Every finding on record at Gardens Court

Based on record review and interviews, the facility failed to provide care and services to prevent accidents for 4 of 4 sampled residents, as evidenced by failure to ensure Resident #111 had adequate supervision during transfer, failure to ensure Resident #70 had padded side rails and floor mats near the bed, failure to ensure Resident #121 had padded side rails, and failure to investigate an accident reported on Resident #85.The findings included:1) Record review revealed Resident #111 was admitted to the facility on [DATE]. Review of the annual assessment dated [DATE] documented Resident #111 required substantial assistance with going from sitting to lying position, going from lying to sitting and transferring from bed to chair. Review of the medical diagnosis documented Resident #111 had a history of falls, muscle weakness, cognitive communication deficit, displaced fracture of left femur, and abnormal posture. During an observation on 01/05/26 at 10:56 AM, Resident #111 was noted lying in bed with his head elevated, with facial grimacing. His knees were bent inward towards his body, and he was holding on to the right-side rail with his right hand. The resident was asked if he was in pain. He pointed at his legs and said yes, both of my legs. When asked are you able to straighten out your legs he attempted to unbend his leg but couldn't. When asked do you get out of bed, Resident #111 stated Sometimes. During an observation on 01/05/26 at 11:00AM, Staff B, Certified Nursing Assistant (CNA) entered the resident's room and brought in a sit-to-stand mechanical lift, left it and returned shortly, informed the resident that she was going to get him out of bed and proceeded to get him dressed. She brought the mechanical lift closer to the bed and assisted the resident to a sitting position on the side of the bed. She grabbed his hands to place them on the bar of the lift and as he was having a difficult time sitting up, she stated You have to sit up. The resident started to lean backward, and his hands were letting go of the bar. She stated, You have to help me; you have to sit up. I need to get help. She left the room while the resident was sitting on the side of the bed and as he was trying to hold on to the bar the mechanical lift began to move because it was not locked. Staff B, CNA and Staff C, CNA entered the room, Staff B sat the resident up straight and they put a green sling around his back and attached it to the mechanical lift. Resident #111 began to lean to the left and fall backward, Staff B, CNA pushed him back up to a sitting position and said what's going on you have to sit up. Staff C, CNA lifted the lift slightly and told the resident, you have to stand up. The resident stated I can't. Staff C, CNA attempted to straighten his legs, but the resident was unable to. Resident #111 noted to have facial grimacing and stated, I can't do it. Staff C, CNA stated We can't use this lift with him maybe the hoyer lift. He used to be able to do this. Staff C let the lift down and the resident was placed in a sitting position on the side of the bed. Staff B and Staff C, CNA unattached the sling from the lift and the resident fell backwards on the bed with the sling underneath him. They repositioned the resident in the bed and removed the sling from underneath him and the mechanical lift was removed from the room. During an interview on 01/05/26 at 11:42 AM, Staff B, CNA, was asked if Resident #111 is usually transferred using the sit-to-stand lift, Staff C, CNA said yes. When asked are you assigned to him often, she stated, Not often. I'm a floater. Review of the care plan dated for Resident #111 did not reveal any documentation regarding the use of the sit-to-stand mechanical lift for transfer. Review of the physician orders for Resident #111 did not reveal any orders to use the sit-to- stand mechanical lift for transfer. Review of Kardex revealed documentation that Resident #111 is to be transferred with a mechanical lift sit-to-stand lift with 2-person assistance. During an interview on 01/07/26 at 09:06 AM with Staff A, Registered Nurse (RN), when asked are you familiar with Resident #111 and how he transfers, she stated, Yes. She was asked if she was aware of the situation that happened on 01/05/26 when the aides were attempting to transfer him with the sit to stand lift, she stated, Yes, the aides should have come and got me. I am sorry. 2) Record review revealed Resident #70 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] revealed Resident #70 required supervision with rolling from left to right in bed and she was dependent on transferring from the bed to chair. Review of medical diagnosis revealed Resident #70 had a history of Seizures and Dementia (memory loss). During an observation 01/05/26 at 11:40 AM, Resident #70 was noted lying in bed on her right side. The bed was raised in a high position. Bilateral floor mats were noted folded on top of each other on the right side of the bed near the wall. Review of a physician order dated 07/24/25 instructed staff to ensure Resident #70 had bilateral floor mats at the bedside. Review of a physician order dated 07/24/25, instructed staff to ensure Resident #70 had padded sided rails every shift for Seizure precaution. During an observation on 01/06/26 Resident #70's bed was noted without padding on the side rails. During an observation on 01/07/2026 at 8:29 AM Resident #70 was noted sleeping in bed. The bed was raised in high position. There was no padding on the side rails. Bilateral floor mats noted folded against the wall on both sides of the bed. During an observation on 01/07/2026 at 11:36 AM, Resident #70 was noted lying in bed lying on her right-side with the bed raised in high position. No padding was noted on the side rails. Bilateral floor mats were observed folded against the wall. During an interview on 01/07/2026 at 11:50 AM, Staff A, RN was asked do you have any residents with padded side rails, she stated Let me check. She proceeded to go up and down the hall checking the resident's room on the 323-334 hall. Staff A and the surveyor entered Resident #70's room. Bilateral floor mats were folded against the wall, bed was in high position, no padding was on the side rails. Staff A, RN was asked if the floor mats were supposed to be near the bed, she stated, That was needed for her in the past, because she used to move around a lot, but she doesn't move around as much anymore. At that time, Staff A, RN was made aware that the residents still had an order to have the floor mats. She then placed the mats down on the floor near the resident's bed and left the room. She went to the UM (Unit Manger) and asked, Do you know where the padding for the side rails is kept, the surveyor needs to see them. Staff, D, the UM, went to the storage closet and showed a light blue rectangle shaped pad. She stated, this is the one and there is another kind as well, that I use for the residents on my unit. When asked if a resident had an order for them does the padding stay on the bed, she stated Yes, they shouldn't take them off unless they are transferring the resident, but then they should be put back on. 3) Record review revealed Resident #121 was readmitted to the facility on [DATE]. Review of medical diagnosis revealed Resident #121 had a documented history of muscle weakness and Dementia (memory loss). Review of a physician order dated 07/08/25, staff were instructed to ensure Resident #121 had padded side rails every shift for preventative treatment. Review of a progress noted dated 07/04/25, revealed documentation that Resident #121 sustained a skin tear to his left lateral wrist. The resident said he thinks he hit his arm on the side rail on the bed. During an observation on 01/06/26 at 9:52 AM, Resident #121's bed was noted without padding on the side rails. Review of the January Treatment Administration Record (TAR) for Resident #121 revealed staff signed to acknowledge that the side rails were padded. During an observation on 01/07/26 at 08:32 AM, Resident #121s bed noted without padding on the side rails. During an interview on 01/07/2026 at 09:20 AM, when asked if there were any special safety precautions used for Resident #121 while in bed, Staff D, Certified Nursing Assistant (CNA) asked, Do you mean as far as side rail? Yes, I make sure they are up and I put the bedside table in front of him. 4) Review of the facility policy titled, Incident and Reportable Event Management revised 09/23/25, documented in part, Definitions: Event Management includes, but is not limited to, the following types of events: . Transfer Injury . The Five I's to Event Management: . If an event occurs, the facility will follow the 5 I's in an effort to minimize the potential for recurrence. 1. Incident (what happened or was reported as happening) 2. Injury (provide care and document the injury) 3. Interview (who saw the resident last or at the time of the event 4. Investigate (why did it happen) 5. Intervention (what mitigation effort are we using). This policy further describes the process to investigate an event to include interview by the licensed nurse to obtain as much information as possible, and an investigation by the nurse and interdisciplinary team (IDT). Review of the record revealed Resident #85 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the assessment prior to the event of 10/05/25, documented Resident #85 was totally dependent upon staff for bed mobility and transfers. A progress note dated Tuesday 10/07/25 at 3:06 PM written by the direct care nurse, documented the daughter of Resident #85 told the nurse that while being transferred on Sunday (10/05/25), the resident hit her left leg and was now complaining of pain. This note documented the physician was notified and an order for an x-ray of the left leg was received. Further review of the record revealed the order for the left leg x-ray was entered into the electronic medical record (EMR) on 10/07/25 at 7:15 PM by the Evening Supervisor. Review of this x-ray revealed Resident #85 had acute nondisplaced fractures of the proximal tibia and fibula. During an interview on 01/08/26 at 1:52 PM, when asked about the fracture sustained by Resident #85, the Director of Nursing (DON) explained that she spoke with the daughter after the identification of the fracture, and she confirmed her mother did not sustain a fall and reported that her mother felt the pain when her legs were placed on the air mattress. The DON stated they had determined the fractures were pathological in nature due to the presence of osteopenia. During a side-by-side review of the record, when shown the progress note that documented the daughter had reported to the direct care nurse that her mother had pain after a transfer, the DON stated she was not aware of that note or event, that the direct care nurse should have reported that event, and that there should have been an incident report. During an interview on 01/08/26 at 3:15 PM when asked if she was told the daughter of Resident #85 reported on 10/07/25 that the resident had pain after a transfer on 10/05/25, the Second Floor Unit Manager stated she had not been notified. When asked if they should have completed an incident report to look into the transfer, the Unit Manager stated she thought so, but that it may not have been done as there was no fall or injury at that time. When asked if an incident report had been completed for Resident #85 around or after the time of the event, the Unit Manager looked in the EMR and stated there was none. During an interview on 01/08/26 at 3:40 PM, when asked if she was informed the daughter of Resident #85 reported on 10/07/25 pain after staff transferred her mother the previous Sunday, the Evening Supervisor stated she did not. When asked if she would expect to be told and or expect the direct care nurse to do an incident report the Evening Supervisor stated she would. Upon review of the record, the Evening Supervisor noted she herself had entered the x-ray for Resident #85 into the EMR. The Evening Supervisor stated she only recalled a concern with the resident's feet being swollen and she ended up in the hospital. During an interview on 01/08/26 at 4:13 PM, when asked if a family member tells a nurse her mother hit her legs while being transferred and was now in pain, would you expect an incident report be completed, the Risk Manager stated, Of course. The Risk Manager agreed the incident with the transfer should have been investigated. The Risk Manager stated she would have investigated had she known. The Risk Manager stated she recalled asking staff if Resident #85 fell or something, and the staff stated she hadn't hurt herself. The Risk Manager stated she was unaware of the progress note for Resident #85 dated 10/07/25 or she would have completed an incident report and investigation herself.

Based on record review and interviews, the facility failed to provide care and services to prevent electrolyte imbalance as evidenced by ensuring Resident #14 had adequate hydration, for 1 of 1 sampled resident reviewed for hydration. The findings included: Record review revealed Resident #14 was readmitted to the facility on [DATE]. Review of medical diagnosis revealed Resident #14 had a history of dysphagia (difficulty swallowing) following cerebral infarction (stroke), gastrostomy (feeding tube), dementia (memory loss). Review of the care plan dated 11/29/25 documented a focus that Resident #14 required tube feeding related to dysphagia with a goal that she will remain free of side effects or complications related to tube feeding with the interventions that Resident #14 is dependent on staff for tube feeding and water flushes. A second focus documented Resident #14 was at risk for dehydration or potential fluid deficit related to the resident readmitted with feeding tube with a goal that the resident will be free of symptoms of dehydration. During an observation on 01/06/26 at 9:10AM, Resident #14 noted lying in bed on her right side with her head elevated. There was a pole with a feeding pump attached, which had a bottle of light brown formula that had approximately 260 ml (milliliters) remaining with a label dated 01/05/26 at 2:00 PM and a clear bag with clear liquid with approximately 1200 ml in it, with a label dated 01/05/26 at 2:00 PM, hanging on the pole. The tubing connected to both were connected to the resident. The settings on the pump read the feeding was at a continuous rate of 50 ml per hour and the total feed infused was 809 ml. During an interview on 01/06/26 at 9:20 AM, Staff A, Registered Nurse (RN) was called into Resident #14's room and was asked what is the flush setting. Staff A pushed the show flush button on the pump, and the setting was noted to be at 15 ml every hour. She stated, it says 15 ml an hour, but it should be 150 ml every shift. At that time, Staff A, RN reset the pump to 150 ml every 8hours with next flush to be administered in 448 mins.Review of a physician order dated 12/08/25, stated the staff was instructed to provide 150 ml water every 8 hours via pump.During an interview on 01/06/26 at 9:32 AM, the Director of Nursing (DON) was made aware that the settings on the feeding pump were not set properly and there was concern that the resident had not received any flush. At that time, she called the Dietitian to come to the third floor. The Dietician arrived and the DON told her that there was an issue with Resident #14's flush settings. The Dietitian, DON and surveyor went to the resident's room and Staff A, RN went into the room as well. The bag of the liquid in the clear bag was still hanging with approximately 1200 mls in it. The DON stated this is a newer pump and she was not sure how to see the history. The Surveyor pressed on the menu and chose view history. The history was reviewed by the surveyor, Dietitian, DON, and Staff A, RN, and it was noted that, according to the pump, 0 flush was received by the resident for the past 3 days. The DON stated she will get an order for STAT labs to make sure the resident is not dehydrated. Review of January's Medication Administration Record (MAR) for Resident #14 revealed staff signed acknowledging that 150 ml of water was administered via pump every shift.Review of a physician order dated 01/06/26 revealed blood work was ordered (STAT CBC CMP) for Resident #14.Review of the CBC CMP lab results dated 01/06/25 revealed Resident #14 had an electrolyte imbalance and elevated liver enzymes. Lab results from 01/06/2026 were: Sodium 155 (137-145); Potassium 3.3 (3.5-5.1); Chloride 118 (98-107); BUN 38 (9.0-20.0); BUN/Creat 57 (10-20); ALT 168 (<=150); and AST 119 (17-59). During an interview on 01/07/26 at 8:27AM, Staff A, RN stated she made sure the flush is still set correctly on Resident #14 pump.During an observation on 01/07/26 at 8:35 AM, it was noted that 480 ml of flush had been infused since 01/06/26. Review of physician orders dated 01/07/25 instructed staff to administer Resident #14 bolus 250 ml of purified water via peg tube (feeding tube) every shift until 01/08/2026 23:59; and instructed state to administer Resident #14, potassium chloride Liquid 20 MEQ/15ML (10%) give 20 mEq via g-tube one time a day for hypokalemia (low potassium).Review of another physician order dated 01/08/26, revealed a portable upper abdominal liver ultrasound was ordered for Resident #14.

Based on policy review, record review, and interview, the facility failed to ensure complete and accurate documentation in the medical records for 3 of 28 sampled residents. The record lacked the refusal to utilize an anchor to prevent infections during the use of an indwelling urinary catheter for Resident #44; contained two orders for the use of the indwelling urinary catheter with two different sized catheters for Resident #44; lacked any documentation related to an observed dressing the left elbow of Resident #103, and lacked complete information related to an issue with a wound dressing for Resident #159. The findings included: Review of the policy titled, Nursing Documentation revised 08/10/23 documented, Medical Records . The medical record must also reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. 1) Review of the record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included Urinary Retention with Obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a scale of 0 to 15, indicating the resident was cognitively intact. This MDS also documented the use of an indwelling urinary catheter. Review of the record revealed two current orders for the use of an indwelling urinary catheter, one for the use of a size 18 catheter with a 10 cc (cubic centimeter, amount of fluid held) balloon, and the other for a size 20 catheter with a 30 cc balloon. The orders and care plan lacked any information related to the use of an anchoring device, which should be used to help prevent urinary tract infections. During an interview on 07/08/24 at 10:20 AM, Resident #44 stated he was going to the urologist later that day to get his indwelling urinary catheter removed. During an observation on 07/09/24 at 9:15 AM, Resident #44 was in bed and staff at his bedside. The drainage tubing for the urinary catheter was noted. During a subsequent interview on 07/10/24 at 12:03 PM, Resident #44 confirmed he went to the urologist the previous day, the indwelling catheter had been removed, but had to be reinserted. When asked if he had an anchor for the indwelling urinary catheter, Resident #44 responded, I don't like to wear that. On 07/11/24 at 2:38 PM, when asked about the anchor for the indwelling urinary catheter for Resident #44, the Second Floor Unit Manager stated there should be an order for the anchor and the resident should be wearing one. During an observation by the Unit Manager, Resident #44 did not have the anchor and stated he did not want the catheter tied down in any way. The Unit Manager agreed there should be documentation in the medical record regarding the anchor and or refusal. Further review of the record lacked any documentation related to the resident's refusal to wear the anchor, or education as to the risks versus the benefits. 2) Review of the record revealed Resident #103 was admitted to the facility on [DATE], with a readmission after a short hospital stay on 06/14/24. Review of the current MDS assessment dated [DATE] revealed a BIMS score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident had a skin tear at that time. A progress note dated 06/18/24 by the Wound Care Nurse (WCN) documented the resident had a dry scab formation to his left elbow that was left open to air, or without a dressing. The progress notes and current orders lacked any documentation related to a current issue with the resident's left arm. During an observation on 07/08/24 at 10:43 AM, Resident #103 was in bed and a large gauze wrap was noted to the resident's left elbow. There was no documented date on that dressing. When asked about the dressing, the resident stated he thought there was some oozing or something, but he was unsure. Resident #103 denied any pain and no drainage was noted. On 07/09/24 at 9:24 AM, the same gauze wrap was noted to the resident's left elbow. When asked about the dressing, the resident stated he thought it was bruised and was oozing. There was still no drainage noted. During an interview on 07/11/24 at 1:52 PM, Staff B, Certified Nursing Assistant (CNA) stated the resident did not have any current dressing to his left arm, but she thought there had been one last week, but she was not sure. During an interview on 07/11/24 at 2:21 PM, Staff C, Registered Nurse (RN) explained there was some edema (swelling) and slight oozing to the resident's left elbow, and she thought the dressing had been applied by the Wound Care Nurse but was unsure. The RN stated she had removed the dressing the day before last, indicating on 07/09/24. When asked about the gauze wrap to the left arm of Resident #103 on 07/11/24 at 2:50 PM, the WCN was unaware of any issues or dressings. She reviewed the electronic record and found no documentation related to the elbow and or dressing. Upon observation of the resident at this time, there was no dressing noted and there appeared to be a small round area to the left elbow that had been open or draining but was closed and dry at that time. 3) Review of the record revealed Resident #159 was admitted to the facility on [DATE] with a diagnosis to include aftercare following joint replacement surgery. A current order dated 07/05/24 documented to monitor the left hip surgical site for signs and symptoms of infection. The record lacked any other current orders related to the hip surgery. During an interview on 07/08/24 at 3:02 PM, a wound VAC (machine attached to a wound that provides light suctioning to collect drainage) was noted disconnected from Resident #159 and had been set on the corner of the dresser. When asked why the VAC was not on the wound and or running, Resident #159 stated explained it had been placed by the surgeon during his hip replacement surgery, and he noticed it had stopped this past weekend, on Saturday. Resident #159 stated none of the staff knew what to do, so he called the phone number on the back of the machine. Resident #159 stated the VAC company explained it was scheduled to run for a certain amount of time and then turn off. The VAC company stated it was okay and ensured he had a scheduled follow up appointment with the surgeon. Resident #159 stated he was scheduled to see the surgeon on 07/09/24, the next day. Review of the record revealed a progress noted dated Sunday 07/07/24 at 12:47 PM by the direct care nurse that documented a lack of suctioning noted to the wound VAC. This note documented the wound VAC technical support was called and the nurse was informed the wound VAC was operating as per the intent. The note documented MD notified and made aware. MD stated, 'will see patient.' The note lacked which physician was notified and what care was to be provided regarding the VAC. The record lacked any additional orders at that time. The record lacked any notification to the surgeon. Further review of the record lacked any MD note from 07/07/24. A progress note dated 07/08/24 at 7:19 PM documented notification to the surgeon with interventions that it was OK to disconnect and additional wound dressing instructions. The record lacked any orders for the changes in care as per this MD notification. A progress note dated 07/09/24 at 8:16 AM documented, in part that as per Resident #159, the wound VAC stopped on Saturday 07/06/24, and that the resident had called the wound VAC company. The record lacked any interventions on Saturday. During an interview on 07/11/24 at 3:13 PM, the Weekend Supervisor stated to her knowledge, the VAC stopped on Sunday 07/07/24. The Supervisor agreed the resident had called the wound VAC company (unsure when) and the direct care nurse had also called the company. The Supervisor stated they had called both the attending physician who stated she would see the resident and also the answering service for the surgeon. The Supervisor stated the surgeon's office had told them it was OK that the VAC had stopped running and that they could either replace the wound VAC dressing with an OPT site dressing or leave the wound VAC dressing in place. This information was not documented in the progress notes of 07/07/24 nor was there an order for these interventions.

Based on policy review, interview and record review, the facility failed to treat 3 of 4 sampled residents in a dignified manner (Residents #67, #103, and #35). The findings included: Review of the facility policy titled, dignity revised on 09/25/23, documented, each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. All residents will be treated with dignity and respect. 1) Record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included: Anxiety Disorder. The quarterly Minimum Data Set assessment, reference date 06/14/24 recorded a brief interview for mental status score of 15, which indicated Resident #67 was cognitively intact. This MDS recorded no mood/behavior issues. The care plan dated 05/14/24 revealed Resident #67 was very hard of hearing and prefers things written down at times in order to communicate. On 07/08/24 at 10:34 AM, Resident #67 was observed alert and oriented. An interview process was started with her, and during this time, Resident #67 divulged that Staff A, a Certified Nursing Assistant (CNA), threw a wash cloth at her, and Staff A left her in the bathroom by herself and closed the door. Resident #67 also stated Staff A was rough with her during care. Resident #67 further stated that one time Staff A brought in her food tray, and at that time her purse was on the table. Staff A did not remove the purse from the table, but she placed the food tray on the counter. When Resident #67 asked Staff A how long it would take to put the purse on the bed and put the food tray on the table instead of the counter, Staff A screamed at her. Resident #67 stated Staff A was always screaming. Resident #67 denied telling anybody about the concerns because she was afraid of retaliation from Staff A. Resident #67 stated, Please don't tell Staff A or anybody that I said anything, or Staff A will be twice as mean to me, that's why I didn't say anything to the facility. Resident #67 stated she was sure other people had also complained about Staff A. When asked if she felt Staff A was verbally abusing her, Resident #67 stated she did not feel it was abuse but did not like the way she was being treated by Staff A. On 07/10/24 at 12:22 PM, a subsequent interview was held with Resident #67 she voiced she doesn't ever want Staff A in her room, she stated, I don't even want her to look at me. On 07/10/24 at 12:50 PM, an interview was held with the DON (Director of Nursing) and she voiced that she had spoken to Resident #67. The resident explained what happened, when it happened, and told the DON the name of Staff (Staff A). The DON revealed that she believed the resident, based on the information the resident had provided. The DON confirmed that Staff A usually speaks loudly, she has a strong loud tone of voice, and the DON said she has always told Staff A she was too loud and needed to lower her tone of voice and to respect the residents because this is their home. The DON informed Staff A of the accuracy of the events described by Resident #67, and the accuracy of the description the resident gave regarding Staff A. The DON stated, There's no way Resident #67 could make that up. The DON further stated, Staff A could be at the nursing station talking to somebody, and you could hear her all the way at the end of the hallway. 25404 2) Review of the record revealed Resident #103 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, on 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident had not exhibited any behaviors and required partial to total assistance for care. During an interview on 07/09/24 at 9:40 AM, Resident #103 stated he only had one complaint. The resident stated, I had trouble with one nurse in the middle of the night. She came in the room and yelled at me that the bed was too high. She was nasty. Resident #103 continued the nurse told him when he gets home he can put the bed as high as he wants, on the roof if he'd like, but not at the facility. When asked if he felt it was verbal abuse, the resident stated no. When asked if he felt as if she treated him with dignity, Resident #103 stated, [ ] no. She came in yelling the bed was too high. She didn't care. she had an attitude. It wasn't very nice telling me to put my bed on the roof. When asked if he reported the event to anyone, Resident #103 explained the next morning when he went to therapy, the therapist asked him how his night was, so he told his therapist what happened. When asked how the therapist responded, Resident #103 stated, They told me I should mention it to someone. When asked if he mentioned it to anyone else, the resident stated no. During an interview on 07/11/24 at 3:38 PM, the Social Services Director denied any knowledge of the event, but agreed it was inappropriate. 3) Review of the record revealed Resident #35 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented a BIMS score of 13, indicating the resident had minimal cognitive impairment. This same MDS documented the resident had not exhibited any behaviors and required partial to total assistance for care. During an interview on 07/09/24 at 11:12 AM, when asked if staff treat him with respect and dignity, Resident #35 stated, A couple of the aides and a nurse are mean. When asked how they are mean, the resident gave an example that at times he doesn't want his blanket over him because it is too heavy, but they make me have the blanket. A heavy blanket was noted over his legs. Resident #35 was unable to give any other examples, but again stated that some of the staff were mean.

Based on clinical and administrative record review and staff interview, the facility failed to provide the necessary treatment prescribed by the physician for 1 of 3 sampled residents, reviewed for pressure ulcers (Resident # 1). The findings included: Review of the clinical record for Resident # 1 revealed that the resident was originally admitted to the facility on [DATE]. The resident was admitted to the facility with a pressure ulcer. Review of the Wound Care Notes from April 2023 revealed on 04/05/23, the physician documented that the resident had a Stage IV pressure Injury Sacral region, Osteomyelitis, MRSA (Methicillin-resistant Staphylococcus aureus). The Stage IV decubitus measured 6.5 x 6.5 x 0.3 cm. No surrounding erythema present, 100% granulation tissue within injury. Moderate serous drainage. No odor. Undermining 2 to 5.00 1.5 cm. Left Buttock region: DTI, dusty color; Pink epidermis 3.0 x 1.5 cm superficial excoriation. Plan Irrigate injury at sacrum with Dakins solution. Pack decubitus loosely using Ag Alginate ribbon cover with Hydrocolloid dressing. Change daily and as needed. Clinical record documented the Wound Care physician saw the resident weekly and documented his assessment each week. However, on 05/16/23 the physician noted that the resident's wound was now measuring 8.5 x 13.5 x 0.5, No surrounding erythema present. 80% granulation tissue within injury. Moderate serosanguinous drainage 1+ odor. Undermining from 2 to 5.00 2.8 cm. Plan Wash injury at sacrum with Dakins' solution. Pack decubitus loosely using Dakins' damp gauze, cover with Hydrocolloid dressing. Change daily and as needed. Further review of the Treatment Administration Record for April and May documented a 05/10/23 entry noting sacral wound wash with Dakins' solution 0.25% pack loosely with Alginate cover with Duoderm daily and as needed every day shift. The nurses placed their initials in the appropriate box to indicate that the dressing was completed on 05/11/23 to 05/28/23. An interview was conducted on 06/15/23 at 12:40 PM with the Wound Care Nurse, who stated she changes the dressing four times a week and she rounds with the Wound Care physician on Wednesday. The wound care is done by the floor nurses on the weekend and on Thursday. The resident was admitted with a Stage IV wound. The surveyor further questioned the WCN regarding the change in the physician's order on his 05/16/23 visit when the resident wound changed and was emitting an odor. The Wound Care Physician prescribed for the Dakins' solution gauze to be packed loosely into the wound. The surveyor explained that the implementation of this order was not documented on the TAR. The Wound Care Nurse and the Minimum Data Set Assessment Coordinator also searched the electronic clinical record and were unable to confirm this order was input for May 16, 2023 or thereafter, thus the physician order for the Dakins' gauze pack loosely into the wound was not implemented. A telephone interview was conducted on 06/15/23 at 1:50 PM with the Wound Care Physician. He confirmed he changed the resident's wound care order when he noted that wound had developed an odor and prescribed for the Dakins' Solution wet to dry dressing. The wet to dry Dakins' solution helps decrease the amount of drainage and odor. Once there is improvement and the drainage is decreased he will use the Alginate.

Based on observations, interview, record reviews, and review of the facility's policy, the facility failed to ensure staff who were not up-to-date with all recommended COVID-19 vaccine doses took precautions to mitigate the transmission and spread of COVID-19 for one of one sampled resident (Resident (R) 1). Specifically, the facility's Contracted Staff (CS) 1, who was a hairdresser failed to wear an N95 mask while in the facility; and failed to be tested weekly for COVID-19. This failure had the potential to affect all residents and staff in the facility. Findings include: Review of the facility's policy titled, Covid-19 (SARS-CoV-2) Vaccination Program Policy for Associates, revised 03/31/22 revealed .The facility will ensure that associates .will be fully vaccinated against COVID-19, unless the otherwise is exempted by a medical or religious exemption .Mitigation strategies for not fully-vaccinated, pending or granted exemption, or delayed vaccine status .requiring staff who have not completed their primary vaccination series to use a NIOSH approved N95 or equivalent or higher-level respirator for source control regardless of whether they are providing direct care to or otherwise interacting with patients . Review of CS1's COVID-19 Vaccine Exemption Form dated 01/07/22 and signed by the Administrator revealed CS1 was granted a religious exemption and had not received the COVID-19 vaccination. The exemption form revealed .if granted, accommodation provided: use of N95 masks while in facility [sic] weekly testing when scheduled. The form was signed by CS1. During an observation on 04/12/22 at 9:50 AM at the second-floor elevator, CS1 entered the elevator with this surveyor. CS1 was wearing only a surgical face mask. CS1 stated she was a contracted hairdresser, and she was not vaccinated. Observation on 04/12/22 at 9:56 AM revealed CS 1 sitting in the hair salon on the third floor wearing only a surgical mask. There were no residents in the salon. Observation on 04/12/22 at 10:18 AM revealed CS1 in the salon on the third floor, curling R1's hair, wearing only a surgical mask. Review of R1's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R1's Immunization Record, located in the resident's EMR under the Immunizations tab revealed the resident had received two COVID-19 vaccinations; however, the resident had not received the booster dose. Observation and interview on 04/12/22 at 10:20 AM revealed CS1 now had donned an N95 masked. The CS stated a nurse had just come and told her to put the N95 mask on. CS1 also stated she had never been told she was to wear an N95 mask before unless there was COVID-19 in the facility. Interview on 04/12/22 at 10:22 AM with the Minimum Data Set Coordinator (MDSC) who was sitting at the third floor Nurses' station revealed she had asked CS1 if she had an N95 mask. The MDSC stated even though CS1 stated she carried one in her purse; she gave the CS a new one to put on. Interview on 04/12/22 at 2:02 PM the Infection Preventionist (IP) stated it was her expectation CS1 would have had on an N95 mask while she was in the building due to her not being vaccinated for COVID-19. Interview on 04/12/22 at 2:26 PM with the Administrator revealed it was his expectation CS1 would have had on an N95 mask since she was not vaccinated. 2. Review of CS1's POC [point of care] Test Result Reporting, provided by the facility, revealed CS1 was not tested between the weeks of 02/22/22 and 03/01/22 (missed one week of testing) and was not tested between the weeks of 03/22/22 and 04/05/22 (missed one week of testing). During an interview on 04/12/22 at 2:02 PM the IP confirmed CS1 was not tested weekly. The IP stated CS1 may not have been in the building the day of testing that week. The IP stated the facility tested unvaccinated staff weekly if they worked on that day and if CS1 worked in the building the testing dates, she should have gotten tested . Interview on 04/12/22 at 2:26 PM with the Administrator revealed he did not know if CS1 was in the facility the weeks she missed testing; however, if she was here anytime during the week she should have been tested . The Administrator stated he did not think there was a facility policy related to unvaccinated staff testing.

Based on observation, interview and record review, the facility failed to accurately code a Minimum Data Set (MDS) discharge assessment for Resident #102 and a hearing assessment for Resident #82 for 2 of 22 sampled residents assessed for MDS. The findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an initial interview with Resident #82 on 01/04/22 at 10:22 AM she stated that she could not hear and to come closer and speak louder. She stated that she did not have a hearing aide. Subsequent interviews with Resident #82 on 01/05/22 at 3:31 PM and 01/06/22 at 9:57 AM revealed the resident could not have a conversation without the surveyor speaking very loud. A review of the resident's admission assessment with an assessment reference date (ARD) of 09/14/21, section B hearing , speech and vision, revealed it was coded as adequate in ability to hear which means no difficulty in normal conversation, social interaction or listening to TV (television). A quarterly MDS with an ARD of 12/15/21 under section B is also coded as adequate in ability to hear. A review of nursing monthly summary notes dated 11/05/21 and 12/07/21 revealed Resident #82's hearing is poor in both ears. On 01/05/22, an interview was conducted with the Social Service Director who stated that Resident #82 can hear adequately and if she could not, it must be new so she will call the family. A review of a Social Service progress note dated 01/05/22 revealed the Social Service Director called her POA (power of attorney) who said that she has had an impairment for sometime, however, as it has been described to him, it appears it has progressed. Hospice provider will be advised to address possible wax build up and/or authorize an ENT consult. In an interview with Staff C, Certified Nursing Assistant (CNA), on 01/06/22 at 1:45 PM, she stated that Resident #82 has been hard of hearing since she came in. An interview was conducted on 01/06/22 at 1:33 PM with Staff B, MDS Coordinator who filled out the MDS for Resident #82 Section B. Staff B stated that he did not have to raise his voice in speaking with her and there were no nurses notes that indicated she was hard of hearing so he coded hearing as adequate. He further stated he will see if it needed to be changed. 2. On 01/05/22 at 1:22 PM, a closed record review for hospitalization was conducted for Resident #102. The discharge MDS was coded as discharge status-acute hospital on 12/17/21. A review of the resident's discharge summary note dated 12/17/21 revealed the resident was discharged home on 12/17/21 via wheelchair with husband. An interview was conducted with Staff A, MDS Coordinator, on 01/06/22 at 9:51 AM. She stated the discharge MDS was incorrect. It should have been coded as entered from hospital and discharged into community and she coded it that she entered from community and discharged to hospital. She further stated that she will modify the MDS now.

Based on interview and record review, the facility failed to report an adverse incident for 1 of 4 sampled residents reviewed for falls (Resident #53). The findings included: A review of the facility's policy Area of Focus: Incident and Reportable Event Management, not dated, documented to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. Record review revealed Resident #53 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Assessment, dated 02/17/21, documented the resident had mild cognitive impairment, and required total dependence of two-person assist with bed mobility. Resident #53 was care planned for at risk for falls, dated 08/14/20. An intervention included to assist with activities of daily living as needed. Resident #53 was care planned for activities of daily living self-care performance deficit, dated 10/11/18. Interventions included assistance by staff for bathing/showering and assistance by staff to turn and reposition in bed. Record review revealed a Progress Note dated 05/13/21, at 10:30 AM, that documented: At approximately 10:30 AM while giving morning care the CNA (Certified Nurse Assistant) reported, I lost my balance slipped and fell on the floor causing the resident to roll on her left side and fell out of the bed on top of me. Resident was assessed and stated: I don't remember what happened. I am feeling OK, I don't feel any pain or any discomfort. Resident was assisted back to bed. Small bruise noted to resident left forearm. Denies any c/o (complaints of) pain nor discomfort at this time. Neuro checks in progress, no change noted in health status. Dr (doctor) notified. New order received for X-Ray to left shoulder, elbow and hip. (Family member) made aware. A Progress Note dated 05/13/21, at 4:30 PM, documented Resident #53 was sent out to the hospital for evaluation of a left femur fracture. An interview was conducted with the Assistant Director of Nursing (ADON) on 01/06/22 at 11:00 AM. The ADON stated she was the one who investigated Resident #53's fall on 05/13/21. The ADON acknowledged the comprehensive assessment dated [DATE], that documented the resident required total dependence of two-person assist with bed mobility. The ADON stated the incident was not reported to authorities, including the State Survey Agency.

Based on observation, interview, record review, the facility failed to assess a resident with a hearing deficit for 1(Resident #82) of 2 sampled residents reviewed for hearing. The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an initial interview with Resident #82 on 01/04/22 at 10:22 AM she stated that she could not hear and to come closer and speak louder. She stated that she did not have a hearing aide. Subsequent interviews with Resident #82 on 01/05/22 at 3:31 PM and 01/06/22 at 9:57 AM revealed the resident could not have a conversation without this surveyor speaking very loud. A review of the resident's admission assessment with an assessment reference date (ARD) of 09/14/21,section B hearing , speech and vision, reveals it was coded as adequate in ability to hear which means no difficulty in normal conversation, social interaction or listening to TV (television). A quarterly MDS with an ARD of 12/15/21 under section B is also coded as adequate in ability to hear. A review of nursing monthly summary notes dated 11/05/21 and 12/07/21 revealed Resident #82's hearing is poor in both ears. On 01/05/22 an interview was conducted with the Social Service Director who stated that Resident #82 can hear adequately and if she could not, it must be new so she will call the family. A review of a Social Service progress note dated 01/05/22 revealed the Social Service Director called her POA (power of attorney) who said that she has had an impairment for sometime, however, as it has been described to him, it appears it has progressed. Hospice provider will be advised to address possible wax build up and/or authorize an ENT consult. Without surveyor intervention, Resident #82 was not assessed for a hearing deficit.

Based on interview and record review, the facility failed to provide adequate supervision of a resident to prevent a fall, resulting in injury, for 1 of 4 sampled residents reviewed for falls (Resident #53). The findings included: A review of the facility's policy Area of Focus: Fall Management, not dated, it was documented to promote patient safety and reduce patient falls by proactively identifying, care planning, and monitoring of patients' fall indicators. The facility must ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Resident #53 was admitted to the facility on [DATE] with a diagnosis including [CONDITION(S)]. A Comprehensive Assessment, dated 02/17/21, documented the resident had mild cognitive impairment, and required total dependence of two-person assist with bed mobility. Resident #53 was care planned for at risk for falls, dated 08/14/20. An intervention included to assist with activities of daily living as needed. Resident #53 was care planned for activities of daily living self-care performance deficit, dated 10/11/18. Interventions included assistance by staff for bathing/showering and assistance by staff to turn and reposition in bed. Record review revealed a progress note dated 05/13/21, at 10:30 AM, that documented: At approximately 10:30 AM while giving morning care the CNA (Certified Nurse Assistant) reported, I lost my balance slipped and fell on the floor causing the resident to roll on her left side and fell out of the bed on top of me. Resident was assessed and stated: I don't remember what happened. I am feeling OK, I don't feel any pain or any discomfort. Resident was assisted back to bed. Small bruise noted to resident left forearm. Denies any c/o (complaints of) pain nor discomfort at this time. Neuro checks in progress, no change noted in health status. Dr (doctor) notified. New order received for X-Ray to left shoulder, elbow and hip. (Family member) made aware. A Progress Note dated 05/13/21, at 4:30 PM, documented Resident #53 was sent out to the hospital for evaluation of a left femur fracture. A review of the fall investigation of Resident #53 on 05/13/21 revealed a written statement, dated 05/13/21, by Staff D (the CNA involved in the incident). The written statement documented when the CNA turned Resident #53 to change the resident, the CNA slipped on the floor and fell , and the resident fell off the bed on top of the CNA. The CNA documented she rolled the resident off of her and attempted to sit the resident up. The CNA documented she was not able to sit the resident up. The CNA called for help. An interview was conducted with the Assistant Director of Nursing (ADON) on 01/06/22 at 11:00 AM. The ADON stated she was the one who investigated Resident #53's fall on 05/13/21. The ADON acknowledged the comprehensive assessment dated [DATE], that documented the resident required total dependence of two-person assist with bed mobility. The ADON further acknowledged Resident #53's care plan did not specify the resident required an assist of two-persons with activities of daily living. The ADON was not able to provide any documentation of an investigation of why Staff D slipped and fell , or why Resident #53 fell out of bed.

Based on observation and interview, the facility failed to serve residents meals in a sanitary manner. The findings included: On 12/07/20 at 9:45 AM, during the initial tour of the Main Kitchen, accompanied by the Cook, the following was noted: 1. A partial case of plastic disposable lids stored under a work table in a box no cover. 2. Dish rag in sink instead of in a bucket with sanitizing solution. 3. Dirty can opener mounted on work table with unknown black particles on blade. 4. 3 ceiling vents with black dust. 5. Commercial toaster was noted to be dirty, rusted and black. 6. 4 gallons of regular milk with an expiration date 12/6/20, on the shelf in the walk in refrigerator. 7. 2 half pint skim milk container date 12/4/20.on the shelves in the walkin refrigerator 8. One 5lb container of cottage Cheese date12/4/20 found in walk in refrigerator. 9. A full size steam table pan with fruit crisp no date in walk in refrigerator. 10. Walk in Refrigerator and Freezer door gasket needs cleaning. They were covered with food and dirt. 11. Boxes stored on top shelves of the dry storage room was above the red line. On 12/10/20 at 10:00 AM, during a tour of the Nourishment pantries on the 2nd and 3rd floor unit accompanied by the Certified Dietary Manager, it was noted that the microwave had rust spots on the inside of the ceiling of the unit. On 12/10/20 at 10:30 AM, during an interview with the Certified Dietary Manager, he confirmed the findings.

Based on interview and record review, the facility failed to assess the effectiveness of pain medication in a timely manner for 1 of 1 sampled residents reviewed for pain (Resident #27). The findings included: On 12/08/20 at 11:58 AM, during an interview with Resident #27, he stated that he is on as needed pain medication every 8 hours, and expressed issues with the timings of some of the as needed pain medication. A review of Resident #27's Medication Administration Record [REDACTED]. The dosage was changed on 11/27/2020 to 10 mg every 8 hrs as needed, and then changed back to 5 mg every 6 hours as needed on 12/08/20. The Resident is also on [MEDICATION NAME] 100 mg every 12 hours for [MEDICAL CONDITION] pain. During the December MAR indicated [REDACTED] 1) On 12/04/2020 at 22:26 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 23:40 hrs, a follow-up for medication effectiveness was completed. This was 1 hour and 14 minutes after administration. 2) On 12/05/2020 at 06:30 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 08:29 hrs, a follow up for medication effectiveness was completed. This was 1 hr 59 min after administration. 3) On 12/05/2020 at 15:07 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 17:05 hrs, a follow up for medication effectiveness was completed. This was 2 hrs 02 min after administration. 4) On 12/05/2020 at 23:11 hrs, 10 mg of [MEDICATION NAME] was administered for pain; on 12/06/2020 at 23:11 hrs, a follow up for medication effectiveness was completed. This was 2 hrs 25 min after administration. 5) On 12/06/2020 at 07:05 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 08:58 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 53 min after administration. 6) On 12/06/2020 at 15:09 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 17:04 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 55 min after administration. 7) On 12/06/20 at 23:11 hrs, 10 mg of [MEDICATION NAME] was administered for pain; On 12/07/2020 at 01:05 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 54 min after administration. 8) On 12/07/2020 at 7:11 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 10:14 hrs, a follow up for medication effectiveness was completed. This was 3 hrs 03 min after administration. 9) On 12/07/2020 at 15:29 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 19:21 hrs, a follow up for medication effectiveness was completed. This was 3 hrs 52 min after administration. 10) On 12/08/2020 at 03:35 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 04:51 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 16 min after administration. 11) On 12/08/2020 at 12:16 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 13:48 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 32 min after administration. 12) On 12/08/2020 at 23:10 hrs, 10 mg of [MEDICATION NAME] was administered for pain; On 12/09/2020 at 01:02 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 52 min after administration. 13) On 12/09/2020 at 5:20 hrs, 10 mg of [MEDICATION NAME] was administered for pain; at 07:18 hrs, a follow up for medication effectiveness was completed. This was 1 hrs 58 min after administration. Resident #27's Care Plan, dated 10/27/2020, documents Resident #27 is at risk for alteration in comfort related to muscle weakness, and impaired mobility. One of the interventions documented is to Evaluate the effectiveness of pain interventions. On 12/10/20 at 11:10 AM, Staff A (RN) stated, Pain assessment should be completed within 30 minutes to an hour. The maximum would be 2 hours . On 12/10/20 at 3:04 PM, during an interview with the Director of Nursing, she confirmed that Professional nursing standards would be to access a resident for the effectiveness of administered pain medication 30 minutes to an hour after the pain medication is given.

Based on observation, interview and record review, the facility failed to apply an elbow splint as ordered to prevent worsening of contractures for 1 of 2 sampled residents reviewed for range of motion (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's record revealed a comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and required extensive two-person assist with activities of daily living. Resident #8 was care planned to wear an elbow extension splint on the right elbow throughout the day as tolerated and to be removed by staff for exercises, activities of daily living, and skin checks. A review of Resident #8's orders revealed an order dated 10/03/20 for occupational therapy clarification: patient to wear right elbow extension splint throughout the day as tolerated. Staff to remove for hygiene, skin checks, an exercises. Further review revealed an order dated 10/09/20 for Restorative Care: Splint/Brace right elbow extension splint on throughout the day as tolerated. Resident #8 was observed on 12/09/20 at 9:00 AM, 12:00 AM, 2:00 PM, and 4:00 PM in bed with his right arm contracted to his chest. Resident #8 did not have a right elbow splint in place. Resident #8 was observed on 12/10/20 at 9:30 AM and 11:30 AM in bed. Resident #8 did not have a right elbow splint in place. An interview was conducted with Staff G, a restorative certified nurse assistant (CNA), on 12/10/20 at 11:30 PM. Staff G stated Resident #8 was not on restorative services. Staff G stated the resident was discharged from restorative services on 10/25/20, and was not being seen for restorative care. Staff G stated it was Resident #8's CNA's responsibility to apply the splint to the resident's elbow. An interview was conducted with Staff H, a CNA assigned to Resident #8, on 12/10/20 at 11:40 PM. The CNA stated she was not aware Resident #8 was ordered to have a right elbow splint in place. The CNA located a splint on the resident's counter and left it in place. An interview was conducted with the Director of Rehabilitation on 12/10/20 at 11:50 PM. The Director stated Resident #8 has completed occupational therapy and was referred to restorative therapy on 10/09/20. The Director further stated they taught the restorative CNA and the resident's private duty aide range of motion exercises for Resident #8 and how to apply the resident's elbow splint. A review of the Restorative Nursing Communication Tool dated 10/09/20 documented Resident #8 was at risk of increased contractures in right elbow. The goal documented was to maintain range of motion of right elbow. A device of a right elbow splint to be on throuhgout the day as tolerated. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 12/10/20 at 1:00 PM. An observation of Resident #8 revealed the resident in bed, with the elbow splint in bed next to the resident. They both acknowledged Resident #8 did not have a right elbow splint in place as ordered.

Based on observation and interview, the facility failed to maintain and repair wheelchairs for 5 of 8 sampled residents reviewed (Resident #2, #3, #4, #5 and #6) for wheelchair function and maintenance. The findings included: During an interview on 02/04/20 at 1:57 PM, the wife of Resident #2 stated that her husband's wheelchair was not functioning properly. Observation of the wheelchair revealed a missing right brake and the wheel tread was visible worn and cracked. Photographic evidence was obtained and shared with facility management. During an interview on 02/04/20 at 2:10 PM, the daughter of Resident #3 stated that her father's wheelchair leg rest was worn. Observation of the wheelchair revealed torn padding on the leg rest and the chair was visible dirty. Photographic evidence was obtained and shared with facility management. During an interview on 02/04/20 at 2:30 PM, Resident #4 stated that she uses her wheelchair when she goes to the shower and that the brakes are not working. Observation of the wheelchair revealed the left brake did not function. Photographic evidence was obtained and shared with facility management. During an observation on 02/04/20 at 2:35 PM, Resident #5's left wheelchair brake handle was split open. Photographic evidence was obtained and shared with facility management. During an interview on 02/04/20 at 3:10 PM, Resident #6 stated that the wheels on his wheelchair are worn and stick. Observation on Resident #6's wheelchair revealed worn tire tread, pitted paint and brakes that rubbed against the wheels. Photographic evidence was obtained and shared with facility management. During an interview on 02/04/20 at 4:10 PM, the Maintenance Director stated that the facility maintains a calendar for cleaning and maintenance of all the wheelchairs in the facility. Review of the facility 'Wheelchair Maintenance Calendar' revealed that all wheelchairs are cleaned and repaired monthly. The Maintenance Director reviewed the photographic evidence and agreed with the findings.

Based on observation, interview, and record review the facility failed to ensure the call light was in reach for 1 of 3 sampled residents observed for call lights (Resident #1). The findings included: On 12/20/19 at 11:30 AM, an observation was conducted of Resident #1. At this time, the call light was noted to be out of the resident's reach. Further observations revealed Resident #1 is not able to lift his arms due to physical limitations. It was noted that the resident was provided with a flat call light that must be placed near his hand or arm so that he can roll over and press it. Observations noted that the call light was sitting up by his pillow and was out of reach. Not having use of a call light could potentially affect his care when needed by staff. Review of Resident #1's record revealed the resident is totally dependent on staff for food and fluids, and all ADL's (Activities of Daily Living). The most recent MDS (Minimum Data Set) assessment for a significant change, dated 11/07/19 documented the resident has a BIMS (Brief Interview for Mental Status) of 15, indicating intact cognition. A second observation of Resident #1 on 12/20/19 at 1:55 PM revealed the call light was placed on the right side of the resident's abdomen. When asked if he could reach his call light, he attempted, but could not. A review of the facility's policy titled, 'Resident Call System' revealed under Procedure, bullet point 5 states The call light must be positioned within reach of the resident at all times. Return demonstration must be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. In an interview with the Director of Nursing (DON) on 12/20/19 at 5:00 PM, the DON agreed that Resident #1's call light must be in a place where he can easily lean on it to get assistance from staff.

Based on observation and interview, the facility failed to serve meals in accordance to the resident's preferred palatable temperature and failed to honor a resident's food preference for 1 of 24 sampled residents (Resident #25). The findings included: During an interview with Resident #25 on 04/10/19 at 9:22 AM, she stated that her meals are not served at an acceptable temperature that is palatable. The resident stated that the food trays are transported to the wing on a food cart and the cart sits in the hallway for a period long time before the CNA passes them out to the residents. Resident #25 also stated that the food cart for her unit is the last unit to receive the food and her room is at the end of the hallway, which is last to be served at every meal. The resident has to ask the staff to reheat her meals. The resident further expressed that twice she received stalks of broccoli for her vegetable, which she does not like and was very upset. She stated that she reported this to the Certified Dietary Manager and told him of her preference. On 4/10/19 at 3:15 PM, an interview was conducted with the Certified Dietary Manager. He was informed of Resident #25's concern of cold food and failure of the facility to honor her food preference. He stated that he is familiar with the resident and confirmed that the resident previously reported the concern to him regarding receiving broccoli stems. He confirmed he was aware that the resident could not enjoy her vegetables because she did not like the broccoli stems, which were served to her.

Based on observation, interview and record review, the facility failed to ensure proper labeling of medications related to frequency of administration for 3 of 11 sampled residents (Resident #64, #79 and #251) reviewed for medications. The findings included: 1) A medication storage observation was made on 04/09/19 at 2:46 PM, of the 3rd floor east medication cart, with Staff D, a Registered Nurse (RN). Review of the label on the Controlled Medication Utilization Record for Resident #64 documented [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 10-325 milligrams (mg), give one tablet by mouth three times daily at 6 AM, 12 noon, and 6 PM. This label also documented to give one tablet by mouth every 4 hours as needed for non-acute back pain. The corresponding bubble pack with the tablets contained the same label. Review of the current order dated 03/07/19 documented [MEDICATION NAME] 10-325 mg, give one tablet by mouth one time a day for non-acute pain at 6 PM. During this observation, Staff D was asked the facility process when the frequency was changed for a medication. The RN explained that a Direction Change sticker was to be placed on the label. The RN stated she had asked for a roll of the labels just recently, but did not catch the concern regarding Resident #64's medication, as she does not give that medication on her shift. 2) During a review of Resident #79's record, it was noted that there were discrepancies between the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 3) Record review for Resident # 251, revealed that there was an inaccuracy of the record for the physician order [REDACTED]. The MAR indicated [REDACTED]. On 04/10/19 at 02:54 PM, a side by side review of the a forementioned resident records and an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who confirmed the findings regarding the discrepancies.

Based on observation, interview and record review, the facility failed to provide appropriate resident centered activities for 1 of 24 sampled residents (Resident #52), who was assessed as needing sensory activities. The findings included: During an observation on 04/08/19 at 10:22 AM, Resident #52 was in the common area (an area off the nurse's station used for restorative dining and activities), sitting in a recliner type chair. The resident's head was down and her eyes were closed. Staff called out her name once, but the resident did not respond. On 04/08/19 at 4:33 PM, Resident #52 was in her room sitting in her chair, with her head down and appeared to be sleeping. On 04/09/19 at 9:39 AM, Resident #52 ate breakfast in the main dining room, was then taken down the hall and put her outside of her room by the Unit manager, and then was taken into her room as the CNA made her bed. At 10:01 AM, Resident #52 was taken back to the common area. Some of the residents were participating in the parachute with a large balloon activity, but Resident #52 was sitting at a separate table away from the parachute, with no activity. On 04/09/19 at 4:13 PM, Resident #52 was in the main dining room, sitting at a table by herself, all the way to the side, during BINGO. The other residents were in the middle of the dining room. An empty BINGO card was in front of Resident #52 out of her reach. There were no BINGO chips. No one was sitting with the resident or assisting her in any way. Staff were not assisting Resident #52 to participate in any manner. On 04/10/19 at 8:44 AM, Resident #52 was in bed, but more alert with her eyes open, answering simple questions. The resident wanted to stay in her bed. At 11:45 AM, Resident #52 was in the common area during a table bowling activity. Resident #52 was in the room, but sitting back away from the table. The resident's eyes were open and she was watching the activity. Staff did not include Resident #52 in the activity. On 04/11/19 at 10:20 AM, Resident #52 was sitting in the common area near a table with a low functioning gadget/toy in front of her, but out of her reach. The staff did not assist her with this activity. During an interview on 04/11/19 at 10:36 AM, Staff C, an Activity Certified Nursing Assistant (CNA) was asked about the activities for Resident #52. The Activity CNA stated they sit with the resident and chat with her, and make sure she is comfortable. The Activity CNA stated the resident loves her coffee and they read to her. Staff C stated that sometimes she can see the big balloon and will bounce it back and forth. On 04/11/19 at 10:48 AM the Activity Director was made aware of the observations of the week, and was taken to the common area to observe Resident #52, who was still there with the low functioning item out of her reach. The Activity Director agreed with the observation. The Activity Director explained Resident #52 comes to activities daily to get stimulation. The Activity Director stated they always have music playing and she gets hand massages. The Activity Director stated Resident #52 needs that sensory stimulation. Review of the record revealed Resident #52 was admitted to the facility on [DATE]. Review of the current quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident did not answer the questions and is cognitively impaired. This MDS documented Resident #52 needed extensive assist for all Activities of Daily Living (ADLs). Review of the Annual MDS dated [DATE] documented it was very important for Resident #52 to participate in activities involving music, pets, groups, outside for fresh air, and religious services/practices, as per her family. Review of the care plan dated 12/21/18 documented Resident #52 was unable to make social activity preferences known, but that she spends time with group activities. The documented goal was to maintain involvement in cognitive stimulation, and social activities as desired. An intervention included to provide activities that are compatible with physical and mental capabilities. Review of the Individual Resident Daily Participation Record for (MONTH) and (MONTH) 2019 lacked any documented pet activity, outdoor activity, or hand massage or other low sensory activity, and only documented two religious activities. Activity progress notes dated 09/13/18 and 12/06/18 both documented she enjoys and or receives sensory stimulation and/or hand message, but the participation records lack any sensory stimulation except music and television. This record documented Resident #52 was actively participating in the parachute activity on 04/09/19, but was observed at a separate table during that activity, as noted above.

Based on observation, interview and record review, the facility failed to provide hair washing/shampooing for 1 of 24 sampled residents (Resident #7). The findings included: During an observation on 04/09/19 at 10:20 AM, Resident #7's hair appeared flat and greasy. During an interview on 04/09/19 at 12:13 PM, Resident #7's son stated the staff do not provide routine hair washing, and that is why he started having her go to the beauty salon. The son explained that when his mom lived at home, she would shower daily and wash her hair every other day. On 04/10/19 at 8:46 AM, Resident #7 was sitting in the restorative dining room waiting for breakfast. Her hair was combed, but remained very flat and looked greasy. Review of the record revealed Resident #7 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) score of 5, indicating she was cognitively impaired. This MDS also documented Resident #7 needed the total care of one for bathing. Review of the care plan dated 09/27/18 documented Resident #7 had self-care performance deficit for activities of daily living, including the need for assistance with bathing and showering. During an interview on 04/10/19 at 2:27 PM, Staff A, a Certified Nursing Assistant (CNA) stated Resident #7 does not like showers, but will usually agree to one once a week. When asked about hair washing or shampooing, Staff A stated, She goes to the beauty shop for her hair. During an observation and interview on 04/11/19 at 9:21 AM, the 3rd floor Unit Manager agreed Resident #7's hair looked like it needed washing and stated she should get her hair washed with her shower. On 04/11/19 at 9:29 AM the facility's beautician stated Resident #7's son signs her up about every 6 weeks or so for color. The beautician was standing near the restorative dining room and Resident #7 was sitting in her wheelchair across the open area. When asked to look at her hair, the beautician agreed it didn't look clean, stated she was not sure what the girls were doing, but explained her hair does not look flat and greasy like that when she does it. The beautician stated the condition of many of the resident's hair was poor, and that she sometimes has to wash a resident's hair three times to get it clean. During a supplemental interview on 04/11/19 at 9:50 AM, Staff A stated she does not use any product in Resident #7's hair, but when the resident wakes up, her hair is sticking up in all directions, so she will wet it to flatten it down. On 04/11/19 at 10:27 AM, Staff B, another CNA who works with Resident #7 stated she goes to the beauty shop to get her hair done. When asked how often, the CNA was unsure. Review of the hair appointment sheets from (MONTH) (YEAR) to the present time revealed Resident #7 had only been to the beautician three times, on 07/31/18, 11/27/18, and 02/21/19. Review of the Shower Schedule revealed Resident #7 was scheduled for a shower on the 7 AM to 3 PM shift, on Tuesday and Friday. This Shower Schedule documented instructions on the bottom for the CNAs to document a refusal in the ADL Tracker and to inform the nurse or Unit Manager. Review of the ADL tracker for (MONTH) 2019 documented Resident #7 prefers showers and had them scheduled for Tuesday and Friday, along with a PRN (as needed) option. This ADL record documented showers were provided. Review of the progress notes for February, (MONTH) and (MONTH) 2019 lacked any refusals of care. During an interview on 04/11/19 at 1:40 PM the Director of Nursing (DON) agreed the resident's hair should be washed at least weekly. The DON stated she would put in place a new process to have a hair washing day, or some other means to ensure a resident's hair is washed. The DON stated the resident should not have to go to the beauty shop to get her hair washed.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plans for 2 of 24 sampled residents (Resident #5 and #25) were prepared by an interdisciplinary team (IDT), and reviewed and revised after each assessment. The facility failed to ensure the comprehensive care plan was reviewed and revised by the IDT after the initial comprehensive assessment for Resident #25. The facility failed to incorporate the enitre IDT in the care planning process related to Resident #5 speaking a foreign language. The findings included: 1) Review of the record revealed Resident #25 was admitted to the facility on [DATE]. Further review of the record lacked any evidence of the incorporation of the IDT in the care planning process, or evidence of any care plan meeting. The record indicated a 5 day admission comprehensive assessment was completed on 02/07/19. During an interview on 04/10/19 at 10:09 AM, Staff E, a Minimum Data Set (MDS) Coordinator was asked about the care planning process. Staff E explained the care plan meeting was documented on the Care Plan Conference Record for each resident. When asked to locate and provide this record for Resident #25, Staff E could not locate it in the record. On 04/10/19 at 10:33 AM, Staff E returned with a binder and stated that she maintains a list of residents as they are admitted . She found Resident #25 listed and stated they had planned for a care plan meeting on 02/20/19, but stated she thought she was going to be discharged from the facility on 02/18/19, as per a hand written note on the invitation letter. The MDS Coordinator stated Resident #25 and her daughter decided at the last minute to stay at the facility as private pay. The MDS Coordinator stated they usually have their care plan meetings at day 14, coordinating with the completion of the comprehensive assessment. The MDS Coordinator confirmed Resident #25 was missed, but she was scheduled in (MONTH) 2019. 2) During initial observations the morning of 04/09/19, the surveyor was informed by Staff D, a Registered Nurse (RN), that Resident #5 speaks Russian, but if you tell her you don't speak Russian and to please speak English, she will do so most of the time. On 04/10/19 at approximately 8:45 AM, Resident #5 was observed ambulating independently into the restorative dining room, and rearranged some chairs and items lying around the room. At 9:15 AM Resident #5 was back in her room lying down. Her breakfast tray was untouched. At 9:35 AM, Staff B, a Certified Nursing Assistant (CNA) went into the room and assisted Resident #5. Staff B told the surveyor the resident speaks very little English. On 04/10/19 at 1:11 PM, the son of Resident #5's roommate, who visits daily, stated he had never heard Resident #5 speak English, had never heard any staff speak Russian, and had never heard any of the staff ask the resident to speak English. He had only heard Resident #5 speak Russian. During an interview with the Registered Dietetic Technician and the Registered Dietician on 04/10/19 at 4:00 PM at the nurse's station, Resident #5 wandered up to the surveyor and started speaking Russian. The surveyor slowly stated to the resident, I don't speak Russian. Please speak to me in English. Resident #5 began speaking English. Both dietary personnel stated they were not aware they should ask the resident to speak English, and stated that would have been nice to know in order to better communicate with the resident. During an interview on 04/10/19 at 4:25 PM, the Social Services Director (SSD) agreed Resident #5 could speak English when cued to do so. Upon review of the current care plans, the SSD agreed that specific individualized intervention was not part of the care plan addressing communication. On 04/10/19 at 4:39 PM, Staff D, the RN who provided direct care for Resident #5 and had previously informed the surveyor of how to communicate with the resident, was asked if she is part of the care planning process. She stated she was not. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the current MDS dated [DATE] documented Resident #5 has clear speech, sometimes is understood and sometimes understands. Review of the current care plan dated 01/14/19 related to impaired cognition/impaired decision making, lacked the intervention to cue Resident #5 to speak English. Review of the current Care Plan Conference Record dated 04/04/19 lacked involvement of the physician or a direct care RN. During an interview on 04/11/19 at approximately 10:00 AM, the Director of Nursing explained they started including a nurse and CNA in the care planning meetings as of 04/01/19. When asked how the physician or physician designee is involved in the care planning process, the DON explained they are in the building several times weekly, interacting with the residents and staff, but was unable to provide documented evidence of their participation in the care planning process.

Based on observation, interview and medical record review the facility failed to implement the interventions documented on the skin and fall care plans for 2 of 19 sampled residents (Resident #8 and Resident #278 respectively). Findings include: 1. On 03/16/11 at 10 AM Resident #8 was observed lying on the bed. The resident was very thin. The resident's chest and clavicle region was bony and protruding. The resident was receiving oxygen via a nasal canula. The resident's skin was pale, dry and flaky. The resident was alert and he was able to answer a few questions. The resident stated he remembered having a wound to the right hip. The resident stated he had pain in that area but now he is fine. The resident also stated the air mattress he was lying on was given to him when he had the sore to his hip. The resident also verbalized he needed assistance to move on the bed. Medical record review was conducted on 03/16/11. Resident # 8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's past medical history included diabetes, high cholesterol, [MEDICAL CONDITION], steroid use and intermittent history of [MEDICAL CONDITION]. The form titled Initial Data Collection Tool/Nursing Service dated 01/18/11 documented the resident was admitted with bruises to the right and left lower extremities, bruises to the left upper extremities and an incision to mid chest labeled as CABG (Coronary Artery Bypass Graft). The initial assessment with a picture of the body did not document any pressures ulcers on admission. The initial nurses notes dated 01/18/11 documented the resident had redness to the coccyx region. The most recent MDS 30 day assessment with reference date of 2/7/11 revealed resident # 8 was assessed as cognitively intact based on the brief interview for mental status (score of 14). The resident was assessed as having no memory deficits, [MEDICAL CONDITION] or behaviors. The resident functional status was assessed as requiring limited assistance with bed mobility with two or more persons physical assistance. The resident was assessed as requiring extensive assistance with two or more persons assistance with transfers. The resident's balance was assessed as not steady only able to stabilize with human assistance. The resident was also assessed as frequently incontinent of bladder and occasionally incontinent of bowel. Under skin conditions the resident was assessed as at risk for pressure ulcers. The care plan section documented a care plan for potential for skin breakdown due to impaired mobility, [MEDICAL CONDITION], respiratory disease and incontinence. The care plan was dated 01/25/11. The goal of the plan of care was documented as resident to maintain skin integrity thru next review date of 5/3/11. The approaches documented on the care plan included: have 1-2 staff as needed to move resident to prevent friction, teach resident risk factors, barrier cream to buttocks and air mattress in place. On 01/27/11 an approach of scheduled toileting program was added to the care plan. Further review of the nurses' notes, treatment records and wound care nurses notes revealed Resident # 8 received the air mattress on 02/16/11. The record failed to present any documentation that the air mattress was in placed prior to the development of the stage III pressure ulcer to the right hip. The February 2011 treatment record documented the air mattress was ordered on [DATE]. The nurses notes dated 02/16/11 documented the air mattress was put in place on that date. Review of the monthly flow report, Activity of Daily Living (ADL), which was completed by the Certified Nursing Assistants, was conducted on 03/17/11. The flow sheet documented resident # 8 required extensive assistance with bed mobility 27 days out of 41 days from 01/19/11 to 02/28/11. The report also documented the resident required limited assistance with bed mobility 6 days out of 41 days from 01/19/11 to 02/28/11. Review of the nurses notes dated from 01/18/11 to 02/15/11 failed to document the resident was repositioned by the nursing staff, or encouraged to reposition on his own, or that the resident was educated on off loading his right side prior to the development of the stage III pressure ulcer. Review of the wound care nurses notes revealed the following entries: On 02/15/11 the wound care nurses notes documented "resident complained of discomfort to right hip. Observed small open area to right hip with yellow wound bed... stage III.....resident instructed to shift position ...low air mattress and wound consult evaluation ordered". On 02/22/11 wound care nurses notes documented "ongoing treatment to right hip stage III with improvement noted....no signs of infection.... risk explained to resident". The pressure ulcer status record dated 02/15/11 documented the resident had a stage III to right hip measuring 0.6 x 0.5 x 0.2 cm. Yellow covered 100 % of wound bed. Interview with the Certified Nursing Assistant (CNA) who is typically assigned to resident # 8 was conducted on 03/17/11 at 12:30 PM. The aide stated the resident has dry and fragile skin. The aide also verbalized that she sometimes assisted the resident in repositioning, but the resident was able to reposition himself. The aide verbalized the resident scratches frequently and that he currently had a skin tear to his left leg. Interview with the Wound Care Nurse was conducted on 03/17/11 at 4:30 PM. The Wound Nurse reviewed her notes and verified the resident received a loss air mattress on 02/15/11. The nurse stated the resident preferred to lye on his right side, as he liked to look out the window. The nurse also verbalized as soon as she found the stage III ulcer, the air mattress was put into place and the resident was educated on off loading his right side. Interview with the Wound Care Nurse was conducted on 03/17/11 at 4:30 PM. The nurse stated the floor nurse advised her on 02/15/11 Resident # 8 was complaining of discomfort to the right hip. The wound nurse performed a skin observation and she found the stage III pressure ulcer to the right hip. The Wound Nurse stated she implemented the loss air mattress and a wound care consult immediately. Interview was conducted with the Case Manager on 03/17/11 at 5 PM. The Case Manager reviewed the clinical record and she was not able to find any documentation validating the intervention of an air mattress was put into place prior to the development of the stage III pressure ulcer. The Case Manager stated maybe when the resident was transferred to the hospital the air mattress was taken out. The Case Manager and Wound Care Nurse discussed the implementation of the air mattress and the Wound Nurse reiterated she placed the air mattress on 2/15/11 when she found the stage III pressure ulcer. The Case Manager then stated the MDS Coordinator created the care plan and they were not able to explain how the intervention was communicated to the nursing staff. Interview with the Certified Nursing Assistant assigned to Resident # 8 was conducted on 03/18/11 at 8:09 AM. The aide stated she sometimes would assist the resident with repositioning, but she stated the resident was able to do it on his own. The aide stated the resident skin was fair and dry skin. Interview with the Licensed Practical Nurse (LPN) was conducted on 03/18/11 at 8:16 AM. The nurse stated the resident needs encouragement with care. She described the resident's skin as dry, flaky and easily bruised due to steroid use. She stated the resident favored the right side. The nurse stated the resident had no open areas. She stated he had multiple scabs from scratching and a few bruises. When the wound to the right hip was brought to her attention, the nurse asked the aide what happened. The nurse verbalized the aide stated he was always scratching. The nurse also stated the resident used the urinal. The nurse described the resident was not always successful in placing the urinal correctly. The nurse verbalized the increased possibility of wet skin, compromised nutritional status and the fact that he preferred to lye on the his right side contributed to the pressure ulcer development. Interview with the Minimum Data Set (MDS) Coordinator/RN was conducted on 03/18/11 at approximately 10 AM. The Coordinator stated he created and reviewed Resident # 8's care plan. He stated the interventions were typically carried thru the treatment record or physician orders. The Coordinator verbalized he was not sure why the resident did not have the air mattress implemented as documented on the care plan. Then he stated maybe he forgot to put the date on the intervention, maybe the resident was not supposed to get an air mattress until he developed the pressure ulcer. 2) According to the record review conducted on 3/17/11, Resident # 278 has an admitting [DIAGNOSES REDACTED]. MDS (minimum data set) coded for 5 day assessment with an ARD (assessment review date) of 3/11/2011 documents under section G: functional status: documents the resident requires extensive assist with bed mobility, transfer, locomotion on the unit, and off the unit, dressing, toilet use and personal hygiene, resident not steady when transferring surface to surface, impairment on both sided of lower extremity, mobility devices wheelchair, resident believe he is capable of increase independence and so does the direct care staff, type of support is coded as " two + person physical assist " for areas such as transfer and bed mobility. Assessments are documented as follows: dated 3/4/11; Fall risk evaluation dated 3/4/11 noted a total score of 18, a resident who scores a 10 or higher is at risk for falls; resident reevaluated on 3/12/11 total fall risk score 20 , the changes made on the fall risk assessment occurred under the history of falls in the last 90 days. Falls reduction checklist dated 3/6/11 documents interventions such as PT OT evaluation, side rails 1/2 for enabler (this was order on the original admission orders [REDACTED] Evaluation for use of side rails dated 3/11/11 documents contributing factors for resident need to use side rails are weakness, balance deficit, and knees buckles, resident will use side rails with bed mobility and transfer. A review of the care plans document care plans for the following areas of problem or need: Care plan initiated on 3/11/11 problem potential for fall due to [MEDICAL CONDITION] impaired bed mobility and independent transfers and psychoactive medication use. Approaches include, Provide assistance of 2 staff with all transfer and slide board use, role= nursing and rehab. Care Plan for at risk for physical injury from falls was initiated on 3/4/11 and updated on 3/12/11, interventions include "assist of 2 for transfers and again on 3/12/11 assist of 2 staff for transfers, discipline nursing. Physical therapy progress report dated 3/6/11documents an evaluation was completed on this date-3/15/11 the evaluation documents under "current level of function at SOC (start of care) #3 Transfer: Bed<> (to and from) wheelchair- The patient is able to safely transfer from bed <> wheelchair requiring maximum assistance x 2 (76-99%assit with 2 people) with 30% verbal instruction/cues". Physical therapy progress report dated 3/6/11-3/15/11 documents current status for transfer bed<>wheelchair as the patient is able to safely transfer from bed <> wheelchair requiring maximum assistance x 2 (76%-99% assist with 2 people) with initiation cue and 30% verbal instruction/cues. Nursing notes documents on 3/12/11 at 1015 am the resident was being transferred from the bed to the chair, had to be lowered down to the floor as stated by CNS. Excoriated areas noted as left medial forearms and right knee dressing applied to areas. c/o (complains of )back pain denied when it happened then denied pain or discomfort vital signs 98.1-heart rate 86, resp. rate 18 B/P 141/80. At 1130 am MD notified of occurrence said to monitor for any acute pain, no x-ray if resident continue to deny pain. Wife is at the bedside at this time no discomfort was voiced. At 2 pm ABT continues for urinary tract infection with adverse reactions, no c/o discomfort post occurrence no acute distress. On 3/1311 noted document resident denies any c/o pain from fall. Staff interview conducted with nurse on duty on 3/17/11 at 1240 pm, she stated the CAN (certified nurse assistant) called her in and told her that the resident was lowered to the floor; the male cna and the resident stated the resident did not fall. He had some excoriation from the fall to the left forearm and right knee. treatment for [REDACTED]. The resident cannot bear any weight (wt.) on his lower extremities. I make sure they (the C.N.A. ' s) have to have 2 person assist male or not. Interview with CNA on 3/17/11, at 12:51 AM, I was the CNA on duty the day his accident happens. He revealed this was the first day he took care of this resident, after helping him with his day care (bathing, cleaning, helping with his clothes) " I had to transfer him to the wheel chair. I thought I could do it myself but when I saw he was too heavy I lowered him to the floor and called the nurse. I knew he was a 2 person assist but as male I thought I could do it. But now I don ' t assume anymore. I always get help when transferring him. The resident cannot help with transfer. The resident cannot move his lower extremities. " Staff interview conducted on 3/18/11 at 9:44 am with a CNA. She revealed that during report she is told if a new resident is a one or 2 person assist, and they wear a green band on their hand or I ask the nurse if I have questions. Staff interview with the risk manager registered nurse on 3/18/11 at 9:46 am, she stated there was an incident report filled out immediately. I spoke with the C.N.A., who is a new to us and educated him, also in-serviced him on the use of the lift. She requested to have PT reevaluate the resident to see how much assistance he needs. PT places green bands on the residents and denotes what type of assistance the resident needs for transfer, 1, 2 H (Hoyer). There was not a green band with a 2 at that time of the fall. Staff interview with the physical therapy manager conducted on 3/18/11 at 9:54 am, she stated the green band is applied when the nurse does the admission and places a number on it. After we do our evaluation then we leave it as is, if it was correctly assessed or change it accordingly. When new employees go through orientation I am responsible for the TIP, (total intergraded protection) program, it includes how to prevent skin tears and transfer training and I also do quarterly transfer training. Resident # 278 observation and interview conducted on 3/16/11 at 10 am, resident is sitting in his wheel chair on his way to attend a group activity. He stated he was feeling good today. Resident is in no apparent distress at this time, dressings to left forearm and right knee clean and dry. Resident #278 observation conducted on 3/16/11 at 2pm, resident sitting in his wheel chair on his way to physical therapy, no change in dressings Resident observation and interview conducted on 3/17/11 at 1pm the resident is observed to be sitting in his wheelchair watching TV, in apparent distress. Resident observation 3/18/11 at 9:15 am resident in bed eating breakfast, he states he feels good, no pain. Bandages noted on left forearm and right knee, clean and dry. Resident stated that ever since he fell there are always 2 staff members helping him transfer and they use the lift or a board. A Green band with a #2 noted on resident wrist.

Based on observation, interview and medical record review the facility failed to prevent an avoidable pressure ulcer for 1 of 3 sampled residents (Resident # 8), as evidenced by the development of a stage III pressure ulcer. The findings include: On 03/16/11 at 10 AM Resident # 8 was observed lying on the bed. The resident was very thin. The resident's chest and clavicle region was bony and protruding. The resident was receiving oxygen via a nasal canula. The resident's skin was pale, dry and flaky. The resident was alert and he was able to answer a few questions. The resident stated he remembered having a wound to the right hip. The resident stated he had pain in that area but now he is fine. The resident also stated the air mattress he was lying on was given to him when he had the sore to his hip. The resident added he was not able to move himself on the bed, he needed assistance. An observation of the resident's right hip was conducted on 03/17/11 at approximately 8:13 AM. The right hip wound was healed. The resident's right hip had a round area measuring approximately 0.2 cm with darker pigmentation than the rest of the skin, dark pink in color. Medical record review was conducted on 03/16/11. Resident # 8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s past medical history included diabetes, high cholesterol, [MEDICAL CONDITION], steroid use and intermittent history of [MEDICAL CONDITION]. The form titled Initial Data Collection Tool/Nursing Service dated 01/18/11 documented the resident was admitted with bruises to the right and left lower extremities, bruises to the left upper extremities and an incision to mid chest labeled as CABG (Coronary Artery Bypass Graft). The initial assessment with a picture of the body did not document any pressures ulcers on admission. The initial nurses notes dated 01/18/11 documented the resident had redness to the coccyx region. The admission Braden Scale (a form used to predict pressure sore risk) dated 01/18/11 documented a total score of 16. The total score key deemed 15-18 "At Risk". The back of the Braden Scale form documented resident at risk due to decreased or impaired bed and chair mobility and urinary and bowel incontinence. Review of the wound care nurses notes revealed the following entries: On 02/15/11 the wound care nurses notes documented "resident complained of discomfort to right hip. Observed small open area to right hip with yellow wound bed... stage III.....resident instructed to shift position ...low air mattress and wound consult evaluation ordered". On 02/22/11 wound care nurses notes documented "ongoing treatment to right hip stage III with improvement noted....no signs of infection.... risk explained to resident". The pressure ulcer status record dated 02/15/11 documented the resident had a stage III to the right hip measuring 0.6 x 0.5 x 0.2 cm. Yellow covered 100 % of wound bed. The weekly skin integrity data collection form dated 02/15/11 failed to document any open areas or skin conditions. The weekly skin integrity data collection form dated 02/22/11 documented dry skin as the only skin concern. A wound care consult dated 02/17/11 documented the chief complaint as devitalized tissue in wound. The wound type was described as pressure with measurements of 0.6 x 0.3 x 0.1 cm. The consultation also documented excessive necrotic (dead) tissue, yellow in color with mild drainage amount. Clinical stage was documented as unstageble and MDS stage was documented as stage III. Treatment listed as [MEDICATION NAME]. The Notes section documented: Due to necrotic tissue covering wound possible DTI (deep tissue injury) present, use treatment to prepare for debridement and educated resident to offload hip. A follow up wound consult dated 02/24/11 documented under notes: "Patient has high risk factors, included [MEDICAL CONDITION] unspecified and [MEDICAL CONDITION]". The readmission/return Minimum Data Set (MDS) with reference date of 01/25/11 revealed Resident # 8 was cognitively intact based on the brief interview for mental status (score of 13). The resident was assessed as having no memory deficits, [MEDICAL CONDITION] or behaviors. The resident functional status was assessed as requiring two persons assistance with bed mobility and transfers. The resident's balance was assessed as not steady but able to stabilize with human assistance. Under skin conditions the resident was assessed as at risk for pressure ulcer, and as not having any pressure ulcers on admission. The most recent MDS 30 day assessment with reference date of 2/7/11 revealed resident # 8 was assessed as cognitively intact based on the brief interview for mental status (score of 14). The resident was assessed as having no memory deficits, [MEDICAL CONDITION] or behaviors. The resident functional status was assessed as requiring limited assistance with bed mobility with two or more persons physical assistance. The resident was assessed as requiring extensive assistance with two or more persons assistance with transfers. The resident's balance was assessed as not steady only able to stabilize with human assistance. The resident was also assessed as frequently incontinent of bladder and occasionally incontinent of bowel. Under skin conditions the resident was assessed as at risk for pressure ulcers. The care plan section documented a care plan for potential for skin breakdown due to impaired mobility, [MEDICAL CONDITION], respiratory disease and incontinence. The care plan was dated 01/25/11. The goal of the plan of care was documented as resident to maintain skin integrity thru next review date of 5/3/11. The approaches documented on the care plan included: have 1-2 staff as needed to move resident to prevent friction, teach resident risk factors, barrier cream to buttocks and air mattress in place. On 01/27/11 an approach of scheduled toileting program was added to the care plan. Further review of the nurses' notes, treatment records and wound care nurses notes revealed Resident # 8 received the air mattress on 02/16/11. The record failed to present any documentation that the air mattress was in placed prior to the development of the stage III pressure ulcer to the right hip. The February 2011 treatment record documented the air mattress was ordered on [DATE]. The nurses notes dated 02/16/11 documented the air mattress was put in place on that date. Review of the monthly flow report, Activity of Daily Living (ADL), which was completed by the Certified Nursing Assistants, was conducted on 03/17/11. The flow sheet documented resident # 8 required extensive assistance with bed mobility 27 days out of 41 days from 01/19/11 to 02/28/11. The report also documented the resident required limited assistance with bed mobility 6 days out of 41 days from 01/19/11 to 02/28/11. Review of the nurses notes dated from 01/18/11 to 02/15/11 failed to document the resident was repositioned by the nursing staff, or encouraged to reposition on his own, or that the resident was educated on off loading his right side prior to the development of the stage III pressure ulcer. Interview with the Wound Care Nurse was conducted on 03/17/11 at 4:30 PM. The Wound Nurse reviewed her notes and verified the resident received a loss air mattress on 02/15/11. The nurse stated the resident preferred to lye on his right side, as he liked to look out the window. The nurse also verbalized as soon as she found the stage III ulcer, the air mattress was put into place and the resident was educated on off loading his right side. The nurse stated they were very aggressive in healing the ulcer and they kept the air mattress as a preventative measure. A nutritional note dated 01/07/11 documented resident had very low body weight and a Body Mass Index (BMI) of less than 18.5. The assessment also noted the resident was taking [MEDICATION NAME] a steroid medication that increases the risk of skin breakdown. The nutritional assessment dated [DATE] documented the resident's height as 5 feet 10 inches and a weight of 111.4 pounds on 01/18/11. Interview with the Certified Nursing Assistant (CNA) who is typically assigned to resident # 8 was conducted on 03/17/11 at 12:30 PM. The aide stated the resident has dry and fragile skin. The aide also verbalized that she sometimes assisted the resident in repositioning, but the resident was able to reposition himself. The aide verbalized the resident scratches frequently and that he currently had a skin tear to his left leg. Interview with the Wound Care Nurse was conducted on 03/17/11 at 4:30 PM. The nurse stated the floor nurse advised her on 02/15/11 Resident # 8 was complaining of discomfort to the right hip. The wound nurse performed a skin observation and she found the stage III pressure ulcer to the right hip. The Wound Nurse stated she implemented the loss air mattress and a wound care consult immediately. Interview was conducted with the Case Manager on 03/17/11 at 5 PM. The Case Manager reviewed the clinical record and she was not able to find any documentation validating the intervention of an air mattress was put into place prior to the development of the stage III pressure ulcer. The Case Manager stated maybe when the resident was transferred to the hospital the air mattress was taken out. The Case Manager and Wound Care Nurse discussed the implementation of the air mattress and the Wound Nurse reiterated she placed the air mattress on 2/15/11 when she found the stage III pressure ulcer. The Case Manager then stated the MDS Coordinator created the care plan and they were not able to explain how the intervention was communicated to the nursing staff. Interview with the Certified Nursing Assistant assigned to Resident # 8 was conducted on 03/18/11 at 8:09 AM. The aide stated she sometimes would assist the resident with repositioning, but she stated the resident was able to do it on his own. The aide stated the resident skin was fair and dry skin. Interview with the Licensed Practical Nurse (LPN) was conducted on 03/18/11 at 8:16 AM. The nurse stated the resident needs encouragement with care. She described resident ' s skin as dry, flaky and easily bruise due to steroid use. She stated the resident favored the right side. The nurse stated the resident had no open areas. She stated he had multiple scabs from scratching and a few bruises. When the wound to the right hip was brought to her attention, the nurse asked the aide what happened. The nurse verbalized the aide stated he was always scratching. The nurse also stated the resident used the urinal. The nurse described the resident was not always successful in placing the urinal correctly. The nurse verbalized the increased possibility of wet skin, compromised nutritional status and the fact that he preferred to lye on the his right side contributed to the pressure ulcer development. Interview with the Minimum Data Set (MDS) Coordinator/RN was conducted on 03/18/11 at approximately 10 AM. The Coordinator stated he created and reviewed Resident # 8's care plan. He stated the interventions were typically carried thru the treatment record or physician orders. The Coordinator verbalized he was not sure why the resident did not have the air mattress implemented as documented on the care plan. Then he stated maybe he forgot to put the date on the intervention, maybe the resident was not supposed to get an air mattress until he developed the pressure ulcer.