Every finding on record at Garden Valley Retirement Village

The facility reported a census of 45, which included four residents that had physician orders for pureed diets. Based on observation, interview, and record review the facility failed to provide food prepared in accordance with recipes to ensure conservation of nutritive value, flavor, palatability, and appearance for four residents that received pureed diets. This placed the affected residents at risk for impaired nutrition and diminished enjoyment of their meals. Findings included: - On 06/10/25 at 10:39 AM observation of Dietary Staff BB preparation to pureed lunch menu items revealed the lack of recipes to provide guidance to the dietary staff to ensure the nutritional value and palatability of the food items. On inquiry, Dietary Staff BB and Dietary Staff EE confirmed they could not find recipes to instruct the cook on the preparation of pureed menu food items which included Orange Chicken, Lo Mein noodles, and apple pie. Dietary Staff BB stated she expected the staff to follow the recipes for food preparation and service to ensure the residents received the proper nutritional value of the ordered diets. She verified the facility had four residents who received pureed diets (mechanically altered food). She confirmed the current menu cycle as week four and the first day of the weekly cycle as Sunday (06/08/25, two days prior). Dietary Staff BB verified the 06/10/25 lunch menu included Orange chicken, broccoli, Lo Mein noodles, and apple pie. On 06/10/25 at 11:00 AM, during Dietary Staff FF's preparation to puree apple pie, observation revealed he lacked a recipe to provide guidance for appropriate measurements and preparation to ensure nutritional value and palatability. On inquiry, Dietary Staff FF confirmed he was not able to find the recipe for apple pie and reported he did not always use the recipes for puree food. Dietary Staff BB instructed Dietary Staff FF to remove the crust from the apple pie before pureeing. On 06/10/25 at 11:10 AM, observation revealed Dietary Staff DD pureed the apple pie using the recipe provided for apple crisp. She poured apple juice into the blender directly from the juice container without following the measurements recipe for apple crisp. Dietary Staff BB stated pie was served at room temperature. The temperature of the pureed apple pie was 80 degrees. On 06/10/25 at 11:10 AM, when asked how he knew how much he was serving in each bowl, Dietary Staff FF asked Dietary Staff DD, who responded the dessert bowls were four ounces. Dietary Staff FF stated the dessert bowls were only three-quarters full, so the serving size was probably three ounces. When asked why only three portions of apple pie were plated when the facility had reported four residents with pureed diets, Dietary Staff FF stated the fourth resident was transitioning to a regular diet and they were starting with regular dessert. On 06/10/25 at 10:49 AM, Dietary Staff EE stated she cooked Sunday (06/08/25) and could not find the pureed recipes for the menu items. She reported she did not always use the recipes to prepare the residents' meals to ensure portion sizes or nutritional value. Dietary EE stated she knew how much she usually served the residents. In an interview on 06/10/25 at 11:00 AM, Dietary Staff FF confirmed he was not able to find the recipe for apple pie and reported he did not always use the recipes for puree food. The undated policy Standardized Recipes, documented standardized recipes will be used for all menu items, including pureed and therapeutic diets. Each recipe will include the name of the product, number of servings, ingredients, measurement and/or weight of ingredients, the procedure for assembling/method of production serving sizes, modifications for therapeutic diets if applicable, and the registered dietician will approve recipe changes or new recipes utilized for a menu item.

The facility reported a census of 45 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to provide adequate care and services for Resident (R) 41's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to perform the PICC dressing change every five days and failed to label the antibiotic medication that was administered. These deficient practices placed R41 at risk for complications related to the PICC line and medication administration via the PICC. Findings included: - R41's Electronic Health Record (EHR) included diagnoses of cellulitis (skin infection caused by bacteria) of the buttock, paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone). R41's 04/26/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R41was dependent on staff for toileting, lower body dressing, footwear, and transfers. The MDS documented R41 required maximal assistance with showers and bed mobility. The MDS documented R41 had one pressure ulcer Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) not present on admission. R41's 04/30/25 Functional Abilities Self-Care and Mobility Care Area Assessment (CAA) documented R41 required varying levels of assistance with his activities of daily living (ADL) related of paraplegia. Staff would continue to assist resident with his daily care. R41's EHR documented Entry Tracking Record MDS which documented R41 readmitted to the facility from the hospital on [DATE]. R41's Care Plan dated 06/05/25 instructed the Licensed Nurse (LN) to change the PICC line dressing every five days. The plan instructed staff to observe and report concerns of infection or changes in length (of the PICC) to the physician. The plan instructed staff to administer medications as ordered and educate the resident regarding infection prevention as indicated. Staff were to monitor for signs and symptoms of infection, including fever, chills, nausea, vomiting, and pain every shift and notify the physician of adverse effects from the antibiotics. R41's Physician Orders ordered Vancomycin (antibiotic) intravenous (IV-administered directly into the bloodstream via a vein) solution reconstituted 1.5 grams, give 1.5 grams intravenously two times a day for wound abscess (cavity containing pus and surrounded by inflamed tissue) until 07/18/25, date ordered 06/10/25. R41's Physician Orders ordered PICC line dressing. Change sterile dressing every five days and as needed. May use sterile dressing kit, date ordered 06/06/25. R41's 06/05/25 at 03:35 PM Progress Note documented R41 had a PICC line to his left arm and received Vancomycin IV twice a day for 42 days. Last administration was on 06/05/25 at 11:24 AM. R41's EHR, Medication Administration Record, and Treatment Administration lacked any documentation that R41's PICC line dressing was changed. During an observation on 06/09/25 at 02:30 PM, R41 reported he was on an antibiotic but was not sure why; he was in the hospital recently for kidney stones and had surgery. Observation revealed R41's PICC line dressing on his left arm was intact and dated 06/03/25. During an observation on 06/10/25 at 10:30 AM, R41 had IV Vancomycin 1.5 grams infusing into his PICC line. The IV bag had no label containing the resident's name, amount and route to be administered, date and time prepared, or expiration date. During an observation on 06/10/25 at 03:36 PM. Administrative Nurse D completed R41's PICC line dressing. She verified the date on old dressing was 06/03/25. Administrative Nurse D said she expected staff to change the dressing per the physician orders and reported the PICC line dressing should have been completed on 06/08/25, and said it was two days late. On 06/10/25 at 10:32 AM, LN H reported that she had just hung the bag of Vancomycin and confirmed she did not label the bag as there was no label for it when she prepared the bag. LN H reported she would go back down to R41's room and label the bag with a marker. LN H reported that a Registered Nurse would complete the PICC line dressing as it was out of her scope of practice. The facility's policy Central Venous Catheter Care and Dressing Changes dated March 2022 documented the purpose of this procedure is to prevent complications associated with IV therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. A physician's order is not needed for this procedure.

The facility reported a census of 45 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to implement provider orders based on the Consultant Pharmacist's (CP) monthly medication review (MRR) and ensure an MRR review system that mitigated duplication or omissions for Resident (R) 38. The deficient practice placed the resident at risk of receiving unnecessary medications. Findings included: - R38's Electronic Health Record (EHR) included diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R38's 09/06/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition, and noted R38 had no behaviors. The MDS documented R38 utilized a wheelchair for locomotion and required moderate assistance for the application of footwear, dressing, bathing, and toileting. The MDS documented R38 received an antidepressant (a class of medications used to treat mood disorders). R38's 09/10/24 Cognitive Loss Care Area Assessment (CAA) documented R38 had moderate vascular dementia with other behavioral disturbances. The CAA lacked the analysis and care plan decisions. R38's 09/10/24 Psychotropic Drug Use CAA documented R38's use of an antidepressant and risk for adverse effects. R38's 04/26/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. The MDS documented R38 had inattention, was continuously easily distractible, or had difficulty keeping track of what was said. The MDS documented R38 received an antidepressant, an opioid (a class of controlled drugs used to treat pain), and an antibiotic (medication used to treat bacterial infection). R38's Care Plan dated 12/15/22 directed staff to administer medications as ordered and review black box warnings located under the orders tab next to the medications on the medication administration record. The plan directed staff to monitor for antidepressant medication side effects such as dry mouth, nausea, blurred vision, drowsiness, constipation, urinary retention, hypotension (low blood pressure), appetite changes, headache, insomnia (inability to sleep), and sedation. The plan instructed staff to monitor routinely for possible dose reduction. An update dated 05/19/25 documented a gradual dose reduction (GDR) of R38's antidepressant was not successful. R38's Physician Orders dated 05/02/25 documented venlafaxine HCl oral tablet (antidepressant) 100 milligrams (mg), give 100 mg by mouth, one time a day related to major depressive disorder. The 03/23/25 CP MRR documented R38 had been taking venlafaxine 150 mg daily for about a year and a half. Federal guidelines required periodic reviews to find the lowest effective dose. The CP asked if it was appropriate to try a reduction to 75 mg when R38's current supply ran out. R38's Progress Notes on 3/24/25 at 10:02 AM, documented a fax was sent to R38's physician reporting R38 had been taking venlafaxine 150 mg daily for about a year and a half and indicated the guidelines and recommendation from the 03/23/25 MRR. The note documented staff awaited a response. On 03/25/25 R38's physician extender responded, on the 03/23/25 MRR, in writing to decrease the venlafaxine to 75 mg daily due to the federal guideline requirement; a prescription was sent to pharmacy. R38's EHR lacked evidence staff acknowledged and acted on this order on 03/25/25. R38's Medication Administration Record documented the venlafaxine order was reduced to 75 mg daily on 04/12/25. The EHR lacked a progress note for the medication change. On 04/16/25 R38's physician responded on the 03/23/25 MRR in writing and checked the box indicating the physician disagreed with the recommendation. The physician documented on the MRR and wrote previous attempts to GDR R38's antidepressant were unsuccessful and made the resident more despondent. R38's Progress Note on 05/02/25 at 02:09 PM, documented staff faxed the physician to clarify the dose of venlafaxine following gradual dose reduction recommendations form pharmacy. R38's Progress Note on 05/02/25 at 04:17 PM, documented that staff received a new order from the physician to increase the venlafaxine to 100 mg by mouth daily for depression. R38's Progress Note on 05/07/2025 at 04:27 PM, documented R38 hollered for help; staff assisted the resident and in 20-30 minutes, R38 hollered out again. The note documented the behavior was repetitive that afternoon. During an observation on 06/09/25 at 02:49 PM, R38 cried and reported that she had a funny feeling the facility was going to keep her permanently and said she had an apartment she wanted to go back to. R38 reported she wore a splint on her left hand and had four broken bones, but she could not recall what happened. During an observation on 06/11/25 at 12:20 PM, R38 remained in bed. She reported she just did not feel well. On 06/11/25 at 02:13 PM, Certified Nurse Aide (CNA) M reported that R38's confusion had gotten worse. On 06/11/25 at 04:06 PM, Licensed Nurse (LN) G reported that she did not complete the MRR, and said that Administrative Nurse D would complete the MRR reports. On 06/12/25 at 09:28 AM, Administrative Nurse D reported that the nurse faxed the MRR to the physicians. Administrative Nurse D stated she did not understand why R38 had two separate MRR forms from two different providers regarding the GDR for venlafaxine. Administrative Nurse D reported that R38 should not have had a GDR completed as the resident had a failed GDR in the past and reported that R38 had increased behaviors recently. Administrative Nurse D said that R38 should be on the 150 mg dose of venlafaxine. The facility's Drug Regimen Review dated April 2013 documented the consultant pharmacist would monitor the ordering, storage, distribution, and use of medications in the facility. The policy lacked what nursing would complete with in regard to the MRR.

The facility reported a census of 45 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when the facility failed to identify and change ineffective fall interventions and failed to fully implement all interventions aimed at preventing falls for Resident (R) 38, who had multiple falls. This deficient practice placed R38 at risk for further falls and related injuries. Findings included: - R38's Electronic Health Record (EHR) included diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and hemiparesis/hemiplegia (weakness and paralysis on one side of the body). R38's 09/06/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R38 utilized a wheelchair for locomotion and required moderate assistance for the application of footwear, dressing, bathing, and toileting. The MDS documented R38 required supervision for standing. The MDS documented R38 was occasionally incontinent of the bladder. The MDS documented R38 had one non-injury fall since the previous assessment. R38's 09/10/24 Fall Care Area Assessment (CAA) documented R38 had impaired mobility, weakness, use of an antidepressant (a medication used to treat mood disorders), a history of falls, and was at risk for falling. The CAA noted staff assisted R38 with all activities of daily living (ADL) as needed. R38's 03/03/25 Quarterly MDS documented a BIMS score of 10, which indicated moderately impaired cognition. R38's 04/26/25 Quarterly MDS documented a BIMS score of five, which indicated severely impaired cognition. The MDS documented R38 had inattention, was easily distractible, or had difficulty keeping track of what was said, continuously. R38 had one non-injury fall, one fall with injury, and one fall with major injury since the previous assessment. R38's Care Plan dated 09/30/22 documented R38 was at risk for falls related to poor safety awareness, and unsteady balance and gait and included the following interventions: 09/30/22: The staff would ensure R38's environment was clutter-free and free from spills and/or clutter. The staff were to ensure adequate lighting and ensure the resident's personal items were within reach. Staff would ensure the call light was within reach and encourage use. Staff would provide appropriate footwear when transferring and ambulating R38. R38 required the assistance of one staff for dressing. 08/24/23: The staff placed Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in R38's wheelchair under the cushion to prevent the cushion from sliding. 08/27/23: The staff provided gripper socks to R38 to use when she was in bed. 10/13/23: The staff educated R38 to keep appropriate footwear on at all times while transferring. 12/10/24: The staff encouraged R38 to utilize non-skid socks and/or appropriate footwear when transferring. 03/21/25: R38 went to the hospital for evaluation, with an Ace wrap and splint applied to her left forearm. The plan documented R38 stated she would call for help with all transfers from then on. R38's Fall Risk Tool on 08/27/23, 10/13/23, 12/20/23, 06/08/24, 07/28/24, 12/20/24, and 01/13/25 recorded R38 was at moderate risk for falls. R38's Fall Risk Tool on 12/22/23 and 03/20/25 recorded she was at high risk for falls. The Fall Note dated 10/13/23 at 05:40 PM, documented R38 sat on the floor next to her bed and wheelchair. R38 reported that she was changed into her pajamas and nonskid socks. The note said R38 told staff she slipped and landed on her bottom while she looked for her hat. The note documented R38's wheelchair was locked, and the resident did not have on nonskid socks. R38 was educated on the importance of keeping non-skid socks or proper footwear when transferring or ambulating. The note documented R38 was encouraged to use the call button for assistance. The Fall Note dated 12/20/23 at 01:30 AM, documented staff heard R38 yelling and found R38 next to her bed sitting on the floor. R38 had no shoes or socks on, the wheelchair was next to her and locked, and the call light was on at the time of the fall. Staff had just left the area of the resident's room. The note documented R38 reported she slid and sat on the floor. The note recorded a fall intervention as staff reminded R38 to wear shoes or nonskid socks. The Fall Note dated 06/08/24 at 01:19 PM, documented R38 sat up on the floor, near the restroom doorway with her legs outstretched in front of her; she had bare feet. R38 reported she needed to go to the bathroom and the wheelchair was too far away from her bed. The note recorded the fall intervention was staff encouraged R38 to use her call button and wear slippers or nonskid socks during ambulation or transfers; the wheelchair was to be placed within reach of the resident, as she has a history of not using her call button. The Fall Note dated 07/27/24 at 09:52 PM, documented R38 sat up against her bed with her legs stretched out towards the television; R38 reported her wheelchair started to move so she placed herself on the floor. The note documented staff removed R38's wheelchair and provided her with a working wheelchair. The Fall Investigation Report dated 07/29/24 documented R38 sat on the floor when her wheelchair slipped during a transfer. The report documented the root cause analysis was the wheelchair was not locked before R38 attempted to transfer. The report noted wheelchair brake extenders were ordered to add to R38's wheelchair and her plan of care was updated. The Fall Note dated 12/10/24 at 10:45 AM, documented R38 sat on the floor in front of her bed, her wheelchair was locked, and her call light was not on. R38 had regular cotton socks on. The note recorded R38 said she was getting out of bed and into her wheelchair to go to the restroom and she said she did not wear her slippers because she did not think she would slip. The note recorded the fall intervention was staff encouraged R38 to use her call button for assistance with toileting and staff applied nonskid socks. Staff encouraged R38 to always use nonskid socks or slippers when transferring or ambulating. The Progress Note dated 12/11/24 at 11:17 AM documented R38 expressed a desire to participate and receive therapy services; she wanted to walk again. The note documented R38 had a recent fall without injury, and she was agreeable to receive therapy services and agreeable to commit to therapy schedule. The Progress Note dated 12/11/24 at 11:35 AM documented the facility submitted for authorization with the resident's insurance company for therapy services. The Physician Orders dated 12/12/24 at 10:13 AM, directed physical therapy to evaluate and treat. R38's EHR lacked evidence the above PT evaluation was completed for R38. The Fall Note dated 01/13/25 at 03:28 PM, documented R38 screaming from her room. R38 was in a praying position on her knees in front of her bed and reported she was trying to put her clothes on. The note documented an intervention in which staff applied nonskid socks and educated R38 on the importance of wearing them. Staff encouraged R38 to always call for help when changing clothes or getting ready. The Fall Note dated 03/20/25 at 10:06 PM, documented R38 yelled from her room and was observed seated upright on the floor with her face covered in blood. R38 reported she transferred herself from her wheelchair to her bed and thought she could make it without assistance. R38 went to the hospital. The Progress Note dated 03/21/25 at 01:10 AM, documented R38 returned from the hospital with sutures for a right forehead laceration (cut) and a fracture of the fourth metacarpal (bone of the hand) of her left hand; she had a splint and ace wrap on her left forearm. The Fall Investigation Report dated 03/21/25 documented R38 reported she transferred herself from her wheelchair to her bed and thought she could make it without assistance. The report noted R38 removed her shoes and nonskid socks before transferring herself. R38 denied harm and reported she was the only one in the room when she fell. The intervention documented R38 went to the hospital for an evaluation and received an ace wrap and splint for her left forearm. R38 reported she would now call for help with all transfers. During an observation on 06/09/25 at 02:49 PM, R38 started to cry and reported that she had a funny feeling the facility was going to keep her permanently and said she had an apartment she wanted to go back to. R38 reported she wore a splint on her left hand and had four broken bones but she could not recall what happened. Further observation revealed R38's wheelchair lacked a Dycem pad, wheelchair brake extenders, or anti-roll back appliances. During an observation on 06/11/25 at 12:20 PM, R38 remained in bed. She reported she just did not feel well. Further observation revealed a wheelchair with the brakes locked sat next to her bed but there was no Dycem, or brake extenders noted on the wheelchair. During an observation on 06/12/25 at 10:35 AM, R38 sat in her wheelchair. Further observation revealed the wheelchair lacked brake extenders. On 06/09/25 at 04:52 PM, R38's representative reported that R38 had been very confused for about a year. On 06/11/25 at 02:13 PM, Certified Nurse Aide (CNA) M reported she was not sure if R38 should have Dycem on her wheelchair but said it would be on the care plan if she needed if. CNA M then reported the Dycem must have gone to laundry. On 06/12/25 at 10:40 AM Administrative Nurse D reported if there was a concern with R38's wheelchair, the concern may have been placed in the Technology, Solutions, and Services for Building Management system (TELS- a technology-based system focused on optimizing building operations by offering solutions for life safety, asset management, maintenance, and repair services to building management professionals) for maintenance staff to address. On 06/12/25 at 10:24 AM, Maintenance Supervisor U reported he completed quarterly maintenance checks of the facility's wheelchairs, and said TELS would send him an alert to have the task completed in March, June, September, and December. On 06/12/25 at 10:50 AM, Certified Medication Aide (CMA) S reported R38 had never had brake extenders on her wheelchair. CMA S reported all staff had access to TELS to report concerns. On 06/11/25 at 02:13 PM, CNA M reported that R38 would not be able to remember to use the call light or not get up by herself since she started here about four months ago. CNA M said R38's confusion had gotten worse. On 06/11/25 03:34 PM, CMA S reported that R38 had increased confusion for over a year and that the resident would not remember to call staff for assistance. On 06/12/25 at 11:13 AM, Administrative Nurse D reported she was not the Director of Nursing in July 2024 but said the brake extenders should have been placed on R38's wheelchair and on the care plan. On 06/12/25 at 11:17 AM, Maintenance Supervisor U reported he did not have a report to show wheelchair maintenance was completed and said he did not have time to look at every wheelchair in the facility as he was the only maintenance personnel. He reported he could not recall placing brake extenders on R38's wheelchair and he could not locate that request in TELS. On 06/12/25 at 08:30 AM, Therapy Staff HH reported she was not able to locate any documentation for a therapy evaluation for R38. Therapy Staff HH reported she would receive an order from nursing for an evaluation, then the business manager would check for insurance and then the evaluation would be completed. Therapy Staff HH reported she had no evaluation or any notes for R38 in the computer or papers filed. On 06/12/25 at 08:35 AM, Therapy Staff JJ reported if R38 refused therapy, a form would be filed in the business office. On 06/12/25 at 08:45 AM, Business Office Manager (BOM) KK reported she had no documentation in R38's EHR or a paper file for a therapy evaluation in December 2024. BOM KK reported R38 had different insurance in December 2024 and R38 would have had a co-pay for insurance. BOM KK reported that R38 refused to pay the co-pay and recalled that R38's family member who assisted in decision making would follow R38's decision and not pay for therapy. BOM KK reported she did not document this conversation. On 06/12/25 at 09:28 AM, Administrative Nurse D reported she expected staff to document when a resident refused any treatment, therapy, or medication order prescribed by a physician in the EHR or the therapy form that R38 refused to pay her co-pay for therapy. On 06/11/25 at 04:06 PM, Licensed Nurse (LN) G reported that R38 would not always remember to call staff for assistance. LN G said all residents should always have their fall interventions in place. On 06/12/25 at 09:28 AM, Administrative Nurse D reported R38 had attention-seeking behavior when first admitted . Administrative Nurse D reported R38's cognition became more impaired and confirmed R38's fall interventions could have been different to prevent falls because the resident would not remember the education provided and she expected staff to implement all fall interventions. The facility's policy Fall Guidelines - Assessing Falls and Their Causes dated October 2010 documented the purpose of this procedure are to provide guidelines for assessing a resident after a fall to assist staff in identifying caused of the fall. The facility's policy Assistive Devices and Equipment dated January 2020 documented the facility maintains and supervised the use of assistive devices and equipment for residents. Devices are documented in the residents' care plan.

The facility reported a census of 45 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair for Resident (R) 45. This placed the resident at risk for impaired dignity and poor hygiene. Findings included: - R45's Electronic Health Record (EHR) revealed diagnoses of a need for assistance with personal care, muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) R45's 12/24/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R45 had no depression and no behaviors. The MDS documented R45 had lower extremity impairment on one side. The MDS documented R45 was dependent on staff for dressing, footwear, and transfers and required maximal assistance for bed mobility, sit-to-stand, personal hygiene, and bathing. R45's 01/07/25 Functional Abilities Self-Care and Mobility Care Area Assessment (CAA) documented R45 triggered related to the residents need for assistance with his daily cares. Staff would continue to provide care and support in residents daily needs encouraging independence as appropriate while maintaining safety with cares. R45's 04/25/25 Quarterly MDS documented a BIMS score of 15. The MDS documented R45 had no depression or behaviors. The MDS documented R45 had lower extremity impairment on one side and was dependent on staff for dressing, footwear, and transfers; he required maximal assistance for bed mobility, sit-to-stand, personal hygiene, and bathing. R45's Care Plan documented on 01/05/24 directed staff to shave R45 on bath days and as needed. R45's Personal Hygiene Tasks documented that R45 required maximal assistance or was dependent on staff for hygiene tasks. R45's Bathing Task documented R45 received bathing on 06/03/25 and 06/06/25. On 06/09/25 at 02:09 PM, R45 reported that he should be shaved at least once a week. R45 had prominent beard growth on his face with irregular borders and a mustache. R45 reported the staff would have to shave him because he could not do it himself. R45 said he liked to be clean shaven but he could not recall the last time he was shaved. On 06/10/25 at 05:05 PM, R45 sat in the dining room for supper. Observation revealed prominent beard growth on his face with irregular borders and a mustache. On 06/12/25 at 08:01 AM R45 was in dining room finishing breakfast. His facial hair remained. R45 reported again that he preferred to be clean shaven. On 06/12/25 at 10:55 AM, R45 sat in the lobby. His facial hair was removed. R45 smiled and said it felt good. On 06/11/25 at 03:04 PM, Certified Nurse Aide (CNA) M reported that the staff followed the shower list and provided bathing to residents on the list. CNA M said sR45 was on the shower list for Tuesday and Fridays during the day shift. On 06/11/25 at 03:25 PM, CNA M reported if a resident asked to be shaved, she would shave them. CNA M reported staff would shave residents on their shower days or when the resident asked. On 06/11/25 at 03:27 PM, Licensed Nurse (LN) G reported after the CNA gave a bath, the LN checked to see if the residents were shaved and if they were not, the LN staff would shave the residents because the CNA staff were quite busy. During an interview on 06/12/25 at 09:20 AM, Administrative Nurse D reported if the residents had no cognitive issues, they could request a shave on their scheduled shower days, and she expected staff would shave any of the residents including residents that were confused. Administrative Nurse D reported she expected staff to shave a resident daily and as needed if they requested that as part of their care. Administrative Nurse D reported that R45 generally would not talk a lot and did not complain. The facility's policy Activities of Daily Living (ADLS) Supporting dated March 2018 documented residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs including appropriate support and assistance for hygiene (bathing, and grooming).

The facility reported a census of 45 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 43 received services to maintain his abilities of activities of daily living (ADL). This deficient practice placed the resident at risk for a decrease in functional abilities and decreased independence. Findings included: - R43's Electronic Health Record (EHR) included diagnoses of unspecified dislocation of the right shoulder, muscle weakness, and unsteady gait. R43's 07/11/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R43 had impairment of the upper extremity on one side. R43 was dependent on staff for toileting, transfers, showering, dressing, footwear, personal hygiene, and bed mobility. The MDS documented R43 was independent with wheelchair mobility. R43's 07/18/24 Functional Abilities Self-Care and Mobility Care Area Assessment (CAA) documented R43 had impaired mobility and weakness, and required staff assistance to complete ADL; staff would assist as needed with all ADL. R43's 03/28/25 Quarterly MDS documented a BIMS score of 15. The MDS documented R43 had impairment of the upper extremity on one side. R43 was dependent on staff for toileting, transfers, showering, dressing, footwear, personal hygiene, and bed mobility. The MDS documented R43 was independent with wheelchair mobility. R38's Care Plan documented on 07/21/23 refer to therapy as needed. The care plan dated 06/10/25 lacked any instructions for the staff to ambulate the resident. R43's 01/10/25 Physical Therapy Encounter Note documented R43's received gait training with a front wheeled walker and minimal assist of two. R43 was able to advance his right lower extremity with some circumduction (a body movement where the distal end of a limb or body part describes a circle while the proximal end remains relatively fixed) for 15 feet one time, without a loss of balance. R43's 01/13/25 Physical Therapy Encounter Note documented R43 received gait training with a front-wheeled walker and minimal assistance from the therapist for 25 feet, one time. R43's 01/16/25 Physical Therapy Encounter Note documented R43 received gait training with a front-wheeled walker and minimal assistance from two therapists; R43 ambulated 10 feet three times. R43's 01/16/25 Physical Therapy Note documented R43's new goal was to safely ambulate on a level surface for 100 feet using a front wheeled walker and a right ankle and foot orthoses (AFO- an external device fitted to the body, used to prevent a physical deformity, stabilize a joint or joints, reduce pain. improve mobility or performance) with minimal assist. The note recorded R43's baseline was 20 feet. R43's 02/07/25 Physical Therapy Encounter Note documented R43 performed gait training with a front-wheeled walker and minimal assistance of two for 18 steps with the wheelchair following him. R43's 02/10/25 Physical Therapy Discharge Summary documented R43 ambulated 20 feet with minimal assistance 90 percent of the time. R43's prognosis to maintain his current level of function was good with consistent staff follow-through. The summary documented R43's discharge recommendation was to remain a long-term resident. The discharge summary lacked any recommendations to nursing to continue the current level of ambulation. R43's EHR lacked evidence of a formal or informal walking program or restorative activity. During an observation on 06/09/25 at 03:04 PM, R43 was in the lounge working on a cycle machine and requested to converse later. During an observation on 06/11/25 at 08:15 AM, R43 propelled himself backward in his wheelchair to the 300 hallway from the dining room. On 06/10/25 at 08:20 AM, R43 reported that he should be receiving therapy but he was not, and he wanted to know why. He reported that when he asked staff why not, he never received a reason. He reported that he had been walking in therapy in February and had walked since therapy was discontinued. On 06/10/25 at 03:16 PM, Certified Nurse Aide (CNA) N reported the facility had a Restorative Aide but was not sure who it was. CNA N reported that she would only complete exercises or ambulation for a resident if she was asked to do it, and the resident's care plan had the directions for what was required. CNA N reported that she did not know if R43 ever ambulated. On 06/10/25 at 03:19 PM, Certified Medication Aide (CMA) T reported that the facility did have a restorative aide, and all the CNA/ CMAs were responsible for completing any ambulation, or range of motion for the residents. CMA T verified the information should be on the care plan. CMA T reported that R43 could not ambulate. On 06/10/25 at 03:25 PM, Licensed Nurse (LN) H reported that CNA/CMAs were responsible for completing any range of motion exercises including ambulation for the residents that required this if it was care planned. LN H reported that R43 could not ambulate and stated he required a sit-to-stand lift. On 06/11/25 at 07:59 AM, Therapy Staff JJ reported the facility did not have an exercise program for the residents once they were discharged from therapy services. Therapy Staff JJ reported the nursing staff was required to apply splints, perform exercises, range of motion, and ambulate the residents. Therapy Staff HH reported the Physical Therapist wrote recommendations to nursing for what the staff would need to complete to maintain the resident's level of function. Therapy Staff JJ reported if a resident had a decline in ADL, the therapy department was notified by nursing and an evaluation was ordered. Therapy Staff JJ said the therapist would not know if the resident had a decline if nursing did not let them know. On 06/11/25 at 01:01 PM, Therapy Staff HH reported that R43 had asked for therapy recently and she reported that R43 had not declined so he would not qualify for therapy. Therapy Staff HH reported that R43's discharge therapy notes were not accurate. Therapy Staff HH reported R43 really did not ambulate in therapy in January and February 2025. On 06/12/25 at 09:53 AM, Administrative Nurse D reported R43 received skilled services including therapy from November 2024 through February 2025. Administrative Nurse D reported nursing received a recommendation from therapy when a resident was discharged . She reported she was not aware that R43 could ambulate in therapy and did not receive any recommendations from therapy after R43 was discontinued from therapy. Administrative Nurse D reported that nursing did receive the discharge note from therapy. The facility's policy Activities of Daily Living (ADLS) Supporting dated March 2018 documented residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Including appropriate support and assistance with mobility (transfer, ambulation, including walking), Interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

The facility reported a census of 45 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, interview, and record review the facility failed to ensure that the discharge needs were identified, and an appropriate discharge plan was created for Resident (R) 39. This placed the resident at risk for unmet care needs and inappropriate discharge. Findings included: - R39's Electronic Health Records (EHR) documented diagnoses which included surgical amputation (surgical removal of a body part), acute osteomyelitis left ankle and foot (local or generalized infection of the bone and bone marrow), cellulitis (skin infection caused by bacteria) left lower limb, morbid obesity, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, unsteadiness, lack of coordination, Stage 4 pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone) of the left ankle, venous insufficiency (poor circulation), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), and hypertension (HTN-elevated blood pressure). R39's 04/15/25 Modified admission Minimum Data Set (MDS) documented the resident entered the facility on 04/09/25 and the Brief Interview for Mental Status (BIMS) score was 15, indicating cognitively intact. She exhibited no behaviors and did not exhibit social isolation. R39 reported being around animals and pets, going outside when the weather was nice, participating in religious activities, and having snacks available between meals was very important to her. She required substantial/maximum assistance for toileting hygiene, dressing, applying footwear, toileting, and transfers. R39 had an indwelling catheter (a tube inserted into the bladder to drain the urine into a collection bag) and was always continent of bowel. She received scheduled pain medication and reported almost constant pain rated an eight on a 0-10 scale (zero indicating no pain and 10 the worst pain imaginable) that almost constantly interfered with day-to-day activities. She fell in the 2-6 months prior to her admission and had recent surgery requiring skilled nursing facility care which included orthopedic (bone) surgery. Her formal skin assessment revealed she was at risk for pressure ulcers/injury and the MDS noted she received pressure-reducing devices as well as a turning and repositioning schedule. She had a surgical wound, applications of ointments/medications other than to her feet, and received opioids (narcotic pain medication), antibiotics, and antiplatelet (medications used to prevent blood clotting) medications. The resident participated in her assessment and expressed a desire to be discharged from the facility with the overall goal of returning to the community. The MDS noted referrals were not made to the local contact agency due to a discharge date three or fewer months away. The Cognitive Loss/Dementia Care Area Assessment and Referral to the Community Care Area Assessments (CAA) dated 04/21/25 did not trigger. The Functional Abilities/Mobility CAA dated 04/21/25 documented the resident required varying levels of assistance with her activities of daily living (ADLs) following a recent hospitalization. She was working with therapies for strengthening and endurance and staff would continue to assist the resident with her daily care. R39's Care Plan dated 04/23/25 with an initial care plan entry of 04/09/25, directed staff to initiate discharge planning after skilled rehabilitation care. The plan noted R39's desire was to be discharged to her prior living setting. The plan directed staff to provide the resident with community resources and assess the placement setting to ensure her needs could be met. The plan directed staff to confer with the care team and her physician to determine the resident's discharge needs. R39's Care Plan lacked any updates related to her discharge plan and or progress toward discharge to the community. R39's EHR reviewed from 04/09/25 through 06/12/25 lacked Social Service admission Notes, Social Service Progress Notes, and/or Discharge Plan or other evidence of discharge planning. On 06/10/25 at 01:24 PM, R39 sat in her recliner with her feet elevated. Her wound dressings were intact extending from below her left knee to her toes. She reported she was going to leave the facility even if it was against medical advice. She reported she had not agreed to stay in the facility for long-term care and no one would give her information about when Medicare would stop paying for her care. R39 stated she only received a thousand dollars a month and she could hardly live on that amount in the community, where she lived in a recreational vehicle (RV) park, which included her utilities. The resident stated she had to get out the minute Medicare stopped paying for her care because she could not afford to lose her Medicaid payment to the facility. She stated she had a support dog for panic attacks and the dog was staying with her friend in Nebraska while she received care in the facility. Upon inquiry, she stated no one was assisting with helping her make arrangements to be discharged from the facility. She reported her RV needed repair and that she needed to have the expanded part moved into the RV, and the blocks removed so she could hook her truck to the RV and pull it to Nebraska to live where her friend lives. She stated she did not necessarily want to move to Nebraska and would like to stay in Kansas. R39 reported she would not qualify for public housing because she was a felon with a drug record from 20 years ago and public housing would not allow her service animal. R39 said staff kept telling her she could stay at the facility, but that was not something she would agree to. The resident reported she could not have her dog at the facility, and she was going to leave against medical advice (AMA) if needed. R39 said the facility would not give her a discharge date in order to plan for help. She stated she feared losing everything. She said she felt the facility was like a prison and reported she had been in prison from 2001 through 2003, so she knew what she was talking about. She repeatedly stated she would not stay one day longer than Medicare would pay and she had informed the facility of that from day one. R39 reported her foot and leg would take a long time to heal, but she has changed the dressing herself prior to hospitalization and she would again. She reported she had home health come out and change dressings and it was the home health nurse who sent her to the hospital. On 06/11/25 at 11:43 AM, Social Service X confirmed R39 had informed the facility staff she wanted to be discharged back to the community upon her admission. Social Service X reported she was responsible for discharge planning, social service progress notes, and updating care planning related to discharge planning. She confirmed R39's clinical record lacked Social Service admission Notes, Social Service Progress Notes, and/or Discharge Plan. Social Service X reported she should have completed her documentation regarding the resident's discharge plan and the challenges she faced trying to successfully discharge R39 back to the community. She reported the resident was not making progress with therapy so the facility would issue her a beneficiary notice regarding the end of skilled services due to the resident no longer meeting skilled criteria. Social Service X reported she was not aware the resident was a felon and would not qualify for public housing. On 06/12/25 at 09:03 AM, Administrative Staff A confirmed the above findings and reported he was not aware that social services notes and/or a discharge plan for R39 had not been completed. He stated discharge planning should be initiated on the day of admission and documentation updated to keep up with the resident's progress and goals. Administrative Staff A stated he expected the social service staff to keep the residents informed of timelines in their care and assist the residents with setting up necessary services for a successful discharge home. He stated he was aware that R39 wanted to be discharged to Nebraska. The facility policy Discharging the Resident, dated 01/2025, documented the purpose of the procedure is to provide guidelines for the discharge process. The resident should be consulted about the discharge Discharges can be frightening to a resident. The policy did not address the discharge planning process.

The facility reported a census of 53 residents with 13 residents reviewed. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for Resident (R)41 for the provision of needed dental services and R7 for care and maintenance of an indwelling urinary catheter (a hollow flexible tube that collects urine and leads to a drainage bag). This placed the residents at risk to not receive appropriate cares and treatments. Findings included: - The 06/26/23 Electronic Health Records (EHR) documented R41 had the following diagnoses: generalized weakness, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals, especially people with multiple chronic medical conditions) and need for assistance with personal care. The 12/28/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 05/09/23 Quarterly MDS documented a BIMS of 14, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 12/28/22 Activities of daily living(ADL) Functional / Rehabilitation Potential Care Area Assessment (CAA) documented the resident required staff to assist to complete ADLs. The Dental Care CAA was not triggered by the assessment. The Care Plan dated 05/17/23 lacked documentation specific to dental and oral care. The 09/28/22 Physician Orders in the EHR documented that staff may refer to ancillary services as needed for dental services. On 06/26/23 at 02:56 PM, R41 observed to have broken/missing teeth with gums having reddened appearance. R41 reported that he had requested staff make a dentist appointment for him but was unable to recall the date of the request. On 06/28/23 at 11:00 AM, R41 stated that it bothered him that he doesn't have top dentures or good teeth. Further stated that his teeth made chewing some foods more difficult, but he managed to eat whatever foods served. On 06/28/23 at 01:30 PM Licensed Nurse (LN) K reported it was the director of nursing who updated the care plans. LN K reported the charge nurses did not implement or revise the care plans. On 06/29/23 at 09:04 AM, Administrative Nurse B acknowledged the need for R41 to be seen/evaluated by a dentist. The facility's policy Routine Dental Care, revised 04/2007, documented that each resident will receive routine dental care which includes daily dental and oral hygiene plan of care. The facility failed to develop and implement a person-centered care plan for Resident (R)41. This placed the resident at risk to not receive appropriate cares and treatments. 31078 - Resident (R)7's Electronic Medical Record (EMR) revealed the resident had diagnoses that included acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required extensive assist of two staff for daily cares. The resident was always incontinent of urine. The Quarterly MDS dated [DATE] revealed unchanged cognition. The resident required extensive assistance with daily cares and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 03/01/23 revealed the resident was incontinent of bladder and required staff with all toileting and incontinent cares as needed. The resident's care plan for incontinence dated 04/05/22 revealed the resident was at risk for bowel and/or bladder related to incontinence, history of Cystitis (irritation of the urinary bladder), hydronephrosis (excess urine accumulation in kidney(s) that causes swelling of kidneys) with renal and ureteral calculus (kidney stone) obstruction. R7 wore briefs. Staff were to assist with peri-care following incontinence and as needed. The Care Plan lacked documentation that the resident had an indwelling urinary catheter, or the care required for staff guidance to care for the catheter. The physician orders dated 04/02/23, revealed orders to change the catheter monthly with a size 16 French, 30 cubic centimeters (cc) balloon, along with catheter care every shift and as needed. On 03/24/23 at 09:25 AM, the nurses progress notes revealed the Foley (urinary) catheter was in place and patent upon readmission from the hospital. Observation on 06/27/23 at 12:22 PM revealed the resident sat at the dining table eating lunch independently. The resident had a urinary catheter. On 06/27/23 01:49 PM R7 reported she could not remember how long she had her catheter but quite a while. On 06/27/23 at 12:00 PM Licensed Nurse (LN) C reported the resident had sepsis (systemic infection of the blood) due to having Pyelonephritis (sudden and severe inflammation of kidney due to a bacterial infection) that was a chronic condition for her. She is unable to empty her bladder without the catheter and had issues with her kidneys and bladder. On 06/29/23 at 9:00 AM Administrative Nurse B verified R7's care plan lacked the guidance for the resident's indwelling catheter and the care of the catheter. Review of the facility's policy Comprehensive Care Plan dated 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed, implemented, and reviewed quarterly, annually and with a significant change for each resident. The facility failed to ensure the development of a comprehensive care plan to include the resident's use of an indwelling urinary catheter or the care to maintain the catheter.

The facility reported a census of 53 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one Resident (R)41, with failure to identify poor dentition (of, or related to teeth) as evidenced by worn and broken teeth. This placed the resident at risk for uncommunicated care needs. Findings include: - The 06/26/23 Electronic Health Records (EHR) documented R41 had the following diagnoses: generalized weakness, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals, especially people with multiple chronic medical conditions) and need for assistance with personal care. The 09/13/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 12/28/22 Annual MDS documented a BIMS of 13, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 05/09/23 Quarterly MDS documented a BIMS of 14, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 12/28/22 Activities of daily living (ADL) Functional / Rehabilitation Potential Care Area Assessment (CAA) documented the resident required staff to assist to complete ADLs. The Dental Care CAA was not triggered by the assessment. The Care Plan dated 05/17/23 lacked documentation related to dentition and oral care. The 09/28/22 Physician Orders in the EHR documented that staff may refer to ancillary services as needed for dental services. Review of the EHR MDS Nursing Summary documented the following: 1. The 03/28/22 quarterly nursing summary, completed by Administrative Nurse B, documented no possible dental issues. 2. The 06/13/22 quarterly nursing summary, completed by Administrative Nurse B, documented no possible dental issues. 3. The 09/06/22 quarterly nursing summary, completed by Consultant Nurse F, documented obvious or likely cavity or broken natural teeth. 4. The 12/22/22 annual nursing summary, completed by Administrative Nurse B, documented no possible dental issues. 5. The 02/06/23 quarterly nursing summary, completed by Administrative Nurse B, documented no possible dental issues. 6. The 05/03/23 quarterly nursing summary, completed by Administrative Nurse B, documented no possible dental issues. The EHR Progress Notes reviewed from 09/01/22 through 06/28/23 lacked documentation related to dentition, dental care or appearance of R41's teeth. On 06/26/23 at 02:56 PM, R41 observed to have broken/missing teeth with gums having reddened appearance. R41 reported that he had requested staff make a dentist appointment for him but was unable to recall the date of the request. On 06/28/23 at 11:00 AM, R41 stated that it bothered him that he doesn't have top dentures or good teeth. Further stated that his teeth made chewing some foods more difficult, but he managed to eat whatever foods served. On 06/28/23 at 03:38 PM, Certified Nurse Aide (CNA) G stated that she had helped R41 with oral care. On 06/28/23 at 03:56 PM, CNA H revealed that she had never helped R41 with oral cares and stated that by the time day shift starts R41 is already dressed and seated in the dining area. On 06/28/23 at 10:48 AM, Licensed Nurse (LN) I stated that R41 had voiced concerns about his teeth but was unable to recall on what date this had occurred. Further stated that the facility scheduler (Social Services J) and transportation personnel had been notified and an appointment had been scheduled but was unable to recall the date of the appointment. Additionally, LN I stated that when assigned to do the quarterly assessment, the assessment is a full head-to-toe assessment of every body system that also included an oral assessment. On 06/28/23 at 04:14 PM, Social Services J denied knowledge of any upcoming dentist appointment for R41. Further, Social Services J telephoned the transportation personnel who denied knowledge of any upcoming dentist appointment for R41. On 06/29/23 at 09:04 AM, Administrative Nurse B stated the MDS services are provided by a contracted company and are not on-site. Administrative Nurse B further stated that the bedside nurse assigned the assessment task would perform the full head-to-toe assessment; then once the nurse who completed the assessment signed the assessment, the assessment would be exported to the contracted MDS company. Administrative Nurse B confirmed inaccurate assessments and MDS data and cited an oversight error by the nurse who completed the assessments. Administrative Nurse B was unable to provide explanation regarding discrepancy between 09/06/22 nursing assessment and 09/13/22 MDS assessment. Administrative Nurse B stated that her expectation for bedside and MDS assessments to be accurate and reflect the resident's status at the time of the assessment. The facility policy MDS Assessment Coordinator, revised 11/2019, documented that a registered nurse (RN) was responsible for conducting and coordinating the assessment and must certify the accuracy of the assessment. The facility failed to accurately complete the MDS for R41 with failure to identify poor dentition. This placed the resident at risk for uncommunicated care needs.

The facility census totaled 53 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to revise Resident (R) 8's care plan related to physician ordered stockings used for edema. Findings included: - R 8's Electronic Medical Record (EMR) listed the following diagnoses: congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), hypothyroidism (condition characterized by decreased activity of the thyroid gland) and, renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The resident required extensive assistance of two staff for daily care. Review of the Care Plan dated 11/26/21 revealed the resident had edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and R8 was at risk for complications related to CHF and edema in bilateral (both) legs. Staff were to administer medications as ordered, monitor skin integrity routinely and notify nurse/physician of changes and provide the resident an appropriate diet. On 03/02/23, staff were to provide Surepress wraps (elastic wraps for controlling edema) to bilateral lower extremities on daily while awake. The care plan lacked guidance to staff that the wraps discontinued and lacked staff guidance related to the resident required [NAME] stockings (a compression stocking that work by applying gradual gradient pressure on legs, starting with the most pressure at the ankle and decreasing further up the leg). The Physician order dated 05/03/23 revealed staff were to apply [NAME] Sensifoot Diabetic Mild Compression Socks in the morning and remove the [NAME] stockings in the evening. Observation on 06/27/23 11:43 AM revealed Certified Nursing Assistant (CNA) D as she propelled the resident from her room in a wheelchair. The resident had thick white socks that came to her knee that CNA D reported they were her compression socks. On 06/27/23 at 11:47 AM, CNA D reported the resident was to wear the socks everyday due to her swelling. Staff apply the socks daily, and the resident was unable to apply or take off the socks. On 06/28/23 at 01:30 PM, Licensed Nurse K reported the physician ordered the [NAME] when the manufacturer stopped making the Surepress Wraps and they were no longer available. The resident liked wearing the socks much more than the wraps. LN K reported it was the director of nursing's responsibility to update the care plans. The charge nurses did not update care plans. Review of the facility policy named Comprehensive Care Plan dated 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed, implemented, and reviewed quarterly, annually and with a significant change for each resident. The facility failed to revise Resident (R) 8's care plan related to physician ordered stockings used for edema.

The facility reported a census of 53 residents, with 13 residents sampled, including one resident reviewed for dental services. Based on interview and record review, the facility failed to provide dental services or access to dental services for Resident (R) 41, due to widespread dental decay. This placed the resident at risk for further deterioration of dentition (of or having to do with teeth). Findings included: - The 06/26/23 Electronic Health Records (EHR) documented R41 had the following diagnoses: generalized weakness, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals, especially people with multiple chronic medical conditions) and need for assistance with personal care. The 12/28/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 05/09/23 Quarterly MDS documented a BIMS of 14, indicating intact cognition. The assessment documented no identified concerns with swallowing or dentition. The 12/28/22 Activities of daily living (ADL) Functional/ Rehabilitation Potential Care Area Assessment (CAA) documented the resident required staff to assist to complete ADLs. The Dental Care CAA was not triggered by the assessment. The Care Plan dated 05/17/23 lacked documentation specific to dental and oral care. The 09/28/22 Physician Orders in the EHR documented that staff may refer to ancillary services as needed for dentist services. On 06/26/23 at 02:56 PM, R41 observed to have broken/missing teeth with gums having reddened appearance. R41 reported that he had requested staff make a dentist appointment for him but was unable to recall the date of the request. On 06/28/23 at 03:56 PM, CNA H revealed that she had never helped R41 with oral cares and stated that by the time day shift starts, R41 is already dressed and seated in the dining area. On 06/28/23 at 10:48 AM, Licensed Nurse (LN) I stated R41 had voiced concerns about his teeth but was unable to recall on what date this had occurred. Further stated that the facility scheduler (Social Services J) and transportation personnel had been notified and an appointment had been scheduled but was unable to recall the date of the appointment. On 06/28/23 at 04:14 PM, Social Services J denied knowledge of any upcoming dentist appointment for R41. Further, Social Services J telephoned the transportation personnel who denied knowledge of any upcoming dentist appointment for R41. On 06/29/23 at 09:04 AM, Administrative Nurse B acknowledged the need for R41 to be seen/evaluated by a dentist. Administrative Nurse B stated that a bedside nurse had contacted her (unknown date) related to R41's dental concerns where she advised the bedside nurse to follow procedure and notify the physician to obtain any required orders and notify Social Services J to arrange transportation. Administrative Nurse B stated that the bedside nurse failed to follow instructions as given and that the dentist appointment had not been made until 06/28/23. The facility's policy Routine Dental Care, revised 04/2007, documented that each resident will receive routine dental care which includes daily dental and oral hygiene plan of care. The facility failed to provide dental services or access to dental services for R41, due to widespread dental decay. This placed the resident at risk for further deterioration of dentition.

The facility census totaled 53 residents, with 13 sampled, including five residents for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of black box warnings (BBW- serious or life-threatening side effects of medications) for psychotropic (affects how the brain works and causes changes in awareness, thoughts, feelings, or behaviors) medications for three of the five residents reviewed. Resident (R) 13, R17, and R28. These failures placed the residents at risk for adverse effects related to monitoring of BBW psychotropic medication use. Findings Included: - R13's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 08/03/21 documented paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), coronary artery disease (CAD - abnormal condition that may affect the flow of oxygen to the heart), and major depressive disorder (major mood disorder). The 05/18/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R13 received antipsychotic and antidepressant medication daily in the seven-day look back period. The 05/25/23 Care Plan for R13 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 08/18/22 for R13 for Risperdal (a medication used to treat schizophrenia), 0.5 milligrams (mg), twice a day. In addition, an order on 08/19/22 for Celexa (a medication used to treat depression). These psychotropic medications have BBW associated with them. Review of the April 2023 through June 2023 Electronic Medication Administration Record (EMAR) documented R13 received Celexa and Risperdal daily. Observation on 06/27/23 at 03:35 PM, revealed R13 sat in her wheelchair, pleasant mood, and visited with staff. On 06/29/23 at 08:05 AM, Licensed Nurse (LN) I reported she was not sure what the BBW were. LN I stated she would observe the residents for adverse effects from their medications. LN I did not know where to find the BBW and did not know the difference. On 06/29/23 at 08:40 AM, Administrative Nurse B confirmed she expected all nurses be familiar with BBW medications and know where to find them. Administrative Nurse B revealed she did not know LN I did not know where to find the BBW. The facility did not provide a policy regarding BBW psychotropic medications as requested on 06/29/23. The facility failed to monitor psychotropic medications with black box warnings for R13. 31078 - R17's Electronic Medical Record (EMR) revealed diagnoses that included hypertension (elevated blood sugar), heart failure (changes to the structure of your heart so it does not work as well and cannot pump enough blood to meet the body's needs), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), and benign prostatic hyperplasia/hypertrophy- ([BPH] non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating severely impaired cognition. The resident required limited assistance of one for daily cares. The resident did not require pain medication. Medications included insulin injections and antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions) seven days of the 7-day observation period. The Quarterly MDS dated [DATE] revealed no changes. The Care Area Assessment (CAA) dated 01/07/23, revealed the use of medications with the risk for adverse reactions. Staff should monitor for drug effects. Notify the physician as needed. A gradual dose reduction as indicated. Review of the Care Plan dated 02/09/2022 revealed the resident was at risk for adverse effects related to the use of antidepressant, diabetic, cardiac, and diuretic medications. Provide Medications as ordered. Review Black Box warning (BBW- serious or life-threatening side effects of medications) if applicable, located on the medication administration record (MAR). Review of the physician orders revealed: 1. Zoloft Oral Tablet, 50 milligrams (MG), one tablet by mouth one time a day for depression, inappropriate behaviors, ordered 04/13/2023. 2. Depakote Tablet Delayed Release, 250 MG, 1 tablet by mouth two times a day, for Inappropriate behaviors, ordered 02/19/2022. Observation on 06/26/23 at 03:30 PM revealed the resident up in chair watching a program on the TV. The resident in good spirits with no complaints of discomfort. On 06/29/23 at 08:05 AM, Licensed Nurse (LN) I reported she was not sure what the BBW were. LN I stated she would observe the residents for adverse effects from their medications. LN I did not know where to find the BBW and did not know the difference. On 06/29/23 at 08:40 AM, Administrative Nurse B confirmed she expected all nurses be familiar with BBW medications and know where to find them. Administrative Nurse B revealed she did not know LN I did not know where to find the BBW. The facility did not provide a policy regarding BBW psychotropic medications as requested on 06/29/23. The facility failed to monitor psychotropic medications with black box warnings for R17. - Resident (R) 28's Electronic Medical Record (EMR) revealed the following diagnoses: hemiplegia and hemiparesis (weakness and paralysis following a nontraumatic intracerebral hemorrhage (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting right dominant side, dysphagia (difficult swallowing), and cognitive deficit (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Medications included antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications daily during the seven-day observation period. Review of the Annual MDS dated [DATE] revealed no changes. The Psychotropic drug Use Care Area Assessment (CAA) dated 03/29/23 revealed staff were to monitor for drug effects and notify the physician as needed. Gradual dose reduction as indicated. Review of the Care Plan dated 12/14/21 revealed R28 was at risk for adverse effects and included the following: 1. Anti-anxiety use: Review Black Box Warnings. The warnings located under orders tab next to medication on the Medication Administration Record (MAR). 2. Antidepressant use: Review Black Box Warnings. The warnings located under orders tab next to medication on the Medication Administration Record (MAR). Review of the physician orders revealed: 1. Buspirone HCl Oral Tablet, 5 milligrams (MG), one tablet by mouth, two times a day for anxiety, ordered 04/17/23. 2. Fluoxetine HCl Oral Solution 20 MG/5 ML, give 1.25 Milliliters. (ml) by mouth, one time a day related to major depressive disorder, ordered 12/14/2023. Observation on 06/27/23 at 11:26 AM revealed the resident sat in her wheelchair in her room. On 06/29/23 at 08:05 AM, Licensed Nurse (LN) I reported she was not sure what the BBW were. LN I stated she would observe the residents for adverse effects from their medications. LN I did not know where to find the BBW and did not know the difference. On 06/29/23 at 08:40 AM, Administrative Nurse B confirmed she expected all nurses be familiar with BBW medications and know where to find them. Administrative Nurse B revealed she did not know LN I did not know where to find the BBW. The facility did not provide a policy regarding BBW psychotropic medications as requested on 06/29/23. The facility failed to monitor psychotropic medications with black box warnings for R28.

The facility census totaled 53 residents, with 13 sampled, including five residents for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of black box warnings (BBW- serious or life-threatening side effects of medications) for two of the five residents reviewed. Resident (R) 13 and R29. These failures placed the residents at risk for adverse effects related to monitoring of BBW medication use. Findings Included: - R13's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 08/03/21 documented paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), coronary artery disease (CAD - abnormal condition that may affect the flow of oxygen to the heart), and major depressive disorder (major mood disorder). The 05/18/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R13 received antipsychotic and antidepressant medication daily in the seven-day look back period. The 05/25/23 Care Plan for R13 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 08/18/22 for R13 for Risperdal (a medication used to treat schizophrenia) 0.5 milligrams (mg) twice a day, an order on 08/19/22 clopidogrel bisulfate (blood thinner) 75 mg daily, Celexa (a medication used to treat depression), and an order on 04/29/23 for Mobic (a medication used to treat pain) 15 mg daily. All these medications have BBW associated with them. Review of the April through June 2023 Electronic Medication Administration Record (EMAR) documented R13 received Mobic, Celexa, Risperdal, and clopidogrel bisulfate daily. Observation on 06/27/23 at 03:35 PM, revealed R13 sat in her wheelchair, pleasant mood, visited with staff, with no bruising visible on R13. On 06/29/23 at 08:05 AM, Licensed Nurse (LN) I reported she was not sure what the BBW were. LN I stated she would observe the residents for adverse effects from their medications. LN I did not know where to find the BBW and did not know the difference. On 06/29/23 at 08:40 AM Administrative Nurse B confirmed she expected all nurses be familiar with BBW medications and know where to find them. Administrative Nurse B revealed she did not know LN I did not know where to find the BBW. The facility failed to provide a policy as requested on 06/29/23. The facility failed to monitor medications with black box warning adverse effects for R13. - R29's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 06/29/23 documented pain and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The 05/05/23 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R29 received an antidepressant medication daily in the seven-day look back period. The 05/11/23 Care Plan for R29 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 02/16/23 for R29 for sertraline (a medication used to treat depression) 75 milligrams (mg) daily, an order on 02/23/23 tramadol (medication used to treat pain) 50 mg four times a day, and an order on 04/13/23 for trazodone (a medication used to treat depression) 50 mg daily. All these medications have BBW associated with them. Review of the April through June 2023 Electronic Medication Administration Record (EMAR) documented R29 received sertraline, tramadol, and trazodone daily. On 06/29/23 at 08:05 AM, Licensed Nurse (LN) I reported she was not sure what the BBW were. LN I stated she would observe the residents for adverse effects from their medications, however LN I did not know where to find the BBW and did not know the difference. On 06/29/23 at 08:40 AM Administrative Nurse B confirmed she expected all nurses be familiar with BBW medications and know where to find them. Administrative Nurse B revealed she did not know LN I did not know where to find the BBW. The facility did not provide a policy regarding BBW as requested on 06/29/23. The facility failed to monitor medications with black box warnings for R29.

The facility reported a census of 50 with 16 sampled residents. Based on interview and record review the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized in accordance with accepted professional standards and practices by the failure to have resident information scanned into the Electronic Health Record (EHR) in a timely manner. Findings included: - Upon entrance on 08/16/21 Administrative Nurse B informed the survey team the facility only used electronic records. Review of the Electronic Health Record during the survey 08/17/21-08/19/21 revealed lack of complete information on the 16 sampled residents. On 08/17/21-08/19/21, multiple requests (verbal and electronic) were made for information related to the failure to locate items in the EHR for residents in the sample who did not have physician orders, laboratory results, physician up to date progress notes, and admission and discharge records readily accessible and available for surveyor review. Observation on 08/18/21 at 02:00 PM of the Medical Records office revealed large piles approximately three feet over the height of the desk, along with piles of charts on top of the wall of cabinets (all of these documents were waiting to be scanned into the resident's EHR). During an interview on 08/18/21 at 02:00 PM Medical Records Staff O reported she was behind in scanning records in due to the fact she must do the transportation tasks, also. Medical Records Staff O said the transportation driver quit about 18 months ago and was not replaced so she did all of the transportation driving for all the [CONDITION(S)] residents and resident's physician visits. Medical Records Staff O stated when she has time, she will scan records in. Interview on 08/19/21 at 02:09 PM with Administrative Staff A revealed Medical Records Staff O knew were everything was located in her office and stated it was organized chaos. Administrative Staff A stated staff O lived close and would come in anytime anyone needed paperwork and said when a resident had an emergent visit to the hospital, EMS must wait for staff O to come in and find the papers to give to EMS. The facility failed to maintain complete, accurately documented, readily accessible, and systematically organized medical records on each resident in accordance with accepted professional standards and practices, by the failure to have resident information scanned into the electronic medical record in a timely manner.

The facility reported a census of 50 residents, with 16 residents sampled, including one for review of dental services. Based on observation, interview, and record review the facility failed to provide Resident (R) 35 with the assistance needed to repair her broken dentures after staff identified it as a concern over two months prior, 06/17/21-08/19/21. Findings included: - Review of the 02/19/21 R35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/30/21 Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 12, indicating moderate cognitive impairment. The MDS noted R35 did not have any broken or chipped or cracked dentures. Review of the 07/21/21 Quarterly MDS documented a BIMS of 14, indicating intact cognition, and noted R35 did not have any broken or chipped or cracked dentures. Review of the 07/14/21 Care Plan documented staff were to report missing or broken dentures to the Social Worker. Review of the Progress Note written on 06/17/21 at 11:58 AM by Social Worker N, documented R35 with two teeth broken off her dentures, requiring a dental appointment and repair. During an observation on 08/17/21 at 11:53 AM, R35 showed surveyor her dentures with two teeth in the upper left missing. An interview on 08/17/21 at 11:54 AM with R35 revealed she did not remember telling staff that her dentures were broken. An interview on 08/18/21 at 10:57 AM with revealed Licensed Nurse (LN) P revealed staff member did not know R35 had broken dentures and stated she would be making a dental appointment for R35. An interview on 08/19/21 at 11:20 AM with Social Worker N revealed she did not remember R35 notifying her of the broken dentures but said it must have happened because it was documented. Social Worker N stated she must have forgotten to follow up with the nursing team. An interview on 08/19/21 at 11:45 AM Administrative Nurse E revealed she did not know R35 had broken dentures and she expected staff to notify the nurse and bring the dentures to Social Worker N, for scheduling a repair and dental appointment. Review of the undated Dental Examination/Assessment Policy documented residents [after a facility assessment] who needed dental services would be promptly referred to a dentist. The facility failed to ensure R35 received the assistance needed to obtain dental services when staff noted R35 with broken dentures, from over two months prior.

The facility census totaled 50 with 16 residents sampled. Based on observation, interview, and record review the facility failed to provide Resident (R) 46 with adaptive eating utensils and/or plate to improve the residents' ability to eat independently. Findings included: - On 08/16/21 at 11:35 AM during the noon meal observation, R46 ate his noon meal with his left hand and no specialized eating utensils or plate. R46 scooped up foot onto the regular eating utensil with his left hand and with some of his meal falling to the table from his eating utensil and on to R46's lap. Observation revealed R46 exhibited limited use of his right arm. On 08/19/21 at 12:34 PM R46 stated he had not heard of a plate guard and stated no one at the facility had mentioned any help with his eating. He stated he had been right-handed his whole life and was trying to get used to using his left hand for a lot of Activities of Daily Living (ADLs). R46 stated he had had multiple strokes and his right hand was practically useless. On 08/17/21 at 10:17 AM Certified Nurse Aid (CNA) F stated if she noticed a change or need for a resident, she informed the nurse and probably the DON. On 8/18/21 at 01:48PM Licensed Nurse (LN) E stated the CNA's informed the nurse of any needs they noted for residents. LN E said if the nurse noted a resident need for an assistive eating device, the LN would obtain an order for the resident to be seen by therapy. On 08/19/21 at 09:07 AM regarding therapy LN K stated the nurse would observe the resident, or if the resident had an incident and the LN would get an order to have therapy evaluate the resident, and therapy would make recommendations. She stated the CNA's watch the residents closely at dining and would let the nurses know, or if the nurse would see something different with a resident. On 08/19/21 at 09:15 AM Dietary Staff (DS) J stated they currently only had two built up silverware utensils for residents to use in the facility. DS J stated the facility used to have a divided plate used for a resident. On 08/19/21 at 01:25 PM Therapy Staff (TS) D stated she had observed the resident a while ago but not lately and said the CNA's will let the nurse know, or therapy know, so therapy staff could observe and make recommendations. Review of the facility policy Adaptive Devices procedure manual 2011 edition, documented each resident will be observed during meals for the ability to consume meals with regular eating utensils. If difficulty in eating is observed any member of the Inter Disciplinary Team (IDT) can refer a resident for evaluation for use of appropriate adaptive devices. The facility failed to provide R46 with adaptive eating utensils and/or plate to improve the residents' ability to eat independently.

The facility reported a census of 50 residents, with 16 sampled, including one for accuracy of assessments in the Minimum Data Set (MDS). Based on observation, interview, and record review the facility failed to accurately document resident (R) 35's dental status by the failure to document the broken dentures of R35. Findings included: - Review of the 02/19/21 R35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/30/21 Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 12, indicating moderate cognitive impairment. The MDS noted R35 did not have any broken or chipped or cracked dentures. Review of the 07/21/21 Quarterly MDS documented a BIMS of 14, indicating intact cognition, and noted R35 did not have any broken or chipped or cracked dentures. Review of the MDS Nursing Summary dated 07/16/21 completed by Administrative Nurse E documented No natural teeth or tooth fragment(s) (edentulous) Review of the Progress Note written on 06/17/21 at 11:58 AM by Social Worker N, documented R35 with two teeth broken off her dentures, requiring a dental appointment and repair. During an observation on 08/17/21 at 11:53 AM, R35 showed surveyor her dentures with two teeth in the upper left missing. An interview on 08/17/21 at 11:54 AM with R35 revealed she did not remember telling staff that her dentures were broken. An interview on 08/18/21 at 10:57 AM with revealed Licensed Nurse (LN) P revealed staff member did not know R35 had broken dentures and stated she would be making a dental appointment for R35. An interview on 08/19/21 at 11:20 AM with Social Worker N revealed she did not remember R35 notifying her of the broken dentures but said it must have happened because it was documented. Social Worker N stated she must have forgotten to follow up with the nursing team. An interview on 08/19/21 at 11:45 AM Administrative Nurse E revealed she did not know R35 had broken dentures and she expected staff to notify the nurse and bring the dentures to Social Worker N, for scheduling a repair and dental appointment. An interview on 08/19/21 at 11:53 AM with Administrative Nurse Q revealed the facility nurse completed a resident assessment with each MDS completed. Administrative Nurse Q stated the form was sent back to them self and entered into the MDS. Administrative Nurse Q did not lay eyes on R35 and relied solely on the information sent to her by the facility to complete the necessary MDS's. Review of the 11/2019 Resident Assessments Policy documented all staff members were to sign the MDS Resident Assessment Form, attesting to the accuracy of such information. The facility failed to accurately document R35's dental status by the failure to document her broken dentures.

The facility had a census of 50 residents with 16 included in the sample. Based on interview and record review the facility failed to provide Resident (R) 28, R42, and R150 or their representative with a bed-hold policy upon transfer to a hospital. Findings included: - The 07/23/21 signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Significant Change MDS dated [DATE] revealed no significant changes in Activities of Daily Living (ADL) assistance. The resident had shortness of breath (SOB) and received oxygen (O2) therapy. Review of the Care Plan dated 08/11/21 revealed the resident required assistance with all meals. The 06/30/21 at 10:29 AM Nurse's Progress Note revealed R28 choked on her food at breakfast and transferred to the emergency room (ER). The Nurse's Progress Note dated 06/30/21 at 11:40 AM revealed the resident admitted to the hospital for observation. Review of the Electronic Health Record (EHR) lacked evidence of a bed hold policy notice upon transfer to the hospital. Observation on 08/17/21 at 11:55 AM revealed the resident sat at the dining table feeding herself the noon meal. The meal was pureed, and the resident ate with no difficulty noted. During an interview on 08/18/21 at 10:25 AM Certified Nursing Assistant (CNA) F reported the resident had a recent hospital stay for aspiration. During an interview on 08/18/21 at 11:20 AM Administrative Nurse E thought the nurses took care of the bed hold when residents transferred to the hospital, but she did not know for sure, because if a nurse sent a resident to ER they might not know by the end of their shift whether the resident admitted or not. Administrative Nurse F called Business Office staff I who informed her the bed holds were done at the time of the admission to the nursing facility and they did not give a bed hold policy to the resident or representative at the time of hospitalization . Interview on 08/18/21 at 12:06 PM revealed Administrative Nurse B stated the facility bed hold policy was with Medicaid residents and those residents have 10 day to return, with skilled they are discharged after 3 days with no return. Administrative Nurse B stated the facility gave the bed hold policy to residents during admission process and did not give the bed hold policy for therapeutic leave or hospitalization . Review of the undated Bed Hold Policy given to resident and representative on admission failed to include the amount the resident would have to pay to keep his room if the bed hold did not apply. The resident had 24 hours to notify the facility of their wish to hold the room. If the resident chose to not hold the room the resident could still come back to that room if available or come to another semi-private room if available or when one became available. The facility failed to provide R28 or his representative with a bed-hold policy upon transfer to a hospital. - Review of Resident (R) 42's signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident required extensive assistance of one staff for transfers, ambulation, locomotion and toileting. The resident had a surgical wound with wound care and received Occupational Therapy (OT) and Physical therapy (PT) for rehabilitation. Review of the Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 07/23/21 revealed R42 had a change in status due to recent hospitalization and failed home trial, with subsequent weakness and therapy were addressing strength, endurance, mobility, and self-cares. Review of the Nurse's Progress Note dated 07/26/21 at 04:04 PM revealed the physician notified the nurse to send the resident to the emergency room (ER) for possible infection to right knee. Review of the Nurse's Progress Note dated 07/26/21 at 04:09 PM revealed the resident admitted to the hospital. The Electronic Health Record lacked evidence of a bed hold policy given upon transfer to the hospital. During an interview on 08/18/21 at 11:20 AM Administrative Nurse E thought the nurses took care of the bed hold when residents transferred to the hospital, but she did not know for sure, because if a nurse sent a resident to ER they might not know by the end of their shift whether the resident admitted or not. Administrative Nurse F called Business Office staff I who informed her the bed holds were done at the time of the admission to the nursing facility and they did not give a bed hold policy to the resident or representative at the time of hospitalization . Interview on 08/18/21 at 12:06 PM revealed Administrative Nurse B stated the facility bed hold policy was with Medicaid residents and those residents have 10 day to return, with skilled they are discharged after 3 days with no return. Administrative Nurse B stated the facility gave the bed hold policy to residents during admission process and did not give the bed hold policy for therapeutic leave or hospitalization . Review of the undated Bed Hold Policy given to resident and representative on admission failed to include the amount the resident would have to pay to keep his room if the bed hold did not apply. The resident had 24 hours to notify the facility of their wish to hold the room. If the resident chose to not hold the room the resident could still come back to that room if available or come to another semi-private room if available or when one became available. The facility failed to provide R42 or his representative with a bed-hold policy upon transfer to a hospital. - Review of R150's Minimum Data Set (MDS) tracking form dated August 2021 revealed the resident discharged to the hospital on 08/03/21 and returned to the facility on [DATE]. Review of R150's medical record lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to R150 or her representative. During an interview on 08/18/21 at 11:20 AM Administrative Nurse E thought the nurses took care of the bed hold when residents transferred to the hospital, but she did not know for sure, because if a nurse sent a resident to ER they might not know by the end of their shift whether the resident admitted or not. Administrative Nurse F called Business Office staff who informed her the bed holds were done at the time of the admission to the nursing facility and they did not give a bed hold policy to the resident or representative at the time of hospitalization . Interview on 08/18/21 at 12:06 PM revealed Administrative Nurse B stated the facility bed hold policy was with Medicaid residents and those residents have 10 day to return, with skilled they are discharged after 3 days with no return. Administrative Nurse B stated the facility gave the bed hold policy to residents during admission process and did not give the bed hold policy for therapeutic leave or hospitalization . Review of the undated Bed Hold Policy given to resident and representative on admission failed to include the amount the resident would have to pay to keep his room if the bed hold did not apply. The resident had 24 hours to notify the facility of their wish to hold the room. If the resident chose to not hold the room the resident could still come back to that room if available or come to another semi-private room if available or when one became available. The facility failed to provide a copy of the bed hold policy for R150 or her representative for her 08/03/21 hospitalization .

The facility census totaled 50 with 16 residents sampled. Based on observation, interview, and record review the facility failed to provide Resident (R) 42 with the right to a dignified existence when staff failed to serve her in a timely manner once she was seated for the noon meal on 08/16/21. R42 waited nearly an hour for her meal at the table, while other residents around her ate and staff served another resident who arrived to the table after R42. Findings included: - On 08/16/21 at 11:17 AM during the noon meal observation, staff brought R42 to the dining room to a table with two other residents who had been served and were eating. At approximately 12:05 PM staff brought another resident to the table and sat across from R42, and the staff served the other resident at 12:08 PM, while R42 continued to sit at the table with all other residents eating. On 08/16/21 at 12:08 PM Dietary Staff (DS) C stated it was both the CNA's and dietary staffs' responsibility to ensure the staff served all the residents in the dining room in a timely manner. She stated the CNA usually informed the dietary staff that a resident was in the dining room, if they came in after the first serving, so the dietary staff could prepare and serve their meal. On 08/16/21 at 12:10 PM Certified Nurse Aid (CNA) F stated if they brought a resident into the dining room, after first service, they informed the cook or dietary aide so the dietary staff could get the residents food to them. On 08/16/21 at 12:49 PM CNA G stated she brought R42 into the dining and informed the kitchen R42 was at a table and CNA G went on to assist other residents with their meals. On 08/18/21 at 11:20 AM with R42 stated the staff usually served pretty quickly and she did not remember this incident, but stated she was probably visiting with neighbors and did not pay any attention. On 8/18/21 at 01:48PM Licensed Nurse (LN) E stated she expected all the residents to be served in a timely manner at all meals, regardless of when they entered the dining room. Review of the facility policy Quality of Life-Dignity revised August 2009 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The facility failed to provide the right to a dignified existence by failing to serve R42 in a timely manner at the noon mealtime.

The facility census totaled 56 residents. The facility had one main kitchen where all food was prepared. Based on observation, interview and record review the facility failed to store and serve food items in a sanitary manner by the failure to remove undated foods items from one refrigerator, wear gloves/hairnets properly when serving food at a meal times, and failed to sanitize a thermometer used to obtain the temperature of food items prior to serving. Findings included: - The initial kitchen tour on 10/14/19 at 02:27 PM revealed an open/used package of butter and a large sour cream tub, which had no open date located in the walk-in refrigerator. Observation on 10/16/19 at 10:30 AM revealed Dietary Staff (DS) O prepared to puree broccoli with the blade to the food processor incorrectly seated in the device. DS O turned the food processor off, reached into the container (which had food in place) with her bare hand, reseated the blade, and proceeded to puree the food item. Observation on 10/16/19 at 11:25 AM revealed DS P served food while she wore a hairnet with the front, side, and back hair exposed. Observation on 10/16/19 at 11:35 AM revealed DS Q measured the temperature of resident food by taking a thermometer (which had no cover) out of a cup filled with different, unclean items. DS Q stuck the thermometer directly into a pan full of rice without cleaning the thermometer probe. After obtaining the temperature of the rice, DS Q took the thermometer out and wiped it with a dry rag, which sat by the serving table and put the thermometer in another food item located on the steam table. DS Q stated she cleaned the thermometer and held up the dry rag to indicate what she cleaned the thermometer with. DS Q further stated she ran out of alcohol pads so she could not use them to clean the thermometer. DS Q called an unknown staff member to request alcohol pads. Once another staff member brought the alcohol pads to DS Q she resumed testing the temperature of the food. DS Q dropped the alcohol pad into a pan of cheese sauce and retrieved it with her bare fingers. Observation on 10/16/19 at 11:50 AM revealed the kitchen counters with dry cereal bowls on the counter and breakfast items remained out from the morning meal. The kitchen floor had several pieces of paper, which looked like salt and pepper packets laying on the floor around the kitchen. Staff did not attempt to pick the papers up but walked over them. A wadded-up paper towel laid under the counter and staff did not sweep the kitchen floor. During an interview on 10/16/19 at 11:35 AM DS Q reported picking the pad up with her bare hands was probably the wrong way to retrieve the dropped alcohol pad. During an interview on 10/16/19 at 11:45 AM DM N stated the cheese would not be used and she would replace the cheese sauce. Review of the facility policy Proper Hand Washing Procedure and Proper Use of Gloves dated (YEAR) revealed Gloves were to be used whenever direct food contact was required. Review of the facility policy Monitoring Food Temperatures for Meal Service dated (YEAR) revealed thermometers were washed, rinsed, sanitized before and after each meal use. An alcohol swab may be used to sanitize between uses while taking temperatures during the same meal, or if contamination of the thermometer occurs. Review of the undated facility policy Food Preparation and Service revealed dietary staff shall wear hair restraints so that hair does not contact food. The facility failed to store and serve food items in a sanitary manner by the failure to remove undated foods items from one refrigerator, wear gloves/hairnets properly when serving food at a meal times, and failed to sanitize a thermometer used to obtain the temperature of food items prior to serving.

The facility census totaled 68 residents with 4 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to perform causal analysis, review and/or develop interventions, and provide adequate supervision to resident #69 after he/she fell the second time within a 24-hour period and required treatment in an emergency room with 7 sutures (stiches) to his/her head. This failure to determine causal factors and provide adequate supervision affected resident's #10 and #13 as well. The facility further failed to prevent accidents by the failure evaluate safety concerns and potential for injury from hot liquids for resident #12, which led to him/her spilling hot coffee and receiving 1st [MEDICAL CONDITION] the coffee. Findings included: - Review of resident #69's [DIAGNOSES REDACTED]. Review of the significant change minimum data set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. The resident required extensive 1-person assistance for locomotion and transfers. He/she had 2 or more falls since the last assessment with 1 fall resulting in a non-major injury. Review of the quarterly MDS, dated [DATE], revealed a BIMS score of 12, indicating intact cognitive status. He/she required extensive assist of 1 staff member for locomotion and transfers and had 2 or more falls since the last assessment with none resulting in injury. Review of the Cognitive loss care area assessment (CAA), dated 5/3/18, revealed the resident had a decline in cognitive function due to his/her [MEDICAL CONDITION]'s disease. Review of the fall CAA, dated 5/3/18, revealed the resident had frequent falls related to the progression of [MEDICAL CONDITION]'s disease. The falls happened more to the resident trying to go to the bathroom by him/herself and the resident's balance and safety had declined. Review of the resident care plan, revised on 7/15/18, advised staff the resident had deficits in his/her activities of daily living (ADLs) and personal cares related to poor balance, cognitive decline, and poor coordination due to progression of [MEDICAL CONDITION]'s. Staff were to anticipate and meet the resident's needs in addition to reminding the resident to use his/her wheelchair, to get up slowly and/or ask for help if he/she felt unsteady, and to take his/her time and slow down while walking. Staff offered toileting every 2 hours and kept non-skid socks on the resident. Two staff members with a gait belt assisted the resident when he/she ambulated or wanted to ambulate. On 8/31/18, the care plan revision instructed staff to encourage the resident to sit in a reclining wheelchair with foot pedals in front of the nurses' station to encourage socialization and staff visualization. On 9/5/18, the care plan was revised to reflect that an appointment was being established with neurologist and the facility was meeting with the resident's family and disease specialist for recommendation for appropriate and successful interventions. Staff were instructed, on 9/19/18, to observe and anticipate the resident's impulsive actions of standing and intervene for safety. An intervention of providing a safety mat when the resident was reclining on furniture or the couch in the commons area was added on 9/23/18. Review of the resident medical record, from 8/17/18 to 10/11/18 revealed the resident had a total of 8 separate falls in 8 weeks (8/26/18, 8/30/18, 2 on 8/31/18, 9/8/18, 9/19/18, 9/23/18, and 10/9/18) with the resident requiring 7 sutures to his/her head after the second fall on 8/31/18. Review of the fall investigations for all 8 falls revealed that for 7 of the falls, the causal factors were identified as [MEDICAL CONDITION]'s disease progression, safety unawareness, and/or impaired judgement. The fall investigation dated 8/26/18 identified the causal factor as the resident had been administered a laxative which might have increased his/her urge to use the toilet. Review of nursing notes dated 8/31/18 at 5:56 AM revealed staff found the resident in a seated position holding his/her knees to his/her chest. The resident denied any complaints of pain and had normal range of motion of his/her extremities. Staff noted a small open area to the right side of the resident's head. No other outward signs of injuries were noted. The resident reported he/she was headed back from the bathroom when he/she fell . The clinical record lacked evidence of interventions implemented after the fall and prior to the second fall that day. Review of a nursing note dated 8/31/18 at 3:56 PM revealed the resident had attempted to go to the bathroom when he/she lost balance, fell , and hit his/her head on the toilet. Emergency medical services transported the resident to the hospital emergency room for evaluation. Nursing note dated 8/31/18 at 6:33 PM revealed the resident returned to the facility from the emergency room with 7 sutures and an order to follow up with his/her family practice doctor in 5 days. Observation of the resident on 10/11/18 at 11:50 AM revealed the resident sat in his/her wheelchair at the dining room table. The resident was lifting him/herself up out of the wheelchair and sitting immediately back down. This activity continued during the 10 minutes of observation. During an interview with direct care staff A on 10/10/18 at 2:53 PM revealed the staff needed to know where the resident was, always, due to his/her impulsive behavior. Staff attempted to perform frequent checks while the resident was in his/her room. Interview with direct care staff F and G on 10/11/18 at 6:10 AM revealed the resident could get up by him/herself and he/she was a major fall risk. Staff F and G did not believe there was enough staff to adequately monitor the resident to prevent or intervene when the resident got up by him/herself. Licensed nursing staff D, on 10/10/18 at 3:00 PM, revealed the resident had done better with not falling since the foot rests were added to his/her wheelchair. But stated it still required all staff to monitor the resident from getting up and walking by him/herself. During an interview licensed nursing staff H, on 10/11/18 at 6:45 AM, revealed the resident was a major fall risk and he/she did not believe there was enough staff to supervise the resident to prevent him/her from falling. Interview with licensed nursing staff C on 10/11/18 at 11:28 AM revealed the resident was very impulsive and would just rise out of his/her wheelchair without knowing why they were doing it. The resident did not want to wait for help and would not summon help when needed. There had been multiple times staff C observed the resident up walking without staff assistance. Staff were instructed to provide routine toileting and offer snacks to the resident. Interview with administrative nursing staff E on 10/11/18 at 12:55 PM revealed the interdisciplinary team members gathered together to meet after a resident fell to review the fall and determine the causal analysis (why the resident fell ). He/she reported they reviewed the last time the residents were toileted, seen, and ate. Resident #69 always attempted to take him/herself to the restroom, when he/she fell . The facility had arraigned for a urology consult to evaluate the resident, but currently thought the urge to toilet was more of a behavior. The resident was very fidgety and then suddenly, he/she stood up. Staff E reported the resident could be seated right next to a staff member and then just fall as the resident gets up and falls very quickly. He/she reported the falls were going to increase due to the resident's disease process. Review of the policy entitled Fall Guidelines - Assessing Falls and Their Causes, revised 10/2010, revealed nursing staff, in collaboration with the interdisciplinary team, would begin to try and identify the possible causes of the incident. The facility failed to identify causal factors, implement and/or review interventions based on the causal factors, and provide adequate supervision to prevent resident #69, identified at risk for falls, from falling a second time during a 24-hour period, which required emergency room treatment of [REDACTED].#10 and 13. - Review of resident #12's signed medication review sheet dated 8/28/18 revealed the following Diagnoses: [REDACTED]. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 12, which indicated moderately impaired cognition. The resident required supervision of 1 for eating. Review of the activity of daily living (ADL) care area assessment (CAA) dated 6/20/18 revealed the resident required assistance with ADLs. Review of the resident's care plan initiated 3/29/16 revealed the following interventions: 9/26/18 - The resident liked to drink coffee throughout the day and evening. Staff would assist the resident and provide his/her coffee in safe drinking container to avoid spills and keep at safe temperature 9/26/18 - Staff would serve coffee at room temperature. 9/26/18 - Staff would ensure the resident received coffee in a closed, insulated mug with coffee from the coffee shop, which would be regulated at a specific temperature. Staff would not reheat coffee in a microwave for any reason. If the coffee cooled and was lukewarm or cold staff would dispose of the coffee and refill with new coffee. 9/30/18 - The resident would have an 8-ounce cup with a lid for use in his/her room and bed for warm beverages. The resident's care plan lacked any intervention related to him/her drinking coffee in bed prior to him/her spilling coffee on him/herself and [MEDICAL CONDITION] the right side of his/her body on 9/25/18, although staff reported concerns over the resident drinking coffee in bed on 8/30/18. Review of the health status note dated 8/30/18 at 3:27 AM revealed the resident up all night, which the resident had a habit of doing. The resident requested many cups of coffee and Honey Buns. The resident went to sleep and dropped his/her Honey Bun and plate on the floor. The plate broke and there was glass all over the floor and Honey Bun. The resident became upset and told an unidentified direct care staff someone came in, took his/her Honey Bun and threw it away. The resident did not mention there was glass all the Honey Bun. The writer worried the resident would be burned with his/her hot coffee. The note revealed the resident would throw fit if staff hinted he/she should not drink hot coffee in bed. Review of the health status note dated 9/25/18 at 5:00 AM revealed the resident had his/her usual pitcher of coffee with a lid at 12:20 AM. An unidentified direct care staff answered the resident's call light and the resident stated when he/she picked up his/her pitcher of coffee it slipped out of his/her hand, spilled and burned him/her on the right side of his/her body from the right upper arm to right hip. The resident's shirt and soaker pad were changed. Staff applied cool washcloths to the reddened areas for 20 minutes, then applied antibiotic cream and a pain-relieving cream. The resident's physician ordered staff to wash the area gently twice a day, and apply antibiotic cream until healed. The resident would not have any more unsupervised coffee in a pitcher. Staff notified the director of nursing and the administrator. Review of the health status note dated 9/25/18 at 8:15 AM revealed staff notified the resident's representative the resident could no longer have coffee unsupervised. Review of the late entry health status note dated 9/25/18 at 9:18 AM revealed the resident had discoloration to the right upper axilla, with no blistering, which measured 5.5 centimeters (cm) X 2 cm. The resident had a tan dry skin surface, to the right side the breast, with no blister, which measured 4.5 cm by 2.5 cm. The resident had rosy discoloration to the lateral right arm, with no blistering, which measured 2 cm X 4 cm. The resident had a tan area with no blistering to the right lateral abdomen, which measured 0.8 cm X 0.4 cm. The resident had a light tan appearance on the right trochanter, with no blistering, which measured 1.2 cm X 1 cm. Review of the late entry health status note dated 9/25/18 at 5:20 PM revealed the resident's physician assessed [MEDICAL CONDITION] the resident and placed no new orders. The physician explained to the resident he/she could have coffee, but not hot coffee. Review of the health stats note dated 9/25/18 at 7:56 PM revealed the resident's physician assessed the resident'[MEDICAL CONDITION] be 1st degree burns. The physician placed a new order, which stated the resident could only have coffee at room temperature. Review of the occupational therapy (OT) evaluation/plan of treatment dated 9/27/18 revealed OT was referred to the resident due to new onset of decreased neuromotor control, decreased coordination, decreased judgment and decreased skin integrity, which placed the resident at risk for compromised general health, decreased ability to return to prior level of assistance, decreased ability to return to prior level of supervision, decreased participation with functional tasks, decreased skin integrity, depression and dehydration. The clinical impression included the resident could benefit from assistive equipment while drinking coffee. The resident could be required to sit upright (while drinking coffee) to decrease the chance for spills. The resident had the physical ability to drink beverages safely with good posture, while up in his/her wheelchair. Review of the nutrition note dated 10/9/18 revealed the resident [MEDICAL CONDITION] the skin observation tool. Observation and interview of the resident on 10/9/18 at approximately 4:30 PM revealed the resident sat in his/her chair in his/her room. The resident reported he/she spilled coffee on him/herself and was burned several days ago. The resident reported staff warmed up coffee for him/her and it was hot. The resident pointed out a pitcher the facility provided for his/her coffee. The resident reported he/she did not know if the staff member who warmed up his/her coffee was distracted when they gave it to him/her that hot. Interview on 10/11/18 at 6:10 AM with direct care staff F and direct care staff G revealed they looked at resident care plans and asked the nurse to know what care to provide residents. Staff F stated the resident used a glass coffee cup for a while, then would fall asleep and the glass cups would break. Staff F stated the resident slept most of the time when he/she checked on him/her and he/she tried to take the glass from the resident's hand if he/she slept. Staff F stated the facility switched to a grey pitcher with a lid, but the resident continued to fall asleep with the coffee. Staff F stated he/she got coffee from the coffee pot because the temperature was regulated and did not know why the staff member heated coffee up in a microwave. Interview on 10/11/18 at 6:45 AM with licensed nurse H revealed a couple of years ago the facility got in trouble because they were not letting the resident have coffee in bed. The facility turned down the coffee pots at the time they got in trouble for not letting the resident have his/her coffee. Staff H reported they added water to the resident's coffee at times because he/she would fall asleep with coffee in hand. The resident had a new cup, which only allowed a small amount of coffee to come out if the resident spilled it. Staff were not allowed to reheat coffee in the microwave any longer. Staff H felt the direct care staff who warmed up the resident's coffee in the microwave did not know the resident's history of falling asleep with coffee. Interview with administrative nursing staff E on 10/11/18 at 12:16 PM revealed the resident had been at the facility a long time and always drank coffee. Staff heated coffee up for him/her and it had never been a problem. One night, a direct care staff went to get the resident coffee, the resident did not drink it, so the resident asked the staff member to heat it up, which he/she did by placing the coffee in the microwave for about one minute. Staff E believed the temperature of the coffee was over 140 degrees. The facility begged the resident in the past not to drink coffee in bed, but that is just where he/she liked to drink it. Staff E stated the resident liked his/her coffee hot. Staff E tried taking the resident's coffee away before but was told he/she couldn't do that because it was against his/her rights. Review of the Safety of Hot Liquids policy dated 9/27/18 (dated after the incident with resident #12) revealed residents would be evaluated for safety concerns and potential injury from hot liquids. Appropriate precautions would be implemented to maximize choice of beverages while minimizing the potential for injury. The facility failed to prevent accidents by the failure evaluate safety concerns and potential for injury from hot liquids for resident #12, which led to him/her spilling hot coffee and receiving 1st [MEDICAL CONDITION] the coffee.

The facility census totaled 68 residents. The sample included 31 residents for abuse. Based on observation, interview, and record review, the facility failed to protect all residents in the facility from physical abuse after resident #14 made an allegation of that direct care staff I hit him/her, and direct care staff I continued to work the remainder of his/her shift (approximately 7 hours). This deficient practice placed all residents in the facility in immediate jeopardy. Findings included: - Review of resident #14's [DIAGNOSES REDACTED]., problems with functioning in social environments). Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, which indicated no cognitive deficits. The resident did not display any [MEDICAL CONDITION] (thinking and emotions that indicate the person experiencing them has lost contact with reality) or behaviors during the 7-day observation period. He/she received antipsychotics, antidepressants, and hypnotic medications 7 of the 7 day observation period. The resident's activity of daily living (ADL) care area assessment (CAA) dated 11/16/16 revealed the resident got upset easily when he/she had to wait. Review of the [MEDICAL CONDITION] drug use CAA dated 11/16/16 revealed the resident received antipsychotic, antidepressant, and hypnotic medications for some time prior to becoming a resident in the facility. The resident received [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] disorder) for [MEDICAL CONDITION] depression and an unspecified [MEDICAL CONDITION]. The resident's reported overall mood was cooperative and he/she could become upset at times, but he/she seemed to be settling in. Review of the resident's plan of care included: Staff was to encourage the resident to follow his/her recommended diet and extra food choices were available from the kitchen, initiated on 11/16/16. On 1/17/17, to avoid conflict between another resident and resident #14, the resident moved to the other unit. The staff revised the care plan on 4/2/17 stating that snacks of the resident's preference would be available on his/her unit. The resident reported he/she was short tempered and would work on counting to 10 to try and cool down. On 4/6/17, the facility updated the care plan to reflect the resident had behaviors including yelling at others, being short-tempered, and angered easily. The resident would take other residents labeled food out of the refrigerator. Review of the investigation submitted to the Kansas Department of Aging and Disability Services (KDADS), revealed on 4/2/17 around 10:30 PM, resident #14 went to the other unit to obtain some snacks. Direct care staff I worked on the West unit and was delivering snacks to the residents to the West side when resident #14 approached him/her. Staff I stated the resident started yelling after he/she was advised he/she could not have a snack from the West side. Direct care staff I reported resident #14 hit him/her them on the right side of his/her back and he/she advised the resident he/she would report them to administration of the facility. Resident #14 replied that staff I hit him/her on the left arm/hand and he/she was going to report them. There were no direct witnesses to the event. Other staff members reported hearing yelling and cussing but denied seeing direct care staff I mistreat any residents in the past. Staff I contacted administrative nursing staff G on 4/2/17 at 11 PM via phone to report the incident stating the resident had hit him/her and the resident was reporting direct care staff I him/her. The facility reported that direct care staff I finished his/her shift, which ended at 6 AM on 4/3/17, while being paired with another direct care staff member. Direct care staff I was then placed on suspension on 4/3/17 at 7:01 PM . Observation on 5/1/17 at 3:29 PM revealed the resident participated in a group bingo activity. He/she conversed with other residents and interacted with staff without behaviors noted. Interview with resident #14 on 5/1/17 at 1:45 PM revealed he/she denied any staff members hitting him/her while a resident at the facility. Interview with direct care staff I on 5/3/17 at 5:53 AM revealed he/she was in the nourishment area of the West unit on 4/2/17 when resident # 14 came to the area and demanded a snack. He/she replied they were for the residents on his/her unit and asked the resident to talk to his/her nurse to get a snack. Staff I reported the resident then struck him/her in the back and started to yell and cuss. He/she told the resident he/she would report him/her and the resident then reported staff I hit him/her. He/she reported completing his/her shift without incident the remainder of the night on the west unit. Direct care staff I reported calling the director of nursing (DON) after the incident, approximately around 11 PM, for guidance with the situation. Interview with direct care staff BB on 5/8/17 at 3:23 PM revealed he/she did complete the shift on 4/2/17 with direct care staff I. Staff BB reported the nurse brought staff I to him/her and told him/her they needed to work together. The nurse did not tell him/her why they needed to be paired together for care. Staff BB reported he/she drank a lot of tea during the shift to keep him/her awake and focused, so he/she usually had to go to the bathroom a lot. He/she stated he/she did not recall specifically if he/she went to the bathroom after he/she and staff I were paired together, but he/she thought he/she did go to the bathroom and did so by him/herself. Staff BB reported if staff I needed to go to the bathroom, he/she would have gone by him/herself, though he/she could not remember specifically if he/she had that night. Staff BB stated it was not unusual for him/her and staff I to be paired with each other because most residents needed 2 staff assistance with cares. If he/she saw another staff member hitting a resident, he/she would try to place their hand to protect the resident and would advise that staff member they could not do that and report to the nurse. Interview with administrative staff F and administrative nursing staff G on 5/2/17 at 3:45 PM revealed direct care staff I had been paired with direct care staff BB to complete his/her shift after the allegation on 4/2/17. Administrative staff G reported placing direct care staff I on suspension on 4/3/17 at 7:01 PM until the investigation was completed on 4/6/17. Interview with consultant nursing staff V on 5/3/17 at 7:30 AM revealed he/she wanted to explain the events of 4/2/17. He/she reported the administrative nursing staff G had contacted him/her that evening along with another consultant. He/she reported the decision was made to remove direct care staff I from the floor until interviews with the other staff members were completed. After interviewing the other staff, they felt there had not been enough evidence to substantiate the abuse reported by resident #14 and the facility felt like pairing up staff I with another staff member for the remainder of the shift negated the potential for abuse. The decision to allow residents to sleep and complete the investigation in the morning was made by consultant nurse V and administrative nurse G at that time as well. They reported the regional manager for KDADS called the next day advising the direct care staff needed to be suspended until the investigation was complete. Review of the undated facility policy, entitled abuse, neglect, and exploitation prevention policy and procedure, revealed that while the investigation is being conducted, the employee accused of resident abuse would be immediately suspended. If an employee had been the alleged perpetrator of abuse, neglect, or exploitation, the employee would need to be immediately barred from any further contact with the residents through the suspension pending the outcome of the investigation. The facility failed to protect all residents in the facility from physical abuse when the facility allowed direct care staff I to continue working after resident #14 made an allegation that he/she hit him/her, and the staff member continued to work. This deficient practice placed all residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 5/3/17 when they: 1) Educated the staff on the current abuse, neglect, and exploitation policy. 2) A clinical consultant will review grievances weekly and monitor to ensure appropriate action was taken, including resolution of grievance, protection of residents if applicable and reporting grievance to KDADS if indicated for eight weeks. 3) The administrator will notify clinical consultant of any allegations of abuse to ensure policies and procedures are maintained and followed including protection of residents. In addition, the administrator or designee will interview five cognitive residents and five employees weekly regarding appropriate care and protection of residents for eight weeks. This deficient practice remained at a scope and severity of an F.

The facility had a census of 68 residents, with 11 residents selected for sample. The sample included 4 residents with pressure ulcers. Based on observation, interview and record review, the facility failed to have a system in place to ensure 3 of 4 residents received the necessary care and services (implementation of pressure reduction interventions prior to development of pressure ulcers, routine skin assessments to identify early development of skin breakdown, measurement of existing pressure ulcers to determine worsening/improvement, timely repositioning to promote healing of pressure ulcers, and/or timely initiation of antibiotic therapy ordered for treatment of [REDACTED]. (Residents #4, 5, 8) Resident #5 developed a facility acquired pressure ulcer after staff failed to assess for the presence/absence of skin breakdown after readmission to the facility and for a 14 day time period after readmission. Although the facility identified the resident as very high risk for skin breakdown after readmission, staff failed to implement appropriate pressure reduction interventions to prevent development of pressure ulcers. Two weeks after readmission to the facility, staff identified the presence of an unstageable pressure ulcer to the coccyx (small triangular bone at the base of the spine) and pressure related skin changes to one heel. After identification of the pressure ulcers, staff failed to reassess the resident's skin/pressure ulcers for a 12 day time period and the wounds deteriorated. On 2/14/17, staff failed to reposition the resident for a time period of 3 hours. Staff notified the physician of a malodor from the coccyx wound on 2/14/17, and obtained an order for [REDACTED].#5's pressure ulcers, failure to reposition the resident as directed by the care plan, and failure to administer antibiotics ordered for a pressure ulcer infection in a timely manner placed the resident in immediate jeopardy. Findings included: - Resident #5's clinical record included an 11/10/16 Annual Minimum Data Set (MDS) which identified the resident with no cognitive impairment, verbal behaviors directed toward others 4-6 days during the seven day observation period, no rejection of care, the need for extensive assistance of 2 staff for bed mobility and total dependence of two staff for transfers and toileting. The resident had functional limitations in range of motion (ROM) on both sides of the upper and lower extremities, used a wheelchair for mobility and experienced occasional urinary incontinence. According to the MDS, the resident had a risk for pressure ulcer development and had no current or recently healed pressure ulcers. The 1/19/17 Significant Change MDS identified the resident with long and short term memory problems, severely impaired decision making abilities, acute onset of mental status change, rejection of care 1-3 days during the seven day observation period and total dependence on two staff for bed mobility, transfers and toileting. The resident lacked the ability to ambulate and used a wheelchair for mobility. The resident had no changes in ROM from the previous assessments. and had total incontinence of bowel and bladder. According to the MDS, the resident continued with a risk for pressure ulcer development and had no current or recently healed pressure ulcers. Care Area Assessments (CAAs) dated 2/3/16 included: Pressure Ulcers: Described a current pressure ulcer on the coccyx and placement of heel protectors on the feet. According to the CAA, skin impairment is likely considering resident's physical and emotional state. Activities of Daily Living (ADLs): ADLs did not trigger for further assessment Braden skin assessments (assessments used to measure the resident's risk for skin breakdown) identified the resident as very high risk for breakdown on 1/12/17 and high risk for breakdown on 1/19/17 and 2/14/17. The 12/5/13 Care Plan included: Skin: Identified the resident with actual and potential for skin impairment due to decreased mobility and incontinence of bowel and bladder. The facility reviewed/revised the care plan on 2/1/17 to include application of heel protectors while in bed, the need for repositioning at least every two hours and wound care per physician's orders [REDACTED]. On 2/13/17, staff revised the care plan which identified actual breakdown to the coccyx and right heel. The care plan lacked evidence of implementation of appropriate interventions to prevent skin breakdown upon the resident's readmission to the facility on [DATE] or upon identification of the resident's very high risk for skin breakdown noted on the Braden skin assessment completed on 1/12/17. ADLs: Described the resident's need for assistance of 1 - 2 staff for bed mobility and use of a full sling lift for all transfers. On 2/13/17, staff noted the resident's deteriorated condition and wound. According to the Progress Notes, resident #5 transferred to a behavioral health unit on 12/27/16 and returned to the facility on [DATE]. Review of skin assessment documentation revealed the following: 11/25/16: noted the presence of a scratch on the right lower leg with no other skin issues. 12/9/16 (14 days since the previous assessment): Noted the presence of a pressure area to the sacrum (large triangular bone between the two hip bones) which measured 1.8 centimeters (cm) by 0.5 cm. According to the note, the resident used the bed pan and stayed on the bedpan for long periods of time per his/her preference. 12/23/16 (14 days since the previous skin assessment): Noted the resident's refusal to allow the skin assessment. The clinical record included no evidence staff reapproached the resident at a later time in an attempt to gain permission to complete the skin assessment. 1/23/17: (one month since the prior skin assessment and 14 days after the resident's readmission to the facility on [DATE]): Noted the presence of a pressure wound to the coccyx which measured 2.3 cm long by 2 cm wide with unstageable depth. The assessment also identified the presence of soggy heels . 1/23/17 Weekly Wound Tool: Described the coccyx wound with thick necrotic (dead) tissue present and no drainage or odor from the wound. 2/5/17: Weekly Wound Tool (no assessment completed in the previous 12 days); Described the resident's physical condition which included severe diaphoresis (sweating), uncontrollable shaking, temperature of 100 degrees Fahrenheit (F) (normal temperature range is 97.8 - 99 degrees F), pulse rate of 126 9 (normal pulse rate is 60-100 beats per minute) and respiratory rate of 27 (normal respiratory rate is 12 - 16 breaths per minute). According to the assessment, the resident's right heel had a worsening stage 2 pressure ulcer which measured 4.4 cm by 5.9 cm with no depth. The assessments contained no measurements or description of the coccyx pressure ulcer. According to the documentation, staff used heel protectors, floated heels and repositioned the resident as part of the pressure ulcer treatment plan. The documentation also noted placement of an air mattress on the resident's bed on that date. 2/9/17 Weekly Wound Tool: Described wound assessments completed by a contracted wound care specialist who described the coccyx wound as worsening with the presence of 95% soft eschar (a thick dark scab which consisted of dead tissue) and 5% yellow slough (layer of dead tissue usually yellow or cream colored), a large amount of drainage and measurements of 6.5 cm long by 7 cm wide (2.5 inches by 2.75 inches) with no measurement of the wound depth. Progress Notes included: 12/27/16 at 8:35 a.m.: Described the resident's transfer to a behavioral health unit 1/9/17 at 3:30 p.m.: Described the resident's readmission to the facility from the behavioral health unit. The Readmission Nursing Assessment dated 1/9/17 identified the resident with no skin conditions at this time and noted a 10/26/16 weight (more than 2 months prior) of 233 pounds (lbs). The admission assessment lacked evidence staff weighed the resident upon readmission. 1/19/17 at 2:23 p.m.: Described Durable Power of Attorney (DPOA) notification of the resident's weight loss of more than 50 lbs. since October 2016. 1/19/17 at 2:54 p.m.: Described a weight loss of 54 lbs. since 10/26/16. Staff notified the resident's physician of the weight loss. 1/20/17 at 5:04 p.m.: Described a meeting with the resident's DPOA to discuss the 54 lb. weight loss and the resident's refusal to eat, drink or take medications. 1/21/17 at 6:10 a.m.: Described a report from direct care staff related to the presence of a soft heel and pressure area to the buttocks. The resident also experienced vomiting and other illnesses which necessitated transfer to the emergency room for further evaluation. Upon the resident's return later that morning, emergency room documentation noted the presence of a sacral decubitus (pressure ulcer). 1/23/17 at 10:13 a.m.(48 hours after the hospital noted the presence of a sacral pressure ulcer): Described the first assessment of the coccyx/buttock pressure ulcer which measured 2.5 cm by 2.3 cm with necrotic tissue in the wound bed. The note also described the presence of soggy heels. 1/23/17 at 1:41 p.m.: Described an order from the resident's physician to place the resident on comfort care. 1/31/17 at 9:01 p.m.: Described a visit by the resident's physician with new orders noted for treatment of [REDACTED]. 2/5/17 at 11:11 a.m.: Described the presence of an open wound on the sacral pressure ulcer and included eschar is gone and wound is open. 2/5/17 at 1:01 p.m.: Described the presence of foul smelling drainage from the sacral pressure ulcer which seeped out the bottom of the dressing. Measurements of the wound revealed 6 cm long by 6 cm wide with a depth of 2.6 cm. (2.3 inches by 2.3 inches with a depth of 1 inch). 2/10/17 at 1:40 p.m.: Described new orders for treatment of [REDACTED]. 2/14/17 at 12:49 p.m.: Described a licensed nurse's request sent to the physician for an antibiotic to treat the pressure ulcer on the resident's coccyx. 2/14/17 at 2:50 p.m.: Described a physician's orders [REDACTED]. According to the note, staff were waiting on delivery of the medication. 2/14/17 at 9:05 p.m.: Described continued inability to administer [MEDICATION NAME] due to medication not delivered from the pharmacy. During an observation on 2/14/17 at 11:10 a.m., Direct Care Staff N and Direct Care Staff O repositioned resident #5 in bed. The resident's room had a strong malodor which Staff N reported came from the pressure ulcer on the coccyx. The resident wore soft padded booties on both feet. During an observation on 2/14/17 at 1:30 p.m., resident #5 lay in bed, positioned with a slight turn to the left, with pillows supporting the back. During an observation on 2/14/17 at 4:30 p.m. (3 hours after the previous observation), the resident remained in bed in the same position, with a slight turn to the left and pillows supporting the back. During an interview on 2/14/17 at 4:35 p.m., Direct Care Staff Y confirmed neither he/she or the other staff assigned to the unit changed the resident's position since they came on duty at 2:00 p.m During an observation on 2/15/17 at 9:15 p.m., Direct Care Staff P and Direct Care Staff Q changed the resident's gown and bed linens due to wetness from perspiration. The resident also had extremely pale/grayish colored skin and uncontrollable shaking of his/her body. According to Staff Q, they changed the resident's gown earlier in the shift also due to excessive sweating so this was actually the second clothing change within 3 hours. Licensed Nurse U entered the room to complete a dressing change to the coccyx wound, and removed a saturated dressing from the coccyx. Upon removal of the dressing, a strong malodor permeated the room. The wound itself was a gaping, deep, black pressure ulcer covered with black necrotic tissue. The right heel had a large area of dark, thick appearing eschar which covered the entire heel and extended around to in the inner heel area. Review of the clinical record on 2/15/17 at 3:00 p.m., nearly 6 hours after the previous observation/interview, revealed no evidence of a thorough nursing assessment of resident #5's condition even though the resident presented with increased sweating which necessitated clothing changes, increased malodor to the wound, and uncontrollable shaking of his/her body. The clinical record also lacked evidence staff monitored the resident's vital signs since 2/12/17, three days earlier, even though the resident exhibited signs/symptoms of infection of the pressure ulcer and had a significant change in his/her physical condition At surveyor request, Administrative Staff B completed a nursing assessment of resident #5 at approximately 4:00 p.m. on 2/15/17. A 2/15/17 Progress Notes written at 4:59 p.m. noted a pulse rate of 121, respiratory rate of 24, and axillary temperature of 98.5 F (equivalent to an actual temperature of 99 - 100 degrees F), Administrative Nurse B also reported coccyx wound measurements of 8 cm long by 9 cm wide by 3 cm depth (3.1 inches long by 3.5 inches wide by 1.1 inches deep). During an interview on 2/15/17 at 9:20 a.m., Licensed Nurse U reported he/she did not think resident #5 had a fever because the resident's skin felt cool to the touch. According to Nurse U, the resident's pressure ulcer showed signs of worsening and the malodor which came from the wound probably indicated infection. During an interview on 2/16/17 at 3:50 p.m., Licensed Nurse U reported he/she failed to complete a nursing assessment or obtain vital signs in a timely manner for resident #5 on 2/15/16 even though the resident had significant sweating and increased involuntary shaking of the body. According to Nurse U, he/she took vital signs at approximately 4:30 p.m. on 2/15/16, approximately 7 hours after Nurse U completed a dressing change to the resident's pressure ulcer and noted increased wound odor, diaphoresis and uncontrollable shaking of the body. Nurse U also confirmed staff failed to administer the antibiotic to resident #5 during the morning hours of 2/15/17 even though the medication arrived from the pharmacy at approximately 8:30 a.m. on that date. Nurse U reported he/she signed for the medication upon its arrival and assumed a medication aide knew to administer it as soon as possible. Nurse U confirmed the resident received the first dose of antibiotic on 2/15/17 at approximately 4:00 p.m., approximately 14 hours after the physician ordered the medication. During an interview on 2/14/17 at 11:15 a.m., Direct Care Staff N reported the resident did not utilize the padded booties on the feet prior to development of the skin breakdown on the right heel. Staff N also reported placement of an air mattress on the resident's bed after development of the pressure ulcer on the coccyx. According to Staff N, staff should reposition resident #5 at least every 2 hours. During an interview on 2/15/17 at 9:30 a.m., Licensed Nurse U reported the resident had a red spot on his/her coccyx upon return to the facility from the behavioral health unit on 1/9/17. Nurse U also reported the skin breakdown on the right heel happened approximately one week earlier and, after development of the skin breakdown, staff implemented an intervention to ensure placement of soft booties on both feet. During an interview on 2/15/17 at 3:30 p.m., Corporate Consultant Z reported facility policy required completion of skin assessments by a licensed nurse weekly. Consultant Z reported the facility previously identified lack of consistent skin monitoring per facility policy. During an interview on 2/16/17 at 1:43 p.m., Direct Care Staff O reported resident #5 had a sore on his/her bottom upon readmission to the facility on [DATE], and described the areas as very small, black, with red around it. Staff O reported he/she advised Licensed Nurse U of the area but did not know if Nurse U assessed it himself/herself. According to Staff O, the facility started to use an air mattress on the resident's bed and booties on the resident's feet after the pressure ulcers developed. During an interview on 2/16/17 at 3:30 p.m., Direct Care Staff T denied knowledge of skin breakdown/pressure ulcers on resident #5's feet or coccyx upon readmission to the facility on [DATE]. Staff T reported placement of an air mattress on the resident's bed after development of the pressure ulcers. According to Staff T, the resident required repositioning at least every two hours. During an interview on 2/16/17 at 3:50 p.m., Licensed Nurse U denied recall that anyone told him/her about skin breakdown on the resident's coccyx upon readmission to the facility on [DATE]. Nurse U confirmed he/she failed to complete a thorough nursing assessment or take vital signs in a timely manner on 2/15/17 when the resident experienced significant sweating and shaking. Nurse U also confirmed he/she failed to ensure administration of [MEDICATION NAME] 500 mg that morning immediately after the medication arrived from the pharmacy, and stated, I just assumed the med aide knew to give it right away. According to Nurse U, the resident received the first dose of [MEDICATION NAME] at approximately 4:30 p.m. on 2/15/17, more than 24 hours after the physician ordered the medication for treatment of [REDACTED]. During a telephone interview on 2/16/17 at 9:50 a.m., Physician AA, resident #5's primary care physician, described the resident as chronically noncompliant with treatment. Physician AA denied knowledge staff failed to administer [MEDICATION NAME] to the resident for more than 24 hours after he/she ordered it for treatment of [REDACTED]. In response to a review of staff failure to complete skin assessments weekly, Physician AA reported facility staff must adhere to the standards for providing good care to the residents and described lack of such assessments as a problem. According to Physician AA, resident #5 lacked the ability to move without assistance for the past 2 years and that meant staff had to ensure the resident had every opportunity to reposition and utilize pressure reduction equipment, particularly in light of the resident's noncompliance with treatment. Physician AA reported he/she thought staff just kind of gave up on the resident due to his/her noncompliance, and that attitude resulted in some of the previously described care issues. The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol with a revision date of February 2014 directed staff to completed a full skin assessment for all admissions in order to detect ulcerations or alterations in skin. Although requested, the facility failed to provide a policy related to weekly skin assessments for all residents and/or development/implementation of timely pressure reduction interventions prior to development of skin breakdown. The facility failed to have a system in place to ensure resident #5 received the necessary care and services (implementation of pressure reduction interventions prior to development of pressure ulcers, routine skin assessments to identify early development of skin breakdown, measurement of existing pressure ulcers to determine worsening/improvement, timely repositioning to promote healing of pressure ulcers, and/or timely initiation of antibiotic therapy ordered for treatment of [REDACTED]. This facility failure placed resident #5 in immediate jeopardy. The facility abated the immediate jeopardy on 2/17/17 at 10:20 p.m. by implementation of the following measures: Review of all residents to ensure completion of weekly skin assessments and timely treatment of [REDACTED]. Review of all residents to ensure timely administration of medications after receipt of physician's orders [REDACTED]. Review of all residents to ensure implementation of appropriate interventions for residents deemed at high risk for pressure ulcer development. Completion of staff education on wound and skin issue identification, assessment, notification and documentation. After abatement, the deficient practice remained at a scope/severity of G. - Resident #8's clinical record included a 9/1/16 Quarterly Minimum Data Set (MDS) that identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15), the need for extensive staff assistance with bed mobility and transfers, a risk for pressure ulcer development, no current or recently healed pressure ulcers, and pressure reduction devices for the chair and bed. The 12/7/17 Significant Change MDS identified the resident with no changes in cognition or assistance needed with bed mobility and transfers. According to the MDS, the resident had a risk for pressure ulcer development, had no current or recently healed pressure ulcers, and utilized pressure reduction devices in the chair and bed. Care Area Assessments (CAAs) dated 12/13/16 included: Activities of Daily Living (ADLs): Described the resident's need for staff assistance with all care due to weakness. Pressure Ulcers: Described the presence of a callous on the resident's heel and noted the resident's risk for pressure ulcer development due to decreased mobility and occasional bladder incontinence. The 12/2/15 Care Plan included: Pressure Ulcer: Described the presence of a pressure ulcer on the resident's left heel and use of heel protectors to both feet when in bed, with placement of pressure reduction cushions in the recliner and wheelchair. The 11/9/16 Braden skin assessment, an assessment used to determine a resident's pressure ulcer risk, identified the resident as high risk for development of pressure ulcers. According to Progress Notes, resident #8 was hospitalized from [DATE] until 11/9/17. An 11/9/16 Admission Skin Assessment identified the presence of a hard skin spot on the resident's left heel. Additional skin assessments included: 11/15/16: identified the presence of a heel blister on the left heel 11/22/16: identified an ongoing left heel blister 11/29/16: identified the presence of dry skin and callous on the left heel 12/13/16 (no skin assessment in the previous two week time period): noted the presence of a left heel skin issue coded as other on the assessment form, with no other description of the area. 12/20/16: noted debridement of the left heel callous and new onset of a blister on the left iliac crest. A Weekly Wound Tool dated 12/21/16 described the presence of a Stage 2 pressure ulcer on the right buttock which measured 2 centimeters (cm) by 2 cm with no depth. According to the documentation, the wound consisted of 10% necrotic tissue (blackened, dead tissue). The clinical record lacked evidence of completion of a skin assessment/assessment of resident #8's Stage 2 pressure ulcer between 12/21/16 and 1/8/17, an 18 day time period. A 1/8/17 skin assessment identified the presence of a scab type wound adjacent to the sacrum (large triangular bone located between the two hip bones) which measured 3 cm long by 1.5 cm wide. A Weekly Wound Tool dated 1/11/17 documented the presence of a Stage 2 worsening pressure ulcer on the buttock which measured 1.3 cm long by 2.3 cm wide with no depth. According to the documentation, the wound consisted of 100% necrotic tissue. The clinical record lacked evidence of completion of skin assessments/assessments of the pressure ulcer to the heel in the time period from 12/20/16 - 1/11/17, a 22 day time period. A Weekly Wound Tool dated 1/11/17 described the resident's left heel pressure area which measured 0.7 cm long by 0.5 cm wide with no depth and covered with 100% necrotic tissue. The clinical record lacked evidence of assessment of resident #8's pressure ulcers in the 19 day time period between 1/11/17 and 1/30/17. A progress note dated 1/30/17 at 9:22 p.m. described a 2 cm long by 2 cm wide blister with a black middle to the left buttock but lacked other assessments of the wound. On 1/31/17, a skin observation tool noted the presence of a coccyx pressure ulcer and a left heel pressure ulcer. The documentation lacked other measurements or descriptions of either wound. A Progress Note dated 2/2/17 at 12:05 a.m. described a half dollar size reddened area to the left upper buttock with an open spot in the center which measured 3 millimeters (mm) at the widest point. The clinical record lacked evidence of additional assessments of the resident's pressure ulcers until 7 days later. On 2/9/17, Weekly Wound Tools referred to a Stage 2 left heel pressure ulcer and a Stage 3 coccyx pressure ulcer but lacked measurements/descriptions of the actual wounds. Although requested on 2/20/17 at 10:30 a.m., the facility failed to provide evidence of additional assessments of resident #4's skin/pressure ulcers in the time period from 12/13/16 - 2/15/17. During an observation on 2/15/17 at 1:45 p.m., Licensed Nurse V removed a dressing on the resident's left heel and exposed a closed area where the pressure ulcer recently healed. Nurse V then removed a dressing to the resident's left upper buttock and exposed an open wound with no drainage. According to Licensed Nurse V, the buttock wound was a Stage 2 pressure ulcer which showed signs of recent improvement. During an interview on 2/15/17 at 3:30 p.m., Corporate Consultant Z reported facility policy required completion of skin assessments by a licensed nurse weekly. Consultant Z reported the facility previously identified lack of consistent skin monitoring per facility policy as an issue. During an interview on 2/16/17 at 3:50 p.m., Licensed Nurse U reported he/she didn't really know who had the responsibility for completion of weekly skin assessments. The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol with a revision date of February 2014 lacked specific directives related to completion of weekly skin assessments. The facility failed to have a system in place to ensure resident #4 received the necessary care and services (routine skin assessments to identify early development of skin breakdown, measurement of existing pressure ulcers to determine worsening/improvement) to prevent development of pressure ulcers and promote healing of current pressure ulcers. - Resident #4's clinical record included progress notes which documented admission to the facility on [DATE]. Due to the recent admitted , Minimum Data Set (MDS) assessments and Care Area Assessments (CAAs) lacked completion at the time of review of the clinical records. The 2/6/17 Care Plan included: Activities of Daily Living (ADLs): Described the resident's need for staff assistance with repositioning every 2 hours and directed staff to float the right heel or use heel protectors. Right heel blister: Described the presence of a right heel blister present on admission as well as skin breakdown to the buttocks. The care plan directed staff to turn the resident every 2 hours, encourage side to side positioning to keep the resident off the buttocks, and use of heel protectors to both heels. A 2/6/17 Braden Scale skin assessment, an assessment used to determine a resident's risk for development of pressure ulcers, identified the resident as moderate risk for skin breakdown. Progress Notes included: 2/6/17 at 6:00 p.m.: Described the resident's admission to the facility and presence of a 6 centimeter (cm) long and 8 cm wide large blister to the right heel. During an observation on 2/14/17 at 9:40 a.m., resident #4 had a dressing to his/her right heel and foot. Neither foot had a pressure reduction boot as directed by the care plan. The resident had a pillow placed under the calf of the R leg, but the foot extended off the end of the pillow and rested directly on the bed. During an observation on 2/14/17 at 12 noon, the resident had pillows under both lower legs but both feet hung off the edges of the pillows and rested directly on the mattress. Neither foot had a a pressure reduction boot in place as directed by the care plan. During an observation on 2/14/17 at 2:10 p.m., resident #4 sat in a recliner with his/her feet elevated. Neither foot had a pressure reduction boot in place as directed by the care plan. During an observation on 2/15/17 at 2:00 p.m., the resident rested on his/her back in bed. The resident had a pillow beneath his/her lower leg but the right heel rested directly on the mattress. Neither foot had a pressure reduction boot in place as directed by the care plan. Licensed Nurse V removed the dressing from the resident's right foot to reveal an area of dark red discoloration which extended across the heel and to the area just beneath the inner ankle. Portions of the area obviously contained fluid and some of the fluid leaked onto the dressing. During an observation on 2/16/17 at 11:00 a.m., resident #4 again lay in bed with a pillow placed beneath the lower right leg. The right foot extended off the end of the pillow, and the heel rested directly on the mattress. Neither foot had a pressure reduction boot in place as directed by the care plan. During an interview on 2/15/17 at 2:00 p.m., Licensed Nurse V reported staff should place both of resident #4's feet on pillows in order to keep them from touching the mattress. During an interview on 2/16/17 at 1:28 p.m., Direct Care Staff G reported resident #4 did not have soft boots for his/her feet but staff kept the feet elevated on pillows in order to reduce pressure. The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol with a revision date of February 2014 lacked specific directives related to placement of pressure reduction boots and/or staff implementation of pressure reduction strategies as directed by the care plan. The facility failed to have a system in place to ensure resident #4 received the necessary care and services (pressure reduction to the heels as directed by the care plan) to prevent development of pressure ulcers and promote healing of a current pressure ulcer. .

The facility census totaled 73 residents. Based on observation, record review and interview, the facility failed to ensure the environment was as free as possible from accident hazards. During initial tour of the facility, observation revealed water temperatures above 140 (148.1, 149.7, and 147.9) degrees Fahrenheit (F) in the sinks of the unlocked bathrooms located in the commons area by the coffee shop, employee break room and the physical therapy room. The bathrooms were unlocked and accessible to residents, visitors, and staff. The facility identified 35 residents as independently mobile with access to these areas. These elevated water temperatures had the potential for third degree burns (an injury to the skin which extends into the muscle layer) within 5 seconds, placing these residents in immediate jeopardy. The facility also failed to ensure an environment free from accident hazards when during initial tour of the facility, observation revealed 2 residents (#75 and #8) had bed rails with unsafe gaps which had a potential for entrapping the resident. Findings Included: - On initial tour of the facility on 11/2/16 at 9:09 AM, observation of the sink in the unlocked bathroom closest to the coffee shop had a water temperature of 148.1 degrees Fahrenheit (F). At that time, maintenance staff U measured the water temperature at 142 degrees F on his/her temperature gun. Staff U reported he/she did not know of the hot water. During this time, further observations of the sink in the unlocked bathroom closest to the employee break room water measured 149.7 degrees F and the unlocked physical therapy sink had water measuring 147.9 degrees F. Therapy staff and residents were present in the therapy room. Review of the hot water logs revealed documented water temperatures between 110-120 degrees F weekly on 10/4/16, 10/10/16, 10/19/16, and 10/27/16. The logs included the sinks identified previously with unsafe hot water temperatures. Interview with maintenance staff U on 11/2/16 at 9:26 AM revealed he/she had removed the mixing valves ( a device used to maintain and limit mixed hot water to a desired, selectable temperature) on 10/27/16 to the sinks due to staff complaining the water did not get hot enough. Staff U reported he/she planned on rechecking the temperatures during the upcoming weekly water temperature monitoring. He/she reported the facility had multiple hot water heaters for the facility and the hot water heater which supplied those three sinks also supplied the kitchen and needed to produce water hot enough for cleaning of the dishes. He/she thought that was why the water measured above the acceptable range of 120 degrees F. Interview with activity staff X on 11/2/16 at 3:15 PM revealed some of the more independent residents used the restrooms. Interview with direct care staff E on 11/2/16 at 3:08 PM revealed he/she said one resident used the commons areas restroom. Interview with therapy staff Y on 11/2/16 at 3:13 PM revealed sometimes the residents who could walk used the commons area restrooms. Interview with administrative staff O on 11/2/16 at 4:14 PM revealed maintenance staff U removed the mixing valves on 10/27/16 and the temperatures on the hot water log dated 10/27/16 were from after staff U removed the mixing valves and they were within the range of 105-120 degrees F. Review of the undated policy entitled monitoring water temperatures revealed, maintenance staff would check the water temperatures weekly in the sinks and showers in common areas and bathing rooms. The elevated water temperatures placed the 35 independently mobile residents in immediate jeopardy. The facility abated the immediate jeopardy on 11/ 2/16 by implementation of the following actions: The facility revised the policy entitled monitoring hot water temperatures and added staff will be educated to inform maintenance staff immediately if water temperatures feel too hot to touch. Maintenance staff will disable any water sources reported by staff immediately and until temperatures are investigated and/or corrected The facility educated all staff regarding the monitoring of hot water temperatures using the new policy. The facility educated all maintenance staff on 11/2/16 regarding monitoring water temperatures after replacing or removing mixing valves. Specifically water temperatures must be checked daily for 7 days after replacement of the mixing valve. The mixing valve must be replaced the same day it was removed. The facility would monitor the affected sinks daily for 7 days beginning on 11/2/16. Water temperatures would be reported to the administrator weekly for 4 weeks and monthly thereafter. Water temperatures would be addressed by the facilities quality improvement committee. The scope and severity remained at an E. - Review of resident #75's signed physician note dated 8/12/16 revealed the following Diagnoses: [REDACTED]. Review of the quarterly MDS (minimum data set) dated 6/8/16 revealed a BIMS (brief interview for mental status) score of 5, indicating severely impaired cognition. Resident #75 required extensive assist of 2 staff members for bed mobility and transfers. The resident used a wheelchair and had impairment in range of motion to both lower legs. Review of the significant change MDS dated [DATE] revealed a BIMS score of 2, indicating severe cognitive impairment. The resident required total dependence for bed mobility and transfer. Review of the cognitive loss CAA (care area assessment), dated 8/19/16, revealed staff had noticed a decline in resident's cognition. Review of the falls CAA, dated 8/19/16, revealed the resident readmitted after a fall which resulted in a femur fracture. The resident had not had any attempts at climbing out of bed or wheelchair since his/her re-admission. Review of the care plan, revised on 9/10/15, revealed the resident had been identified at risk for falls related to dementia, impaired decision making ability and a history of falling. Review of the care plan, revised on 8/29/16, guided staff to watch for the resident trying to stand up in the wheelchair. There was no information regarding side rail use or safety in the care plan. Review of the electronic medical record failed to provide a side rail assessment had been conducted. Observation on 11/3/16 at 9:59 AM revealed the resident's bed had side rails attached to the bed frame, which covered approximately one quarter length of the bed. The bed rail had three horizontal metal bars which where adjustable. The space between the metal bars varied based on the location of the bar, ranging from 5 inches to 6 ½ inches. During an interview on 11/7/16 at 7:32 AM direct care staff CC reported the resident used the bed rail to grab onto while staff provided cares During an interview on 11/7/16 at 3:59 PM direct care staff G reported maintenance staff checked side rails, the direct care staff did not. He/she reported they had not noticed any problem with side rails on the resident's bed. Interview with licensed staff K on 11/2/16 at 3:27 PM revealed the resident could get caught in the gap. During an interview with maintenance supervisor U on 11/2/16 at 3:22 PM revealed every single rail he/she installed, he/she made sure it had a gap of less than 2 inches from the rail to the bed. He/she revealed he/she depended on the direct care staff to report issues with the side rails, by writing them in the maintenance book so he/she would know to inspect and fix the problem. The facility failed to provide a policy regarding side rail measurements. Review of the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on 3/10/06, revealed the safe limit of space between the rail was 4 ¾ inches or less. The facility failed to ensure that resident #75's side rail was less than 4 ¾ inches as recommended to prevent resident entrapment. - Review of resident #8's signed physician history and physical dated 8/11/16 revealed the following Diagnoses: [REDACTED]. Review of the annual MDS (minimum data set) dated 3/16/16 revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident required extensive assistance of two or more persons for bed mobility. The resident's CAAs (care area assessments) dated for 3/16/16 were not completed. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition. The resident required extensive assistance of two persons in bed mobility. Review of the care plan dated 9/7/16 revealed the care plan lacked information regarding bed rails. Observation on 11-2-16 at 3:11 PM revealed a 7 inch gap between the mattress and the bottom of the rail. Interview on 11-8-16 at 9:20 AM resident stated he/she has never been entrapped in the side rails. Interview on 11-2-16 at 3:22 PM maintenance staff U stated any problems the direct care staff noticed in a room he/she wrote in a book and he/she checked it out. Maintenance staff U thought the maximum gap was 4 inches inside of rails and measured the gap at 6.5 inches. The facility failed to provide a policy regarding side rail measurements. Review of the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on 3/10/06, revealed the safe limit of space between the rail was 4 ¾ inches or less. The facility failed to ensure that resident #8's side rail was less than 4 ¾ inches as recommended to prevent resident entrapment.

The facility census totaled 73 residents with 23 sampled. Two of the sampled residents (closed records) were reviewed related to formulation of advanced directives which indicated if a resident chose resuscitation in the event of cardiac/respiratory arrest (cessation of a heart beat and respirations). Based on interview and record review the facility failed to ensure staff knew how to identify a resident that was a full code (desired to be resuscitated should his/her heart and breathing stop) and failed to initiate CPR (cardiopulmonary resuscitation) for one sampled resident, #122 that chose resuscitation. This failure contributed to the resident's death. The facility identified 29 of 73 residents who desired to have a full code status. The failure for staff to know how to identify residents desired CPR and immediately initiate CPR in the event of [MEDICAL CONDITION] (cessation of a heartbeat and respirations) had the potential to affect all residents with a full code status, including resident #122 who died . Findings included: - Review of resident #122's admission MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 15 indicating no cognitive impairment. The resident required extensive assistance of 2 staff for all cares except supervision with eating. The resident did not have any respiratory problems or a prognosis of 6 months or less to live. Review of the return to community referral CAA (care area assessment) dated [DATE] revealed the resident and family would like him/her to return home when able. Review of the care plan dated [DATE] revealed the resident had recent open heart surgery and permanent pace maker and defibrillator placement. However, the care plan failed to identify the resident's code status related to his/her wishes to be resuscitated should his/her heart stop beating and he/she stop breathing. Review of the advanced directives document dated [DATE] and signed by the residents' DPOA(Durable Power of Attorney) revealed he/she had not signed a DNR (do not resuscitate) and did not wish to sign one. Review of the revised physician's orders [REDACTED]. During an interview on [DATE] at 5:22 PM direct care staff B reported he/she and direct care staff C took the resident to the bathroom on [DATE] around 5:00 PM. When staff B and staff C helped the resident, staff B noticed the resident wheezing and much weaker than before. Staff B said when he/she and staff C got the resident to the bathroom, the resident could not stand much and Staff B told the resident to give him/her a bear hug and when staff B put the resident's arms around him/her they resident's arms just dropped off his/her shoulders. Staff B called direct care staff D to come and help and staff B and staff D barely got the resident onto the toilet. Staff C then went and told licensed nursing staff H the resident could hardly stand and was really weak and wheezing. Staff B stated another aide came into the room and tried to get the resident to respond to him/her and the resident did not. When staff B and staff D tried to stand the resident off the toilet his/her knees dropped to the floor and then staff B and staff C and 2 other aides picked the resident up and put him/her in bed. Staff B reported by the time staff got the resident into the bed the resident looked pale. Licensed nurse H then came in and the resident lacked a pulse. During an interview on [DATE] at 8:36 AM administrative nursing staff I reported he/she went to the resident's room when an aide told licensed nurse staff K that licensed nursing staff H needed help. Staff I stated he/she grabbed a stethoscope because he/she knew the resident had a history of [REDACTED]. Staff I did a quick assessment and the resident did not have an apical (pulse obtained through the chest wall near the heart) pulse and was not breathing. The resident was a creamy, grayish, pasty color, had no signs of life and staff H told staff I it had already been over 10 minutes that the resident was not breathing. Staff I asked the DPOA if he/she wanted them to start CPR and the DPOA responded yes, but was afraid it had been too long. Staff I stated he/she felt like CPR would have been futile but checked the headboard and foot board to see if they came off in order to have a hard surface to be able to do chest compressions effectively and they did not. Staff I then attempted a few compressions on the bed and could tell he/she did not get an adequate compression. Staff H brought in the crash cart (a cart with emergency equipment on it) and then EMS (emergency medical services) showed up right after that. Staff I reported it was about 5:21 PM when staff came to get help and it was between 5:25 PM and 5:30 PM when he/she arrived in the room and CPR had not been started at that time. Staff I stated at the time he/she did not know what the heart sticker on the resident's door meant. During an interview on [DATE] at 10:12 AM licensed nursing staff H reported when staff notified him/her the resident was unresponsive he/she grabbed his/her stethoscope and blood pressure cuff and upon arrival to the room, saw the resident unresponsive on the toilet. He/she then did a sternal rub (rubbed the resident's chest with the knuckles of his/her fist) and the resident did not respond. Staff I looked and the resident was slumped over to the side with his/her eyes partially opened and was still breathing at that time. Staff H stated this was about 5:20 PM when he/she called the physician to let him/her know that the resident was unresponsive and the physician said to send the resident to the hospital. Staff H went back to check on the resident and told direct care staff A to get the other licensed nursing staff K. Staff H thought EMS was actually called around 5:23 PM or so after administrative nursing staff I arrived to the resident's room. Staff H reported the resident had a heart (sticker) on his/her door to indicate his/her code status but staff I did not know what it meant and staff H said he/she did not know for sure what it meant. Staff H stated he/she then went to look in the medical record and found the resident was a full code. Staff H stated he/she did not initiate CPR because staff I delegated duties to him/her and told him/her to check the code status, call EMS, and get the crash cart. Staff H stated he/she got the crash cart and it did not have a back board to put under the resident in order to perform adequate compressions for CPR or oxygen on it. Staff H stated he/she had not received any training on how to identify a resident's code status prior to the resident's death. During an interview on [DATE] at 8:48 AM administrative nursing staff L reported all licensed nursing staff were CPR certified and he/she expected them to initiate CPR immediately for a resident who chose to be a full code if they experienced [MEDICAL CONDITION]. Staff L stated he/she would have expected the nurse on duty at the time the resident was not breathing and did not have a pulse to initiate CPR. Staff L reported since he/she worked in the facility for the past 7 months there were not any inservices on what to do when staff found a resident unresponsive or without a pulse. During an interview on [DATE] at 8:49 AM administrative staff O reported he/she worked in the facility about 6 months and had not provided any training prior to the resident's death. Review of the policy revised ,[DATE] revealed if staff found a resident unresponsive and not breathing normally, a licensed staff member who was certified in CPR should initiate CPR unless it is known a DNR order existed for that individual; or if there were obvious signs of irreversible death, such as rigor mortis (one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Rigor mortis can occur as soon as thirty minutes after death). The facility failed to immediately initiate CPR for a resident that wanted to have CPR in the event of cardiac/respiratory arrest and failed to train staff on how to identify a resident's desire to be a full code (have CPR initiated) or be a DNR (do not resuscitate) and the resident died . This failure placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] by implementation of the following actions: The facility developed a policy and procedure that identified how and when the facility would train staff on the initiation of cardiopulmonary resuscitation (CPR) / basic life support (BLS) in victims of sudden [MEDICAL CONDITION]. The policy also included how and where the facility staff could identify a resident's code status. The facility educated all nursing staff to ensure they knew how to identify a resident's code status quickly without delay of treatment. The facility educated all non-nursing staff regarding what to do if they found a resident unresponsive. The facility completed an audit of all code status identifies to ensure accuracy. The facility implemented new code blue kits kept in the nurse's stations which include essential items for performing CPR. The immediate jeopardy remained at the scope and severity of a G.

The facility reported a census of 73 residents with 26 residents in the sample. Based on observation, interview, and record review the facility failed to provide necessary care and services and maintain the highest practicable physical and mental well being for 2 of 26 residents reviewed. (#75, # 112) Resident had Findings Included: - Review of resident #112 ' s Admission MDS (minimum data set) dated 3/23/15 revealed the resident had a BIMS (brief interview for mental status) of 4 which indicated the resident was severely cognitively impaired. The MDS revealed the resident required limited assist with one staff for bed mobility, transfers, walk in room, walk in the corridor, dressing, and personal hygiene. The MDS revealed the resident required extensive assistance with one person for toilet use, locomotion off the unit and on the unit. The MDS revealed the resident was frequently incontinent of urine and always continent of bowel. The MDS revealed the resident required scheduled pain medication. The resident did not have any pain over the past five days. Review of the Cognitive loss dementia CAA (care area assessment) dated 3/23/15 revealed the resident received scheduled narcotic pain medication. The resident had a history of [REDACTED]. The resident received a narcotic pain patch. He/she remained at risk for further decline in cognition secondary to diagnosis. Review of the care plan dated 3/16/15 revealed the resident had chronic pain related to [DIAGNOSES REDACTED]. Review of a fall investigation dated 4/11/15 at 10:15 AM revealed the resident took him/herself to the bathroom. The resident complained he/she had pain to his/her left ribs. Review of nurse note dated 4/12/15 at 10:06 PM revealed the resident had complaints of pain to his/her left ribs. The staff gave the resident PRN (as needed) Tylenol as ordered. A pain assessment was completed on 4/12/15 at 4:30 PM indicating the resident had pain of 7/10, with 10 being the worst imaginable pain. Staff failed to document in the nurse note the resident went to theER on [DATE]. Review of the ER forms dated 4/15/15 revealed the resident had multiple rib fractures. The ER staff wrote a new order to have [MEDICATION NAME] (a pain relief medication) every 4 hours for pain. Review of the nursing note dated 4/15/15 revealed [MEDICATION NAME] Tablet 5-325 MG give 1 tablet by mouth every 4 hours for rib pain for 7 days x 1 week. The medication was not available. Review of the nurse note dated 4/16/15 at 2:30 a.m. revealed the resident was seen in the ER today and had 5 fractured ribs. The resident had orders for scheduled [MEDICATION NAME]. A pain assessment was completed on 4/16/15 at 9:03 a.m. indicating the resident had pain at a level of 4/10. Review of the MAR (medication administration record) revealed the resident did not receive any PRN Tylenol in March and in April the resident required a PRN Tylenol on 4/12/15 for pain at a level of 6/10 at 5:04 AM, 4/13/15 for pain at a level of 9/10 at 11:51 AM, 4/14/15 for pain at a level of 7/10 at 6:07 PM and 4/15/15 for pain at a level of 8/10 at 7:36 PM. The notes indicate all of the PRN Tylenol doses listed above resulted in effective pain relief. Observation on 04/15/2015 at 7:22 AM revealed the resident was in the exam room being weighed by staff. He/she yelled out oh, oh, oh when staff lifted him/her with the gait belt. Observation on 04/15/2015 at 8:31 AM revealed the therapy department put a gait belt around the resident, told him/her to push off and stand up, grab onto the walker the resident sat down sideways. Therapy staff stated he/she was complaining of pain in his/her stomach and back. Observation on 04/15/2015 at 10:04 AM revealed the resident hollering out help me, help me, no staff around responding, please, please help me...he/she continued to cry out. The residents alarm sounded at 10:09AM the resident was yelling help me help me. At 10:10 AM direct care staff C entered the room and asked what was wrong and if he/she was hurting, the resident stated he/she hurt so bad and rated his/her pain at 10/10. The resident reported he/she wanted something right now for pain. Direct care staff II went to get the nurse at 10:20 a.m. Licensed nurse J entered the room at 10:21 a.m. and told the resident he/she had two [MEDICATION NAME]es on right now and only could have one other PRN medication. Staff J asked the resident if he/she could think of anything staff could do to make him/her feel better. When licensed nurse J assessed the resident he/she called out ouch. The resident reported he/she felt bad everywhere. Observation on 04/15/2015 at 10:54 AM revealed licensed nursing staff J called EMS (emergency medical services) to take the resident to the ER (emergency room ). The resident had weakness on the side and rib pain. Observation on 04/15/2015 at 11:02 AM revealed EMS arrived to take the resident to the hospital. The resident yelled out oh, oh while he/she got on the gurney. Observation on 04/15/2015 at 1:38PM revealed the resident came back from the hospital with new orders for [MEDICATION NAME] 5 mg/325 tablets every 4 hours for pain. 04/15/2015 at 7:26 AM an interview with the resident revealed he/she was still in pain from his/her fall. He/she stated it still hurt when he/she stood and it took a minute for him/her to get his/her balance. He/she said he/she could not describe the pain level and he/she did not get any pain medication. This was prior to the resident being sent to the hospital. Interview with family member JJ on 04/15/15 at 11:02 AM revealed the resident was in pain last night. Interview with direct care staff BB on 04/15/2015 at 7:36 AM revealed the resident did not get any pain medication that morning. He/she could only have Tylenol 650 mg (milligram) every 24 hours for pain and it had only been 14 hours and 29 min since last dose. The resident had complained to staff BB the last 3 days about pain on his/her shoulders and the lower left side in the ribs. Staff BB stated he/she reported it to the nurse that he/she was in pain and the nurse said he/she would assess the resident. 04/15/2015 at 8:11 AM the nurse J returned and reported the resident was on a [MEDICATION NAME] and that is why the resident was limited on the amount of Tylenol he/she could have. Interview with direct care staff H on 04/15/2015 at 3:30 PM revealed last night the resident reported he/she was in pain and the nurse gave the resident two Tylenol because that was order for he/she to have for pain. Direct care staff H stated it was just reported by nurse J that he/she had broken ribs and had new medications. Interview with direct care staff E on 04/16/2015 at 6:05 AM revealed the resident had more pain now and he/she cried out ouch more when staff moved him/her. Interview with direct care Staff I on 04/16/2015 at 9:14 AM revealed the resident never complained of pain before the fall. The resident hollered more he/she complained of pain to his/her shoulder and chest. Interview with Licensed Staff J on 04/16/2015 at 12:06:38 PM revealed the resident was not in pain before the fall. Interview with administrative staff B on 04/16/2015 at 12:57 PM revealed the resident had chronic pain and he/she was on [MEDICATION NAME] due to [MEDICAL CONDITION]. Staff B stated the [MEDICATION NAME]es were working to control his/her pain. Staff B said the resident ' s pain had increased since the fall. If he/she is now all of sudden complaining of pain all over and the pain patches are no longer working it was abnormal and we needed to assess him/her. He/she now has 5 rib fractures from the fall. The physician comes several times a week and will see him/her to re-evaluate pain and the ribs. An interview on 4/20/15 at 1:15 p.m. with consultant KK revealed he/she was not told the resident ' s ribs were hurting and was rating his/her pain level at a 10/10. Consultant KK also reported the facility failed to inform him/her the resident had increased confusion from his/her baseline. Consultant KK revealed when the facility called to send the resident to the hospital they didn ' t clarify or paint a clear picture the resident fell and hit his/her ribs until he/she reviewed the x-ray showing the 5 fractured ribs. Review of the pain assessment and management policy revised October 2010 revealed staff were to observe the resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain. The facility failed to monitor and assess resident #112 for increased pain and the effectiveness of pain management. - Review of resident # 75's annual MDS (Minimum Data Set) dated 12/14/2014 revealed a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment with no signs or symptoms of [MEDICAL CONDITION], no acute change in mental status, and no rejection in cares. He/she scored 6 on the PHQ 9 mood interview, which indicated mild depression. He/she required extensive assistance of one staff with bed mobility, transfers, and eating and had severe visual impairment and did not wear corrective lenses. He/she received [MEDICAL TREATMENT]. Review of the Cognition CAA (Care Area Assessment) dated 1/1/2015 revealed the resident was alert to self and place and unable to recall year or day, spoke some English, but preferred to speak Spanish and at times would not answer staff if English was spoken. Review of resident #75's quarterly MDS (Minimum Data Set) dated 3/13/2015 revealed a BIMS score of 4, which indicated severe cognitive impairment. He/she had not experienced signs or symptoms of [MEDICAL CONDITION], had not rejected cares, had highly impaired vision, and scored a 1 on the PHQ 9 (mood indicator) mood interview, which indicated minimal depression. He/she required extensive assistance of one staff with transfers, dressing, eating, toileting, and personal hygiene, limited assistance of one staff with bed mobility, and locomotion on and off the unit and used a walker and wheelchair for mobility. Review of the resident's care plan dated 1/12/2015 revealed he/she required assistance with ADLs and the care plan directed staff to provide total assist with dining. He/she was received [MEDICAL TREATMENT] 3 times weekly and the care plan directed the staff to encourage and remind the residence of the importance of going to [MEDICAL TREATMENT] appointment, if he/she choose not to go to [MEDICAL TREATMENT] the staff were to call the resident's family member to talk and convince him/her to go. Review of a social service progress note dated 3/25/2015 revealed the resident had been refusing [MEDICAL TREATMENT] frequently. Review of nursing progress notes dated 3/20/15, 3/25/2015, 3/30/2015, 4/6/2015, 4/8/2015, 4/10/2015, 4/13/2015, and 4/15/2015 revealed the resident refused [MEDICAL TREATMENT]. During an observation on 04/15/2015 at 6:58 A.M. the resident was lying in bed with his/her eyes opened. Direct care staff MM entered the room and asked the resident if he/she wanted a shower. He/she declined per translation from the direct care staff MM. During an observation on 04/15/2015 10:38:24 AM direct care staff MM informed the resident the nurse had rescheduled his/her [MEDICAL TREATMENT] for tomorrow at 7:30 am. Resident shook head up and down in a yes fashion. During an interview on 04/15/2015 at 8:12 A.M. the resident reported he/she would refuse [MEDICAL TREATMENT] if the staff transporting him/her was Staff NN as he/she was not able to speak Spanish, per translation by direct care staff SS. During an interview on 04/15/2015 at 10:35 A.M. the resident reported he/she was not going to [MEDICAL TREATMENT] today because he/she had diarrhea and because direct care staff NN was the staff who would be transporting today, per translation by direct care staff MM. During an interview on 04/16/2015 10:32:41 A.M. direct care staff NN reported the resident preferred Spanish speaking drivers and on days he/she needed to go to [MEDICAL TREATMENT] staff NN would try to take a Spanish speaking staff member with him/her. Staff NN reported there was a language barrier between him/herself and the resident and the issue was brought to his/her attention approximately 6 months ago. During an interview on 04/16/2015 at 12:27:49 P.M. direct care staff PP reported he/she was Spanish speaking and had not accompanied the resident on any [MEDICAL TREATMENT] transports. During an interview on 04/16/2015 at 12:29:37 P.M. direct care staff QQ reported he/she was Spanish speaking and had not accompanied the resident on any [MEDICAL TREATMENT] transports. Staff QQ reported Staff EE transported the resident to [MEDICAL TREATMENT] today. During an interview on 04/16/2015 at 12:31:45 P.M. direct care staff EE reported he/she was Spanish speaking and picked the resident up from [MEDICAL TREATMENT] today, but prior to today it had been 5 to 6 months ago since his/her last transport. During an interview on 04/16/2015 at 8:50:13 A.M. administrative nursing staff C reported the resident was scheduled to go to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays at 11:00 A.M. Staff C reported the resident would ask would was transporting him/her to [MEDICAL TREATMENT] and he/she did not want Staff NN to transport. Staff C reported the resident had reported he/she felt uncomfortable due to staff NN was unable to communicate with him/her in Spanish. Staff C reported he/she believed there was a language barrier because staff NN was not able to speak Spanish. Staff NN was assigned to transport the resident to [MEDICAL TREATMENT] on 04/15/2015 and Staff C reported he/she should not have been as the resident refused [MEDICAL TREATMENT]. Staff C reported there was no documentation in the medical record regarding staff attempts to determine cause of refusals, however he/she was aware of the resident's concerns and preference to have a Spanish speaking staff transport. During an interview on 04/16/2015 at 12:25:30 P.M. social service staff RR reported he/she was aware the resident refused [MEDICAL TREATMENT] due to transportation concerns, had not visited with the resident regarding these concerns and was unsure if the problem continued. During an interview on 04/16/2015 at 10:12:53 A.M. administrative nursing staff B reported the resident was scheduled for [MEDICAL TREATMENT] three times weekly and refused frequently. Staff B reported the resident did not like Staff NN transporting because he/she was unable to speak Spanish to him/her. Staff B reported the plan was for a Spanish speaking aide to let the resident know he/she would be going to [MEDICAL TREATMENT] on days Staff NN was transporting and would try to have a Spanish speaking staff member transport when available, but there was only one Spanish speaking driver. During an interview on 04/16/2015 at 10:48 A.M. staff B reported he/she could not confirm whether a Spanish speaking staff went on each transport when Staff NN was assigned to transport the resident to [MEDICAL TREATMENT]. Staff B reported this was an intervention when the complaint by resident was first reported approximately 6 months ago. Staff B stated this intervention was not part of the resident's care plan. Although requested, the facility failed to provide a policy regarding provision of services in the resident's language. The facility failed to provide the necessary care and services for resident # 75 by failure to ensure a Spanish speaking staff member accompanied the resident to and from [MEDICAL TREATMENT] for translation when one was available.

The facility reported a census of 73 residents with 26 residents in the sample. Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers for 2 of 2 residents reviewed. (#70, #101) Findings included: - Review of resident #70 ' s significant change in status MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had short and long term memory problems, signs of [MEDICAL CONDITION] to include being inattentive, disorganized thinking, decreased physical activity and had some difficulty in making decisions in new situations. He/she rejected care for 1 to 3 days during the 7 day observation period. He/she required extensive assistance from 2 or more staff for bed mobility, transfers, dressing, and toileting and extensive assistance of one staff for personal hygiene. He/she was identified as being at risk for pressure ulcers, had no pressure ulcers present, and had a pressure relieving mattress and chair cushion. He/she received oxygen therapy. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 2/5/2015 revealed the resident was at risk for skin breakdown due to thin skin, immobility, incontinence, medications and preference to sleep in a recliner at night. The analysis of findings failed to identify use of oxygen tubing as a risk for skin breakdown. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 2, which indicated he/she was severely cognitively impaired. He/she had no signs or symptoms of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness) or rejection of cares during the 7 day observation period. He/she required extensive assistance of 2 or more staff for bed mobility, transfers, dressing, toileting, and personal hygiene. He/she had two stage 2 pressure ulcers with oldest pressure ulcer occurring on 2/10/2015, was at risk for development of pressure ulcers, had a pressure reducing device for his/her bed and chair, received a nutritional or hydration intervention to manage skin problems, and received ulcer care. He/she received oxygen therapy. Review of a Braden Skin Risk assessment dated [DATE] revealed a score of 15, which indicated the resident was at high risk for the development of pressure ulcers. The revised care plan dated 3/29/2015 revealed the resident was at risk for skin issues due to he/she preferred the oxygen tubing tight around his/her face and ears. The care plan directed staff to encourage the resident to keep foam skin protectors to oxygen tubing over ears and to encourage him/her to avoid the oxygen tubing being too tight and pulling down on his/her ears. The care plan prior to the development of the pressure ulcer dated 4/10/2013 failed to identify the resident ' s risk for skin breakdown due to use of oxygen tubing. Review of faxed communication to physician dated 3/23/2015 revealed the resident had an opened area to the back of his/her right ear from the nasal cannula rubbing against his/her skin. Foam protectors were applied to tubing and a request was made for physician advise. Review of a physician order [REDACTED]. Review of skin observation tools by nurse revealed the following: 3/27/2015- right ear 0 cm (centimeters) x 0 cm 0 cm 4/2/2015- right ear pressure wound 2.5 cm x with depth of 0.5 cm. Identified as a stage 3 pressure wound. 4/13/2015- right ear had measurements of 1 cm x 0.6 cm. Wound was identified as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed).Review of a skin integrity evaluation dated 4/10/2015 revealed the wound to the resident ' s right ear was unstageable, which measured 1 cm (centimeter) x 0.6 cm, and had 100% yellow adhered slough (dead tissue, usually cream or yellow in color). During an observation on 04/15/2015 at 4:30 P.M. the resident had a foam protector over the tubing on his/her right ear. During an observation on 04/16/2015 at 7:11 A.M. the resident was eating breakfast at the dining room table and had no foam cushioning to his /her nasal cannula tubing. During an interview on 04/15/2015 at 1:44 P.M. direct care staff HH reported he/she required total assistance with cares. He/she wore oxygen and the tubing over his/her ear caused a sore, which staff HH was unaware how long the wounds had been there. Staff HH reported he/she had not seen him/her pulling at or moving the oxygen tubing. During an interview on 04/15/2015 at 4:07 P.M. direct care staff N reported the oxygen tubing had caused a sore behind the resident's ears because he/she tightened it too tight. Staff N reported he/she would sometimes request the nurse obtain foam protectors from the medication room to make it softer on his/her ears. He/she would inform the nurse when the foam protectors were not in place and would the apply them. During an interview on 4/16/2015 at 7:13 A.M. administrative nursing staff C reported the oxygen tubing was changed monthly and the resident ' s ear cushion sometimes fell off. He/she reported staff could have secured the cushioning with paper tape. Review of the facility ' s revised policy on Pressure Ulcers dated 10/2010 revealed the nurse and physician wound assess and document the resident ' s significant risk factors for developing pressure ulcers. The facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure ulcers. The facility failed to prevent a pressure ulcer to the resident #70 ' s right ear caused from oxygen tubing. - Review of resident #101's admission MDS (Minimum Data Set) dated 11/12/2014 revealed a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. The resident required extensive assist from 2 or more staff with bed mobility, transfers and toileting. The resident used a walker and wheelchair for mobility, and had not rejected care during the 7 day observation period. He/she was frequently incontinent of urine and bowel and had no pressure ulcers. The assessment revealed he/she was at risk for developing pressure ulcers, used a pressure reducing device in his/her chair and bed, and was on a turning and repositioning program. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 11/14/2014 revealed the resident had no pressure areas. He/she had small dark areas to both heels, wore heel protectors and elevated heels with a pillow when in bed. He/she had a special mattress on his/her bed and wheelchair and repositioned every 2 hours when in bed. Review of the quarterly MDS (Minimum Data Set) dated 1/30/2015 revealed the resident displayed short and long term memory problems and was moderately cognitively impaired. He/she required extensive assistance of one staff with bed mobility, extensive assistance of two or more staff with transfers and toileting, and used a wheelchair for mobility. He/she was always continent of urine and bowel. He/she had 2 unstageable pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) with eschar (dead tissue), which were present on admission. He/she had the following skin interventions in place; used a pressure reducing device for chair and bed, turning/repositioning program, and nutrition/hydration. Review of Braden Skin Risk Assessments dated 11/5/2014, 11/12/2014, and 11/19/2104 indicated a low risk for pressure ulcers. The facility failed to accurately assess the resident's risk for skin breakdown; was frequently incontinent of urine and bowel, walked occasionally with therapy, had limited mobility, probable inadequate nutrition, and had potential friction concerns, which would score the resident's risk factor at 13, indicating moderate risk for skin breakdown was present on admission. The Braden Skin Risk Assessments dated 11/26/2014 and 12/3/2014 revealed a score of 14, which indicated a moderate risk for pressure ulcers. A Braden Skin Risk assessment dated [DATE] revealed a score of 10, which indicated a high risk for pressure ulcers Review of resident # 101's revised care plan dated 3/25/2015 revealed the resident had skin impairment to his/her right and left heels. The care plan directed staff to float the resident's heels when in his/her recliner, wear heel protectors when in bed, provide treatment to his/her heels for prevention as ordered, perform weekly skin checks, and provide fortified foods and protein supplements to aide in wound healing. The resident had a pressure relieving mattress on his/her bed and a pressure relieving cushion on his/her wheelchair. The facility failed to provide an initial temporary care plan to determine interventions in place prior to the development of the pressure ulcers to his/her heels. Although requested, the resident's initial care plan was not provided. On 04/16/2015 at 244 P.M. licensed nursing staff C reported the initial temporary care plan could not be located. Staff C reported the initial care plan should have been scanned into the medical record or placed behind the comprehensive care plan in the care plan book. A review of the TAR (Treatment Administration Record) for November 2014 through April revealed there was no treatment in place to the resident's bilateral heels for the month of November 2014. The TAR also lacked documentation of dressing changes on 2/4/15, 2/5/15, 2/21/15, and 2/25/15 to both heels. Review of a nursing admission screening/history dated 11/5/2015 revealed no documentation of wounds to bilateral heels. Review of admission orders [REDACTED]. Review of a faxed physician communication note dated 11/11/2014 revealed the facility started standing orders for pressure ulcer present on admission and requested an order for [REDACTED]. Review of a nursing progress note dated 11/12/2014 revealed staff noted darkened areas to left and right heels. Documentation lacked measurements and staging of the wounds. Review of skin observation tools completed by the nurse revealed the following: On 11/19/2014 there was no documentation of pressure wounds to the resident's right and left heels. On 11/26/2014 the resident had an unstageable arterial wound (wounds causes by poor perfusion to the lower extremities) to his/her left and right heels. On 12/3/2014 there was a left heel blister with no identified stage and a stage 2 pressure ulcer to the right inner heel. On 12/10/2014 there was no documentation of pressure wounds. On 12/17/2014 the resident had pressure ulcers to his/her right and left heels. There was no wound stage or measurements identified in the assessment. On 12/24/2014 there was no skin breakdown at this time. On 12/31/2014 there was no skin issues at this time. On 1/21/2015 the resident had stage one pressure ulcers to his/her right and left heels. On 1/28/2015 the resident had a stage one pressure ulcer to his/her right and left heels. On 1/30/2015 there was no skin breakdown at the time. On 2/18/2015 there was no pressure ulcers at the time. On 2/27/2015 there was no new skin issues noted or reported. On 3/4/2015 the resident had a stage 2 pressure ulcer on his/her left heel which measured 3 cm x 4 cm and a stage 2 pressure ulcer on his/her right heel,which measured 4 cm x 3 cm. On 3/11/2015 the resident had a right heel and left heel pressure ulcer. The stage and measurements of the wounds were not documented. On 3/25/2015 the assessment was blank. On 4/1/2015 the resident had unstageable pressure ulcers to his/her right and left heels. The assessment lacked measurements of wounds. On 4/13/2015 revealed the resident had an unstageable right heel vascular wound, which measured 2.2 cm x 3.2 cm and an unstageable suspected deep tissue vascular wound to the left heel, which measured 3.4 cm x 3.7 cm. Review of a physician progress notes [REDACTED]. The family member had concerns regarding large blisters on the resident's heels. The physician assessment revealed a dark blood filled blister to the left posterior heel, which measured 2 cm (centimeters) x 1 cm and a dark blood fluid blister to the right posterior heel, which measured 2 cm in diameter. The plan was to continue heel protectors, keep pressure off the heels when in bed and when sitting, use a flotation mattress, and a dietary consult to assess for protein supplementation. The documentation lacked type and stage of the wounds to the resident's heels. Review of a physician progress notes [REDACTED]. A physician assessment revealed improved decubitus ulcers. The plan was for the resident to continue with skilled services until his/her wounds completely healed. Review of a nutritional note dated 12/22/2014 revealed a plan to request 2 cal (a nutritional supplement) 60 ml(milliliters) three times daily due to ongoing weight loss and eating less. Staff were to continue to encourage meal time intake, offer milk/juice at meals, and obtain weight weekly. Review of a physician's progress note dated 1/20/2015 revealed the nurse reported the resident's pressure ulcers to his/her heels were healing. The assessment revealed dark calluses on the bottom of the right and left heels with no surrounding [DIAGNOSES REDACTED] (redness or inflammation of the skin) or drainage. There was no dressing in place, but the eschar had not fallen off and could not be forcibly removed. A physician progress notes [REDACTED]. There lacked documentation related to the resident's pressure wounds on his/her left and right heels. Review of a physician progress notes [REDACTED]. Review of a skin observation tool dated 4/10/2015 revealed the resident had scabs to his/her right and left heel. The assessment lacked measurements of wounds. Review of a wound care evaluation dated 4/10/2015 revealed the resident had a left posterior heel, full thickness, unstageable pressure ulcer, which measured 2.2 cm x 3.2 cm with undetermined depth. Physician orders [REDACTED]. 11//28/2014 revealed a physician order [REDACTED]. 12/2/2014 revealed a physician order [REDACTED]. 1/1/2015 revealed a physician order [REDACTED]. 4/13/2015 revealed a physician order [REDACTED]. 4/14/2015 revealed a a physician order [REDACTED]. Review of the medical record dated 11/12/2014 through 4/16/2015 revealed no lab results for [MEDICATION NAME], CBC, or Chemistry as ordered by the physician. During an observation on 04/15/2015 at 7:57 A.M. administrative nursing staff C and direct care staff F assisted the resident to his/her recliner in the room. Staff C elevated the recliner footrest and placed two pillows under the resident's lower legs and positioned the call light on the resident's chest/stomach area. There was a thin blanket covered with a incontinence changing pad in the seat of the recliner. Staff floated the resident's right and left heels were floated with the use of the pillows. He/she had a regular mattress on his/her bed. During observations on 04/15/2015 at 1:10 P.M., 1:25 P.M., 1:39 P.M., 1:55 P.M., 2:09 P.M., 2:20 P.M., 2:35 P.M., 2:50 P.M., 2:55 P.M., 3:11 P.M., 3:24 P.M., 3:32 P.M., and 3:40 P.M. the resident sat in his/her recliner with legs elevated on the recliner's footrest. Two pillows were under both legs and heel protectors were worn. The resident's heels were not positioned in the center of the open heeled area of foam boots and pressure to both heels was not relieved. At 2:20 P.M. direct care staff M entered the room and passed fluids. The was no attempt to check positioning or reposition the resident. At 2:55 P.M. direct care staff N and direct care staff O entered the room, emptied trash, and provided clean linen. There were no attempts to check positioning or reposition the resident. At 3:32 P.M. the resident yelled for help. There were no staff in the vicinity of the resident's room. At 3:38 P.M. the resident activated his/her call light. Direct care staff N and direct care staff O responded to the call light and assisted the resident from his/her recliner to the toilet. At 3:40 P.M. the surveyor requested a skin check after failure to reposition for 2 hours and 28 minutes. Licensed nursing staff P performed skin check of the resident's buttocks after toileting and noted softball sized areas of nonblanchable redness (area pressed on a resident's skin does not return to normal color indicating blood circulation was compromised due to prolonged pressure) to the right and left buttocks. There was white scarring noted to the upper left and right buttocks with no opened areas. Direct care staff N and direct care staff O assisted the resident to his/her recliner. Staff P removed the dressing to the right heel, which revealed dark black eschar with a scant (small) amount of dark brown drainage on the dressing. The left heel revealed large area of black eschar with no drainage. During an interview on 04/15/2015 at 8:05 A.M. the resident reported he/she was unaware of any wounds on his/her body. The resident reported staff usually put a pillow under his/her legs when he/she was in the recliner and sometimes when in the bed, but he/she did not know why. The resident was not sure how often nursing changed his/her dressing. During an interview on 04/15/2015 at 8:22 A.M. dietary staff T reported the resident received a regular diet at this time. The resident's dietary card directed the dietary staff to provide a regular. There was no direction to provide fortified foods, which was ordered on [DATE]. During an interview on 04/15/2015 at 2:24 P.M. direct care staff U reported the resident required assistance with bed mobility and transfers. Staff U reported the resident does not move when he/she sat in his/her recliner. Staff U reported the resident currently had wounds on both heels, wore heel protectors during the night, had three pillows placed under his/her knees to prevent his/her legs from swelling, and received a regular diet. Staff U reported there was no specific way to apply the heel protectors to prevent pressure other than making sure the velcro was applied. Staff U reported the resident had wounds for some time and developed the wounds due to lying in bed and staff did not catch the wounds early enough. During an interview on 04/16/2015 at 7:29 A.M. direct care staff F reported he/she helped the resident with bed mobility and transfers. Staff F reported the resident had wounds to his/her right and left heels. Staff F reported interventions to manage the resident's wounds included pillows under his/her knees and heel protectors. Staff F reported the heel protectors were applied like a boot and the velcro needed to face out. Staff F reported the resident had a cushion to his/her wheelchair and his/her recliner had a pillow like consistency. Staff F reported the resident was on a regular diet with no special instructions and was unsure whether there were any other interventions in place to promote wound healing and prevent the development of further pressure ulcers. Staff F reported care plans were available at the nurses station and he/she looked at the care plans daily. Staff F reported the resident's usual routine was to get up early, go to the dining room for meals, toilet, and then lay in his/her bed or recliner. The resident would let staff know if he/she needed to be reposition. During an interview on 04/15/2015 at 9:15 A.M. following an observation of wound care on 4/15/2015 at 9:05 A.M. licensed nursing staff G reported the resident's wounds to his/her heels were pressure related and he/she was not sure how long the wounds had been present. Staff G reported the nurse was to complete skin assessments weekly with measurements. Staff G was not sure if the wounds had improved and stated a wound nurse from a different company came to the facility weekly to complete wound care. Staff G reported interventions to manager the resident's pressure ulcers included; resident wore heel protectors when in bed, floated heels when in his/her recliner, may be on a vitamin, staff encouraged juices at meal and with snacks, and staff turned and repositioned the resident every 2 hours when in his/her bed and recliner. During an interview on 04/16/2015 at 7:46 A.M. administrative nursing staff C reported the resident had blisters to both heels upon admission, however staff C failed to locate documentation of blisters to both heels in the medical record. Staff C reported interventions on admission included; float both heels and wear heel protectors when in bed. Staff C reported he/she believed the resident was on a regular diet and was unsure why the care plan directed staff to provide a fortified diet. Staff C reported the charge nurse was to complete a weekly skin assessment once weekly. Current interventions included; turn every 2 hours when in bed, stand every 2 hours when the resident was in his/her recliner, float heels and wear heel protectors. Current treatment for [REDACTED]. The resident was to start Santyl wound treatment when the medication arrived from the pharmacy. Staff C reported he/she assessed the resident's wounds weekly and noted the eschar was lifting and looked better. A consultant wound nurse came once monthly and helped with dressings and made recommendations. The consultant wound nurse communicated with the facility who communicated with the physician. Staff C provided one progress note from the wound care nurse dated 4/10/2015. Staff C reported the physician was at the facility on 4/2/2014 and wounds were not assessed. Staff C reported the director of nursing usually updated the care plan as needed and notified families of wound changes. Staff C reported the most recent measurement of right heel pressure ulcer was 2.2 x 3.2 cm and left heel was 3.4 x 3.7 on 4/13/2014. Staff C reported the initial measurements of the left heel was 3 cm x 4 cm and right heel 4 cm x 3 cm dated 3/4/2015. Staff C reported there were no measurements obtained prior to 3/4/2015. The charge nurse was responsible for skin assessment on admission. Staff C was not able to locate the [MEDICATION NAME] level ordered on [DATE]. Staff C reported the resident was on a regular mattress and was not sure why a floatation device mattress was not on the resident's bed. Staff C reported missing signatures on the TAR indicated the dressing changes were not completed. On 04/16/2015 at 12:38 PM administrative nursing staff C reported he/she phoned the lab and there were no results for [MEDICATION NAME], CBC or Chemistry. Staff C stated the lab was not drawn as ordered by the physician on 11/11/2014 and was unsure why. During an interview on 04/16/2015 at 11:10 A.M. wound consultant nurse V stated he/she began working with the facility on 11/13/2014. The first report on the resident was on 4/10/15 at which time staff V revealed stable eschar of the right heel had been noted up until 4/10/2015. The wound measured 2.3 cm x 2.2 cm. Staff V was unable to determine depth. There was 90% unstable eschar and 10% slough(dead tissue, usually cream or yellow in color) towards the center of the wound. Staff V believed wounds on heels were related to pressure. The current plan to treat the right heel wound was to continue with Hydrogel due to Santyl not covered by insurance for the resident. Staff V reported he/she saw the resident monthly and facility could also request additional visits. Staff V reported he/she only assessed wounds which required a dressing and DME (durable medical equipment) supplies were provided by the consultant company. During an interview on 04/16/2015 at 9:18 A.M. administrative nursing staff B reported staff noted the wounds to the resident's bilateral heels 1-2 days after admission. Staff B reported the wounds were facility acquired, and due to being dark fluid filled they were considered deep tissue injury. Staff B reported the initial wound assessment was on 11/12/2014 and revealed arterial unstageable wounds to left and right heels. Staff B reported he/she believed the wounds were arterial but stated there was no documentation to support his/her findings. The physician was first notified of wounds to the resident's heels on 11/12/2014. Staff B reported the notification was not timely and should have been when the wounds were first observed. The resident's family notified the physician of the resident's wounds on 11/21/2014 and requested an assessment. Staff B reported interventions prior to the facility being aware of the wounds included; a pressure reducing mattress and placed in recliner between meals. Staff B reported staff initiated heel protectors and floating of the heels on 11/12/2014 after development of the wounds. Staff B reported the resident was on a regular diet with fortified foods. Staff B reported the diet change was determined in a risk management meeting and fortified foods were added on 12/4/2014. Staff B reported he/she expected the dietary card to indicate the resident's food should be fortified. The registered dietitian assessed the resident on 12/22/2014 and 4/15/15. The residents skin was assessed weekly by the nurse and the wound consultant nurse came to facility to assist with training and make recommendations on wound care monthly. Staff B reported he/she felt the wounds were improving until the right heel opened on 4/10/2015. Staff B stated the fortified foods may help promote wound healing. Staff B was unaware of how often the physician assessed the resident's wounds. Staff B expected nursing staff to complete dressing changes as ordered and not to miss changing the dressing. Staff B reported the resident changed rooms in January or February of 2015 and most likely the floatation device mattress did not follow the resident. Staff B confirmed there was no documentation of reddened areas to the buttocks by licensed nursing staff P and would have expected the nurse complete a skin assessment and inform him/herself. Staff B was not aware the weekly skin assessments had discrepancies regarding documentation of arterial versus pressure ulcers and some lacked some measurements as well as discrepancy in staging of the wounds. During an interview on 04/16/2015 at 1:30 P.M. RD dietitian Y reported the resident was resistive to cares, varied with his/her intake and had some weight loss. Staff Y reported his/her first assessment with the resident was in December 2014 and stated a nutritional assessment should have been completed on admission in November 2014. Staff Y reported his/her initial assessment consisted of a progress note made on 12/22/2014. Staff Y reported he/she was aware of wounds, however there was a lack of documentation regarding wounds present and he/she was unable to recall when he/she first became aware of the wound to the resident's right and left heels. Staff Y reported interventions to help with wound healing included fortified foods. Staff Y reported he/she spoke with administrative nursing staff B on 4/15/2015 and completed a record review. Staff Y revealed he/she had not visited with the resident on 4/15/2015. Staff Y reported he/she was not aware of a [MEDICATION NAME] level ordered by the physician, however stated the results would not have made a difference in the plan of care. Staff Y was not aware of the current stage or severity of the resident's heel wounds and reported the stage and severity was not a factor in the resident's condition and likelihood of improvement regarding his/her nutrition. During an interview on 04/16/2015 at 2:20 P.M. physician GG reported he/she believed the wounds to the resident's heels had healed or almost healed. Staff GG reported the resident had very little areas on his/her heels the last time he/she looked at the resident's heels, which was approximately 2 months ago. Staff GG reported the failure to use a floatation device mattress, turn and reposition every two hours, and provide a fortified diet would negatively impact the wound healing process. Staff GG reported he/she had not been notified of the nonblanchable reddened areas to the residents buttocks and was unaware of a wound nurse consultant assessing the resident. Staff GG stated he/she goes to facility every 2 months and one of his/her nurse practitioners goes every Friday. Staff GG reported communication is completed via fax in between visits and the resident either goes to the doctor's office or was seen at the facility. Staff GG reported he/she had not received a copy of the [MEDICATION NAME] results he/she ordered on [DATE] and was unaware the lab was not drawn. Review of the facility's revised policy on Pressure Ulcers/Skin Breakdown dated 10/2010 revealed the nurse would complete a full assessment of pressure sores including location, stage, length, width and depth, and presence of exudate or necrotic tissue, assess and document current treatments, including support surfaces, the physician would assist staff in defining the type of wound and characteristics, and during resident visits the physician would evaluate and document the progress of wound healing, especially those with complicated or non healing wounds. The facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers and failed to ensure the necessary treatment and services to promote healing and prevent new sores from developing by the failure to follow physician's orders [REDACTED].# 101 to include; obtain [MEDICATION NAME], CBC, and Chemistry, reposition every 2 hours, float heels, apply heel protectors appropriately, provide a floatation device mattress, provide a fortified diet, and complete accurate weekly skin assessment with measurements.

The facility had a census of 73 residents with 26 sampled for review and 4 reviewed for accidents. Based on observations, interview, and record review, the facility failed to ensure 1 of 4 residents sampled for accidents/falls received adequate supervision (failure to implement appropriate fall prevention strategies and determine causal factors for the resident ' s fall) in order to prevent accidents. Resident #112 sustained a fall on 4/11/15 that resulted in 5 fractured ribs. Findings included: -Resident #112 ' s signed physician medical visit on 3/16/15 revealed [DIAGNOSES REDACTED]. The admission MDS (minimum data set) dated 3/23/15 revealed a BIMS (brief interview for mental status) score of 4 indicating the resident had severe cognitive impairment. The resident required limited assist with one staff for bed mobility, transfers, walk in room, dressing, and personal hygiene. He/she required extensive assist with one staff for toilet use and locomotion on and off the unit. The MDS revealed the resident was frequently incontinent of urine and always continent of bowel. He/she received diuretics (increase urine output) medications over the 7 day look back period. The MDS also indicated the resident required scheduled pain medication. He/she had a non-injury fall over the last month prior to admission and a fall over the past 2-6 months prior to admit. The Cognitive loss dementia CAA (care area assessment) dated 3/23/15 revealed the resident is a risk for further decline in cognition secondary to [DIAGNOSES REDACTED]. The Fall CAA dated 3/23/15 stated the resident required assistance to complete transition and balance tests. He/she received diuretics and narcotic pain patches routinely. The resident had a history of [REDACTED]. The fall risk assessments completed on 3/16/15 and 4/12/15 indicated the resident was a high risk for falls. The care plan dated 3/16/15 revealed the resident was at high risk for falls related to his/her cognition and diagnoses. The resident required a safe environment free from spills on the floor, clutter, glare-free, call light in reach, bed in low position at night, and personal items within reach. The resident required placement of an alarm in the bed and chair. The staff were to anticipate and meet needs as necessary as he/she needed prompt response to all requests for assistance. The resident required extensive assistance with two staff for transfer with a walker, toilet use on a toileting program, and bed mobility. The resident ' s temporary care plan dated 4/11/15 revealed the resident had an actual fall and required re-assess pain issues, inspect vision device, implement toileting schedule, toileting immediately when assisted to room, maintain pathway free of obstruction, gripper socks in bed/nonskid footwear, monitor closely during post fall period, call light within reach, alarm pad placed under sheet in bed. The Fall Investigation dated 4/11/15 revealed there were blood drops on the resident ' s floor from the bathroom to the bed. The nurse went to check on the resident and found the resident had a skin tear to the back of his/her right hand approximately 2 x 1.5 cm (centimeters) and to his/her right elbow 9 x 6 cm. The resident complained of pain to his/her left ribs and administered Tylenol as ordered. The resident stated that he/she had called for help and slipped; hit his/her right hand and elbow on the bathroom door. The resident told the day shift staff that he/she fell taking himself/herself to the bathroom and he/she called for help and nobody came. The resident told the day shift he/she crawled from the doorway to his/her bed and got himself/herself up and back in the bed. The resident did complain of pain to his/her left ribs. The nursing note dated 4/11/15 at 11:29 p.m. revealed the nurse went to check on the resident and found the resident had a skin tear to the back on his/her right hand and elbow after taking himself/herself to the bathroom. He/she slipped and hit his/her arm on the door. The nursing note dated 4/12/15 revealed the resident had stated he/she was sore. The resident had told the evening shift he/she had taken himself/herself to the bathroom and called for help, slipped and hit his/her arm on the door in the bathroom. The resident then told day shift on 4/12/15 that he/she fell last night taking himself/herself to the bathroom and that he/she called for help, but that nobody came. The nurse note dated 4/13/15 at 7:15 p.m. revealed the resident reported to be a little sore and his/her blood pressure was 178/98. The nursing note dated 4/14/15 at 6:30 a.m. revealed the resident ' s pain level was at a 4 and his/her blood pressure was 168/78. The facility failed to document the resident left the faciity on [DATE] at 11:14 a.m. via ambulance with increased confusion and increased pain of 10/10. The report from the local hospital dated 4/15/15 revealed the resident had multiple rib fractures. An observation on 4/15/15 at 10:04 a.m. outside the resident ' s room the resident was laying on his/her bed hollering for help. The resident continued to call for help for 5 minutes. The resident never used the call light. The resident ' s alarm began to sound as he/she attempted to get out of bed on his/her own. At 10:10 a.m. direct care staff Z entered the room to ask the resident what he/she needed. The resident stated he/she hurt so bad. Direct Care staff II came into the room and he/she went out to report these findings to the CMA on duty. Nurse AA assessed the resident and he/she yelled out ouch when he/she touched the rib area. The resident then stated he/she needed to go to the bathroom. The direct care staff carefully took the resident to the bathroom where he/she had difficulty following directions by the staff. The resident was fidgeting while sitting on the toilet. The resident began to take off his/her shoes for no reason when asked. Direct care staff applied the resident ' s oxygen and the nurse went and got the vital machine. The resident ' s blood pressure was 80/41 and the nurse reported this was normal for the resident but he/she was going to go and call the doctor. The staff then brought the resident out to the nurse ' s station. An interview on 4/16/15 at 6:05 a.m. with direct care staff CC revealed the resident used a walker before the fall. He/she would not use a call light, he/she just hollered until staff would enter the room and nobody responded away then staff would hear the bed alarm then he/she would be half way to the bathroom. Staff CC reported the resident was a fall risk and had a fall alarm in place before the fall occurred. An interview on 4/16/15 at 9:14 a.m. with direct care staff I reported the resident required limited assist with use of a walker before the fall. He/she had a bed alarm in place. He/she had become more confused, and hollered more often. Staff I also reported the alarm was in place before and after the fall. He/she stated staff had been instructed to make sure it was placed under the sheet so the resident could not roll it up in his/her covers. He/she also reported the resident used a wheelchair for mobility after the fall. An interview on 4/16/15 at 10:54 a.m. with licensed nursing staff AA revealed the resident came to the facility as a high fall risk and had an alarm in place in the bed and chair. He/she required assist of one staff for transfers with use of walker and now required a wheelchair. Direct care staff had come to get me on the morning of the 4/12/15 to tell me that the resident reported he/she had fell the night before. Staff AA interviewed the resident and he/she reported to licensed nursing staff AA he/she hollered and hollered and nobody came into the room, so he/she got out of bed and walked to the door and yelled for help and still nobody came, The resident reported to Staff AA he/she turned around and slipped and fell . He/she crawled back to his/her bed. Staff AA called the DON (director of nursing). An interview on 4/16/15 at 12:57 p.m. with administrative nurse B revealed the resident was a fall risk when he/she arrived in the building and required an alarm on his/her bed and chair. Nurse B reported the resident had a tendency to wrap his/her bed alarm in blankets and the new intervention was to put the alarm under the sheet. He/she would expect staff to maintain adequate supervision knowing the resident hollers instead of using his/her call light. An interview on 4/20/15 at 1:15 p.m. with physician KK revealed when the facility called to send the resident to the hospital they did not clarify or paint a clear picture the resident had in-fact fell and hit his/her ribs until he/she reviewed the x-ray showing the 5 fractured ribs. Review of the Falls, and Fall Risk, Managing policy dated December 2007 revealed if the falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The facility failed to evaluate resident #112 for causal of factors in his/her fall and provide adequate supervision and implement effective interventions in order to prevent a fall on 4/11/15 that resulted with 5 fractured ribs.

The facility reported a census of 73 residents and reported 21 residents as cognitively impaired and independently mobile. Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of accident hazards when water temperatures in hand washing sinks accessible to residents measured: * in the restorative room: 154.0 degrees F (Fahrenheit) on 10/1/12 at 12:30 p.m. and 170.4 degrees F 10/2/12 at 10:10 a.m.; * in the therapy room: 164.0 degrees F on 10/1/12 at 12:55 p.m. and 155.8 degrees F on 10/2/12 at 10:20 a.m.; * in the central hallway men's bathroom: 159.1 degrees F on 10/4/12 at 2:58 p.m. This deficient practice placed the residents who potentially utilized the restorative room, therapy room, and central hallway men's bathroom sinks in immediate jeopardy. The facility also failed to disable an activity stove/oven and keep hazardous chemicals in an area not accessible to the 21 cognitively impaired and independently mobile residents. Findings included: - Observations on tour on 10/1/12 between 12:05 p.m. and 12:55 p.m. revealed an east and a west hallway where residents resided. The facility layout also included a central hallway which included a kitchenette, a restorative room, a therapy room, a coffee shop, a men's bathroom, and a women's bathroom. Observations on initial tour on 10/1/12 at 12:30 p.m. revealed an unattended and opened restorative room with one hand washing sink. The water temperature of the restorative hand washing sink measured 154.0 degrees F. Further observations revealed at 12:30 p.m., the therapy room presented as closed and the door locked. Observations on initial tour on 10/1/12 at approximately 12:55 p.m. revealed an opened therapy room with one staff and one resident present and one hand washing sink. Further observations revealed the water temperature of the therapy room hand washing sink measured 164.0 degrees F. Observations on 10/1/12 at 1:00 p.m. revealed a recheck of the water temperatures of the restorative and therapy room hand washing sinks both presented as 69 degrees F. Observations revealed no staff present in the open restorative room and one staff and one resident present in the therapy room. Observations on 10/2/12 at 10:10 a.m. revealed the water temperature of the restorative room hand washing sink presented as 170.4 degrees F. Further observations revealed no staff present in the room and the door remained opened and unlocked. Upon request on 10/2/12 at 10:12 a.m., Maintenance Staff J witnessed the restorative room hand washing sink water temperature as 170.4 degrees F and verified the temperature as "too hot" for resident use. Staff J confirmed the kitchenette water line connected with the other rooms on the central hallway and that the restorative room lacked a mixing valve on the hand washing sink. During an observation and interview on 10/2/12 at 10:20 a.m., the water temperature of the hand washing sink in the therapy room presented as 155.8 degrees F. Administrative Staff A and Maintenance Staff J verified the therapy room hand washing sink water temperature as "too hot" for resident use. Review of the "Hot Water Temperature in Rooms" logs from 2/12/12 to 9/27/12 lacked monitoring of the current restorative room hand washing sink water temperature (a total of 7 1/2 months). The log also indicated that biweekly the therapy room water temperatures remained between 112 degrees F and 119 degrees F. During an interview on 10/2/12 at 10:13 a.m., Maintenance Staff J reported he/she checked the water temperatures of the common areas used by residents every two weeks and confirmed he/she failed to monitor the restorative room in the biweekly checks. During an interview on 10/2/12 at 10:41 a.m., Direct Care Staff N reported awareness that the restorative and therapy room hand washing sinks water remained too hot for use. Staff N reported he/she failed to report the hot water issue to the maintenance staff. Staff N verified that staff left the restorative room door open without staff present and accessible to residents. During an interview on 10/2/12 at 10:44 a.m., Direct Care Staff L reported awareness that the restorative and therapy room hand washing sinks water remained too hot for use. Staff N reported he/she did not direct residents to use these hand washing sinks as "they are too hot". Staff N reported he/she failed to report the hot water issue to maintenance staff. Staff N verified that staff left the restorative room door open without staff present and accessible to residents. Staff N reported resident #21 periodically used into the restorative room without staff's presence or knowledge. An observation on 10/2/12 at 11:00 a.m. revealed the hand washing sink in the therapy room no longer supplied water for resident use. Further observations revealed the restorative room door as closed and locked. During an interview on 10/2/12 at 11:00 a.m., Maintenance Staff J reported he/she turned off the water to the therapy and restorative room sinks. During observations on 10/4/12 at 2:58 p.m., the water temperature in the central hallway men's common bathroom presented as 159.1 degrees F. Upon request at 10/4/12 at 3:00 p.m., Administrative Staff A and Maintenance Staff J verified the water temperature in the hand washing sink of the central hallway men's bathroom as 159.1 degrees F and verified the temperature as too hot for resident use. Observations on 10/4/12 at 3:23 p.m. revealed the central hallway men's bathroom door presented as locked. During an interview on 10/4/12 at 3:23 p.m., Administrative Staff A reported the central hallway men's bathroom hand washing sink no longer supplied water for resident use. Observations on 10/8/12 at 10:11 a.m. revealed the restorative room door open and no staff present in the room. Further observations revealed the hand washing sink in the restorative room no longer supplied water for resident use. Observations on 10/8/12 at 10:12 a.m. revealed the therapy room's hand washing sink water temperature as 116.8 degrees F. Observations on 10/8/12 at 10:17 a.m. revealed the central hallway men's bathroom hand washing sink presented as 111.3 degrees F. The facility's "Water Temperatures, Safety of" policy, last revised in April of 2010, instructed staff "water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F". The facility failed to ensure that the residents' environment remained as free of accident hazards when water temperatures in hand washing sinks accessible to residents measured in the restorative room:154.0 degrees F (Fahrenheit) on 10/1/12 at 12:30 p.m. and 170.4 degrees F 10/2/12 at 10:10 a.m.; in the therapy room:164.0 degrees F on 10/1/12 at 12:55 p.m. and 155.8 degrees F on 10/2/12 at 10:20 a.m.; and in the central hallway men's bathroom: 159.1 degrees F on 10/4/12 at 2:58 p.m. - On 10/1/12 at 12:30 p.m., observations revealed the West Bath House door unlatched and unlocked. Inside the West Bath House, observations revealed an unlocked cabinet that contained a 3/4 full bottle of "Sunshine Whirlpool/Hard Water Surface" cleanser with a warning label of "caution: keep out of reach of children". On 10/1/12 at 12:34 p.m., observations revealed the coffee shop door unlocked and no staff inside. Further observations revealed the sign on the door indicated "Please Keep This Door Locked". On 10/1/12 at 12:34 p.m., observations revealed the following: 1) The stove top accessible with burners that could be activated. 2) Under the sink a 32 ounce spray bottle of 409 surface cleaner with the label "caution-eye irritant, Keep Out of Reach of Children". 3) A 17 ounce canister of Comet powder bleach disinfectant cleaner with a label which indicated "caution: moderate eye and skin irritant". 4) A 32 ounce, unlabeled, spray bottle which contained blue liquid. Dietary staff A lacked knowledge of the identification of the blue liquid. On 10/1/12 at 12:30 p.m., Administrative Staff C confirmed the West Bath House door should be locked at all times. Staff C reported the facility expected staff to keep hazardous chemicals locked in cabinets and not accessible to residents. On 10/1/12 at 12:40 p.m., Dietary Staff K verified the door remained unlocked when he/she came in and stated that "sometimes the staff leave it unlocked". On 10/1/12 at 12:45 p.m., Administrative Nurse B verified the facility expected staff to lock the coffee shop dining room door when leaving the coffee shop. Nurse B further verified the facility expected staff to ensure that chemicals remained in locked cabinets and the stove top remained disabled to prevent accidents. The facility's 1/7/11 "Storage of cleaning compounds and other hazardous substances" policy instructed staff "cleaning compounds and other hazardous substances ...shall be stored in a location sufficiently secure to deny access to residents". The facility's August 2012 "Safety Precautions, Food Services" policy lacked instructions related keeping residents safe while not in attendance of the stove top. The facility failed to prevent accessibility to harmful chemicals and failed to disable an accessible stovetop when not in use, to prevent serious accidents for the 21 cognitively impaired and independently mobile residents. The facility abated the immediate jeopardy related to hot water temperatures in excess of 140 degrees Fahrenheit on 10/7/12 at 5:00 p.m. when they implemented the following corrective measures: * Contacted a licensed plumber and had equipment installed to ensure water temperatures remained in acceptable ranges throughout the facility * Shut off the water supply to the therapy room until a plumber can install a mixing valve to control the water temperatures * Educated all staff on proper notification of Administration and/or Maintenance staff if water temperatures seem excessively hot to the touch * Developed/implemented a plan to ensure monitoring of water temperatures on the main kitchen line (which supplies the restorative room, therapy room, public bathrooms) multiple times daily for the first week and once weekly thereafter. After removal of the immediate jeopardy, the deficient practice of facility failure to ensure the resident environment remained free of accident/hazards remained at a scope/severity of "E".