Every finding on record at Family Health & Rehabilitation Center

The facility identified a census of 66 residents and four kitchens. Based on observation, record review, and interviews the facility failed to maintain a sanitary environment and store food adequately to prevent contamination. Findings included:- During the initial kitchen inspection on 03/02/26 at 07:35 AM, observation in the food storage room on main hall revealed several cases of water stored directly on the floor. Dietary BB reported the emergency water had been on the floor for a few months.On 03/02/26 at 07:40 AM, observation in [NAME] House revealed the oven had a large amount of burnt dark residue on the bottom. The refrigerator had a staff member's lunch bag at the bottom. Dietary BB removed the lunch bag of the staff member and reported it should be stored in the employee refrigerator. On 03/02/26 at 07:51 AM, the [NAME] and [NAME] House refrigerator had an undated container of cut up apples with cinnamon and an undated bag of hash browns. The freezer had an undated bag of frozen biscuits. Dietary CC reported that all items should be labeled with a date. On 03/03/26 at 12:56 PM, observation of the [NAME] and [NAME] kitchens revealed broken cupboards, scratched cutting boards and the muffin bakery tins were bent with cooked on dark black/brown residue. The bottom shelf of the freezer in the actual kitchen was quite dirty with drops of food and liquids. On 03/03/26 at 01:05 PM, observation in the [NAME] and [NAME] kitchen revealed missing drawers. The cutting boards were very scratched up, and the muffin bakery tins were bent with cooked on dark black/brown residue. Under the steamer table in [NAME], the shelf was dirty with baked food and dust. There was a broken laundry basket on the floor in the storage area between [NAME] and [NAME] labeled kitchen towels, and the basket contained clean kitchen towels. Dietary BB reported that the dietary staff use the laundry area located in each house and confirmed the basket should not be on the ground. Dietary BB reported that the cutting boards and the bakeware would be replaced.On 03/03/26 at 03:00 PM, Administrative Staff A reported she expected the kitchen equipment to be clean and the kitchen to be in good repair. She expected the food to be labeled with a date and items not to be stored on the floor. The facility's policy Food Preparation and Handling Policy revised 01/20/26, noted all food items and products served to elders that will be prepared or served from/in a central kitchen and/or neighborhood kitchen/serving area will be according to standardized recipes. Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhance flavor, and be free of injurious organisms and substances. The kitchen and equipment would be kept clean, neat, orderly and well maintained.

The facility had a census of 66 residents. The sample included 18 residents, with one reviewed for tube feeding (administration of nutritionally balanced liquified foods or nutrients through a tube). Based on observation, record review, and interview, the facility failed to provide appropriate care and services for Resident (R) 4 when staff administered a medication and provided a tube feeding without using the physician's order for the amount of water before and after the procedure. Findings included: - R4's Electronic Medical Record (EMR) documented R4 had diagnoses of artificial openings of the gastrointestinal tract (surgical creation of an artificial opening into the stomach through the abdominal wall) R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. The MDS documented R4 required total staff assistance with activities of daily living (ADLS), had no swallowing disorders, and received tube feedings. R4's Care Plan, revised on 02/17/26, documented R4 dependent with tube feeding and water flushes and instructed staff to provide them per the physician's order. The Physician Order, dated 01/12/26, instructed staff to administer one carton (250 milliliters (ml) of Nutrent 2.0 (nutrition supplement that provides complete, balanced nutrition for long - or short -term tube feeding with increased calorie and protein needs) daily at 10:00 AM and flush the tube with 100ml of free water before and after each bolus feeding. On 03/03/26 at 10:45 AM, observation revealed Licensed Nurse (LN) G, placed gloves on, placed a catheter tip syringe into R4's feeding tube, poured 50 ml of free water, administered R4's Zofran (dissolved in 15 ml of water) through the peg tube, provided 250 ml of Nutrent supplement through the tube, then flushed with 50 ml of water. On 03/03/26AM at 10:45 AM, LN G verified she had flushed R4's peg tube with 50 ml before and after R4's administration of Zofran, and 0 ml before peg tube feeding. LN G stated she had read the order wrong and should have flushed R4's peg tube with 100 mL before and after the peg tube feeding. On 03/04/26 at 11:02 AM, Administrative Nurse D stated she would expect the staff to verify the order, check placement, position the resident in the proper position, flush with water per physician order, give medication and supplement, then flush with physician ordered amount of water. The facility's Enteral Tube Feeding Policy, dated 12/12/23, documented for bolus supplementation, the pharmacy or facility would encode orders into the computer under the medication order entry program. Labeling and dispensing would be as with unit-dose medications.

The facility identified a census of 66. The sample included 18 residents. Based on observation, record review and interviews, the facility failed to identify and implement interventions for Resident (R) 19 to address a nine-day period with no bowel movement.Findings included: -R19's Electronic Medical Record (EMR) recorded a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R19's 11/07/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS recorded R19 required maximal assistance with transfers and toileting hygiene and was frequently incontinent of bowel. R19's 11/17/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R19 had a diagnosis of dementia with behaviors and had an order for medication. R19's Care Plan initiated on 11/07/25 and revised 12/29/25 noted R19 was at risk for altered nutrition and hydration related to dementia and chronic constipation. The plan noted R19 experiences pain related to osteoarthritis. Interventions dated 12/29/25 directed staff to administer medications as ordered and monitor for signs of constipation, such as abdominal distention, decreased bowel sounds, diarrhea, decreased appetite and no bowel movement for two days when administering narcotics. R19's Orders recorded the following physician orders.Enulose Solution (laxative) 10 grams per 15 milliliters (ml), give 30 ml in the morning for constipation dated 07/18/24.Milk of Magnesia suspension (laxative) 400 milligrams (mg) per ml, give 30 ml by mouth as needed for constipation daily, dated 10/27/24. Review of R19's bowel movement task record revealed R19 had a small bowel movement (BM) on 02/02/26 and then had no BM noted from 02/03/26 through 02/11/26. A medium BM was recorded on 02/12/26. Review of R19's February 2026 Medication Administration Record (MAR) revealed the Enulose was not administered on 02/04, 02/07, and 02/08 due to the resident was sleeping (indicated by a 13 on MAR). The MAR indicated the Milk of Magnesia was not administered in the month of February 2026. R19's Progress Notes from 02/02/26 through 02/12/26 lacked evidence a bowel assessment or abdominal assessment was conducted. On 03/03/26 at 09:56 AM, R19 sat on the edge of the bed while Licensed Nurse (LN) I administered his medication. R19 had difficulty swallowing his medications but was provided with juice and R19 was able to swallow the medications. On 03/03/26 at 12:14 PM, Certified Medication Aide (CMA) S reported that the staff has to document incontinence and bowel movements in separate tasks and when documenting the actual BM, she always documented the incontinence section first, as if she knew the resident was incontinent, she would document that even if they did not have a BM. Then, if the resident had a BM she would go back and document the BM. She reported that the dashboard only showed the CMA the last 24-48 hours for records of BM, and the charge nurse had to print off a BM sheet to reflect the last three days. She stated if a resident required any as needed medication for constipation, the charge nurse would give that direction. On 03/03/26 at 12:25 PM, LN I reported that the night nurse would print off the BM report for day shift nurse for residents and reported that it was just the size of BM or none in the past three days. He reported that the facility had a standing order if a resident did not have a BM for three days. LN I reviewed R19's bowel record for February 2026 and counted the nine days of no BM and confirmed the MAR did not indicate that any as needed constipation medications were administered. LN I said that nursing staff were responsible for completing an abdominal assessment when there was no BM and it should be documented in the EMR. On 03/04/26 at 09:12 AM, Administrative Nurse D said that she reviewed R19's BM record that was requested and went on to say that she did not believe the documentation that R19 had no BM during the nine-day period between 02/03/26 and 02/11/26. She stated R19's provider saw him on 02/11/26 and had no issues and said that an abdominal assessment was done then. Administrative Nurse D said she expected the nurse on night shift to run a BM report and give that to the day nurse so the resident could receive as needed bowel medications for constipation. She confirmed the facility had a bowel protocol standing orders and reported that she expected the staff to document in the EMR and to update the provider what interventions were given. She said she expected staff to complete and document an abdominal assessment until the resident had a BM. The facility's policy Bowel and Bladder Management, revised 01/06/26, directed all residents will have bowel patterns monitored each shift through CNA documentation in the electronic charting system. The licensed nurse on each shift will review the bowel report at the beginning of the shift and initiate the bowel protocol when indicated. When a resident has not had a bowel movement approaching three (3) days, the licensed nurse should assess the resident, including: the date and description of last bowel movement, presence of abdominal pain, cramping, nausea, or vomiting, bowel sounds and abdominal assessment, recent dietary and fluid intake, current medications, vital signs and signs of dehydration and stool characteristics (color, consistency, presence of blood, etc.). The bowel protocol is as follows:Step 1: Administer Milk of Magnesia (MOM) 30 ml orally.Step 2: If no bowel movement occurs within 24 hours, administer lactulose 20 ml orally every 2 hours for up to three (3) doses or until bowel movement occurs.Step 3: If no bowel movement occurs after lactulose administration, administer Dulcolax(Bisacodyl) suppository 10 mg per rectum.Step 4: If no bowel movement occurs following the suppository, administer one (1) Fleet enema.Step 5: If there is still no bowel movement following the above interventions, notify the provider for further evaluation and treatment orders.

The facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 12 had been assessed for the ability to safely self-administer his physician-ordered Fluticasone propionate nasal spray (a corticosteroid used to relieve allergy and nasal inflammation symptoms).Findings included:- R12's Electronic Medical Record (EMR) documented diagnoses of allergic rhinitis, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified dementia (progressive mental disorder characterized by failing memory, confusion).R12's Annual Minimum Data Set (MDS) dated 10/06/25 documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R12 used a wheelchair to assist with mobility and had no impairment in upper or lower extremities.R12's Quarter MDS dated 01/06/26 documented a BIMS score of 13, which indicated intact cognition. R12 used a walker or wheelchair to assist with mobility and had no impairment in upper or lower extremities.R12's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/06/25 documented he had his medications managed and overseen by the nurse and physician team.R12's Care Plan lacked documentation he kept Fluticasone Propionate Nasal Spray at his bedside.Review of R12's physician orders documented Fluticasone Propionate Nasal Suspension 50 micrograms per action, spray once in both nostrils one time a day for allergic rhinitis, dated 10/03/24.R12's Assessment tab lacked the Self-Administration of Medication/Treatment Data Collection Tool for Fluticasone Propionate Nasal Spray.On 03/02/26 at 09:09 AM, R12 was seated in his recliner with his feet raised, listening to music. On the dresser right in front of his recliner sat a bottle of Fluticasone Propionate Nasal Spray. R12 stated he did his own nasal spray. R12 reported the nasal spray was not on a schedule, and he took it when he was stopped up.On 03/04/26 at 11:25 AM, the Fluticasone Propionate Nasal Spray sat on R12's dresser. Licenses Nurse (LN) H confirmed that is what was on R12's dresser and that if he had that in his room, he would have been assessed to keep the medication in his room. LN H reviewed R12's chart and confirmed that he did not have the assessment to keep Fluticasone Propionate Nasal Spray in his room. LN H stated she would get that off of R12's dresser and remove it from his room due to him not having the assessment indicating he could keep it in his room.On 03/04/26 at 12:28 PM, Administrative Nurse D stated that if there was no assessment completed for self-administration of the medication, then the resident could not keep any medications in his room. Administrative Nurse D stated R12 should not have had the nasal spray in his room.The facility's undated Self-Administration of Medication policy documented self-administration of medications by residents was generally allowed. The policy documented the competency of the resident was assessed prior to allowing a resident to self-administer medications by the interdisciplinary team. The procedure directed that an assessment would be performed annually and after a significant change of condition.

The facility identified a census of 66. The sample included 18 residents. Based on record review and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 65.Findings included:-R65's Electronic Medical Record (EMR) recorded diagnoses of irritable bowel syndrome, hypertension (high blood pressure), chronic respiratory failure, and urine retention.R65's admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS noted R65 was dependent upon staff assistance for toileting, dressing, and transfers. She had one non-injury fall.R65'S 12/18/25 Falls Care Area Assessment (CAA) triggered secondary to impaired balance with transitions and transfers and her need for assistance with activities of daily living. The CAA noted contributing factors included restricted mobility, medication usage, a need for assistance with transfers and a urinary catheter (tube inserted into the bladder to drain urine). Her risk factors included falls and injuries from falls, pain, and skin breakdown. A care plan would be reviewed to assist in preventing falls and injuries related to falls. R65's Care Plan recorded one Focus, related to activities initiated on 12/08/25. The interventions, initiated on 12/08/25, directed staff to assist R65 to and from activities and to educate the resident daily of the available activities. The plan lacked further Focus areas, goals or interventions.On 03/04/26 at 08:36 AM, Licensed Nurse (LN) J reported that the MDS nurse would complete the comprehensive care plan within 21 days of admission.On 03/04/26 at 09:40 AM, Administrative Nurse E stated R65's Care Plan should have been completed in the timeframe of 21 days and said that R65 had moved the skilled side to the long-term care side around the holidays. Administrative Nurse E stated she had not realized R65's comprehensive plan had not been developed. On 03/04/26 at 01:55 PM, Administrative Nurse D said she expected the admission comprehensive care plan to be completed within 21 days of admission.The facility provided the policy Care Plan Revisions revised on 01/18/26, which noted the Care Planning process included patient assessment, goal setting, interventions, referrals to other health care professionals, evaluation of patient responses to treatment and revision of care and treatment in order to meet the patient's needs.

The facility identified a census of 66. The sample included 18 residents. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 39 received the necessary staff assistance with oral hygiene.Findings included:- R39's Electronic Medical Record (EMR) recorded a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R39's 01/21/26 Annual Minimum Data Set (MDS) documented R39 had a Brief Interview for Mental Status (BISM) score of five, which indicated severe cognitive impairment. The MDS noted R39 was dependent upon staff assistance for oral hygiene.R39's Care Plan recorded interventions dated 12/31/25, which directed staff that R39 required supervision and partial/moderate assistance with eating. He required moderate assistance for oral hygiene tasks and staff should encourage and/or assist him with oral care in the morning and evening. R39's Orders noted an order dated 02/20/25 for staff to offer to brush R39's teeth twice daily (every shift). The consultant dentist's visit summary dated 08/04/25 documented R39 was missing teeth #28-31 (right lower teeth). The cleaning summary noted R39 had heavy food debris, moderate to severe inflammation of the gums, and his oral hygiene was poor though he was cooperative with the cleaning. The summary included directions to staff to please remind/assist R39 with brushing twice daily, focusing on the gumline. The visit summary dated 01/26/26 noted no new findings. The summary indicated R39 had moderate to heavy food debris and generalized severe gum inflammation. R39 had poor oral hygiene but he was cooperative with the cleaning procedure. The summary left directions to staff to remind and/or assist R39 to brush twice daily, focusing on the gumline. Observation on 03/03/26 at 07:50 AM revealed staff assisted R39 with morning care but did not offer oral care at that time. Observation on 03/03/26 at 08:15 AM revealed R39 had a battery-operated toothbrush as well as toothpaste in his bathroom in an emesis basin. The emesis basin and the toothbrush were dry. On 03/02/26 at 10:31 AM, R39's representative reported she was concerned that the staff does not perform oral care on R39 as they should. She reported that she did address these concerns at the care plan meeting she attended about a month ago. On 03/03/26 at 10:23 AM, Licensed Nurse (LN) I reported that he did not provide oral care to R39. He just signed it off on the treatment record and followed up with the aides to make sure they completed it during morning care. On 03/03/26 at 12:08 PM, Certified Nurse Aide (CNA) M reported that she would usually do R39's oral care after breakfast. CNA M said she did not provide R39 oral care that day as she forgot to do it. CNA M verified that R39 could not brush his own teeth. On 03/04/26 at 09:12 AM, Administrative Nurse D revealed she expected the staff to complete R39's oral care. The facility policy Oral Health Care, revised 02/10/25 documented every resident will receive oral care twice daily to ensure the highest level of oral health and oral function.

The facility reported a census of 66 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.Findings included:- On 03/03/2026 at 07:30 AM, observation revealed two garbage receptacles outside, one on the east side and one on the west side. The garbage receptacle outside of the [NAME] House had the lid open on one side, and there were several bags of garbage behind the dumpster that had holes in them as if broken open, gloves, food, and other medical supplies noted. There was garbage on the ground on the side of the dumpster. Dietary CC reported that the lids should always be closed, and the garbage behind and on the side of the container should not be there. On 03/03/2026 at 10:35 AM, Dietary BB reported that there should be no garbage on the ground at the trash dumpsters and the lids should be closed. On 03/03/2026 at 12:30 PM, Administrative Staff A reported that she had been working on a little project regarding the dumpster. She stated the dumpster that had garbage on the ground around it was small, and she was trying to get a new one. She reported she expected the staff to close the lids and not have garbage on the ground. The facility's policy Disposal of Garbage and Refuse Policy, revised on 01/14/26, documented the facility would maintain all outside dumpsters and surrounding refuse storage areas in a clean, sanitary, and well-maintained condition to prevent the creation of a nuisance, pest attraction, or potential contamination risk to food service operations, residents, staff, or visitors.

The facility identified a census of 64 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to ensure Resident (R) 12 was administered her scheduled morning medications within the ordered timeframe. The facility failed to ensure the insulin (a hormone that lowers the level of glucose in the blood) pen and needle were appropriately primed before insulin administration to R161. This resulted in a medication error rate of 46.15%. Findings included: - On 04/22/24 at 12:20 PM Certified Medication Aide (CMA) WW washed her hands and returned to her medication cart to begin dispensing medications for R12. CMA WW pulled up R12's Medication Administration Record (MAR) and pulled R12's medication cards from the medication cart. CMA WW dispensed each medication (listed below) into a medication cup. CMA WW walked with the medication cup over to R12 who sat at the dining table eating lunch. R12 placed several of her medications in her hand at a time and placed them in her mouth and swallowed them without difficulty. R12 continued to place her medications into her mouth until all the pills had been taken. CMA WW returned to her medication cart and laptop to sign off on the medication that R12 had taken. On 04/22/24 at 12:42 PM, Licensed Nurse (LN) J was administering R161 his scheduled lispro insulin. LN J washed her hands and unlocked her cart to gather R161's insulin pen, disposable needle, and an alcohol wipe. LN J verified the amount to administer by looking at R161's MAR. LN J walked over to R161's room after locking her medication cart and the screen on her laptop. LN J donned clean gloves. LN J then knocked on R161's door, she announced herself and told R161 what she was there for. LN J entered R161's room and walked over to where he was seated. LN J took the lid off the insulin pen she held in her hand and opened an alcohol wipe to wipe the hub of the pen for several seconds with the alcohol wipe. LN J then opened the disposable insulin needle and screwed it onto the end of the insulin pen. LN J dialed the insulin pen to 15 units. LN J opened another alcohol wipe as she lifted the sleeve of R161's shirt and wiped his right upper arm with the alcohol wipe and then inserted the insulin needle into R161's arm and administered the insulin. LN J failed to prime the pen and needle with two units of insulin before the administration of the 15 scheduled units. A review of R12's physician's orders revealed a scheduled administration time of 08:00 AM for her omeprazole (a medication used to treat acid reflux) 40 milligrams (mg), probiotic (a supplement taken to improve the good bacteria in the digestive system), ferosul (iron supplement), Thera-m (a multivitamin supplement), acetaminophen (pain reliever, fever reducer), and aspirin. Review of R12's physician's orders revealed a scheduled administration time of 06:00 AM to 10:00 AM for the following medications: nebivolol (a medication used to treat high blood pressure), potassium chloride (a medication used for treatment of low potassium), lisinopril-hydrochlorothiazide (a combination medication used to lower blood pressure and a medication used to rid the body of extra salt and water), and fluticasone propionate nasal suspension (a medication used to treat season and year-round allergies). R12 was administered the above physician-ordered medications outside of the allowable timeframe for medication administration which included up to one hour before and one hour after the scheduled administration time of 08:00 AM and 06:00 AM to 10:00 AM. On 04/22/24 at 01:00 PM, CMA WW stated she was the only CMA passing medications to two houses and she had gotten behind today. CMA WW stated R12's medications should be administered no more than one hour before or one hour after the scheduled time. On 04/22/24 at 12:45 PM, LN J stated she was not aware that the insulin needle needed to be primed before the administration of the insulin. LN J could not say what the policy for insulin administration said. On 04/22/24 LN G stated it was common standard of practice to prime the insulin pen and needle with two units before the scheduled amount. LN G stated she would be re-educating her nursing staff regarding this. LN G stated all medication was expected to be administered within a one-hour window before or after the scheduled time. LN G stated there should not be any reason for R12's medications to be administered late. LN G stated on the long-term care side the nurse and the CMA both should be administering the medication and expected to get all medications given on time. On 04/22/24 at 02:24 PM Administration Nurse D stated she expected staff to prime the insulin pen/needle with two units before administration. Administrative Nurse D stated that was just standard practice and expected her nursing staff to be aware of that. Administrative Nurse D stated she expected nursing staff administering medications to make sure the medications were given within the one-hour window before or after the scheduled time. Administrative Nurse D stated R12 had many medications had a scheduled time between 06:00 AM and 10 AM and should be no reason for the medications to be late. The facility policy Medication Administration last revised 01/16/24 documented: that this facility implements a liberalized medication administration policy for timing of medication administration. In the event the medication was ordered more than daily, the time of administration would be written on the MAR, accompanied by the initials verifying administration and time of administration of the medications. The facility failed to ensure the medication error rate did not exceed five percent when staff failed to ensure R 12 was administered her scheduled morning medications within the allowable timeframe. The facility failed to ensure the insulin pen and needle were appropriately primed before insulin administration to R161. This resulted in a medication error rate of 46.15%.

The facility identified a census of 64 residents. The facility had four medication carts. Based on observation, record review, and interview, the facility failed to ensure accurate reconciliation of controlled substances (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently. This placed residents at risk of medication misappropriation and diversion. Findings included: - On 04/22/24 at 09:18 AM, an observation of the medication cart on [NAME] House revealed the narcotic reconciliation sign-off sheets from 03/07/24 to 03/31/24 lacked a signature on 11 of 152 opportunities. On 04/22/24 at 09:18 AM, an observation of the medication cart on [NAME] House revealed the narcotic reconciliation sign-off sheets from 04/01/24 to 04/21/24 lacked a signature on 16 of 136 opportunities. On 04/22/24 at 11:26 AM Certified Medication Aide (CMA) S stated that the narcotic sign-on and off sheet should be signed after the narcotic count has been completed and the keys to the medication cart have been exchanged between the off-going and the oncoming staff member. On 04/22/24 at 02:11 PM, Licensed Nurse (LN) G stated she expected staff to be signing on and off on the narcotic count sheet at the beginning and end of each shift after the narcotic count was completed and the medication cart keys had been exchanged between the off-going nurse or CMA and the oncoming staff. On 04/22/24 at 02:24 PM Administrative Nurse D stated the narcotic sign-on and off sheets were expected to be signed by the off-going and the on-coming nursing staff at the end and beginning of each shift exchange of the keys for the medication cart. The facility did not provide a policy for controlled medication reconciliation. The facility failed to ensure an accurate reconciliation of controlled substances was consistently completed. This placed residents at risk of medication misappropriation and diversion.

The facility identified a census of 64 residents. The facility had four medication storage refrigerators and four medication carts. Based on observation, record review, and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk of adverse side effects and ineffective medication administration. Findings included: - On 04/22/24 at 07:32 AM the medication refrigerator on the [NAME] House was left unlocked, and there was insulin (a hormone that lowers the level of glucose in the blood) for several residents unsecured. On 04/22/24 at 07:36 AM the medication refrigerator on [NAME] House was left unlocked and insulin for residents was unsecured. The inside of the refrigerator had a large amount of ice formation at the top. On 04/22/24 at 07:38 AM a medication cart on [NAME] House was left unlocked, and there was no nursing staff around the cart to monitor. The Nursing Facility Surveyor (NFS) stayed at the cart until Licensed Nurse (LN) H came and locked the cart. On 04/22/24 at 07:40 AM LN H stated all carts should be locked unless the staff was in site of the cart. LN H stated when a refrigerator was opened for medication it should be immediately locked after each medication pass. On 04/22/24 at 02:24 PM Administrative Nurse D stated she expected nursing staff to keep the medication carts and the medication refrigerators locked when not used. Administrative Nurse D stated nursing staff should lock the medication cart every time they stepped away from the cart or were out of direct sight of the cart. The facility policy Medication Storage last revised 02/14/24 did not address the storage of medications in the medication carts or medication refrigerators. The facility failed to ensure safe and secure storage of medications and biologicals which created a risk for adverse medication effects and ineffective medication administration.

The facility identified a census of 64 residents. The facility identified 25 residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on observations, record review, and interviews, the facility failed to ensure consistent infection control standards were followed related to enhanced barrier precautions, storage of oxygen tubing, indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care, laundry, and shared equipment. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings Included- - On 04/22/24 at 08:00 AM an inspection of the identified EBP rooms revealed Resident (R)45 and R8's rooms lacked the required signage identifying the precautions needed to provide care. All 25 of the reviewed enhanced barrier precaution rooms stored the personal protective equipment (PPE) inside the rooms. An inspection of the facility's [NAME] House laundry room revealed soiled pillows, clothing, and a foot brace lying directly on the floor. On 04/22/23 at 08:19 AM an inspection of R210's room revealed her supplemental oxygen tubing and nasal cannula (tubing that delivers oxygen directly through both nostrils of the nose) draped over the back of the stationary oxygen machine. An inspection of her portable oxygen cylinder revealed the tubing draped over the oxygen cylinder. No clean storage bags or containers were available in her room to store the oxygen tubing. The tubing remained outside of a sanitary storage device until staff provided bags on the morning of 04/23/24. On 04/22/24 at 09:07 AM R44 slept in his bed. His bed was in the lowest position with a fall mat positioned on the floor to the left side. R44's urinary catheter bag lay on the floor at the foot of his bed on the right side. At 11:10 AM R44's catheter bag remained on the floor. On 04/23/24 at 08:38 AM Certified Nurse Aide (CNA) M pushed the Hoyer (total body mechanical lift) out of R45's room back into the hallway after use and returned to R45's room without disinfecting the lift after use. On 04/23/24 at 08:32 AM Licensed Nurse (LN) K prepared R42's enteral feeding (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) supplies. R42 was on EBP due to her percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). LN K failed to wear the required gown while administering R42's enteral feeding. On 04/23/24 at 09:02 AM Licensed Nurse (LN) K completed hand hygiene and gathered supplies for catheter care for R44. LN K donned gloves and a gown and placed the catheter care supplies on the resident's bedside table. LN K adjusted the table knocking over two small bottles from the table onto the floor. LN G picked up the items with her gloved hands and placed them back on the table. Wearing the same gloves, LN K removed R44's covers and unfastened his incontinence brief. LN K inspected R44's groin area and refastened his brief. LN K unfastened R44's catheter stat-lock (device to stabilize the catheter tubing) and prepped the catheter port to be flushed. LN K wiped the catheter port with a sanitary wipe. LN K filled a syringe with 60 milliliters (ml) of saline solution. LN K grabbed R44's catheter port and flushed 60ml of saline solution. R44 became agitated and requested the task be stopped. LN K then removed her gloves but failed to complete hand hygiene before donning clean gloves. LN K wiped R44's catheter port and reattached the stat-lock. LN K repositioned R44 and gathered the supplies used. LN K stated staff were expected to check R44's catheter collection bag placement during each encounter to ensure it was not on the floor. On 04/24/24 at 09:30 AM R44 rested in his bed. His urinary catheter collection bag lay on the floor of the right side of his bed. Yellow urine pooled in the tubing as the bag sat on the floor. Certified Nurses Aid (CNA) UU stated R44's urine collection bag should be attached to the bed and never be on the floor due to contamination risks. She reattached R44's catheter collection bag to his bed. On 04/23/24 at 09:30 AM LN K stated hand hygiene should be completed in between PPE use or when visibly soiled. She stated the urinary collection bag should be secured to the bed and never allowed to touch the floor. On 04/24/24 at 07:30 AM, CNA UU stated the unit's staff were responsible for completing the resident's laundry and maintaining the items in the laundry room. She stated items should never be left on the floor. She stated catheter bags should be stored on the bed or below the level of the bladder and oxygen equipment should be stored in a bag when not in use. She stated hand hygiene should be completed before, during, and after care with the residents. On 04/24/24 at 12:43 PM Administrative Nurse D stated staff were expected to complete hand hygiene and glove changes whenever visibly soiled or in between glove changes. She stated that shared equipment and lifts were disinfected weekly. She stated oxygen tubing and equipment were to be stored in a clean bag when not in use. She stated signage should be posted inside the enhanced barrier precautions rooms along with the personal protective equipment. She was not able to explain what enhanced barrier precautions were or used for. She stated the facility stored the equipment inside the rooms due to the high number of residents on enhanced barrier precautions in the facility. The facility's Infection Control policy revised 07/2023 indicated the facility will ensure the safe handling of medications, medical equipment, laundry, and environment to prevent the transmission of communicable diseases and avoid preventable infections. The policy indicated staff will follow designated standards and contact precautions per federal standards and Centers for Disease Control (CDC) guidelines. The facility's Enhanced Barrier Precautions revised 01/2024 indicated precautions will be implemented for residents with known colonized or targeted drug-resistant organisms for a resident with open wounds, urinary catheters, PEG tubes, and increased risks for infections related to open skin sites. The facility failed to ensure consistent infection control standards were followed related to EBP, oxygen equipment, indwelling catheter care, laundry, and shared equipment. These deficient practices placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to protect Resident (R)25 and other vulnerable residents during the facility investigation after an abuse allegation. This placed R25 and the other residents under the care of Certified Nurse Aide (CNA) TT at risk for unidentified and ongoing abuse and /or neglect. Findings included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, lower extremity deep vein thrombosis (potentially life-threatening blood clot, usually in the legs), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, and confusion). R25's Admission Minimum Data Set (MDS) completed 01/25/24 noted a Brief Interview for Mental Status score of 13 indicating mild cognitive impairment. The MDS indicated she required touch assistance for bathing, toileting, dressing, bed mobility, personal hygiene, and transfers. The MDS noted she had a history of falls. The MDS noted no behaviors or care refusals. R25's Functional Abilities Care Area Assessment (CAA) completed 01/25/24 indicated she required staff assistance to complete her activities of daily living (ADLs). The MDS indicated she had venous wounds to her left lower heel. R25's Pressure Ulcer CAA completed 01/25/24 indicated she had a venous ulcer (wound caused by poor blood circulation) to her lower left extremity. The CAA instructed staff to implement pressure-reducing devices and frequent repositioning. R25's Care Plan initiated 02/11/24 indicated she required supervision for bed mobility, dressing, transfers, meals, bathing, personal hygiene, and toileting. The plan noted she was at risk for pain related to her neuropathy and lower left extremity wound. The plan instructed staff to inspect her for skin breakdown, complete skin checks, and encourage adequate nutrition. The plan instructed staff to respect her wishes, concerns, and preferences. The plan encouraged her to verbalize her fears and concerns. The plan encouraged her to discuss her depression and anxiety. The plan lacked evidence showing a history of accusations and behaviors. R25's EMR under Progress Notes completed by Licensed Nurse (LN) L revealed a note entered on 03/19/24 at 02:36 AM. The note indicated R25 reported to nursing staff at 09:00 PM (03/18/24) that the CNA taking care of her hurt her leg and was rough with her. The note indicated R25 was sobbing and crying. The progress note lacked evidence the situation was reported to the administrator, physician, and family. A Resident/Family Concern form completed 03/19/24 at 07:20 AM indicated R25 reported to Administrative Nurse E that during her shower the previous evening (03/18/24) R25 requested her plastic wound covering be rolled hallway down and cut off after her shower was completed. R25 reported instead of cutting it off staff pulled her wound cover plastic off her leg causing severe pain and burning sensations to her wounded leg. The grievance was signed by Administrative Nurse E and Administrative Staff A. The note indicated LN L was placed on the Do Not Return (DNR) list for the facility after the incident occurred. A review of the facility's investigation completed on 03/19/24 indicated no protective measures, corrective actions, or additional training occurred after the abuse allegation was made known to the facility. A review of Certified Nurse's Aides (CNA) TT's timecard for 03/18/24 indicated she clocked in at 04:47 PM and clocked out at 09:41 PM. CNA TT's records indicated she returned to work on 04/20/24. On 04/24/24 at 11:15 AM R25 sat in her room on her bed. R25 stated she could not remember the specific incident but remembered staff pulling off her leg dressing and that she was left in pain. She stated staff pulled the cover off her wound. She stated she reported it to the facility. She stated she currently felt safe in the facility. On 04/23/24 at 03:45 PM Administrative Nurse D stated she was made aware of the issue, but the facility did not report the issue as an alleged abuse because she reviewed the cameras, and she did not feel the incident was abuse. She stated staff were expected to report abuse, separate the alleged perpetrator, and assess the resident's health/safety. On 04/24/24 at 10:23 AM Administrative Nurse E stated she was called to R25's room by staff to talk to R25 on 03/19/24 at 07:11 AM. She stated R25 was crying and reported she was hurt by the overnight staff during her shower. She stated R25 told her that the staff member pulled her protective plastic shower cover off her leg instead of cutting it off. She stated R25 preferred staff to cut the plastic cover off to prevent pain in her lower extremity wound. Administrative Nurse E stated she immediately reported the incident to Administrative Staff A and Administrative Nurse D at 07:15 AM. On 04/24/24 at 10:12 AM Administrative Staff A stated she was not notified of the allegation until Administrative Nurse E brought the grievance to her on 03/19/24. She identified the alleged perpetrator as Certified Nurses Aid (CNA)TT. She stated she was not notified by the night shift staff of the alleged abuse allegation. She stated LN L was placed on Do Not Return (DNR) status at the facility due to conflicts on the unit. She stated his DNR was not related to the abuse allegation. The facility's Reporting of Abuse Neglect, and Exploitation (ANE) policy revised 01/13/23 indicated all alleged abuse allegations will be immediately investigated by the facility. The policy indicated the resident would immediately be assessed and separated from the alleged perpetrator until a thorough investigation had been completed. The policy indicated the administrator will be immediately notified of all abuse allegations. The facility failed to protect R25 after an alleged abuse allegation. This placed R25 and the other residents under the care of CNA TT at risk for unidentified and ongoing abuse and /or neglect.

The facility had a census of 64 residents. The sample included 16 residents and three Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure three of the three CNA staff reviewed had the required 12 hours of in-service education which included the required dementia management training. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA N, hired on 01/19/23 lacked evidence of dementia in-service training. CNA O, hired on 06/16/20 lacked evidence of dementia in-service training. CNA P, hired on 02/21/22 lacked evidence of dementia in-service training. A review of the Elopement and Missing Resident in-service training provided by the facility included one slide titled Characteristics of dementia and progressive dementia but lacked direction for staff on interventions and methods of approach for residents with dementia. A review of the Communication in-service training provided by the facility included a slide titled Ten Tips for Improving Communication with a Resident with Dementia, but dementia lacked direction on providing care to residents with dementia and how to identify and implement interventions to promote quality of life for residents with dementia. On 04/24/24 at 08:25 AM, Administrative Staff A stated that required in-services were completed electronically. Administrative Staff A stated the dementia training was in the facility's elopement training and communication in-services. On 04/24/24 at 12:44 PM, Administrative Nurse D stated the facility's dementia training was provided electronically at the time of hire and annually. Administrative Nurse D stated she did provide some in-services to the facility staff monthly. Administrative Nurse D stated she was unsure if dementia was a required training topic. The facility's Required Training and In-Services of Staff policy dated 12/08/23 documented the facility developed, implemented, and maintains an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with defined and expected roles. The facility determines the amount and types of training necessary based on the Facility Assessment and individual training needs based on each staff member's performance evaluation. Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers will be consistent with expected roles. It is the policy of this facility that all certified personnel including but not limited to Certified Nurse Aides and Certified Medication Aides participate in regularly scheduled in-service training classes based on Federal Rules of Participation and on identified educational needs of each staff member through competency evaluation. The facility failed to ensure three CNA staff reviewed had dementia management training part of the required 12 hours of in-service education. This placed the residents at risk for inadequate care.

The facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 39's access site for complications at least daily and failed to obtain communication from the dialysis center related to R39's treatment. These deficient practices placed R39 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), end-stage renal disease (ESRD-a terminal disease of the kidneys), and dependence on dialysis. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R39 received dialysis during the observation period. R39's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 03/22/24 documented she required staff assistance with her toileting needs. R39's Care Plan dated 07/07/24 documented the facility would communicate R39's condition with the dialysis provider per a written communication form with each of R39's dialysis visits. The plan of care documented the nursing staff would monitor R39's arteriovenous (AV-a surgically created connection between an artery and a vein) fistula located in her left upper chest, every shift, before and upon return from dialysis for dislodgement, signs, or symptoms of infection such as redness, edema, or drainage. R39's EMR under the Orders tab revealed the following physician orders: Prepare dialysis paperwork every Monday, Wednesday, and Friday dated 06/13/23. Complete dialysis assessment day shift every Monday, Wednesday, and Friday dated 12/17/23. R39's clinical record revealed staff assessed the AV site after R39 returned from dialysis on Monday, Wednesday, and Friday but lacked evidence staff assessed the site on non-dialysis days and as needed. A review of R39's clinical record and information provided by the facility lacked evidence of communication between the facility and the dialysis provider on the following dialysis dates: 01/10/24, 01/19/24, 01/29/24, 01/31/24, 02/09/24, 02/26/24, 03/06/24, 03/15/24, 03/22/24, 03/27/24, 04/01/24, 04/08/24, and 04/22/24. On 04/24/24 at 09:20 AM R39 sat in her wheelchair at the dining room table and ate her breakfast without assistance. R39 sat and visited with several other residents. On 04/24/24 at 09:20 AM, Certified Nurse Aide (CNA) RR stated she assisted R39 with getting her dialysis bag together for R39's scheduled dialysis appointments. On 04/24/24 at 09:40 AM, Licensed Nurse (LN) G stated the nurse would fill out a communication form for R39 to take to the dialysis center and if the communication sheet did not return from the dialysis center when R39 returned, the nurse would call the provider. LN G stated the nurse would document that report from the dialysis center in R39's EMR under the progress note tab. LN G stated R39's AV fistula should be assessed, and the nurse would document the assessment under the assessment tab in R39's EMR. Ln g confirmed R39's EMR under the assessment tab lacked consistent documented assessment of R39's AV fistula. On 04/24/24 at 12:44 PM, Administrative Nurse D stated she expected R39's AV fistula to be assessed for bleeding and/or infection every shift and documented in her EMR. The facility's Hemo-Dialysis Policy dated 12/03/23 documented it was the policy of this facility to provide excellence in care and services to residents with End Stage-Renal Disease (ESRD) receiving heme-dialysis at a certified renal dialysis unit off-site. Facility staff would initiate a written communication form that would accompany the resident off-site to the Dialysis Unit and returned, completed by the Dialysis Unit staff for every visit. Facility staff would inspect and document the fistula site every day for a pulse-if a pulse is not palpated or cannot be auscultated with a stethoscope, notify the Dialysis Unit immediately. Facility staff would assess and document signs of infection daily. The facility failed to monitor R39's dialysis access site at least daily for signs of infection, bleeding, and the status of the dressing in place and failed to obtain communication from the dialysis center. These deficient practices placed R39 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 64 residents. The sample included 16 residents with three reviewed for urinary catheters (a tube inserted into the bladder to drain urine) care. Based on observations, record reviews, and interviews, the facility failed to follow standards of practices related to indwelling catheter care for Resident (R)44. This deficient practice placed R44 at risk for catheter-related complications including urinary tract infections (UTI). Findings included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), aphasia (a condition with disordered or absent language function), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R44's Annual Minimum Data Set (MDS) completed 01/18/24 noted a Brief Interview for Mental Status score of zero indicating severe cognitive impairment. The MDS indicated he required maximal assistance with transfers, bed mobility, bathing, personal hygiene, dressing, and mobility. The MDS indicated he had an indwelling urinary catheter. The MDS indicated he was at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). The MDS indicated he had pressure-reducing devices for his wheelchair and bed in place. The MDS indicated he weighed 164 pounds (lbs.) upon admission. R44's Pressure Ulcer Care Area Assessment (CAA) completed 01/25/24 indicated he returned from an acute care facility with a stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer to his coccyx (area at the base of the spine). The CAA indicated a care plan would address his pressure ulcer risks. R44's Urinary Catheter Care Area Assessment (CAA) completed 01/25/24 indicated he had neurogenic bladder dysfunction and required an indwelling urinary catheter. The CAA indicated a care plan would address catheter care needs. The MDS indicated he was dependent on staff for all his activities of daily living (ADLs). R44's Care Plan initiated on 04/06/23 indicated he was at risk for falls, skin breakdown, and an ADL deficit related to his medical diagnoses. The plan indicated he was dependent on staff to complete transfers, toileting, bed mobility, bathing, dressing, and personal hygiene. The plan instructed staff to provide urinary catheter care each shift. The plan instructed staff to check the tubing for kinks and ensure the catheter collection bag remained below the level of his bladder. On 04/22/24 at 09:07 AM R44 slept in his bed. His bed was in the lowest position with a fall mat positioned on the floor to the left side. R44's urinary catheter bag lay on the floor at the foot of his bed on the right side. At 11:10 AM R44's catheter bag remained on the floor. On 04/23/24 at 09:02 AM Licensed Nurse (LN) K completed hand hygiene and gathered supplies for catheter care for R44. LN K donned gloves and a gown and placed the catheter care supplies on the resident's bedside table. LN K adjusted the table knocking over two small bottles from the table onto the floor. LN K picked up the items with her gloved hands and placed them back on the table. Wearing the same gloves, LN K removed R44's covers and unfastened his incontinence brief. LN K inspected R44's groin area and refastened his brief. LN K unfastened R44's catheter stat-lock (device to stabilize the catheter tubing) and prepped the catheter port to be flushed. LN K wiped the catheter port with a sanitary wipe. LN K filled a syringe with 60 milliliters (ml) of saline solution. LN K grabbed R44's catheter port and flushed 60ml of saline solution. R44 became agitated and requested the task be stopped. LN K then removed her gloves but failed to complete hand hygiene before donning clean gloves. LN K wiped R44's catheter port and reattached the stat-lock. LN K repositioned R44 and gathered the supplies used. LN K stated staff were expected to check R44's catheter collection bag placement during each encounter to ensure it was not on the floor. On 04/24/24 at 09:30 AM R44 rested in his bed. His urinary catheter collection bag lay on the floor of the right side of his bed. Yellow urine pooled in the tubing as the bag sat on the floor. On 04/24/24 at 08:30 AM Certified Nurses Aid (CNA) UU stated R44's urine collection bag should be attached to the bed and never be on the floor due to contamination risks. On 04/24/24 at 12:43 PM Administrative Nurse D stated R44's urinary collection bag should be placed below the level of his bladder. She stated staff should be completing hand hygiene in between glove changes and when touching soiled surfaces or items. The facility did not provide a policy related to urinary catheter care as requested on 04/24/24. The facility failed to follow standards of practices related to indwelling catheter care for R44. This deficient practice placed R44 at risk for complications related to UTI.

The facility identified a census of 64 residents. The sample included 16 residents. One resident was sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 42's fall interventions as directed by her care plan. This deficient practice placed R42 at risk of falls and related injuries. Findings included: - R42's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), epilepsy (brain disorder characterized by repeated seizures), a feeding tube (tube for introducing high-calorie fluids into the stomach), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the facility was unable to conduct a Brief Interview of Mental Status (BIMS) score, R42's MDS documented the resident was rarely or never understood. The MDS documented R42 was dependent on staff for all activities of daily living (ADLs). R42's Falls Care Area Assessment (CAA) dated 06/05/23 documented R42 was at risk for falls related to poor safety awareness and a history of falls. R42 used a wheelchair for mobility. She required staff assistance with transfers and mobility. She had a history of falls with interventions in place. R42 was at risk of falls related to her impaired physical mobility. R42's Care Plan dated 02/03/23 documented that staff would arrange R42's bed next to the wall, and her bed would be in the lowest position. R42's Care Plan dated 03/21/23 documented staff would place a fall mat next to the bed for R42's safety. On 04/22/24 at 07:38 AM R42 laid in bed on her right side, with her eyes shut. R42's floor mat was rolled up next to her small dresser and the bathroom door. R42's bed was pulled away from the wall. On 04/23/24 at 07:36 AM R42 lay in bed on her back, her feet were pulled up next to her chest at times and moving randomly in the air. R42's fall mat was not in place next to her bed and her bed was pulled away from the wall. On 04/24/24 at 08:08 AM Licensed Nurse (LN) I stated every nursing staff member was responsible for the care of each resident. LN I stated all staff members can find the fall precautions for each resident in the care plan. LN I stated each time care plans were updated; it was discussed in the morning during the facility's huddle and report. LN I stated R42's fall mat should have been in place on the floor next to her bed while she was in her bed. On 04/24/24 at 09:00 AM Certified Nursing Aide (CNA)P stated all nursing staff were responsible for the safety of each resident. CNA P said nurses were responsible for ensuring all fall precautions were in place and stated the CNAs got updates for each resident in the report before their shift. CNA P said she was unaware R42's bed should be against the wall. On 04/24/24 at 12:43 PM Administrative Nurse D stated if R42 was in bed, the fall mats should have been in place and the bed should be against the wall. Administrative Nurse D stated all facility nurses knew where the care plans, were. She stated nursing staff knew where the fall preventions were in the care plan. The facility's Falls policy revised on 01/18/24 documented each patient residing at eh facility is provided services and care that ensures that the patients' environment remains as free from accident hazards as possible and that injuries are minimized. The facility failed to ensure R42's bed was next to the wall, and that her fall mats were in place while R42 was in her bed. This deficient practice placed R42 at risk of falls.

The facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to ensure staff reported an allegation of staff-to-resident abuse for Resident (R) 25 to the facility administrator immediately. The facility additionally failed to report R25's allegation of abuse to the State Agency (SA) as required. This placed R25 at risk for unidentified and ongoing abuse and /or neglect. Findings included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, lower extremity deep vein thrombosis (potentially life-threatening blood clot, usually in the legs), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, and confusion). R25's Admission Minimum Data Set (MDS) completed 01/25/24 noted a Brief Interview for Mental Status score of 13 indicating mild cognitive impairment. The MDS indicated she required touch assistance for bathing, toileting, dressing, bed mobility, personal hygiene, and transfers. The MDS noted she had a history of falls. The MDS noted no behaviors or care refusals. R25's Functional Abilities Care Area Assessment (CAA) completed 01/25/24 indicated she required staff assistance to complete her activities of daily living (ADLs). The MDS indicated she had venous wounds to her left lower heel. R25's Pressure Ulcer CAA completed 01/25/24 indicated she had a venous ulcer (wound caused by poor blood circulation) to her lower left extremity. The CAA instructed staff to implement pressure-reducing devices and frequent repositioning. R25's Care Plan initiated 02/11/24 indicated she required supervision for bed mobility, dressing, transfers, meals, bathing, personal hygiene, and toileting. The plan noted she was at risk for pain related to her neuropathy and lower left extremity wound. The plan instructed staff to inspect her for skin breakdown, complete skin checks, and encourage adequate nutrition. The plan instructed staff to respect her wishes, concerns, and preferences. The plan encouraged her to verbalize her fears and concerns. The plan encouraged her to discuss her depression and anxiety. The plan lacked evidence showing a history of accusations and behaviors. R25's EMR under Progress Notes revealed a note entered on 03/19/24 at 02:36 AM. The note indicated R25 reported to nursing staff at 09:00 PM (03/18/24) that the Certified Nurse's Aide (CNA) taking care of her hurt her leg and was rough with her. The note indicated R25 was sobbing and crying. The progress note lacked evidence the situation was reported to the administrator, physician, and family. A Resident/Family Concern form completed 03/19/24 at 07:20 AM indicated R25 reported to Administrative Nurse E that during her shower the previous evening (03/18/24) R25 requested her plastic wound covering be rolled hallway down and cut off after her shower was completed. R25 reported instead of cutting it off staff pulled her wound cover plastic off her leg causing severe pain and burning sensations to her wounded leg. The grievance was signed by Administrative Nurse E and Administrative Staff A. On 04/24/24 at 11:15 AM R25 sat in her room on her bed. R25 stated she could not remember the specific incident but remembered staff pulling off her leg dressing and that she was left in pain. She stated staff pulled the cover off her wound. She stated she reported it to the facility. She stated she currently felt safe in the facility. On 04/23/24 at 03:45 PM Administrative Nurse D stated she was made aware of the issue, but the facility did not report the issue as an alleged abuse because she reviewed the cameras, and she did not feel the incident was abuse. She stated the incident was not reported to the SA. She stated staff were expected to report all alleged allegations of abuse to the administrator immediately and notify the SA. She reported the facility had annual abuse, neglect, and exploitation in-service training. On 04/24/24 at 10:23 AM Administrative Nurse E stated she was called to R25's room by staff to talk to R25 on 03/19/24 at 07:11 AM. She stated R25 was crying and reported she was hurt by the overnight staff during her shower. She stated R25 told her that the staff member pulled her protective plastic shower cover off her leg instead of cutting it off. She stated R25 preferred staff to cut the plastic cover off to prevent pain in her lower extremity wound. Administrative Nurse E stated she immediately reported the incident to Administrative Staff A and Administrative Nurse D at 07:15 AM. On 04/24/24 at 10:12 AM Administrative Staff A stated she was not notified of the allegation until Administrative Nurse E brought the grievance to her on 03/19/24. She stated the allegation was not reported to the SA because R25 had a history of making complaints towards staff and the facility reviewed the situation and felt it was not abuse. She identified the alleged perpetrator as Certified Nurses Aid (CNA)TT. She stated she was not notified by the night shift staff of the alleged abuse allegation. The facility's Reporting of Abuse Neglect, and Exploitation (ANE) policy revised 01/13/23 indicated all alleged or suspected mistreatment, neglect, or abuse will be immediately reported to the facility's administrator. The policy indicated the facility will also report. The facility failed to ensure staff immediately notified the administrator of an allegation of abuse and additionally failed to report the allegation of abuse to the SA. This placed R25 at risk for unidentified and ongoing abuse and /or neglect.

The facility reported a census of 64 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow the physician-ordered parameters related to Resident (R)17's as-needed (PRN) bumetanide (diuretic- medication to promote the formation and excretion of urine). This deficient practice placed R17 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), left femur (large leg bone) fracture (bone break), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R17's Quarterly Minimum Data Set (MDS) completed 04/05/24 noted a Brief Interview for Mental Status score of 11 indicating mild cognitive impairment. The MDS indicated she required touch assistance for transfers, bed mobility, dressing, bathing, personal hygiene, and ambulation. The MDS indicated she took diuretic medication. R17's Urinary Incontinence Care Area Assessment (CAA) completed 01/15/24 indicated she was incontinent of the bladder. The CAA indicated she required partial assistance to the restroom. The CAA indicated she took diuretic medications to assist with her edema. R17's Care Plan initiated 04/09/24 indicated she took medications with Black Box Warnings (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration). The plan indicated she took bumetanide and instructed staff to monitor for weight gain or loss. R17's EMR indicated she was to be weighed every Wednesday and Sunday morning. R17's EMR under Physician's Order revealed an order (dated 01/02/24) instructing staff to administer two milligrams of bumetanide by mouth twice daily for edema. The order instructed staff to monitor R17's weight and administer an additional two milligrams PRN for weight gains over (>) three pounds (lbs.). R17's Medication Administration Report (MAR) indicated the PRN medication had not been administered since ordered. R17's EMR under Weight History indicated she had weight gains of over three pounds on 01/14/24 (3.5 lbs.), 01/21/24 (7.0 lbs.), 03/20/24 (4.0 lbs.), 04/07/24 (4.0 lbs.) and 04/14/24 (3.5 lbs.). On 04/22/24 at 08:03 AM R17 sat in her recliner. Her feet were propped out in the recliner. She reported no pain or current swelling in the lower extremities. R17 reported she completed most of her ADLs with minimal assistance needed. R17 walked to the dining room using her support walker. On 04/24/24 at 10:21 AM Licensed Nurse (LN) G stated nurses would follow the parameters given for diuretic medications and notify the physician if changes occurred for the medications or weights. She stated R17 had concerns with her lower extremity edema but was walking better now. On 04/24/24 at 12:43 PM Administrative Nurse D state staff were expected to follow the ordered parameters of the physicians. She stated the PRN medication should have been given for R17 if her weight increased over three pounds. The facility's Medication Administration policy revised 01/2024 indicated staff will ensure adequate monitoring and medication with black box warnings and significant risks. The policy indicated staff will follow the physician's intended indication and instructions for medication administrations. The facility failed to follow the physician-ordered parameters related to R17's PRN diuretic medication. This deficient practice placed R17 at increased risk for unnecessary medication and side effects.

The facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to ensure infection control practices when direct care staff did not change gloves when going from dirty to clean areas while providing care to Residents (R) 41 and R25. The facility also failed to ensure all staff members and visitors appropriately completed all COVID-19 (respiratory virus) screening, including temperature and signs/symptoms questionnaire. These failures had the ability to affect all 69 residents in the facility. Findings included: - The 08/29/22 through 08/31/22 COVID Screening Sheets were reviewed in each house for thorough completion. Of the 84 sheets reviewed, 42 of the sheets lacked documentation of a recorded temperature or completion of the COVID signs and symptoms questions. On 08/30/22 at 12:31 PM Certified Nurse Aide (CNA) D opened the house door for a visitor to enter the facility. CNA D did not ask the visitor to complete the screening, nor was screening offered or completed by the resident. Visitor entered the building without a mask and walked around the common area. CNA D did not notify the visitor about the mask requirement. CNA D was observed walking away to a resident room, then reappeared at 12:42PM to open the door for a second visitor. This visitor was not asked about screening or offered screening. On 08/30/22 at 12:45PM, a visitor opened the front door for a third visitor, both bypassing the screening at the front door. Visitors observed walking into the common area of the house, without being prompted by staff to complete screening. An interview on 08/30/22 at 12:44 PM with Administrative Nurse C revealed visitors were required to screen for COVID at the main door to the facility Monday through Friday during business hours of 07:00AM through 05:00PM. After screening at the main door, the visitor could come to the resident house they are visiting. Once in the house, the staff would let the visitor in, and the staff were expected to ask if the visitor completed screening at the main door. During off hours and on weekends, visitors would screen for COVID at the house they were visiting. All staff were required to complete self-screening upon entrance into the house they work. All visitors were required to wear a mask in the common area. All the COVID screening were completed on the honor-system, meaning the screening was self-directed and not verified by a staff member. Administrative Nurse C stated that allowing visitors to enter the building without being screened or wearing a mask, was not standard practice. An interview on 08/31/22 at 07:53AM with Administrative Nurse B revealed all staff were required to self-screen for COVID at the beginning of each shift, including temperature and the questions and then sign the sheet. Staff members who work directly in one house, screened themselves at the house they work in, while all other staff members were required to self-screen at the facility's main door. Visitors were required to be screened at the facility's main door Monday through Friday during business hours. During the weekend and on off-hours, visitors could be screened at the house they were visiting. Visitors were required to always wear a mask while in the common area of the house and should be screened by staff, not self-screened. An interview on 08/31/22 at 11:20 AM with Administrative Nurse I revealed staff should screen all visitors upon entry into the building and ensure the screening paper was completed correctly. Staff completed self-screening without verification from another staff member and should always be completed thoroughly. The 02/16/22 Staff, Vendor and Visitor Screening during Pandemic (including COVID-19) policy documented the charge nurse in each house or management team member were to screen staff, visitors, and vendors, which included temperature, screening questions, observe handwashing, complete the log, and place a colored sticker (in a visible area) on the staff member, visitor. or vendor. Staff were to wash their hands, complete screening with the charge nurse, and then clock in for their shift. The facility failed to ensure all persons entering the facility appropriately completed the COVID screening sheets. - On 8/29/22 at 11:40 PM observation revealed Certified Medication Aide (CMA) E provided care to Resident (R) 41 prior to the noon meal. With gloved hands CMA E turned the resident to her back and pulled the resident's pants down to check the resident's brief. The brief was soiled and CMA E removed the brief touching the inside of the brief, then pulled R41's pants back into place. The staff then pivoted the resident to the side of the bed and transferred the resident into a wheelchair. CMA E then took the resident's dentures out of a denture cup and placed them in the resident's mouth, with the same gloved hands she wore to check the residents brief, and then she transferred the resident to the wheelchair. On 08/29/22 at 11:55 AM CMA E reported she did not think about changing gloves before handling the resident's dentures and placing them in the resident's mouth. On 08/31/22 at 11:00 AM Administrative Nurse B reported the staff should not handle resident dentures after checking a residents brief, if wearing the same gloves. The facility's policy named Glove Use dated 01/31/22 revealed all staff were required to wear gloves during direct contact during resident care. The facility failed to provide sanitary care to R41 when CMA E did not change gloves after checking the residents brief, and the placed dentures into the resident's mouth. - Observation on 08/31/22 at 08:40 AM Certified Nursing Aide (CNA) D entered R25's room to get the resident out of bed. CNA D donned gloves placed a gait belt on the resident and assisted the resident with transferring to her wheelchair. CNA D took the resident to the bathroom. The resident holding the grab bar and stood up. CNA D removed the resident's wet brief and assisted her to sit on the toilet. CNA D then removed the resident's nightgown, and then placed a clean shirt, a pull up brief, pants, and slippers back on the resident. CNA D wore the same gloves throughout the transfer, changing the soiled brief, and dressing the resident. CNA D went through the resident's dresser and other clothes twice looking for another pair of pants that fit the resident and socks while wearing the same gloves. CNA D then removed her gloves and replaced them with latex free gloves before providing peri care to the resident. On 08/31/22 at 08:55 AM CNA D reported that she wears the same gloves, and that is why she only touched the outside of the brief so she would not soil her gloves. CNA D stated her hands are so sensitive she cannot change her gloves like other staff. She did remove gloves and replaced them with latex free gloves before peri care. On 08/31/22 at 09:20 AM Administrative Nurse C reported all staff were trained on the proper use of gloves and changing from clean to dirty. The CNA should have removed her gloves after removing the brief and performed hand hygiene when the gloves are removed. She thinks some retraining will be necessary. The facility's policy named Glove Use dated 01/31/2022 revealed all staff are required to wear gloves during direct contact during resident care. The facility failed to provide sanitary care by the failure of CNA D to change gloves during the care of R25.

The facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to appropriately ensure all resident information was protected and kept private when a staff member left a computer screen unattended with resident information on the screen and visible. Findings included: - An observation on 08/25/22 at 08:08AM revealed the medication cart in House-3 was located outside of a resident's room with the computer screen open and contained resident information displaying upon the screen. The cart was left unattended by staff and observation revealed residents in the area, eating breakfast. Interview on 08/25/22 at 08:10AM with Certified Medication Aide (CMA) N revealed it was not normal to leave resident information on display while not using the computer. She stated she stepped away from the medication cart and computer screen to give a resident medication and did not lock the screen before walking away. CMA N stated best practice was to lock the computer screen prior to leaving the area to prevent the sharing of resident information. Interview on 08/31/22 at 08:25AM with Administrative Nurse B revealed resident information should never be left out for anyone to see, and the computer should be locked when not in use. Administrative Nurse B stated anyone walking past the medication cart could read the private resident information when the screen was not locked. The 01/26/22 Medication Storage policy documented the computer screens were to be locked when not in use to protect resident information. The facility failed to ensure the privacy and protection of resident information when a facility staff member left a computer screen up and unattended, with resident specific information displayed on the screen.

The facility census totaled 61 residents. Based on observation, interview, and record review the facility failed to prevent the neglect of a Resident (R) 1 who had bilateral [CONDITION(S)] (a disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness) to his lower limbs when the facility staff failed to ensure he had appropriate foot coverings to prevent partial thickness [CONDITION(S)] (a burn that involves the top two layers of skin) to the left foot when his bare foot sat on hot asphalt, while facility staff operated the wheelchair lift on the transportation van. This failure placed R1 in immediate jeopardy. Findings included: - Review of the Infectious Disease Consultant Progress Note dated 07/08/21 revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R1's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He required extensive assistance of one staff for transfers to and from the bed and wheelchair, and limited assistance of one staff for locomotion while in his wheelchair. The MDS recorded a stage II pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) present upon admission to the facility, an infection to the foot which required application of ointments/medication, and the application of a dressing. The MDS recorded the primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further noted active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS noted the resident had a major surgery in the 100 days prior to admission and noted the resident had a major surgical procedure during the inpatient hospital stay which required active skilled nursing care. Review of the Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 06/29/21 revealed R1 had a decline in function during a recent hospital stay and had a wound vac (negative pressure wound therapy) to his right heel, which created new challenges in his ability to complete his ADLs. Review of the Pressure Ulcer/Wound CAA dated 06/29/21 revealed R1 admitted to the facility with a pressure area to the right heel, which currently had infection. Staff off loaded R1's heel while in bed or in the wheelchair. The CAA documented the resident as alert, oriented, and knew how to help alleviate his risks. He had PVD which inhibited blood flow and healing. Review of the Baseline Care Plan initiated 06/23/21 revealed R1 had a wound vac to the surgical area associated with a stage II pressure ulcer to his right heel and directed the staff to change the wound vac three times weekly. Staff updated the care plan on 06/29/21 to include multiple vitamins with mineral supplement and Prostat (protein supplement) 30 milliliters (ml) twice daily (BID) to promote wound healing. An update to the care plan on 07/08/21 revealed R1 had bullae (blisters of unknown origin) to the planter aspect (bottom) of his left foot and an open blister to the lateral (outside) aspect of his left foot and directed the staff that R1 was to remain on non-weight bearing (NWB) status to his left foot related to the blisters. Review of the Admission Skin assessment dated [DATE] revealed R1 admitted to the facility with [CONDITION(S)] to right heel with a wound vac intact and no other skin breakdown or wounds identified. Review of the Weekly Skin Data Collection Tool dated 07/04/21 revealed R1 had old bruising to his right arm, scattered bruising to his abdomen, bruises to the right lateral foot, bruising to the right lateral big toe, and a wound vac to right foot. R1 had bruises to his left leg, the left heel presented soft and intact, and no other skin issues to the left foot. Review of the Progress Note dated 07/06/21 at 10:01 PM revealed R1 was alert and orientated and able to make his needs known to the staff. He was independent with bed mobility, required limited assistance of one staff for transfers, and extensive assistance of one staff for toileting. He received intravenous (IV) antibiotics with no adverse reactions. The note lacked any new skin issues. Review of R1's Physician Extender Progress Note dated 07/07/21 at 02:17 PM revealed nursing staff reported noting blisters to R1's left foot. The resident reported feeling fine and denied knowledge of how blisters occurred. R1 denied using the left foot to propel his wheelchair or wearing any shoes which could have rubbed his foot. The note documented multiple fluid filled bullae to the sole/ball/heel of left foot and 3rd and 5th toes. R1 had an appointment to see the wound clinic on 07/09/21 and nursing staff were directed to contact Infectious Disease and notify the practitioner if the blisters opened. Review of the Infectious Disease Consultant Progress Note dated 07/08/21 at 04:35 PM revealed R1 was seen due to blisters on the left foot. He developed multiple blisters on the plantar surface of the left foot two days ago. They did not appear to be a drug reaction. Review of the Wound Clinic Progress Note dated 07/08/21 at 10:47 AM revealed R1 had new wounds to the left foot. They documented the wounds appeared to be from a burn and R1's family reported he had a diagnostic test earlier in the week and during transport, R1 did not have a shoe or sock on his left foot. Family stated R1 was outside with his foot exposed, resting on the metal wheelchair footrest [the Wound Clinic Physician later verified through interview it was reported the resident's foot sat on asphalt and not the wheelchair footrest as mentioned in the note]. Wound center staff believed this caused a burn to the planter aspect of his foot resulting in several blisters. Review of the Wound Rounds documentation dated 07/11/21 revealed: 1. Blister #1 located on the left posterior foot measured 4.5 centimeters (cm) length (L) x 5.7 cm width (W) and described as an open blister just superior to the toes on the posterior left foot, wound edges were intact with a notation that R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Infectious Disease (ID) doctor believed these were caused by the gripper socks. 2. Blister #2 measured 1 cm L x 2.7 cm W and was superior to the clear fluid filled blister #1, the peri-wound was intact with no redness noted with a notation R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ID doctor believed these were caused by the gripper socks. 3. Blister #3 identified as a clear, fluid filled blister measured 0.7 cm L x 3 cm W and was superior to blister #2. The blister was intact and the peri-wound was intact with no redness noted with a notation R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ID doctor believed these were caused by the gripper socks. 4. Blister #4 identified as a clear, fluid filled blister measured 1.5 cm L x 4 cm W and was superior to blister #3. The blister was intact and the peri-wound was intact with no redness noted with a notation R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ID doctor believed these were caused by the gripper socks. 5. Blister #5 identified as a clear fluid filled blister measured 4 cm L x 5 cm W and was superior to blister #4 and closest to the heel. The blister was intact and the peri-wound was intact with no redness noted. Review of the Wunderground Historical Weather Data revealed a high temperature on 07/06/21 of 88 degrees Fahrenheit (F). Review of Data Source [NAME] J Thermal Contact [CONDITION(S)] from Street and Highways, Journal of the American Medical Association revealed an air temperature of 87 degrees F could result in asphalt temperatures of 143 degrees F and at 125 degrees F skin destruction could occur in 60 seconds. Per teh 07/13/21 witness statement submitted as part of the facility investigation, Transportation Staff G documented he was not 100 percent sure, since the resident had been on several trips, but documented the resident usually had foot pedals and a sock on for his other appointments. An observation on 07/13/21 at approximately 09:15 AM revealed R1 resting in bed on a pressure reduction mattress, with both feet wrapped with wound dressings. The wheelchair sat next to his bed without foot pedals and no wheelchair pedals were observed in his room at this time. An observation on 07/14/21 at approximately 08:20 AM revealed R1 sat in his wheelchair with dressings to bilateral feet. The resident's foot sat on the floor and no wheelchair foot pedals were observed to the chair or available in his room. In an interview on 07/13/21 at approximately 09:15 AM with R1 and his spouse revealed he admitted to the facility for rehab and wound care to the right foot after surgical intervention at the hospital. R1 revealed he had a doctor's appt on 07/06/21. While R1 waited to be loaded back into the facility transport vehicle at the hospital after being seen by the doctor he reported, Transportation Staff (TS) G let his bare foot sit on asphalt while he lowered the vehicle's wheelchair lift and until he was wheeled up the ramp of the lift to the vehicle. R1 and his spouse reported his son met him at the appointment and reported the resident did not have a sock or gripper socks to the left foot and the wheelchair did not have foot pedals. R1 reported a therapist came in to do his therapy on the morning of 07/07/21 and found the blisters to the bottom of his left foot. R1 revealed at the time he could not think of a reason for the blisters, but stated he had not rubbed his feet on the footboard of the bed, and hadn't worn shoes or socks that could have caused it the blisters. R1's spouse revealed when she notified the resident's son of the incident he stated the resident's left foot sat directly on the asphalt in the hospital parking lot without a sock/and no foot pedals on his wheelchair on 07/06/21, while he waited for the transport driver to lower the lift to the transport van. In a phone interview on 07/14/21 at 01:30 PM with R1's son revealed he came to the facility to meet R1 prior to his medical appointment. He revealed when he arrived on the unit he observed R1 as he sat in the dining room, in his wheelchair, without foot pedals, his feet resting on the floor, and he did not have a sock on his left foot. He revealed shortly after he arrived Transportation Staff G arrived on the unit and wheeled R1 to the van to transport R1 to his appointment. R1's son drove to meet R1 at the hospital for his appointment and stated he was positive his dad did not have foot pedals on his wheelchair because he remembered R1 told him he needed to stop, as he wheeled R1 to his appointmetn inside the hospital, so that R1 could rest his legs. R1's son revealed his dad held his (R1's) legs up while he pushed him in the wheelchair because R1 did not have foot pedals on his wheelchair. When the appointment was over he sat with his dad under the awning in the shade waiting for TS G to get back to the hospital with the van and when the facility van arrived he wheeled R1 to TS G and left to go to his car. An interview on 07/13/21 at approximately 10:15 AM with Certified Nurse Aide (CNA) E revealed the facility expected staff to ensure the residents had foot pedals on their wheelchairs and appropriate footwear on when they left the facility for appointments and as needed when in the wheelchair inside the facility. An interview with Licensed Nurse (LN) D on 07/13/21 at approximately 10:20 AM revealed the facility expected all residents to have foot pedals to the wheelchair and appropriate footwear on when out of the facility for appointments and to her knowledge the resident had foot pedals to his wheelchair. In an interview on 07/13/21 at approximately 10:45 AM Administrator A revealed she was only made aware of the blisters to R1's left foot on 07/12/21 when Administrative Nurse B informed her R1 claimed he received [CONDITION(S)] to his left foot from hot the asphalt while out of the facility for a medical appointment on 07/06/21. In an interview 07/14/21 at approximately 10:30 am with TS G revealed he transported R1 to an MRI appointment on 07/06/21. TS G stated he believed R1 had foot pedals on his wheelchair, a brown slipper sock to his left foot, and a pressure relieving boot to his right foot. TS G revealed R1's son met him at the appointment and called for the van to pick him up when the appointment was over. TS G revealed R1 sat in his wheelchair next to his son under the awning of the hospital when he arrived to pick him up. He stated he was not sure if that area of the hospital had cement/or asphalt. He then stated he wheeled the resident to the van and lowered the lift to load R1 into the transport van. Transportation Staff G revealed the R1 did not say anything or offer any complaints regarding his left foot at the time. In an interview on 07/13/21 at 02:48 PM with Pharmacy Consultant H revealed [NAME] Syndrome (a common adverse reaction to the drug [MEDICATION(S)]) was caused when [MEDICATION(S)] (antibiotic medication) was infused too fast and the pharmacy orders included directions to infuse R1's IV medication over 60 minutes, which would eliminate R1's risk for [NAME] Syndrome. Consultant H revealed he had never heard of an allergic reaction or reaction caused by IV antibiotics which would only affect one area of R1's body and revealed the blisters or a rash associated with a medication adverse reaction would be generalized over the entire body and not just located on R1's left foot. In an interview with Physician/Medical Director J on 07/14/21 at 08:30 AM revealed he was aware of the blisters to the bottom of the resident's feet, he had seen the pictures, reviewed the dressing/treatment orders, but had not seen them personally. In an interview on 07/15/21 at 03:16 PM Wound Care Physician K confirmed he diagnosed R1 with 2nd degree [CONDITION(S)] to the bottom of his left foot on 07/09/21, which were not present when he treated R1 on 07/01/21. Physician K revealed the family reported R1's foot sat on hot asphalt on 07/06/21 while he waited to be loaded into the facility transport van after his appointment. Physician K revealed a 2nd degree burn from hot asphalt would take as little as 3-5 minutes and related to R1's co-morbidities, including PVD and diabetes the healing process would be prolonged. Review of the Elder Abuse, Neglect and Misappropriation policy last revised on 02/16/21 revealed Neglect means the failure or omission by employees of the facility, the elder's legal representative, or family of goods or services that were necessary to attain or maintain psychical, mental, and psychosocial well-being. The facility neglected to ensure R1's left foot was protected with the use of a footwear and/or the use of wheelchair foot pedals during an offsite medical appointment. The facility failure to ensure preventative measures were in place, which allowed R1's foot to rest directly on hot asphalt which caused multiple blisters to the bottom of R1's left foot as a result a burn placing R1 in immediate jeopardy. The facility was notified of the Immediate Jeopardy on 07/14/21 at 04:15 PM. The facility provided an acceptable plan for removal of the immediate jeopardy on 07/15/21 at 02:30 PM, and surveyors verified the implementation of the plan for removal of the immediate jeopardy on 07/19/21 at 12:30 PM when the facility implemented the following: 1. Ensured padded foot pedals on R1's wheelchair 2. Completed an assessment of all residents with assistive devices to ensure each resident who required foot pedals had foot pedals in their rooms or provided foot pedals as needed. 3. Inserviced on a new Transportation Policy, Transportation checklist, and educated all staff for Abuse, Neglect and Exploitation and Skin Integrity Prevention. The deficiency remained at a G (isolated, with actual harm) scope and severity, following removal of the immediate jeopardy.

The facility reported a census of 58 residents with 15 sampled and 2 residents reviewed for accidents. Based on observation, interview, and record review the facility failed to place interventions related to causal factors for 9 falls experienced by resident #34, which included a fall with a fracture to his/her left hip. Findings included: - Review of resident #34's pertinent [DIAGNOSES REDACTED]. Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) could not be completed. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and 1 staff assistance for personal hygiene. The resident had unsteady balance and could only stabilize with human assistance. The resident had functional impairment in range of motion on one side of the lower extremity and used a wheelchair for mobility. The resident had a toileting plan with no improvement, continued on the toileting plan, and was frequently incontinent of bowel and bladder. The resident had no falls since the prior MDS. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a BIMS could not be completed. The resident had no change in activity of daily living (ADL) status or balance since the 9/26/18 MDS. The resident remained on a toileting plan and was frequently incontinent of bowel and bladder. The resident experienced one injury and one non-injury fall since the prior MDS. Review of the fall care area assessment (CAA) dated 9/26/18 revealed the resident had a [DIAGNOSES REDACTED]. The resident's cognitive impairment impacted his/her ability to understand he/she needed assistance to complete tasks and that the resident was unsafe to stand or walk without assistance from staff. The resident had a personal history of falls with the most recent fall resulting in a left [MEDICAL CONDITION] with surgical repair. He/she had a history of [REDACTED]. Review of care plan dated 6/23/18 revealed the following interventions: 4/2/18 - Staff would assist the resident up for the day around 6:00 AM as he/she liked to get up early. 4/2/18 - The resident had a quarter side rail to assist with transfers and bed mobility. 4/2/18 - Staff would assist the resident with walking when restless. 4/2/18 - Staff would assist the resident with bed mobility and transfers as necessary. 4/2/19 - Staff would attempt a drug dosage reduction as recommended by the consulting pharmacist and care plan team. 4/2/18 - Staff would assure the resident's call light was within reach. 4/2/18 - Staff would ensure adequate lighting. 4/2/18 - Physical therapy would evaluate and treat as ordered. 5/17/18 - The resident would have a psychiatric referral. 6/22/18 - Staff educated the resident's family on wheelchair positioning when propelling the resident in his/her wheelchair. 6/22/18 - The resident did not want socks/shoes on and he/she liked to be bare footed. Review of bowel/bladder diary dated 5/18/18-5/20/18 revealed the resident experienced 41 episodes of incontinence. Fall #1: Review of fall investigation dated 7/1/18 at 1:35 PM revealed the resident had an unwitnessed fall with no injury in his/her bathroom. Staff last toileted the resident at 1:00 PM. The investigation identified a possible causal factor related to the fall as toileting. Staff updated the 6/23/18 care plan with an intervention on 7/1/18 which directed staff would educate the resident's family to lower his/her bed into lowest position. The care plan lacked evidence of any intervention related to the resident's need to void after he/she fell as identified as a possible causal factor. Fall #2: Review of fall investigation dated 7/4/18 at 2:55 PM revealed the resident had an unwitnessed fall, with no injury near his/her bathroom. The investigation lacked evidence of when the resident was last toileted. The investigation identified the possible causal factor of the fall as the resident was looking for his/her family member maybe. The staff would prevent major injury related to falls for the resident. The resident's care plan dated 6/23/18 lacked evidence of any updated interventions for the 7/4/18 fall. Fall #3: Review of fall investigation dated 7/20/18 at 5:30 AM revealed the resident had an unwitnessed fall with no injury in his/her room due to the resident got out of bed without assistance and his/her incontinence brief was wet. The resident was last toileted at 3:00 AM. Review of the care plan dated 6/23/18 revealed an update for the 7/20/19 fall, however the intervention was not legible on the care plan copy provided. Fall #4: Review of fall investigation dated 7/25/18 at 2:45PM revealed the resident had an unwitnessed fall with skin tear injury to the right side of his/her forehead in the bathroom due to the resident got up off toilet without assistance. The care plan dated 6/23/18 was updated with an intervention for the fall dated 7/25/18 as staff would not leave the resident unattended in the bathroom. Fall #5: Review of fall investigation dated 8/16/18 at 3:30 PM revealed the resident had an unwitnessed fall in his/her room which resulted in bruising to his/her back measuring 6 centimeters (cm) by 3 cm due to the resident got out of bed without assistance. The staff toileted the resident right after the fall and identified a possible causal factor of the fall as incontinence. The resident was last toileted at 2:00 PM. The care plan updated intervention for the fall dated 8/16/18 as staff would talk with the family to notify the nurses if the family member would not be visiting for an extended period of time. The care plan lacked any intervention related to the possible causal factor of toileting. Fall #6: Review of fall investigation dated 8/16/18 at 9:00 PM revealed the resident had an unwitnessed fall without injury in his/her room due to the resident got out of bed without assistance. The resident was last toileted at 8:45 PM. The investigation lacked any root cause/causal factors for the fall. The care plan dated 6/23/18 was updated with an intervention for the fall dated 8/16/19 to place a silent bed alarm, which staff discontinued and had no date for the discontinuation. Fall #7: Review of fall investigation dated 9/5/18 at 7:30 PM revealed the resident had a witnessed fall without injury near the nurse's station due to the resident got out of his/her wheelchair without assistance. Staff last toileted the resident at 6:00 PM. The resident was fidgeting, had hallucinations, and he/she stated a firehouse and a ghost when asked what he/she was doing. The care plan dated 6/23/18 lacked any intervention related to the fall dated 9/5/18. Fall #8: Review of fall investigation dated 9/12/18 at 9:45AM revealed the resident had a witnessed fall without injury in the dining room due to the resident got out of his/her wheelchair without assistance. Staff last toileted the resident at 8:00 AM. The investigation lacked causal factors related to the fall. The care plan dated 6/23/18 was updated with an intervention for the 9/12/18 fall in which therapy staff were verbally educated to not lock the breaks on the resident's wheelchair. Fall #9: Review of fall investigation dated 9/16/18 at 6:30 PM revealed the resident had an unwitnessed fall with major injury (fracture to his/her left hip) in his/her bathroom. The staff observed bowel movement on the bedroom floor, the shower chair, and the shower floor. The staff identified the root cause/causal factor of the fall as the resident ambulated to the bathroom unassisted and fell in the shower. Review of nurse's note dated 9/16/18 at 7:15 PM revealed at 6:30 PM staff heard the resident screaming in a room and went to check on him/her. The resident's wheelchair sat next to a vacant bed, and the resident sat on the shower floor screaming out in pain with his/her pants down and bowel movement (BM) all over the shower chair, shower floor, and vacant bed. The nurse asked the resident what happened, and the resident stated he/she pushed me although no one else was in room at the time. The nurse assessed the resident and the resident complained of severe pain to the left hip and sent the resident to the emergency room (ER). Review of social services progress note dated 9/17/18 at 10:31 AM revealed the hospital admitted the resident on 9/16/18 with a [DIAGNOSES REDACTED]. Review of nursing progress note dated 9/19/18 at 6:19 PM revealed the facility readmitted the resident from the hospital for skilled with physical therapy/occupational therapy after a left [MEDICAL CONDITION]. The resident fidgeted, cried and was given as needed (PRN) pain medication. The care plan was updated with an intervention for the fall dated 9/16/18 to keep the doors to empty rooms closed. The staff would initiate a bowel and bladder diary when the resident returned from the hospital. Observation on 6/20/19 at 10:13 AM revealed the resident napped in bed in his/her room with the bed in low position. The resident had a floor mattress next to his/her bed and fall mat on the floor next to his/her secondary mattress. Interview with direct care staff [NAME] on 6/24/19 at 1:31 PM revealed staff always found the resident in his/her room after a fall. Staff [NAME] stated he/she thought the resident fell trying to go to the bathroom. Staff [NAME] stated the resident liked to go to the bathroom about every 30 minutes to an hour and staff should take the resident to the bathroom often. The resident leaned forward at times and would fall out of his/her chair, but that had not happened in a while. Interview with direct care staff F on 6/24/19 at 2:12 PM revealed he/she noticed the resident's falls were related to the need to toilet more often than what staff were toileting him/her. Staff F said he/she informed the nurse he/she worked with, but the nurse did not update the resident's care plan. Interview with licensed nurse G on 6/25/19 at 8:12 AM revealed the resident only had one fall since moving to his/her household, but staff toileted the resident at least every two hours, if not sooner. If the resident drank more fluids the staff just watched to see if the resident was getting more anxious. This indicated he/she needed to go to the bathroom and the staff would assist him/her to toilet. Interview with administrative nursing staff B on 6/20/19 2:49 PM revealed fall investigations included the five whys to find out the root cause: witness statements, description of the incident, what the nurse observed, how and why it happened, when the resident was last seen and toileted, what the resident was doing, and if they had an unmet need. The facility management team worked together to identify the root cause. The management team worked with the floor nurses, so they could learn how to properly complete a root cause. Staff B stated he/she would have expected his/her staff to have found a root cause for the resident's falls, which included the resident needed to be toileted more often or checked on more frequently. Further interview with administrative nursing staff B on 6/24/19 at 3:23 PM revealed any time staff implemented a new intervention it should have been documented on the resident's working care plan, so everyone knew what the intervention was. Review of the Falls policy revised 1/12/19 revealed a fall reduction program would be established and maintained to assess all residents to determine their risk for falls. Based on the resident's history of falls and assessment data, the staff would identify interventions related to the resident's specific risks to minimize or eliminate falls with major injury. The facility failed to identify the causal factors and failed to implement effective fall interventions for cognitively impaired dependent resident #34, who experienced 9 falls which resulted in a left [MEDICAL CONDITION].

The facility census totaled 63 residents with 4 residents in the sample. Based on interview and record review the facility failed to supervise staff to ensure 1 dependent resident received the care and services necessary to avoid physical harm (development of an avoidable pressure ulcer), as a result of staff leaving the resident on the bed pan for more than 8 hours (#2). Findings included: - Review of resident #2's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 7/18/14 revealed a BIMS (brief interview for mental status) score of 15 indicating normal cognition. The resident required extensive assist of two for bed mobility, transfers, and toilet use. The resident had an indwelling Foley catheter and was incontinent of bowel. Review of the pressure ulcer CAA (care area assessment) dated 7/18/14 revealed the resident ' s left knee was contracted and had an unstagable pressure area with slough (dead tissue usually cream or yellow in color) behind it, The resident was also admitted to the facility with a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shearing) to his/her right heel that staff was to offload (suspend the heel without anything touching or applying pressure to the heel). The resident required extensive assistance of two staff with daily cares. The resident had a cushion in his/her wheelchair and air mattress on the bed. The CAA had documentation dated 7/21/14 added to the original CAA indicating the resident developed new areas of impaired skin integrity. A stage 1 pressure area to the iliac crest (curved ridge of the top of the pelvic bone) measured 20 cm x 1 cm, and 2 areas to the right buttocks, one was unstagable (full thickness tissue loss in which the base was covered by slough or eschar tissue (dead tissue that is black in color) and one was a stage 2. The resident was at risk for continued skin breakdown. Review of the admission care plan with a date of 7/11/14 revealed the resident was a two person assist with the Hoyer (full body) lift for transfers. Staff identified the resident at risk for pressure ulcers, had a Foley catheter and used a bed pan for bowel movements. The care plan identified skin breakdown at the surgical site and reported the resident had a history of [REDACTED]. Review of the nurse ' s notes dated 7/20/14 at 4:48 p.m. revealed the direct care staff notified the nurse of the resident being left on the bed pan for a long time which resulted in skin redness and possible pressure ulcers or bruising, will continue to monitor. Review of the nurse ' s notes dated 7/21/14 at 4:18 p.m., revealed the nurse observed an area to the resident's buttocks and posterior hip areas. The resident had an area of induration across the posterior hips that was red/purple in color and non blanchable (loses color when pushed on with return of color when pressure released; no immediate return of color indicates tissue damage), and an area on his/her right buttock that was black and hard and another next to that was open with rolled edges. The resident had multiple areas on his/her bilateral buttocks and hips that were red but blanchable. Review of the admission skin assessment dated [DATE] revealed the resident had an open area behind the left knee and a pressure ulcer to the right heel. Review of the skin assessment completed on 7/20/14 after staff removed the resident from the bed pan revealed redness to the resident ' s left and right buttocks. Review of the skin assessment dated [DATE] revealed a suspected deep tissue injury on the sacrum which measured 2.0 centimeters (cm) x 1.0 cm. The assessment also identified the resident with an area that measured 2.5 cm x 2.0 cm and consisted of unstagable black eschar on the right buttock. Review of the wound assessments prior to 7-19-14 revealed no pressure ulcers to the resident ' s buttocks or sacrum. The facility staff reviewed the routine camera surveillance of the halls for the evening of 7-19-14 through the early morning of 7-20-14. The review related to resident #21 identified on 7/19/14 at 8:35 p.m. evening aides #1 and #2 entered the resident ' s room and exited at 8:48 p.m. The next time a direct care staff entered the resident ' s room was at 5:08 a.m. for 29 seconds on 7/20/14. The next direct care staff to enter the room was at 8:20 a.m. the morning of 7/20/14. The camera showed a nurse entering the room at 12:07 a.m. on 7-20-14 and leaving at 12:08 a.m. for a time of 51 seconds in the room. The camera showed the nurse entered the room again at 6:50 a.m. and exited at 6:50 a.m. for a total of 37 seconds in the room. According to the facility investigation on 7/20/14 at 8:20 a.m. a direct care staff entered the resident's room and discovered the resident was laying on a bed pan. When he/she removed the bed pan the resident's buttocks were red and hard to the touch. Interview with direct care staff H on 9-4-14 at 8:40 a.m. revealed this staff worked the evening shift of the 7-10-14. He/she said the resident requested the bedpan several times on the evening shift, and he/she and direct care staff K had put him/her on the bedpan. He/she said the last time he/she and the staff K last put the resident on the bedpan around 10:15 p.m. Staff H said staff K left 25 minutes (10:35 p.m.) early on that night and the two staff had put the resident on and off the bedpan just before staff K left. Staff H said sometimes the resident would be on and off the bedpan frequently because he/she had diarrhea around the time of the incident. Staff H said he/she always strived to leave a resident on the bedpan no longer than 10 minutes but could go up to 15 minutes. Staff H said when he/she went in to take resident #2 off of the bedpan, sometimes the resident would say he/she had not gone yet. Staff H said he/she had told the resident that was okay, to put on the call light when he/she needed to go and staff would assist him/her. Staff H said he/she had never left the resident with the bedpan longer than 15 minutes, and the night of the incident Staff H said he/she did not put the resident back on the bedpan before the end of his/her shift at 11:00 p.m. Interview on 9-3-14 at 4:53 pm. with direct care staff K revealed he/she reported on the evening shift of 7-19-14 at about 10:15 p.m., on last rounds he/she and staff H put the resident on the bedpan, and then took him/her off of it and turned him/her on the right side and used pillows to position the resident. Staff K said he/she and staff H definitely took resident #2 off the bedpan on 7-19-14 even though the resident did not want to give up the bedpan. Staff K said earlier in the shift on 7-19-14 he/she had a talk with the resident because the resident was afraid he/she would have diarrhea. Staff K said the resident had started asking for the bedpan more frequently in the day before the incident. Staff K said he/she talked to the resident earlier on his/her shift on 7-19-14 and told the resident he/she really could not stay on the bedpan more than 15 minutes and told the resident why. Staff K said even though he/she told the resident the importance of not sitting on the bedpan for more than 15 minutes at a time, the resident still did not want to relinquish the bedpan, but did let Staff K take it. Staff K said he/she did report to the house manager just prior to this incident. Staff K said he/she had not shared that with anyone else. Staff K said the second shift direct care staff reports off to the third shift direct care staff to give them information about the residents. During an interview on 8/27/14 at 3:00 p.m. licensed nurse C reported the resident had an unblanchable ring encompassing the buttock to the coccyx that was not open. The resident also had an open area in the middle of the ring on the coccyx area the morning after the resident was left on the bedpan too long. Interview with licensed nurse G on 9-3-14 at 2:13 p.m. revealed he/she worked the day shift when staff found the resident on the bedpan. Direct care staff found the resident on the bedpan and contacted Staff G to do an assessment on the resident ' s skin because he/she believed the resident was on the bedpan since the previous shift. Staff G said he/she could see red marks shaped like the bedpan and the next morning they noticed some areas of breakdown and bruising on the resident ' s buttocks. Staff G said at that time he/she notified the house monitor because he/she was the person responsible for measuring wounds, and notifying the physician for treatment orders. Staff G said he/she monitored direct care staff by making rounds every two hours and noting if the residents had received what he/she should have according to the care plan, such as repositioning at least every two hours. Staff G said he/she was able to consistently make those rounds. During an interview on 8/27/14 at 3:20 p.m. administrative nurse B reported he/she a resident was left on the bed pan an extended period of time. Nurse B reported he/she checked cameras for the night the incident occurred and saw two direct care staff enter resident #2 ' s room at approximately 10:00 p.m. or 10:30 p.m. to put the resident to bed. After that time, only the charge nurse went into the resident ' s room a couple of times for the rest of the shift. No other staff entered until the day shift direct care staff went in to see the resident at 8:20 a.m. and noticed the resident was laying on a bed pan. The night direct care staff reported to staff B; he/she went in and checked the resident about 4:30 a.m. though there was no evidence on the camera that he/she ever entered the room the whole shift. When direct care staff discovered the bed pan he/she completed a skin check and the resident had a ring around the coccyx and buttock that it they shape of the bed pan. On 8/26/14 at 12:10 p.m. administrative staff A reported that he/she remembered being notified at home of the incident and came to the facility. Nursing staff informed administrative staff A that a staff member left a resident on the bed pan for several hours during the night shift. When questioned, none of the direct care admitted to forgetting the resident on the bed pan. The administrative staff reviewed surveillance cameras and discovered direct care staff were not in the resident ' s room all night during his/her shift. A day direct care staff coming on duty found the resident on the bed pan and staff completed a skin check revealing a purple ring where the bed pan had been. Review of the Abuse, Neglect and Exploitation Policy revised on 1/14/13 revealed: It was the policy of this company to ensure that residents have a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation and injuries of unknown origin. Neglect means the failure to provide goods and services to avoid physical harm, mental anguish and mental illness. The facility failed to provide adequate supervision of staff to ensure 1 dependent resident received the care and services necessary to avoid physical harm, from being left on the bed pan in excess of 8 hours during the night shift.

The facility had a census of 72 with 23 sampled residents. Of the 23 sampled residents 3 were looked at for pressure ulcers. Based on observation, record review and interview the facility failed to identify and implement interventions to ensure appropriate care and services were provided to prevent development of new pressure ulcers and failed to provide preventative care for 2 of the 3 sampled residents. (#123 and #188) Findings included: - Review of resident # 123's re-admission (returned from the hospital on 5-28-13) MDS (minimum data set) dated 6-4-13 revealed the staff indicated the resident had moderate cognitive impairment, The MDS further indicated the resident required total assistance of 2 staff for bed mobility, dressing, toilet use, and eating and total assistance of one staff for personal hygiene. The assessment indicated the resident was at risk for developing pressure ulcers and did not indicate the resident had any current pressure ulcers. Review of the significant change MDS dated [DATE] revealed a BIMS score of 99 (unable to complete assessment), The resident required total assistance of 2 staff for bed mobility, transfer, dressing, toilet use and total assistance of 1 staff for personal hygiene. The MDS further indicated the resident was at risk for developing pressure ulcers and had 2 unstageable pressure ulcer slough/eschar (dead tissue, usually cream or yellow in color) and 1 unstageable deep tissue pressure ulcers with one of the three pressure ulcers detected on admission. Review of the pressure ulcer CAA (care area assessment) dated 4-24-13 (conducted with the resident's original admission assessment) indicated the resident's skin was intact and the resident was reliant on staff for all ADL's (activities of daily living), was incontinent of bowel and bladder and was at risk for impaired skin integrity. (Had a high likelihood of having skin problems or breakdown). Review of the pressure ulcer CAA dated 7-10-13 indicated the resident had an unstageable pressure ulcer to the right heel that measured 1.1 cm (centimeters) x 1.0 cm, right Achilles (area located on the back of the ankle) measured 2.1 cm x 1.0 cm and L (left) Achilles measured 0.7 cm x 0.9 cm. CAA indicated treatments were in place and wound care was followed by a professional wound care specialist from an outside source. Review of the original care plan dated 4-30-13 for pressure ulcers directed staff to apply barrier ointment to coccyx area (area located at the top of the buttocks) three times a day and as needed, skin check weekly, keep linens (bed sheets) clean, dry and wrinkle free, low loss air mattress on the bed, provide incontinent care, skin prep to the right heel and off load (relief of pressure) using a prevalon boot (special soft boot for pressure relief). Nursing revised the care plan on 6-24-13 per a physician order to discontinue the multipodus boots (special therapeutic boot for heel pressure relief), use skin prep (chemical skin shield) to right heel and bilateral (both) Achilles daily, wear bilateral prevalent boots. Nursing again revised the care plan on 7-16-13 per physician order for [REDACTED]. Review of the Braden risk assessment (assessment for risk factors) dated 5-28-13 had a score of 12 which indicated the resident was a moderate risk for developing pressure ulcers. Review of the admission skin assessment (returned from the hospital) dated 5-28-13 revealed two red blanchable (when pressure applied to an area of redness white skin coloring can be seen) area noted on the buttocks and 1 stage 2 pressure ulcer on the right heel. Review of the facility licensed nursing weekly skin assessments dated 5-28-13 revealed a note to refer to the admission skin assessment. The facility failed to locate any weekly skin assessments for the month of June 2013. Review of the admission nurse notes dated 5-28-13 at 5:00 p.m., indicated the resident was admitted from the hospital with a [DIAGNOSES REDACTED]. (Not updated on the care plan). Review of the physical therapy daily treatment notes dated 6-10-13 revealed the "patients" heel sores were discussed with nursing unit manager and the physical therapy assistant cut socks to relieve pressure from ankles. Review of the occupational therapy daily treatment notes dated 6-10-13 revealed the therapist discussed the heel sores with nursing and the unit manager. Review of the physician order dated 5-29-13 at 10:40 a.m., directed staff to put prevalon boots on both heels while in bed. (New order was not updated on care plan). Review of a nursing communication dated 6-14-13 from therapy to nursing staff indicated the resident was to wear AFO boot (hard therapeutic boot which relieve heel pressure and maintains correct foot position) while in bed with no socks (care plan not updated to reflect this change). Review of the follow up wound progress note (during wound check round with the wound care specialist) dated 6-17-13 revealed a right Achilles wound acquired on 6-10-13 that measured 2.0 cm x 1.0 cm with an etiology (cause) of trauma which was full thickness with slough adherent, black soft eschar (dead tissue) covering 100% of the base of the wound. (No update to care plan to indicated new pressure ulcer). Review of the interdisciplinary nurse notes dated 6-21-13 at 2:00 p.m., indicated a right Achilles wound that measured 3.1 cm x 1.0 cm with stage 2 open wound. (No notes regarding the left Achilles wound, no update to care plan). Review of the follow up wound progress note dated 7-1-13 revealed a wound to bilateral (both right and left) Achilles heel with the right Achilles wound measuring 2.1 cm x 1.0 cm with etiology of trauma due to brace, full thickness with green drainage, no slough, black hard eschar and the left Achilles wound measuring 0.7 cm x 0.9 cm with etiology of trauma due to brace, full thickness (no stage noted), no drainage, black hard eschar covering 100% of the base of the wound. Weekly skin assessment dated [DATE] at 9:00 a.m. indicated the resident continued with treatment to bilateral heels and Achilles wounds. No other skin issues noted during the assessment. On 7-21-13 the assessment indicated the resident continued with treatment to bilateral lower extremities and no new skin issues noted during assessment. An observation on 8-1-13 at 8:33 a.m. revealed two staff gave a bed bath to the resident. The left buttock had a small pea size dark grey area with red edges which was intact. (Staff stated is from an old pressure ulcer that was healing), on the left Achilles observed a nickel to quarter size area with black eschar covering wound. The resident had on calf length socks on both feet prior to the bath. The heels were not cut out of the socks to relieve pressure as planned. An observation on 8-1-13 at 11:23 a.m. revealed the resident lying in his/her air mattress bed with prevalon (soft) boots on bilateral lower extremities. During an interview on 8-6-13 at 8:10 a.m., direct care staff I reported the resident had been to the hospital and when he/she returned he/she had a sore of his/her bottom and on the right heel. The resident developed a pressure sore on each Achilles due to the socks provided by the family. After discovering the socks were too tight and the shoes were rubbing on the ankles staff decided not to put the shoes or socks on the resident. The resident had the prevalon boots which were soft and was to wear them at all times. During an interview on 8-6-13 at 9:42 a.m., Physical therapy staff J reported the resident returned to the facility from the hospital with a "night splint" (hard boot used for foot positioning and heel pressure relief) to be worn while in bed in a supine (lying flat on the back) position. Staff indicated the resident had been wearing ankle socks provided by the family and began to notice redness to both Achilles areas. This information was reported to the unit manager and another splint was ordered for the right lower extremity. A wound consult from a professional wound care physician was ordered and it was the opinion of the physical therapy staff the wounds were caused by a combination of the ankle socks along with the therapy boots. The ankle socks were to be sent home with the family so the staff would not place them back on the resident's feet. During the interview staff J walked into the resident room and saw the soft prevalon boots in the wheelchair and stated these were not supposed to be used on the resident it was supposed to be the therapy boots. Stated "In fact I told them to remove them from the resident's room so they would not be used." The staff then went to the resident's closet and found the hard therapy boots on the top shelf and reported those were the boots that should be used for this resident. During an interview on 8-6-13 at 12:35 p.m. Licensed nursing staff L reported the care plan was used by all staff to give appropriate care to the resident. Staff L reported the care plan should be updated with any changes in condition and verified there were no changes made to the care plan with regards to the Achilles pressure ulcers and no changes to update the care plan with the new physician orders written by the physician for the care of the Achilles heel wounds. Staff L could not locate any skin assessments for the month of June which were part of the resident's care plan. During an interview on 8-6-13 at 1:00 p.m., Licensed nursing staff M reported the Achilles wounds were acquired by the multipodus therapy boots and the socks provided by the family and verified the interventions on the care plan were not updated to reflect the changes for the appropriate care for the resident. Staff M could not locate any skin assessments for the month of June. During an interview on 8-6-13 at 1:36 p.m. Administrative nursing staff N indicated every resident should have weekly skin assessments regardless if the wounds were being treated by an outside professional, or the facility. Staff N also indicated the resident care plans should be updated with any changes in care or condition. Review of the facility policy for pressure ulcer/stasis (a necrotic, crater like lesion of the lower leg caused by chronic venous congestion) ulcers dated November 2011 revealed the policy statement indicated "a resident who enters a facility without pressure ulcers or stasis ulcers will not develop pressure or stasis ulcers unless the individual's clinical condition demonstrates that they were unavoidable. In addition, if a resident has a stasis or pressure ulcers, he/she will receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing." The policy's general guidelines revealed a skin pre assessment would be done by a licensed nurse to ascertain the condition of a resident's skin prior to admission and on admission. A total skin assessment would be documented on the admission nursing assessment form. The skin assessment would be completed at that time and weekly for the first four weeks after admission and then quarterly or whenever there was a change in cognition or functional ability. The residents identified to be at risk for pressure ulcer development would have pressure reducing devices placed on their bed. If the resident required assistance with repositioning he/she would be repositioned at least every 2 hours. If a resident required assistance with toileting, an individualized toileting plan would be implemented. If the resident was incontinent he/she would receive incontinent care per his/her individualized toileting program. If a resident had a pressure ulcer the designated skin nurse would assess weekly from admission or date of identification of a wound and monitor the condition of the wound and record that information on the skin assessment form. During the course of healing the wound the licensed nurse would contact the appropriate physician for further direction and possible change in the treatment regime, have ongoing monitoring/evaluation of existing plan for effectiveness. The care plan would reflect any pressure ulcers and interventions. The facility failed to provide necessary treatment and services to a resident who had an existing pressure ulcer to prevent new clinically avoidable pressure ulcer from developing by failing to develop and implement interventions as well as evaluate and revise the plan of care for resident #123. - Review of resident #188's closed record revealed a physician order sheet signed on 4-27-13 that included the following Diagnoses: [REDACTED]. Review of the residents face sheet revealed an admission date of [DATE] and a discharge date of [DATE]. Review of the nursing admission assessment, dated 4-19-13, revealed the resident did not have any pressure ulcers upon admission and did not have a history of ulcers. Review of the admission MDS (Minimum Data Set 3.0, a required assessment) dated 4-26-13 revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. The MDS also revealed the resident needed extensive assistance of 2 staff for bed mobility, extensive assistance of 1 for transfers, dressing, and toileting. The resident also had one sided limited range of motion in lower extremities. The MDS identified the resident as being at risk for pressure ulcers and did not have any upon admission. It did identify the resident had a pressure reducing device for his/her bed and chair, had a surgical wound, and staff provided the resident with a turning/repositioning program. Review of the ADL (activities of daily living) CAA (Care Area Assessment) dated 5-1-13 revealed resident had a [DIAGNOSES REDACTED]. It revealed the resident had physical limitations and needed staff assistance with mobility and other daily cares. Review of the nutritional CAA dated 5-1-13 revealed resident had a [DIAGNOSES REDACTED]. Review of the Pressure Ulcer CAA dated 5-1-13 revealed the resident had impaired mobility related to recent right [MEDICAL CONDITION]/surgical repair, a [DIAGNOSES REDACTED]. The CAA finished by identifying the resident lay on his/her back much of the time in bed due to an abduction wedge placement (a cushion in the shape of a wedge intended to keep the leg with a [MEDICAL CONDITION] away from the body). Review of the initial/admission care plan dated 4-19-13 included dressing treatment orders for right hip surgical incision but did not identify any other skin concerns or treatments. On 5-1-13, staff updated the initial care plan to that directed staff on how to care for the resident's pressure ulcer. It included guidance to staff to measure the ulcer, document the assessment on a wound assessment form, assess for pain and initiate order for pain as indicated, notify the physician and obtain treatment orders. The temporary pressure ulcer plan directed staff to notify the wound nurse and dietary, to have heel protectors on the resident. The goal for the pressure ulcer care plan included the ulcer to not get larger over the next 2 weeks. Review of the comprehensive pressure ulcer care plan, dated 5-1-13, identified the resident with a pressure ulcer and identified the resident at risk for the development of further ulcers. The care plan included the following interventions: assess decubitus (pressure ulcer) size, characteristics, presence of drainage and color with wound rounds, monitor for improvement or decline and if no improvement noted in 14 days, call physician for recommendation in change of treatment, turn and reposition at least every 2 hours, encourage adequate nutritional and fluid intake, monitor for signs of infection, provide appropriate pressure relieving devices for promotion of wound healing. Review of the Braden risk assessment dated [DATE] revealed the resident scored a 20 which indicated the resident was not at risk for pressure ulcers. The Braden risk assessments dated 4-26-13 and 5-3-13 had a score of 19 which also indicated the resident was not at risk for pressure ulcers. Review of the nurse's weekly skin assessment sheets revealed the following: 4-19-13 contained no documentation concerning heels. 4-26-13 contained no documentation regarding heels. Review of the skin breakdown investigation report dated 5-1-13 revealed the CNA (Certified Nurse Aide-a direct care staff) reported while putting ted hose (a type of compression stocking used to reduce lower extremity [MEDICAL CONDITION]) on the resident he/she noted a blister on the resident's right heel broke open and drained fluid. The assessment documented the blister measured 3.0 X 3.5 cm (centimeters) with serous (wound drainage that is clear) drainage. It also indicated staff implemented offloading to pressure areas with multipodus boots (a type of boot that "floats" the heel to enhance blood circulation vital to healing by eliminating friction or pressure on the back of the foot). It also revealed a blister on left heel that staff assessed at 1.5 cm X 1.5 cm with black eschar (dead tissue), dry and no drainage. Staff documented on the investigation report the resident's coccyx was at risk for breakdown. Review of the daily skilled nurses note, dated 5-1-13 and lacked a time, revealed the resident had bilateral (both), unstageable ulcers. The note contained the same measurements as the skin breakdown investigation report and identified that staff notified the physician and family. Review of the nurse's weekly skin assessment dated [DATE] contained documentation regarding the resident's bilateral pressure ulcers on heels, the order for the [MEDICATION NAME] to be applied to both heels and offloading (with multipodus boots). Review of the undated, initial wound physician progress notes [REDACTED]. The note contained the order for staff to apply bilateral [MEDICATION NAME] (an elastic compression stocking), place [MEDICATION NAME] (brand name for a powerful topical antiseptic agent that contains providence-iodine) on the heels every other day, Multipodus boots, to the right heel add ABD (abdominal) pad with window every other day. Review of the wound physician's progress note dated 5-20-13 directed staff to discontinue the ted hose and apply [MEDICATION NAME] if available or ace wraps (An elastic, stretchable bandage used to create localized pressure) and to continue [MEDICATION NAME] to heels and off load with boots or float heels. Review of the wound physician's progress notes dated 5-27-13 revealed the following: Right Heel -- 2.5 cm X 3.1 cm with black hard eschar. Left Heel--1.4 cm X 2.0 cm with black eschar and hard. The physician documented the resident had a weight loss and identified that on 5-14-13, the resident had started on sugar-free house shakes (a dietary supplement) three times a day with meals, on 5-16-13 staff started giving the resident extra protein at meals, and on 5-24-13 the resident received an order for [REDACTED].(Deep Tissue Injuries) that originally were blood blisters. The note identified the areas were now improving; the resident has a [DIAGNOSES REDACTED]. Review of the wound physician's progress note, dated 6-10-13 revealed the following: Right heel--3.0 cm X 3.2 cm with black, hard eschar. Left heel--1.5 cm X 1.8 cm with black, hard eschar. The physician documented the residents wounds were stable and directed staff to continue treatment. Review of the June, 2013 MAR (Medication Administration Record) revealed it lacked the orders for sugar-free supplements, both the 3 with meals and the 3 between meals and it did not include the order for the [MEDICATION NAME] twice a day. The MAR indicated [REDACTED]. Review of the June, 2013 TAR (Treatment Administration Record) revealed it lacked indication that completed skin assessments for the resident in the month. Review of the "Resident at Risk" notes revealed: On 5-2-13 staff documented the following: wounds to bilateral heels, has pain, heels with [MEDICATION NAME] daily, multipodus boots while in bed, put on wound physician list. On 5-9-13 the documentation identified: bilateral heel wounds improving, continue current intervention, wound physician recommendations. On 5-16-13 - wounds improving continue with wound physician On 5-23-13 - continue same treatment per wound physician recommendations, improving On 6-3-13 the documentation identified the following: resident with bilateral pressure ulcers now classified as Deep Tissue Injuries per wound physician. Left measures 1.5 cm X 1.5 cm area red/black dry and intact, Right heel 2.6 cm X 3.0 cm red/black dry and intact, bilateral [MEDICATION NAME] to heels daily and as needed. Resident is able to reposition self, ambulates with walker, will monitor till resolved. During an interview on 8-6-13 at 1:44 p.m. Direct care staff W and X remembered the resident and reported that he/she did have pressure ulcers on his/her heels because both staff W and X remembered they had to put "blue boots" (multipodus boots) on the resident. Neither staff W or X could remember if the resident came into the facility with the pressure ulcers, or if the resident developed them after he/she came in. During an interview on 8-6-13 at 4:27 p.m. Direct care staff A reported the resident was fairly independent and only required light assistance from 1 staff. The resident liked to be in bed a lot and would always ask to go back to bed after a meal. He/she had a lot of family that would visit and would take the resident outside and things. As far as staff A could remember the resident was not on a supplement and did not remember him/her having any pressure ulcers On 8-6-13 at 2:28 p.m. Administrative Nurse B stated the resident had bilateral lower [MEDICAL CONDITION] and staff started applying [MEDICAL CONDITION] (an accumulation of lymphatic fluid that causes swelling, most often in the arms and/or legs) wraps. Preventative interventions to prevent impaired skin integrity included an air loss mattress if in bed a lot but confirmed this resident did not have that. On 8-6-13 at 4:38 p.m. Administrative Nurse C reported when a resident admitted to the facility something should be in place, like an air mattress or whatever is appropriate to prevent pressure ulcers, according to the admission information that is provided upon admission. Nurse C stated that if a resident came into the facility not at risk for the development of pressure ulcers, but then became at risk after they admitted , then staff would initiate preventative measures. Review of the pressure ulcer policy dated 11-2011 revealed it was the policy of the facility that a resident who entered a facility without a pressure ulcer will not develop one unless the individuals clinical condition demonstrated they were unavoidable. Under Prevention of pressure ulcers it included the following: 1. Assess the resident's risk factors upon admission, weekly for 4 weeks ... by using the Braden scale, should also be assessed for risk factors that increase a resident's susceptibility to develop a pressure ulcer -- examples listed were -- impaired/decreased mobility and functional ability and co-morbid conditions such as end stage [MEDICAL CONDITIONS] disease diabetes mellitus or cardiac circulation issues. The facility failed to provide preventative measures to prevent the development of 2 pressure ulcers for a resident who was at risk for pressure ulcers.