Based on observations, interviews and record review, the facility failed to identify, assess, document, and provide interventions for pressure ulcers for 2 out of 2 residents reviewed (Residents #23 and #26). The failure to manage Resident #26's pressure wounds resulted in Stage 3 pressure ulcers to her right and left heels. The facility reported a census of 59 residents.Findings include:The MDS assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Resident #26's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of polyarthritis (arthritis in 5 or more joints), lymphedema (swelling caused by an accumulation of protein rich fluid), and obesity. The MDS indicate Resident #26 had a risk for developing pressure ulcers/injuries but did not have any pressure ulcers/injuries. An 802 Form provided by the facility on 2/9/26, reflected the facility had no pressure ulcers not present at admission. On 2/9/26 at 4:16 PM, this resident stated she wears the boots for wounds on her feet. She stated she believes the boots are helping her wounds heal. Has had the boots on during every observation she was seen today. On 2/10/26 at 2:02 PM, She stated that last week the facility had to cancel one of her appointments and so it was rescheduled on Thursday of last week. She stated something today about this and her appointment was cancelled. She does not want to miss her appointments as she wants her wounds to heal. She said they plan to reschedule today's missed appointment. The Skin/Wound Note dated 11/6/25 at 3:06 PM reflected Resident #26's left heel wound resolved. The nurse recommended to discontinue the current treatment and leave the wound open to air. Continue with compression socks on daily and off at bedtime (HS). The Condition Follow-up dated 11/27/25 at 5:48 PM indicated the facility monitored Resident #26 for a right knee replacement, left lower ankle (LLA) skin tear, scattered bruising, and soreness to her left heel. The note reflected Resident #26 had a history of a deep pressure injury (DPI) to her left heel and complained of soreness when the nurse inspected the left heel. The skin looked intact, pink, and dry. Resident #26 requested to elevate her heel due to fear of the injury reoccurring. Resident #26's clinical record included a Condition Follow-up Note for 11/28, 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/7, and 12/8 that reflected she had soreness to her left heel. The notes lacked assessments of her left heel. The Nursing Note dated 12/19/25 at 5:33 PM reflected Resident #26 complained of pain to her previously healed left heel. Upon the nurse's assessment observed a scab that measured 1 centimeter (cm) by 0.8 cm. The nurse applied skin prep to the heel and covered it with Medipore dressing for protection. The nurse faxed Resident #26's provider for a new treatment order. Resident #26's clinical record lacked documentation of her heel after 12/8/25 – 12/19/25. A LN-Skin Evaluation-PRN Weekly form dated 12/27/25, documented Resident #26's left heel as a scab measuring 1 by 1 cm without depth and no applicable stage. The form described the right heel as a red/soft area measuring 0.8 cm by 0.8 cm without depth and no applicable stage. The form reflected the facility sent a fax to the Primary Care Provider (PCP) for a new order (NO) for skin prep BID (twice a day) to bilateral heels and cover with foam border every 3 days and PRN (as needed), float heels while in recliner and in bed. A LN-Skin Evaluation -PRN Weekly form dated 1/3/26, documented Resident #26 had an unstageable pressure ulcer on her left heel. It described it as a 1 cm by 1 cm scab. The nurse applied skin prep to bilateral heels. The note reflected the right heel, healed. The Condition Follow-up Note dated 1/4/26 at 10:49 AM reflected the nurse cleaned Resident #26's bilateral (both) heels with normal saline, patted them dry, applied skin prep, and a Mepilex border dressing due to previous dressing peeling off. The nurse placed a pillow under her heels to prevent further irritation to the area especially to the left side with the scab. The Condition Follow-up Note dated 1/5/26 at 5:42 AM indicated the nurse applied new treatments to Resident #26's heels at 3:00 AM. A LN-Skin Evaluation-PRN Weekly form dated 1/10/26, documented that Resident #26 had a scab to her left heel measuring 0.5 cm by 0.5 cm with 0 depth. The form labeled the stage as not available. It documented Resident #26 had a Stage 1 pressure ulcer on the right heel measuring 0.5 by 0.5 with no depth. The right heel is slightly erythematous (redness of skin) and the left heel still continued to have a scab. The nurse applied betadine to areas and covered with mepilex dressings. The evaluation reflected Resident #26 tolerated treatment well. No complaints of pain at the time with the above areas. Treatment done as ordered with monitoring. A LN-Skin Evaluation-PRN Weekly form dated 1/18/26, documented that Resident #26's heel wounds were unstageable scabs. Left heel measured 1.8 by 0.8 cm and the right heel measured 1 by 1 cm. No depth on either of them. The note reflected the nurse applied skin prep to bilateral heels and covered with a foam border. The Condition Follow-up Note dated 1/18/26 at 11:51 PM documented the nurse applied skin prep to Resident #26's bilateral heels and covered them with a foam border. A LN-Skin Evaluation-PRN Weekly form dated 1/25/26, documented that Resident #26's skin was pink, warm and dry. Skin prep applied to bilateral heels and covered with foam border. The Evaluation lacked an assessment of the heels. A Wound Healing Center Visit Report dated 1/29/26 signed by Staff K, Wound Healing Center Registered Nurse (RN), documented Resident #26 had an open unstageable pressure ulcer acquired on 11/29/25 measuring 0.5 centimeters (cm) in length, 0.6 cm in width and 0.1 cm in depth on her right, posterior calcaneus. Resident #26 had an open unstageable pressure ulcer acquired on 7/29/25 measuring 0.4 cm in length, 0.7 cm in width and 0.1 cm in depth. At the appointment, they debrided (process of removing dead skin and foreign material from a wound) both pressure ulcers on 1/29/26. They documented the tissue debrided as necrotic/eschar (dead, thick, leathery tissue that forms a dry black or brown covering over a wound), subcutaneous, slough (dead tissue beneath the skin's surface). The measurements documented after debridement were 0.5 cm by 0.6 cm by 0.2 cm for the right heel ulcer and 0.4 cm by 0.7 cm by 0.2 cm for the left heel. Resident #26's February 2026 Treatment Administration Record (TAR) directed licensed staff to cleanse the Right and Left Posterior (back) Calcaneus (heels). Cleanse with normal saline daily, apply a thin layer to the wound bed of Santyl ointment (prescription topical enzyme used to remove dead or damaged tissue from chronic skin ulcers promoting wound healing), and cover with Mepilex Border (self-adherent foam dressing) one time a day for wound care. A LN-Skin Evaluation-PRN Weekly form dated 2/2/26, documented that Resident #26's skin was pink, warm and dry. Clean the right and left calcaneus with normal saline daily, apply a thin layer of Santyl (wound ointment) to the wound bed, and cover with Mepilex Border four by four (4x4) one time a day for wound care. Apply heel lift boot bilaterally at all times to bilateral lower extremities. The Evaluation reflected Resident #26 tolerated the treatment well. No other skin issues noted or reported. The Evaluation lacked an assessment of the heels. A Wound Healing Center Visit Report dated 2/3/26 signed by Staff K, documented Resident #26's right calcaneal wound measured 0.8 cm by 1.1 cm by 0.3 cm. Her left calcaneal wound measured 0.1 cm by 0.2 cm by 0.1 cm. The documentation labeled both wounds as Stage 3 pressure ulcers. At the visit, the debrided both wounds and after debridement the right heel ulcer measured 0.8 cm by 1.1 cm by 0.4 cm and the left heel ulcer measured 0.1 cm by 0.2 cm by 0.2 cm. On 2/11/26 at 8:37 AM, watched Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, wash their hands in preparation to do wound care. Resident #26 asked if her wound appointment got rescheduled. Staff A answered she had not had time to check yet that morning but she would. Staff B stated Resident #26 had a wound appointment yesterday and Resident #26 cancelled the appointment. Staff A removed the mepilex dressing from the left lateral leg, cleaned the wound, and applied Santyl to the wound. Staff A left the room to get a dressing for the left anterior calf dressing and the right lateral heel wound. Staff A returned to the room, washed her hands, and put on gloves. Staff A placed a new dressing on the left posterior leg wound, she removed the right heel wound dressing, disposed of it in the trash, opened a normal saline vial, and cleansed the wound by rinsing it with the normal saline. Staff A disposed of the normal saline, opened the dressing and applied the dressing. Staff A didn't remove her gloves nor disinfect her hands in between applying the dressing to left posterior lower leg and applying the new dressing to the right heel wound, including the removal of an old dressing, cleaning of the wound, and applying the new dressing on the right heel. When asked about the treatment for the left heel, Staff A stated that she didn't need to do that one as it was just a scab. Noted a mepilex dressing on the left heel. Directly after this observation, Staff A acknowledged she should have removed her gloves and disinfected her hands in between the separate wound dressings and in between the dirty and clean steps. On 2/11/26 at 9:30 AM, when asked about her cancelled appointment, Resident #26 replied her appointments have been mixed up for the last couple of weeks. She said that last weeks' appointment got moved to Thursday as the facility cancelled it. The previous day, she asked about the appointment that was scheduled as she was just there on Thursday, and they ended up cancelling that one. She stated she wanted to go to her appointments so that her wounds heal. On 2/11/26 at 2:10 PM, Staff B stated she was trying to let Resident #26 know (help this resident understand) that it is important to go to the Wound Clinic because her wounds are not good when she had told the resident that she refused to go to the Wound Clinic. She stated that she could have explained her thoughts about the need to go to the wound clinic better and was probably too harsh in her comment. When Staff B was asked if last week's appointment was cancelled and rescheduled for Thursday, Staff B stated she knew nothing about that. Staff B stated she had been off for 10 days, so didn't know Resident #26 just had her last appointment on Thursday. She stated she was also distracted by the wound treatment and not disinfecting hands or changing gloves. On 2/11/26 at 2:44 PM, Staff K, RN Wound Healing Center, reported the Wound Center diagnoses the ulcers on both of Resident #26's heels as pressure ulcers. On 2/11/26 at 3:30 PM, the Director of Nursing (DON) reported Resident #26 admitted to the facility with the areas on her heels and they didn't develop at the facility. She stated she would get records for the weekly assessments. When asked about why they didn't have Resident #26 coded on the 802 form as having a facility acquired pressure ulcer. She stated the heel wounds weren't pressure ulcers; they were just scabs. She stated the Wound Clinic made the wounds worse by debriding them, and they became larger. The DON stated the heel wounds didn't need debrided, as they were just scabs. When asked if the scabs could hide tunneling or worse wounds underneath them, she stated she didn't feel they were pressure ulcers. When asked about the Wound Clinic diagnosing them as pressure ulcers, she said she would need to look into it more. Following the above interview, the DON said there were 3 types of wound notes, and if the wound assessments weren't found in one of the three types of wound notes, then they weren't done. On 2/11/26 at 4:13 PM, the DON reported the facility didn't do what they should for the pressure and non-pressure wound/skin area weekly assessments. She stated the facility went back and forth with labeling something pressure and then non pressure. She added she knew they are inconsistent. Staff A stated that morning when she didn't do the treatment to the left heel, it was because Resident #2 only had preventative treatment to the left heel and she thought it is to be done every third day. She described the left heel wound as just a skin flap. She acknowledged she called it just a scab that morning. The DON concurred the treatment was preventative. They reviewed the doctor's order and the DON acknowledged the left heel wound treatment needed done daily. Staff A stated she didn't realize that. The DON stated she did the treatment the last 2 days. After Staff A left the room and the Administrator walked into the room. Concerns were shared with the Administrator and the DON regarding the infection control issues observed during the wound treatment completed that morning. Both the Administrator and the DON acknowledged the concerns. They described Staff A as normally so good with infection control and that is why they chose her to do the treatment. On 2/12/26 at 12:00 PM, when asked if Resident #26 had her left heel treatment completed the night before, Staff B and the DON responded Staff A said would it later the previous night as she worked until 10:00 PM and it was an evening shift dressing. The DON asked if the treatment was signed. When reminded that the treatment was for both heels and they are signed as both done in one spot, the DON agreed. After checking Resident #26's dressing on her left heel for the date, observed the date of 2/10/26, indicating that the treatment didn't get one. The DON acknowledged the staff didn't do the treatment to the left heel as ordered. On 2/12/26 at 1:17 PM, attempted to call Staff A, her phone reported it didn't accept messages. A text was sent to Staff A at 1:20 PM, requesting a return call. Prior to the end of the survey, Staff A didn't return the call. The Skin and Wound Monitoring and Management policy reviewed December 2023 instructed the facility to ensure a resident who entered the facility without a pressure injury didn't develop a pressure injury unless individual's clinical condition or other factors demonstrate that a developed pressure was unavoidable. In addition, a resident who had a pressure injury(s) received the necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of the policy directed the following:a. Promote interventions that prevent pressure injury development;b. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); andc. Prevent the development of additional, avoidable pressure injury.The procedure instructed ongoing skin and wound assessments. A licensed nurse would assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. The assessment/evaluation should include but not limited to:a. Measuring the skin injuryb. Staging the skin injury (when the cause is pressure)c. Describing the nature of the injury (e.g., pressure, stasis, surgical incision)d. Describing the location of the skin alteratione. Describing the characteristics of the skin alterationf. Describing the progress with healing, and any barriers to healing which may existg. Identifying any possible complications or signs/symptoms consistent with the possibility ofinfection 2. Resident #23's Census reflected an admission to the facility on [DATE]. Resident #23 transferred and admitted to the hospital on [DATE]. Resident #23 returned from the hospital and was re-admitted to the facility on [DATE]. Resident #23's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension, acute respiratory failure, and weakness. The Hospital Record dated 11/13/25 noted a skin tear on Resident #23's left buttocks present on admission. Resident #23's admission Record - Skin assessment dated [DATE] failed to indicate altered skin integrity on or around their buttock area. The Nursing Note dated 11/21/25 at 11:51 PM documented a full assessment for Resident #23 prior to an emergency room transfer for altered mental status. The Note included findings of the following skin alterationsa. A wound to Resident #23's lower left buttock measuring 6.2 cm x 3 cm with black center.b. Reddened border and wound on his right buttock measuring 4 cm x 2 cm. The Nursing Note dated 11/22/25 at 1:13 AM reflected the same wound information as the note documented on 11/21/25 at 11:51 PM, but included the right wound appeared scabbed over without drainage. The Hospital emergency room Records dated 11/22/25 at 12:20 AM noted the nursing home staff discovered a wound under Resident #23's left buttocks that day and didn't know when it developed. The record included the following notes:a. 11/22/25 at 7:00 AM of Resident #23's assessment. The assessment noted an area of black with reddened border to Resident #23's left upper thigh. Resident #23 reported area as tender to the touch and appeared to have some skin breakdown to the sacrum (above tailbone).b. 11/24/25 at 3:27 PM documented Resident #23's initial hospital wound nurse skin screening found an unstageable pressure wound to his left gluteus (buttock) and coccyx (tailbone) area; a stage 3 pressure wound on his left elbow. The deep tissue injury on Resident #23's right gluteus present on hospital admission on [DATE] appeared to be resolving and a surgical wound upper abdomen. Resident #23's Hospital Discharge records dated 11/28/25 included orders to cleanse all wounds with mild soap and water, gently pat dry. Apply Santyl ointment to left buttock wound, left elbow wound, and coccyx wound. Cover all wounds with border dressing, changing dressing daily, and as needed. Resident #23 to follow up with the wound center, appointment scheduled on 12/2/25 at 9:45 AM. Resident #23's Hospital Records dated 11/28/25 at 10:45 AM documented, the hospital nurse called report to Staff L, RN, at the facility. They notified of Resident #23's hospital discharge with orders to follow up with the wound center, primary care provider, and neurology. Resident #23's Progress Notes failed to indicate transportation to scheduled wound center appointments, wound center visit notes, or future scheduled appointments. During a phone interview on 2/11/26 at 11:00 AM, the wound center receptionist stated Resident #23 was a no show for the scheduled appointment on 12/2/25. The facility provided no follow-up communication. On 2/11/26 at 4:27 PM, the DON explained after she reviewed Resident #23's 11/28/25 hospital discharge document, Resident #23 had a wound center appointment scheduled. The DON couldn't find additional documentation to indicate if Resident #23 attended the appointment. Resident #23's MDS assessment dated [DATE] listed he returned to the facility on [DATE] from an acute hospital stay. The MDS identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension, respiratory failure, encephalopathy (dysfunction of the brain altering function and mental status), weakness, and 2 unhealed, unstageable pressure ulcers. Resident #23's re-admission Skin Assessment record dated 11/28/25 at 11:15 AM, Staff L documented skin problems on admission including a skin tear to left elbow, unstageable coccyx pressure wound, and an unstageable left hip pressure wound. The assessment included an additional notation that Resident #23 fell at home and laid on the floor for 3 days prior to being found. A LN-Skin Pressure Ulcer Weekly form dated 12/6/25 reflected Resident #23 had a pressure area to his left buttock and sacrum. The additional comments reflected the areas to the left buttocks and sacrum area were improving. The facility would continue to monitor and do the treatment as ordered. The Daily Skilled V3.0 – V 2 note dated 12/6/25 documented the overall skin description as skin pink, warm, dry, and intact. He had wounds on his coccyx area, left buttocks, and left elbow. The facility implemented a treatment with dressing changes, cleaning, and applying ordered ointment. Resident #23 reported soreness when the nurse did his treatment. The note lacked an assessment of his wounds with appearance, measurements, or odor. A LN-Skin Pressure Ulcer Weekly form dated 12/18/25, documented that this was a follow-up evaluation for wounds present on admission with an onset date of 11/28/25, unstageable left posterior ischium slough (dead tissue and fluid that forms a yellow, tan, or white, stringy or slimy layer on top of a wound) wound, noting darkened scar tissue surrounding and measuring 2.3 cm x 1 cm. Follow-up evaluation for healed coccyx wound. The Nursing Note dated 12/19/25 directed to continue to do the current treatment to the left posterior ischium wound of Santyl ointment due to a large amount of adherent (sticky) slough covering the surface. A LN-Skin Pressure Ulcer Weekly form dated 12/27/25, documented that this was a follow-up evaluation for wound present on admission with an onset date of 11/14/25, unstageable left posterior ischium wound measuring 2 cm x 0.5 cm with surrounding wound bed measuring 4 cm x 2.5 cm. The wound bed appeared reddened with active bleeding. Resident #23 reported constant sharp pain. Resident #23's December 2025 TAR included an order to cleanse with mild soap and water,gently pat dry, apply Santyl Ointment to left posterior ischium wound, cover with dryborder foam dressing, change dressing daily and PRN every day shift for wound care. The order lacked documentation indicating completion of treatment on 12/19/25, 12/22/25, and 12/29/25. A LN-Skin Pressure Ulcer Weekly form dated 1/3/25, documented the assessment as a follow-up evaluation for a wound present on admission with an onset date of 11/14/25. Resident #23's stage 2 left hip wound measured 2.2 cm x 0.8 cm. The assessment noted the wound as healing well from previous assessment per the nurse and since admission. A LN-Skin Pressure Ulcer Weekly form dated 1/10/25, documented a follow-up evaluation for a wound present on admission with an onset date of 11/14/25. Resident #23's stage 2 left hip wound measured 1.8 cm x 0.8 cm. A LN-Skin Pressure Ulcer Weekly form dated 1/17/25, documented a follow-up evaluation for a wound present on admission with an onset date of 11/14/25. Resident #23's stage 2 left hip wound measured 1.6 cm x 0.8 cm. A LN-Skin Pressure Ulcer Weekly form dated 2/3/25, documented a follow-up evaluation for a wound present on admission with an onset date of 11/14/25. The note defined Resident #23's stage 2 left hip wound as healed. On 2/12/26 at 2:40 PM, the DON, reviewed Resident #23's initial admission skin assessment on 11/14/25, the weekly nursing skin assessments. The assessments failed to indicate skin breakdown from 11/14/25 to ER transfer assessment on 11/21/25. The hospital records documented wounds. The DON acknowledged the inconsistency and accuracy of nursing documentation. The facility provided Skin and Wound Monitoring and Management Policy; reviewed December 2023 directed a licensed nurse must assess/evaluate a resident's skin on admission. The policy instructed to document all areas of breakdown, excoriation, or discoloration, or other unusual findings, on the Initial admission Record. In addition, the policy directed to re-evaluate existing treatment regimen in connection with the resident's clinical presentation, including current interventions and Care Plan considerations, if any wound is non-healing or not showing signs of improvement after 14 days or any time a wound is worsening.
Every finding on record at Fort Dodge Health and Rehabilitation
Fort Dodge, Iowa · CCN 165156
28 findings across 9 inspections, in the inspector's own words, 12 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of February 26, 2026
17 findingsBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure residents received safe and appropriate assistance during transfers for 2 of 3 residents reviewed (Residents #4 and #2). The facility's failure to follow established transfer procedures and provide the necessary assistance placed residents at risk for injury and failed to ensure a safe environment. Resident #4 slid from a mechanical lift sling during a transfer and fell to the floor, sustaining a rib fracture. Resident #2 experienced a fall during a transfer when the staff failed to provide the required level of assistance resulting in complaints of shoulder pain. The facility reported a census of 59 residents.Findings include:1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS listed Resident #4 as dependent on staff for all cares and used a wheelchair for mobility. The MDS included diagnoses of Parkinson's disease (a disease process that affects the brain resulting a balance problems), with contractures of left- and right-hand muscles, stiffness of left and right knees, reduced mobility, bipolar disorder, depression and anxiety. The Care Plan Focus dated 5/20/24 reflected Resident #4 had an activity of daily living (ADLs) self-care performance deficit related to limited mobility, impaired balance, pain, and Parkinson's disease. The Intervention directed to use a full body mechanical lift with the sling sized per his weight. The Nursing Progress note dated 1/5/26 at 4:00 PM indicated as the Certified Nursing Assistants (CNAs) transferred Resident #4 with the use of a full body mechanical lift, one of the full body sling loops came off the top left corner hook. As a result, Resident #4 slid out of the sling feet first to the floor. When Resident #4 began to slide out of the sling, Staff G, CNA, and Staff H, CNA, managed to assist Resident #4 all the way to the floor with his upper body leaning on Staff G to preventing him from hitting his head on the floor. The Director of Nursing (DON) assessed Resident #4 at the time and found no apparent injury. The staff transferred Resident #4 to bed with the assistance of 4. Resident #4 informed Staff I, LPN (Licensed Practical Nurse), who assisted, his right middle ribs were a little sore but didn't feel anything was broken. The nurse administered Tylenol to Resident #4 and continued monitoring to evaluate for further pain or changes. The Nursing Note dated 1/6/26 at 7:05 PM reflected Resident #4 complained of rib pain. Their provider gave new orders to obtain x-rays. The X-Ray results dated 1/6/26 at 8:51 PM noted the detection of an acute right rib fracture of #10 (lower rib). In an interview on 2/9/26 at 3:20 PM, the Director of Nursing (DON) stated the facility provided education and a step for CNAs to stop and check the sling loops were securely on the lift bars during the full-body mechanical lift transfer process. In an interview on 2/11/26 at 3:05 PM, Staff H explained she ran the controls for the mechanical lift while Staff G guided Resident #4 in the sling. As Resident #4 laid in bed, they attached all four loops on the sling to the four hooks on the mechanical lift. They lifted Resident #4 above the bed, and as she started to rotate the lift towards his chair the left loops closest to her came off. When that happened Resident #4 started sliding down out of the sling with his feet landing on the floor. She managed to hold an area of the sling while Staff G held another area and supported Resident #4 while lowering him to the ground using her legs and torso to support his upper body to prevent him from hitting his head. Staff G radioed to the nursing staff for assistance. The DON came and assessed Resident #4. With the help of the nurses, they lifted Resident #4 and transferred him back into bed. On 2/12/26 at 12:40 PM Resident #4 stated Staff G and Staff H, lifted him above his bed to transfer him. Once he got off the bed and hanging in the sling, he started to slide down with his feet landing first on the floor. Staff G and Staff H lowered him to the floor and made she he didn't hit his head. After the incident, the staff checked him over and assisted him to bed. Later he started to have having rib pain. The got him x-rays and found a fracture. Resident #4 stated they transferred okay but sometimes it felt like the CNAs rushed to get it done. The Facility's Investigation provided Staff G's written statement. The statement documented Staff H helped her change, dress, and hook Resident #4 up to the full-body mechanical lift. Staff H raised Resident #4 into the air over his bed. As they pulled Resident #4 back from the bed the loop on Resident #4's right came undone. She held the left side of the sling with her left hand and the back strap handle with her right hand to guide him during the transfer. Resident #4 began to slide out of the sling feet first. As this happened, she used her right arm and leg to try to guide Resident #4 down to the floor. Once Resident #4 got to the floor, she radioed for help. The In-service Attendance Record listed a course title of Time out to ensure all 4 corners of the lift are attached dated 1/7/26 related to the subject lift time out during lift procedure. The facility provided an undated Mechanical Lift Application and Use document with yellow writing of Master indicated it was a checklist to identify the steps to apply and use a mechanical lift. The steps to apply and use a mechanical lift identified the following key steps: a. Attach the sling to the lift by lowering the sling bar and attaching the sling as directed by the manufacturer, examining and position and stability of all hooks and fasteners. (Highlighted in green on the paper)b. Prepare to engage the lift by standing close to the person, depressing the up button on the lift or remote until there is tension on the sling, adjust the lift brackets so the person is in a sitting position. c. Engage the lift to raise the person 2 inches off the bed, then check that the person is secure and comfortable. Continue to lift the person until free of the surface. d. Transfer the person by unlocking the lift wheels, moving the lift away from the bed toward the chair, positioning the lift with the legs on each side of the chair and locking the lift wheels. e. Lower the person onto the chair by having your coworker move the sling into the correct position over the chair. Lowering the lift until the person is in contact with the seat. Standing next to the person and grasp the lift bracket so it does not move or make contact with the person. f. Remove the lift by lowering the sling bar to unhook the sling. Unlocking the wheels and pulling the lift away from the chair, closing the legs of the lift and applying the lift brakes. During a follow-up interview on 2/26/26 at 2:40 PM Staff G said she hooked up Resident #4 at the head of his bed and raised the head of his bed. She explained the facility had 2 machines both the same in the front and the back. They used a blue sling for Resident #4 when they transferred him. All of the slings are blue mesh slings with a hole where their bottom goes. Staff G said as they lifted him the strap on his right side of his legs came off. When this happened, he slowly slid to the floor. This allowed her to get under him to help guide him to the floor. She reported she wracked her brain trying to figure out what happened. The only thing she could think of was that they didn't get the strap all the way on the hook. Since then, the head of therapy did audits on them. Following the incident, they are supposed to talk through the process step by step as they go, no matter. Staff G explained when it happened only her and Staff H were in the room at the time. They are supposed to have 2 people when they transfer with the Hoyer lift. They make sure they communicate as they go. During a follow-up interview on 2/26/26 at 2:50 PM Staff H reported the bottom right strap for him or left side for her had the strap come off. When this happened, his legs came out then his upper torso. Staff H said he used a green outline blue mesh woven grip sling. Staff H reported she might have hooked up his legs but thought she hooked up his head. She added she thought they may have moved/pivoted him in the wrong direction that caused a displacement in the pressure and caused it to pop off. They have a full-body mechanical hook there with safety hooks in the front of the building. They used the one in the back of the building, that didn't have them. Staff H said they had 3 full-body mechanical lifts in the building, 2 of the same and one different. The 2 that were the same didn't have the safety hooks. She thought the one with the safety hooks was older, and she thought they got the other two from a local facility after they closed. 2. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS included a diagnosis of chronic (long-term) kidney disease. The Care Plan initiated 6/16/25 identified Resident #2 at risk for falls related to taking an antidepressant, an opioid and diuretic medications. Resident #2 had diagnoses of coronary artery disease, atrial fibrillation, congestive heart failure, and anxiety. The Progress Notes dated 2/1/26 at 5:51 p.m. documented while the CNA assisted Resident #2 to transfer from the bed to the wheelchair around 4:30 p.m., they fell backward into the bed. Resident #2 stated while both arms landed on the bed, she felt like her right arm hit something. After the incident, she reported right shoulder pain (at 10 out of 10, indicating the worst pain imaginable) and received her scheduled hydrocodone (narcotic pain medication). Resident #2 had slightly limited range of motion (ROM) on the right upper arm. Resident #2 reassessed for pain at 5:50 p.m. and reported at 7/10. After, super Resident #2 assisted and transferred back to bed without complaint. On 2/11/26 at 2:43 p.m. Staff F, CNA (agency), stated she assisted Resident #2 in getting up. No one told her what assistance they needed. She asked Resident #2 what help she needed, and she said she could get herself up. She stood up and Staff F held onto her pants. She took 1 step and fell back on the bed. She got back up and said her shoulder hurt. She reported it to the nurse, and she had a history of shoulder pain. On 2/12/26 at 8:15 a.m. the DON stated the staff member should have used a gait belt on the resident when assisting her.
Based on observations, interviews, and record review, the facility staff failed to provide respect and dignity for 2 out of 19 residents reviewed (Resident #11 and Resident #22). The facility failed to cover Resident #11's catheter bag with a dignity bag. During a wound treatment, the staff spoke disrespectfully to Resident #22. The facility reported a census of 59 residents. Findings include:1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #11 included non-Alzheimer's dementia, reduced mobility and depression. A Brief Interview for Mental Status (BIMS) documented a score of 6 out of 15, which indicated severely impaired cognitive functioning. This resident had an indwelling catheter. On 2/9/26 at 10:30 a.m., observed Resident #11 from the hallway as he laid in bed, his catheter bag hanged off of his bed without a covering. At 3:00 p.m., he continued to have no covering on his catheter bag. At 4:00 p.m., he still didn't have a covering over the catheter bag. On 2/10/26 at 10:00 a.m., witnessed Resident #11 from the hallway, he still didn't have a covering on his catheter bagOn 2/10/26 at 2:30 p.m., observed Resident #11 through an open door from the hallway. His urinary catheter contained urine and didn't have a covering.On 2/10/26 at 2:30 p.m., Staff J, Hospice Nurse, stated she hadn't seen a covering of his urine bag since he had got the catheter. The nurse verified he didn't have a dignity/cover bag over his catheter bag and verified it they could see it from the doorway. On 2/10/26 at 2:45 p.m., observed Resident #11 with a dignity bag on his catheter bag. On 2/10/26 at 3:50 p.m., the Director of Nursing (DON) acknowledged the concern with the catheter not having a dignity bag over the urine bag. The Administrator concurred that it was a silly thing that staff didn't put the covering over the bag, as it should have one over the catheter bag. 2. A MDS dated [DATE], documented diagnoses for Resident #28 included polyarthritis (arthritis in 5 or more joints), lymphedema (swelling caused by an accumulation of protein rich fluid), and obesity. A BIMS revealed a score of 15 out of 15, which indicated intact cognition. It documented that this resident was at risk for developing pressure ulcers/injuries but did not have any pressure ulcers/injuries. On 2/10/26 at 2:02 p.m., Resident #26 stated that her wound appointment was cancelled today because she just went on Thursday (2/5/26). She normally goes to the wound clinic once a week for the wounds on her foot. When asked if she had a wound on just one of her feet, she stated she had a wound on each of her feet. She stated she felt the wounds have improved. She stated last week the facility had to cancel one of her appointments and so they rescheduled it to Thursday of last week. She told the staff that day and they cancelled her appointment. She didn't want to miss her appointments as she wanted her wounds to heal. She said they planned to reschedule the missed appointment.On 2/11/26 at 8:37 a.m., Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, washed their hands (preparing to get ready to do Resident #26's wound treatments). Resident #26 asked if they rescheduled her wound appointment. Staff A answered she didn't have time to check yet that morning, but she would. Staff B asked Resident #26 if she was talking about the wound appointment, and Staff A answered yes. Staff B stated Resident #26 had a wound appointment yesterday, and Resident #26 cancelled it herself. Staff B said this using a harsh tone. Resident #26 waited for a few seconds, and then said, she didn't want to miss her appointments, she wanted to go to wound clinic, and she wanted her wounds to get better.' Staff B did not respond. On 2/11/26 at 9:30 a.m., when asked how it made her feel when it was brought up that she cancelled the appointment, Resident #26 responded said it made her feel bad. She stated the appointments have been mixed up for the last couple of weeks. She said it made her feel like the missed appointments were all her fault and that she should feel guilty about them. She said that last weeks' appointment was moved to Thursday as the facility cancelled it, and yesterday she asked about the appointment scheduled as she was just there on Thursday, and they ended up cancelling that one. She added she wanted to go to her appointments so that her wounds heal. On 2/11/26 at 10:18 a.m., Staff A stated that if it were her, she would not have said what Staff B said to Resident #26 about the appointment being missed, because Resident #26 refused to go. Staff A stated Staff B said it harshly and it didn't need said. On 2/11/26 at 2:10 p.m., Staff B stated that when she told Resident #26 that she (Resident #26) refused to go to the Wound Clinic, Staff B was trying to let Resident #26 know that it is important to go to the Wound Clinic because her wounds are not good. She stated that she could have explained her thoughts about the need to go to the wound clinic better and was probably too harsh in her comment. When Staff B was asked if last week's appointment was cancelled and rescheduled for Thursday, Staff B stated she knew nothing about that. Staff B stated she had been off for 10 days, so didn't know she just had her last appointment on Thursday. 2/11/26 at 4:13 p.m., concerns were shared with the Administrator and the DON regarding the dignity issue observed during Resident #26's wound treatment this a.m. Both the Administrator and the DON acknowledged the concerns. A Resident Rights Dignity and Respect policy revised on 5/6/21, directed the following:POLICY: It is the policy of this facility that all residents be treated with kindness, dignity and respect. PROCEDURES: The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.Schedules of daily activities allow maximum flexibility for residents to exercise choices about what they will do and when they will do it. Residents' individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility.Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and be well groomed.Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the Resident's room.Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the Resident's safety.Violations of the Resident's right to dignity and respect should be promptly reported to the Director of Nursing Services and/or the Administrator.
Based on observation, record review, and staff interview, the facility failed to ensure personal privacy during care for 1 of 6 residents reviewed (Resident #7). The facility reported a census of 59 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident depended on staff for all activities of daily living (ADL's). Diagnoses included traumatic spinal cord injury, aphasia (neurological language disorder affecting a person's ability to speak), and quadriplegia (paralysis of all 4 extremities). Resident #7 had a feeding tube.The Care Plan dated 8/29/22 included Resident #7 required a tube feeding related to a swallowing problem. The interventions included the resident would remain free of side effects or complications related to tube feeding.On 2/11/2026 9:46 a.m. Staff B Licensed Practical Nurse (LPN) went to discontinue Resident #7's feeding and treat the area to the feeding tube insertion site. The resident's abdomen and incontinent pad were uncovered through the treatment and the door (to her room) remained open (leaving the resident exposed from the hall).On 2/12/26 at 8:15 a.m. the Director of Nursing (DON) stated the door to the resident's room should be closed for privacyThe undated facility policy for Dignity and Respect included a residents should be examined and treated in a manner that maintained the privacy of their bodies. A closed door or drawn curtain shielded the resident from passers-by.
Based on interviews and record review, the facility failed to notify the Ombudsman for 2 of 3 residents reviewed (Residents #3 and #35). The facility reported a census of 59 residents. Findings include: 1) A Discharge Summary Note dated 1/22/26 at 3:09 p.m., documented Resident #35 admitted to the facility for Post-Acute Care/Skilled Nursing and Rehabilitation Services. Resident #35 improved and no longer required facility services. Planned discharge date [DATE]. A Census Page documented the facility stopped billing Resident #35 on 1/23/26. On 2/10/26 at 4:45 p.m., an email sent to the Administrator asked for the Ombudsman Notifications for the months of July, August, October, and November 2025 and January 2026. Another email sent on 2/11/26 at 1:19 p.m., asked again for the notices. On 2/11/26 at 1:35 p.m., the Administrator stated that the facility failed to do the Ombudsman Notifications. On 2/12/26 at 1;30 p.m., the DON stated the facility didn't have an Ombudsman policy, as they just follow the guidelines. 2) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included chronic obstructive pulmonary disease. The Census tab in the Electronic Health Record (EHR) listed a hospitalization for Resident #3 on 10/7/25 and active again on 10/13/25. The MDS tab in the EHR documented Resident #3 discharged [DATE] with return anticipated. The facility lacked documentation they notified the Ombudsman of the resident's hospitalization.
Based on record review, staff interview, and review of CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, Preadmission Screening and Resident Review (PASRR) conditions, the facility failed to complete the Minimum Data Set (MDS) assessment accurately for 1 of 20 residents reviewed (Resident #8). The facility reported a census of 59 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 was not considered by the state level II PASRR process to have a serious mental illness. The resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included bipolar disorder and anxiety disorder.The most recent PASRR dated 12/5/23 documented a PASRR Level1 identification Screen reviewed for potential PASRR status showed Resident #8 had evidence of a serious mental illness. However, his condition did not require further PASRR evaluation because his serious mental illness needs had not significantly changed since his previous PASRR Level 2 evaluation. His previous PASRR summary of findings remained valid for his stay at the nursing facility. The services identified in the previous PASRR remained appropriate and should continue.Review of CMS's, Resident Assessment Instrument (RAI) Version 3.0 Manual, PASRR conditions, A1500 directed to code 1, yes: if PASRR Level II screening determined the resident had a serious mental illness, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.On 2/12/26 at 3:15 p.m. the Director of Nursing (DON) stated they reached out to their contact at PASRR and found out they had answered the question in error.
Based on clinical record review and staff interviews, the facility failed to have a baseline Care Plan for 1 of 22 (Resident #55). The facility reported a census of 59.Findings include:Resident #55's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 1/2/26. Resident #55's Census reviewed on 2/16/26 listed an admission date of 1/2/26.Resident #55's clinical record lacked a Baseline Care Plan.On 2/11/26 at 5:02 PM the Director of Nursing (DON) said she couldn't locate a Baseline Care Plan at all in the documents.
Based on record review and staff interview, the facility failed to revise the care plan to reflect a resident's current status for 2 of 20 residents reviewed (Resident #8 and #23). The facility reported a census of 59 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Diagnoses included bipolar disorder and anxiety disorder. The Care Plan dated 12/4/23 identified Resident #8 had Chronic Obstructive Pulmonary Disease (COPD) related to smoking. The Care Plan initiated 11/4/24 identified Resident #8 had the potential for injury related to smoking. The goal read Resident #8 would be compliant with the individual smoking plan until next review. Interventions included completion of a smoking assessment as needed, educating Resident #8 on safe smoking practices, maintaining smoking materials at the nurses' station or other designated area, requiring a smoking apron, smoking times were 8am - 12pm - 4pm, and staff would show Resident #8 the designated smoking areas upon admission and as needed. A Smoking Evaluation dated 12/14/25 at 2:04 p.m. documented Resident #8 had a dexterity problem, smoked 0-3 times a day, and liked to smoke in the afternoon. The resident used a vape and smoked when a friend or his son came to take him out. On 2/9/26 at 2:15 p.m. the Administrator stated they didn't have residents who smoked residing in the facility. On 2/12/26 at 8:15 a.m. the Director of Nursing (DON) stated Resident #8 did not keep smoking materials at the facility, and staff did not assist the resident with smoking. Sometimes they would see him in a family member's vehicle smoking. She said the Care Plan related to smoking did not reflect the resident's status. 2) Review of Resident #23's admission MDS dated [DATE] revealed admission to the facility on [DATE], with a BIMS of 11. The resident's diagnoses included hypertension (high blood pressure), respiratory failure (lung failure), and muscle weakness requiring supervision or touch assist with the use of a walker. A Quarterly MDS dated [DATE] revealed Resident #23's readmission from the hospital on [DATE]. The resident required supervision or touching assist for ambulation with a walker. Review of Resident #23's Care Plan documented the ADL care performance initiated 1/9/26, including the resident's need for supervision or touch assistance with ambulation. The undated facility Care Planning policy instructed the interdisciplinary team (IDT) should develop a Comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. The Care Plan would be revised as needed, and interventions would be implemented. The resident's comprehensive plan of care would be reviewed and/or revised by the IDT after each assessment and updated as appropriate.
Based on observations, interviews and record review, the facility failed to provide bowel interventions for a resident that went without a bowel movement from 2/6/26 at 11:57 a.m. until 2/16/26 at 1:59 p.m. for 1 of 1 resident reviewed (Resident #11). The facility reported a census of 59 residents. Findings include: Resident #11's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS included diagnoses of non-Alzheimer's dementia, reduced mobility and depression. The MDS identified Resident #11 had an indwelling catheter and listed him as always incontinent for bowel movements. Resident #11's Census printed 2/12/26 documented his primary payor as Hospice Medicaid effective 12/12/25. The Bowel Movement/Bowel Continence Response history for the previous 14 days printed 2/12/26 at 3:00 p.m., documented Resident #11 had a medium sized bowel movement on 2/6/26 at 11:57 a.m. The documentation reflected he did not have another bowel movement until 2:12/26 at 1:59 p.m. Resident #11's February 2026 Medication Administration Record (MAR) included the following orders: a. Senna 8.6 mg (milligrams) 1 time a day for bowel regimen. The MAR included documentation Resident #11 received the medication from 2/1/26 to 2/12/26. b. Milk of Magnesia (MOM) suspension 400 mg/5 ml(milliliters), 30 ml by mouth as needed for constipation. The documentation reflected Resident #11 didn't receive MOM from 2/1/26 to 2/12/26.On 2/12/26 at 12:20 p.m., observed Staff C, Certified Nurse Aide (CNA), and Staff D, CNA, talked with Resident #11 and obtained permission to do peri care. As they cleaned Resident #11's back side, they revealed an approximate baseball sized firm stool. On 2/12/26 at 2:35 p.m., Staff E, Registered Nurse (RN), concurred Resident #11's clinical record didn't have documentation he had a bowel movement since the one documented on 2/6/26 at 11:57 a.m., until documented on 2/12/26 at 1:59 p.m. She stated she couldn't find any documentation of bowel intervention. She stated she talked with a nurse and the nurse told her it was because he didn't eat or move much. Staff E stated they should have intervened and are working on getting some as needed bowel medications as he currently only took Senna. On 2/1/226 at 1:30 p.m., the Director of Nursing (DON), stated Staff E let her know what happened with Resident #11. She reported being disappointed with the lack of communication between Hospice and the facility about his lack of bowel movements. She reported the situation as the first time it had happened. She said the CNA informed the DON Resident #11 had a hard time passing stool. She said they are working on how to ensure communication is happening. A Bowel Care Management policy revised May 2021 directed staff that it was the facility's policy to follow physician orders and implement bowel care interventions. The procedure instructed the following: a. Monitor and record resident bowel movements.b. Administer bowel care as ordered.c. If no bowel movement in three days, implement prn bowel care orders per physician orders.
Based on observation, record review, and staff interview the facility failed to perform a feeding tube procedure per the physician's order for 1 resident with a feeding tube (Resident #7). The facility reported a census of 59 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident depended on staff for all activities of daily living (ADL's). Diagnoses included traumatic spinal cord injury, aphasia (neurological language disorder affecting a person's ability to speak), and quadriplegia (paralysis of all 4 extremities). Resident #7 had a feeding tube.The Care Plan dated 8/29/22 included Resident #7 required a tube feeding related to a swallowing problem. The interventions included the resident would remain free of side effects or complications related to tube feeding.The Physician's Orders in the facility Electronic Health Record (EHR) included every day and night shift Check tube placement and patency prior to each feeding/flush/medication administration via air bolus auscultation or residual aspiration. On 2/11/26 at 7:07 a.m. Staff B Licensed Practical Nurse (LPN) prepared medications and entered the resident's room. Staff B stopped the feeding at the pump and disconnected the feeding from the g-tube. Staff B flushed the g-tube with 75 cc's water from the sink, administered the medications and flushed with another 75 ccs. Staff B then checked tube placement. On 2/12/26 8:15 a.m. the Director of Nursing (DON) stated they should check the feeding tube for placement before administering medications.The undated facility policy for Tube Feeding included checking tube for correct placement every shift or every medication administration by auscultation and aspiration. If not in place, hold feeding and medications, and notify the physician for orders.
Based on record review, staff interview, and facility policy review, the facility failed to complete post dialysis assessments for 1 resident reviewed on dialysis (Resident #2). The facility reported a census of 59 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included chronic kidney disease and she received dialysis.The Care Plan identified Resident #2 needed dialysis related to renal failure Initiated 4/19/25. Interventions included the resident had dialysis Monday, Wednesday, and Friday, and obtaining vital signs and reporting significant changes in pulse, respirations and blood pressure immediately.The Nursing Dialysis Communication Records for 12/1, 12/5, 12/8, 12/10, 12/12, 12/17, 12/19, 12/22, 12/23, 12/26, and 12/29/25, lacked vital signs on return from dialysis.The Nursing Dialysis Communication Records for 1/5, 1/9, 1/14, 1/16, 1/19, 1/21, 1/23, and 1/30/26 lacked vital signs on return from dialysis.The Nursing Dialysis Communication Records for 2/2, 2/4, 2/6, and 2/9/26 lacked vital signs on return from dialysis.On 2/12/26 at 8:15 a.m. the Director of Nursing (DON) stated they listed vitals on the return from dialysis for a reason. They needed to be done.The undated facility policy, Dialysis (Renal), Pre and Post Care, documented it was the policy of the facility to assist the resident in maintaining homeostasis (the self-regulating process) pre- and post-renal dialysis.
Based on record review, policy review, staff and provider interview, the facility failed to ensure medication administrations met the accepted professional standards for 2 of 12 residents reviewed (Residents #1 and #32). The Nursing staff failed to administer a prescribed cancer medication to Resident #1 and failed to notify the physician they didn't give the medication. In addition, the nursing staff administered Resident #32 insulin doses higher than ordered by the physician, placing the residents at risk for adverse health outcomes related to omitted and/or incorrectly dosed medications. The facility reported a census of 59 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of multiple myeloma (blood cancer), prostate cancer, anemia (low blood iron), heart failure, kidney failure, type 2 diabetes, bipolar disorder, anxiety disorder, and obsessive-compulsive disorder. Resident #1's Physician's Orders included the following orders dated:a. 11/24/25: Bicalutamide (medication used to treat blood cancer) 50 milligrams (mg), one tablet by mouth once daily for multiple myeloma.b. 6/21/25: Zytiga 250 mg, four tablets on an empty stomach one time daily for malignant neoplasm of prostate (prostate cancer). Resident #1's September 2025 through February 12, 2026, Medication Administration Records (MAR) included documentation of multiple doses of Bicalutamide and Zytiga not administered due to not receiving the medications from the pharmacy. Review of Resident #1's Nursing Progress Notes failed to indicate notification to the Hematology/Oncology Physician of the Bicalutamide and Zytiga missed doses. Resident #1's Hematology/Oncology progress note dated 1/21/26, the Physician noted they discussed that day Resident #1 received Bicalutamide incorrectly for a long time with the care facility he lived, as marked in multiple places on the paper packet Resident #1 brought from the care center. Stage 1 prostate cancer, high risk, Resident #1 has been incorrectly maintained on Bicalutamide secondary to misunderstanding from his nursing home, marked today 1/21/26 on the paperwork needed discontinued. In an interview on 2/12/26 at 9:08 AM, a Registered Nurse (RN) for Hematology/Oncology Physician, reported all communication from patients, their family, and/or the care facility is documented in the patients' chart. The RN reviewed Resident #1's records and couldn't locate documented communication from the care facility notifying the Physician of missed Bicalutamide or Zytiga doses. Further review of Resident #1's records, the RN, stated Resident #1's Hematology/Oncology Physician documented incorrectly maintained on Bicalutamide by the facility, after previous order to discontinue. In an email dated 2/16/26 at 12:40 PM, the DON stated she expected when medications are not available from the pharmacy, the Certified Medication Aide (CMA) must notify the nurse and the nurse is to contact the Doctor, pharmacy, and the resident's family and/or Power of Attorney (POA). 2. Resident #34's MDS assessment dated [DATE], identified a BIMS core of 15, indicating intact cognition. The MDS included diagnoses of diabetes, anxiety disorder and depression. The MDS documented Resident #34 received insulin injections for 7 out of 7 days during the MDS observation period. Resident #34's July through January 2026 MAR/ Treatment Administration Record (TAR) included an order dated 8/18/25 to inject 7 units of Insulin Aspart (short acting insulin) 100/unit/ml (milliliter) two times a day. Notify the provider of glucose (blood sugar) levels less than 70 or greater than 350. The MAR/TARS reflected the facility didn't follow the doctor's order for 7 units of insulin in each of the months. Resident #34's February 2026 MAR/TAR documented on 2/11/26 Day 1(12:00 PM to 3:00 PM) Resident #34's blood sugar (BS) as 189. The MAR/TAR directed to inject 7 units of Insulin Aspart 100/unit/ml two times a day. The order dated 8/18/25 instructed to notify the provider of glucose levels less than 70 or greater than 350. On 2/11/26 documentation reflected he received 9 units. Documentation from 2/1/26 – 2/11/26, indicated Resident #34 received more than 7 units at least once every day. On 2/12/26 at 11:30 AM, Staff B, Licensed Practical Nurse (LPN), stated she administered the insulin on 2/11/26. She reported she gave 9 units as Resident #34 did a carbohydrate count and then told the nurses how many units he needed related to what he has or has not ingested. She stated the facility did this with Resident #34 for as long as she remembered. On 2/12/26 at 11:40 PM, the Director of Nursing (DON), stated Staff B came to her about the situation. She concurred with Staff B they did this with Resident #34 for quite a while now. She stated they messaged the provider to get a clarification order. The DON acknowledged the facility didn't follow the provider's order. On 2/12/26 at 12:02 PM, a message was left for this resident's doctor/provider requesting a return call. This provider did not return the call. The Pharmacy Services Physician Orders policy revised May 2019 directed the facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The procedure instructed no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.
Based on interviews and record review, the facility failed to transport 1 of 2 residents reviewed for wound care (Resident #23) to their Wound Center appointment. The facility failed to ensure transportation for Resident #23 to attended their scheduled wound treatment appointment, resulting in a delay in wound care. The facility reported a census of 59 residents.Findings include:Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure), acute respiratory failure (new short-term lung failure), and weakness. The Nursing Progress Note dated 11/21/25 at 11:51 PM documented a full assessment for Resident #23 prior to an emergency room transfer for altered mental status. The note included findings of skin alteration to Resident #23's lower left buttock with red areas to his right buttock. Resident #23's Hospital Records dated 11/28/25 at 10:45 AM documented the nurse report called to Staff L, Registered Nurse (RN), at the facility, to notifying of Resident #23's hospital discharge orders to follow up with the wound center, primary care provider, and neurology. Resident #23's Hospital Discharge records dated 11/28/25 at 11:15 AM, directed Resident #23 to follow up with the wound center. Resident #23 had an appointment scheduled on 12/2/25 at 9:45 AM. Resident #23's Nursing Progress Notes failed to indicate transportation to scheduled wound center appointment, wound center visit notes, or future scheduled appointments. During a phone interview on 2/11/26 at 11:00 AM, the wound center receptionist stated Resident #23 was a no show for the scheduled appointment on 12/2/25. They didn't receive any follow up communication from the facility. In an interview on 2/11/26 at 4:27 PM, the DON reported after reviewing Resident #23's 11/28/25 hospital discharge document, they had a wound center appointment scheduled. She couldn't find additional documentation to indicate if Resident #23 attended the appointment.
Based on record review, staff interviews, facility policy review, and review of prior survey history, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously cited deficiencies. The facility reported a census of 59 residents. Findings include:Review of the facility's Provider History Report revealed the facility received the same deficiency during the current survey and a complaint survey in November 2025 of the deficiency category free of accident hazards and provision of adequate supervision/assistive devices to prevent accidents (F689).In an interview on 2/9/26 at 3:20 PM, the Administrator stated, QAPI meetings are done monthly with the facility's Medical Director attending at least quarterly. They identified resident falls and the QAPI committee looked at the mechanical lift transfers with the previous incidents with the lift happening a few months before. In an interview on 2/9/26 at 3:20 PM, the Director of Nursing (DON) stated the facility provided education and a step for CNAs to stop and check the sling loops were securely on the lift bars during the full-body mechanical lift transfer process. Review of the facility provided Performance Improvement (QAPI) Plan policy reviewed directed the following:a. The design and scope of the QAPI plan is ongoing and comprehensive. Its purpose is to correct identified deficiencies in quality of services and put mechanisms in place so that our performance can consistently be improved. b. The facility used a systematic approach to determine when an in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. c. The facility applied a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. d. The facility's approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. e. The facility developed policies and procedures regarding expectations for the use of root cause analysis when problems are identified. This element includes a focus on continual learning and continuous improvement. f. The facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences.
Based on observation, record review, and staff interview, the facility failed to provide Enhanced Barrier Precautions (EBP) for 1 of 3 resident's reviewed (Resident #7), failed to adhere to appropriate Hand Hygiene (HH) practices for 3 of 3 residents reviewed (Resident #7, #11, and #26), and failed to employ infection control practices with catheter care for 1 of 2 residents reviewed (Resident #26). The facility reported a census of 59 residents.Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident depended on staff for all activities of daily living (ADL's). Diagnoses included traumatic spinal cord injury, aphasia (neurological language disorder affecting a person's ability to speak), and quadriplegia (paralysis of all 4 extremities). Resident #7 had a feeding tube. The Care Plan dated 8/29/22 included Resident #7 required a tube feeding related to a swallowing problem. The interventions included the resident would remain free of side effects or complications related to the tube feeding. On 2/11/26 at 7:07 a.m. Staff B, Licensed Practical Nurse (LPN), prepared medications and entered the Resident #7's room. Staff B washed her hands and put on gloves. Staff B informed the resident what she was doing. After stopping the feeding at the pump, and disconnecting the feeding from the tube, Staff B changed gloves without hand hygiene. Staff B failed to utilize EBP when working with the feeding tube. On 2/11/26 at 9:46 a.m. Staff B went to discontinue Resident #7's feeding. Staff B washed her hands, gloved, and left the room. Staff B returned to the room with washcloths, put them (directly without a barrier) in the sink and ran water over them. Staff B put on gloves, wrung out excess water from the washcloths, and placed them on a barrier. Staff B removed the feeding tubing from the gastric (g)-tube and changed gloves without hand hygiene (HH). Staff B removed the dressing from the g-tube insertion site and changed gloves with no HH. Staff B wiped around the g-tube insertion site with the washcloths and changed gloves with no HH. She then applied antifungal with a cotton tipped applicator and placed a split dressing around the g-tube. Staff B failed to utilize EBP when working with the feeding tube. The undated Policy for EBP documented it was the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDROs). CMS notes that facilities had some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. High-contact resident care activities were activities that had been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Examples of high-contact resident care activities requiring gown and glove use for residents on EBP included but are not limited to a feeding tube. The undated facility Hand Hygiene policy documented it was the policy of the facility to cleanse hands to prevent the transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Hand washing/hand hygiene was generally considered the most important single procedure for preventing the transmission of infection. Except for situations where hand washing was specifically required, antimicrobial agents such as alcohol-based hand rubs were also appropriate for cleaning hands and could be used for direct care. For specific handwashing and waterless hand hygiene procedures, this facility refers to CDC's most current guidelines. The CDC's Hand Hygiene for Healthcare Workers included gloves were not a substitute for hand hygiene and if the task required gloves, performing hand hygiene before putting on gloves and touching the patient or the patient's surroundings. Always clean hands after removing gloves. 2. A MDS dated [DATE], documented diagnoses for Resident #11 included non-Alzheimer's dementia, reduced mobility, and depression. The MDS identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognitive functioning. Resident #11 had an indwelling catheter. The MDS listed him as always incontinent with bowel. A Care Plan focus initiated 10/3/25, reflected Resident #11 had an indwelling catheter related to an obstruction. On 2/12/26 at 12:20 p.m., Staff C, CNA (Certified Nurse Aide), and Staff D, CNA, talked with Resident #11 and obtained permission to do cares. Both donned their gowns and gloves, then pulled the front of his briefs down and cleansed his groin. Staff C used a separate wipe to wipe the catheter tubing toward his urinary meatus. She cleaned Resident #11's back side that had fecal matter present in his brief. Staff C removed the brief with the bowel movement and cleaned the area. Staff C removed her gloves and clipped the urinary catheter tubing to the sheet, hung the catheter bag on the side of the bed, and clipped the call light to bed within Resident #11's reach. Staff C lowered his bed back to the low position and put the floor mat back into place next to his bed. Both staff washed their hands. Talked with Staff C directly after the observation. Staff C confirmed she wiped the catheter tubing toward the urinary meatus instead of away from it. She acknowledged after removing her gloves after peri-care she didn't wash her hands and before she put on new gloves. Rather she touched several items, including briefs, catheter tubing, a wipes package, bed controls and the call light. Following the observation, when updated about the concerns, the DON acknowledged the infection control concerns. 3. Resident #26's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of polyarthritis (arthritis in 5 or more joints), lymphedema (swelling caused by an accumulation of protein rich fluid), and obesity. The MDS indicate Resident #26 had a risk for developing pressure ulcers/injuries but did not have any pressure ulcers/injuries. Resident #26's February 2026 Treatment Administration Record (TAR) directed licensed staff to cleanse the Right and Left Posterior (back) Calcaneus (heels). Cleanse with normal saline daily, apply a thin layer to the wound bed of Santyl ointment (prescription topical enzyme used to remove dead or damaged tissue from chronic skin ulcers promoting wound healing), and cover with Mepilex Border (self-adherent foam dressing) one time a day for wound care. The TAR Right and Left Posterior Calcaneus (wounds to the heels) cleanse with normal saline daily apply a thin layer to the wound bed of Santyl ointment cover with Mepilex Border 4x4 one time a day for wound care. On 2/11/26 at 8:37 a.m., when Staff A, Licensed Practical Nurse (LPN) and Staff B, LPN, washed their hands, they didn't have paper towels available to dry their hands. Without drying their hands, they applied gloves. Staff B held up Resident #26's left leg while kneeling on the floor as Resident #26 sat in her w/c. Staff A removed the dressing, then cleaned the wound. She applied Santyl (ointment that removed dead skin from wounds) to the wound. Staff A left the room to get a dressing for both the lateral lower left leg dressing and to also get a dressing for the right lateral heel wound. Staff A returned to the room and washed her hands, then turned off the water with her right hand. Again, she put on gloves without drying her hands as the room didn't have no paper towels available to dry her hands. Staff A placed a new dressing on the left lateral lower leg. She then removed the right heel wound dressing, disposed of it in the trash, opened a normal saline vial and cleansed the wound by rinsing it with the normal saline. Staff A disposed of the normal saline, opened up and applied the dressing. Staff A did not remove her gloves nor disinfect her hands in between applying the dressing to left lateral lower leg and applying the new dressing to the right heel wound, including removal of an old dressing, cleaning of a wound and applying a new dressing on the right heel. Directly after this observation, Staff A acknowledged she should have removed her gloves and disinfected her hands in between the separate wound dressings and between the dirty and clean steps. On 2/11/26 at 4:13 p.m., concerns shared with the Administrator and the DON regarding the infection control issues that morning. The Administrator and the DON acknowledged the concerns. They said Staff A is normally so good with infection control and that is why they chose her to do the treatment. An Indwelling Urinary Catheter Care policy reviewed December 2023, directed the facility that each resident with an indwelling catheter would receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. The procedure directed the following:a. Gather equipment and supplies. i. Soap or cleanser ii. Basin with water (disposable wipes may be used as a substitute for soap and water) iii. Gloves iv. 2 clean washcloths and trash bagb. Identify the resident.c. Assemble equipment on a clean surface. Place open trash bag on the bed.d. Explain procedure to the resident.e. Provide privacy with beside curtain (and room door if able). f. Position resident comfortable. Do not unnecessarily expose the resident. g. Perform hand hygiene, using soap and water.h. [NAME] (apply) gloves.i. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag). Use a clean portion of the washcloth or fresh disposable wipe for one cleansing motion. j. Remove gloves and perform hand hygiene with soap and water. A Hand Hygiene policy reviewed July 2014, directed the staff to cleanse their hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. The purpose of the policy described hand washing/ hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Except for situations where hand washing is specifically required, antimicrobial agents such as alcohol-based hand rubs are also appropriate for cleaning hands and can be used for direct care. Some situations require hand washing in areas where sinks are not readily available. In these limited circumstances, alcohol-based waterless hand-washing products may be used. For specific handwashing and waterless hand hygiene procedures, this facility refers to CDC's most current guidelines.
Based on record review and staff interview, the facility failed to ensure residents were offered/administered influenza and or pneumonia vaccines for 4 of 5 residents reviewed (Resident #2, #5, #6, and #7). The facility reported a census of 59 residents.Findings include: 1) Based on review of a record printed off by the Director of Nursing (DON) on 2/12/26 at 10:12 a.m. Resident #2 was due for an influenza vaccine on 9/1/26. The resident's clinical record lacked documentation she had been offered the flu vaccine. In an email dated 2/16/26 at 11:18 a.m. the DON It appeared Resident #2 was due for the flu vaccine on 9/1/25. The DON had not found that she received them. Unfortunately, the vaccine provider had not sent a list of vaccines he provided. 2) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #5 was not up to date with the influenza vaccine. The resident's clinical record lacked documentation he had been offered the flu vaccine. 3) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #6 had the flu vaccine 11/8/25, but not up to date on other vaccines. The resident's clinical record lacked documentation she had been offered/given a pneumonia vaccine. 4) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #7 was not listed as up to date on current vaccines. The resident's clinical record lacked documentation she had been offered/given the flu or pneumonia vaccine. On 2/12/26 at 10:33 a.m. the DON stated the vaccine provider came in and did vaccine clinics, but they didn't give the facility a list of the residents that received the vaccines.
Based on record review and staff interview, the facility failed to ensure residents were offered/administered COVID vaccines for 5 of 5 residents reviewed (Resident #2, #5, #6, #7 and #10). The facility reported a census of 59 residents. Findings include:1) Review of an immunization record printed off by the Director of Nursing (DON) on 2/12/26 at 10:12 a.m. indicated Resident #2 was due for a COVID-19 vaccine on 9/1/25. The resident's clinical record lacked documentation she had been offered the COVID-19 vaccine. In an email dated 2/16/26 at 11:18 a.m. the DON It appeared Resident #2 was due for the COVID vaccine on 9/1/25. The DON had not found that she received them. Unfortunately, the vaccine provider had not sent a list of vaccines he provided. 2) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #5 was not up to date with the COVID-19 vaccine. The resident's clinical record lacked documentation he had been offered the COVID vaccine. 3) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #6 was not up to date with vaccines. The resident's clinical record lacked documentation she had been offered/given the COVID vaccine. 4) In an email on 2/16/26 at 11:18 a.m. the DON documented Resident #7 was not listed as up to date on current vaccines. The resident's clinical record lacked documentation she had been offered/given the COVID vaccine. 5) Review of an immunization record printed off by the Director of Nursing (DON) on 2/12/26 at 10:08 a.m. indicated Resident #10 was due for a COVID-19 vaccine on 9/1/26. The resident's clinical record lacked documentation she had been offered/given the COVID vaccine. On 2/12/26 at 10:33 a.m. the DON stated the vaccine provider came in and did vaccine clinics, but they didn't give the facility a list of the residents that received the vaccines.
Inspection of November 17, 2025
1 findingBased on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure a resident needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 61 residents. Findings Include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score was a 4, indicating severe cognition. The MDS listed Resident #2 as dependent on the facility staff for all activities of daily living (ADL's). The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, aphasia (difficulty speaking), diabetes mellitus, and arthritis. The MDS listed Resident #2's weight as 318 pounds. The Nursing Note dated 9/24/25 at 11:52 AM, reflected Staff A, Certified Nursing Assistant (CNA), called Staff C, Licensed Practical Nurse (LPN), to Resident #2's room because Resident #2 fell out of the mechanical lift. Upon entering the room Staff C observed Resident #2 on the floor laying on the legs of the mechanical lift. Resident #2 denied hitting her head. Staff C called for help to get Resident #2 off the floor. The staff assisted Resident #2 to bed to complete a thorough assessment with the mechanical lift. Resident #2 back in bed, able to do a full assessment. Resident #2 stated she had severe back pain originating on the left side and radiating to the right side. Resident #2 is alert and oriented times (x) 2. Resident #2 able to wiggle both toes. Pulses palpable (can feel pulses on touch) on all extremities. No obvious bruises or injuries noted. Resident #2 sent to the emergency room due to the nature of fall being from at least 4 feet or higher. Order to send to the hospital by physician. A Certified Nurse Aide (CNA) noted Resident #2 had the wrong type of mechanical sling, a purple sling, but should have a blue or black sling due to the purple being too small for her. Therapy confirmed the CNAs used the wrong sling to transfer Resident #2. Resident #2 left with an ambulance for the hospital at approximately 9:50 AM. The Emergency Department (ED) Provider Notes dated 9/24/25 reflected Resident #2 fell from a full body mechanical lift as the staff transferred from her wheelchair to her bed when a piece came loose. She reported back pain but denied knowing what body part she landed on. Resident #2 weighed 325 pounds. The CT (specialized imaging of the body) Thoracic Spine (middle area of the back) impression identified Resident #2 had a mildly depressed T12 (lower part of the middle section of the back) compression fracture (a break or crack in the bones of the back spine that causes the bone to collapse). The facility's Investigation Summary dated 9/24/25 reflected on 9/24/25 Staff B cared for Resident #2 on the morning of the incident. She provided morning (am) cares to include placing the mechanical lift sling under Resident #2 to prepare her for transfer to the wheelchair. After getting Resident #2 ready for transfer, Staff B asked Staff A to assist with transferring her to the wheelchair. After breakfast, as Staff A and Staff B transferred Resident #2 back to bed to change her, she fell when the sling became dislodged from the full-body mechanical lift at Resident #2's left shoulder. Upon investigation the facility determined Staff B placed the wrong size sling under Resident #2 in the morning and hooked up the left side of the sling to the mechanical lift. Staff A moved the machine to the bed and Staff B guided Resident #2. When they got close to the bed Staff B let go Resident #2 and turned her back to get the bed pad ready. As this happened, Resident #2's sling disconnected from the full-boy mechanical lift machine and Resident #2 fell. The Fall Incident Report dated 9/24/25 at 9:30 AM indicated Resident #2 fell from the full-body mechanical lift. When the staff got her from the floor to her bed with the full-body mechanical lift, Resident #2 reported intensified pain in her back. The nurse sent Resident #2 to the hospital due to the height of the fall and the possibility of a head injury. Resident #2 complained of pain at an 8, indicating severe pain. The Incident Report included staff witnesses from the staff who assisted Resident #2 at the time of the fall of the following: a. Staff A reported as they went to change Resident #2 after breakfast, they hooked her up to the full-body mechanical lift. Staff B checked the loops and stated they were good to go. Staff A started lifting Resident #2 up as Staff B held her legs. Then Staff B let go to pull down the bed to get her into it, when Resident #2 fell out of the sling. b. Staff B stated they used the full-body mechanical lift on Resident #2 up and to position her, but they needed a bed pad. So, Staff B turned to put the bed pad on the bed. As she turned around, she heard Staff A gasp and Resident #2 fell out of the sling. Staff she didn't see whether she hit her head or not. She stayed with Resident #2 while Staff A got the nurse. Staff B reported they used a sling too small for Resident #2. She learned that only after Resident #2 fell out of the sling. Staff B stated she used the only sling in the closet and denied knowing the sling had appropriate colors. The Supply Company's Multi-Brand Compatible Slings guide dated June 2021 listed the trim color purple with a recommended user weight of 125 - 200 pounds for all slings with that color trim. The sling with the blue color trim had a recommended user weight of 275 - 500 pounds. The Supply Company's undated Slings Multi-Brand Compatible Owner's Manual dated November 2022 listed a warning Important! If the sling is not properly applied, personal injury and damage to the sling could result. This sling is intended ONLY for use with the lifts indicated in the most recent version of the Compatibility Guide. Never alter slings, exceed the weight limit, or use this sling with any other make or model of resident lift. Never exceed the maximum safe working load of either the resident lift or resident sling. Interview on 11/12/25 at 2:13 PM Staff B, stated she went to the closet to get a full-body mechanical lift sling. At the time the facility didn't have the sizing charts in the closet to tell you what color of sling for the correct size to use. Staff B stated the closet only had one color sling in there at the time. Staff B stated she placed the sling under Resident #2 where the bottom was close to the back of the thigh/knee area. Staff B stated they safely transferred her prior to breakfast. Staff B stated that Staff A needed assistance in changing Resident #2. Staff B denied connecting the sling to the mechanical lift, she reported Staff A connected it before she got there. Staff B stated the sling had blue on top connected and she didn't remember the color on the bottom. She stated they never used the black one. Staff B stated she had her hands on Resident #2's legs and noticed she didn't have a bed pad on her bed. So, she turned to put one on and as soon as she turned back around, Resident #2 fell to the floor. Staff B stated the sling straps did not break to her knowledge, she thought they slipped off the lift. Staff B stated she usually connected the sling with the blue on top and purple on the bottom. Staff B described the slings themselves as hard to read because of the worn tag and the facility put them in the dryer to dry. Staff B stated she used a blue sling with a purple trim on it. She stated she knew now the sling was a smaller one. She stated the facility didn't have signs in the closet and they didn't specify what slings went with what resident and that day the facility only had purple slings in the closet. Staff B stated that she was instructed to go get a sling from the laundry. Staff B described the tags as so distorted. She watched them pull the sling out of the dryer. Staff B stated that she can't say definitively who hooked up what but she stated Staff A stood behind her so she believed she hooked up the sling. Staff B looked them over and they looked good so they proceeded with the lift. Staff B stated that when she looked, they were all in the loops. Interview with Staff A on 11/12/25 at 3:15 PM stated Staff B partnered with her to transfer Resident #2. She stated they transferred her from the bed to the wheelchair prior to breakfast. After breakfast, Staff B stated Resident #2 needed to go to the bathroom, so Staff A hooked up the right side and Staff B hooked up the left side. Staff B stated everything was good. Staff A stated she didn't remember what color they used when hooking up the sling to the lift. Staff A explained she ran the control to lift Resident #2. Staff B held her legs, and let go of them to do something with Resident #2's bed. At that time, Resident #2 fell out of left upper corner of the sling. Staff A stated Staff B might have lifted Resident #2's legs up too high. Staff A stated after Resident #2 fell, she ran and got the nurse. Staff A described the transfer as nothing different than before, except Staff B put the wrong size sling on her. Staff A stated she should have checked the sling. Staff A stated that the sling didn't break or the strap tear. Staff A stated Resident #2 liked to move around while they transferred her in the lift, or talk with her hands, or grab ahold of the bar above her. Staff A stated she couldn't remember if Resident did that or not that day. On 11/12/25 at 4:15 PM observed Staff G, CNA, Staff H, CNA, and Staff I, CNA, transfer Resident #2 with the full-body mechanical lift. Staff I placed a blue mesh sling, size extra-large, under Resident #2, brand name is from a supply company. The staff placed the blue strap on top and the green strap on the bottom and proceeded to transfer Resident #2 to the wheelchair. An interview on 11/12/25 at 4:00 PM the Director of Nursing (DON) verbalized the facility had different brands of slings that they used. The DON stated the sling Resident #2 fell from, went back into circulation because it didn't have anything wrong with it. The User Manual of the mechanical lift dated 2024 the facility used instructed the following under safety precautions: a. Do not use a sling unless it is recommended for use with the lift. b. Always check the sling is suitable for the particular patient and is of the correct size and capacity. c. Never use a sling which is frayed or damaged d. Always fit the sling according to the instructions provided (user instructions). In addition, the manual included a WARNING from the company that they RECOMMEND THE USE OF GENUINE HOYER PARTS. Hoyer slings and lifts are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Interview on 11/13/25 at 9:26 AM the sales department of the supply company stated they haven't approved use of the brand of the full-body mechanical lift the facility used with the type of sling used to transfer Resident #2. They stated they have approved slings to use with some of the lower models of that brand of full-body mechanical lift. Interview on 11/13/25 at 9:34 AM the company of the full-body mechanical lift the facility used stated they recommend using the sling chart as a guidance for their mechanical lifts. They stated they provide a size chart for options regarding the size and weight of the patient. They recommend using their brand of slings due to the fact the company hasn't tested the other multi-brand slings with their lifts. The facility policy titled Fall Management System reviewed November 2020 identified the facility as committed to promoting resident autonomy (making their own decisions) by providing an environment that remained free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. For a Mechanical Lift Transfers, a resident should be in anatomical body alignment. The resident should roll to the right, position sling under left side, then roll left and position sling under right side, attach sling to mechanical lift, slowly raise resident up, and guide the direction of mechanical lift. Place the resident into chair or onto their bed. Residents with a Fall Risk Evaluation score of 10 or above are considered high risk and will have an individualized Care Plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to manage falls and will consider the particular elements of the assessment that put the resident at risk.
Inspection of August 27, 2025
2 findingsBased on observation, clinical record review, resident interview, staff interview, Physician interview, Nurse Practitioner (NP) interview, and facility policy review, the facility failed to complete thorough assessments and interventions when 3 of 3 residents (Residents #1, #4 and #5) sustained skin breakdown. In addition, the facility failed to properly assess one (1) resident following a fall (Resident #2). Resident #1 had a previous history of an amputation on his left foot. Following his surgery, the facility failed to follow physician orders, complete thorough skin assessments, and failed to follow treatments. Per the Podiatrist, Resident #1 had an additional amputation due to the lack of care and treatment he received. This resulted in an immediate jeopardy situation.On 8/14/25 at 5:20 p.m. the Iowa Department of Inspections and Appeals staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/14/25 and decreased the scope to G, after the facility staff completed the following:The Director of Nursing (DON) and the nursing staff identified all residents with wounds.The DON met with Wound Nurse and updated her on the residents with wounds.Assessed all residents with wounds which included measurements, documentation, and notified the primary care physicians. All staff re-educated on proper assessments and utilization of the wound vac. The facility identified a census of 64 residents.Findings include:The Complex Wound Management policy and procedure reviewed July 2022 instructed the facility to provide documentation that enabled the medical staff to evaluate the status of wounds. A complex wound be identified as an arterial ulcer, diabetic neuropathic ulcer, pressure ulcer and/or venous insufficiency ulcers. The Procedure directed the following: a. Complete a weekly skin assessment on all residents and document it in the resident's medical record. b. Measure each wound in centimeters (cm) weekly. Measurements, size and depth, drainage, odor, color and a short statement on the progress (or lack of) on the Skin Pressure Weekly or Skin Ulcer Non-Pressure Weekly forms. c. Use the treatments ordered by the medical provider. If the wound didn't have improvement, the facility must call the medical provider for an evaluation. d. Consider a significant change based on the information in regards to the presence of pressure ulcer(s). The staff must complete a Minimum Data Set (MDS) and Care Plan as soon as identified.According to an email dated 8/28/25 at 10:39 AM the Corporate Clinical Market Leader confirmed the facility's wound policy directed the staff to measure all wounds, even jagged edged wounds as they aren't exempt to the policy.Resident #1's MDS assessment form dated 5/5/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognitive skills. The MDS reflected Resident #1 didn't exhibit rejection of care. He required substantial/maximum assistance with most activities of daily living (ADL's). He didn't walk. The MDS included diagnoses of atherosclerotic native arteries of the left leg with ulceration of the calf, coronary artery disease (CAD), peripheral vascular disease (PVD), diabetes mellitus (DM) with diabetic neuropathy and malnutrition. The assessment indicated Resident #1 had a risk for pressure ulcers but didn't have pressure ulcers at the time of the assessment. However, he had surgical wounds and moisture associated skin damage (MASD). The assessment indicated Resident #1 didn't have a turning and repositioning program.The Care Plan included the following Focuses and Interventions as dated: a. 4/11/25: Potential for pressure injury or impairment to skin integrity related to (r/t) diabetes mellitus (DM). The Interventions instructed the following: i. 5/13/25: Float heels when rested as he allowed. ii. 4/11/25: Left foot heel protector boot when he rested and as he allowed iii. 4/11/25: Provide preventative maintenance to his coccyx as directed and as needed (PRN). iv. Weekly and PRN skin assessments.b. 5/13/25: Actual impairment to the skin integrity r/t a surgical wound to the left foot mid amputation. The Interventions directed the following: i. 5/13/25: Administration of treatment to the left stump as ordered. ii. 5/13/25: Monitor/document location, size and treatment of the skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration and etc. to the Physician. iii. 5/13/25: Weekly skin assessments.c. 7/14/25: Infection of the left surgical site. The Intervention instructed to complete daily dressings by applying betadine-soaked gauze with a non-compressed gauze roll to the left foot surgical site until they could apply the wound vac. Resident #1 had an order that directed no weight bearing and protective boots on at all times.d. 5/15/25: ADL self-care performance deficit r/t limited mobility and impaired balance. The Intervention listed Resident #1 as dependent on staff with toileting hygiene, dressing, and rolling from left to right in the bed.e. 7/10/25: Unstageable pressure ulcer to his left outer ankle. The Interventions reflected the following: i. 7/10/25: Administer treatments as ordered and monitor for effectiveness. ii. 7/10/25: Assess, record, and monitor wound healing. Measure the length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report improvements and decline to the Physician.The LN-Initial admission Record signed 4/4/25 effective 3/28/25 listed Resident #1 had the following skin issues:a. Left foot fifth toe had a dry intact blood blisterb. Left bottom of the foot center is dark and soft.c. Left heel is non-blanchable and appeared as a deep tissue injury.The Emergency Department (ED) to Hospital - admission dated 5/2/25 indicated on 4/29/25 Resident #1 had a partial amputation to his left foot.The Post - Acute Discharge Report dated 5/13/25 identified Resident #1 discharged from the hospital to the nursing home.Following Resident #1's return, his clinical records lacked measurements of his surgical incision 4 times in May 2025 and 3 times in June 2025. The Wound Center Wound Assessment Details dated 6/25/25, noted eschar (dead tissue) in the surgical wound of his left foot. The LN - Skin Ulcer Non-Pressure Weekly dated 7/2/25, reflected Resident #1's surgical wound had moderate odor, drainage, and the incision reopened. The open area of the wound measured 7x4 cm. The LN - Skin Ulcer Non-Pressure Weekly assessment dated [DATE] indicated on 7/2/25 Resident #1 had a new wound to his left outer ankle.A Braden Scale for Predicting Pressure Sore Risk forms dated 4/28/25, 5/27/25, 6/18/25, and 7/10/25 placed the resident at high risk for pressure ulcers.The facility's undated time line of events related to Resident #1's left foot included the following:a. 3/28/25 - admitted to the facility with a dried intact blood blister on his left foot 5th toe, a dark and non-blanchable area on the bottom of his left foot, a hard, round area to his upper coccyx, a dark soft area on the center on the bottom of his left foot, the left heel appeared to have been a deep tissue injury (DTI) dark red in color and all his right toes amputated. The facility failed to complete thorough assessments of the above documented skin issues. b. 4/4/25 - The facility failed to provide a complete assessment of Resident #1's following areas: left 5th toe, the bottom of his left foot, left planter foot, and his coccyx area. c. 4/10/25 - Left 5th toe and left planter foot - healed.d. The facility failed to provide a complete assessment of the bottom of Resident #1's left foot, coccyx, and his scrotum on the assessments done on 4/11/25, 4/19/25, 4/24/25 and 4/27/25. h. hospitalized [DATE] through 5/13/25.i. 5/13/25 - Resident #1 returned to the facility with the following wounds: i. Coccyx ulcer that measured 0.5 cm x 0.3 cm surrounded by calloused skin ii. The left foot surgical incision following an amputation identified but assessed.j. 5/16/25 - The facility failed to provide a complete and thorough assessment of Resident #1's left foot's stump and coccyx area. k. The facility failed to do complete assessments of the resident's left foot stump on 5/22/25, 5/28/25, and 6/3/25.l. 6/11/25 - Removed sutures to left foot incision.m. 6/12/25 - Identified Resident #1's left foot stump didn't have sutures, but had 11 steri strips in place. The note lacked a complete assessment. The coccyx - healed with scar tissue.n. 6/17/25 - The facility failed to provide a complete and thorough assessment of Resident #1's left foot stump. o. 6/25/25 -The wound on Resident #1's left foot stump declined and revealed a grade 1 wound with etiologies (starting cause) of diabetic/wound ulcer and a dehisced (opened) wound that measured 1.7 x 2.8 x 1.4 cm. Resident #1's wound had subcutaneous (fat) tissue exposed with no tunneling or undermining, red granulation tissue (a new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.) within the wound bed along with eschar (dead tissue). The peri wound skin appeared dry, scaly, and with maceration (break down of skin from moisture). In addition, the wound had a moderate amount of serosanguinous drainage with the wound bed described as black/brown and edges macerated with surrounding scar tissue.p. 7/2/25 - The lateral (side) aspect of the left foot stump's surgical site had an area that measured 3.0 x 1.5 x 0.8 cm with a moderate amount of serosanguinous drainage, moderate odor, granulation tissue in the wound bed and undefined wound edges. Resident #1 had a new unstageable area on his left-outer ankle that measured 1.0 cm x 1.5 cm. The Timeline described the wound as a dry, thick, scabbed area with surrounding tissue didn't' have discoloration, drainage, undermining, or tunneling. The note reflected the wound bed had black/brown eschar and defined wound edges.q. 7/9/25 - The left foot stump measured 3.0 x 4.6 x 1.6 with a moderate amount of seropurulent drainage (a watery pinkish color, usually a sign of a localized infection) with a foul odor. The wound bed presented with granulation tissue, macerated wound edges, and surrounding scar tissue. The left outer ankle remained unstageable and measured 1.1 x 0.9 x 0.2. The wound description listed a moderate amount of serosanguinous drainage, wound bed black/brown, defined wound edges and normal surrounding tissue. The right coccyx area reopened as a stage II area that measured at 2.0 x 1.0 x 0.1, no drainage, wound bed beefy red, wound edges fibrotic calloused and surround scar tissue.r. The facility failed to complete assessments to Resident #1's left foot and coccyx areas on 7/21/25, 7/28/25 and 8/4/25. According to an email dated 8/29/25 at 10:27 AM the DON confirmed the facility failed to assess Resident #1's open areas on 7/21/25, 7/28/25 and 8/4/25.The Podiatry Physician Progress Notes form dated 7/10/25 identified Resident #1 presented to the office for a post-operative visit from his left midfoot amputation with delayed primary closure performed on 5/6/25. The Podiatrist performed a procedure to debride with sharp dissection (cutting) a lesion on Resident #1's lateral wound. The Podiatrist removed a lesion from the epidermal (a type of skin tissue) layer with a 15 blade. The Podiatrist described the wound with no underlying infection noted and had healthy granular tissue noted on the underlying lesion. The lateral wound measured 4.0 x 2.0 x 1.0 and the medial wound measured 3.0 x 2.0 x 1.0 with exposed bone. The Assessment identified Resident #1 had diagnoses of atherosclerosis (a condition of a buildup of fats, cholesterol, and substances in and on the artery walls causing a narrowing of arteries and reduced blood flow) of the lower extremity, diabetic nephropathy (kidney disease) associated with type 2 DM, uncontrolled type 2 DM with hyperglycemia (increased blood sugar), amputation of the left midfoot and a post-operative examination. The Orders directed to apply a wound vacuum (vac).A Podiatrist Progress Record form dated 7/10/25 included an order for a wound vac at 125 mmHg (millimeters of mercury which measured the pressure of the device) to start when available. The order directed to run the wound vac continuously and change it every Monday, Wednesday and Friday.The Wound Culture with Grain Stain collected 7/4/25 reflected Resident #1's left foot had a heavy growth of pseudomonas aeruginosa (bacterial infection). The NP documented they spoke with podiatry who reported the Wound Center saw Resident #1 that day. They said he likely had a colonization (build of bacteria that becomes part of the body's normal flora) of bacteria but did have heavy growth, so they wanted him started on Augmentin 500 - 125 milligrams (mg) twice a day for 7 days. According to an Order Details form dated 7/15/25 at 5:52 PM the staff scheduled to change the wound vac every 30 minutes on Monday, Wednesday and Friday starting 7/16/25.Resident #1's Medication Admin Audit Report form printed 8/26/25 at 1:58 PM identified a schedule to change his wound vac on 7/16/25 as 6:00 AM, 6:30 AM, and 7:00 AM. The record indicated the nurse changed the wound dressing at 5:09 AM, 10:59 AM, and 11:00 AM.The eMAR - Medication Administration Note dated 7/16/25 at 4:52 AM indicated Resident #1 got his wound vac changed twice the day before. He required and received an overlay of a clear, adherent dressing to have maintained the unit's function. During an interview on 8/8/25 at 12:57 PM the DON confirmed Staff E, Registered Nurse (RN), entered the Physician Order incorrectly.A handwritten Podiatrist Progress Note form dated 7/25/25 the Podiatrist documented the wound vac cannot be left off.A handwritten Podiatrist Progress Note form dated 8/1/25 the Podiatrist documented Resident #1 arrived at his Podiatrist appointment for a second week in a row without a wound vac or a dead vac. He reinforced it was unacceptable. The note included to send supplies and charge vac.The Nursing Noted related to 8/5/25 at 11:06 PM reflected when his family took him outside to smoke cigarettes, his foot had gnats on it so they brought him back inside. The nurse washed all pressure relief items and changed the dressing to his foot. His dressing had serous drainage with odor. The day shift updated the wound physician on 8/5/25 about the staff not changing his wound vac. The physician gave an order to apply a dressing and restart his wound vac on 8/6/25.The Nursing Note dated 8/6/25 at 7:20 AM indicated the nurse spoke with Resident #1 and he agreed to get evaluated in the ED per his daughter's request because of him vomiting. When the NP visited the facility, they gave an okay for him to be evaluated in the ED. According to an interview on 8/12/25 at 1:00 PM Resident #1's Podiatrist confirmed he expected the facility staff to follow his orders. The Podiatrist indicated the first couple weeks Resident #1 laid down granulation tissue. He explained that without the wound vac running continuously, it directly caused a thick, soupy drainage that affected the granulation tissue and caused further deterioration of his foot. He described measurements as an essential factor in wound management and he expected the staff to measure the jagged incision as well. He explained the deterioration of the wounds resulted due to the lack of appropriate care and treatment of the wounds. Resident #1 had co-morbidities (multiple diagnoses) such as DM which placed him at a higher risk but ultimately those co-morbidities didn't cause his amputations, rather the main contributor of lack of care and treatment. The entire situation caused the Podiatrist frustration because the first time he arrived for an appointment, he didn't have his wound vac attached. When he called the facility, no one answered the telephone. The second time Resident #1 arrived for his appointment with his wound vac not functioning. The Podiatrist called the facility repeatedly until someone finally answered the telephone. The Podiatrist described the entire situation as not acceptable at all.During an interview on 8/19/25 at 5:45 PM Staff B, Registered Nurse (RN), indicated she knew of Resident #1's wound vac device. She reported she worked once with Staff C, RN, who planned to change the device but left the shift without changing the wound vac. Staff B reported the DON went out of town when Resident #1 received his wound vac order. Staff B explained she didn't receive education on wound vacs and/or the proper placement. When the wound vac device arrived, the DON directed her to do the treatment. She told the DON she didn't feel comfortable without training and the DON became upset with her. Staff B reported he didn't get his wound vac changed on 8/4/25 as the physician ordered. She added she knew the facility sent him to the hospital on the 5th or 6th. During an interview on 8/20/25 at 12:54 PM Staff C confirmed she couldn't change Resident #1's wound vac on 8/4/25 because she trained another nurse, had 3 admissions and no management staff support in the facility.During an interview on 8/8/25 at 12:09 PM Staff F, CNA, confirmed when Resident #1 sat in his chair, he had the wound vac always unplugged and nonfunctional.During an interview on 8/8/25 at 12:20 PM Staff G, CNA, confirmed when Resident #1 got up for meals, he had his wound vac unplugged and nonfunctional.During an interview on 8/8/25 at 2:34 PM Staff I, CNA, confirmed she found the wound vac shut off or unplugged. She knew that because it beeped when it didn't function.2. Resident #4's MDS assessment dated [DATE], indicated he had a short- and long-term memory deficit and severely impaired cognition. The MDS listed Resident #4 as dependent on staff with activities of daily living (ADL's). The MDS reflected Resident #4 didn't walk. The MDS included diagnoses of type II diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia and malnutrition. The MDS indicated Resident #4 didn't have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS identified he had a risk for pressure ulcers/injuries. The MDS reflected he had diabetic foot ulcer(s). He had pressure reducing devices in the bed and chair, but didn't have a turning/repositioning program.Resident #4's MDS assessment dated [DATE], lacked documentation of his skin issues. The form indicated Resident #4 didn't have a risk for pressure ulcers. He had pressure reducing devices in the bed and chair, but didn't have a turning/repositioning program.The Care Plan Focuses indicated the following for Resident #4: a. 5/25/18: Potential for pressure injury or impairment to skin integrity r/t limited mobility, incontinent of bowel and bladder and DM. The Interventions directed the following: i. 5/6/25: Mat placed on wall by window due to resident rubbed his feet and fingers which caused an abrasion. ii. 5/25/18: Weekly skin checks and PRN.b. Potential/actual impairment to skin integrity r/t fragile skin which caused MASD. The Interventions instructed the following: i. 6/12/25: Administration of treatments as ordered.c. 5/25/18: ADL self-care performance deficit r/t limited mobility and slow response. i. 5/12/25: Non-ambulatory. ii. 5/25/18: Required assistance from 1 staff repositioned in bed. Review of the facility's undated timeline of skin breakdown areas the facility lacked an adequate assessment on the following injuries and dates:a. 5/28/25, 6/3/25, 6/10/25, 6/12/25, 6/17/25, 6/19/25, 6/24/25, 6/25/25 - Left great toe diabetic ulcer, left foot 3rd digit diabetic ulcer, outer aspect of the left foot diabetic ulcer and the left pinky toe diabetic ulcer. b. 6/19/25, 6/25/25, 7/2/25 - Right upper buttock with a 3.2 cm intact blister, coccyx 2.0 x 1.0 unopened dry area with no further assessments completed.c. Resident #4's record lacked further completed assessments until 7/17/25. At the time Resident #4's right buttock area contained an assessment. The assessment indicated Resident #4's outer aspect of the left foot wound healed. d. 7/24/25 - The right buttock and outer aspect of the left foot - healed. e. 8/6/25 - Coccyx area healed, onset of a left knee area measured 1.5 x 1.8 x 0.2 unstageable with slough and eschar, no tunneling or undermining, moderate amount of serosanguinous drainage with no odor, wound edges defined with erythema on the surrounding tissue with no further assessments of any other areas completed. f. 8/12/25, 8/13, 8/15 - The facility failed to complete a thorough assessment of Resident #4's left abdominal blister, left knee, and the top of his right buttock.g 8/15/25 - Resident #4 presented with a right shin abrasion that measured 4.0 x 1.0 as a scabbed area with no further assessments completed. o. 8/16/25 - Stage II right buttock measured 3.0 x 2.0 x 0.1 with a scant amount of serous drainage noted on the dressing removed. Also noted a flat pink area located above the stage II area that measured 0.5 x 0.5 and not open at that time, a bandage had been noted on the resident's right shin, when removed noted an area that measured 4.0 x 1.0 with no drainage and no erythema noted on the surrounding tissue. No further assessments completed. p. 8/20/25 - The facility failed to complete a thorough assessment of Resident #4's left knee area and right buttock. During an interview on 8/27/25 at 11:55 AM the Corporate Clinical Market Leader indicated the facility failed to provide any assessments of Resident #4's left pinky toe.3. Resident #5's MDS assessment dated [DATE] included diagnoses of type II DM, malnutrition, a cognitive deficit and lymphedema. The assessment indicated Resident #4 had a risk for pressure ulcers/injuries and had 1 unstageable pressure injury which presented as a deep tissue injury.Review of LN-Skin Pressure Ulcer Weekly forms revealed the following as dated: a. 7/2/25 at 5:55 PM - Right buttock measured 15 cm x 7.5 cm, non-blanchable and dark purple in color, left buttock measured 12 cm x 9 cm with no further assessment and her right gluteal fold measured 2.0 cm x 1.0 cm x 0.2 cm deep. The staff further described the right gluteal fold Description tab as the area not open and remained with a scarred area with no further assessment/documentation. b. 7/10/25 at 10:17 AM - The facility failed to complete an assessment of the resident's right buttock. The resident now presented with an area on the left buttock that measured 6.5 cm x 3.5 cm x 0.0 cm described as a dark purple, non-blanchable areas up higher on the buttock than the area to the right side and the right gluteal fold measured 10 cm x 8.0 cm x 0.0 cm described as purple in color located on the lower aspect of the right buttock, a fatty area that the resident had near the gluteal fold. c. The facility failed to assess the above documented skin areas 7/14/25, 7/21/25, 7/28/25 and 8/6/25.During an interview on 8/26/25 at 4:30 PM the Corporate Clinical Market Leader, DON and the Assistant Director of Nursing (ADON) reported the week of 8/25/25 the ADON started her first week in the role of the skin care nurse on a full-time basis. The prior nurses who performed skin assessments failed to properly assess all areas and also mis-coded if the skin areas presented as pressure, non-pressure, MSAD and/or a diabetic ulcer so the facility couldn't track areas and paint a complete picture of what actually occurred with the residents' skin issues.A Quality Improvement Activity Sheet form dated 8/27/25 at 2:53 PM reflected the facility started a project on 8/4/25 for skin/wound assessments, due to the facility's identification of incomplete wound assessment with incomplete weekly documentation.4. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severely impaired cognition. Resident #2 required substantial to maximal assistance of staff with toileting and transfers. The MDS listed Resident #2 as non-ambulatory (nonwalking). The MDS included diagnoses of non-Alzheimer's dementia, age related physical debility, lumbago with sciatica (back pain with nerve involvement), weakness, and other reduced mobility.During an interview on 8/7/25 at 2:48 PM Staff D, CNA indicated after Resident #2 fell Staff H, RN, stated let's get her up without an assessment.During an interview on 8/8/25 at 12:00 PM Staff F, CNA, indicated after Resident #2 fell Staff H failed to assess them while positioned on the floor. During an interview on 8/8/25 at 12:15 PM Staff G, CNA, indicated Staff H failed to assess Resident #4 while on the floor.During an interview on 8/8/25 at 1:30 PM Staff H confirmed she failed to assessed Resident #2 while on the floor rather she performed an assessment once staff moved/positioned her in the wheelchair. Staff H added she had no excuses and/or reason for her failure to assess Resident #2.During an interview on 8/21/25 at 1:05 PM Resident #2's NP confirmed he expected the facility staff complete a thorough assessment of Resident #2 while on the ground after she fell prior to transferring her to the wheelchair. In addition, the NP confirmed even if her legs appeared the same length with no noticeable internal or external rotation of her lower extremities, the staff should have done a thorough head-to-toe assessment of Resident #2 prior to moving her. A thorough assessment may not reveal any damage, but they expected it done before moving her. The NP indicated he suspected all of her fractures occurred at the time of the fall.The History of Present Illness dated 7/18/25 at 8:27 AM the Physician documented Resident #2 came to the ED. The evaluation listed Resident #2 sustained a closed fracture of the right distal femur (outer part of the upper leg) and a closed fracture of the left proximal tibia (inner side of the leg bone).
Based on observation, photos, staff interview, and facility policy review the facility failed to maintain resident rooms and care equipment in a clean, sanitary and homelike environment. The reported a census of 64 residents.Findings include:1. On 8/14/25 at 1:38 PM observed dried, brown, long, running stains that ran down the wall beside Resident #4's bed.On 8/15/25 at 1:30 PM witnessed Resident #4's wall continued to have the stains.On 8/27/25 at 11:00 AM witnessed the stains remained on Resident #4's wall. Photos taken during an observation on 8/15/25 at 11:10 AM revealed the following: a. Buildup of dust, dirt, and debris on a stand-up lift device positioned along the wall on the 100 hallway. b. Buildup of a brown/rust substance along a scale device attached to the anterior portion of a total lift device also positioned along the wall on the 100 hallway. Photos taken during an observation on 8/15/25 at 11:30 PM revealed the following: a. A bedside fall mat positioned beside Resident #4's bed contained a torn plastic covering which exposed the inner foam cushion (not sanitizable). b. The plastic covering of the fall mat contained a large amount of white stains and discoloration. c. The floor had a buildup of dust, dirt and debris throughout Resident #4's room. 2. Photos taken during an observation on 8/15/25 at 11:33 AM revealed a torn pillow/positioning device which exposed the inner foam (not sanitizable) on a bed in room [ROOM NUMBER]. An observation on 8/15/25 at 11:35 AM revealed a heating element that ran along the wall in a hallway by a resident's wheelchair scale in poor repair with the inner heating elements exposed and jagged edges. An interview on 8/20/25 at 10:06 AM Staff A, Certified Nursing Assistant (CNA), described the resident rooms as unclean and could use a deep clean. According to an interview on 8/20/25 at 12:54 PM Staff C, Registered Nurse (RN), described resident rooms as absolutely uncleaned as they contain dust, dirt and debris and the residents deserved more.
Inspection of May 22, 2025
1 findingBased on clinical record review, facility policy review, staff, family, and Advanced Registered Nurse Practitioner (ARNP) interviews, the facility failed to assess a resident's lung sounds, before and after administering a nebulizer treatment (a medication that turns liquid medication into a mist, which is inhaled to treat respiratory conditions. It helps relax breathing muscles and makes it easier to breathe). In addition, the facility failed to intervene when the resident had shortness of breath (SOB) on exertion (walking, bathing, and transferring), sitting, at rest, and when lying flat in bed on 4/16/25, 4/17/25, 4/18/25, 4/19/25, and 4/21/25 for 1 of 3 residents reviewed (Resident #1). Without the assessment, the staff failed to notice the change in Resident #1's lungs, delaying the transfer to the hospital. On 4/22/25, the hospital admitted Resident #1 and tested positive for parainfluenza (lung infection) and passed away on 5/5/25. The facility identified a census of 63 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate impaired cognitive decisions, is able to be understood and understand and no behavior or mood issues. The resident required dependent assistance for activity of daily living (ADL) and oxygen used in last 7 days. The MDS included diagnoses of heart failure, arthritis, non-Alzheimer's dementia, anxiety, depression, chronic obstructive pulmonary disease (long-term lung disease), and chronic respiratory failure with hypoxia (lung disease with low oxygen levels in the blood). The Care Plan Focus dated 2/24/24, indicated Resident #1 received diuretic therapy due to chronic obstructive pulmonary disease (COPD) with (acute) exacerbation (increased difficulty with breathing). The Interventions directed the following: a. 2/24/24: Administer medication as ordered. b. 2/24/24: May cause dizziness, postural hypotension, fatigue, and an increased risk for falls. Observe for possible side effects every shift. c. 2/24/24: Report pertinent lab results to the Medical Doctor The Care Plan Focus dated 4/12/25 reflected Resident #1 had oxygen therapy related to COPD. The Interventions instructed to provide oxygen per Medical Doctor orders. The Medication Administration Note dated 4/17/25 at 9:08 AM indicated Resident #1 received AR formoterol Tartrate Nebulization Solution (a long acting medication that is used to relax the airway muscles, making breathing easier) 15 micrograms (MCG)/2 milliliters (ML). Inhale orally by a nebulizer 2 ML two times a day for COPD with acute exacerbation. The Medication Administration Note dated 4/21/25 at 11:10 PM identified Resident #1 received Albuterol Sulfate inhalation nebulization solution (Albuterol) (2.5 MG/3 ML) 0.083% (medication to help open the airway). Inhale 1 vial orally via nebulizer every 4 hours as needed (PRN) for SOB. Resident #1 reported I can't breathe honey. The Condition Follow-up Note dated 4/21/25 at 11:15 PM from start of: 4/21/25, reflected the staff monitored Resident #1 due to reporting she couldn't breathe. The nurse documented the vital signs as: a. Blood Pressure (BP) 129/86 (average 120/80) position: sitting, right arm b. Temperature (T) 97.0 Fahrenheit (average 98.6), route: forehead (non-contact) c. Pulse (P) 120 beats per minute (expected 60-100), type: regular d. Respirations (R) 24.0 breaths per minutes (expected 12-20) e. Current Conditions: identified Resident #1 had audible wheezes with a low pulse oxygen level (measurement used to determine amount of air in the body). Confirmed oxygen set up. The nurse started an as needed (PRN) albuterol nebulizer treatment, repositioned her to 45-degree angle in bed, and increased her oxygen to 4 liters per nasal cannula (L/NC) and her pulse oximeter (ox) ratings (level of oxygen in the blood) increased to 90 %. When the nurse listened to her lungs, they heard congestion with wheezing throughout (a whistling sound as the person breathes). Resident #1 looked diaphoretic (very sweaty) with a blood sugar of 247 (expected 70-150). She rested during her albuterol nebulizer (neb) treatment and her pulse oximeter increased to 95% with supplemental oxygen at 4 L/NC. The Condition Follow up Note dated 4/21/25 at 11:33 PM, from start of: 4/21/25, reflected the nurse monitored Resident #1 due to a report she couldn't breathe with pulse ox reading of 80% with oxygen at 2 L/NC. Her pulse ox read 97% after an increase to 4 L/NC. The nurse described her lung sounds continued to sound diminished, coarse, congested, and wheezes throughout. The nurse documented her vital signs as: a. BP 117/81 Position: Lying right arm b. T 97.4 Forehead (non-contact) c. P 107 Pulse Type: Regular d. R 24.0 The Condition Follow up Note dated 4/21/25 at 11:55 PM, from start of: 4/21/25 indicated the nurse spoke with Resident #1's Power of Attorney, who reported she didn't like her going to emergency room (ER) at night but it sounded like she needed to go. Resident #1's daughter explained she might need her Lasix (medication used to remove excess fluid from the body) dose increased. The nurse heard an audible expiratory wheeze (whistle-like sound as someone breathes out and can be heard without a stethoscope). The nurse documented Resident #1 had zero improvement in her lung sounds. The nurse documented the vital signs as: a. BP 117/81 Position: Lying right arm b. T 97.6 Route: Forehead (non-contact) c. P 107 Pulse Type: Regular d. R 25 The section labeled Current Conditions identified the nurse waited for a return call from the on-call physician. The Condition Follow up Note dated 4/22/25 at 12:04 AM, from start of: 4/21/25, reflected the nurse monitored Resident #1 for SOB and abnormal lung sounds. The nurse increased Resident #1's supplemental oxygen to 4 L/NC and provided a PRN albuterol neb treatment. The nurse documented Resident #1's vital signs as: a. BP 117/81 Position: Lying right arm b. T 97.6 Forehead (non-contact) c. P 107 Pulse Type: Regular d. R 25.0 The section labeled Current Conditions identified the nurse received orders to send Resident #1 to the ER via ambulance for evaluation and treat due to her altered pulmonary (respiratory or lung) symptoms. The Medication Administration Note dated 4/22/25 at 12:10 AM indicated the nurse gave Resident #1 an Albuterol (2.5 MG/3 ML) 0.083% neb treatment due to SOB. The nurse labeled the treatment as effective. The Nursing Note dated 5/5/25 at 11:54 AM identified the hospital called and reported Resident #1 passed away. Resident #1's daughter called and instructed no one could take anything out of Resident #1's room. The nurse sent all medications back to the pharmacy and destroyed the narcotics with 2 nurses. Resident #1's April 2025 Treatment Administration Record (TAR) included an order dated 3/28/24 for staff to monitor for signs and/or symptoms of SOB every shift as exhibited (shown) by the following code: a. 0 = NONE b. 1 = SOB on exertion (e.g. walking, bathing, and transferring) c. 2 = SOB when sitting at rest d. 3 = SOB when lying flat - The documentation indicated Resident #1 didn't have signs and/or symptoms of SOB on any shift on 4/2/25, 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, and 4/15/25. - Resident #1 did have SOB on exertion and while lying down on: i. Day shift: 4/7/25, 4/8/25, 4/16/25, 4/17/25, 4/19/25, and 4/21/25 ii. Night shift: 4/16/25 (also while at rest) and 4/18/25. Resident #1's clinical record lacked documentation of her lung sounds before or after the twice daily nebulizer treatment. The Emergency Department (ED) Note dated 4/22/25 at 12:57 AM, documented Resident #1's chief complaint as Shortness of breath. When Resident #1 presented to the ED, she needed increased oxygen due to the difficulty breathing. Resident #1 reported having worsening problems with breathing and having a cough for over the past several weeks. Overnight the nurse found her to with low oxygen saturation despite receiving her usual 2 liters of oxygen through the nasal cannula (L/NC), diaphoretic (sweating excessively), and notably dyspneic (short of breath). She arrived using 4 L/NC with her oxygen saturation in the low to mid 90% (expected over 90%). The hospital diagnosed her with parainfluenza, acute on chronic respiratory failure with low blood oxygen levels (increased trouble with long-term lung issues), COPD exacerbation, shortness of breath, and generalized edema (swelling). Interview on 5/20/25 at 4:00 PM, Resident #1's family reported they expressed concerns to the facility a week before that Resident #1 complained more about SOB and having difficulty with breathing. Resident #1's family didn't think the facility took her concerns serious. If the facility took the concerns serious, they said she might be alive. Interview on 5/22/25 at 8:55 AM, Staff A, ARNP, verified they expected the facility staff to complete lung sounds before and after a nebulizer treatment. In addition, if Resident #1 had more shortness of breath on exertion, rest, or just lying flat they expected the facility to notify them, so they could give orders or send to her to the closest ED. Interview on 5/22/25 at 11:30 AM, Staff B, Registered Nurse (RN), explained they expected the nurses to complete lung sounds prior to and after giving a nebulizer. Resident #1's clinical record lacked documentation of the staff assessing her lung sounds per professional standards of nursing. Interview on 5/22/25 at 2:00 PM, the facility Director of Nursing (DON), confirmed Resident #1's clinical record lacked documentation of the staff's assessment of her lung sounds before or after administering her nebulizer treatment. The DON reported they expected the nurse to complete lung sounds and as it is a standard of practice to complete lung sounds. The Policy and Procedure for Change of Condition and Reporting dated July 2024, directed to communicate all changes in a resident's condition with the physician. The section related to Acute Medical Change instructed to communicate any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior with a request for a prompt physician visit and/or acute care evaluations. The licensed nurse in charge has the responsibility to notify the physician.
Inspection of March 7, 2024
1 findingBased on clinical record review, staff interviews, resident interviews, facility records, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well-being for 2 of 2 resident reviewed (Resident #268 and #24). The facility failed to complete assessments and interventions for a resident who had bed bugs and a resident diagnosed with a urinary tract infection. Findings include: 1. Resident #268's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS described Resident #268 as dependent on staff for bed mobility, transfers, and toilet transfers. Resident #268 did not walk during the assessment period. Resident #268's MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), seizure disorder, non-st elevation myocardial infarction (heart attack) and hemiplegia and hemiparesis following cerebrovascular disease affecting one side (stroke with paralysis on one side of the body). Resident #268's Clinical Census documented they resided in room [ROOM NUMBER] from 10/15/23 to 2/12/24. The eMAR- Medication Administration Note on 10/24/23 at 11:40 PM indicated Resident #268 had an over the counter (OTC) lotion was applied to their dry itchy skin. The Nursing Note on 10/25/23 at 4:41 PM indicated Resident #268 complained of itching skin and had a small rash to her left arm and one above the right knee. The note identified the facility sent a notice to Palliative Care (comfort care that you can still receive treatment), who said they would see Resident #268 on rounds the following day. The Nursing Note on 11/8/23 at 4:47 AM reflected Resident #268 reported acute (new) itching to their right elbow, right knee, right ankle and left arm. Lotion applied to the areas. The Nursing Note on 11/8/23 at 3:35 PM identified new orders for Triamcinolone acetonide 0.1% cream (topical corticosteroid to help relieve skin inflammation, itching, dryness and redness) to apply twice a day for two weeks and loratadine (antihistamine) 10 mg (milligrams) daily for two weeks. A Skin Evaluation weekly form dated 10/25/23 documented Resident #268 had a rash to the left front shoulder and right front knee. The skin evaluation reflected Resident #268 complained of itching on the side of her left arm and above her right knee. Observed Resident #268 had a small rash at those sites that looked like some type of bug bite. The nurse notified palliative care and requested hydrocortisone cream. A Physician Fax Form dated 10/25/23 at 9:00 AM documented Resident #268 complained of itchy skin. Resident #268 had two different spots where a small rash appeared like a bug bite of some sort. The form suggested a plan of action as a hydrocortisone cream to help with the itching. The provider replied they would see on rounds the next day. Staff A, Registered Nurse (RN), noted the order on 10/25/23. The provider signed the form on 10/26/23 and didn't provide further information or directions. A Physician Progress Note dated 11/8/2023 identified the Assistant Director of Nursing (ADON) notified the provider Resident #268 had bites to lower extremities with intense itching present. Resident #268's family requested an order for an oral antihistamine in addition to hydrocortisone cream. The Nurse Practitioner responded by asking if the patient had bed bugs and recommended the facility assess for bed bugs. The Nurse Practitioner gave new orders for Triamcinolone acetonide 0.1% cream apply twice daily for two weeks and loratadine 10 milligrams (mg) daily for 2 weeks for pruritus (itching). The Interdisciplinary Team (IDT) - Care Plan Review dated 11/8/23 at 10:33 AM documented Resident #268 and her sister had a care conference with the facility. Resident #268 had concerns due to the requested hydrocortisone cream on 10/26/23 didn't get ordered. Resident #268 stated the Nurse Practitioner saw her on rounds but did not order the as needed cream as requested. The note included a statement the facility planned to heat treat her room. A facility form titled Bed Bug treatment last updated 1/8/24 documented they sprayed room [ROOM NUMBER] for bed bugs on 10/26/23, 11/6/23, 11/15/23, 11/22/23, and 12/7/23. In addition, the form reflected the facility heat treated her room on 11/8/23. Resident #268's clinical record lacked of documentation of the Nurse Practitioner seeing her on the 10/26/23 rounds. Resident #268's October 2023's Medication Administration Record (MAR) lacked a treatment option of hydrocortisone cream. Resident #268's November 2023 MAR included an order for Triamcinolone Acetonide External Cream 0.1%. The documentation listed a 7, other / see Nurse Notes, for 11/8/23 and 11/9/23. The eMAR-Medication Administration Note dated 11/8/23 at 4:18 PM listed the facility didn't have the Triamcinolone Acetonide External Cream 0.1% yet. The eMAR-Medication Administration Note dated 11/9/23 at 5:04 PM listed the facility didn't have the Triamcinolone Acetonide External Cream 0.1% yet. On 2/29/24 at 11:19 AM, the ADON reported he knew Resident #268 had bed bug bites. He stated the Nurse Practitioner came to see her on rounds and when she learned about the bed bugs, she refused to visit Resident #268. The Nurse Practitioner left without ordering something. The ADON reported he would have to look to see if Resident #268 received any treatment orders from 10/25/23 to 11/8/23. He reported the facility didn't have an exterminator come to the facility to verify the cause of the bites. He stated the facility had bouts of bed bugs in the past and the staff knew what to look for. On 2/29/24 at 1:27 PM, the ADON verified the facility didn't get orders for Resident #268's rashes and/or bug bites from 10/25/23 until 11/8/24. Resident #268's clinical record lacked follow-up or a request for treatment for Resident #268's bites from 10/26/23 to 11/8/23. The clinical record lacked documentation that Resident #268 had bed bugs, when the bed bugs were first identified, and a treatment plan to eradicate them. On 2/29/24 at 1:45 PM, Resident #268 reported a nurse told her she had bed bugs. She stated the nurses looked at the bites/rash areas and could tell they were from bed bugs. She stated she didn't know if the facility had the bugs before. She thinks it might have spread but was not positive. She stated she knew the facility treated other resident rooms and bed bugs travel. She reported the facility sprayed her room a couple of times and ran a heater. When they did the heat treatment, they moved her to a different room and she stayed overnight for one night. Resident #268 reported having rashes to her arms that itched all the time. She said it took a while to get some cream for her rash. She reported it took around a week and a half for her to get the cream. She stated the staff did not provide any other treatments to her rash until the cream came in. On 3/4/24 at 8:19 AM, the Director of Nursing (DON) reported she expected the staff to get the treatment for the rash in a timely manner or at least for the staff to apply lotion to the areas to help the resident feel comfortable. On 3/4/24 at 8:35 AM, Resident #268's sister reported she attended a care conference on 11/8/24 and asked about a treatment for Resident #268's bed bug bites, as she hadn't received anything. It took several days to get a cream or treatment for the bed bug bites. Resident #268 needed something to help her get relief from the bed bugs bites/rash as she had them pretty severe. The staff at the care conference couldn't find any notes in the record. Resident #268 asked for the cream at times and the staff refused to do it for her. She explained the staff didn't have good communication. Resident #268 had called her on 10/26/23 and told her she got the bed bugs the day before on 10/25/23. Resident #268 told her she didn't sleep at all due to the itching. On Friday, 10/27/23 Resident #268 waited to get cream for the bites. She reported 11/8/23 as the first time the facility did a heat treatment on Resident #268's room. Resident #268 told her the facility sprayed the room several times. The staff took Resident #268 from her room along with her clothes and showered her before the care conference on 11/8/23. She stated that afternoon, the nurse noticed the full-body lift sling on Resident #268's wheelchair from her room. She reported being unhappy as she visited Resident #268 all day and did not want to bring bed bugs home with her. She added it only took one bed bug. She was so concerned she bought herself a steamer and washed her clothes at home. She stated she looked up online how to deal with bed bugs. She believes the facility is incompetent and she felt bad for all the people who live there. On 3/24/24 at 9:11 AM, Staff B, Social Worker/Licensed Practical Nurse (LPN), stated Resident #268 complained to her of getting bit. She went to Resident #268's room and observed red marks on her left arm. Resident #268 asked for hydrocortisone cream. She went to Staff C, LPN, regarding Resident #268's concerns. Staff C stated there should be a standing order for the cream and that she gave it. Staff B stated she was not familiar with the facility's standing orders so she thought the concern was taken care of. She learned Staff D, RN, refused to apply the hydrocortisone cream when Resident #268 asked for the cream because she didn't have an order. Resident #268 went to her before the care conference wanting some money to buy a few items including hydrocortisone cream. Staff B stated at the care conference she learned Resident #268 didn't have an order for hydrocortisone cream. Resident #268 voiced she didn't get it at all. Staff B stated the day of the care conference on 11/8/23 the staff got new orders. Staff B stated Staff C said she put hydrocortisone cream on Resident #268. Staff B stated that there had been conversations with administrative staff on which one the facility should eat, either the facility providing medication without a physician order or not providing a treatment. She stated she wasn't sure which one the facility decided to do as she didn't make those types of decisions. On 3/4/24 at 1:04 PM, Staff E, Certified Nurse Aide (CNA), reported finding a live bug a few months before in room [ROOM NUMBER], she put it in some tissue, and showed it to the Administrator. On 3/4/24 at 11:10 AM, Staff C reported they didn't remember applying hydrocortisone cream on Resident #268 in October or November 2023, as she can't remember back that far. Staff C thought the facility's standing orders included hydrocortisone cream. Staff C looked at the laminated standing order form at the front nurses' station and acknowledged she didn't see hydrocortisone cream listed. Staff C didn't recall Resident #268 having bed bugs. If she used a standing order, she would send out an order for signature and add the order in the computer so it could be documented. The Change of Condition Reporting policy revised 7/2023 directed all changes in resident condition need communicated to the physician and documented. The Acute Medical Change section of the policy instructed the following: a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse will notify the physician. b. All Nursing actions will be documented in the nursing progress notes as soon as possible after resident needs have been met. 2. Resident #24's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #24 as independent with bed mobility, transfers, toilet transfers, and walking 150 feet. The MDS described Resident #24 as occasionally incontinent of urine and didn't have a toileting program. Resident #24s MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), renal disease (kidney), diabetes mellitus, asthma and adjustment disorder with mixed anxiety and depressed mood (usually a short-term change in mood due to a recent change). The Care Plan dated 1/30/24 indicated Resident #24 had bowel and bladder incontinence related to disease process, medication side effects, and poor toileting habits. The Care Plan directed the staff to document and report signs and symptoms of urinary tract infections that would include pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. In addition, the Care Plan directed staff to ensure Resident #24 had an unobstructed path to the bathroom. The eMAR-Medication Administration Note dated 2/13/24 at 10:46 PM reflected Resident #24 received 650 mg (milligrams) of acetaminophen (Tylenol) for complaints of right-side pain. The Condition Follow-up Note dated 2/19/24 at 4:46 PM documented the nurse monitored Resident #24 for the start of Augmentin (antibiotic). a. Vital Signs documented in the progress note included the following: i. Blood Pressure: 119/70 on 2/19/24 at 9:07 AM ii. Temperature: 98.1 on 2/16/24 at 8:33 PM iii. Pulse: 90 beats per minute on 2/19/24 at 9:07 AM iv. Respirations: 18 per minute on 2/16/24 at 8:33 PM Resident #24's Laboratory report dated 2/14/24 reflected the staff collected a urinalysis microscopic specimen (UA) at 7:15 PM. The report identified the urinalysis (UA) as abnormal, with the final culture results listed as greater than >100,000 CFU per ML (colony-forming unit per milliliter) of Escherichia coli (bacteria/pathogen). The Laboratory Report indicated the Nurse Practitioner responded to the culture and ordered Augmentin 875 milligrams (mg) one tablet twice a day for 7 days. Resident #24's Clinical Record for Resident #24 lacked documentation on when and why the resident needed a UA, when they obtained it, and any urinary assessments, and Physician notification regarding the change in condition. On 2/26/24 at 1:57 PM, Resident #24 reported she took an antibiotic for a urinary tract infection (UTI). Resident #24 said a nurse told her she had an infection. They did a urine culture. She reported her right side hurt and the staff told her to drink water. One nurse decided to get a urine sample. She stated she completed antibiotics sometime that week. She stated the antibiotic helped and her pain in the right side had improved. On 2/27/24 at 11:58 AM, the Director of Nursing (DON) reported the facility nurse used the facility standing order to obtain and send out the UA. The DON verified Resident #'s chart had no documentation about the collection of the urinalysis, the delivery to the lab, and the reason why they collected the UA. She acknowledged Resident # didn't have any urinary assessments documented prior to the start of the ATB. In addition, the clinical record lacked documentation the facility notified the Primary Care Physician about the reason for the UA. She stated she expected the nurse to document in the progress notes that when they sent the urinalysis, they continued to monitor the resident while waiting for the results to come back, and the notification to the Physician. On 2/27/24 at 3:19 PM, the DON reported she didn't have a policy for UTIs or a policy regarding standing orders. She reported she had a policy for condition changes that addressed PCP notification. The Change of Condition Reporting policy revised July 2023 directed all changes in resident condition will be communicated to the physician and documented.
Inspection of June 29, 2021
1 findingBased on observation, staff, family, ARNP (advanced registered nurse practitioner) and resident interview, and record review, the facility failed to protect 4 of 9 female residents reviewed (Resident #39, #33, #32, and #21) from sexual abuse by Resident #8. Resident #32 was the only interviewable and she expressed fear of being assaulted by Resident #8. The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 showed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had delusions in the seven day lookback period. The resident had one to three days in the seven day lookback period of the following behaviors: A. Physical behavioral symptoms directed toward others (examples are: hitting, kicking, pushing, scratching, grabbing, abusing others sexually). B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). D. Wandered the facility The resident used antipsychotics and antidepressants for seven of the last seven days in the lookback period. The resident used an antianxiety medication for one day of the last seven days in the lookback period. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] showed a BIMS score of 9, indicating moderate cognitive impairment. The resident used an antidepressant for seven out of seven days in the lookback period. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] showed a BIMS score of 3, indicating severe cognitive impairment. The resident used an antidepressant for seven out of seven days in the lookback period. Nursing Note Information: 6/21/20 at 11:20 AM revealed staff and other residents reported Resident #8 very inappropriate at this time. Resident observed touching other female residents and staff's breasts and asking female residents to go to bed with him. States that his wife wouldn't care and he doesn't care if she did. Resident #8 was redirected multiple times to keep hands to self and social distancing. Resident told staff to Shut up and leave me alone. Resident taken to room where he continued to tell staff to shut the hell up. 6/22/20 at 10:12 AM documented an investigation initiated. No staff witnessed Resident #8 touching other residents. Education provided to all the staff on redirecting residents with behaviors and to separate residents. The Psychiatrist with the Mental Health clinic notified of behaviors and planned to do a tele-health conference 6/23/2020 with Resident #8 and the ADON (assistant Director of Nursing). 6/23/20 at 8:45 AM showed Resident #8 saw on the ARNP (advanced registered nurse practitioner) on rounds per via video telehealth, awaiting any new orders. 6/23/20 at 11:10 AM order received to add [MEDICATION(S)] (antidepressant)10 milligrams (MG) by mouth every night in addition to the 40 MG tablet he already used. 7/7/20 at 7:57 PM Resident #8 tried to kiss and inappropriately touch another female resident who rejected his advances. Resident #8 was redirected and promptly said when seeing the CMA, She's got big boobs, I want her to sit on my lap. Resident #8 again redirected and kept with staff until his mood changed. The eMAR-Medication Administration Note dated 10/2/20 at 12:55 AM revealed before Resident #8 went to bed, staff redirected Resident #8 from asking a female resident if her husband used prostitutes, from asking staff to provide sex, and from asking staff to allow touching of their body parts. 10/18/20 at 2:04 AM Resident #8 rested in bed consistently for the past thirty minutes. Previously, Resident #8 was independently out of bed multiple times to ambulate hallways in various stages of dress. Resident #8 consistently declined wearing clothes. 10/23/20 at 1:38 AM Resident #8 defiant and combative with staff during the shift. Resident #8 verbally insulted, hit, and kicked multiple staff members. 10/27/20 at 3:06 AM Resident #8 walked down the hallway and sat in an electric wheelchair, turned it on and proceeded to drive into walls and doors. The owner of the wheelchair yelled him and he yelled back. The staff was finally able to get him to stop and go back to his room. A Social Service Summary dated 12/4/20 at 12:55 PM identified Resident #8 as alert but with [CONDITION(S)] and dysphagia. The resident could direct his care, and make needs known. Resident #8 had a BIMS of 3 and confused at times, but redirects easily. Resident #8's orientation, cognition, and reasoning skills vary over the course of the day. Resident #8 may miss the intent of the message or answers to verbal stimuli inappropriately at times. Resident #8's said his appetite was good, but he had a decline in intakes. Resident #8 slept well. Resident #8's behaviors were addressed on his current care plan along with his psychosocial well-being. Resident #8 reported missing his wife. Resident #8's wife is very supportive, and continues to assist with medical and financial decision making. 12/17/20 at 2:47 PM CNA (certified nurse aide) reported Resident #8 slapped a therapy assistant across the face when she told him he could not enter a female resident's room, as he tried to do. Resident #8 did recall the incident and stated the staff was bossy. Staff informed Resident #8 he should keep his hands to himself and seek out staff if he having problems. 12/19/20 at 9:40 PM Resident #8 experienced increased inappropriate sexual behaviors. Resident #8 redirected to his room numerous times throughout the day. The nurse re-educated Resident #8 and he was not receptive to education given. 12/31/20 at 2:12 AM Resident #8 ambulated in the hall and CNA came behind him with a wheelchair. Resident #8 sat down on the floor and said his leg was broken. The CNAs assisted him in to the wheelchair and Resident #8 punched a CNA in the stomach. Resident #8 then picked up a chair in the dining room and threatened to throw it at her. The CNAs got the nurse and Resident #8 found in another resident's bathroom. Resident #8 refused to leave the room and called the nurse names. Resident #8 was soaked in urine and refused to leave the other resident's room and get himself cleaned up. Resident #8 stated threatening and inappropriate things to staff. Nurse and staff backed away from the situation and planned to reapproach after a few minutes. 1/15/21 at 10:45 PM Nurse redirected Resident #8 from trying to touch two female residents on three occasions within a four minute time frame. Resident #8's level of belligerence increased with Resident #8 stating the intent to touch or do whatever he wanted to the females. Resident #8's spouse called to visit with Resident #8 as alternating staff and cool down time periods were ineffective. 3/13/21 at 4:25 AM Resident #8 wheeled up to the nurses station in his wheelchair multiple times through the shift, naked. Resident #8 continued to undress after the staff dressed him. Resident #8 went into multiple residents rooms tonight naked and became argumentative when redirected back out of the rooms. 3/13/21 at 9:14 PM Resident #8 wheeled himself out to the lobby, and approached a female resident. Resident #8 told female resident why don't you suck it? Staff told Resident #8 that was inappropriate and he needed to go to his room. Resident #8 then approached another female resident and attempted to kiss her. Staff again told Resident #8 he needed to go back to his room if he was inappropriate to the females. As staff went to push him out of the common area, he started yelling and belligerent to the female staff member. She pushed him half way down the hall and let himself propel the rest of the way to his room. 3/16/21 at 1:03 AM Resident #8 returned to bed after following staff during rounds. Resident #8 redirected from entering other residents' rooms multiple times. Resident #8 denies pain or unmet needs. Resident #8 continued to remove sleep clothes and exit room wearing depends or nothing. Staff provided drinks and water. 3/23/21 at 4:36 AM Resident #8 independently out of bed via a wheelchair to locate staff multiple times through the night. Resident #8's mood mostly friendly with some outbursts of anger, stating he will kill someone, or cursing and name calling. 3/30/21 at 12:04 AM Resident #8 independently out of bed (OOB) with a wheelchair to the common area then self-mobilized down the hallway yelling hello at doorways as he passed. Staff gently requested that Resident #8 ceased stating hello to sleeping residents in their room. 4/15/21 at 5:08 AM Resident #8 remained calm, pleasant, and awake all night while up in a wheelchair. Resident #8 wandered through the facility frequently attempting to awaken other residents by calling out at various rooms. Resident #8 removed his clothing and depends multiple times then stated I guess I'll go back to bed. Resident went back to room for ten minutes at a time. 4/19/21 at 7:05 PM facility received an order to start [MEDICATION(S)] ([MEDICATION(S)]) (antipsychotic) 25 milligrams (MG) to give 25 MG by mouth at bedtime for behaviors. Resident #8 and his spouse aware of the new order and follow-up visit with the psychiatrist at the Mental Health Clinic on 6/16/21 at 11:00 AM. 4/29/21 at 3:45 PM a visitor reported to the staff that, while no staff around in the front lobby, Resident #8 approached them and asked to suck their tits. The visitor reported that Resident #8 reached out but did not make contact. Incident reported to the staff and the residents immediately separated before contact could occur. 4/29/21 at 4:05 PM Resident #8 went into room [ROOM NUMBER] at 3:55 PM and grabbed Resident #32's left breast. Resident #32 said she did not hear Resident #8 come into the room and it startled her. She hit him with her book that she had been reading and the resident said that if she did that again he would hit her. Resident then proceeded to leave her room by himself. 5/2/21 at 1:27 PM Resident #8 made sexual comments and actions towards staff during the day. Close supervision given to Resident #8. Resident #8 did attempt to speak inappropriately to a female resident but staff immediately intervened and redirected him to his room. Resident laid in bed and rested. 5/5/21 at 1:03 AM Resident #8 remained in his room until he independently got OOB (out of bed) with the wheelchair to the staff station near the common room. Resident #8 appeared calm, pleasant, continent of bladder, and bowel. Resident #8 calmly redirected and stated I want pussy at 7:30 PM. He then resumed resting in bed with a call light within reach. 5/14/21 at 9:50 AM Call placed to Resident #8's spouse to notify of the incident. Nurse spoke to Resident #8's spouse in regards to referring him to the Geriatric Psychiatric Hospital (GPH) with hopes of medicine management. Resident #8's spouse in agreement, and would assist with anything needed. 5/14/21 at 8:18 PM At 6:08 PM the CMA (certified medication aide) came inside from break and witnessed Resident #8 kissing a female resident in the common area. Staff separated residents and Resident #8 told to go back to his room. At 7:30 PM Resident #8 followed the nurse down the hallway along with another female resident. Resident #8 propositioned the female resident to go to his room with him. The nurse told Resident #8 that was not appropriate and he needed to go back to his room. Resident #8 then grabbed the female resident's breasts. The nurse separated the residents and sent Resident #8 to his room, where he laid down in bed. DON notified of the incident at 7:33 PM. 5/14/21 at 9:39 PM On-Call doctor for the ARNP notified of the resident to resident incident. On-Call doctor denied the need for the resident to be seen in the emergency room (ER) at the time. The nurse informed the On-Call doctor of medical management and that he saw a Psychiatrist at the Mental Health Clinic with no resolution of behaviors. The facility requested the resident to be evaluated at GPH. On-Call doctor was in agreement and encouraged to proceed with placement on Monday. The nurse called the GPH and started the admission process. 5/22/21 at 12:44 AM Resident #8 up as tolerated (ad lib) via his wheelchair to the common area carrying his clothing. Resident #8 requested assistance with the application of his clothing. 5/28/21 at 3:50 PM CNA reported she witnessed Resident #8 wheel himself to room [ROOM NUMBER]. Resident #8 then sat in the door way and asked the 2 female occupants of the room if he could come in and [OBSCENITY] them. The CNA immediately intervened and removed him from the doorway then escorted him back to his room. The nurse explained to Resident #8 that this type of behavior was inappropriate. 5/28/21 at 11:35 PM Resident #8 independently OOB self-mobilizing by wheelchair to the common area wearing only depends. Resident #8 then returned to his room while unsuccessfully trying to enter two other resident rooms. 5/29/21 at 12:25 AM Resident #8 independently out of his room in his wheelchair, wearing only his pull up saying hello to the staff. Resident #8 directed staff to Push him back to his room. Staff helped the resident to his room. 5/29/21 at 1:55 AM Resident #8 independently OOB by wheelchair. 5/29/21 at 2:00 AM staff continued to watch Resident #8 for his safety and for the safety of others. Redirected resident from entering 2 other resident rooms. 5/29/21 at 2:19 AM Resident #8 independently got OOB and went to the staff in his wheelchair. 5/29/21 at 11:03 PM Resident #8 rested in his room until 10:00 PM. When Resident #8 got up ad lib wearing depends and a t-shirt. Resident #8 followed the staff and said Hello into other resident doorways. Resident #8 redirected with gentle verbal requests. 6/3/21 at 7:29 PM Resident #8 went up to the nurses' station to spontaneously threaten to beat the crap out of two CNAs. The nurse intervened and Resident #8 said he would [OBSCENITY] ing kill the nurse. The staff assisted Resident #8 to his room while being behind him in a wheelchair. Resident #8 stated he would kill the nurse and swung his arm behind him, trying to hit the nurse. Resident #8 then turned his body around to strike the nurse. Resident #8 eventually ended up in his room. Resident #8 stopped his verbal discourse as Resident #8's only intent was to physically assault the staff. Resident #8 then said that he didn't want anyone in his room. Staff said they understood and reminded Resident #8 that his blood sugars were brittle and he may require nursing intervention to avoid issues. Resident #8 then said please don't kill me and then repeated that he wanted zero people talking to him that night. 6/8/21 at 1:27 AM Resident #8 up independently by his wheelchair wearing a hand towel. 6/14/21 at 12:26 PM call placed to GPH on Resident #8's referral, and spoke with GPH Staff B. GPH Staff B said there was a 16 bed wait at the time. An update was given, GPH Staff B would let the facility know if there is anything else they needed. 6/14/21 at 12:45 PM Call placed to the ARNP in regards to the GPH referral with updates and some recommendations. A verbal order received to initiate [MEDICATION(S)] (antianxiety)scheduled and as needed (PRN) every two hours for [CONDITION(S)] with a 180 stop date. 6/14/21 at 12:50 PM call placed to Resident #8's spouse with updates on the GPH referral, and the new stop kit for Resident #8's door. Resident #8's spouse also informed of trying [MEDICATION(S)] for increased agitation and [CONDITION(S)] with risks and benefits discussed. Resident #8's spouse verbalized understanding and verbal consent given. She denied further questions or concerns. Resident #8's spouse in complete agreement and very appreciative of all the facility did. 6/14/21 at 5:00 PM Resident #8 independent in his wheelchair to the nurses' station. Resident #8 assisted back to his room to put on his non-skid socks, as a resident self-propelled wheelchair. 6/15/21 at 3:59 PM call received from GPH Staff B requesting more progress notes since 5/14/21, notes faxed per request. GPH Staff B stated the waiting list continued but will follow up as soon as possible. Resident #8's spouse was notified that GPH requested more information. Resident #8's spouse denied questions or concerns. 6/15/21 at 6:58 PM identified Resident #8 as lethargic but awakens when his name is called or at meals. Resident #8 laid in bed between meals and wakes easily. Resident #8 showed no inappropriate behaviors and no inappropriate behaviors reported that day. 6/16/21 at 11:15 AM virtual appointment was held with the psychiatrist from the Mental Health clinic. Resident #8 told her that he thought of harming himself but didn't have plans. Resident #8 said he saw fire in his room and the staff didn't take care of it. Resident #8 said he heard fire alarms. The nurse informed the psychiatrist that the fire alarm rang the day before for a fire drill, and Resident #8 did not have a fire in his room. The psychiatrist reviewed Resident #8's current medications and didn't change anything at the time. Resident #8's room had no objects that the resident could use to harm himself. Resident #8 wasn't able to get out of bed the last couple of days without staff assistance. Resident #8's bed positioned in low position with a floor mat next to his bed. Resident #8's spouse notified of the new orders. 6/16/21 at 1:40 PM a new order to change Resident #8's PRN time frame on [MEDICATION(S)] from every two hours to every four hours PRN (as needed). 6/16/21 4:05 PM the nurse placed a call to the Mental Health clinic to speak to the psychiatrist. The psychiatrist unavailable at that time. Nurse reported the facility was looking for recommendations for the resident to go for evaluation. The Mental Health clinic staff then informed the nurse to look to the facility Social Worker as there was nothing they could do to assist with placement. 6/16/21 at 5:05 PM call placed to the ARNP for a medication evaluation in regards to Resident #8 needing more staff assistance. After review of medications, new orders received to discontinue the scheduled and PRN [MEDICATION(S)] and to reduce the [MEDICATION(S)] to 12.5 MG for 7 days and then discontinue. No further orders received at the time. 6/17/21 at 3:50 PM the facility received a Physician Fax Form signed by the ARNP stating she agreed with the discontinuation of the scheduled PRN [MEDICATION(S)], and the now decreased [MEDICATION(S)] 12.5 MG for seven days then discontinued. 6/17/21 at 5:00 PM Resident #8 made inappropriate comments to the nurse at the nurses' station. The nurse notified Resident #8 that the comment was very inappropriate and redirected him to his room with supervision. All interventions for Resident #8 in place. 6/19/21 at 7:05 PM Resident #8's spouse left her visit with Resident #8. The spouse stated that she wanted him to have something PRN for the agitation she noted during her visit. As requested by the wife, the ARNP was called and explained the situation. The ARNP said they would address nonmedical interventions such as assisted to a private area with decreased stimulus in the room. Staff were available PRN. Resident #8 was provided with a drink and a snack. Staff provided assistance when Resident #8 yelled help repeatedly while resting in bed because he wanted his channel changed on the television (TV). The ARNP said no new orders at the time. 6/19/21 at 7:24 PM Resident #8 exited his room to the connecting toilet and left his room through the shared bathroom to the other male resident's room. Resident #8 stated he was getting the hell out of this torture chamber. Resident #8 screamed and kicked at the nurse saying Let me out! Attempts to check Resident #8's vital signs and assessment were unsuccessful. Resident #8 threw the blood pressure cuff and pulse oximeter after he removed them. Resident #8 yelled at a passerby male resident addressing him as a bastard. Staff redirected the agitated male resident that was called a bastard. The staff remained in the room with Resident #8 who stated he was going to assault the nurse and break the window. Addendum dated 6/19/21 at 7:31 PM Resident #8 threw his foot pedals out of his wheelchair to the floor. Resident #8 was seated in his wheelchair, in his room repeatedly kicking the nurse. The nurse gently explained that when Resident #8 was calmer, they couldn't return to the common area. The nurse encouraged Resident #8 to take advantage of the calmer private environment of his room. Resident #8 punched the nurse in the jaw and continued to kick the nurse. The nurse waited for secondary staff, while Resident #8 punched and kicked the nurse. Resident #8 assisted outside at that time by alternate staff. 6/19/21 at 7:39 PM Resident #8 went outside with two staff members for safety. 6/19/21 at 7:49 PM the nurse notified the ARNP of Resident #8's status. The nurse received an order to send Resident #8 to the emergency room (ER) for behaviors. 6/19/21 at 7:52 PM the nurse called for an ambulance transfer to the ER for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/19/21 at 8:11 PM nurse stopped charting to attend to Resident #8 in the parking lot. Resident #8 attempted to enter cars, yelling at staff that he was getting out of there. Resident #8 attempted to enter the nurse's car then hit and kicked the car. The police, fire department, and Emergency Medical Technicians (EMTs) arrived and intervened with Resident #8. They were able to get him on the gurney and into the ambulance. Resident #8 struck the fireman and was resistive with their interventions. Resident #8 asked the nurse to call his spouse when he was out with the police. 6/19/21 at 9:02 PM the nurse called Resident #8's spouse. She said yes to hold the Resident #8's bed. Resident #8's spouse stated that she went home earlier and stopped her visit with Resident #8, as he stated the visit was completed and that he wanted to go to his room. Resident #8 assisted to his room at that time. Per Resident #8's spouse, she spoke with the ARNP and there were no new orders but to continue the non-pharmacological interventions at that time. One nurse printed out the paperwork for Resident #8 to transfer to the ER and provided to the EMTs. The other nurse outside while the EMTs, the police and the fire department attempted to encourage Resident #8 to utilize the gurney. Another nurse telephoned Resident #8's spouse and notified her of the transport. When in room with Resident #8, he addressed another male resident as a bastard and threatened him. The nurse did close Resident #8's door to attempt to de-escalate his interactions with other residents. At that time, Resident #8 did have the nurse pinned against the door while he verbally threatened the nurse. Resident #8 punched the nurse in the jaw and repeatedly kicked the nurse who used a cell phone to notify the on-call nurse while waiting for additional staff to intervene. When the staff intervened, Resident #8 assisted outside with two staff for safety. Resident #8's behavior continued to escalate after he demanded the second staff person get the hell away. Resident #8 began to open car doors, kicked, and hit the nurse's car. The nurse notified the ARNP of Resident #8's status and the order to transport by ambulance to the ER for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 appeared excited to see the police, the fire department and EMTs. Then Resident #8 was agitated and refused to go with the EMTs. Resident #8 threatened the supportive staff by striking and kicking, until he received medication. Resident #8 was then assisted by ambulance to the ER. The nurse telephoned a report to the ER. 6/20/21 at 2:41 AM explained that Resident #8 admitted to hospital. 6/20/21 at 6:00 PM Resident #8 returned to the facility with new orders. Resident #8 was positive for the novel Coronavirus 2019 (COVID19). The new orders were to continue the current medications of [MEDICATION(S)] 25 MG 1 tablet daily PRN agitation. Resident #8 was in a foul, grumpy, and groggy mood. Resident #8 refused a meal at that time. Resident #8 laid in bed while in the low position. Fall precautions in place as well as COVID19 precautions. Resident #8's spouse notified of his return. 6/21/21 at 5:41 PM Resident #8 on isolation protocols per COVID19 stipulations. Resident #8 compliant throughout the day with staying in his room. Resident #8 easily redirected if he tried to come out of his room. Resident #8's recliner moved into his room and he sat in it on and off throughout the day. 6/22/21 at 12:52 PM facility received orders from the ARNP to continue [MEDICATION(S)] 12.5 MG daily. CNA behavioral charting review The 10/20 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 10/2/20. The 11/20 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 11/18/20. The 1/21 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 1/6/21 and 1/26/21. The 2/21 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 2/17/21. The resident's health record lacked a progress note related to this incident. The 3/21 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 3/3/21, 3/11/21, 3/13/21, 3/16/21, and 3/20/21. The 4/21 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 4/9/21 and 4/17/21. The 5/21 Documentation Survey Report showed documentation of inappropriate sexual behaviors on 5/11/21 and 5/22/21. Care Plan review The Care Plan problem dated 4/20/20 explained that Resident #8 had the potential to demonstrate verbally abusive behaviors related to dementia that were sexual in nature. The goal dated 4/21/20 said Resident #8 would demonstrate effective coping skills through the review date. The Care Plan included the following interventions dated 4/21/20. A. Assess Resident #8's coping skills and support system. B. Document observed behavior and attempted interventions. C. Give as many choices as possible about care and activities. D. Provide positive feedback for good behavior. Emphasize the positive aspects of Resident #8's compliance. E. Redirect Resident #8 when he is making inappropriate statements to staff or just general statements. F. Remind Resident #8 that his spouse does not like his inappropriate behaviors, they would be reported to her, as Resident #8 does not like to upset her. Resident #8 generally would be sorry for his behavior, or express he does not recall it happening. G. Remove Resident #8 from the common areas when he is being inappropriate and take to his room for a calming redirection. H. The intervention dated 4/29/21 said to consult with the Mental Health clinic in regards to Resident #8's behavior fax sent on 4/29/21. I. The Intervention dated 5/14/21 said the GPH admission process initiated J. A stop kit was applied to Resident #8's door to his room to detour other residents from wandering in his room and encourage Resident #8 to wait for staff before leaving his room. The Care Plan problem dated 4/20/20 identified Resident #8 with a potential to demonstrate physical behaviors related to dementia. The Care Plan goal dated 4/20/20 was: resident will harm himself or others through the review date. The Care Plan problem included the following interventions dated 4/20/20: A. Assess and anticipate Resident #8's needs such as food, thirst, toileting needs, comfort level, body positioning, and pain. B. Assist Resident #8 to call spouse when upset, or expresses frustration with other residents. Spouse requested Resident #8 call after supper. C. Document observed behavior and attempted interventions. D. If Resident #8 grabs inappropriately, redirect him that behavior inappropriate and will report to his spouse, as he does not like to upset her. E. If Resident was upset, talk to him about his Army days and the military structure for his band of brother unit, he does remember that aggressive behaviors are not tolerated in the military. F. When Resident #8 exhibits agitation, guide him away from source of distress. Staff to engage calmly in conversation. If Resident #8's exhibits aggressive response, staff directed to walk calmly away, and approach Resident #8 later. G. The intervention dated 8/25/20 revealed Resident #8 often undresses in his room, especially at night. Staff to assist with getting his pajamas or boxers back on. H. The intervention dated 6/14/21 revealed Resident #8's spouse made arrangements to with him on the patio in the evening hours after supper, three to four days a week. Intervention review Resident #8's list of interventions from 10/1/20 through current provided by the facility as follows A. Assess and anticipate Resident #8's needs such as food, thirst, toileting needs, comfort level, body positioning, and pain. B. Assist Resident #8 to call spouse when upset, or expressing frustration with other residents. The spouse requested that Resident #8 call after supper. C. Document observed behavior and attempted interventions. D. When Resident #8 grabs inappropriately, redirect him that behavior inappropriate and staff will report to spouse, as he does not like to upset her. E. Spouse made arrangements to sit with Resident #8 on the patio in the evening hours after supper, three to four days a week. F. 4/29/21 facility consulted with the Mental Health Clinic regarding the resident's behavior on that day. G. 5/14/21 Hope Harbor admission process started H. 6/14/21 visited with GPH Staff B and notified of 16 people on the waiting list before the resident. I. Redirect Resident #8 when making inappropriate statements to staff or just general statements. J. Remind Resident #8 that spouse does not like his inappropriate behaviors, and facility would report to her, as Resident #8 does not like to upset her. Resident #8 generally sorry for his behavior, or express he does not recall it happening. K. Remove Resident #8 from the common areas when inappropriate and take to room for calming redirection. L. 5/5/21 a contract signed for a new order for Psychotherapy program to begin. M. 6/14/21 a stop kit applied to the resident's door to his room to detour other residents from wandering in his room and encourage Resident #8 to wait for staff before leaving his room. N. 6/2/21 Resident #8's spouse to come to the building to see him if needed. O. 6/8/21 Psychotherapy program started P. Pharmacy review Q. Medications adjusted - i. 4/19/21 - Started [MEDICATION(S)] 25 MG at bedtime. ii. 5/28/21 - [MEDICATION(S)] 0.5 MG one dose given iii. 6/14/21 - Started [MEDICATION(S)] 0.5 MG daily at 4:00 PM, then every two hours PRN. Observations On 6/9/21 at 7:49 AM observed Resident #8 wheeling in the hallway near his room alone. The ADON stopped him to help him with something, then the ADON left down the hall to direct the surveyor to another resident's room. The resident continued down the hall alone. On 6/14/21 at 8:40 AM observation showed Resident #8 lay in his bed in his room with no staff in his room or in the hallway. On 6/16/21 at 11:41 AM, observed Resident #8 alone sitting up on the side of the bed yelling for help. One housekeeper in hall four doors down from Resident #8's room with no other staff in the hall. Resident #8's call light not on. Two CNAs assisting another resident in their room. On 6/16/21 at 11:47 AM saw the Administrator remove a yellow barrier, [TRUNCATED]
Inspection of January 3, 2017
2 findingsBased on clinical record review and staff and resident interview the facility failed to implement and follow interventions to prevent the development of pressure sores for one of one resident reviewed who was identified on admission at risk and developed multiple facility acquired pressure ulcers (Resident #8). The facility identified a resident census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #8 dated 1/4/17, documented an admission date of [DATE], and included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility and transfer, with a risk of developing pressure ulcers, no unhealed pressure ulcers and no repositioning program. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). A physician transfer order report dated 12/22/16, included a directive for a knee immobilizer and care instructions for a broken lower leg. A Braden Scale for Predicting Pressure Sore Risk dated 12/22/16 at 3:30 p.m., documented the resident scored a 10 for high risk of pressure sores. The form documented the resident had a displaced bicondylar [MEDICAL CONDITION] tibia, subsequent encounter for closed fracture. The form documented the resident had slightly limited sensory perception, constantly moist skin, chairfast with very limited mobility, poor nutrition and a friction and shear problem. The care plan dated 12/22/16, included no problem of a risk for altered skin integrity or pressure sore. Review of a Treatment Administration Record for January 2017, revealed a directive to remove (leg immobilizer) once a day for skin checks and cleaning then re-apply. A skin alteration incident sheet dated 1/12/17 at 11:16 a.m., documented the therapy assistant called the nurse into the room to look at an area to lower left leg. Nurse observed area to posterior calf, red wound bed, no signs or symptoms of infection, area 2.0 centimeters (cm) x 2.0 cm top area and 1.0 cm x 0.5 to lower area. The form documented the predisposing factors had been resident wore brace and unable to bend leg, foot pedal had to be up at all times. A physician fax form dated 1/12/17, reported the resident had an area to posterior calf 2.0 cm x 2.0 cm and 1.0 cm x 0.5 cm A skin alteration incident sheet dated 1/12/17 at 9:30 p.m., documented the nurse had been summoned to resident room by Certified Nurse Aide to assess two blisters, one on each heel. Complained of heels burning. Fax out to primary care provider to update and receive treatment order, both heels floated at all times as of now. The form included no measurements. The second page of the form had been left blank. A physician fax form dated 1/13/17, reported a 2.0 cm x 1.0 cm fluid filled blister on each lateral heel, skin intact, would like to apply skin prep two times daily until resolved and will float heels. On 1/14/17, the facility added a problem of pressure ulcers to bilateral heels related to immobility. The problem included the following interventions: a. Call light within reach, initiated 1/14/17. b. Daily body checks, initiated 1/14/17. c. Encourage fluid intake and assist to keep skin hydrated, initiated 1/14/17. d. Float heels at all times, initiated 1/19/17. e. Heel lift boot bilateral lower extremities, to be worn anytime resident's heels could be resting on any kind of surface, initiated 1/26/17. f. Needs moisturizer applied to skin. Do not massage over bony prominences and use mild cleansers for Peri-care/washing, initiated 1/14/17. g. Protein supplement daily, initiated 1/26/17. h. Requires pressure relieving/reducing device on bed/chair, initiated 1/14/17. i. Treat areas to heel and other skin issues per physician orders, initiated 1/16/17. j. Turn and reposition every two hours, initiated 1/26/17. k. Wound center as ordered, initiated 1/27/17. A wound nurse recommendation sheet dated 1/24/17, documented the resident had been seen for initial assessment of wound. Resident has wound to each heel-right lateral heel measures 2.0 cm x 2.0 cm and left lateral heel measures 1.5 cm x 1.5 cm. Both wound areas are light purple intact but non blanchable. Resident also has wound to left posterior lower leg. This is an unstageable pressure wound measuring 6.8 cm x 2.5 cm x 0.5 cm. The sheet included a directive for no pressure to heels and had been noted 1/25/17. A wound healing center report for 1/26/17, documented the resident had a wound on the left lateral lower posterior leg (wounding event not known) , left lateral calcaneus (gradually appeared), and right lateral calcaneus (gradually appeared). The report documented the primary etiology of all three wounds had been pressure ulcer. The report documented the measurements as follows: a. left lateral posterior lower leg, open-6.0 cm x 2.4 cm x 0.2 cm b. left lateral calcaneus, open-1.4 cm x 1.5 cm x 0.1 cm c. right lateral calcaneus, open-2.0 cm x 2.0 cm x 0.1 cm The form documented the left lateral posterior lower leg ulcer to be a Stage 3, and the left and right lateral calcaneus ulcers to be unsteageable. The report documented all three of the pressure ulcers had a large amount of necrotic (dead) tissue (67-100%). The form documented the resident required debridiment (removal of damaged tissue) of the left lower leg wound with a topical anesthetic applied to ease pain. A wound healing discharge instruction sheet dated 1/26/17, included the following directives: a. Wound #1 left lateral posterior lower leg-cleanse with normal saline, apply Calcium Alginate (anti-microbial wound dressing) with silver to wound bed, cover with foam dressing and secure. b. Wound #2 left lateral calcaneus-cleanse with normal saline, [MEDICATION NAME] daily, cover with foam dressing and secure, heel lift boot anytime heels could be resting on any kind of surface. Turn and reposition every two hours. c. Wound #3 right lateral calcaneus-cover wound with foam dressing, secure in place, heel lift boot anytime heels could be resting on any kind of surface. Turn and reposition every two hours. Clinical record revealed an order to discontinue brace to left leg dated 1/26/17. A physician order [REDACTED]. The facility MDS nurse stated during interview on 1/30/17 at 1:20 p.m., they did not know why the resident did not initially have a problem on the plan of care for potential for pressure sore but did now. The MDS nurse agreed the resident had been at risk of developing a pressure sore on admission due to a fracture which required a leg immobilizer and decreased mobility but did not know why it had not been placed on the care plan. The MDS nurse verified staff removed the immobilizer one time per day and checked the resident skin for breakdown. The MDS nurse stated staff repositioned all residents every two hours but only documented it one time per shift. At 1:52 p.m., the resident sat in a recliner with their feet elevated on two pillows and the bilateral heels resting on the pillows. The resident wore socks and no heel boots. The resident stated they did not feel the facility had been taking good care of their wounds because they had just used the call button to have staff come in and put pillows under their feet because their heels had been on the chair and it hurt. The resident stated the wound on their leg had been from a brace that had sometimes felt too tight. At 4:00 p.m., the surveyor asked the facility MDS nurse what could have been done to prevent the pressure sores. The MDS nurse stated off loading the residents heels. On 1/31/17 at 7:30 a.m., the facility Administrator stated they believed the open areas had not been pressure sores but were venous. The Administrator stated the resident always had their heels elevated. The Administrator stated they did not know if the facility had acquired heel lift boots for the resident, and stated this morning had implemented a Braden scale check list for staff to use on all residents to ensure appropriate interventions were placed and followed for residents. The Administrator stated the wound nurse classified everything as a pressure sore even if it had not been and they had told the wound nurse to stop doing that. At 7:40 a.m., the surveyor asked the Administrator to accompany them to the facility dining room to show the surveyor where the resident sat. The resident sat in a wheel chair with their bilateral feet on the wheel chair pedals. The pedals were not elevated. The left foot rested directly on the center of the pedal, the right leg slightly extended with the right heel directly on the pedal. The surveyor pointed this out to the Administrator who then stated the resident had foam dressings on the heel ulcers. The Administrator then went to the resident's room and found two foam boots and placed them on the residents bilateral feet. Staff A (Certified Nurse Aide, CNA) at 7:51 a.m., approached the surveyor and stated they had made sure the residents heels were floated when they had transferred the resident into the wheel chair that morning. Staff A stated the resident would not put heel boots on for them but had done so for the Administrator. Staff A stated one day they were not floating the resident's heels and the next day they were. Staff A stated they did not know when the intervention to float the resident's heels started. The wound clinic nurse stated during interview at 8:00 a.m., the areas on the residents leg and heels were definitely pressure sores, even though the residents circulation had been compromised the wounds developed from pressure to the areas. The wound nurse stated the leg immobilizer should have been checked every shift to be sure it had not been compromising circulation more or rubbing on the skin. The wound nurse stated the facility would not have needed to wait for the wound clinic to call the orthopedic surgeon to get the immobilizer discontinued and could have done this after the open areas had been discovered. At 8:45 a.m., the resident sat in a recliner as Staff B (Registered Nurse, RN) completed a treatment to the bilateral heels. Staff B measured a dark purple are to the left lateral heel to be 1.5 cm x 2.0 cm. Staff B measured a dark purple are to the right lateral heel to be 2.0 cm x 2.5 cm. Staff B applied [MEDICATION NAME] foam dressings to both heels at which time the facility Director of Nursing commented the dressings cost 5 dollars each. Upon completion of the treatment the facility Director of Nursing stated the facility would be having a different wound clinic nurse see the resident and complete the treatment to the left lower leg.
Based on observation, record review, and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents for 1 of 1 resident reviewed for accidents. Resident #13 admitted to the facility 10/1/16 and had 11 falls from admission until 12/22/16; with the fall on 12/22/16 resulted in fracture. Facility census was forty-eight (48) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/12/16 and 11/18/16 assessed Resident #13 with a brief interview for mental status (BIMS) score of 12 (moderate cognitive impairment). The MDS revealed the resident admitted to the facility on [DATE] from other. The resident had no behavior symptoms including rejection of care. The resident required extensive assistance of staff with bed mobility, transfers, ambulation in room, dressing, toileting, personal hygiene and bathing. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident used a walker and wheelchair for mobility. The 11/18/16 MDS revealed the resident was frequently incontinent of bowel and bladder. According to the MDS the facility did not try a scheduled toileting or prompted toileting program for the resident. The resident had [DIAGNOSES REDACTED]. The 11/18/16 MDS identified the resident with 2 or more falls since the prior assessment. Nursing progress (NP) notes dated 10/1/16 at 11:51 a.m. revealed the resident admitted to the facility with physical therapy (PT) and occupational therapy (OT) orders. An OT discharge summary identified the resident started OT on 10/4/16 and ended 11/18/16. OT documented the resident had poor insight into balance deficits which put the resident at risk for falls without CGA (contact guard assistance) and verbal cues for safe and efficient use of a front wheeled walker (FWW). The resident required assistance with pants over ankles and verbal cues for safety and physical assistance with balance in bringing pants over hips. The resident is at risk for fall without physical support by staff. The resident reached maximum rehab potential due to decreased cognition and balance deficits. The discharge recommendations were: toileting schedule. A PT discharge summary identified the resident started PT on 10/5/16 and ended 11/18/16. PT discharge recommendation was for one staff to assist the resident with transfers and daily ambulation. The current care plan contained a problem dated 10/3/16 of with the resident being at risk for ADL (activities of daily living) self-care performance deficit related to disease process of Parkinson ' s disease. The care plan contained interventions dated 10/3/16 that directed staff to provide standby assistance for transfers and standby assistance and one staff with dressing. There were no toileting interventions until 10/5/16 when the care plan directed staff to toilet the resident every 1.5 hours. The care plan also identified on 10/3/16 the resident as at risk for falls related to gait and balance problems related to Parkinson ' s disease. 1). Fall NP notes dated 12/22/16 at 1:45 p.m. identified an unwitnessed fall in the bathroom. Staff found the resident on the floor with the right leg bent at the knee ad under the resident's body. The resident's right ankle was painful to the touch, swollen and bruised. Staff phoned and faxed the physician's office. On the same date at 7:13 p.m. the facility had not heard back from the physician. NP notes dated 12/23/16 at 2:41 a.m. revealed the resident activated the call light at 10 p.m. and complained of increased pain. The resident identified the pain as 10/10 on a scale of 0 to 10 with 10 being the worst imaginable pain. The resident stated he/she wanted to go to the hospital. At 10:30 p.m. staff notified the resident's responsible party of the resident's request. At 10:55 p.m. the facility informed the physician who stated the resident could transfer to the ER for evaluation. At 11:37 p.m. the resident loaded in the ambulance and transferred to ER. At 1:50 a.m. the resident returned to the facility with right tibia fracture and ordered for Tramadol (narcotic) 50 mg. every 4 hours as needed for pain. An IR dated 12/22/16 at 6:42 p.m. revealed an unwitnessed fall in the resident's bathroom. On 12/23/16 the director of nursing (DON) added the intervention of keep resident out of room when not in recliner or bed (The resident already had the intervention of do not leave resident in room in wheelchair on intervention was already in place 10/18/16). An investigation dated 12/22/16 at 1:45 p.m. revealed Staff A (registered nurse) saw the resident on the dining room 5 minutes prior to the fall. Staff A identified checked yes' that staff followed the toilet plan and that staff toileted the resident before lunch. The resident did not use the call light. On 12/27/16 at 9:38 p.m. Staff A RN stated she just saw the resident coming down the hall in his/her wheelchair. She went to give a medication and when she came back the DON was in the resident's room and the resident was on the floor. 3 staff got the resident out of the bathroom. She stated she was not familiar with staff names so she was not sure who the CNA was. Staff A stated the resident was wheeling in the direction of his/her room when she last saw the resident but the resident's door was shut was she didn't think the resident would go in there. She stated there were no other staff in the dining room at the time because they were taking residents back to their rooms after lunch. She stated she estimated the resident was alone for only 3 minutes. She stated the resident forgets and does not remember he/she can ' t toilet self. On 12/27/16 at 5:40 p.m. the DON stated she walked by the resident's room and saw the resident on the floor. She stated staff was in the dining room but no one saw the resident go in his/her room. She stated the resident moved to that room with the intent for more supervision. The resident used to be at the end of the hall. On 1/3/17 at 10:53 p.m. Staff E CNA stated she was on the resident's hall that day. She heard a page from the DON and entered the resident's room. She observed the resident on the floor in the bathroom with his/her foot twisted around. She stated she did not see the resident go to his/her room because she was in another room repositioning a resident. She stated she tried to keep the resident out of his/her room most of the day by redirecting him/her. A radiology report dated 12/23/16 identified the resident slipped while trying to stand around 2 p.m The resident had generalized right ankle pain with lateral bruising. The x-ray identified a comminuted mildly displaced fracture of the distal fibula at the level of the ankle joint. An after visit summary identified the [DIAGNOSES REDACTED]. NP notes dated 12/23/16 at 12 p.m. revealed the resident returned from the physician. The resident was nonweightbearing to right lower leg. Staff was directed to keep the new splint on and not remove it. A major injury determination form dated 12/23/16 at 1 p.m. revealed the injury sustained was not a major injury. 2). Fall NP notes dated 12/19/16 at 11:49 a.m. revealed staff observed the resident laying on the floor on the left side with feet at the base of the stool and upper half of the body out into the room. The resident's knee was by the door jam. Staff did not observe injury. The resident identified self as going to the bathroom and fell off the stool. An IR dated 12/19/16 at 3:55 p.m. revealed an unwitnessed fall in the resident's bathroom. The resident toileted self. An investigation form dated 12/19/16 at 3:55 p.m. identified staff took the resident to the front 10 minutes prior to the fall. The area for toileting plan indicated N/A (not applicable). The investigation did not identify when staff last toileted the resident. The resident did not use the call light. The area for toileting plan indicated N/A (not applicable) The investigation did not identify when staff last toileted the resident. The care plan did not identify a new intervention following the incident other than to say the resident started on antibiotics on 12/15/16 for UTI. NP notes dated 12/15/16 at 7:14 p.m. revealed the physician ordered Bactrim DS (antibiotic) 800/160 mg. twice a day for 7 days to treat urinary tract infection (UTI). NP notes dated 12/17/16 at 6:03 a.m. and 1:31 p.m. identified the resident with intermittent confusion NP notes dated 12/14/16 at 7:54 p.m. revealed the physician ordered Levaquin (antibiotic) 500 milligrams (mg.) daily for 7 days, a chest x-ray and Albuterol nebulizer treatments for wheezing. NP notes dated 12/8/16 at 8:07 a.m. revealed the resident self transferred into the bathroom. Staff reminded the resident to use the call light. NP notes dated 12/11/16 at 3:22 p.m. identified increased confusion. The resident forgot recent past and wanted to go to the hospital out the front door. 3). Fall NP notes dated 11/28/16 at 10:30 a.m. revealed staff went to the resident's room to answer the call light and found the resident on the floor at the foot of the recliner. The resident slid out of the recliner when he/she tried to get up to go to the bathroom. NP notes dated 11/29/16 at 6:49 a.m. revealed staff would move the resident to a new room with increased visual observance. An IR dated 11/28/16 at 10:30 a.m. revealed an unwitnessed fall in the resident's room. An investigation dated 11/28/16 at 10:30 p.m. The investigation identified staff last saw the resident at 10 p.m. The investigation did not identify what staff did or what the status of the resident was at that time. The resident tried to use the walker when the fall occurred. The investigation identified yes when asked if staff followed the toileting plan. On 12/28/16 at 4:27 p.m. the Administrator emailed the surveyor to clarify the time of the incident on 11/28/16 as 10:30 p.m. The Administrator stated the nurse did not put it in military time. NP notes did not identify the actual date or time of the room change. However NP notes dated 11/30/16 at 2:46 p.m. revealed the resident adapted well to the room change. Past history of falls/interventions: NP notes dated 11/13/16 at 1:42 a.m. identified the resident with difficulty repositioning on memory foam mattress. NP notes dated 11/15/16 at 5:08 a.m. identified the resident in a hospital bed. 4). Fall NP notes dated 11/10/16 at 7:06 p.m. revealed the resident fell . An IR dated 11/10/16 at 4:40 p.m. revealed an unwitnessed fall in the resident's room. Staff found the resident on the floor when staff went to get the resident for supper. The IR identified the resident ambulated without assistance. An investigation dated 11/10/16 at 4:40 p.m. identified staff peeked in on the resident 10 minutes earlier and observed the resident in the recliner. The resident did not use the call light and didn't remember what he/she tried to do. The area for toileting plan indicated N/A (not applicable) The investigation did not identify when staff last toileted the resident. The care plan contained an addendum dated 11/10/16 that identified the resident received a hospital bed and staff rearranged the room. On 12/27/16 at 9:38 p.m. Staff A RN (registered nurse) identified herself as the nurse when the 11/10/16 incident occurred. She stated the resident was in the recliner prior to the incident and that he/she had the recliner controller. Staff A stated the resident could get the recliner high enough so he/she could step out of the recliner. She stated the resident was trying to reach his/her walker but it was out of reach. NP notes dated 10/25/16 at 5:42 a.m. revealed the resident was noncompliant with the call light and staff caught the resident ambulating to the bathroom without assistance twice that shift. NP notes dated 10/24/16 at 2:49 p.m. identified staff would toilet the resident hourly. NP notes dated 10/23/16 at 6:50 p.m. revealed staff checked on the resident and found the resident in the process of taking self off the toilet. Staff educated the resident about safety issues. 5). Fall NP notes dated 10/23/16 at 10:55 a.m. revealed staff found the resident sitting on the floor next to the bed with legs crossed under the resident, arms at side. Two staff assisted the resident into the wheelchair. The resident identified self as going to the bathroom when the fall occurred. The NP note identified that staff would try a hospital bed for the resident because he/she had trouble getting in and out of bed. Staff education provided on answering the call light as soon as possible. An IR dated 10/23/16 at 10:45 a.m. identified an unwitnessed fall in the resident's room. The resident activated the call light prior to the fall. An investigation dated 10/23/16 at 10:45 a.m. did not identify when staff last saw the resident other than staff toileted the resident after breakfast. The investigation was checked yes when asked if staff followed the toilet plan. The resident did not have shoes on. NP notes dated 10/23/16 at 5:28 a.m. revealed the resident continued to self-transfer. NP notes dated 6:21 p.m. contained a late entry for 10/22/16 (no time given). The NP notes identified the resident continued to self transfer. NP notes dated 10/22/16 at 3:12 p.m. revealed staff caught the resident self transferring to the bathroom. Staff reminded the resident to ask for help. 6). Fall NP notes dated 10/20/16 at 9:45 p.m. revealed staff observed the resident in the prone position on the floor with legs straight back and arms bent at the side. Staff observed the left chair in the high position. Staff removed the recliner controller at that time. NP notes dated 10/21/16 at 9:30 a.m. identified staff unplugged the lift chair. An IR dated 10/20/16 at 9:45 p.m. revealed an unwitnessed fall in the resident's room. The resident did not use the call light and was trying to get to the bathroom. The IR identified the resident ambulated without assistance. An investigation dated 10/20/16 at 9:40 p.m. identified the resident did not wait for assistance and did not use the call light. The resident was seen 10 minutes before the incident when staff attempted to assist the resident with bedtime care but the resident refused. The area for toileting plan indicated N/A (not applicable) The care plan did not contain an intervention to ensure staff unplug the recliner. The Kardex directed staff to keep controller away from the resident. On 12/29/16 at 4:22 p.m. Staff C RN stated she thought the resident raised the recliner and slid out. 7). Fall NP notes dated 10/18/16 at 5 p.m. revealed staff found the resident lying on the floor on his/her back. The resident stated he/she hit their head. An IR dated 10/18/16 at 6:33 p.m. revealed an unwitnessed fall in the resident's room. The resident identified self standing up from the wheelchair and when he/she sat back down, the wheelchair went out from under the resident. An investigation dated 10/18/16 at 5 p.m. identified staff saw the resident 10 minutes prior to the fall. Nothing was documented in the area that identified what staff did with or for the resident when last seen. The resident did not activate the call light. The area identifying whether staff followed the toilet plan was blank. Staff checked yes in the area asking whether there was evidence the resident toileted self or was incontinent. An entry dated 10/18/16 at 7:52 p.m. revealed staff observed a bruise to the top back of the resident's head by the intact staples. The entry also identified that an intervention after the incident was hipster pads. A late entry dated 10/18/16 at 8:50 p.m. identified staff tightened the resident's wheelchair brakes following the incident and directed staff not to leave the resident in his/her room in the wheelchair. The care plan did not contain the intervention to not leave the resident in his/her room in wheelchair. The Kardex did contain the intervention and also identified the wheelchair brakes were tightened/repaired. NP notes dated 10/19/16 at 3:29 p.m. revealed staff removed 17 staples from the scalp laceration. On 12/20/16 at 12 p.m. Staff D RN stated she did not recall if there was a problem with the wheelchair brakes or if the resident didn't lock them. She stated the resident was incontinent at the time of the incident. She stated the resident had a recliner that he/she lifted up and then would try to self-transfer independently. 8). Fall NP notes dated 10/11/16 at 11 p.m. revealed staff observed the resident laying sideways on the floor in front of the recliner with walker nearby. The call light was not activated. The resident sustained [REDACTED].) by 2.5 cm.) to the back of the head on the right side. Staff notified the physician who directed staff to send the resident to the emergency room (ER) for evaluation. NP notes dated 10/12/16 at 12:20 a.m. revealed ER called and reported a CT (computerized tomography) scan was negative and the resident received 15 staples to the back of the head. They would be sending the resident back to the facility. The resident returned to the facility at 1 a.m. with a dry dressing covering the wound on the back of the head. NP notes dated 10/12/16 at 4 p.m. revealed the resident complained of headache throughout the day. The staples and bandage contained a moderate amount of dried blood. The resident self transferred once that day. An IR dated 10/11/16 at 11 a.m. revealed an unwitnessed fall in the resident's room. The resident ambulated without assistance. An investigation dated 10/11/16 at 11 p.m. stated it appeared the resident fell asleep in the recliner and slid out. The resident was seen 30 minutes prior to the fall. Nothing was documented in the area that identified what staff did with or for the resident when last seen. The resident did not activate the call light. The investigation identified the resident as independent in the resident's room. The area for toileting plan indicated N/A (not applicable) NP notes dated 10/13/16 at 9:23 a.m. revealed staff added Dycem (nonskid mat) to the resident's recliner. The care plan did not contain the Dycem intervention. The Kardex did contain the Dycem intervention. On 12/29/16 at 4:22 p.m. Staff C RN (registered nurse) stated she initially thought the resident tried to walk per self. After she finished taking care of the resident and the resident's injury, she went back to the room and observed the recliner in a raised high position. Staff C thought the resident raised the recliner up with the controller and slid out. She stated didn't think the resident could be independent in room at that time but needed to check the care plan to be sure. She stated she wrote N/A by toilet schedule because she needed to check with the CNA. She stated the resident would not wait for help. 9). Fall NP notes dated 10/10/16 at 10:50 p.m. revealed staff found the resident on the floor next to the sink laying on the left side with his/her head laying against the bathroom floor. Three staff assisted the resident up from the floor. Staff instructed the resident to wear the correct shoe size. An IR dated 10/11/16 at 5:05 a.m. identified an unwitnessed fall in the resident's room. The resident stated he/she attempted to go to bed from the recliner the resident used the wheeled walker without assistance and wore improper footwear. In the other information section of the IR, the nurse documented that the resident's shoes don't fit and the resident needs to call for assistance. The resident needs a hospital bed instead of a regular bed because the mattress sinks down too much. An investigation dated 10/10/16 identified the resident did not use the call light and DID use the walker when the fall occurred. The area indicating whether a toilet plan was followed, staff checked N/A (not applicable) Staff saw the resident one hour and 20 minutes before the fall. At that time the resident sat in the recliner. NP notes dated 10/11/16 at 5:11 p.m. identified the intervention following the fall was to keep the walker close to the resident at all times due to the resident's self transfers to make the resident as safe as possible. (The resident fell using the walker.) 10). Fall NP notes dated 10/4/16 at 10:31 p.m. revealed the resident stated he/she took self to the bathroom and when he/she took slippers off to apply a new brief, he/she slipped and bumped his/her head on the wall. An incident report (IR) dated 10/4/16 at 9:40 p.m. revealed an unwitnessed fall in the resident's bathroom. Staff found the resident sitting on the bathroom floor with arms at sides and knees bent with legs out in front of the resident. The resident ambulated without assistance and wore improper footwear. According to the facility investigation form, staff toileted the resident 20 minutes prior to the fall. The investigation stated the call light was on but that the resident activated it after the fall. NP notes dated 10/5/16 at 4:38 p.m. identified staff would assist the resident to the bathroom every 1.5 hours. The resident did not sustain injury. (The resident self transferred and fell 20 minutes after toileting so lengthening toileting to 1.5 hours not effective.) 11). Fall NP notes dated 10/3/16 at 4:40 a.m., revealed staff observed the resident laying supine on the floor between the bed and wheelchair with legs bent at the knees and arms at his/her side. The resident identified self as transferring from bed to wheelchair and then losing his/her balance. The resident did not sustain injury. After the fall, the care plan revealed staff would order PT/OT evaluation and treatment per orders. (Already ordered on [DATE]) An incident report (IR) dated 10/3/16 at 440 a.m. revealed an unwitnessed fall in the resident room. The resident did not sustain injury. The investigation identified the resident did not use the call light and the resident attempted to self-transfer when the fall occurred. Staff saw the resident one hour and 10 minutes before the fall when they passed ice water and emptied the urinal. NP notes dated 10/2/16 at 10:30 a.m. revealed one staff assisted the resident with walking and toileting. Observation On 12/27/16 at 3:13 p.m. observation showed the resident in a wheelchair with the right lower extremity resting in a half splint wrapped with an ace wrap on an elevated leg extender. The resident identified the leg as sore. The resident stated he/she did not know what happened to the leg. At that time, the OT asked the resident if he/she remembered going to the hospital. The resident replied no and then asked, Did I go to the hospital? On the same date at 5:20 p.m. observation showed the resident in the dining room for supper. At that time, the surveyor asked Staff B CNA when the resident last used the toilet. Staff B stated she toileted the resident at 2 p.m. and 4:30 p.m. Staff B stated the resident was on a 2 hour bathroom schedule.
Inspection of October 11, 2016
2 findingsBased on observation, record review, resident and staff interviews, the facility failed to ensure each resident remained free of resident to resident abuse. Concerns were identified for one resident (Resident #2) abused by 2 residents; and Resident #3 who was involved in previous incidents, threw hot coffee in the face of Resident #9. The facility reported a census of 50 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 6/11/16, assessed Resident #2 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The [MEDICAL CONDITION] symptoms came and went with changing severity. The resident had no behavior symptoms identified. The resident required limited staff assistance with bed mobility, toileting, ambulation and eating. The resident was independent in a wheelchair on the unit. The resident had [DIAGNOSES REDACTED]. Nursing progress notes dated 8/13/16 at 9:30 p.m. and documented by Staff F LPN (licensed practical nurse) revealed Resident #2 sat in the lobby and another resident came up to Resident #2 and hit the resident in the side of the head with a hard back book. On 9/15/16 at 9:25 a.m. Staff F stated Resident #3 hit Resident #2 with a hard back book. Staff F asked Resident #3 if he/she hit the other resident and Resident #3 admitted he/she did and gave Staff F the book. Staff F stated there was another time Resident #2 went in Resident #3's room and a few days later Resident #3 came up behind Resident #2 and pulled back with an open hand from behind as if to hit the other resident. On 9/13/16 at 9:15 a.m. Staff B ( the outgoing Administrator) stated the residents were in the lobby and Staff A CNA was present but happened to look down when the incident occurred. When Staff A looked up the book was on the floor. When staff asked Resident #3 if he/she hit Resident #2 with the book, Resident #3 replied yes. Resident #2 laughed when asked. On 9/13/16 at 2:33 p.m. Staff A stated she heard a boom and saw Resident #2 fussing with his/her wig and talking trash under his/her breath. Resident #3 nodded yes when asked if he/she hit the other resident with a book. Staff A stated she thought Resident #3 hit the other resident in the back of the head with the book. On 9/13/16 at 2:23 p.m. Staff H CNA stated if Resident #2 gets too close to Resident #3 that Resident #3 will bring his/her hand back as if to strike or swing a book. She stated a month or so ago she observed Resident #3 draw his/her hand back and a nurse yelled to get Resident #2 away from the other resident. That time, staff could intervene in time before Resident #3 made contact. Observation showed on 9/13/16 at 4 p.m. the resident wheeled down the hall. Resident #3 stepped out of his/her room and glared at Resident #2. At that time, Staff M (housekeeper) called for CNAs (certified nurse aides) and stated after the 8/13/16 book incident Resident #3 threw a glass of water on the back of the left shoulder of Resident #2. Staff F stated Staff B (the outgoing Administrator) knew of the incident. Observation showed on 9/15/16 at 4 p.m. a female resident yelling at Resident #2 about getting too close to her. Staff intervened. Review of Resident #2's nurses notes revealed only the 8/13/16 incident was documented in Resident #2's record. Resident #2's care plan contained a problem dated 11/3/13 that revealed the resident had a potential behavior problem related to dementia. The care plan directed staff to intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. An addendum dated 8/14/16 directed staff to monitor the resident if wheeling close to other residents. Review of Resident #3 record information: A MDS with assessment reference date of 8/16/16 assessed Resident #3 with a BIMS score of 7 (severe cognitive impairment) The MDS did not identify any behavior symptoms. The resident transferred and ambulated independently. The resident admitted to the facility 5/10/16. The resident was 69 inches tall and weighed 211 pounds. Nursing progress notes dated 6/29/16 at 11:15 p.m. revealed Resident #3 walked up behind another resident who sat in a wheelchair and tried to hit the resident on the back of the head. Staff redirected Resident #3 to his/her room. Resident #3's care plan dated 8/14/16 contained a potential for injury to self or others related to unsafe behavior of carrying a lot of items at one time, episodes of becoming agitated with others when they come near his/her personal space and striking out related to confusion secondary to dementia. Prior to 8/14/16 the care plan did not contain information regarding a potential for resident to resident incident, even though interviews identified potential incidents had occurred. On 9/13/16 at 11:27 a.m. Resident #3 laid on his/her bed. The resident was very quiet and did not answer questions. On the same date at 11:55 a.m. the resident walked independently from his/her room to the living room and sat in an easy chair. 2. A MDS with assessment reference date of 7/20/16 assessed Resident #9 with a BIMS score of 15 (no cognitive impairment). The resident was independent with bed mobility and transfers and used a wheelchair for mobility. An incident report dated 9/25/16 at 7:20 p.m. and completed by Staff N RN (registered nurse) revealed Resident #3 had an incident with Resident #9. The incident report revealed a nurse aide yelled for the nurse and when the nurse arrived, she observed coffee all the front lobby and Resident #9 holding his/her face. A nurse aide and Resident #9 told the nurse that Resident #9 threw hot coffee in Resident #9's face. The action following the incident was to separate the residents and remove coffee cups from the resident. Staff assessed Resident #9 and applied cool rags and ice packs to Resident #9's face. Staff assessed redness and warmth to Resident #9's face and ear. Staff did not observe blistering. On 10/11/16 at 1:14 p.m. Staff N RN stated the incident occurred around 7 p.m. She stayed over to help pass medications and went to report off. She went to the front and Resident #9 told her that Resident #3 stole his/her pop. The next thing she knew was Staff K CNA yelled for a nurse. She observed bright red skin on Resident #9's right side of face and neck. The resident and floor were covered with coffee. The redness was gone the next day but the resident stated it hurt. She stated the intervention following the incident was to keep an eye on the resident so he/she stays put in the dining area with coffee. Staff N said its difficult. She stated coffee is available to all residents and Resident #3 is still able to get his/her own coffee. The resident's cups also have lids if he/she leaves the dining area. She had not seen the resident remove the lids. On the same date ay 4:25 p.m. Staff N stated she did not know if the coffee Resident #3 threw was hot and she could not remember if the resident said it was. On 10/11/16 at 1:37 p.m. Staff K CNA stated that she walked up the hall to the front and saw Resident #9 upset. Resident #9 said his/her soda was gone and asked Resident #3 if he/she took it and Resident #3 shook his/her head yes. After Resident #9 said something to Resident #3, Resident #3 walked behind Staff K and all of a sudden coffee went everywhere. Resident #9 exclaimed that the other resident threw hot coffee on him/her. When questioned if the coffee was hot, Staff K stated yes it was-the resident just got it and came from the coffee pot and Resident #9 said it was. Staff K stated the back of Resident #9's head and neck appeared very very red. She got a cold washcloth for the resident. Staff K stated Resident #9 discharged from the facility after the incident and she wasn't sure what they were doing for interventions for Resident #3. On 10/11/16 at 4 p.m. the Administrator stated she did not think the coffee Resident #3 threw was hot. Applying a reasonable person concept, Resident #2's BIMS score of 3 and [DIAGNOSES REDACTED]. Most persons would view being hit with a hard back book in the head or having hot coffee thrown in their face as a painful event. 3. A MDS dated [DATE] assessed Resident #4 with a BIMS score of 15 (no cognitive impairment). The resident had no behavior symptoms identified. The resident required supervision with transfers and was independent with ambulation in room and in wheelchair out of room. The resident had [DIAGNOSES REDACTED]. On 9/13/16 at 10:38 a.m. the resident informed the surveyor that a couple days ago he/she slapped Resident #2 on the arm because the other resident was in the way. The resident stated a staff saw the incident. Resident #4 stated he slapped the resident's arm for the same reason a couple weeks ago. On 9/15/16 at 12:42 p.m. the resident again stated he/she slapped Resident #2 as reported in the earlier interview. Review of nursing progress notes identified threatening behavior towards other residents on 3/6/16 at 5:49 p.m., misconduct in the dining room on 4/21/16 at 4:06 p.m. and tried to go after another resident on 9/10/16 at 4:44 p.m. Nothing was documented regarding Resident #4 slapping Resident #2. On 9/13/16 at 3:05 p.m. Staff G CNA stated a couple days ago she heard that Resident #4 slapped Resident #2. She didn't know who saw it. She only heard about it. 4. Facility policy revealed that it was the policy of the facility that residents will be free from misappropriation of property, verbal, physical and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility, staff, other residents, consultants or volunteers, staff or other agencies serving the residents, family members or legal guardians, friends or other individuals.
Based on observation, record review, resident and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 6 residents. Resident #5 fell with fracture when 1 staff transferred the resident instead of 2 as the care plan directed. Resident #8 fell when Staff D reported both CNAs were outside smoking, leaving one staff in the building. Resident #2 required close supervision due to resident to resident incidents. Documentation revealed staff found Resident #2 with blue foam coming from his/her mouth after eating a denture tablet. Staff didn't know where the resident got the denture tablet. Resident #3 threw hot coffee on Resident #9 after other resident to resident incidents with another resident. The facility identified a census of fifty (50) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 4/14/16 assessed Resident #5 with a brief interview for mental status (BIMS) score of 15 (no cognitive impairment). The resident required extensive assistance of 2 staff with bed mobility, transfers and toileting. During the assessment, the resident did not ambulate. The resident had functional limitations in range of motion of both lower extremities. The resident used a walker and wheelchair for mobility. A balance during transitions and walking test revealed the resident was not steady and only able to stabilize with staff assistance while moving from seated to standing, moving on and off the toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The MDS revealed the resident did not take a scheduled pain medication. The MDS indicated the resident did not have falls prior to the assessment. An incident report dated 7/4/16 at 6:10 a.m. revealed a CNA (certified nurse aide) lowered the resident to the floor when the resident's legs gave out. Staff did not observe injuries at that time. A care plan contained a problem dated 4/26/16 that identified the resident at risk for an ADL (activity of daily living) self care deficit related to limited mobility, activity intolerance, fatigue, disease process and impaired balance. The care plan contained a transfer directive dated 4/26/16 that directed staff to use an easy stand to transfer the resident and hoyer PRN. However under the history section of the care plan, there was an addendum dated 6/20/16 that directed staff to transfer the resident with 2 staff and a platform walker and gait belt. EZ stand PRN (as needed). Nursing progress notes dated 7/3/16 at 8:15 p.m. revealed a CNA lowered the resident to the floor that evening as the CNA got the resident ready for bed. The resident's legs went weak and he/she could not stand so the CNA assisted the resident to the floor. Staff did not observe redness or injury. Nursing progress notes dated 7/5/16 at 3:49 p.m. identified the resident with pain in legs. Staff administered analgesics with relief noted. The resident also had difficulty with weight bearing that day. On the same day at 5:25 p.m. the facility informed the physician of the resident's increased weakness. The physician ordered Bactrim DS (antibiotic)one tablet twice a day for 7 days for weakness and probable UTI (urinary tract infection). Nursing progress notes dated 7/8/16 at 8:49 a.m. revealed the resident complained of pain to the right leg when standing or moving but declined pain medications. On the same date at 11:30 a.m. the facility discussed making an appointment with the physician for increased pain and swelling. At 12:14 p.m. the facility placed a call to the physician's office for an appointment. The physician was out for 2 weeks so the facility made an appointment with the PA (physician assistant) for 7/12/16. The entry revealed the resident had increased pain and swelling of the lower extremities. Nursing progress notes dated 7/12/16 at 8:32 a.m. revealed the resident ached with movement or touch and staff administered PRN analgesics with relief. On the same date at 3:15 p.m. the resident returned from the PA appointment. The resident refused the x-ray and returned with orders for Tylenol 500 milligrams (mg.) 1 to 2 tablets PRN and apply ice for 20 minutes and PT (physical therapy) Nursing progress notes dated 7/14/16 at 8:32 a.m. identified the resident with right knee pain and that the resident had an x-ray that day. The resident used the hoyer lift and 2 staff for assistance. A x-ray report dated 7/14/16 revealed a probable right patellar ligament injury/rupture. A MRI was recommended for further evaluation. The x-ray also identified a large right knee joint effusion and no obvious fracture. The x-ray identified that the resident's osteopenia made x-ray interpretation difficult. In the result notes, the PA documented that there was a concern about patellar ligament injury so will get MRI for further evaluation. Nursing progress notes dated 7/19/16 at 4:01 a.m. revealed the resident began using Tramadol (narcotic analgesic) for knee pain. Nursing progress notes dated 7/23/16 at 4:07 p.m. revealed the resident reported pain in legs with repositioning but subsided shortly. Nursing progress notes dated 7/28/16 at 6 p.m. revealed the resident returned to the facility from ER (emergency room ) with a [DIAGNOSES REDACTED]. Fractures are located above and below the knee. The resident should wear a brace to the knee and no weight bearing for 6 weeks. Nursing progress notes dated 7/29/16 at 2:30 p.m. and documented by the director of nursing (DON) revealed the physician signed a major injury determination form for knee fracture and identified the injury as not a major injury. The DON documented that he resident elected not to have surgery and the DON was unsure of actually when the fracture occurred. The x-ray on 7/14/16 was negative for fracture. The resident was lowered to the floor on 7/4/16. The resident admitted to the facility due to inability to transfer per self. The DON wrote that the resident's ability to transfer continued to be compromised and possibly fell at home before admission. Physician: On 9/20/16 at 1:42 p.m. the surveyor asked the physician about a fracture not identified on the 7/14/16 x-ray and then the 7/28/16 x-ray showing a fracture. The physician responded via office nurse that the fracture was present on the 7/14/16 incident but the resident had a huge effusion and they couldn't see it then. It was visible on the second x-ray. The physician stated the fracture was from the original incident (on 7/3/16). Therapy Notes: Review of physical therapy notes from 6/15/16 through 7/2/16 did not identify the resident with pain. Physical therapy notes from 7/5/16 through 7/14/16 (after the 7/3/16 fall) and 7/20/16 through 7/26/16 identified the resident with pain with movement. emergency room and X-ray reports 7/28/16: ER progress notes dated 7/28/16 at 2:14 p.m. revealed the resident fell 2 weeks ago and landed on the right knee. The resident was unable to bear weight since. The x-ray at the time was felt to show some buckling of the patellar tendon and the large joint effusion. The resident still cannot bear weight or strengthen the right knee. The physician documented he decided to perform an MRI and it showed a nondisplaced fracture of the femoral head. ED (emergency department) provider notes dated 7/28/16 at 1:28 p.m. revealed the knee pain was associated with injury. The resident refused surgery and returned to the facility with the right knee immobilized and no weight bearing for 6 weeks. The assessment was closed nondisplaced fracture of condyle of the right femur and right meniscus tear. A x-ray report dated 7/28/16 revealed an x-ray showed a fracture through the right medial femoral condyle as identified on the MRI. Observation: Observation showed on 9/20/16 at 3:10 p.m. the resident in bed with a brace on the right leg. The resident stated he/she still has pain with movement of the right extremity. Staff Interview: On 9/13/16 at 2:33 p.m. Staff A CNA stated she was fairly new at the time of the 7/3/16 incident and didn't know she could look up transfer directives on the computer. She stated she transferred the resident by herself using a gait belt. She stated they got 6 to 8 inches from the bed and the resident went down to the floor. Staff A stated she later found out the resident should transfer with 2 staff. She stated she found out about the computer transfer directives when she signed a counseling form for the incident. A counseling disciplinary notice dated 7/6/16 identified that Staff A did not follow the care plan. The corrective action was: educated the CNA to follow plan of care unless supervisor informs staff differently. A review of Staff A's personnel file did not contain evidence of orientation to nurse aide duties or computer orientation. On 9/15/16 at 3:20 p.m. the DON stated if Staff A did not have a CNA orientation check sheet in her personnel file then she didn't have one. On 9/15/16 at 3:25 p.m. the human resources/marketing director stated there is not a training sheet for computer orientation. (On 9/20/16 at 3:05 p.m., when asked about the discrepancy between the incident date documented as 7/3/16 at 8:15 p.m. in the nursing progress notes versus 7/4/16 at 6:10 a.m., the Director of Nursing stated the nurse probably documented the incident report on 7/4/16 at 6:10 a.m. but the incident occurred 7/3/16 at 8:15 p.m.) 2. A Minimum Data Set (MDS) with assessment reference date of 7/11/16 assessed Resident #8 with a brief interview with mental status (BIMS) score of 14 (no cognitive impairment). The resident required extensive assistance of one staff with bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. The resident was nonambulatory during the assessment. A balance during transitions and walking test revealed the resident as not steady and only able to stabilize with staff assistance. The resident used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The resident did not have a history of falls. A fall incident report dated 9/10/16 at 3:15 a.m. revealed staff observed the resident laying on the floor in the prone position beside the bed with arms at side and legs straight out. The resident stated he/she attempted to get to the toilet. The resident did not sustain injury. Nursing progress notes dated 9/13/16 at 6:36 p.m. revealed Staff B (administrator) asked the resident how the fall occurred. The resident stated he/she didn't know. The resident was on the bed and then on the floor. The resident stated Staff C CNA found him/her. Time card records showed Staff C CNA, Staff D CNA and Staff E RN (registered nurse) worked when the incident occurred. On 9/15/16 at 12:50 p.m. Staff D CNA stated she and Staff C were outside smoking when the fall occurred. She stated they stand outside so they can see the call light board. The resident's call light came on and Staff C put her smoke out and went to the resident's room and found the resident in the floor. Staff D finished her cigarette and came in about 1.5 minutes later. When she went in, Staff E came around the corner and said the resident fell . On 9/15/16 at 2:20 p.m. Staff C CNA denied being outside when the resident's call light came on. She stated she was coming up the 500 hall when the fall occurred. (Resident #8 resided on the 100 hall) On 9/15/16 at 4:03 p.m. Staff E RN stated she thought one staff was out smoking and the other staff was in the resource room when the fall occurred. She stated she worked in another area of the building but normally came to the side where Resident #8 lives around that time of the night. On 9/14/16 at 9:35 a.m. observation showed the resident laying in bed. The resident denied knowledge of the incident. 3. A Minimum Data Set (MDS) with assessment reference date of 6/11/16 assessed Resident #2 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The delirium symptoms came and went with changing severity. The resident had no behavior symptoms identified. The resident required limited staff assistance with bed mobility, toileting, ambulation and eating. The resident was independent in a wheelchair on the unit. The resident had [DIAGNOSES REDACTED]. A care plan dated 8/19/13 revealed the resident required supervision and assistance with all decision making. The care plan dated 12/1/14 also identified that the resident liked to rummage and go in other resident rooms. Staff was to redirect the resident. Nursing progress notes dated 8/13/16 at 8:25 p.m. revealed staff observed the resident chewing with blue foam coming from his/her mouth. Staff observed a denture wrapper in the resident's lap. Staff notified the physician who said the resident would be fine and not worry about it. On 9/19/16 at 4 p.m. the DON stated staff didn't know where the resident got the denture tablet. 4. A Minimum Data Set (MDS) with assessment reference date of 6/11/16, assessed Resident #2 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The delirium symptoms came and went with changing severity. The resident had no behavior symptoms identified. The resident required limited staff assistance with bed mobility, toileting, ambulation and eating. The resident was independent in a wheelchair on the unit. The resident had [DIAGNOSES REDACTED]. Nursing progress notes dated 8/13/16 at 9:30 p.m. and documented by Staff F LPN (licensed practical nurse) revealed Resident #2 sat in the lobby and another resident came up to Resident #2 and hit the resident in the side of the head with a hard back book. On 9/15/16 at 9:25 a.m. Staff F stated Resident #3 hit Resident #2 with a hard back book. Staff F asked Resident #3 if he/she hit the other resident and Resident #3 admitted he/she did and gave Staff F the book. Staff F stated there was another time Resident #2 went in Resident #3's room and a few days later Resident #3 came up behind Resident #2 and pulled back with an open hand from behind as if to hit the other resident. On 9/13/16 at 9:15 a.m. Staff B (outgoing Administrator) stated the residents were in the lobby and Staff A CNA was present but happened to look down when the incident occurred. When Staff A looked up the book was on the floor. When staff asked Resident #3 if he/she hit Resident #2 with the book, Resident #3 replied yes. Resident #2 laughed when asked. On 9/13/16 at 2:33 p.m. Staff A stated she heard a boom and saw Resident #2 fussing with his/her wig and talking trash under his/her breath. Resident #3 nodded yes when asked if he/she hit the other resident with a book. Staff A stated she thought Resident #3 hit the other resident in the back of the head with the book. On 9/13/16 at 2:23 p.m. Staff H CNA stated if Resident #2 gets too close to Resident #3 that Resident #3 will bring his/her hand back as if to strike or swing a book. She stated a month or so ago she observed Resident #3 draw his/her hand back and a nurse yelled to get Resident #2 away from the other resident. That time, staff could intervene in time before Resident #3 made contact. Observation showed on 9/13/16 at 4 p.m. the resident wheeled down the hall. Resident #3 stepped out of his/her room and glared at Resident #2. At that time, Staff M (housekeeper) called for CNAs (certified nurse aides) and stated after the 8/13/16 book incident Resident #3 threw a glass of water on the back of the left shoulder of Resident #2. Staff F stated Staff B (administrator) knew of the incident. Observation showed on 9/15/16 at 4 p.m. a female resident yelling at Resident #2 about getting too close to her. Staff intervened. Review of Resident #2's nurses notes revealed only the 8/13/16 incident was documented in Resident #2's record. Resident #2's care plan contained a problem dated 11/3/13 that revealed the resident had a potential behavior problem related to dementia. The care plan directed staff to intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. An addendum dated 8/14/16 directed staff to monitor the resident if wheeling close to other residents. Review of Resident #3 record information: A MDS with assessment reference date of 8/16/16 assessed Resident #3 with a BIMS score of 7 (severe cognitive impairment) The MDS did not identify any behavior symptoms. The resident transferred and ambulated independently. The resident admitted to the facility 5/10/16. The resident was 69 inches tall and weighed 211 pounds. Nursing progress notes dated 6/29/16 at 11:15 p.m. revealed Resident #3 walked up behind another resident who sat in a wheelchair and tried to hit the resident on the back of the head. Staff redirected Resident #3 to his/her room. Resident #3's care plan dated 8/14/16 contained a potential for injury to self or others related to unsafe behavior of carrying a lot of items at one time, episodes of becoming agitated with others when they come near his/her personal space and striking out related to confusion secondary to dementia. Prior to 8/14/16 the care plan did not contain information regarding a potential for resident to resident incident, even though interviews identified potential incidents had occurred. On 9/13/16 at 11:27 a.m. Resident #3 laid on his/her bed. The resident was very quiet and did not answer questions. On the same date at 11:55 a.m. the resident walked independently from his/her room to the living room and sat in an easy chair. Incident between Resident #3 and Resident #9 which occurred after the above incidents: A MDS with assessment reference date of 7/20/16 assessed Resident #9 with a BIMS score of 15 (no cognitive impairment). The resident was independent with bed mobility and transfers and used a wheelchair for mobility. An incident report dated 9/25/16 at 7:20 p.m. and completed by Staff N RN (registered nurse) revealed Resident #3 had an incident with Resident #9. The incident report revealed a nurse aide yelled for the nurse and when the nurse arrived, she observed coffee all the front lobby and Resident #9 holding his/her face. A nurse aide and Resident #9 told the nurse that Resident #9 threw hot coffee in Resident #9's face. The action following the incident was to separate the residents and remove coffee cups from the resident. Staff assessed Resident #9 and applied cool rags and ice packs to Resident #9's face. Staff assessed redness and warmth to Resident #9's face and ear. Staff did not observe blistering. On 10/11/16 at 1:14 p.m. Staff N RN stated the incident occurred around 7 p.m. She stayed over to help pass medications and went to the front to report off. Resident #9 told her that Resident #3 stole his/her pop. The next thing she knew Staff K CNA yelled for a nurse. She observed bright red skin on Resident #9's right side of face and neck. The resident and floor were covered with coffee. The redness was gone the next day but the resident stated it hurt. She stated the intervention following the incident was to keep an eye on the resident so he/she stayed put in the dining area with coffee. She stated coffee is available to all resident and Resident #3 is still able to get his/her own coffee. The resident's cups also have lids if he/she leaves the dining area. She had not seen the resident remove the lids. On the same date at 4:25 p.m. Staff N stated she did not know if the coffee Resident #3 threw was hot and she could not remember if the resident said it was. On 10/11/16 at 1:37 p.m. Staff K CNA stated that she walked up the hall to the front and saw Resident #9 upset. Resident #9 said his/her soda was gone and asked Resident #3 if he/she took it and Resident #3 shook his/her head yes. After Resident #9 said something to Resident #3, Resident #3 walked behind Staff K and all of a sudden coffee went everywhere. Resident #9 exclaimed that the other resident threw hot coffee on him/her. When questioned if the coffee was hot, Staff K stated yes it was-the resident just got it and came from the coffee pot and Resident #9 said it was. Staff K stated the back of Resident #9's head and neck appeared very very red. She got a cold washcloth for the resident. Staff K stated Resident #9 discharged from the facility after the incident and she wasn't sure what they were doing for interventions for Resident #3. On 10/11/16 at 4 p.m. the Administrator stated she did not think the coffee Resident #3 threw was hot. Observations: Observation revealed on 10/11/16 at 12:03 p.m. Resident #3 in the dining room with 2 cups of coffee in uncovered styrofoam cups. At 12:20 p.m. of the same date identified the resident at the dining room table with the 2 uncovered cups of coffee. At 12:35 p.m., the resident got up carrying the 2 cups of uncovered coffee. Staff N redirected the resident to sit down and finish his/her drinks. The resident went back to the table. Staff N covered one of the cups with a lid and told the resident to drink the other one. Staff N told the resident he/she could take the covered one with him/her. At 12:42 p.m. the resident got up without the covered cup. The resident stopped at the coffee machine but did not have a cup. The resident then went to his/her room. At 12:50 p.m., the resident returned to his/her spot in the dining room and took the lid off of the coffee cup. The resident then exited the dining area but before leaving dumped the coffee from the cup in the trash and got fresh hot coffee. The resident then went into the hallway and poured the coffee from the cup into the laundry hamper sitting outside Resident #4's room. During this time, no staff intervened. The surveyor notified Staff O LPN of the coffee in the laundry hamper and Staff O said she would put a new bag in the hamper. Resident #3's care plan contained an addendum dated 9/25/16 that directed staff to redirect the resident if carrying cups without lids and offer cup with lid. An intervention dated 9/26/16 identified 15 minute checks. On 10/11/16 at 12:12 p.m. Resident #4 stated the resident still came in his/her room and poured coffee in his/her trash. The resident had done it that day. On 10/11/16 at 5 p.m. the Administrator stated the facility would get sturdier cups with harder to remove lids.
Inspection of February 17, 2016
1 findingBased on observation, record review and staff interviews, the facility failed to complete documentation of assessments of pressure sores for 3 of 8 residents reviewed. (Resident#1, #2, #22) The facility reported a census of 50 residents. Findings include: 1. Resident #2's Minimum Data Set ((MDS) dated [DATE] had documentation of the following Diagnoses: [REDACTED]. The care plan with no date identified the resident with the problem of has actual impairment to skin integrity related to pressure on hip and directed staff to: a. consulted Skin educator as needed. (12/23/15) b. Encourage good nutrition and hydration in order to promote healthier skin. c. Has a pressure relieving/reducing mattress, and pillows to protect the skin while in bed. d. Has a gel cushion in the wheelchair (checked 12/23/15) e. Observe/document location, size and treatment of [REDACTED]. Progress notes dated 12/23/15 at 11:35 a.m., documented a facsimile set for treatment for [REDACTED]. Suggested [MEDICATION NAME] or santyl. Awaiting further orders, continuing to monitor. Progress notes dated 12/26/15 at 10:20 a.m., documented this nurse was asked to look at resident buttocks. This nurse observed an oblong area to left medial buttock and upper medical buttock by coccyx. Area by coccyx superficial abrasion with minimal serosanguinous drainage. Area to medical, distal end to left buttock has eschar to outer distal edge with yellow, white slough in center. Purulent drainage, no odor. Area assessed. Physician informed and treatment requested. Progress notes dated 1/8/16 at 10:32 a.m., documented phone call to office for treatment orders for left hip since no return faxes have come through. Progress notes dated 1/9/16 at 5:53 a.m., documented no return call received regarding treatment requests. Resident has been repositioned every one and one-half to 2 hours through this 12 hour shift. Linens have been clean and dry. Has been cooperative with cares. Progress notes dated 1/12/16 at 6:23 a.m., documented verbal order sent to be signed for treatment for [REDACTED]. Progress notes dated 1/12/16 at 11:53 a.m., documented signed fax back for left hip wound treatment of [REDACTED]. Apply Santyl and calcium arginate to wound bed and cover with foam and border. Change daily. The Skin Pressure Ulcer Weekly form dated 12/30/15, documented pressure ulcer site #2, initial evaluation, onset date unknown, left buttock blackened pressure sore, unstageable with size 2 cm by 3 cm with no depth. The Skin Pressure Ulcer Weekly form dated 1/6/16 at 10:24 a.m. documented Pressure ulcer Site #2 with follow-up on left buttock with yellowish drainage with yellowish white center and black eschar surrounding the tissue and measured 2.5 cm by 3.5 cm with 0.4 cm depth. The Skin Pressure Ulcer Weekly form dated 1/13/16 at 1:57 p.m., documented Pressure ulcer site #2 follow-up on left buttock with yellowish drainage with yellowish white center and slough and red edges and measured 4.0 cm by 2.5 cm with a depth of 1.0 cm. Interview on 1/14/16 at 8:00 a.m., the facility director of nursing stated that the expectations of the nursing staff is to get orders for treatments for the resident for the open area the same day or to keep notifying the physician until an order is received. 2. The MDS assessment reference dated 12/28/15, documented Resident #22 with [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, and toilet use and activity of transfers only occurred once or twice, and resident with impaired functional limitations on both sides of the upper and lower extremities. The MDS documented the resident with being at risk for developing pressure ulcers and has more than one or more unhealed pressure ulcer at Stage 1 or higher and foot problems of [MEDICAL CONDITION]. The Clinical Transfer Report dated 10/3/15, documented resident with [DIAGNOSES REDACTED]. The Admission Assessment Comprehensive dated 10/23/15, documented skin integrity included left lower leg (front), right lower leg (front) and right lower leg (front) open sore. Right buttock/pressure ulcer, Stage 4, decubitus 6.1 centimeter (cm) by 3.8 cm by 0.5 cm deep, curbed indent in skin. Left buttock/pressure ulcer, Stage 4, decubitus 15.1 cm by 6.8 cm by 0.4 cm deep. The Branden Scale for Predicting Pressure Sore Risk dated 10/23/15, documented resident with a score of 11 for which indicates high risk. A skin assessment/evaluation-weekly form dated 10/28/15, documented no new skin issues. A Multi Wound Chart Detail report dated 11/3/15, documented left ischium, right gluteal fold and right lower let medial pressure areas. A skin assessment/evaluation-weekly form dated 11/4/15, documented no new skin issues observed or noted during shower. Bed bath given and treatments done as ordered. A skin assessment/evaluation-weekly form dated 11/18/15, documented no new skin issues observed. Skin warm, dry, continues with current treatments. Resident denies complaints. An I-heal form dated 11/18/15, documented left ischium and right gluteal fold pressure injury. A readmission form dated 12/2/15, documented resident with skin integrity of right and left buttock pressure areas, with no measurements or description. A Braden Scale for Predicting Pressure Sore Risk dated 12/2/15, documented the resident with a score of 10 for which indicates high risk. A Braden Scale for Predicting Pressure Score Risk dated 12/9/15, documented the resident with a score of 12 for which indicates high risk. A progress note dated and signed by the physician on 12/10/15, documented follow up recent emergency room visit for [MEDICAL CONDITION]. Toe has pus coming out of the end of the right great toe and has an ulcer on the left. Orders received to use [MEDICATION NAME] and non stick dressing daily to wounds both feet. Needs daily dressing to sacral ulcers as well. The Skin Pressure Ulcer Weekly dated 12/10/15, documented right hip Stage 2 pressure ulcer, right buttock pressure area, and left buttock Stage 4 pressure area. A skin assessment/evaluation-weekly form dated 12/12/15, documented now new skin issues observed. Resident continues to receive wound care to chronic open areas as ordered. A skin assessment/evaluation-weekly form dated 12/16/15, documented no new skin issues observed. A Skin Pressure Ulcer Weekly form dated 12/17/15, documented Stage 2 pressure area on right hip, Stage 4 pressure area on right buttock, and a Stage 4 area on left buttock. A skin assessment/evaluation-weekly form dated 12/23/15, documented no new skin issues observed. A Skin Pressure Ulcer Weekly form dated 12/23/15, documented a Stage 2 pressure area on right hip, Stage 4 pressure ulcer area on right and left buttock. A skin assessment/evaluation-weekly form dated 12/30/15, documented no new skin issues. Skin warm, dry, and intact. A I-heal form dated 12/30/15, documented pressure injury to left ischium, and right medial left lower leg. A discharge instructions form instructed staff to apply [MEDICATION NAME], gauze with roll gauze to left foot daily. A Skin Pressure Ulcer Weekly form dated 12/30/15, documented Stage 2 pressure area to right hip, Stage 4 pressure area to right and left buttock. A skin assessment/evaluation-weekly form dated 1/6/16, documented no new skin issues. Skin warm, dry, and intact. A Skin Pressure Ulcer Weekly form dated 1/6/16, documented Stage 2 pressure area to right hip, Stage 4 pressure areas to right and left buttocks. A skin assessment/evaluation-weekly form dated 1/10/16, documented no new skin issues. skin warm, dry and intact. A skin assessment/evaluation-weekly form dated 1/17/16, documented no new skin issues at this time. A skin assessment/evaluation-weekly form dated 1/20/16, documented no new skin issues. A skin Pressure ulcer weekly form dated 1/20/16, documented a Stage 2 pressure area to right hip, and Stage 4 pressure ulcers to the right and left buttocks. A Wound Healing Center Progress note dated 1/27/16, documented resident seen today for evaluation of ulcers in the left ischium, left lower extremity and foot and new area in right trochanter. Exam: left ischium: wound #51 measuring 9.5 cm by 15 cm by 0.1 cm in size. This ulcer has a large amount of serous exudate, it has a large amount of necrotic tissue that seems to be related to pressure, and mild amount of granulation tissue. Left 5th toe: Patient has ulcer #60, measuring 0.5 cm by 0.5 cm by 0.1 cm in size, with large amount of necrotic tissue, no evidence of exudate, no evidence of granulation tissue. In the left foot patient has ulcer #61: it measures 2 cm by 2 cm by 0.1 cm in size, it has large amount of necrotic tissue, minimal amount of granulation tissue and serosanguineous exudate. In the left malleolus lateral aspect patient has ulcer #62, it measurers 2.2 cm by 2.5 cm by 0.1 cm in size, it has a large amount of necrotic tissue, no evidence of granulation tissue and no evidence of exudate. In the left great toes patient has ulcer #64, it measures 1 cm by 1 cm by 0.1 cm in size, it has small amount of exudate, large amount of necrotic tissue and minimal amount of granulation tissue. In the right trochanter patient has ulcer #65, this is new since has assessment, it measures 5 cm by 4.5 cm by 0.1 cm in size, it has a large amount of necrotic tissue, no evidence of exudate or granulation tissue. The pressure ulcer in the left ishcium looks significantly worse with increased amount of necrotic tissue. Patient has new ulcers as well that are clearly related to pressure, and especially has developed a new ulcer in the right trochanter area that is large and is has a very large amount of necrotic tissue. Patient will have areas derided. A history and physical dated 1/27/16, documented resident with chief complaint of dizziness and [MEDICAL CONDITION] since today afternoon. A re-admit comprehensive assessment dated [DATE], documented no skin issues. A I-heal form dated 2/9/16, documented resident with pressure areas to left ischium and left fifth toe, lateral side. A discharge instructions included to apply [MEDICATION NAME] to right and left toes daily and both 5th bilateral toes and bilateral feet. Santyl to left ankle and right hip and left buttock. A skin pressure ulcer weekly form dated 2/10/16, documented Stage 3 pressure area to right hip with unknown onset date, Stage 4 pressure area to left buttock, and Stage 2 pressure area to left outer ankle with unknown onset date. A skin pressure ulcer weekly form dated 2/17/16, documented Stage 4 pressure area to right hip with unknown onset date, Stage 4 pressure area to left buttock, and Stage 2 pressure area to left outer ankle with unknown onset date A skin ulcer non-pressure weekly form dated 2/17/16, documented left outer foot venous (stasis) ulcer, right outer foot, venous (stasis) ulcer and right heel, venous (stasis) ulcer. An updated skin ulcer non-pressure weekly form dated 2/17/16, handed to this surveyor by the facility director of nursing with the following additional areas to the resident, areas to right foot on great toe measures 2.5 cm by 0.7 cm with necrotic tissue to medial aspect and lateral aspect of toe is pink skin loss. 2 nd toe area measures 0.2 cm by 0.3 cm pink skin loss to lateral aspect of toe. Area to 3rd toe on right foot measures 0.5 cm by 0.5 cm on bottom towards crease of toe with pink skin loss, anterior area measures 0.2 cm by 0.4 cm with necrotic area. Area to 4th toe right foot measures 0.5 cm by 0.5 cm with pink skin loss. Areas are treated with [MEDICATION NAME]. No drainage from any areas, Surrounding skin intact. This surveyor asked Staff E on 2/17/16 at 10:45 a.m., to measure the residents wounds and document them. Staff E proceeded to measure the residents right hip, right outer foot, right heel, left buttock, left outer ankle and left outer side of foot. Staff E stated that the area on the residents left outer side of foot was a small spot and not is bigger and will notify the doctor of the other areas and the new areas. Interview on 2/17/16 at 1:33 p.m., the facility corporate nurse confirmed and verified that the admit skin assessment for 2/4/16 had no documented skin issues or areas and that staff need to do a head to toe skin assessment on all residents when admitted to the facility Interview on 2/17/16 at 4:55 p.m., the facility director of nursing stated that Staff E failed to measure the areas on the residents toes due to them being scabbed over and the treatment is for [MEDICATION NAME] only. 3. Review of Resident #1 medical chart revealed [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress notes noted: 1/6/2016 at 5:13 a.m., a 3x2 cm (centimeter) intact blister noted to right lateral heel; heels floated and heel protector applied; fax out to PCP (Primary Care Physician) to update and req. (request) skin prep order 1/6/2016 at 3:30 p.m., a 3x3 cm pressure ulcer to right heel, Area appears to be a flattened blister without erythemic (redness of the skin) edges, fax out to physician for skin prep, floating heel, and heel protector 1/8/2016 at 7:01 p.m., Received signed skin prep order for bid until healed Late entry dated 1/6/2016 12:56 p.m., a 2x3 pressure sore to the resident's right outer heel. Sore measured and assessed. Request for orders was sent to Doctor for treatment Review of Resident #1's Skin Pressure Ulcer Weekly dated 1/6/2016 at 1:07 p.m. noted: Site 1-c Onset Date unknown 1.-intitial eval, b. Present on Admission 2. No, c. Onset Date unknown a1. 6) unstageable (non-removable dressing/device), a2. size in CM (Length xWidth) 2x3, a9. 6) wound bed-Black/Crown (Eschar), a10. Wound Edges, 1a) Defined Review of Resident #1's Skin Pressure Ulcer Weekly dated 1/13/2016 at 2:21 p.m. noted: Site 1-b. Present on Admission 2. No, c Onset Date unknown 2. follow up, a1. 6) unstageable (non-removable dressing/device), a2. size in CM (Length xWidth) 2x3, a9. 6) wound bed-Black/Crown (Eschar), a10. Wound Edges, 1a) Defined Observation on 1/11/2016 at 1:45 p.m., revealed Resident #1 sitting in recliner with feet elevated and white socks on. Under the bed a heel protector laid on the floor. At 3:30 p.m. observation revealed Resident #1 in recliner, white socks on and heel protector still under the bed. Resident #1 stated the nurse was bringing something for right leg/foot pain. Resident #1 pulled up the left leg slack leg and revealed multiple scabbed pinpoint areas. Resident #1 stated the area itches and had been there sometime. At 2:50 p.m. observation revealed Resident #1 moving feet back and forth on recliner foot rest with eyes closed. At 4:45 p.m. Resident #1 requested to use the bathroom. Staff put a brace on right foot over a white sock, then pushed a white tennis shoe on over the sock and brace. A heel protector remained under the bed on the floor. Observation on 1/13/2016 at 8:55 a.m. revealed staff assisting Resident #1 off the bed to transfer to the wheel chair. Brown scabbed area noted on right outer heel and multiple pinpoint scabbed areas on left leg. Resident #1 complains of pain when sock, brace and white tennis shoe placed on right foot. At 8:55 a.m. Staff D, CNA, unaware of any protective measure for Resident #1's right heel. At 12:20 p.m. Treatment Nurse measured Resident #1's pressure ulcer on right heel, at 2.3 x 3 cm area and described the area to be covered with eschar and defined edges. The Treatment Nurse stated possible cause could be the brace left on right foot while in the chair throughout the day, stated the CNA's were to float heels when in the recliner. The Treatment Nurse read the nurse note dated 1/6/2016 at 3:30, stated the heel boot good idea and would get one for the resident. The Treatment Nurse then became aware of the heel protector under the bed and stated was unaware of the intervention. Review of Resident #1's Medication Review Report dated on or after January 1/12/2016 noted Weekly Skin Check ordered on [DATE] and remained active. Review of Resident #1's January 2016 Medication Administration Report (MAR) noted Weekly Skin Check ordered on [DATE], the MAR indicated [REDACTED] In an interview on 1/13/2016 at 10:55 a.m., Staff E confirms Resident #1's medical record lacked a skin sheet for the skin issues on the left leg. In an interview on 1/13/2016 at 4:15 p.m., the Director of Nursing confirmed the Care Plan (plan of care used to inform staff of interventions and goals of the resident) lacked an interventions for the left leg issues and the heel protectors for right foot Pressure Ulcer. Based on observation, record review and staff and resident interviews, the facility failed to complete skin assessments and implement interventions to prevent the development and promote healing of pressure ulcers (Resident #1, #2, #22). The facility reported a census of 50 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 12/7/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident required extensive assistance of 1 person for toilet use. The MDS identified the resident had 1 Stage IV pressure ulcer. The MDS reflected the resident had a pressure reducing device in the chair, on the bed and pressure ulcer care was provided. The MDS did not identify a turning an positioning program for the resident. The MDS identified the definition of Stages of pressure ulcers as the following: Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is a full thickness tissue loss with exposed bone, tendon or muscle. Sough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The Care plan (not dated) identified the resident had a focus area with an actual impairment with skin integrity pressure area on hip. The interventions directed staff to: *Consult skin educator as needed (12/23/15), * Encourage good nutrition and hydration in order to promote healthier skin, * Pressure reducing mattress and pillows to protect the skin while in bed, *Gel Cushion in wheelchair (checked 12/23/15) *Observe for side effects of the antibiotics and over the counter pain medications: [REDACTED]. *Observe/document location, size and treatment of [REDACTED]. to physician. The Care Plan identified the resident had a [DIAGNOSES REDACTED]. The interventions directed the staff to encourage repositioning or assist the resident to reposition at least every 2 hours (helps with off- loading pressure). The Progress Notes dated 12/23/15 at 11:35 a.m., documented a facsimile set for treatment for [REDACTED]. Suggested [MEDICATION NAME] (silver-antibacterial cream) or Santyl (assists with healing). Awaiting further orders, continuing to monitor. The Progress Notes dated 12/26/15 at 10:20 a.m., documented this nurse was asked to look at the resident ' s buttocks. This nurse observed an oblong area to left medial buttock and upper medical buttock by coccyx. Area by coccyx superficial abrasion with minimal serosanguinous drainage. Area to medial, distal end to left buttock has eschar (area of dead tissue/cells) to outer distal edge with yellow, white slough in center. The area had purulent drainage and no odor. The nurse assessed the area, informed the physician and requested a treatment. The Progress Notes dated 1/8/16 at 10:32 a.m., reflected the nurse phoned the physician ' s office for treatment orders for the left hip area since no return faxes have been received. The Progress Notes dated 1/9/16 at 5:53 a.m., documented no return call received regarding treatment requests. The resident has been repositioned every one and one-half to 2 hours through this 12 hour shift. Linens have been clean and dry. The resident had been cooperative with cares. The Progress Notes dated 1/12/16 at 6:23 a.m., documented a verbal order sent to be signed for treatment for [REDACTED]. Progress notes dated 1/12/16 at 11:53 a.m., documented signed fax back for left hip wound treatment of [REDACTED]. Apply Santyl and Calcium Arginate to wound bed and cover with foam and border. Change (dressing) daily. The Skin Pressure Ulcer Weekly form dated 12/30/15, documented the pressure ulcer site #2, initial evaluation, onset date unknown, left buttock blackened pressure sore, unstageable with size 2 cm by 3 cm The Skin Pressure Ulcer Weekly form dated 1/6/16 at 10:24 a.m. documented Pressure ulcer Site #2 with follow-up on left buttock with yellowish drainage with yellowish white center and black eschar surrounding the tissue and measured 2.5 cm by 3.5 cm with 0.4 cm depth. The Skin Pressure Ulcer Weekly form dated 1/13/16 at 1:57 p.m., documented Pressure ulcer site #2 follow-up on left buttock with yellowish drainage with yellowish white center and slough and red edges and measured 4.0 cm by 2.5 cm with a depth of 1.0 cm. (enlarged). On 1/14/16 at 8:00 a.m., the facility DON (Director of Nursing) was interviewed and stated the expectations of the nursing staff are to continue to ask the physician on a daily basis or more often if an order is needed for a resident with an open area. 2. Resident #22 had a MDS assessment with a reference date of 12/28/1 which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, and toilet use. The MDS identified the resident with impaired functional limitations on both sides of the upper and lower extremities. The MDS documented the resident as at risk for developing pressure ulcers and had more than one or more unhealed pressure ulcer at Stage I or higher and foot problems with [MEDICAL CONDITION]. The Clinical Transfer Report dated 10/3/15, documented resident with [DIAGNOSES REDACTED]. The resident had a skin debridement of the ischial (lower leg) ulceration. The Admission Assessment Comprehensive dated 10/23/15, documented skin integrity included left lower leg (front), right lower leg (front) and right lower leg (front) open sore. Right buttock/pressure ulcer, Stage IV, decubitus 6.1 centimeter (cm) by 3.8 cm by 0.5 cm deep, curbed indent in skin. Left buttock/pressure ulcer, Stage IV, decubitus 15.1 cm by 6.8 cm by 0.4 cm deep. The Braden Scale for Predicting Pressure Sore Risk dated 10/23/15, documented the resident had a score of 11. A score of 11 identified high risk for pressure ulcers. A skin assessment/evaluation-weekly form dated 10/28/15, documented no new skin issues. A Multi Wound Chart Detail report dated 11/3/15, documented left ischium; right gluteal fold and right lower left medial pressure areas. A Skin Assessment/Evaluation-Weekly form dated 11/4/15, documented no new skin issues observed or noted during shower. Bed bath given and treatments done as ordered. A Skin Assessment/Evaluation-Weekly form dated 11/18/15, documented no new skin issues observed. Skin warm, dry, continues with current treatments. Resident denies complaints. An I-heal form (hospital wound center) dated 11/18/15, documented the resident ' s left ischium and right gluteal fold pressure injury. A readmission form dated 12/2/15, documented resident with skin integrity of right and left buttock pressure areas, with no measurements or description. A Braden Scale for Predicting Pressure Score Risk dated 12/9/15, documented the resident with a score of 12. A score of 12 identified the resident at high risk for pressure ulcers. A Progress Note dated and signed by the physician on 12/10/15, documented a follow up recent emergency room visit for [MEDICAL CONDITION]. Toe has pus coming out of the end of the right great toe and has an ulcer on the left. Orders received to use [MEDICATION NAME] (antibiotic ointment) and non- stick dressing daily to wounds on both feet. Needed daily dressing to sacral ulcers as well. The Skin Pressure Ulcer Weekly dated 12/10/15, documented the right hip as Stage II pressure ulcer, right buttock pressure area, and left buttock Stage IV pressure area. A skin assessment/evaluation-weekly form dated 12/12/15, documented now new skin issues observed. Resident continues to receive wound care to chronic open areas as ordered. A skin assessment/evaluation-weekly form dated 12/16/15, documented no new skin issues observed. A Skin Pressure Ulcer Weekly form dated 12/17/15, documented Stage II pressure area on right hip, Stage IV pressure area on right buttock, and a Stage IV area on left buttock. A Skin Assessment/Evaluation-weekly form dated 12/23/15, documented no new skin issues observed. A Skin Pressure Ulcer Weekly form dated 12/23/15, documented a Stage II pressure area on right hip, Stage IV pressure ulcer area on right and left buttock. A Skin Assessment/Evaluation-weekly form dated 12/30/15, documented no new skin issues. Skin warm, dry, and intact. A I-heal form dated 12/30/15, documented pressure injury to left ischium, and right medial left lower leg. A discharge instructions form instructed staff to apply [MEDICATION NAME], gauze with roll gauze to left foot daily. A Skin Pressure Ulcer Weekly form dated 12/30/15, documented a Stage II pressure area to right hip, Stage IV pressure area to right and left buttock. A Skin Assessment/Evaluation-weekly form dated 1/6/16, documented no new skin issues. Skin warm, dry, and intact. A Skin Pressure Ulcer Weekly form dated 1/6/16, documented Stage II pressure area to right hip, Stage 4 pressure areas to right and left buttocks. A skin assessment/evaluation-weekly form dated 1/10/16, documented no new skin issues. Skin warm, dry and intact. A skin assessment/evaluation-weekly form dated 1/17/16, documented no new skin issues at this time. A skin assessment/evaluation-weekly form dated 1/20/16, documented no new skin issues. A skin Pressure ulcer weekly form dated 1/20/16, documented a Stage 2 pressure area to right hip, and Stage 4 pressure ulcers to the right and left buttocks. A Wound Healing Center Progress note dated 1/27/16, documented the resident seen today for an evaluation of ulcers in the left ischium, left lower extremity and foot and new area in right trochanter. Exam: left ischium: wound #51 measuring 9.5 cm by 15 cm by 0.1 cm in size. This ulcer has a large amount of serous exudate; it has a large amount of necrotic tissue that seems to be related to pressure, and mild amount of granulation tissue. Left 5th toe: Patient has ulcer #60, measuring 0.5 cm by 0.5 cm by 0.1 cm in size, with large amount of necrotic tissue, no evidence of exudate, no evidence of granulation tissue. In the left foot patient has ulcer #61: it measures 2 cm by 2 cm by 0.1 cm in size, it has large amount of necrotic tissue, minimal amount of granulation tissue and serosanguinous exudate. In the left malleolus lateral aspect patient has ulcer #62, it measurers 2.2 cm by 2.5 cm by 0.1 cm in size, it has a large amount of necrotic tissue, no evidence of granulation tissue and no evidence of exudate. In the left great toes patient has ulcer #64, it measures 1 cm by 1 cm by 0.1 cm in size, and it has small amount of exudate, large amount of necrotic tissue and minimal amount of granulation tissue. In the right trochanter patient has ulcer #65, this is new since has assessment, it measures 5 cm by 4.5 cm by 0.1 cm in size, it has a large amount of necrotic tissue, no evidence of exudate or granulation tissue. The pressure ulcer in the left ischium looks significantly worse with increased amount of necrotic tissue. Patient has new ulcers as well that are clearly related to pressure, and especially has developed a new ulcer in the right trochanter area that is large and is has a very large amount of necrotic tissue. Patient will have areas derided. A history and physical dated 1/27/16, documented resident with chief complaint of dizziness and [MEDICAL CONDITION] since today afternoon. A re-admit comprehensive assessment dated [DATE], documented no skin issues. A I-heal form dated 2/9/16, documented resident with pressure areas to left ischium and left fifth toe, lateral side. A discharge instructions included to apply [MEDICATION NAME] to right and left toes daily and both 5th bilateral toes and bilateral feet. Santyl to left ankle and right hip and left buttock. A Skin Pressure Ulcer Weekly form dated 2/10/16, documented Stage III pressure area to right hip with unknown onset date, Stage IV pressure area to left buttock, and Stage II pressure area to left outer ankle with unknown onset date. A Skin Pressure ulcer weekly form dated 2/17/16, documented Stage IV pressure area to right hip with unknown onset date. Stage IV pressure area to left buttock, and Stage II pressure area to left outer ankle with unknown onset date. A skin ulcer non-pressure weekly form dated 2/17/16, documented left outer foot venous (stasis) ulcer, right outer foot, venous (stasis) ulcer and right heel venous (stasis) ulcer. An updated skin ulcer non-pressure weekly form dated 2/17/16, handed to this surveyor by the facility DON with the following additional areas to the resident, areas to right foot on great toe measures 2.5 cm by 0.7 cm with necrotic tissue to medial aspect and lateral aspect of toe is pink skin loss. Second toe area measures 0.2 cm by 0.3 cm pink skin loss to lateral aspect of toe. Area to 3rd toe on right foot measures 0.5 cm by 0.5 cm on bottom towards crease of toe with pink skin loss, anterior area measures 0.2 cm by 0.4 cm with necrotic area. Area to 4th toe right foot measures 0.5 cm by 0.5 cm with pink skin loss. Areas are treated with [MEDICATION NAME]. No drainage from any areas, Surrounding skin intact. This surveyor asked Staff E on 2/17/16 at 10:45 a.m., to measure the resident ' s wounds and document them. Staff E proceeded to measure the resident ' s right hip, right outer foot, right heel, left buttock, and left outer ankle and left outer side of foot. Staff E stated that the area on the resident ' s left outer side of foot was a small spot and not bigger and will notify the doctor of the other areas and the new areas. On 2/17/16 at 1:33 p.m., the facility
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