she would expect staff who had not completed routine testing on the scheduled date to be tested prior to their next scheduled shift. DON indicated the infection preventionist (IP)-A collected vaccination records of contracted staff and worked with SSD-A on the process. DON stated she would expect IP-A and SSD-A would assure staff who required testing had it completed according to the guidelines. DON confirmed the facility had no testing records of the contracted staff other than the pool staff. DON indicated proper testing of staff was important to prevent transmission of COVID-19 in the facility. On 5/4/22, at 2:27 p.m. IP-A confirmed she did not have records of contracted staff's COVID-19 vaccination status and indicated DON and Administrator were responsible for that. IP-A stated she was not responsible to assure COVID-19 testing was completed. The facility policy titled COVID-19 Testing Policy, undated, identified testing would be performed to reduce the risk for serious illness and death related to the COVID-19 pandemic. The policy identified the facility's routine testing intervals were based on the county COVID-19 level of community transmission. The policy further identified any staff that refused testing would not be allowed to work. The policy lacked identification of procedures to determine testing needs and results of individuals providing services under arrangement and volunteers. Additionally, the policy lacked identification of procedures for staff testing of individuals who did not complete testing on the facility scheduled testing dates as required.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 1 of 1 residents (R17) reviewed for allegations of abuse. In addition, the facility failed to protect the resident and report to the State Agency (SA) the results of the investigation within 5 working days for 1 of 1 allegations of abuse reviewed. Findings include: R17's admission Minimum Data Set (MDS) dated [DATE], indicated R17 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R17 required staff supervision for bed mobility, limited assistance of one staff for transfers, ambulation, dressing, toileting, personal hygiene, bathing and was independent with eating. Review of R17's Record of Grievance/Complaint form dated 4/2/22, revealed the following: -R17 wrote a complaint about nursing assistant (NA)-C stating she had her call light on because she required assistance with wiping. NA-C entered R17's room and asked R17 what she wanted, R17 said she told NA-C and NA-C replied what are you going to do when you go home, drag your butt across the floor? R17 indicated NA-C was often snarly with her. - The grievance form indicated the director of nursing (DON) investigated the complaint and R17 was interviewed and confirmed the complaint. The DON interviewed NA-C and NA-C admitted she asked R17 why she needed assistance and had encouraged R17 to participate in her cares. NA-C could not recall saying anything derogatory or sarcastic to R17. - The form identified NA-C would apologize to R17 for offending her and would proceed in assisting R17 when ever she called without question. Review of R17's medical record lacked any documentation of the SA being notified of the allegation of verbal abuse. On 5/4/22, at 1:59 p.m. the DON confirmed the above findings and indicated she had not considered the incident to be an allegation of abuse. The DON stated she had interviewed R17 and NA-C and confirmed she not spoke to other staff or residents to determine if there had been other allegations. The DON indicated the facility's usual practice was to ensure the resident was safe, remove the staff member from the floor, report the allegation to the SA and begin the investigation. The DON stated part of the investigation would be to interview other residents and staff and to submit the results of the investigation to the SA within 5 days. The DON confirmed NA-C had never been removed from the schedule during the investigation nor was there an investigation sent to the SA. On 5/4/22, at 2:31 p.m. the administrator confirmed the above findings and indicated he could not recall if he had been notified of the allegation involving NA-C. The administrator stated the facility's abuse process was to complete a grievance, report it immediately to the SA, investigate the allegation and submit the results of the investigation to the SA. The administrator indicated if the allegation involved a staff member they were to be removed from the schedule until the investigation was completed. Review of the facility policy titled, Abuse Prevention Plan revised on 1/28/21, Review of the facility policy titled, Abuse Prevention Plan revised on 1/28/21, indicated the facility would report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property immediately to the administrator of the facility and to other officials in accordance with State laws. The policy indicated the allegations would be reported immediately, but not later than two hours after the allegation had been made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours after the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with state law. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including the State survey and certification agency) within 5 working days of the incident, and if the alleged violation was verified appropriate action would be taken.

Based on observation, interview and document review the facility failed to ensure dignity was maintained for 1 of 1 resident (R13) who utilized an incontinent pad. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R13 required staff supervision with bed mobility, eating, limited assistance with transfers and extensive assistance of one staff for dressing, toileting, personal hygiene and bathing. The MDS identified R13 was occasionally incontinent of urine and continent of bowel and was not on a toileting program. R13's care plan revised on 5/3/22, indicated R13 required staff assistance with toileting tasks due to occasional incontinence of bladder and wore a brief. The care plan identified R13 was independent with mobility once up in her motorized scooter. During observations on 5/2/22, at 3:22 p.m. R13 was observed outside seated in her scooter smoking. A white incontinent pad was draped over R13's entire seat and hung down the sides of her scooter. The white incontinent pad was visible to other residents and visitors. - at 3:35 p.m. R13 re-entered the building independently and went to the commons area to sit where other residents were present. R13's white incontinent pad remained the same and was visible to other residents. - at 4:18 p.m. R13 was observed outside smoking seated in her electric scooter and the white incontinent pad remained the same. - at 4:20 p.m. R13 re-entered the facility and went to the commons area to sit where other residents were present. R13's white incontinent pad remained the same. - at 4:46 p.m. R13 was observed outside smoking and continued to have a white incontinent pad on the seat of her scooter visible to other residents and visitors. - at 4:51 p.m. R13 remained the same. During observations on 5/3/22, at 10:45 a.m. R13 was observed outside seated in her scooter smoking. A white incontinent pad was draped over R13's entire seat and hung down the sides of her scooter. The white incontinent pad was visible to other residents and visitors. - at 12:30 p.m. R13 was observed seated on her electric scooter out in the commons area with other residents present. R13's white incontinent pad remained the same. - at 1:43 p.m. R13 was observed seated on her electric scooter out in the dining room area with other residents while she looked at her cell phone. R13's white incontinent pad remained the same. - at 3:24 p.m. R13 was observed outside smoking and her white incontinent pad remained the same. During observations on 5/4/22, at 7:17 a.m. R13 exited her room in her electric scooter. R13's seat of her scooter had a white incontinent pad draped over the entire seat of her electric scooter and was visibly hanging down the sides of her scooter exposed for other residents and visitors to see. R13 wheeled down the hallway and went out side to smoke. - at 7:40 a.m. R13 was seated in the commons area on her electric scooter with other residents present. R13's white incontinent pad remained the same. - at 8:05 a.m. R13 was seated in the commons area on her electric scooter eating her breakfast independently with other residents present. R13's white incontinent pad remained the same. On 5/2/22, at 6:29 p.m. R13 indicated she was incontinent of urine at times and utilized incontinent products to mange it. R13 stated she disliked having the incontinent pad placed on the seat of her electric scooter since it hung down and looked awful. R13 stated she believed it did not look good at all to have the incontinent pad visible to others especially if people knew what the pads were used for. R13 expressed she especially felt that way when she was at a restaurant. On 5/4/22, at 11:32 a.m. nursing assistant (NA)-D stated R13 was incontinent of bladder at times, wore a brief and required staff assistance with toileting and incontinent brief changes. NA-D indicated R13 had an incontinent pad on the seat of her scooter to protect the cushion from becoming soiled in case she had an incontinent episode. NA-D stated the facility had different colored incontinent pads which could have been used instead of the white ones or disposable pads and indicated they all provided the same level of absorbency. On 5/4/22, at 10:06 a.m. registered nurse (RN)-B stated R13 was incontinent of urine and required staff assistance with personal hygiene and incontinent cares. RN-B indicated R13 used an incontinent pad on the seat of her scooter to prevent the seat of her scooter from becoming soiled. RN-B stated she was not certain if R13 had concerns about the white incontinent pad placed on the seat of her scooter being visible to other residents and visitors however indicated she had not asked R13 about it. RN-B confirmed the white incontinent pad was visible to other residents and visitors and verified it could have been a dignity issue for R13. On 5/4/22, at 11:59 a.m. the director of nursing (DON) stated R13 was incontinent of urine at times and wore a brief. The DON indicated R13 required staff assistance with toileting and pericares and was not aware R13 utilized an incontinent pad on the seat of her scooter. The DON stated the facility had different types of incontinent pads which had patterns on them and was not certain why staff chose to use the white pads. The DON confirmed use of an incontinent pad which was visible to other residents and visitors could be a dignity issue. The DON stated she would expect staff to use the right type of incontinent pad on the seat of R13's scooter to prevent it from being visible to other residents and visitors. Review of the facility policy titled, Resident Rights, Dignity and Privacy undated, indicated staff would promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality.

Based on interview and document review, the facility failed to immediately report to the administrator and no later than 2 hours, to the State Agency (SA) an allegation of staff to resident verbal abuse for 1 of 1 residents (R17) who was reviewed for allegations of abuse. Findings include: R17's admission Minimum Data Set (MDS) dated [DATE], indicated R17 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R17 required staff supervision for bed mobility, limited assistance of one staff for transfers, ambulation, dressing, toileting, personal hygiene, bathing and was independent with eating. Review of R17's Record of Grievance/Complaint form dated 4/2/22, revealed the following: -R17 wrote a complaint about nursing assistant (NA)-C stating she had her call light on because she required assistance with wiping. NA-C entered R17's room and asked R17 what she wanted, R17 said she told NA-C and NA-C replied what are you going to do when you go home, drag your butt across the floor? R17 indicated NA-C was often snarly with her. - The grievance form indicated the director of nursing (DON) investigated the complaint and R17 was interviewed and confirmed the complaint. The DON interviewed NA-C and NA-C admitted she asked R17 why she needed assistance and had encouraged R17 to participate in her cares. NA-C could not recall saying anything derogatory or sarcastic to R17. - The form identified NA-C would apologize to R17 for offending her and would proceed in assisting R17 when ever she called without question. Review of R17's medical record lacked any documentation of the SA being notified of the allegation of verbal abuse. On 5/2/22, at 4:05 p.m. R17 stated there had been an incident with NA-C who had not been very nice to her about three weeks ago. R17 indicated NA-C came into her room to assist R17 in the bathroom when NA-C stated what are you going to do when you get home,drag you butt across the floor? R17 confirmed NA-C's statement made her feel about an inch high and it hurt her feelings. R17 indicated the DON spoke with her, stated NA-C was having an off day and advised R17 not to take the statement personally. R17 stated the DON said she would speak with NA-C about the incident to obtain her view of the incident. In a follow up interview on 5/4/22, at 7:07 a.m. R17 indicated the incident made her feel like she was putting NA-C out when R17 asked her for assistance. R17 stated the incident had made her very upset and it made her heart hurt. R17 indicated NA-C was not nice and just did her job. R17 stated she felt she had been mentally abused by NA-C when she made that comment to her. R17 indicated she had informed registered nurse (RN)-B about the incident and was provided a grievance form to complete. On 5/4/21, at 10:15 a.m. RN-B indicated R17 wanted to file a grievance about a month ago regarding a statement NA-C made related to how R17 was going to manage independently when she went home. RN-B stated she was not able to remember the details however it had something to do with R17 requiring assistance in the bathroom. RN-B indicated R17 completed the grievance form and the form was turned in after RN-B had left for the day. On 5/4/22, at 10:37 a.m. NA-C stated she had entered R17's bathroom to assist R17 with toileting tasks. NA-C indicated a plan had been in place for R17 to return home soon and NA-C had asked R17 how she was going to manage those tasks when she returned home. NA-C stated the DON had asked her what had happened and she told her the same thing. NA-C indicated she had expressed a desire to go speak with R17 about the incident to the DON and the DON granted her permission to do so. NA-C stated she apologized to R17 the next day by herself and R17 informed her it was not what she said but how she had said it. NA-C confirmed she continued to work with R17 and other residents after the incident occurred and was not provided any education regarding the incident. On 5/4/22, at 1:59 p.m. the DON confirmed the above findings and indicated R17 had reported to her after she had placed her call light on, NA-C answered the call and asked R17 what she wanted. The DON indicated NA-C asked R17 what her plans were when she returned home as she would not have assistance at home. The DON stated R17 expressed she had an uneasy feeling related to the incident. The DON indicated she had spoke to NA-C the next day and NA-C stated she would apologize to R17. When reviewing the grievance form with the DON, the DON verified R17 was angry about the incident. The DON stated NA-C had worked at the facility for a significant amount of time so she had not considered the incident to be an allegation of verbal abuse. The DON indicated R17 completed a grievance form which described the incident. The DON confirmed the facility had not reported the incident to the SA. On 5/4/22, at 2:31 p.m. the administrator confirmed the above findings and indicated he could not recall if he had been notified of the allegation involving NA-C. The administrator stated the facility's abuse process consisted of the resident completing a grievance form and staff were expected to report the incident immediately. The administrator indicated if the allegation involved a staff member they would be taken off the schedule until the investigation was completed. The administrator indicated they review their grievances in the morning at the managers meeting everyday. Review of the facility policy titled, Abuse Prevention Plan revised on 1/28/21, indicated the facility would report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property immediately to the administrator of the facility and to other officials in accordance with State laws. The policy indicated the allegations would be reported immediately, but not later than two hours after the allegation had been made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours after the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with state law.

Based on observation, interview and document review, the facility failed to administer medication in a sanitary manner for 1 of 1 resident (R1) who was observed during a medication pass. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R1 had [DIAGNOSES REDACTED]. The MDS also indicated R1 required staff assistance and supervision with activities of daily living (ADL's). R1's current Electronic Medication Record (EMAR) was reviewed from 1/1/21 to 1/27/21 and revealed R1 was currently receiving [MEDICATION NAME] tablet 0.5 milligrams (mg) by mouth daily related to anxiety disorder and one [MEDICATION NAME] capsule by mouth daily related to colon health at 4:00 p.m. During observations on 1/25/21 at 3:10 p.m. R1 was seated at a table in the dining room area attending a resident council meeting and was actively participating. Registered Nurse (RN)-A entered the dining room area with a paper medication cup and a glass of supplement in her hand. RN-A approached R1, handed her the paper medication which contained her medications, R1 proceeded to dump the pills in her mouth as one fell down the front of her chest area and down onto the floor. RN-A picked up the pill off the floor and told R1 she would go get her a new one, R1 indicated she would just take that one and RN-A said ok. RN-A proceeded to use a used Kleenex setting on R1's walker in front of her and quickly wiped off the pill and handed to R1. R1 proceeded to take the pill independently and then took a drink of supplement. RN-A immediately left the dining room while R1 continued with her meeting. RN-A did not get R1 a new pill nor did she educate the R1 on why she should be given a new pill after it fell on the floor. On 1/25/21 at 7:18 p.m. RN-A confirmed the above finding and indicated she had given R1 two pills. RN-A indicated she gave R1 a [MEDICATION NAME] and [MEDICATION NAME]. RN-A indicated R1 wanted that pill and indicated she offered to get her a new one. RN-A verified she should of thrown the pill that fell on the floor away and should of gotten R1 a new medication pill. RN-A indicated this was odd to her but thought it was the resident's right to take the dirty pill and indicated this was an infection control issue. On 1/27/21 at 2:26 p.m. the director of nursing (DON) confirmed the above finding and indicated she would expect staff to pick up the pill, identify the pill and discard of the dropped pill appropriately. The DON also indicated she would expect staff to get R1 a new pill and to provide education to the resident about the pill being dropped and focusing on infection control based measures. The DON confirmed staff should not have given R1 the dirty pill after being dropped on the floor. Review of facility policy titled, Pharmacy Services revised on 4/2014, indicated medications are administered and prescribed in accordance with good nursing principals and practices and only by persons legally authorized to do so. Under section C number-4 the policy indicated medications dropped on the floor, use another dose from the medication supply and make a note on the MAR and the compromised medication shall be destroyed per facility policies and procedures.

Based on interview and document review, the facility failed to ensure an alleged violation of resident to resident physical abuse was immediately, and no later than two hours reported to the State Agency (SA) for 1 of 2 residents (R22) reviewed for allegations of abuse. Findings include: R22's admission Minimum Data Set (MDS) assessment dated [DATE], identified R22 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R22 required one to two staff assistance with most activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting, personal hygiene and bathing. R22's admission Care Area Assessment (CAA) dated 1/27/20, identified R22 had moderate cognitive impairment and had experienced a progressive decline over the past month. The CAA identified R22's mood was down, often refused cares and she had displayed verbal and physical behaviors towards staff. The CAA indicated R22 required assistance of one or two staff with transfers, ambulation and toileting. The CAA identified R22 informed staff during the interview five to six little old ladies had beat her up on the day of admission. R22's care plan revised on 3/23/20, identified R22 would be free from abuse and neglect. The care plan indicated R22 was confused to place and situation and was alert and oriented to self and time. The care plan identified R22 required assistance with dressing, grooming, bathing, transfers and toileting. R22's care plan indicated she had Anxiety and Depression and demonstrated physically and verbally abusive behavior at times during cares. Review of R22's progress notes from 1/15/21 through 1/25/21, included the following: On 1/16/20, at 10:27 a.m. MDS Coordinator identified R22 stated she had two watches missing and five or six little old ladies beat her up. R22 stated they were whaling on me. R22 stated the incident had happened on the day of admission. MDS Coordinator informed the administrator of the allegation. Review of the Nursing Home Incident Report (NHIR) submitted to the SA identified R22 stated she had two watches and $100 missing. Additionally, R22 stated five or six old ladies beat her across the hall and stated they kicked and scratched her on the day of admission. The NHIR identified the incident occurred on 1/16/20, at 11:00 a.m. and was reported to the SA on 1/16/20, at 2:04 p.m. over three hours after the incident occurred. On 1/27/21, at 11:48 a.m. in an interview MDS Coordinator reviewed R22's 1/16/20, 10:27 a.m. progress note and confirmed she had been informed by R22 at that time of the allegation of abuse. MDS Coordinator confirmed the allegation of abuse had not been submitted within the two hour time frame and was reported to the SA 3 1/2 hours after she learned of the allegation. MDS Coordinator she stated it had not been reported immediately because R22 had confusion and had made allegations in the past and MDS Coordinator believed it really had not happened. MDS Coordinator confirmed abuse could happen to confused residents too and stated the allegation should have been reported within the two hour time frame requirements. On 1/27/21, at 11:57 a.m. in an interview director of nursing (DON) stated it was expected all allegations of abuse be reported immediately and no later than two hours after the allegation occurred. The DON confirmed R22 stating she had been beat up by five or six little old ladies was a form of physical abuse. The DON confirmed the facility had not reported the allegation timely and verified the report was not made to the SA until 3 1/2 hours after the allegation had been made. The DON confirmed the report was made to the SA 1 1/2 hours late. The DON stated all staff are mandated reporters and any of the licensed nursing staff were able to submit a report to the SA. On 1/27/21, at 12:02 p.m. the administrator indicated the staff had an algorithm to refer to when an allegation of abuse was made. The administrator stated it was expected all allegations of abuse would be reported immediately and no later than two hours after the allegation was made. Review of facility algorithm titled Abuse, Neglect, or unexplained injury Reporting Decision Tree dated 11/16, instructed staff to report all allegations of abuse immediately, but not later than two hours after the allegation was made or after forming suspicion of. Review of facility policy and procedure titled Abuse Prevention Plan revised 2/5/20, instructed staff to report all abuse allegations immediately to the administrator and to the SA immediately but not later than two hours after discovery of the incident.

Based on observation, interview and document review the facility failed to ensure staff competency for common use glucometer which included infection control procedures for proper disinfection between residents. This deficient practice had the potential to affect 11 residents(R7, R21, R10, R9, R14, R17, R3, R2, R34, R11, R18) who currently received routine blood sugar testing with the facility common use glucometer. Findings include: On 1/8/19, at 5:50 p.m. trained medication aide (TMA)-B entered R10's room, applied gloves, then cleansed R10's middle finger with an alcohol swab, and used a lancet to poke the residents finger. TMA-B inserted a test strip into the glucometer, and obtain a blood sample from the resident. She then placed the glucometer with the contaminated test strip still inserted in the glucometer back in the black fabric and mesh zipper glucometer case with other blood glucose testing supplies which included lancets, test strip container, and alcohol swabs. TMA-B then controlled R10's bleeding, picked up the glucometer, removed the contaminated test strip and set the meter back in the case. She then removed her gloves and threw the gloves into the garbage. TMA-B sanitized her hands, and zipped the fabric glucometer case shut. She pushed R10's wheelchair out of the room and down the hall towards the dayroom. TMA-B stopped at the medication cart, placed the glucometer case on the medication cart, and continued to assist R10 into the dining room. TMA-B then returned to the medication cart, put on gloves, unzipped the fabric glucometer case, removed the glucometer, cleaned the glucometer and test strip container with a PDI Sani-wipe for an approximate combined 30 seconds. TMA-B removed her gloves, placed the glucometer back into the fabric case, zipped it shut, and stated she would go and get the next resident. On 1/8/19, at 5:55 p.m. TMA-B assisted R9 into the room, placed gloves on and opened an alcohol swab, and used it to clean the residents right middle finger. TMA-B then opened the glucose test strip container, and placed a test strip in the glucometer. TMA-B poked R9's with a disposable lancet, obtained a blood sample, and placed the meter on left side of cloth case with the test strip with the residents blood sample up in air. TMA-B used a cotton ball on R9's finger, grabbed the dirty blood glucose test strip with the residents blood sample on it and placed it in her glove, removed her gloves rolling the test strip inside, and threw them in the garbage. TMA-B then placed the glucometer in the fabric and mesh case, zipped it shut, and pushed R9 to the dining room. At 5:59 p.m. TMA-B walked back to the medication cart, and placed the glucometer case on top of cart. TMA-B then put on gloves and used a purple top PDI Super Sani-wipe to clean the glucometer for approximately 10 seconds, cleaned the strip container for about 10 seconds, set the glucometer and test strip container on the inside of the open fabric glucometer case, and removed her gloves and used hand sanitizer, and zipped the glucometer case shut. TMA-B then placed the closed glucometer case in the left side plastic pocket of medication cart. On 1/8/19, at 6:12 p.m. during an interview, TMA-B confirmed the glucometer on the medication cart was a common use glucometer, and stated it was used for multiple residents in the facility. TMA-B stated the above observation was her usual practice. On 1/10/19, at 7:44 a.m. TMA-A entered R9's room, applied gloves, unzipped glucometer case and laid it open directly on the residents bed linens. TMA-A then used a alcohol wipe to clean R9's finger, and used a disposable lancet, and poked the residents finger. TMA-A used her glove to wipe away the drop of blood on the resident finger, then obtained a blood sample on the glucometer test strip. TMA-A stated R9's blood glucose was 87, removed the test strip from the glucometer, removed her gloves, and put the glucometer back in the fabric glucometer case and zipped it shut. TMA-A brought the glucometer in its case back to the medication cart, and and placed it in the left pocket of the cart without cleaning or sanitizing it. At 7:57 a.m. the glucometer case remained zipped shut resting in the side pocket of the medication cart. TMA-A stated she had no more glucometer checks that morning, and verified the glucometer was used to check the blood glucose levels for multiple resident in the facility. TMA-A demonstrated disinfecting the glucometer between residents, and removed the dirty glucometer from the cloth black case and wiped down it with a PDI Super-Sani disinfecting wipe for 5-6 seconds, and stated she would repeat that process after each glucometer check. TMA-A placed the glucometer back in the black cloth case, zipped it shut, and placed it in the side pocket of the medication cart. TMA-A stated some staff wipe the glucometer down with a disinfecting wipe and then wrap the meter in a wet disinfecting wipe. TMA-A stated I don't wrap it in the disinfecting wipe because they have such harsh chemicals, and I don't want to damage the glucometer. TMA-A indicated she did not know why some staff wrap a wet disinfecting wipe around the glucometer, and stated I suppose, to show it had been cleaned. On 1/10/19, at 8:06 a.m. LPN-A stated her usual practice was to take the entire glucometer black cloth case into the residents room and set it down on a paper towel. LPN-A stated after checking the residents blood glucose level she would wipe the glucometer with a PDI Super-Sani disinfecting cloth for 2 minutes, and wrap the meter in a wet disinfecting wipe. LPN-A stated the glucometer needed to remain wet and in contact with the PDI Super-Sani disinfecting cloth for 3 minutes. LPN-A stated she recently had completed glucometer training and competency testing a few moths ago, and indicated the training included how to clean and disinfect the multi-use glucometer. A review of the facility provided staff educational materials and training materials from EduCare titled Blood Glucose Testing, dated (YEAR), indicated the learning objectives of the training was to: -Articulate the principals of blood glucose testing-the what, why, when, and how -Demonstrate the proper technique for blood glucose testing -Respond appropriately to low blood sugars The EduCare Knowledge Assessment, dated (YEAR), included questions on various topics of blood glucose testing, obtaining a blood sample, and response to an abnormal reading. The facility training/education, and knowledge assessment lacked any information on how to properly clean or disinfect the common use glucometer to prevent the spread of blood born pathogens. Review of facility provided staff education skills competency documentation titled Licensed Staff Skills Validation Checklist - Blood Glucose Monitoring, undated, revealed only 6 of 13 facility licensed nursing staff and TMA's had completed the competency training from 5/18/18, to 11/20/2018, and revealed no additional staff competency training was completed from 11/20/18, to 1/11/19. The staff skills checklist included multiple steps and techniques for obtaining a blood glucose sample, and operation of the Assure Prism glucometer. In addition, the checklist included a steps for infection control and maintenance of the glucometer which required staff to demonstrate/explain proper handling of blood glucose monitoring equipment using standard precautions, but failed to provide any instructions for proper cleaning and disinfection of the common use glucometer. On 1/10/19, at 8:18 a.m. DON stated she would expect the glucometer to be properly cleaned between every resident use with a wet contact time of 2 minutes according to PDI Super Sani-wipes manufactures guidelines. The DON stated information for disinfecting the common use glucometer between residents was completed in EduCare training upon hire. The DON stated she was in process of completing a skills audit and competency with return demonstration for staff, but indicated not all the staff who obtain blood glucose samples in the facility had completed the training and skills competency. The DON stated the glucometer training and skills competency began on 5/18/18. The DON verified the facility had always used a common use glucometer, and stated the current Assure Prism model has been in use in the facility for over 1 year. On 1/11/19, at 8:46 a.m. IC-RN indicated they had been working on staff training and competency testing, and stated she had assisted with completing the training with a few of the staff. IC-RN stated all staff should be aware of the required 2 minute wet contact time to disinfect the common use glucometer. Review of the facility provided, Assure Prism User Instruction Manual, dated 11/2015, indicated on page 4 all parts of the glucometer should be considered potentially infectious and was capable of transmitting blood-borne pathogens between residents and healthcare professionals. The manual further indicated the section titled Cleaning and Disinfecting Procedures: instructed the user to wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a wipe approved to clean blood and body fluids. The section titled Disinfecting instructed the user to allow the exterior of the meter to remain wet for the corresponding contact time for each disinfectant. Review of the manual's tested disinfecting wipes indicated PDI Super Sani-wipes was an approved disinfecting wipe. Review of the facility disinfecting, PDI Super Sani-wipes manufactures guidelines product label, under directions, To Disinfect revealed the surface to be cleaned needed to remain wet for a full two(2) minutes. Review of facility policy, Evansville Care Campus - Disinfection of Blood Glucose Monitors, undated, indicated the purpose of disinfecting the common use glucometer was to reduce and prevent the spread of infectious agents between residents. The policy directed staff to disinfect the glucometer after each use. The procedure included steps for wiping the glucometer with the designated wipe, and instructed staff to provide disinfection contact time per chemical recommendations. The policy instructed staff to follow the manufacturer's recommendation for disinfection.

Based on observation, interview and document review the facility failed to ensure proper hand hygiene was maintained for 2 of 2 residents (R21, R33) observed for personal cares. In addition, the facility failed to ensure proper infection control practices were implemented for 1 of 1 residents (R18) observed to receive first aid. In addition, the facility failed to ensure the common use blood glucometer machines were properly disinfected according to manufacture's recommendation after resident use for 2 of 2 residents (R9, R10) observed for glucometer use, which had the potential to effect 11 residents (R7, R21, R10, R9, R14, R17, R3, R2, R34, R11, R18) who received blood glucose testing with the multi-use glucometers . Findings Include: R33's 14-day Minimum Data Set (MDS), dated [DATE], identified R33 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R33 required extensive assistance with all areas of daily living (ADL) and did not walk in the corridor during the assessment period. On 1/10/19, at 8:54 a.m. R33 was in room, nursing assistant (NA)-A and NA-B assisted each other to apply the standing lift harness. NA-B secured the harness to the lift and activated lift to bring R33 to a standing position. NA-A donned gloves, checked R33's incontinent brief for incontinence and then removed it. NA-A cleansed R33's perineal area with wet wipes, doffed the gloves and with NA-B's assistance reapplied a clean brief. NA-A continued to provide cares for R33 without sanitizing his/her hands. NA-A pulled R33's pants up, pushed the controls on the foot board of the bed to adjust the height and head of the bed, then arranged the pillows on the bed, and adjusted the lift sheet. NA-B maneuvered the lift and sat R33 down on to the bed. Without sanitizing his/her hands, NA-A continued removed the lift harness and unbuckled the leg strap. NA-A again, adjusted the bed height with the use of the buttons on the foot board of the bed, placed a noodle under the bed linens on the out side of R33's bed, tucked a pillow under R33, on the right side, and clipped the call light on to the blanket near R33's hands. NA-A gathered the garbage and carried it out of R33's room to the utility room where it was placed in a covered bin. NA-A then washed his/her hands in the utility room sink. On 1/10/19, at 9:02 a.m. NA-A verified his/her usual practice as described above. NA-A indicated hands were washed prior to donning gloves, then gloves are removed after providing peri cares, then all other tasks are completed for the resident, and hands were washed after all tasks are done/before moving on to another resident. On 1/11/19, at 9:46 a.m. the infection control-registered nurse (IC-RN), identified the expectation that staff wash their hands when they enter a residents room, or use hand sanitizer prior to donning gloves. The ICN indicated following provision of perineal cares, before moving on to a clean area, staff were expected to remove the gloves and either wash their hands or use a hand sanitizer to prevent cross contamination. On 1/11/19, at 10:46 a.m. the director of nursing (DON) verified the usual facility policy for staff providing incontinent cares as follows: Complete hand hygiene, apply gloves, peri care provided wiping front to back, removed gloves, complete hand hygiene with soap and water or hand sanitizer, apply new brief, pull up pants, place the resident in a safe place, complete hand hygiene again with hand sanitizer or soap and water. The undated facility policies titled, Hand washing Policy and Alcohol - Based Hand Rub Policy, identified the policy was to prevent the spread of infections from one resident to another, to protect staff from infections, to prevent the transfer of communicable diseases, and to prevent the spread of infections through blood and body secretions. R21 R21's quarterly MDS, dated [DATE], identified R21 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS further identified R21 required extensive assistance with all activities of daily living. R21's care plan, last reviewed 12/4/18, identified R21 required assistance for the physical process of toileting, related to weakness and unsteadiness. R21's care plan instructed staff to assist with transferring to toilet and provide perineal cares. On 1/10/19, at 8:11 a.m. R21 was in the bathroom with NA-B providing assistance. R21 had a bowel movement while seated on the toilet. The toilet was in between the wall, to R21's right side and the sink to the left. NA-B applied gloves, then assisted R21 to stand up. NA-B performed R21's perineal cares with the right gloved hand, while she held onto the gait belt around R21's waist with the left hand. NA-B instructed R21 to sit back down while she held onto the gait belt, then removed the right hand glove. NA-B applied a new incontinence brief to R21 while seated. Without sanitizing her hands, NA-B then applied a new glove to the right hand, R21 stood again with cuing and assistance, while NA-B completed perineal cares. NA-B pulled up R21's brief and pants, removed the gloves, and assisted R21 to walk from the bathroom to the dining room while she held the gait belt with her right hand and held R21's left hand with her left hand. NA-B assisted R21 to sit down in a chair near the dining room table and removed the gait belt. NA-B took a clothing protector off the table in front of R21, applied it over the front of his shirt, then secured it behind his neck. NA-B then returned to R21's bathroom, applied gloves, secured two plastic garbage bags, then placed a new bag in the garbage can. NA-B brought the garbage bags to the soiled utility room and placed them in a large garbage container. NA-B removed her gloves then washed her hands in the soiled utility room sink. On 1/10/19, at 8:26 a.m. NA-B confirmed she removed her gloves after completing perineal cares for R21, then walked R21 to the dining room without completing hand hygiene. NA-B indicated her usual process was to wash her hands before she touched anything in the dining room. NA-B further indicated her usual practice was to complete hand washing after she assisted residents to a location then helped them sit down. NA-B indicated she felt if she completed hand hygiene when she removed her gloves, R21 would walk off or fall. NA-B indicated she had been provided annual training for hand hygiene, but she had not had competency observations completed with her. On 1/10/19, at 8:52 a.m. DON indicated her expectations were for staff to complete hand hygiene between residents and to use soap and water anytime they were visibly soiled. DON indicated her expectation was for hand hygiene to be performed before and after gloves were used. DON confirmed hand sanitizer was available for staff to carry, in each resident's rooms and each bathroom had a sink to use for handwashing. DON confirmed the staff received hand hygiene training when they were hired and annually. DON confirmed not all staff had competency observations for hand hygiene completed, but the facility was in the process of completing competency training for all. R18 R18's quarterly MDS dated [DATE], identified R18 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS further identified, R18 required extensive assistance with dressing and personal hygiene, and had no skin problems. R18's care plan, last reviewed 12/10/18, identified R18 had chronic progressive decline in intellectual functioning characterized by deficit in memory, judgement and decision making and thought process related to dementia. R18's care plan further identified a potential for alteration in skin integrity and included instructions to monitor for open areas. On 1/8/19, at 2:54 p.m. R18 was seated in a cloth armed chair in the sitting area near the nurses desk. R18 had a small scab on the top of his left hand. R18 scratched the scab off with his left hand, which resulted in a small drop of blood. R18 held his hand up to surveyor, looked at his hand and said little devil. At 3:04 p.m. surveyor notified activities director (AD)-A of the wound. R18's hand had a small amount of blood on his hand, which he showed to AD-A, then he wiped the top of his hand onto the front of the left arm of the chair. AD-A notified LPN-B. LPN-B approached R18 and informed him she had needed to wash her hands, and was going to put a band-aid on the wound. LPN-A applied the band-aid, without prior cleansing of the area and did not wear gloves. AD-A returned and cleansed the front of the chair with a sanitizing wipe and towel. On 1/10/19, at 4:12 p.m. during a phone interview, LPN-B indicated she did not wash R18's wound on the top of his hand prior to applying the band aid, and did not wear gloves. LPN-B indicated her usual practice for wound care depended on the situation. LPN-B indicated she was aware R18 picked his scabs and her usual practice was to just put a band-aid on it. LPN-B indicated she felt just applying a band-aid would be fine. LPN-B indicated if there was a large amount of blood or if she needed to clean up blood she would apply gloves. On 1/11/19, at 9:30 a.m. DON indicated she would expect first aid to be completed if a resident picked a scab. DON indicated she would expect the area to be evaluated, cleansed then to apply the appropriate dressing. DON also indicated she would expect gloves to be worn, and the incident documented in R18's health record. On 1/8/19, at 5:50 p.m. trained medication aide (TMA)-B entered R10's room, applied gloves, then cleansed R10's middle finger with an alcohol swab, and used a lancet to poke the residents finger. TMA-B inserted a test strip into the glucometer, and obtain a blood sample from the resident. She then placed the glucometer with the contaminated test strip still inserted in the glucometer back in the black fabric and mesh zipper glucometer case with other blood glucose testing supplies which included lancets, test strip container, and alcohol swabs. TMA-B then controlled R10's bleeding, picked up the glucometer, removed the contaminated test strip and set the meter back in the case. She then removed her gloves and threw the gloves into the garbage. TMA-B sanitized her hands, and zipped the fabric glucometer case shut. She pushed R10's wheelchair out of the room and down the hall towards the dayroom. TMA-B stopped at the medication cart, placed the glucometer case on the medication cart, and continued to assist R10 into the dining room. TMA-B then returned to the medication cart, put on gloves, unzipped the fabric glucometer case, removed the glucometer, cleaned the glucometer and test strip container with a PDI Sani-wipe for an approximate combined 30 seconds. TMA-B removed her gloves, placed the glucometer back into the fabric case, zipped it shut, and stated she would go and get the next resident. On 1/8/19, at 5:55 p.m. TMA-B assisted R9 into the room, placed gloves on and opened an alcohol swab, and used it to clean the residents right middle finger. TMA-B then opened the glucose test strip container, and placed a test strip in the glucometer. TMA-B poked R9's with a disposable lancet, obtained a blood sample, and placed the meter on left side of cloth case with the test strip with the residents blood sample up in air. TMA-B used a cotton ball on R9's finger, grabbed the dirty blood glucose test strip with the residents blood sample on it and placed it in her glove, removed her gloves rolling the test strip inside, and threw them in the garbage. TMA-B then placed the glucometer in the fabric and mesh case, zipped it shut, and pushed R9 to the dining room. At 5:59 p.m. TMA-B walked back to the medication cart, and placed the glucometer case on top of cart. TMA-B then put on gloves and used a purple top PDI Super Sani-wipe to clean the glucometer for approximately 10 seconds, cleaned the strip container for about 10 seconds, set the glucometer and test strip container on the inside of the open fabric glucometer case, and removed her gloves and used hand sanitizer, and zipped the glucometer case shut. TMA-B then placed the closed glucometer case in the left side plastic pocket of medication cart. On 1/8/19, at 6:12 p.m. during an interview, TMA-B confirmed the glucometer on the medication cart was a common use glucometer, and stated it was used for multiple residents in the facility. TMA-B stated the above observation was her usual practice. On 1/10/19, at 7:44 a.m. TMA-A entered R9's room, applied gloves, unzipped glucometer case and laid it open directly on the residents bed linens. TMA-A then used a alcohol wipe to clean R9's finger, and used a disposable lancet, and poked the residents finger. TMA-A used her glove to wipe away the drop of blood on the resident finger, then obtained a blood sample on the glucometer test strip. TMA-A stated R9's blood glucose was 87, removed the test strip from the glucometer, removed her gloves, and put the glucometer back in the fabric glucometer case and zipped it shut. TMA-A brought the glucometer in its case back to the medication cart, and and placed it in the left pocket of the cart without cleaning or sanitizing it. At 7:57 a.m. the glucometer case remained zipped shut resting in the side pocket of the medication cart. TMA-A stated she had no more glucometer checks that morning, and verified the glucometer was used to check the blood glucose levels for multiple resident in the facility. TMA-A demonstrated disinfecting the glucometer between residents, and removed the dirty glucometer from the cloth black case and wiped down it with a PDI Super-Sani disinfecting wipe for 5-6 seconds, and stated she would repeat that process after each glucometer check. TMA-A placed the glucometer back in the black cloth case, zipped it shut, and placed it in the side pocket of the medication cart. TMA-A stated some staff wipe the glucometer down with a disinfecting wipe and then wrap the meter in a wet disinfecting wipe. TMA-A stated I don't wrap it in the disinfecting wipe because they have such harsh chemicals, and I don't want to damage the glucometer. TMA-A indicated she did not know why some staff wrap a wet disinfecting wipe around the glucometer, and stated I suppose, to show it had been cleaned. The facility provided a list of current residents who received routine blood sugar testing with the facility common use glucometer which included 11 residents (R7, R21, R10, R9, R14, R17, R3, R2, R34, R11, R18). On 1/10/19, at 8:18 a.m. DON stated she would expect the glucometer to be properly cleaned between every resident use with a wet contact time of 2 minutes according to PDI Super Sani-wipes manufactures guidelines and confirmed the facility utilized Assure Prism glucometers. On 1/11/19, at 8:46 a.m. IC-RN stated the common use glucometer needed to be cleaned between resident use and staff should use PDI Super Sani-wipes, with a 2 minute wet contact time per manufactures guidelines. IC-RN stated the disinfection process needed to be followed to prevent spread of blood-borne pathogens. IC-RN stated all staff should be aware of the required 2 minute wet contact time to disinfect the common use glucometer. Review of the facility provided document titled, Assure Prism User Instruction Manual, dated 11/2015, indicated on page 4 all parts of the glucometer should be considered potentially infectious and was capable of transmitting blood-borne pathogens between residents and healthcare professionals. The manual further indicated the section titled Cleaning and Disinfecting Procedures: instructed the user to wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a wipe approved to clean blood and body fluids. The section titled Disinfecting instructed the user to allow the exterior of the meter to remain wet for the corresponding contact time for each disinfectant. Review of the manual's tested disinfecting wipes indicated PDI Super Sani-wipes was an approved disinfecting wipe. Review of the facility disinfecting, PDI Super Sani-wipes manufactures guidelines product label, under directions, To Disinfect revealed the surface to be cleaned needed to remain wet for a full two(2) minutes. Review of facility policy, Evansville Care Campus - Disinfection of Blood Glucose Monitors, undated, indicated the purpose of disinfecting the common use glucometer was to reduce and prevent the spread of infectious agents between residents. The policy directed staff to disinfect the glucometer after each use. The procedure included steps for wiping the glucometer with the designated wipe, and instructed staff to provide disinfection contact time per chemical recommendations. The policy instructed staff to follow the manufacturer's recommendation for disinfection.

Based on interview and document review , the facility failed to provide the required notices when residents discharged from a Medicare Part A stay for 3 of 3 residents (R20, R4, R200) reviewed who remained in the facility. Findings include: R20's CMS- form, Medicare Part A listed services started 9/19/18, and the last covered day of Part A service was 10/3/18. The form indicated the denial notice given when skilled level of care ended. R20 remained in the facility after 10/3/18. R20's record review revealed the facility provided a form titled CMS- , Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), which explained that the services provided would no longer be covered under Medicare beginning 10/4/18. R20's record lacked evidence the Notice of Medicare Non-Coverage (NOMNC) had been provided to the resident or resident representative. R4's CMS- form, Medicare Part A listed services started 6/5/18, and the last covered day of Part A service was 7/30/18. The form indicated the denial notice given discharge end of skilled services. R4 remained in the facility after 7/30/18. R4's record review revealed the facility provided a form titled CMS- , Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), which explained that the services provided would no longer be covered under Medicare beginning 7/30/18. R4's record lacked evidence the facility had provided the Notice of Medicare Non-Coverage (NOMNC) to the resident or resident representative. R200 discharged from the facility on 10/5/18 and had received Medicare Part A services until 10/4/18. R200's record lacked evidence the facility had provided the SNFABN. On 1/9/19, at 1:59 p.m. the Minimum Data Set coordinator (MDSC) stated she shared responsibility of providing the beneficiary notices when Medicare part A services were ending. The MDSC verified the above findings. The MDSC stated the usual facility practice was to provide the resident with only the SNFABN for residents were were discharging from skilled services and remained in the facility. The MDSC indicated she thought the SNFABN was all inclusive document with no further forms needed when providing Medicare A denials. The MDSC further verified residents who come to the facility for skilled services with the plan to go home, were not given the SNFABN nor the NOMNC form when a skilled services end date is determined. The requested facility policy was not provided.

Based on interview and document review, the facility failed to ensure an alleged violation of resident to resident abuse was immediately reported to the administrator and immediately, no later than two hours, reported to the State agency (SA) for 1 of 3 residents (R34) for allegations of abuse. Findings include: R34's admission Minimum Data Set (MDS), dated [DATE], indicated R34 had severely impaired cognition and [DIAGNOSES REDACTED]. The MDS also indicated R34 required supervision with bed mobility, transfers, walking, and eating, as well as, extensive assistance with dressing, personal hygiene and toilet use. R34's MDS further indicated verbal and other behavioral symptoms which occurred one to three days that put R34 at significant risk for physical illness or injury and significantly interfered with R34's care. R34's care plan, last reviewed 11/20/18, identified R34 had a history of [REDACTED]. It indicated R34 was resistive with cares at times, became belligerent with staff and had a history of [REDACTED]. R34's care plan listed various interventions which included monitoring interaction of R34 with others for appropriateness, monitoring target behaviors, reporting to doctor if no improvement or an increase in behaviors, and when R34 was refusing cares or angry/upset to leave in a safe place and return a few minutes later and try again. Review of untitled incident report #863, dated 6/1/18, at 6:00 p.m. identified the alleged incident was witnessed by trained medication aid (TMA)-A. The report indicated R34 became agitated at another resident (R5) in the dining room, because R5 backed up his/her wheelchair and ran into R34 and the table R34 was seated at. The report indicated R34 then stood up, pushed R5's wheelchair and then punched R5 on the top of left shoulder. The report further indicated the facility administrator was notified of the alleged incident on 6/2/18, at 1:35 p.m., a total of 19 hours and 35 minutes after the alleged incident. Review of Incident Report Summary, dated 6/2/18, indicated at 6:14 p.m. the facility reported to the SA an allegation of physical abuse of hitting or punching which occurred on 6/1/18, at 6:00 p.m. between R34 and R5. The SA was notified of the alleged resident to resident abuse 24 hours and 14 minutes after the alleged incident. On 1/10/19, at 11:22 a.m. TMA-A stated R34 had dementia and his mood could change quickly and get agitated. She indicated the normal process when a resident to resident altercation was witnessed was to keep all residents safe and separate the affected residents, check for injuries and report to the charge nurse. TMA-A stated abuse was reported to the administrator and SA within 24 hours, unless there was injury, then the report would be done immediately. On 1/10/19, at 11:57 a.m. licensed practical nurse (LPN)-A stated R34 could be aggressive, but responded well to one on one supervision and reapproaching. LPN-A stated if a resident to resident altercation was reported, staff would separate the residents, and keep all residents safe. LPN-A indicated the administrator would be called after the alleged incident, but believed the abuse report to the SA was reportable in 24 hours. On 1/10/19, at 4:05 p.m. the administrator stated the facility reported all alleged abuse, which included resident to resident abuse. The administrator stated abuse was reported to the SA immediately after staff notify him. He indicated the normal abuse reporting procedure was staff contacted the administrator and are given direction to either report the allegation to the SA or not. If the facility was reporting to the SA, the staff followed step by step directions located near the nurse's station. The administrator reviewed untitled incident report #863, dated 6/1/18, and confirmed the date and time he was updated, and could not recall why there was a delay in his, or the SA notification. Review of the facility's policy titled Abuse Prevention Plan, undated, revealed the facility staff were to report all alleged abuse to the facility administrator and the SA immediately. However, the facility's policy failed to include that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures prior to the start of the investigation.

Based on interview and record review, the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of an emergency transfer for 2 of 2 resident (R33, R34), reviewed for hospitalization . Findings include: R33's 14 day Minimum Data Set ((MDS) dated [DATE], identified R33 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R33 required extensive assistance with all areas of daily living (ADL) and did not walk in the corridor during the assessment period. Review of R33's progress notes from 12/9/18, to 12/10/18, revealed: -12/9/18, 33's respiratory symptoms of cough and headache progressed quickly to a fever of 102.9, crackles in the lungs and decreased oxygen saturation. Facility staff called the physician on call at the hospital, who gave the order to transport R33 to the hospital via ambulance. -12/9/18, R33 was admitted to the hospital with [REDACTED]. -12/10/18, the social services designee (SSD) spoke with R33's sister and she would like the facility to hold the room for R33 while he is at the hospital. Review of R33's clinical record identified a form titled, history and physical examination [REDACTED]. The form identified R33 was transitioned to the hospital this morning after he demonstrated a very harsh cough, some [MEDICAL CONDITION] and increased work of breathing and high fever. The form further identified R33 was admitted to the hospital with [REDACTED]. A form titled Inpatient Discharge Summary, date of service 12/12/18, identified a hospital admission date of [DATE], for acute hypoxemic [MEDICAL CONDITION] relating to pneumonia, probable aspiration, with a discharge date of [DATE]. On 1/11/19, at 9:51 a.m. the social services designee (SSD) indicated she was responsible to provide residents the information regarding bed holds. The SSD indicated residents were given information regarding bed holds on admission and if the resident is admitted to the hospital, the resident or representative was offered a bed hold. The SSD verified R33 was admitted to the hospital on [DATE], and the bed hold was given 12/10/18. The SSD identified R33 was transferred by ambulance at 4:45 a.m. which was a Sunday. The SSD identified resident admitted to the hospital on a Saturday or Sunday are provided bed holds on Monday when the SSD returned to work. On 1/11/19, at 10:49 a.m. the director of nursing (DON) identified residents and families receive and sign the bed hold information on admission. The DON identified when a resident was admitted to the hospital, the facility called the family to offer the bed hold. DON did not offer any further information regarding R33. R34 R34's admission Minimum Data Set (MDS), dated [DATE], indicated R34 had severely impaired cognition and [DIAGNOSES REDACTED]. The MDS also indicated R34 required supervision with bed mobility, transfers, walking, and eating, as well as, extensive assistance with dressing, personal hygiene and toilet use. R34's MDS further indicated verbal and other behavioral symptoms which occurred one to three days that put R34 at significant risk for physical illness or injury and significantly interfered with R34's care. Review of R34's progress notes from 12/1618, revealed: -12/16/18, R34 attempted to stand up in room from wheelchair and fell . R34 hit head on guest chair in room and landed on right side. Facility staff called hospital to update physician and received an order to transport to hospital for evaluation. R34 was sent to hospital via ambulance. There was no indication the bed hold policy had been reviewed with family or resident prior to transfer to the hospital. On 1/8/19, at 3:06 p.m. family member (FM)-A stated R34 had a fall on 12/16/18, and due to a recent [MEDICAL CONDITION] repair, FM-A wanted R34 evaluated by a physician. FM-A indicated they were unsure if the facility offered a bed hold for the facility initiated transfer on 12/16/18. On 1/10/19, at 11:22 a.m. trained medication aide (TMA)-A stated nursing staff was not responsible for offering a bed hold, as the social service designee (SSD) completed the bed holds for the facility. On 1/10/19, at 11:57 a.m. licensed practical nurse (LPN)-A stated if a resident's family were in the facility at the time of transfer then nursing staff would offer a bed hold, if not the SSD completed the process. LPN-A indicated the bed hold information used to be offered by the nursing staff at the time of transfer, however SSD was now completing. On 1/10/19, at 12:18 p.m. SSD indicated the process for offering bed hold information was a form in the admission packet was reviewed and signed on admission, and if a resident went to the hospital, she would call the resident or resident representative and ask if they want to hold the bed. SSD indicated if a resident was to transfer to the hospital on a Friday evening, she would call the resident or representative on Monday, when she returned to work. SSD confirmed bed hold notifications were not done at the time of transfer, but when SSD was working Monday through Friday. SSD reviewed R34's medical record and confirmed no bed hold information was offered to R34 on 12/16/18, as R34 went to the emergency room and came back the same day. SSD stated she would not offer bed hold information to a resident who was transferred to the emergency department and returned the same day. On 1/10/19, at 4:01 p.m. the administrator stated all residents are offered bed hold information by nursing staff when they transfer, and SSD calls the resident or representative to follow up. The administrator stated bed hold information should be offered on emergency and acute care transfers. He stated his expectation would be if a resident went to the emergency room , bed hold information would be offered. Review of the policy titled, Bed Hold Policy, undated, indicated the following: According to the Federal Resident Bill of Rights as of (MONTH) 1, 1993, Evansville Care Campus must inform you of the bed hold and readmission policy at the time of a hospital or therapeutic leave.

Based on interview and document review, the facility failed to notify the Long Term Care (LTC) Ombudsman of a facility initiated transfer for 1 of 2 residents (R34) reviewed for hospitalization . Findings include: R34's admission Minimum Data Set (MDS), dated [DATE], indicated R34 had severely impaired cognition and [DIAGNOSES REDACTED]. The MDS also indicated R34 required supervision with bed mobility, transfers, walking, and eating, as well as, extensive assistance with dressing, personal hygiene and toilet use. R34's MDS further indicated verbal and other behavioral symptoms which occurred one to three days that put R34 at significant risk for physical illness or injury and significantly interfered with R34's care. Review of R34's progress notes from 12/12/18, to 12/1618, revealed: -12/12/18, facility received call from nurse at hospital with R34's updated status: R34 fractured left hip and would be transferred to another hospital for further treatment. There was no indication the Ombudsman had been notified of R34's transfer to the hospital. -12/14/18, R34 was readmitted to facility for LTC placement after hospitalization for left [MEDICAL CONDITION] repair. -12/16/18, R34 attempted to stand up in room from wheelchair and fell . R34 hit head on guest chair in room and landed on right side. Facility staff called hospital to update physician and received an order to transport to hospital for evaluation. R34 was sent to hospital via ambulance. There was no indication the Ombudsman had been notified of R34's transfer to the hospital. On 1/10/19, at 12:18 p.m. social service designee (SSD) indicated she was unaware of the facility's process for updating the LTC Ombudsman as it was a nursing department duty. On 1/10/19, at 12:30 p.m. director of nursing (DON) stated the facility practice was LTC Ombudsman was updated each time a resident left the building for acute care. The DON indicated the form used to fax the LTC Ombudsman, titled Notice of Voluntary Resident/Patient Transfer or Discharge, was attached to the Ambulance Transfer Form and was sent to LTC Ombudsman after each transfer. The DON reviewed R34's medical record at that time and indicated R34's medical record lacked an Ambulance Transfer Form and a Notice of Voluntary Resident/Patient Transfer or Discharge form from R34's 12/16/18, acute care hospital transfer. The DON stated the facility expected R34 to return that day, so the facility potentially did not complete the forms. A policy for LTC Ombudsman notification of a facility initiated transfer was requested, however none were provided.

Based on observation, interview and document review, the facility failed to ensure a comprehensive reassessment was completed, and failed to implement interventions, to prevent the worsening of reoccurring pressure ulcers for 1 of 1 resident (R32) reviewed with current stage 3 and stage 4 pressure ulcers. This deficient practice resulted in actual harm for R32 whose stage 3 and stage 4 pressure ulcers deteriorated. Findings include: R32's significant change Minimum Data Set ((MDS) dated [DATE], identified R32 had independent daily decision making skills, and had [DIAGNOSES REDACTED]. The MDS identified R32 required extensive assist of two staff for bed mobility, transfers and toilet use. The MDS identified R32 had one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured blister); and one stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed, slough may be present but does to obscure the depth of tissue loss and may include undermining and tunneling) which were present upon admission/entry or reentry. R32's MDS further listed pressure ulcer interventions including a pressure relieving device for the chair, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care for R32. R32's Care Area Assessment (CAA) dated 2/9/16, indicated R32 was alert and orientated, refused the use of an alternating pressure pad and repositioning, and had been educated on the importance of repositioning. The CAA identified R32 had one stage 2 pressure ulcer and one stage 3 pressure ulcer to left hip and right buttock. The CAA further identified R32 was at risk for development of further pressure ulcers, required staff assistance with bed mobility, and was frequently incontinent of urine. The CAA further indicated R32 required a special mattress or seat cushion and a regular schedule of turning every hour. R32's quarterly MDS dated [DATE], identified R32 had moderate impaired cognition and had no behaviors or rejection of cares. The MDS identified R32 was at risk for pressure ulcers, had two stage 2 pressure ulcers, two stage 3 pressure ulcers and no stage 4 pressure ulcer (Full thickness tissue loss with bone exposed, tendon, muscle, slough or eschar tissue may be present on some parts of the wound bed, often including undermining and tunneling). R32's quarterly MDS dated [DATE], indicated R32 had moderately impaired decision making skills, and had no behaviors or rejection of care. The MDS indicated R32 required extensive assistance of two staff for bed mobility, transfers and toilet use, and indicated R32 had one stage 2 and one stage 3 pressure ulcer which were present upon admission/entry or reentry. The MDS also indicated R32 had one stage 4 pressure ulcer which had not been present upon admission/entry or reentry. The MDS listed pressure ulcer interventions including use of a pressure relieving device for the chair, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care and applications of ointments/medications for R32. R32's quarterly MDS dated [DATE], identified R32 had moderate impaired daily decision making skills, both short term and long term memory problems and rejection of cares less than daily, behaviors not directed at others less than daily. The MDS indicated R32 required extensive assist of two staff for bed mobility, transfers and toilet use, and identified R32 as having one stage 1 pressure ulcer (intact skin with non-blanchable redness of localized area usually over bony prominence), one stage 3 pressure ulcer, and one stage 4 pressure ulcer, which were present upon admission/entry or reentry. R32's current care plan revised on 11/30/16, identified R32 had dementia, hallucinations and pressure ulcers to right buttocks, right ischial tuberosity, left iliac crest and left hip. R32's care plan also indicated R32 required assist of 2 staff and a full mechanical lift for transfers. Interventions included: extra protein in diet (resident has been resistive to other supplements), seen by wound specialist (treatment as ordered, notify the wound specialist if area worsens or does not improve), prefers to sit up in wheelchair the majority of the day or side of bed (encourage repositioning), pressure relieving cushion provided for the wheelchair, reposition every hour is offered (resident will many times refuse), and rest back in recliner or in bed for 1 hour in AM (morning) and 1 hour mid afternoon with heels floated as ordered. R32's current Resident Care Sheet dated 11/29/16, identified R32 had pressure sores, required assist of one staff for bed mobility, for repositioning every hour, did not ambulate and required assist of two staff for transfers using full mechanical lift. On 11/30/16, at 3:05 p.m. R32 was observed lying on her left side, covered with blankets, resting quietly. A standard wheelchair with a black foam cushion was observed in R32's room near her bed. At that time, nursing assistants (NA)-B and NA-C entered R32's room to provide personal cares. NA-B and NA-C removed R32's covers and the pillow from behind the right side of her back, R32 was observed to be lying on a regular mattress. R32 had an indwelling catheter in place and had been incontinent of a medium soft dark black bowel movement, which was noted to extend from the bottom of her left iliac crest dressing, all the way down to the top of her right lower buttocks dressing. At 3:10 p.m. NA-B was observed to clean R32's buttocks with wipes, then removed the soiled 3 inch (in) x 3 in dressing from R32's left iliac crest, which had a moderate amount of yellow drainage noted on the foam dressing, NA-B discarded the soiled dressing into the soiled brief then proceeded to remove a soiled 4 in x 4 in dressing from R32's right lower buttocks which had a moderate amount of yellow drainage noted on it. R32 was observed to have a pink 4 x 4 in intact foam dressing on her left hip and another noted on her left lower buttocks. At 3:12 p.m. licensed practical nurse (LPN)-B entered the room, while NA-B and NA-C were caring for R32. LPN-B had them reposition R32 to her right side so she could dress her ulcers. During the wound care, R32's right lower buttocks was observed to have an open wound which measured approximately 3 cm (centimeters) x 4.5 cm x 2 cm deep, with tunneling at approximately 4 o'clock and 9 o'clock, the wound bed was noted to be very dull pink/gray color with slough (dead tissue that may have a yellow or white appearance) noted throughout. The outer skin around R32's ulcer was dark purple/red in color with scar tissue present, which extended out approximately 2 inches around the entire opening of the the ulcer, and faded to a red/pink color further out from the opening of the ulcer. R32's skin around the ulcer was not blanchable. R32's left iliac crest had an open wound which measured approximately 2 cm x 2 cm x 1 cm deep, with an excoriated area that extended out from the right surface of the wound at about 5 o'clock measuring approximately 1 cm x 0.5 cm. The wound bed was noted to be a very dull pink/gray color with slough noted throughout the wound bed. The outer skin around the ulcer was dark purple/red in color with scar tissue present, which extended out approximately 1 inch around the entire opening of the the ulcer and faded to a red/pink color further out from the opening of the ulcer, the skin around the ulcer was not blanchable, there were multiple light tan scabs noted from the bottom of R32's left iliac crest opening to the top of her anus area, which was also noted to be bright red in color. The skin where the two pink intact foam dressings were located, on the left hip and left lower buttocks, was observed to be red around the outer edges of the dressings. At 3:18 p.m. NA-B indicated she did not know the last time R32 had been repositioned on the day shift because the day staff had not reported to her the last time R32 had been repositioned. NA-B stated R32 was sleeping when she got to work and had not been repositioned at 2:15 p.m. when she had arrived at work. At 3:24 p.m. LPN-B indicated R32 had pressure ulcers for years and indicated the ulcers get better, then come back. LPN-B also confirmed R32 had a current stage 4 ulcer on her right lower buttocks with tunneling present on both sides of the ulcer, a stage 3 ulcer on her left iliac crest, and LPN-B indicated she had not seen R32's other breakdown areas on her left hip and left lower buttocks. At 3:35 p.m. LPN-B and NA-B transferred R32 via mechanical lift from her bed to her wheelchair and placed a blanket on her lap and shoulders. A seat cushion was in the wheelchair. At 3:44 p.m. LPN-B and NA-B placed a tray with a cup of coffee and bar, and exited the room. During continuous observations on 11/30/16, at 4:25 p.m. R32 was seated in a standard wheel chair in her room, with a walker/tray in front of her, door partially closed, with blankets on her shoulders and lap. At 4:34 p.m. R32 remained seated in her wheelchair in her room, and yelled help, help, help. At 4:40 p.m. NA-B entered R32's room and offered to reposition R32. R32 stated, No. NA-B exited the room. At 5:00 p.m. R32 remained seated in the regular wheel chair and yelled help, help, help. NA-B briefly entered R32's and exited the room. R32 remained in the position in her wheelchair. NA-B was not observed to offer R32 repositioning. At 5:15 p.m. NA-A entered R32's room briefly and informed R32 it was almost supper time. After NA-A exited the room, R32 remained in her room, seated in her wheelchair, in the same position. NA-A had not offered or assisted R32 to reposition. At 5:25 p.m. NA-A again entered R32's room and assisted R32 to propel her wheelchair into the dining room. NA-A did not offer or assist R32 to reposition. At 5:39 p.m. R32 was observed to be calmly seated at a table and visiting with table mates. At 6:00 p.m. R32 remained seated in the wheelchair and staff delivered her supper meal, she immediately started eating the meal independently. At 6:17 p.m. R32 remained seated in the wheelchair until NA-D assisted her out of the dining room and into the living room area. At 6:31 p.m. R32 was observed propelling herself down the hallway of the facility. NA-A approached R32 and assisted R32 back to her room. NA-A exited the room at 6:33 p.m. and did not offer to reposition or assist her to reposition. At 6:48 p.m. NA -B and NA-C entered to assist R32 for evening cares. R32 remained seated in her wheelchair in the same position. At 6:54 p.m. NA-B and NA-C transferred R32 via mechanical lift from her wheelchair to the edge of her bed. R32 went directly from the wheelchair to the bed without being provided pressure relief/offloading. NA-B and NA-C adjusted the pillow around R32 and lifted the head of bed for her comfort. At 6:59 p.m. NA-B and NA-C exited the room. R32 had not been repositioned or offered assistance to reposition from 4:40 p.m. to 6:54 p.m. (total of 2 hours and 14 minutes). On 11/30/16, at 7:01 p.m. NA-B stated the last time she had attempted to reposition R32 was before her supper break. She stated R32 required every hour repositioning and needed assistance from staff with all of her ADLs. NA-B indicated R32 was confused, the confusion had worsened, and would refuse cares and repositioning at times. On 11/30/16, at 7:20 p.m. NA-A stated R32 required assistance with all of her ADLs and was confused. He stated he had not offered R32 repositioning as he did not normally work down this hallway, and felt it was the responsibility of the person working that hallway to reposition R32. R32's Braden Scale (a tool used to identify risk for skin breakdown/pressure ulcers) assessment tool dated 11/7/16, identified R32 was chairfast, had very limited mobility, had current pressure ulcers to the right buttocks, right ischial tuberosity, left hip, and iliac crest and was at risk for development of pressure ulcers. The form listed R32 refused repositioning at times and refused alternating pressure pad, had pressure relieving cushion in chair, had been educated and physician aware. Review of R32's Tissue Tolerance Tool form (TTT-tool used to determine skins ability to with stand pressure and determine appropriate turning and repositioning schedules) from 1/29/16, to 8/9/16, revealed the following: -1/29/16, to be repositioned every hour for sitting and lying. Check for redness, resident has stage 2, pressure ulcer on right hip, must be repositioned every hour, pressure reduction device to chair, float heels pillow or boots, high protein supplement-ensure. -2/10/16, to be repositioned every hour for sitting and lying, pressure ulcer on right buttocks, pressure reduction device to chair. -5/9/16, to be repositioned every hour for sitting, pressure reduction device to chair-ROHO cushion, has air cushion in w/c, resident has pressure ulcers to right buttocks, coccyx and left hip. No tissue tolerance for lying documented. -8/8/16, to be repositioned every hour for sitting, pressure reduction device to chair-ROHO cushion, resident has pressure ulcers to right buttocks, coccyx and left hip. -8/9/16, to be repositioned every hour for lying and offer hourly. R32 was not able to reposition self, no pressure reduction device, she is to be repositioned hourly due to pressure ulcers, often noncompliant. TTT shows resident can tolerate up to 1 ½ hours but is repositioned hourly as she allows. Review of R32's weekly Pressure Skin Condition Reports/Skin Wound Note/Progress Notes from 3/1/16, to 12/2/16, revealed a lack of documentation that a comprehensive skin assessment had been done when R32 developed the ulcers. The notes also revealed the following related to R32's wounds: - 3/1/16, pressure ulcer to left hip was unchanged from last week, stage 2, measuring 0.5 centimeters (cm) x 0.7 cm, wound bed 100% slough, dressing applied, right buttocks, stage 3 no wound bed visualized, no measurements, treatment applied right buttocks stage 2 right below stage 3 ulcer, 100% granulation tissue, no measurements, treatment applied, left heel has resolved, left ischial tuberosity- reddened area noted after bath, no open area. - 3/8/16, right buttocks stage 3 unchanged, no measurements, right buttocks stage 2 right below stage 3 resolved, [MEDICATION NAME] applied, left hip stage 2 measures .0.5 cm x 1.0 cm, wound bed 100% slough, new dressing applied. - 3/11/16, new ulcer to left iliac crest, stage 2, measuring 3.5 cm x 1.2 cm, red bloody, no slough. Documentation listed no current interventions. - 3/15/16, right buttocks stage 3 no measurements, no documentation, left hip stage 2 measures 0.3 cm x 0.5 cm, wound bed 100% granulation, left iliac crest, stage 2, measuring 1.7 cm x 1.2 cm, 50% black and 50% granulation tissue. Documentation listed no current interventions. - 3/23/16, right buttocks stage 3, small open area measures 0.3 cm x 0.2 cm, left hip stage 2, no change, measures .0.3 cm x 0.5 cm, wound bed 100% granulation, new Allevyn dressing applied, left iliac crest, stage 3, measuring 2.4 cm x 1.5 cm, 75% granulation tissue and 25% slough, dressing applied. - 3/29/16, right buttocks stage 3, no wound bed to measure, area indented but appears to be how it has healed, dressing applied, left hip stage 2, no change, measures 0.3 cm x 0.5 cm, wound bed 100% granulation, dressing applied, left iliac crest, stage 3, measuring 2.4 cm x 1.4 cm, 100% granulation tissue, on antibiotic due to wound infection, dressing applied, followed by wound specialist. - 4/5/16, right buttocks stage 3, no wound bed visible, dressing applied left hip stage 2, no change, measures 0.5 cm x 0.7 cm, wound bed 100% slough, dressing applied, left iliac crest, stage 3, measuring 2.1 cm x 1.4 cm, 100% slough, dressing applied, seen by wound specialist on 4/4/16, no changes were made to orders. -On 4/19/16, right buttocks stage 3 has reopened measuring 2.8 cm x 1.5 cm, 100% granulation tissue, cleansed with Chlora-prep, dressing applied per order, left hip stage 2, deteriorating, measures 2.0 cm x 1.0 cm, wound bed 100% granulation, cleansed with Chlora-prep, dressing applied per order, left iliac crest, stage 3, measuring 2.0 cm x 1.5 cm, 95% black eschar, 5% slough, Chlora-prep, dressing applied, New ulcer stage 2 right buttocks 0.5 cm x 0.7 cm, 100% granulation tissue. Wound specialist updated via fax on 4/18/16, regarding new ulcer. -On 4/26/16, measurements from wound specialist: right buttocks stage 3 has measuring 0.5 cm x 3.5 cm, site previously closed ulcer, left hip stage 2, deteriorating, measures 1.7 cm x 0.5 cm, left iliac crest, stage 3, measuring 2.0 cm x 1.5 cm, right buttocks stage 2 measures 0.3 cm x 0.2 cm. Wound specialist ordered continue to cleanse sites, use Allevyn dressing on all sites except right buttock apply skin barrier [MEDICATION NAME] twice a day, keep free of stool, follow up in one month or sooner if need arises, continue to reposition every 2 hours. -On 5/3/16, right buttocks stage 3 measuring 2.5 cm x 1.7 cm, 100% granulation tissue, surrounding tissue deteriorating, left hip stage 2, measuring 2.0 cm x 1.5 cm, wound bed 100% slough, cleansed, dressing applied per order, left iliac crest, stage 3, measuring 2.0 cm x 1.6 cm, granulation and slough with possible amount of necrotic tissue , surrounding tissue deteriorating, right buttocks stage 2 100% granulation tissue, surrounding tissue red/purple but does blanch. Dressing changes completed as ordered. -On 5/31/16, right buttocks stage 3 measuring 1.8 cm x 3.0 cm, deteriorating, macerated with slough, possible depth hard to visualize, area cleansed, left hip stage 2, measuring 1.8 cm x 1.0 cm, wound bed 50% slough, 50 % scabbed, cleansed, dressing applied per order, left iliac crest, stage 3, measuring 2.6 cm x 2.0 cm, 100% stringy slough with possible amount of necrotic tissue, surrounding tissue deteriorating, right buttocks stage 2 area closed last week, measuring 0.7 cm x 0.6 cm, wound bed pink, excoriation distal to this opening, cleansed, dressing applied. Note area of concern to on left ischial tuberosity, areas appear fragile and high risk for breakdown, skin prep applied. -On 6/7/16, right ischial tuberosity stage 3, measuring 2.1 cm x 2.8 cm, deteriorating with slough and eschar present, dressing applied, left hip stage 2, measuring 2.0 cm x 1.0 cm, wound bed 50% slough, 50 % scabbed, cleansed, dressing applied per order, left iliac crest, stage 3, measuring 2.8 cm x 2.1 cm, 95% slough, 5% eschar at bottom of wound, dressing applied, right buttocks stage 2 no wound bed observed to area, tissue discolored red/purple in color, left ischial tuberosity, opened up to stage 2, measuring 2.3 cm x 1.2 cm, wound bed shallow, with one spot of slough, applied dressing. Continues to be followed by wound specialist. -On 6/21/16, right ischial tuberosity stage 3, measuring 3.0 cm x 2.0 cm x 0.4 cm, wound bed beefy with macerated edges, cleansed, dressing applied, left hip stage 2, measuring 1.5 cm x 1.5 cm, wound bed 25% slough, 75 % scabbed, cleansed, dressing applied per order, left iliac crest, has progressed to a stage 4, measuring 2.3 cm x 2.4 cm x .04 cm, wound bed visible dark gray, cleansed, dressing applied, left ischial tuberosity, no wound bed visible, healed. -On 7/5/16, right ischial tuberosity stage 3, measuring 3.2 cm x 2.4 cm x 1.8 cm, wound bed beefy, cleansed, dressing applied, left hip stage 2, measuring 1.0 cm x 1.0 cm, wound bed slough, cleansed, dressing applied per order, left iliac crest, stage 4, measuring 1.9 cm x 2.0 cm x 1.5 cm, with tunneling at 12 o'clock, wound bed beefy, cleansed, dressing applied, -On 8/2/16, right ischial tuberosity stage 3, measuring 3.0 cm x 1.8 cm x 1.7 cm, cleansed, packing, dressing applied, left hip stage 2, measuring 0.5 cm x 0.7 cm, wound bed scabbed unable to assess, cleansed, dressing applied per order, left iliac crest, stage 4, measuring 2.0 cm x 1.5 cm x 1.5 cm, wound bed 80% slough, 20% pink tissue, cleansed, packing, dressing applied. -On 8/30/16, right ischial tuberosity stage 3, measuring 3.0 cm x 2.0 cm x 2.0 cm surrounding tissue presenting maceration, excoriation and denudement, flushed with normal saline, cleansed, dressing applied, left hip stage 2, is healed, skin light pink where open area was, left iliac crest, stage 4, measuring 3.0 cm x 2.2 cm x 1.2 cm, wound bed deteriorated, area flushed with normal saline, cleansed, skin prep applied, dressing applied. Resident followed by wound specialist. -On 9/21/16, right ischial tuberosity stage 3, measuring 1.5 cm x 2.5 cm x 1.8 cm slight deeper but narrower than last week, dressing saturated with tan colored drainage, left iliac crest, stage 4, measuring 1.7 cm x 3.0 cm x 1.1 cm, depth decreased, width increased with inner edge of wound continuing to breakdown, dressing saturated with tan colored drainage, areas cleansed with normal saline and [MEDICATION NAME] swabs, apply skin prep around wound, dressing applied. -On 10/25/16, right ischial tuberosity stage 3, measuring 2.4 cm x 2.9 cm x 2.4 cm, areas of discoloration surrounding wound measuring 2.5 cm x 5.0 cm, wound bed more healthy but continues to deteriorate, small amount of drainage, area cleansed and dressed, with no pain, left iliac crest, stage 4, measuring 2.5 cm x 3.2 cm x 1.5 cm, wound larger than last week, [MEDICAL CONDITION], redness noted, small amount of drainage, area cleansed and dressed, left hip measured area 1.2 cm x 1.5 cm beginning to look like it breaking down again, covered with non-adherent pad per order. -On 11/1/16, right ischial tuberosity stage 3, measuring 3.2 cm x 4.0 cm x 2.6 cm, area has deteriorated since last week, scant amount of drainage, wound bed light pink/almost gray, area cleansed and dressed, with no pain, left iliac crest, stage 4, measuring 2.5 cm x 3.4 cm x 1.0 cm, wound continues to fill, but breaking down closer to residents midline, wound bed mixture of granulation tissue and slough, small amount of drainage, area cleansed and dressed, left hip measured area 0.3 cm x 0.4 cm beginning to look like it breaking down again, no wound bed, covered with non-adherent pad per order. -On 11/8/16, right ischial tuberosity stage 3, measuring 3.5 cm x 3.5 cm x 3.0 cm, with tunneling at 11 o'clock measuring 4.5 cm, scant amount of drainage, wound bed light pink/gray, area cleansed and dressed, left iliac crest, stage 4, measuring 2.0 cm x 3.0 cm x 1.3 cm, wound bed mixture of granulation tissue and slough, scant amount of drainage, area cleansed and dressed, left hip, no stage, measured 1.4 cm x 1.2 cm no wound bed, area continues to be scabbed, beginning to look like it breaking down again, covered per order. -On 11/15/16, right ischial tuberosity stage 3, measuring 3.2 cm x 4.2 cm x 3.6 cm, with tunneling at 11 o'clock measuring 4.0 cm, wound continues to deteriorate, wound bed light pink/gray, continue treatment. left iliac crest, stage 4, no measurements, left hip, no stage, measured - no measurements. -On 11/22/16, right ischial tuberosity stage 3, measuring 3.5 cm x 4.6 cm x 2.5 cm, with tunneling at 10 o'clock measuring 4.0 cm, scant amount of drainage, wound bed 25 % sough, remainder gray, area cleansed and dressed per order, left iliac crest, stage 4, measuring 1.9 cm x 3.0 cm x 1.5 cm, wound measures larger, continues to have deeper portion and newer, rolled edges, wound bed 50% slough, 50% pink granulation tissue, small amount of serosanguinous drainage, area cleansed and dressed, left hip, no stage, no change, measured 1.4 cm x 1.2 cm, area continues to be scabbed, covered per order, left ischial, no stage, observed at wound care appointment on 11/21/16, measured 1.6 cm x 1.0 cm, no wound bed, area covered with padded dressing in hopes of preventing further breakdown. -On 11/28/16, right ischial tuberosity stage 3, measuring 3.5 cm x 5.0 cm x 2.3 cm, with tunneling at 10 o'clock measuring 3.5 cm and at 5 o'clock measuring 3.2 cm, this is a deterioration from last week with addition of another area of tunneling and increased width, scant amount of serous drainage, wound bed grayish color, area cleansed and dressed applied, left iliac crest, stage 4, measuring 1.5 cm x 2.5 cm x 0.9 cm, improvement from last week, wound bed 50% slough, 50% granulation tissue, small amount of serosanguinous drainage, area cleansed and dressed, left hip, no stage, no change, measured 0.4 cm x 0.6 cm, slightly smaller than last week, area remains scabbed, covered per order, left ischial tuberosity, measuring, 2.0 cm x 1.5 cm, which is larger, than last week, hard to define edges of open area, areas cleansed, dressing applied. Review of R 32's wound specialist correspondence from 3/1/16, to 12/1/16, revealed the following: -3/3/16, resolving stage 3 pressure ulcer on left trochanter measuring 0.5 cm x 0.5 cm x 0.1 cm, with stage 1 P/U extending surrounding tissue 2 cm area, nursing home (NH) continue to reposition every 2 hours , apply padding to wheel chair to prevent further breakdown. Buttocks and per-region improved and almost resolved, NH continue [MEDICATION NAME] spray and [MEDICATION NAME] daily, with repositioning every 2 hours. Stage 3 P/U to right gluteal fold remains closed. -3/21/16, 3 open areas Left iliac crest, stage 3, 2.0 cm x 1.7 cm x 0.1 cm with 0.6 cm peri meter redden blanchable skin intact, 100% yellow slough, left greater trochanter, stage 3, 0.3 cm x 0.2 cm x 0.1 cm wound culture done, 100% sough, right ischial tuberosity, stage 4, previously resolved, 2.5 cm x 2.0 cm x 0.1 cm, 100% pink [MEDICATION NAME] tissue. NH continue to toilet as need, reposition every 2 hours, instruct patient importance of treatments, Foley catheter in place, follow up in 10 days, [MEDICATION NAME] started x 7 days. - 4/4/16, stage 3 to left buttocks , area nearly healed , has now reopened as direct result of shearing from worn out wheelchair padding. Measures 0.3 cm x 0.7 cm x 4 millimeters (mm), left trochanter stage 2, 0.8 cm x 0.3 cm x 2 mm, left ischial tuberosity, stage 2, 1.7 cm x 1.3 cm x 2 mm. Staff to order new, wider chair and pad for the pt as this direct cause of further breakdown and erosion, resident family understands and agrees. -4/11/16, stage 3 to left buttocks , area nearly healed , has now reopened as direct result of shearing from worn out wheelchair padding. Measures 2 cm x 3 cm x 4 mm, left trochanter stage 2, 1.5 cm x 0.5 cm x 1 mm, left ischial tuberosity, stage 2, 1.7 cm x 1.4 cm x 1 mm, sacrum has now developed stage 1, measures 1 cm x 3.5 cm. Staff to order new wider chair and pad for the pt as this direct cause of further breakdown and erosion, resident family understands and agrees. 4/18/16, wound specialist notified via facsimile of new stage 2 on coccyx area measuring 0.5 cm x 0.7 cm, covered with foam dressing, doctor noted continue to pad areas and monitor, issues will not resolve until patient has appropriate new wheelchair and pad. -4/25/16, 4 open areas- left iliac crest, stage 3, measuring 2.0 cm x 1.5 cm x 0.1 cm, 40% yellow slough, 60% gray slough, right iliac crest, stage 3,measuring 0.3 cm x 0.2 cm 0.1 cm, 100% slough, left greater trochanter stage 3, measuring 1.7 cm x 0.5 cm less than 0.1 cm , 100% slough, previously resolved stage 4 to right ischial tuberosity, measures 0.5 cm x 3.5 cm x 0.1 cm , 100 % pink [MEDICATION NAME] tissue. Provider had written order for new wheel chair evaluation and cushion at previous wound care visit, patient received new ROHO cushion on 4/22/16, no documentation of new wheelchair provided. Improvement to peri regions, less pain and eating better, NH staff continue toileting and reposition every 2 hours, Foley catheter in place. -5/19/16, chronic right buttocks stage 2 ulcer, left greater trochanter stage 3 ulcer, left ischial tuberosity stage 3 ulcer, ulcers cleaned and treated, continue same treatments. Continue use of new pad and chair. - 6/20/16, chronic right ischium stage 4 ulcer, right side of tail bone stage 3, left greater trochanter stage 3 ulcer, ulcers cleaned and treated, treatments Xeroform, skin prep, Allevyn dressing. - 8/1/16, chronic stage 4 ulcer to right ischium, stage 3 ulcer to sacrum, stage 2 ulcer left greater trochanter, ulcers cleaned and treated, continue same treatment. - 9/15/16, has stage 4 ulcer to right ischial tuberosity that was previously healed, stage 3 ulcer to sacrum, stage 2 ulcer to right heel, left greater trochanter fully closed. Noticed cushion in wheel chair several pockets are with out air, no longer providing her cushion and off loading that is required, new cushion has been requested by N/H. - 9/28/16, has stage 4 ulcer to right ischial tuberosity that was previously healed, stage 3 ulcer to sacrum. Patient and family concerned the pad on the wheelchair deflates and is not being checked daily which creates pressure on the right ischium and right sacrum. Orders for nursing staff to inspect her seat pad daily and reinflate daily. -10/6/16, has stage 4 ulcer to right ischial tuberosity that was previously healed, stage 3 ulcer to sacrum, ulcers cleaned and treated and instruction for wheel chair needs to be replaced , no exceptions!! 10/18/16, wound specialist notified via facsimile R32's pressure ulcers getting worse with odor, more drainage. -10/20/16, has stage 4 ulcer to right ischial tuberosity that was previously healed, stage 4 ulcer to sacrum, started an antibiotic for wound infections. - 11/10/16, has stage 4 ulcer to right ischial tuberosity that was previously healed, stage 4 ulcer to sacrum. Review of R32's progress notes from 3/1/16 to 12/1/16 revealed the following: -3/10/16, cooperative with repositioning -3/18/16, has not been compliant with repositioning. -3/31/16, confused and hallucinating, has been compliant with repositioning. -4/4/16, seen by wound specialist, no changes in wound care orders, did comment that resident needs a new wider wheelchair and cushion. -4/6/16, cooperative with repositioning and is laying in bed off of pressure sores resting at this time. -4/14/16, refusing to be repositioned as scheduled. -4/21/16, continue to pad areas and monitor, issues will not resolve until the patient has appropriate wheelchair pad. -4/23/16, has been cooperative with repositioning, asked to be repositioned from the wheel chair to the bed. R32 has been requesting repositioning frequently through out the shift. -5/4/16,will be discharged from occupational therapy on 5/10/16 due to no further changes to wheelchair cushion as is not eligible by the insurance. The goal is for the resident to continue with optimal pressure relief with every hour repositioning. -5/10/16, was compliant with position changes tonight. -5/12/16, has refused reposition several times. -6/2/16, seen by wound specialist, facility had communicated wounds were looking worse from last appointment and requested R32's plan of care and goals for wound healing be discussed. The wound specialist had replied wounds stable and improving, goal of wound care to prevent infection and keep from deteriorating or new pressure ulcers developing. Healing may occur in long range but unable to relieve source of wounds which is pressure. -6/9/16, compliant with repositioning. -6/10/16, refuses to reposition every hour, repositioned 3 times though out shift. -6/30/16, wound specialist had called faciilty after recent visit to notify them R32's tailbone had broken down, necrotic tissue debrided. He also indicated he was aware resident is difficult but needs to air out areas as much as possible and too much chair time will only continue to worsen area. -7/5/16, compliant with repositioning with night. -7/17/16, resident was compliant with all repositioning. -8/2/16, semi complaint with repositioning tonig

Based on observation, interview and document review, the facility failed to ensure appropriate interventions were implemented after falls to ensure an environment free of accident hazards for 2 of 4 residents (R12, R55) in the sample with a history of falls. This practice resulted in actual harm for R12. Findings include: R12 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified R12 had problems with recall, and moderate cognitive impairment identified by the Brief Interview of Mental Status (BIMS) score of 11. The MDS identified R12 required staff assistance with chair and bed transfers, required staff supervision for walking in room and toileting. The MDS further identified R12 was not steady with walking, and turning around and facing opposite direction while walking. The Care Area Assessment (CAA), dated 8/30/12, identified R12 had been admitted from the hospital with a [DIAGNOSES REDACTED]. The CAA also identified R12 had a [DIAGNOSES REDACTED]. The CAA identified R12 was at risk for injury and directed staff to monitor and assist resident as needed, and anticipate her needs when unable to communicate them. Further the CAA identified R12 was at risk for falls, due to weakness, side effects of medication, confusion, poor vision and hearing. R12 was unsteady, used a wheeled walker for ambulation, but due to her confusion does not always remember to use it or ask staff for assistance. R12 had fallen on the day after admission. The care plan, revised 12/6/12, identified falls problem and listed interventions that included encourage resident to use handrails or assistive devices properly, supervision and limited assistance to transfer and ambulate with use of wheeled walker, non slid footwear, and resident has alarms to alert staff when attempting to self transfer, reinforce need to call for assistance. During observations on 12/11/12, at 7:12 a.m., R12 was seated in a wooden chair in front lobby of the facility, a white cord was hanging from the seat of the chair, connected to a white box on the back of the chair. R12 had a red, rigid cast on her right forearm, and a black sling on her right shoulder and forearm. At 7:47 a.m., nursing assistant (NA)-F was on R12's right side, holding her upper arm above the cast, while assisting R12 to ambulate with wheeled walker into the dining room. NA-F held a white square, plastic pad with a cord connected to pad in her other hand. On 12/12/12, at 10:03 a.m., licensed practical nurse (LPN)-B stated R12 had confusion at times, had recently fallen in her room subsequently sustaining a fractured wrist. She stated R12 had attempted to pull the cast off right arm occasionally since the cast had been applied. LPN-B stated R12 had fallen previously in facility and fractured her left wrist, and bed and chair alarms were placed for a time, but then removed. She confirmed R12 presently utilized a chair alarm and bed alarm, and staff were to check her every 2 hours during the night to prevent further falls. On 12/12/12, at 10:59 a.m., NA-F stated R12 utilized a chair alarm when in a chair and a bed alarm when in bed. NA-F confirmed the alarms sounded when R12 attempted to self transfer, to alert staff for assistance, and had experienced no new falls since return from the hospital. Review of the R12's incident reports revealed: - 8/18/12, 10:43 a.m., resident found sitting on the floor next to her bed and chair, with resident complaining of pain in her left wrist and right side. The post fall assessment identified R12 had intermittent confusion, presently in physical therapy and directed staff to use alarms on bed and wheelchair, although resident disregards the alarms. The post fall follow up note on 8/31/12 indicated resident was attempting to ambulate without assistance and was pushing chair out of her way. She had a history of [REDACTED]. Because of her ongoing complaints of discomfort, R12 was seen by doctor on 8/31/12 and found to have a fracture of her left wrist. At the time of the fall she was unsteady and required stand by assistance with walker for transfers and ambulation. R12 was forgetful, and the cause of the falls was determined to be from transferring without assistance and new surroundings. The physical therapy note, dated 8/23/12, identified R12 had been seen for treatment of [REDACTED]. The note identified R12 required CGA (contact guard assistance) of one staff. R12 was able to ambulate with 4 wheeled walker and supervision. The note indicated therapy would be stopped at this time. - 11/4/12, at 6:48 p.m., R12 was found sitting in the middle of the floor near her table. R12 could not explain how she fell , was noted to have a temperature of 100.7 and had no injuries. The post fall assessment identified R12 was forgetful, lacked safety awareness, and had been ambulating without assistance. Walker was not near the location where the resident was found. The foot rest of the resident's chair was still in the up position and the blanket that she had wrapped around her legs was laying in the chair. The report identified R12 was not aware she had fallen, one hour after the incident. The post fall follow up note identified R12 had a history of [REDACTED]. She is confused, [DIAGNOSES REDACTED]. Prevention of further falls involves treatment of [REDACTED]. - 11/5/12, at 3:40 p.m., identified daughter was with R12, when lost balance, leaned on wall and slid down to the floor.No injuries were noted and no documentation of interventions to prevent further falls. The post fall follow up notes identified R12 had exhibited poor judgement by climbing over the extended legs of her recliner, may have tripped on blanket on 11/4/12, seen by physician on 11/6/12 and narcotic medication stopped and antibiotic started. She will continue to ambulate with a walker independently and staff provide stand by assistance when needed. R12 exhibited poor judgement by climbing over the legs of recliner. Staff will monitor for safety. -11/7/12, at 9:39 a.m., identified staff found resident lying on the floor holding right wrist. Resident stated, "I think my arm is broken." R12 was transferred to the hospital by ambulance for evaluation. The post fall assessment identified R12 was confused, forgetful, ambulated without assistance and was found in TED hose, did not have nonslip shoes on. Alarms placed on chair and bed upon return from hospital to attempt to prevent further falls. A follow up note on 11/14/12, indicated R12 was given a small wheelchair for her mobility needs and a tab alarm had been placed on her wheelchair and a sensor alarm placed on her bed. Review of the fall risk assessment done on 8/22/12, identified R12 was at high risk for falls, and the fall risk assessment completed on 11/20/12, identified R12 contined to be at moderate risk for falls. Review of the progress notes from 11/1/12 to 12/13/12 revealed on 11/6/12, physician was concerned about recent falls due to her risk of fractures. The note identified R12 did not remember to use the call light to ask for help, and disregarded or removed alarms in the past. The physician had stopped the narcotic pain medication, ordered lab tests and ordered orthostatic blood pressures to be done due to history of a recent fall after a position change. However, the notes lacked documentation of further immediate interventions to prevent further falls. On 11/15/12, the notes indicated R12 was very confused, tired and not easy to redirect. On 11/21/12, resident not using call light all shift, knocking on wall and calling out. R12 reeducated on use of call light to no avail. On 12/1/12, notes indicated R12 continues to self transfer, tabs alarm sounds frequently during the shift, observed to use the call light times one only. On 12/4/12, resident has been trying to transfer herself, and not using call light appropriately at times. Sensor pad alarms alert staff if she tries to transfer self. On 12/8/12, not using call light, self transferring. Re-educated resident several times to call light usage, does not retain. On 12/11/12, needed re educating on the use of call light, attempted to self transfer x4, chair alarm alerted staff to respond each time. On 12/13/12, the notes indicated many attempts to self transfer. Review of R12's form titled Weights and Vitals Summary from 8/17/12 to 12/13/12 revealed the facility had not completed orthostatic blood pressure monitoring for R12 until 11/16/12, a total of 9 days after fall with fracture. Review of the facility policy titled Falls Protocol, dated 7/21/12, identified any unwitnessed falls by a cognitively impaired resident must have a falls assessment completed, including neurological checks, orthostatic blood pressure checks. Review of the facility policy titled Assessment After A Fall, dated 7/21/12, indicated after each fall vital signs would be monitored every 8 hours for 24 hours, orthostatic blood pressures twice a day for 3 days would be completed and interventions would be put in place to minimize or eliminate future falls. On 12/13/12, at 11:09 a.m., the director of nursing (DON) confirmed R12 had sustained fractures to the right and left wrist after falls in the facility. She added R12 had been confused since admission and had poor safety judgement. The DON confirmed the facility policy and R12 continued to be high risk for further falls. The DON stated the physician had stopped the narcotic and started the antibiotic in response to the 11/4/12 fall. The DON confirmed the orthostatic blood pressures were not completed timely. She stated the resident experienced an additional fall on 11/5/12, staff were to monitor for behaviors, and continue orthostatic blood pressures. However, no other interventions were put in place to prevent further falls. The DON stated the alarms had been removed when physical therapy was stopped after the first fracture, and stated the chair and bed alarm had been added after R12 sustained the second fractured wrist. She confirmed R12 continued to be forgetful, poor safety judgement and was found on the floor on 11/7/12 and sustained a fractured right wrist at that time. R55's [DIAGNOSES REDACTED]. R55 was identified by the admission MDS dated [DATE], to require staff assistance for bed mobility, transfers, toileting, personal hygiene, ambulation, and locomotion, and to have a BIMS of 10, indicating moderate cognitive impairment. The care plan, revised 11/27/12, directed R55's care for; a chronic progressive decline in intellectual functioning characterized by deficit in judgment, decision making and thought process related to dementia; and decreased physical mobility. R55 had potential for falls related to weakness and unsteadiness at times when fatigued, will remove shoes and will leave walker and walk away without it. Interventions included R55 to utilize hand rails and assistive devices properly, reinforce need to call for assistance, monitor unsteadiness. Observation on 12/12/12, at 7:34 a.m. NA- F assisted R55 with personal hygiene and dressing. At 7:40 a.m. R55 was standing in the center of the room, stepped away from the walker, crossed the left foot in front of the right foot, turned direction and brought the right foot forward. R55's feet were entangled and balance was unsteady. Review of fall reports confirmed the following 4 falls; 10/28/12, at 2:40 p.m. an unwitnessed fall in the hallway. The intervention implemented was R55 to use a walker and instructed how to use it. 10/29/12, at 8:30 p.m, unwitnessed fall in hallway. The intervention implemented of staff to monitor and encourage to use walker, staff to stand by resident when walking, and a plan to review with the doctor and to perform possible labs. On 11/6/12, an unwitnessed fall by the nurses station, with an intervention to make a physical therapy referral "when insurance is available." On 11/19/12, an unwitnessed fall in the west hallway, with an intervention for "further evaluation of R55's condition to search for something treatable." Immediate Interventions were not implemented following each fall to prevent further falls for this resident. The falls reports repeatedly identified: mental status; confused. Predisposing physical factors; gait imbalance, and impaired memory. Predisposing situation factors; wandering and ambulating without assistance. Interview with registered nurse (RN)- A on 12/13/12, at 9:59 a.m. confirmed the facility policy for falls, that R55 had repeatedly fallen, and the interventions for R55's falls as follows; 10/28/12, use of walker and instructions how to use it. 10/29/12 at 2:40 p.m., staff monitor use of walker and stand by assist, 10/29/12, at 8:30 p.m., 11/6/12, and 11/19/12 no new immediate interventions to prevent further falls. RN-A stated R55 walked constantly, staff walked with R55 when possible but can not do one on one with R55," There was nothing else we could do." The facility policy titled Assessment After A Fall dated 7/21/12, indicated use of a fall assessment tool to assist in determining cause, planning for solutions and tracking purposes. The policy directed staff to have falls reviewed by an RN with in 24 hours of the fall to get interventions in place.

Based on observation, interview, and document review, the facility failed to implement interventions to prevent the development of a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Eschar may be present) pressure ulcer (PU) for 1 of 1 resident (R18) who developed a pressure ulcer in the facility. The facility's failure to implement interventions resulted in actual harm for R18. Findings include: R18's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated severe cognitive impairment. The MDS also indicated R18 required extensive assistance of one staff for transferring, and bed mobility. R18 was non ambulatory. Additionally, the MDS indicated R18 had intact skin and was not at risk for the development of pressure ulcers. The Cognitive / Loss Dementia Care Area Assessment (CAA) indicated R18 required staff assist for transferring at night, and was not at risk for pressure ulcer development. The current plan of care (POC) dated 2/9/11, indicated R18 had forgetfulness and some confusion. The POC also indicated R18 required one staff assist for transferring, and personal cares. Additionally, the POC indicated R18 was at risk for alteration in skin integrity and directed staff to reposition the resident as the tissue tolerance assessment directed. The POC addendum dated 3/12/12, indicated R18 had pressure ulcers to the left heel. The ""Initial Admission / Readmission" form dated 2/28/12 indicated R18 returned to the facility with left leg immobilizer on and elevated. The skin observation portion of the form indicated some bruises and surgical staples otherwise skin intact. The 2/28/12, "Nurses Notes" indicated R18 returned from the hospital. Skin pale, and warm. The note further indicated R18 had surgical related bruises, otherwise skin intact. The "24 Hour Admission / Readmission Vital Signs" form dated 2/29/12, indicated surgical incision with dry and intact skin. The 3/1/12, Nurses Note indicated [MEDICAL CONDITION] to all extremities. R18 is non weight bearing to left leg. The 3/2/12, Nurses Note indicated R18 was to be transferred with a mechanical lift. The 3/4/12, Nurse Note indicated R18 wore the left leg immobilizer at all times. The note further indicated R18 had [MEDICAL CONDITION] in bilateral lower extremities and the left heel's skin was clear and intact. The 3/5/12, Nurse Note indicated R18 returned from medical visit with orders to wear left leg immobilizer at all times. The 3/6/12, Nurse Note indicated [MEDICAL CONDITION] in bilateral lower legs with legs elevated. The 3/9/12, Nurse Note indicated left heel had four reddish, purple areas that do not blanch. Left leg immobilizer has metal stays that have been poking the posterior heel. [MEDICATION NAME] applied. Staff adjusted the immobilizer so metal supports do not poke left heel. The 3/9/12, physician fax referral/notification form indicated R18 had 4 reddish purple areas to left heel which appear to be from the metal stays in the immobilizer. The form also indicated staff had aligned the brace so it sat slightly off center to prevent pressure. The 3/14/12, Nurse Note indicated left heel is open with serous drainage. The 3/15/12, 10:30 a.m. Nurse Note indicated left heel open area measures 2 cm x 2.7 cm and 20% open. The remaining 80% was faint purple with intact eschar (necrotic tissue), blister. The note further indicated left heel ulcer #3 was unchanged. Left heel pressure ulcer #2 was identified as a stage two (partial thickness loss of dermis) which measured 0.8 cm x 0.6 cm and 0.2 cm deep. Ulcer #4 had combined with ulcer #1. The left leg remains in immobilizer. The 3/15/12, 12:00 p.m. Nurse Noted indicated orthopedic department was notified of difficulties with the immobilizer which kept sliding down with metal stay resting on the left heel. The immobilizer was altered by facility staff per the direction of the orthopedist. The 3/16/12, Nurse Note indicated no change in wounds. The 3/17/12, Nurse Note indicated immobilizer remained on. Staff off load left heel. The 3/22/12, 2:35 p.m. Nurse Note indicated Ulcer #1 healed. Ulcer #3 closed layer of fragile skin, and Ulcer #2 resolved. The 3/23/12, Nurse Note indicated left heel ulcer #3 is combined with heel ulcer #2. Heel ulcer #1 is resolved. Heel Ulcer #2 was reddish, purple in color and measured 3.7 cm x 3.2 cm. with 0.2 cm depth. The 3/25/12, Nurse Note indicated no change to pressure ulcers. The 3/26/12, Nurse Note indicated 0.5 cm new red area to right side of ulcer. The 3/26/12, physician fax referral / notification form indicated left heel ulcer started out as three ulcers then combined to one large ulcer with light eschar. The note further indicated a new 0.4 cm red to purple area was noted below current ulcer. An order to consult a wound specialist was given. The 3/29/12, Nurse Note indicated approximately 0.1 cm thickness of white skin tissue came off at ulcer site, Large site of ulcer continue with light colored brown eschar. Right side of ulcer 0.1 cm depth. The 3/3012, 10:30 a.m. late entry for 3/27/12, Nurse Note indicated left heel was scabbed over. The 3/30/12, 10:00 p.m. Nurses Note indicated R18's heels were to be off loaded. The 3/31/12 Nurse Note indicated left heel measure 2/7 cm x 2.8 cm and 80% covered by black eschar tissue with the remaining 20% pale yellow. The note further indicated the upper portion of the wound was 0.6 cm x 0.6 cm eschar, and the lower wound measured 0.7 cm x 0.6 cm was intact with small amount of drainage. Additionally, the note indicated R18 was no longer wearing the immobilizer with the heel offloaded at all times with positioning devices. The 4/2/12, Nurse Note indicated R18's heel ulcers was evaluated by a wound specialist. The 4/2/12, "physician's orders [REDACTED]. The "Pressure Ulcer Documentation" form indicated pressure ulcer #1 was reddish purple and measured 0.8 cm x 1.7 cm. On 3/15/12, the form indicated an increase in size, with scant drainage. The wound measured 2 cm x 2.7 cm with 20% open and 80% faint purple. On 3/23/12, the wound was identified as resolved. The "Pressure Ulcer Documentation" form indicated on 3/9/12, wound #2 measured 1 cm x 0.8 cm and was reddish purple in color. On 3/15/12, the wound was identified as pale pink in color and measured at 0.8 cm x 0.6 cm. On 3/23/12, the documentation indicated an increase in the size of the wound. It further indicated the wound was reddish, purple and measured at 3.7 cm x 3.2 cm. On 3/30/12, a 0.5 cm additionally open area was noted to left heel. and also described a larger 3.7 cm area was noted. On 3/31/12, the wound measured 3.4 cm x 2.7 cm with 80% black (eschar) and 20% yellow tissue with some drainage. The "Pressure Ulcer Documentation" form indicated on 3/9/12 wound #3 measured 0.6 cm x 0.6 cm and was reddish, purple in color. On 3/23/12, the documentation indicated wound #3 had combined with wound #2. The "Pressure Ulcer Documentation" form indicated on 3/9/12, wound #4 measured 1 cm x 1 cm and described as reddish, purple. On 3/15/12, the documentation indicated ulcers #1 and #4 had combined and will be measured / identified as wound #1. The "Pressure Ulcer Documentation" form indicated on 3/31/12, wound #5 measured 0.6 x 0.6 cm and 100% covered with black eschar with small amount drainage. The "Pressure Ulcer Documentation" form indicated on 3/31/12, wound #6 measured 0.7 cm x 0.6 cm with 100% black eschar covering it with small amount drainage. The "Tissue Tolerance Assessment" form dated 3/9?12, and signed by the registered nurse (RN) on 3/16/12, indicated R18 tolerated pressure while sitting for 2 hours without change in skin condition. The nurse summary portion indicated R18 utilized a left leg immobilizer and had three left heel pressure sores prior to the assessment which required monitoring, and heel to be floated with the use of pillows. The undated RN note identified on 3/19/12, R18 was observed to have 4 pressure related unblanchable, purple areas on posterior left heel. The note also indicated R18 was at high risk for skin breakdown. Additionally, the note indicated R18 was weak post surgical repair, and required physical assistance of 2-3 staff for transfers. R18 wore a left leg immobilizer which repeatedly slid down the leg with the posterior metal portion of the immobilizer resting on the left heel. Staff repositioned the immobilizer several times a day. The note further indicated staff had been watching the positioning of the immobilizer in an attempt to keep it off the heel. Pillows were used to position the left foot and staff were directed to offload the foot while in the wheelchair, recliner, or bed. The "Quarterly Skin Integrity Check" form dated 2/2012, indicated no change in skin condition. The "Braden Scale For Predicting Pressure Sore Risk" dated 3/5/12, indicated R18 was at risk for the development of pressure ulcers. On 4/3/12, at 8:45 a.m., R18 was seated in the wheelchair with slippers on both feet. R18's heels was observed to be resting on the pedals of the leg rests. On 4/4/12, at 7:00 a.m. R18 was observed seated in the recliner. Both heels was observed resting on a pillow. At 1:13 p.m. LPN-A (licensed practical nurse), and RN-A was observed to perform the left heel wound treatment. The left heel wound appeared blackish, red in color and covered approximately 50% of the heel. RN-A stated the wound was the result of the ill fitting immobilizer. On 4/5/12, at 8:04 a.m. LPN-A verified R18's stated the left heel ulcer was a direct result of the ill fitting immobilizer. LPN-A stated the ulcer could have been prevented. At 8:37 a.m. nursing assistant (NA)-A stated R18's pressure ulcer was from the immobilizer she wore because it was too long and the metal part rested on the heel. At 1:07 p.m. R18 was seated in the recliner. The left heel was resting on top of a pillow. At 1:10 p.m. NA-C stated R18's pressure ulcer on left heel was caused from the immobilizer pushing on the left heel. At 1:18 p.m. NA-C verified R18's heel was not offloaded, and stated it should be. NA-C offloaded the left heel. At 2:24 p.m. RN-A verified R18's skin was intact upon hospital return. RN-A also stated the immobilizer continually slid down R18's leg with any type of movement. Additionally, RN-A stated staff repositioning the brace often was not enough to prevent the ulcer. RN-A stated the facility should have been aggressive at preventing the ulcer. RN-A verified R18's heel was to be offloaded at all times. On 4/6/12, at 8:09 a.m. the director of nursing (DON) stated she was unaware of the ill fitting immobilizer and she would expect staff to offload the heel at all times. Additionally, the DON stated staff should have intervened sooner with the ill fitting immobilizer in order to prevent the ulcers. The facility's "SKIN CARE / ASSESSMENTS POLICY AND PROCEDURE" revised on 12/2009, indicated resident's skin integrity is preserved through adequate nutrition and hydration, daily inspection of the skin, compliance with proper body alignment, and positioning, and maintenance of maximum mobility. The policy directed staff to monitor for the presence of skin irritants, and to document any special devices to prevent / heal skin problems and the use of pressure relieving devices or preventative skin interventions.