Every finding on record at Grand Plains Skilled Nursing by Americare

The facility reported a census of 51 residents. The sample included six residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from resident-to-resident abuse when, on 09/03/25 at approximately 05:00 AM, Resident (R)1 wandered into R2's room and struck R2, a cognitively and physically impaired resident, in the head. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion).R1's 07/28/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment documented R1 had physical behavioral symptoms directed towards others, rejection of care, and wandering behaviors that occurred one-to-three days during the look-back period.The 07/28/25 Behavioral Symptoms Care Area Assessment (CAA) documented R1 had wandering behaviors with rejection of care. The CAA documented risk factors included invading others' space and disruptions during activities and in the common areas.R1's 08/19/25 Significant Change Minimum Data Set was incomplete.R1's Care Plan dated 07/29/25 documented R1 wandered aimlessly and directed staff to develop a rapport and trust with R1 through regular visitation. The plan directed staff to anticipate R1's needs by following his physical or non-verbal indicators of discomfort and distress and follow up as indicated. Review of R1's EHR Progress Notes revealed the following: On 09/03/25 at 07:52 AM, Licensed Nurse (LN) G documented on 09/03/25 at 05:00 AM, staff heard someone yelling and found R1 in R2's room. R2's wife reported R1 had hit her and was trying to hit R2. LN G documented R2 nodded his head to indicate yes and rubbed the left side of his forehead when asked if R1 had hit him. LN G documented R2 had a red area on the left side of his forehead. LN G documented Administrative Staff A ordered one-on-one observation of R1.On 09/05/25 at 11:45 AM, LN I documented R1 left the facility with facility staff and his wife to go to a behavioral health unit (BHU).On 09/29/25 at 05:15 PM, LN I documented R1 arrived at the facility via Emergency Medical Services (EMS) from the hospital.The facility's investigation documented on 09/03/25 at 05:00 AM, staff heard yelling from R2's room and entered to find R1 swinging (fists) at R2's wife. Staff were able to remove R1 from R2's room and returned R1 to his room. The nurse assessed R2 and found a red mark on his upper left forehead without swelling or bruising.LN G's undated and unnotarized Witness Statement documented on 09/03/25, someone was yelling down the hall, and R1 was found in R2's room. R2's wife was present and reported R1 had hit her and said she was unsure if R1 had struck R2. R2 nodded yes when asked if R1 had hit him and rubbed the left side of his forehead. LN G documented R2 appeared to have a red area on the left side of his forehead. LN G also documented R1 was violent with staff and struck staff. LN G notified Administrative Staff A and was instructed to notify EMS and Law Enforcement Officers (LEO). Administrative Staff A ordered one-on-one observation for R1.Certified Nurse Aide (CNA) M's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA O heard yelling and went to investigate. Upon entering R2's room, R1 was standing between the bed and the wall with his arm up like he was ready to swing at R2; R2's wife was shielding him from R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O.CNA O's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA M heard yelling and went to investigate. R1 was observed with his arm up as if to hit R2, and R2's wife was attempting to block R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O.Administrative Staff B's undated and unnotarized Witness Statement documented on 09/03/25 at approximately 05:15 PM, she helped complete a care plan in R2's room and did not notice any marks on R2.Administrative Staff A's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time; no injuries were observed on R2's face or arms.Social Services X's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time; no injuries were observed on R2.Administrative Staff A's undated and unnotarized Witness Statement documented on 09/05/25 at 12:45 PM, LN I reported to Administrative Staff A that R2 had a black eye. Administrative Staff A documented that she and Activity Z went to R2's room and did not observe any bruising, swelling, or redness in R2's eyes or face.Administrative Nurse D's undated and unnotarized Witness Statement documented on 09/03/25 and 09/05/25 at unknown times, she looked at R2's face and did not see any bruising.Activity Z's unnotarized Witness Statement, dated 09/05/25 at 12:30 PM, documented she went with Administrative Staff A to R2's room to provide informational materials to R2's wife, and R2 did not have swelling, redness, or bruising to his face.Consultant GG's undated and unnotarized Witness Statement documented on 09/08/25 at approximately 10:30 AM, she was visiting with R2's wife regarding consultant/contract services after R2's discharge home, when R2's wife started to report unhappiness about how an abuse situation was handled. Consultant GG stopped R2's wife and reported the concern to Administrative Staff A. Administrative Staff A came into the room to speak with R2 and his wife. R2's wife stated she wanted to press charges against another resident.Administrative Staff A's unnotarized and undated Witness Statement documented on 09/08/25 at an unknown time, R2's wife reported to Consultant GG that she wanted to report to LEO and requested charges be filed against R1. Administrative Staff A went into the room and met with R2's wife, who requested to speak to LEO. Administrative Staff A called the police, and a LEO met with R2's wife.Review of the facility's investigation revealed documentation of one-on-one observation of R1 from 09/03/25 through 09/04/25.During an observation on 10/01/25 at 12:25 PM, R2 sat in his wheelchair in his room with his wife present.During an observation on 10/01/25 at 01:00 PM, R1 rested on his bed in his room with family present.During an interview on 10/01/25 at 12:25 PM, R2's wife reported R1 entered R2's room four times that she knew of before the incident on 09/03/25. R2's wife stated she was able to redirect R1 out of R2's room without incident, but on the morning of 09/03/25, she was awakened by R1 entering the room; R1 interlaced his fingers, raised his hands above his head, and tried to strike R2. R2's wife said she placed her arms and body between R2 and R1 and started yelling for help, and R1 struck her prior to staff responding and removing R1. R2's wife stated that at the time of the incident, she was unsure if R1 had struck R2 but confirmed facial bruising later developed.During an interview on 10/01/25 at 12:40 PM, CNA N reported on the morning of 09/03/25, the night shift informed her of an altercation between R1 and R2. Upon entering R2's room, she observed a bruise to R2's face near his eye. CNA N said if staff observed or suspected resident-to-resident abuse, staff should separate the residents and alert the nurse with the two-way radio, ensure the residents were safe, follow instructions from the nurse, and immediately fill out a report and/or witness statement.During an interview on 10/01/25 at 12:55 PM, Certified Medication Aide (CMA) R said if resident-to-resident abuse was observed or suspected, staff were instructed to separate the residents and redirect them as appropriate to ensure a safe environment. Staff would then alert other staff to notify the nurse, then follow instructions the nurse provided, and provide a written report and/or witness statement for the nurse. CMA R reported she was aware of the incident between R1 and R2 but was not directly involved in the event.During an interview on 10/01/25 at 01:15 PM, CNA P reported when she came to work on the morning of 09/03/25, R2 had bruising on his face near his eye. CNA P said Administrative Staff A spoke with staff to convince them nothing happened to R2.During an interview on 10/01/25 at 02:15 PM, LN H said if staff observe or suspect resident-to-resident abuse, they should separate the residents to ensure safety and alert other staff to let the nurse know or notify the nurse directly. When the nurse arrived in the area, the nurse would perform assessments and provide aid if needed, and document any injuries in the report and in the EHR progress notes. LN H said the nurse would collect written statements by any staff directly involved, notify administration and law enforcement, and fill out an incident report, including the witness statements from staff. LN H said she was aware of the incident between R1 and R2 but was not directly involved in the incident.During an interview on 10/01/25 at 02:40 PM, Administrative Staff A said that if resident-to-resident abuse was observed or suspected, the expectation was for staff to separate, ensure the safety of the residents, provide aid as necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported R1 entered R2's room and struck R2 and hit R2's wife. Administrative Staff A confirmed LEO and EMS were notified. Administrative Staff A reported R1 was placed on one-on-one observation by Administrative Staff A until 08:00 AM, when R1's wife arrived and assumed one-on-one observation until she left at 06:00 PM. Staff then provided one-on-one observation if R1's wife was not present until R1 was transferred to a BHU. Administrative Staff A stated she had not reported the incident to the SA as required.The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that the facility prohibited abuse from any perpetrator that included but was not limited to staff, volunteer, contracted staff, vendor, family member, visitor, or any other resident.This deficient practice was cited at a scope and severity of G (actual harm, isolated) to reflect fear and anxiety because of the noncompliance using the reasonable person concept due to R2's impaired cognition.

The facility reported a census of 51 residents. The sample included six residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to initiate protective actions to prevent the opportunity for additional resident-to-resident abuse, as required. On 09/03/25 at approximately 05:00 AM, Resident (R)1 wandered into R2's room and struck R2, a cognitively and physically impaired resident, in the head. R1 was placed on one-on-one observation by facility staff; however, R1 continued to wander into other resident's rooms with the potential to harm other residents on the unit. (Refer to F600) Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion).R1's 07/28/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment documented R1 had physical behavioral symptoms directed towards others, rejection of care, and wandering behaviors that occurred one to three days during the look-back period. The 07/28/25 Behavioral Symptoms Care Area Assessment (CAA) documented R1 had wandering behaviors with rejection of care. The CAA documented risk factors included invading others' space and disruptions during activities and in the common areas. R1's 08/19/25 Significant Change Minimum Data Set was incomplete.R1's Care Plan dated 07/29/25 documented R1 wandered aimlessly and directed staff to develop a rapport and trust with R1 through regular visitation. The plan directed staff to anticipate R1's needs by following his physical or non-verbal indicators of discomfort and distress and follow up as indicated. R1's EHR Progress Notes revealed a note dated 09/03/25 at 07:52 AM, by Licensed Nurse (LN) G, which documented on 09/03/25 at 05:00 AM, staff heard someone yelling and found R1 in R2's room. R2's wife reported R1 had hit her and was trying to hit R2. LN G documented R2 nodded his head to indicate yes and rubbed the left side of his forehead when asked if R1 had hit him. LN G documented R2 had a red area on the left side of his forehead. LN G documented Administrative Staff A ordered one-on-one observation of R1. In a progress note dated 09/03/25 at 10:11 PM, LN G documented that the resident received one-on-one observation and had wandered in and out of other residents' rooms. R1 became violent and shattered the lid of a toilet tank.In a note dated 09/05/25 at 11:45 AM, LN I documented R1 left the facility with facility staff and his wife to go to a behavioral health unit (BHU).Review of the facility's investigation revealed documentation of one-on-one observation of R1 from 09/03/25 through 09/04/25.During an observation on 10/01/25 at 01:00 PM, R1 rested on his bed in his room with family present. During an interview on 10/01/25 at 02:40 PM, Administrative Staff A said that if resident-to-resident abuse was observed or suspected, the expectation was for staff to separate, ensure the safety of the residents, provide aid as necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported R1 entered R2's room and struck R2 and R2's wife. Administrative Staff A confirmed LEO and EMS were notified, but not the State Survey Agency. Administrative Staff A reported R1 was placed on one-on-one observation by Administrative Staff A until 08:00 AM, when R1's wife arrived and assumed one-on-one observation until she left at 06:00 PM. Staff then provided one-on-one observation if R1's wife was not present until R1 was transferred to a BHU. The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that he facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be removed from contact with the resident during the course of the investigation. The resident suspected of elder-to-elder abuse will be provided supervision by staff until the physician, family, and facility management staff assess and provide treatment options to stop any further aggressive, abusive behavior by the elder. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

The facility reported a census of 51 residents. The sample included six residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Agency, as required. (Refer to F600) Findings included:- Review of R1's EHR Progress Notes revealed the following: On 09/03/25 at 07:52 AM, Licensed Nurse (LN) G documented on 09/03/25 at 05:00 AM, staff heard someone yelling and found R1 in R2's room. R2's wife reported R1 had hit her and was trying to hit R2. LN G documented R2 nodded his head to indicate yes and rubbed the left side of his forehead when asked if R1 had hit him. LN G documented R2 had a red area on the left side of his forehead. LN G documented Administrative Staff A ordered one-on-one observation of R1. The facility's investigation documented on 09/03/25 at 05:00 AM, staff heard yelling from R2's room and entered to find R1 swinging (fists) at R2's wife. Staff were able to remove R1 from R2's room and returned R1 to his room. The nurse assessed R2 and found a red mark on his upper left forehead without swelling or bruising. LN G's undated and unnotarized Witness Statement documented on 09/03/25, someone was yelling down the hall, and R1 was found in R2's room. R2's wife was present and reported R1 had hit her and said she was unsure if R1 had struck R2. R2 nodded yes when asked if R1 had hit him and rubbed the left side of his forehead. LN G documented R2 appeared to have a red area on the left side of his forehead. LN G notified Administrative Staff A and was instructed to notify EMS and Law Enforcement Officers (LEO). Administrative Staff A ordered a one-on-one observation for R1. Certified Nurse Aide (CNA) M's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA O heard yelling and went to investigate. Upon entering R2's room, R1 was standing between the bed and the wall with his arm up like he was ready to swing at R2; R2's wife was shielding him from R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O. CNA O's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA M heard yelling and went to investigate. R1 was observed with his arm up as if to hit R2, and R2's wife was attempting to block R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O. Administrative Staff A's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time; no injuries were observed on R2's face or arms. Administrative Staff A's unnotarized and undated Witness Statement documented on 09/08/25 at an unknown time, R2's wife reported to Consultant GG that she wanted to report to LEO and requested charges be filed against R1. Administrative Staff A went into the room and met with R2's wife, who requested to speak to LEO. Administrative Staff A called the police, and a LEO met with R2's wife. During an observation on 10/01/25 at 01:00 PM, R1 rested on his bed in his room with family present. During an interview on 10/01/25 at 12:25 PM, R2's wife reported R1 entered R2's room four times that she knew of before the incident on 09/03/25. R2's wife stated she was able to redirect R1 out of R2's room without incident, but on the morning of 09/03/25, she was awakened by R1 entering the room; R1 interlaced his fingers, raised his hands above his head, and tried to strike R2. R2's wife said she placed her arms and body between R2 and R1 and started yelling for help, and R1 struck her prior to staff responding and removing R1. R2's wife stated that at the time of the incident, she was unsure if R1 had struck R2, but confirmed facial bruising later developed. During an interview on 10/01/25 at 01:15 PM, CNA P reported that when she came to work on the morning of 09/03/25, R2 had bruising on his face near his eye. CNA P said Administrative Staff A spoke with staff to convince them that nothing happened to R2. During an interview on 10/01/25 at 02:40 PM, Administrative Staff A said that if resident-to-resident abuse was observed or suspected, the expectation was for staff to separate, ensure the safety of the residents, provide aid as necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported R1 entered R2's room and struck R2 and R2's wife. Administrative Staff A confirmed LEO and EMS were notified. Administrative Staff A stated she had not reported the incident to the SA as required. The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that the Administrator would notify the SA within 24 hours of the incident unless the incident met the definition of a crime against a person or resulted in serious bodily injury, then the report would be made to LEO and SA no later than two hours after the incident.

The facility reported a census of 49 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - On [DATE] at 02:40 PM during an initial tour of the main kitchen, refrigerator and dry food storage areas with Kitchen Manager CC, the following areas of concern were observed: One unsealed bag of ham open to air undated in walk in freezer. Two bag of undated and unlabeled chicken patties. Two bag of undated and unlabeled chicken nuggets. One bag of undated and unlabeled tater tots. One bag of undated and unlabeled French fries. Eight bottles of expired Lemon Juice dated [DATE]. On [DATE] at 03:28 PM an interview with Kitchen Manager CC, revealed she expected staff to label, and date opened food items. Kitchen Manager CC, revealed that the above concerns identified with dry storage and freezer storage, which included undated and unsealed items were unacceptable. The facility's policy Food Receiving and Storage undated revealed that all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Foods will be rotated using a first in- first out system. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility identified a census of 49 residents. The sample included 13 residents. The facility identified residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on observations, interviews, and record review, the facility failed to ensure the EBP residents were cared for by staff using appropriate precautions. Further the facility failed to ensure staff used appropriate hand hygiene and glove changes with resident care. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 03/10/25 at 04:58 PM, observation of two unidentified Certified Nurse Aides provided care for an unidentified resident. Resident (R) had enhanced barrier precaution (EBP) sign on the door instructing staff to gown and glove when providing close contact care for the resident. Both CNAs were not wearing gowns while taking the resident, with an indwelling catheter, to the restroom. On 03/11/25 at 11:02 AM, observation of CNA N and CNA O provided toileting care for R36. R36 had a sign on his door instructing staff to use EBP when performing close contact care. Both CNAs where not wearing the appropriate personal protective equipment (PPE). On 03/11/25 at 11:02 AM, CNA N revealed she had not been educated to wear a gown with close contact care with a resident with an indwelling catheter. CNA N confirmed the sign on the door and that she should have worn a gown with her gloves. On 03/11/25 at 11:02 AM, CNA O revealed she should have had a gown on during the care for R36. On 03/12/25 at 10:40 AM, Licensed Nurse (LN) I performed percutaneous endoscope gastrostomy tube (PEG - a tube inserted through the wall of the abdomen directly into the stomach) for R6, not wearing appropriate PPE. CNA P entered the room to assist with care for R6, not wearing appropriate PPE. On 03/12/25 at 11:03 AM, LN I confirmed he should have worn a gown for the peg tube feeding and that he had not. LN I confirmed the sign on the door instructed staff to use EBP for close contact care with R6. On 03/05/25 at 09:05 AM CNA P confirmed she should have worn a gown as instructed on the resident's door. On 03/12/25 at 01:04 PM, CNA M and CNA N were performing peri care on an unknown resident. CNA M cleans resident peri area with a wipe, then with the same gloved hands touches the residents head, pillow, blanket, and oxygen tubing. On 03/12/25 at 01:20 PM, CNA M confirmed she did not change gloves from dirty to clean and should have. CNA M confirmed she had been educated to do so. On 03/05/25 at 09:45 AM, Licensed Nurse (LN) I confirmed each resident with EBP should have a sign on their door instructing staff to use EBP with close care of those residents. LN I revealed the supplies were in the closets right on both ends of the hallways. On 03/12/25 at 06:56 AM, Administrative Nurse D revealed every resident with EBP should have a sign on their door. She confirmed she would expect all staff providing close care for those residents to wear the appropriate PPE. Administrative Nurse D stated they had the supplies in two closets on all the halls and that they were looking into hanging storage on the doors for the PPE. Administrative Nurse D stated they had put the PPE on the halls as they felt the carts in the hallway would have cluttered the halls. The facility's Enhanced Barrier Precautions (EBP) policy dated 2025 documented that the policy of the facility was to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms, that employ targeted gown and glove use during high contact resident care activities. The facility failed to ensure staff followed EBP protocol with tube feedings, catheter care and glove use. This deficient practice placed the residents at risk for infection.

The facility reported a census of 49 residents. Based on observation, interview, and record review, the facility failed to ensure the availability of proper maintenance equipment for the dishwasher and appropriate monitoring to automatic sanitizing to maintain properly functioning equipment. Findings included: - On 03/10/25 at 03:28 PM Kitchen Manager CC was observed making sanitizer water that registered at 50 parts per million. Kitchen Manager CC was unable to provide chlorine test strips to test the chlorine level in the dishwasher. Interview on 03/10/25 at 03:54 PM with Kitchen Manager CC revealed dietary staff were expected to test the sanitizer level daily. There was no written log of the results of the sanitizer test as staff were trusted to be testing it as expected. Kitchen Manager CC revealed, sanitizer was working 03/06/25 to her last knowledge. Kitchen Manager CC revealed, being unaware how long kitchen staff have been without chlorine testing strips for the dishwasher. Staff had not brought either of these issues to Kitchen Manager CC's attention. The facility failed to provide a policy related to maintaining properly functioning equipment. The facility failed to maintain mechanical equipment in safe operating condition.

The facility reported a census of 49 residents with 13 residents sampled. Based on observation, interview, and record review the facility failed to protect the privacy and dignity of Resident (R) 36 when the indwelling catheter bag was left with no privacy cover. These practices had the potential to lead to negative psychosocial effects related to dignity. Findings included: - The Electronic Health Record (EHR) for R36 included the diagnosis of neuromuscular bladder. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated mildly impaired cognition. The assessment documented R36 as dependent on staff for all cares. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 12/29/24 documented R36 required a urinary catheter and was dependent on staff. Observations on 03/10/25 at 04:58 PM, 03/11/25 at 11:02 AM, 03/12/25 at 08:38 AM, R36's indwelling catheter drainage bag was facing the window in his room with no privacy cover, covering it from the staff and public that parked in the parking lot and walking down the sidewalk right next to the window. The blinds on the window are open for each observation. Interview on 03/13/25 at 10:45 AM, CNA Q revealed if there were an enhanced barrier precautions sign on their door, she would wear a gown and gloves when providing close contact care. CNA Q would expect every indwelling urinary catheter drainage bag to have a privacy cover on it. Interview on 03/13/25 at 11:23 AM, Licensed Nurse (LN) K confirmed all urinary indwelling catheter drainage bags would have a privacy cover on them. Interview on 03/14/24 at 08:25 AM, Administrative Nurse B stated her expectation was to have a privacy cover on the urinary indwelling catheter drainage bag. The facility's Promoting/Maintaining Resident Dignity policy dated 2024 documented the facility would protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintained or enhanced resident's quality of life by recognizing each resident's individuality. The facility failed to protect the dignity of R36 when his indwelling catheter bag was left open to the public with no privacy cover. This deficient practice had the potential to lead to negative psychosocial effects related to dignity.

The facility reported a census 49 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - Initial tour of the outside trash dumpsters on 03/10/25 at 02:40 PM with Kitchen Manager CC, revealed four dumpsters had the lids in the open position, one of which was missing the dumpster lid. Dumpster lids were all failed to completely cover the trash cans. On 03/10/25 at 02:40 PM, Kitchen Manager CC, revealed she was not aware of the requirement to have trash covered. On 03/13/25 at 04:48 PM, Administrative Staff A stated that the dumpsters belonged to the city. The facility lacked a policy related to garbage and refuse handling and disposal. The facility failed to provide sanitary garbage and refuse containers that were maintained with lids closed or otherwise covered. This deficient practice had the potential to lead to harborage and feeding of pest animals.

The facility had a census of 42 residents. The sample included 12 residents, with two reviewed for pressure ulcers/pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to implement interventions to prevent the development of a facility-acquired, right heel pressure ulcer for Resident (R)22 and R39 who were at risk for pressure injuries. Findings included: - R22's Electronic Medical Record (EMR) documented she admitted to the facility on [DATE] from the community. R22's EMR documented she had diagnoses of unsteadiness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and reduced mobility. R22's Admission Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R22 required extensive assistance of one staff for transfers, walking in the room, toilet use, and bed mobility. The MDS recorded the resident had pressure reducing devices to her bed and chair but had no pressure ulcers and was not at risk for pressure injuries. The 09/23/22 Pressure Ulcer Care Area Assessment triggered and addressed in the care plan. The 09/10/22 Braden Scale (an assessment used to measure risk for pressure ulcer development) documented R22's score was 18, which indicated R22 was at risk for developing a pressure ulcer. R22's Quarterly MDS dated [DATE], documented R22 had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS documented the resident did not walk and required total staff assistance with locomotion. R22 required extensive staff assistance with most activities of daily living (ADL) including bed mobility. The MDS documented the resident had lower extremity impairment on one side. The MDS recorded the resident had one unhealed stage three (full thickness skin loss) pressure injury, was at risk for pressure injuries, and had pressure reducing devices on her bed and wheelchair but was not on a turning and/or repositioning program. R22's ADL Care Plan, revised on 04/14/23, documented R22 required one staff assistance with ADLs except eating. R22's Skin Integrity Care Plan dated 09/28/22 and revised on 12/08/22 directed R22 was at risk for alteration in skin integrity as evidenced by a pressure area to the right heel. The care plan instructed the charge nurse to perform weekly skin assessments and notify the nurse if R22 had any new skin issues (initiated on 09/28/22). The care plan instructed staff to place heel protectors on R22 at all times and place a pressure reducing mattress to her bed at all times (created on 03/10/23 with initiation backdated to 10/05/23). The care plan lacked evidence of pressure injury preventative measures developed and/or implemented prior to development of the pressure injury. A Nurses Note, dated 10/06/22 at 10:15 AM documented staff noted an intact blister to R22's right heel which measured 4.7 centimeters (cm) by 6.7 cm. Staff notified the physician and staff placed heel lift boots on R22's bilateral feet. The note recorded staff would use skin prep (liquid skin protectant) twice a day to the area. The 12/05/22 at 09:30 AM, Wound Specialist Note documented R22 had an unstageable (full-thickness pressure injuries in which the base is obscured by slough [moist, loose, stringy dead tissue] and/or eschar [dry dead tissue]) pressure ulcer on her right heel. The wound was there for over a month. R22 received clindamycin (antibiotic medication) for infection. The note documented the right heel ulcer was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), and the ulcer increased in size in all dimensions by one millimeter (mm). The bone was exposed, and a wound culture was obtained. The note documented a vacuum assisted closure device (Wound-Vac-device which decreases pressure on the wound to help the wound heal more quickly) was ordered. The 01/19/23 at 09:15 AM Wound Specialist Note documented R22's right heel ulceration to the posterior (back) aspect of the right heel measured 4 cm by 3.4 cm and was granular in nature, had odor, and a Wound-Vac was placed on the ulcer. The 05/15/23 at 02:45 PM Wound Specialist Note documented R22's ulcer to the posterior (back) aspect of the right heel measured 3.8 cm by 2.2 cm and had one area of eschar on the top of the wound, and the physician instructed staff to use Santyl (a medication used to remove dead skin tissue and aid in wound healing) on the area with eschar. On 06/22/23 at 10:35 AM, R22 sat in a recliner with the footrest up and heel protectors on. LN H asked the resident if he could change the dressing to her right heel. R22 consented. LN H applied gloves, sat the items on a bedside table after removing other items, then removed the residents heel protector boot on her right foot. LN H removed a four-by-four gauze pad and revealed a small amount of serosanguineous (semi-thick reddish drainage) drainage on the dressing. The wound was approximately 4 cm in diameter with approximately 4 cm long with 0.25 cm wide eschar at the top of the wound. The wound area presented with visible eschar, at the top. On 06/26/23 at 04:07 PM, LN I stated when R22 was first admitted to the facility she walked short distances in her room to the bathroom, but not in the hallway. LN I verified the only interventions in place prior to the resident acquiring a pressure ulcer to her right heel was the charge nurse was to do weekly skin checks and notify the nurse of any new skin issues. On 06/27/23 at 09:50 AM, Administrative Nurse D verified appropriate preventative measure were not in place prior to R22 acquiring the pressure ulcer to her right heel, in the facility. Administrative Nurse D stated she was not employed at the facility at the time of R22's admission, but if she had been, she would have initiated appropriate preventative measures for R22 due to the resident's risk for developing pressure ulcers. The facility's Pressure Injury Prevention and Management Policy, revised 01/01/23, documented the facility should establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriate. The facility failed to develop interventions that addressed R22's risk for pressure ulcer development which resulted in a facility-acquired, unstageable pressure ulcer to the resident's right heel. 27168 - R39's Physician Order Sheet included diagnoses of arterial sclerotic heart disease (ASHD-a condition where the arteries become narrowed and hardened due to buildup of fat in the artery wall.), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillization (rapid, irregular heartbeat), and hypertension (elevated blood pressure). R39's Admission Minimum Data Set (MDS) assessment, dated 04/17/23, recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, walking in room, dressing, toilet use, personal hygiene, and had functional impairment of upper extremity on one side. The MDS further documented the resident had a surgical wound. The 04/19/23 Pressure Ulcer Care Area Assessment (CAA) documented the resident had no pressure ulcers. The Urinary Incontinence CAA, documented R39 required two staff assistance with toileting, and the resident was incontinent and wore incontinent products. R39's Braden [Scale (an assessment tool used to assess and document a resident's risk for developing pressure ulcers) dated 04/12/23, documented a score of 16.0 which indicated the resident was at risk for pressure ulcer development. The Skin Integrity Care Plan, dated 04/19/23 directed the charge nurse to perform weekly skin assessments and notify the charge nurse of any skin alterations. The Activities of Daily Living [ADL] Care Plan, dated 04/19/23 directed two staff to assist the resident with toileting and the required incontinent products. The plan directed R39 required assistance of two staff with bed mobility, dressing and toileting. The Progress Notes, dated 06/08/23 at 10:38 AM, recorded the nurse left a message for the physician concerning R39 buttocks. The note recorded R39's scratch/wound was healed although there were petechia (pinpoint spots on the skin) noted on R39's buttocks and the skin were deep purple in color, in the area of the scratch/wound. The Weekly Pressure Ulcer Healing Assessment, dated 06/14/23, documented R39 had a facility-acquired right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 0.5 centimeters (cm) by 0.5 cm with no depth, a scant amount of exudate (secretion) with serosanguineous (exudate mixed with blood) drainage and was inaccurately documented as a stage one (skin intact, but red and non-blanchable). The assessment documented an order to change the dressing, pat dry, apply calcium alginate (highly absorbent material), and cover with Mepilex AG (a nonstick soft spongy grey foam pad that has silver within it and the foam dressing shields the wound and the silver helps to kill the bacteria). The Weekly Pressure Ulcer Healing Assessment, dated 06/22/23, documented R39 had a right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 3.4 cm by 7.0, with no depth, a moderate amount of serosanguineous drainage and noted the wound size had increased. The nurses cleansed with wound cleanser, patted dry, applied Mepilex AG, and changed the dressing on Monday, Wednesday, and Friday. On 06/21/23 at 12:00 PM, R39 laid on his back in bed and visited with his guests. On 06/22/23 at 09:00 AM, R39 laid in bed on his back. Administrative Nurse E, Certified Nurse Aide (CNA) M, and CNA N positioned R39 on his left side. Administrative Nurse E removed the old dressing and cleansed the open area on R39's right buttocks with wound cleanser. The wound appeared as a two-inch reddened round area with approximately three-quarters of an inch open. Administrative Nurse E applied a Mepilex dressing and covered with an Opsite (a breathable, flexible, waterproof dressing) dressing. Administrative Nurse E stated the wound treatment was recently changed after the resident's representative took a picture of the area and showed it to the physician's office, and the physician changed the treatment to a different dressing. On 06/22/23 at 09:10 AM, Administrative Nurse E verified R39 developed a facility-acquired pressure ulcer on his right buttocks. Administrative Nurse E verified in mid-May, the resident developed a scratch on his bottom that went away and then developed the pressure area mid-June. Administrative Nurse E stated the physician thought the area could be a [NAME] Ulcer (a term used to describe the development and rapid progression of a pressure-based tissue injury in residents identified as being imminently terminal) however she checked with the physician, and he did not diagnose the ulcer as a [NAME] ulcer but instead diagnosed a facility-acquired pressure ulcer. On 06/26/23 at 02:00 PM interview with Administrative Nurse D verified R39 had a scratch that was noted on his bottom mid-May and that went away in a few days. On 06/14/23 the resident developed a pressure area to his bottom and verified the pressure ulcer was facility acquired. Administrative Nurse D stated after the development of the ulcer the physician ordered an air mattress on the bed, and before the air mattress, the staff changed R39's position hourly. Administrative Nurse D verified the nurse who documented the stage one ulcer on the Weekly Wound Assessments should have documented at least a stage two ulcer (an open wound which extends into the layers beneath the skin) due to the skin area was open. Administrative Nurse D verified the interventions, including an air mattress or skin treatments, were not documented in the care plan and should be. The Pressure Injury Prevention and Management, policy dated 01/01/23, documented the facility was committed to the prevention of avoidable pressure injury, prevent infection and the development of additional pressure ulcers. The facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, interventions to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. A Licensed Nurse would conduct a pressure injury risk assessment, using the Braden scale, on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly. The Braden scale would be used in conjunction with other risk factors not captured by the risk assessment tool. After completion of the assessments/evaluations the interdisciplinary team would develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions on a resident's care plan would be modified as needed. The facility failed to implement preventative measures to prevent a facility-acquired stage two pressure ulcers for R39, who was at risk for pressure ulcer development. The facility failed to identify and respond to deep purple discoloration which evolved into an open pressure injury. The facility further failed to accurately assess R39's facility acquired pressure injury to obtain appropriate treatment orders. These deficient practices placed R39 at risk for further injury and/or delayed wound healing.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) for Residents (R) 4, R36, R29 and R147 was labeled in accordance with currently accepted professional standards with an open date or expiration date, failed to discard expired insulin, and failed to ensure refrigerated stock medications were not expired. This deficient practice placed residents at risk for treatment with expired or ineffective medication. Findings included: - On 06/21/23 at 09:02 AM, observation revealed Certified Medication Aide (CMA) R dispensing medications from the north/west medication cart. On 06/21/23 at 09:05 AM, observation revealed the medication room refrigerator held: Two boxes of influenza (flu)vaccines, expiration date 05/06/2023. A box of Tylenol (pain reliver and fever reducer) suppositories expiration date 01/2023. A box of promethazine (drug used to treat allergies and to prevent vomiting) suppositories, expiration date 05/2023. On 06/21/23 at 09:17 AM, observation of the nurse's medication cart revealed: R4's Levemir (long acting) insulin pen was not dated when opened. R29's Basaglar (long acting) insulin pen was not dated when opened. R147's Novolog (fast acting) insulin pen was not dated when opened. R36's Novolog insulin pen was dated 04/16/23 (65 days old). The Novolog insulin pen storage directions stated the pens could be used for up to 28 days. On 06/21/23 at 09:05 AM, CMA R verified the expired medications in the medication room refrigerator. On 06/21/23 at 09:17 AM, Licensed Nurse G verified the undated and expired insulins on the nurse's medication cart and stated nurses were to date all insulin pens when they were opened. The facility's Labeling of Medications and Biologicals policy, dated 2023, stated all medications and biologicals would be labeled in accordance with current accepted pharmacological practices. The facility's Medication Storage policy, dated 2023, stated all medication rooms are routinely inspected by the consultant pharmacist for outdated, discontinued, or deteriorated medications. The facility failed to ensure the insulin pens for R4, R36, R29 and R147 were labeled, in accordance with currently accepted professional standards, with an open date or expiration date; failed to discard expired insulin, and failed to ensure the refrigerated stock medications were not expired. This placed the residents at risk for treatment with expired or ineffective medication.

The facility had a census of 42 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R)20 and R21, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055. This placed the resident, or their representatives at risk to make uninformed decisions about their skilled services and at risk to incur charges if exercising their right to appeal. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility failed to provide R20, or her representative, the completed form 10055, knowing she may have to pay out of pocket. The resident's skilled services ended on 02/09/23. The facility staff failed to provide R21, or her representative, the completed form 10055, knowing she may have to pay out of pocket. The resident's services ended on 11/03/22. On 06/27/23 at 09:15 AM, Administrative Staff B and Nurse Consultant GG verified the facility had not provided R20 or R21, and/or their representative the CMS form 10055. The facility's Advance Beneficiary Notices policy, dated 01/01/23, recorded the facility would inform Medicare beneficiaries of his/her potential liability for payment and a Medicare liability notice would be issued to Medicare beneficiaries upon admission or during a resident ' s stay, before the facility provides an item or service that is usually paid for by Medicare, but may not be paid for in particular instance because it is not medically reasonable and necessary. The current CMS approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). The facility failed to provide R20 and R21 or their representatives, the completed 10055 form when discharged from skilled care, which placed them at risk to make uninformed decisions about their services and continuation of their skilled services.

The facility had a census of 42 residents. The sample included 12 residents, with two reviewed for skin conditions. Based on observation, record review, and interview, the facility failed to update Resident (R)39's care plan with interventions related to prevention of pressure injuries and failed to update R11's care plan with instructions to staff regarding hopsice care. This placed R39 at risk for further injuries to his skin due to uncommunicated or unmet needs and R11 at risk for unmet care needs Findings included: - R39's Physician Order Sheet included diagnoses of arterial sclerotic heart disease (ASHD-a condition where the arteries become narrowed and hardened due to buildup of fat in the artery wall.), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillization (rapid, irregular heartbeat), and hypertension (elevated blood pressure). R39's Admission Minimum Data Set (MDS) assessment, dated 04/17/23, recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, walking in room, dressing, toilet use, personal hygiene, and had functional impairment of upper extremity on one side. The MDS further documented the resident had a surgical wound. The 04/19/23 Pressure Ulcer Care Area Assessment (CAA) documented the resident had no pressure ulcers. The Urinary Incontinence CAA, documented R39 required two staff assistance with toileting, and the resident was incontinent and wore incontinent products. R39's Braden [Scale (an assessment tool used to assess and document a resident's risk for developing pressure ulcers) dated 04/12/23, documented a score of 16.0 which indicated the resident was at risk for pressure ulcer development. The Skin Integrity Care Plan, dated 04/19/23 directed the charge nurse to perform weekly skin assessments and notify the charge nurse of any skin alterations. The Activities of Daily Living [ADL] Care Plan, dated 04/19/23 directed two staff to assist the resident with toileting and the required incontinent products. The plan directed R39 required assistance of two staff with bed mobility, dressing and toileting. The Progress Notes, dated 06/08/23 at 10:38 AM, recorded the nurse left a message for the physician concerning R39 buttocks. The note recorded R39's scratch/wound was healed although there were petechia (pinpoint spots on the skin) noted on R39's buttocks and the skin were deep purple in color, in the area of the scratch/wound. The Weekly Pressure Ulcer Healing Assessment, dated 06/14/23, documented R39 had a facility-acquired right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 0.5 centimeters (cm) by 0.5 cm with no depth, a scant amount of exudate (secretion) with serosanguineous (exudate mixed with blood) drainage, and was inaccurately documented as a stage one (skin intact, but red and non-blanchable). The assessment documented an order to change the dressing, pat dry, apply calcium alginate (highly absorbent material), and cover with Mepilex AG (a nonstick soft spongy grey foam pad that has silver within it and the foam dressing shields the wound and the silver helps to kill the bacteria). The Weekly Pressure Ulcer Healing Assessment, dated 06/22/23, documented R39 had a right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 3.4 cm by 7.0, with no depth, a moderate amount of serosanguineous drainage and noted the wound size had increased. The nurses cleansed with wound cleanser, patted dry, applied Mepilex AG, and changed the dressing on Monday, Wednesday, and Friday. On 06/21/23 at 12:00 PM, R39 laid on his back in bed and visited with his guests. On 06/22/23 at 09:00 AM, R39 laid in bed on his back. Administrative Nurse E, Certified Nurse Aide (CNA) M, and CNA N positioned R39 on his left side. Administrative Nurse E removed the old dressing and cleansed the open area on R39's right buttocks with wound cleanser. The wound appeared as a two-inch reddened round area with approximately three-quarters of an inch open. Administrative Nurse E applied a Mepilex dressing and covered with an Opsite (a breathable, flexible, waterproof dressing) dressing. Administrative Nurse E stated the wound treatment was recently changed after the resident's representative took a picture of the area and showed it to the physician's office; the physician changed the treatment to a different dressing. On 06/26/23 at 2:00 PM interview with Administrative Nurse D verified the interventions including an air mattress or skin treatments were not documented in the care plan and should be. The facility's Care Plan Revisions upon Status Change policy, dated, December 2016, documented the purpose of the procedure is to provide a consistent process for reviewing and revising the care plan for that resident experiencing a status change. The comprehensive care plan would be reviewed, and revised as necessary, when a resident experienced a status change. The unit manager would conduct an audit on all residents experiencing a change of status, when identified, to ensure the care plans have been updated to reflect current resident's needs. The facility failed to revise R39's care plan with an appropriate intervention to prevent pressure injuries. This placed R39 at risk for further injury to his skin due to uncommunicated and/or unmet care needs. 32358 - R11's Electronic Medical Record (EMR) documented she had diagnoses of cerebral infraction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain ), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). R11's Significant Change Minimum Data Set (MDS), dated [DATE], documented R11 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented the resident required total staff assistance with locomotion on and off unit and limited staff assistance with the rest of her activities of daily living (ADLs). The MDS documented the resident received hospice services. The Care Area Assessment (CAA) did not trigger for hospice services. R11's Hospice Care Plan, revised 05/02/23, documented R11 would make her needs known and instructed staff to follow hospice care plan. The care plan lacked instructions which included what services, hospice would provide for R11. On 06/21/23 at 03:30 PM, observation revealed R11 sat in a recliner in her room, smiled and visited with staff. On 06/27/23 at 09:50 AM, Administrative Nurse D verified R11's hospice care plan lacked instructions to staff on care hospice would provide and what facility staff would provide. The Hospice Services and Facility Agreement, dated 10/10/20, documented hospice would develop a written plan of care in consultation with facility for each hospice patient, in accordance with the following criteria all hospice services furnished to the patient would be in accord with the plan of care. The hospice plan of care would also specify the palliative and supportive care that is to be provided the discipline who would provide the services and the hospice representative responsible for coordinating care. The facility failed to update R11's hospice care plan with information on care hospice would provide and care facility staff would provide. This placed R11 at risk for uncommunicated and/or unmet care needs.

The facility had a census of 42 residents. The sample included 12 residents. Based on record review and interview the facility failed to deliver mail on Saturdays. Findings included: - On 06/26/23 at 1:15PM, during the resident council meeting, four residents present at the meeting, voiced they had not received their mail on Saturdays. On 06/26/23 at 01:32 PM, Activity Staff U verified residents did not receive their mail on Saturday. Activity Staff U stated the business office usually picked up mail during the week and they were not there on Saturdays. Activity Staff U stated on Monday mornings she did two different deliveries of residents mail, one from Saturday, then Monday's mail. On 06/27/23 at 10:47 AM, Administrative Nurse D stated mail was delivered to the facility by the post office on Saturdays and it was placed in the mail box at the entrance door. Administrative Nurse D stated the nurse or nurse aide on duty should get the mail and deliver it to residents. The facility's Resident Rights Policy, revised on 01/01/23, documented the resident had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. The facility failed to ensure residents received their mail on Saturdays.

The facility had a census of 38 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to perform blood sugar testing in a sanitary manner when Licensed Nurse (LN) D failed to clean the facility glucometer (instrument used to calculate blood glucose) after using it on an unidentified resident and/or before using it to test another Resident (R)20. The facility also failed to ensure staff handled R2's urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) in a sanitary manner. Findings included: - Observation on 03/02/22 at 07:30 AM LN D completed a blood sugar check for an unidentified resident without cleaning the glucometer before returning it to the top drawer of the medication cart. Observation on 03/02/22 at 08:10 AM LN D took a resident to her room and proceeded to use the same glucometer she used on R20 resident without cleaning the glucometer between residents. On 03/02/22 at 8:15 AM LN D stated she wiped down the glucose monitor with disinfecting wipes prior to putting it away in the medication cart. LN D acknowledged she had not done that when she checked blood sugar of first resident. She acknowledged the same glucometer was used on both residents, but she had not cleaned it after the first resident. The 09/2014 Blood Sampling- Capillary (Finger Sticks) policy documented, Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. The facility failed to cleanse a glucometer used for multiple residents in between residents. - The 03/01/22 Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/09/21 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment and R2 had an indwelling urinary catheter. The 03/11/21 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 had a urinary catheter and noted to provide cares as ordered and as needed (PRN), monitor skin with cares, and report changes to the nurse for further assessment. The 10/26/21 Care Plan documented R2 was at risk for self-care deficit and activities of daily living (ADL) function. Interventions included a suprapubic (catheter inserted into the bladder through the abdomen) urinary catheter. The 06/29/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/01/22 at 11:50 AM revealed R2 laid on his back with a pillow under his head. He had a urinary catheter in place, however the urinary drainage bag laid on the floor in full contact with the carpet. On 03/01/22 at 03:10 PM Certified Nurse Aide (CNA) F stated the urinary catheter bag should always be off the floor. If he found the catheter bag laying on the floor, he would rehang the catheter bag. The 01/2020 Incontinent Care and Catheter Care Policy and Procedure did not address how to handle the catheter tubing in a sanitary manner. The facility failed to ensure sanitary handling of the R2's urinary catheter bag and tubing.

The facility census totaled 38 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide written notice to the State Ombudsman of the 01/15/22 facility-initiated hospitalization transfer of Resident (R)18. Findings included: - R18's 02/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/27/21 Five-day Scheduled Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The 01/26/22 Admission MDS documented a BIMS score of eight, which indicated moderately impaired cognition. The Fall Care Area Assessment (CAA) dated 01/26/22 documented R18 had a fall out of bed at the hospital but has had no falls since readmission. R18 had a [CONDITION(S)] disorder (violent involuntary series of contractions of a group of muscles). The 11/02/21 Care Plan revealed R18 was at risk for falls related to frequent falls at home and a history of falls. The 01/15/22 Nurses Note documented R18 was not tracking right and could not follow simple commands. The staff notified the physician and the physician ordered the staff to send R18 to the emergency room to be checked out. R18 left with Emergency Medical Staff (EMS) to a local hospital. The 01/20/22 Nurses Note documented R18 readmitted to the facility from the hospital with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/01/22 at 11:00 AM revealed R18 had a dark purple bruise under his left eye and a bruise on his other cheek that lined up with his glasses. R18 was awake and alert and able to tell what happened to cause the bruising and talked about a fall he had awhile back. He could not say where of how it happened only that it did and not occur at the facility. On 03/02/22 at 10:00 AM Social Service Designee (SSD) E reported the facility sent a monthly log to the ombudsman with all discharges from the facility. SSD E stated they did not send the report and did not know whether discharges to the hospital were included in the report. On 03/02/22 at 10:20 AM Administrative Staff A reported it was her responsibility to notify the Ombudsman and she sent a list monthly with all the discharges on it. She did not know the regulation included discharges to the hospital and she had not put hospital discharges on the list. Administrative Staff A stated she did not include R18 on the ombudsman list for 01/2022. The 09/2018 Emergency Transfer Notification Policy documented, The state ombudsman will be sent a list of emergency transfers on a monthly basis. The facility failed to notify the ombudsman of R18's 01/15/22 facility-initiated hospitalization transfer.

The facility reported a census of 38 residents with 12 included in the sample. Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident who used a urinary catheter (tube inserted into the bladder to drain urine into a collection bag) by failing to place the urinary drainage bag in a dignity cover for Resident (R) 2. Findings included: - The 03/01/22 Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/09/21 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment and R2 had an indwelling urinary catheter. The 03/11/21 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 had a urinary catheter and noted to provide cares as ordered and as needed (PRN), monitor skin with cares, and report changes to the nurse for further assessment. The 10/26/21 Care Plan documented R2 was at risk for self-care deficit and activities of daily living (ADL) function. Interventions included a suprapubic urinary catheter. The 06/29/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/01/22 at 11:50 AM revealed R2 laid on his back with a pillow under his head. He had a urinary catheter in place, however the urinary drainage bag laid on the floor under the bed and lacked a dignity cover. On 03/01/22 at 03:10 PM Certified Nurse Aide (CNA) F stated the urinary catheter bag should always be in a dignity cover. If he found the catheter bag without a dignity cover, he would get a cover to put over the dignity bag. On 03/03/22 at 08:51 AM Licensed Nurse (LN) D stated the dignity covers used did not cover the catheter bags entirely but that is what the facility had. On 03/03/22 at 09:00 AM Administrative Nurse B stated she agreed the dignity covers did not cover the entire catheter bags and were open at the bottom. The catheter bags hung out the bottom when they became fuller. She would research to order something different. The facility's 01/2020 Incontinent Care and Catheter Care Policy and Procedure policy documented Foley catheter drainage bags will be covered by a dignity bag at all times. The facility failed to maintain dignity for R2 by not placing his urinary catheter drainage bag inside a dignity cover.

The facility census totaled 38 residents, with 12 residents included in the sample and one resident reviewed for discharge. Based on interview and record review the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-and post-discharge medications, and develop a post-discharge plan of care, including discharge instructions for Resident (R) 39. Findings included: - On 03/02/22 the Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 01/24/22 Discharge Minimum Data Set (MDS) documented R39's memory was ok. The undated Care Plan revealed R39 had a goal to return to the community. The 01/24/22 Nurses Note documented R39 was discharged to the local hospital emergency room . The medical record lacked evidence of a discharge summary provided to R39 or his responsible party. On 03/02/22 at 04:16 PM Licensed Nurse (LN) D stated she would document the resident's medications, an overview of the resident's stay at the facility, anything to do with home health or hospice or any needed appointments. LN D stated she would go over this information with the resident and or their family and have them sign it and keep a copy for the facility and send a copy with them. On 03/02/22 at 04:26 PM Administrative Nurse B revealed she expected a recapitulation to be completed but did not know who was responsible to complete them. The 12/2016 Discharge Summary and Plan policy documented, The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. A copy of the following will be provided to the resident and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. The facility failed to develop a discharge summary, recapitulation, and discharge instructions for R39.

The facility census totaled 31 residents, with three sampled for medication administration. Based on interview and record review the facility failed to ensure pain medications were available to meet the needs of Resident (R)1. The facility failed to obtain R1's physician ordered 15 milligrams (mg) of [MEDICATION(S)] (opioid medication used to treat severe pain) medication to be administered twice per day. The investigation confirmed R1 was without pain medication from admission on 10/30/21 until 11/03/21 when the staff contacted the physician for an alternate pain medication after the resident reported pain at a 10/10 (worst pain on a scale of one to 10). Findings Included: - Resident (R) 1's pertinent diagnoses from the 11/10/21 Physician's Orders in the Electronic Medical Record (EMR) revealed he suffered from [CONDITION(S)] arthritis (an infection in the joint fluid/tissues due to surgery) of the left shoulder following a previous procedure. The 11/05/21 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 15, indicating intact cognition. He received scheduled and as needed (PRN) pain medication due to frequent 05/10 pain. R1 received opioids (narcotic pain medication) during the review period. The 11/05/21 Pain Care Area Assessment (CAA) revealed R1 suffered from an infection, arthritis, and chronic pain. He received [MEDICATION(S)] (opioid pain medication) 15 milligram (mg) tablets twice a day for pain. The 11/01/21 Comprehensive Care Plan revealed the resident suffered pain. The 10/30/21 Progress Notes revealed R1 admitted to the facility on [DATE] at 12:30 PM after left shoulder surgery that resulted in an infection. On 10/30/21 at 06:42 PM the Nurses Note revealed Licensed Nurse (LN) E noted R1's left shoulder was swollen, red, and he grimaced with movement when he used this arm to stand and hold onto his walker. The 10/30/21 Physician Inter-Agency Transfer Record and Admission Orders revealed R1's physician ordered [MEDICATION(S)] 15 mg tablets twice a day for pain. The 10/30/21 to 11/03/21 Pain Scales (an assessment tool that measures pain levels/intensity, from 0-10 with a higher number representing increased levels of pain) revealed R1's pain increased without pain medication intervention for the following dates/times: 10/30/21 at 10:30 PM- pain rated 01/10 10/31/21 at 09:13 AM- pain rated 02/10 and at 02:12 PM- pain rated 05/10 The 11/01/21 at 01:56 AM Nurses Note revealed R1's left shoulder continued to be swollen, red, and painful with movement. The 11/01/21 to 11/03/21 Pain Scales revealed R1's pain increased without pain medication intervention for the following dates/times: 11/01/21 at 08:30 AM- pain rated 10/10 and during night shift- pain rated 06/10 11/02/21 at 06:14 AM- pain rated 06/10, at 09:57 AM- pain rated 05/10, at 02:40 PM- pain rated 05/10 and during night shift- pain rated 04/10 11/03/21 at 01:23 AM- pain rated 04/10 The Pain Scales on 11/03/21 at 03:16 AM documented R1 reported his pain at 10 out of 10 . The 11/03/21 at 03:12 AM Physician Order obtained by LN D revealed R1 received [MEDICATION(S)] (opioid pain medication) 5/325 mg tablet every 6 hours PRN for R1's severe pain. The 11/3/2021 at 03:23 AM Nurses Note revealed R1's pain medication [[MEDICATION(S)]] not on hand at this time. R1's Medication Administration Record (MAR) from 10/30/21 to 11/08/21 revealed the staff did not administer R1's [MEDICATION(S)] and documented medication not received yet and/or awaiting hard script from provider. Interview with Certified Nurse Aide (CNA) C on 12/15/21 at 07:35 AM revealed R1 complained of pain often and asked for pain pills, and CNA C notified the nurses. Interview with CNA H on 12/15/21 at 10:41 AM revealed R1 had surgery on his left shoulder prior to admission to the facility, he frequently experienced pain and the aides reported that pain to the nurses and the Certified Medication Aides (CMAs). She stated, they would say the facility did not have the pain medications, and this went on for about four days or more. Interview with CMA I on 12/15/21 at 11:03 AM revealed R1 had a [MEDICATION(S)] order for pain and the facility was waiting on a physical prescription from the provider. CMA I stated, it took three to four days to obtain the physical script. Interview with LN G on 12/15/21 at 12:35 PM revealed [MEDICATION(S)] required a physical prescription that the facility sends to the pharmacy to order the medication. She stated, I would have requested the physical prescription from the provider, sent it to the pharmacy, and documented. I am not sure what happened. Interview with LN F on 12/15/21 at 01:03 PM revealed LN E reported R1's left shoulder condition and pain to me. LN F assessed him right at the end of the shift and told LN J that R1's shoulder had doubled in size/redness and was causing him severe pain. LN F stated when R1 admitted on [DATE] with orders for pain medications. Interview with Administrative Nurse B on 12/15/21 at 12:08 PM revealed she expected the nurses to call the resident's provider for a different opioid pain medication that was already in the facility such as [MEDICATION(S)] or [MEDICATION(S)]. Administrative Nurse B stated if the facility did not have a specifically ordered pain medication, she expected the nurses to call the provider and pharmacy and ask them to send the orders to another pharmacy, to get the medications faster. The 01/01/18 Policy and Procedure Administration of Medication policy revealed this policy was to ensure accuracy in administration of medication. If a resident did not take the medication(s) ordered, the certified medication aide or licensed nurse's initials and an explanation should be documented on the resident's Medication Administration Record. The policy lacked information about obtaining medications not already on hand. The facility failed to obtain R1's [MEDICATION(S)] medication to be administered twice per day for pain. R1 was without pain medication from admission on 10/30/21 until 11/03/21 when the staff contacted the physician for an alternate pain medication after the resident reported pain at a 10/10.

The facility census totaled 28 residents, with 14 included in the sample with all reviewed for neglect. Based on observation, interview, and record review the facility failed to prevent incidents of neglect of two residents. On [DATE] Certified Nurse Aide (CNA) E left Resident (R)9 and R14 in the whirlpool and shower alone without notifying other staff to ensure the appropriate assistance and a call light in reach for approximately 30 minutes to an hour. This failure placed both residents in immediate jeopardy. The facility also failed to prevent an incident of neglect of R3 on [DATE] when CNA C and D failed to ensure R3 had her call light within reach when staff assisted the resident to the commode for toileting, which resulted in R3 being seated on her commode without assistance for approximately three hours. Findings included: - Review of R9's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 9's [DATE] Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident required limited to extensive assistance of one staff with transfers/walking/bathing due to an impairment to her lower extremity on one side and she used a walker/wheelchair for ambulation. The [DATE] Activities of Daily Living (ADL) Care Area Assessment (CAA) revealed R9 required extensive assistance of one staff with her ADLs. The [DATE] Baseline Care Plan revealed R9 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] and [DATE] Fall Risk Evaluation revealed score of nine. A score of 10 or above indicated a high risk for falls. The [DATE] to [DATE] Certified Nurse Aide (CNA) Task for Bathing revealed the resident required one staff assistance for bathing. Review of the [DATE] Incident Investigation revealed at 08:15 AM on [DATE] CNA E left the facility for a task per LN H. At approximately 08:,d+[DATE]:00 AM, LN H went to check on R9, and she could not be found in her room. LN H found R9 in the shower/whirlpool room in the water filled whirlpool with the curtain closed. Per interview with CNA E by Administrative Nurse B, she admitted to leaving the resident unattended while bathing and did not let any other staff know to take over because she believed the resident could be left unattended. CNA E's [DATE] Incident Statement revealed when questioned by Administrative Nurse B, CNA E told her R9 requested a bath from CNA E, and she helped her into the whirlpool. CNA E said LN H knew she left the facility for a task but did not notify her or any other staff that either resident was in the shower/whirlpool. CNA I's [DATE] Witness Statement revealed at approximately 08:30 AM. R9 was found in the whirlpool filled with water and no staff in attendance. LN H's [DATE] Witness Statement revealed at approximately 07:50 AM, LN H requested CNA E complete a task for her, and CNA E accepted and left the facility. R9 was not in her room, and after searching found her in the whirlpool room in a filled whirlpool, and R9 stated she was getting worried due to the water was draining out. LN H noted that CNA E did not tell her she had any residents in the shower/whirlpool when LN H gave her the task. She noted that CNA E returned to the facility at approximately 08:45 AM. Observation of R9 on [DATE] at 03:15 PM revealed the resident lying on her bed, reading a book, glasses in place, with her wheelchair locked by her bed and call light in place in room. Interview with R9 on [DATE] at 03:15 PM revealed the incident happened a couple months ago, and she was left by staff alone in the filled whirlpool tub with no call light near me, after staff told the resident she was going to answer a call light and would be back. R9 then stated, I was afraid I would go under the water, or that I would get another fracture, because I had fractures from just standing or sitting, my bones just break. She also stated, staff usually stayed with her when she bathed. She got tired of sitting there in the tub, because it took forever for someone to find her, and then all of a sudden staff appeared. The staff asked her why she was alone in the whirlpool, and she told them what happened. She required one staff assistance for transfers and showering. She also said she had some leg pain for a little while after the incident. Interview with CNA C on [DATE] at 06:15 PM revealed R9 required one staff assistance for bathing, and staff always stay in the shower room with the resident when they used the whirlpool. Interview with CNA Q on [DATE] at 04:49 PM revealed R9 required one staff assistance for bathing, and when the residents bathed in the whirlpool, staff stayed with them. Interview with CNA N on [DATE] at 09:12 AM revealed when a resident bathed in the whirlpool, a staff member always stayed with them. Interview with CNA J on [DATE] at 09:53 AM revealed one staff stayed with residents in the whirlpool/shower. Interview on [DATE] at 03:17 PM with CNA V per phone revealed the call light in the whirlpool room was located behind the whirlpool on the left side; not easily seen unless pointed out and not easily reached unless handed to the resident. Interview with LN M on [DATE] at 01:14 PM stated, she had never heard of that happening, but would report it to the Director of Nursing (DON) immediately and reprimand the CNAs responsible. Interview with Administrative Nurse B on [DATE] at 06:55 PM revealed she expected staff to stay with residents while in the whirlpool and shower and should ensure the resident had a call light near them. The facility's revised ,d+[DATE] Shower/Tub Bath policy revealed [staff] stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Review of [DATE] .Abuse, Neglect and Exploitation Policy and Procedure revealed the purpose of the components of this policy is to ensure that all residents of this facility will be free of neglectful treatment. The definition of Neglect means the failure of this facility and its employees to provide services to a resident that are necessary to avoid physical harm or pain. The facility failed to prevent an incident of neglect of R9 on [DATE] when CNA E left the resident in the filled whirlpool alone without notifying other staff to ensure the appropriate assistance and a call light in reach for approximately 30 minutes to an hour. This failure caused the resident to be fearful of sliding into the water in the whirlpool bath. - Review of R14's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident required extensive assistance of two staff for transfers and bathing did not occur during review period. The resident had an unsteady gait due to an impairment to one side of his upper/lower extremities (limbs) and used a wheelchair. The [DATE] Cognitive and Activities of Daily Living (ADL) Care Area Assessments (CAA) revealed R14's impaired cognition included short term memory loss. He experienced limited mobility related to weakness, impaired balance, and decreased activity tolerance. R14 required extensive staff assistance with ADLs and mobility for safety. Review of the [DATE] Baseline Care Plan revealed R14 remained alert/oriented with [CONDITION(S)] improving after hospitalization and he received [MEDICATION(S)] (blood thinner) daily. He required the assistance of two staff for transfers, did not ambulate, and required set-up assistance for bathing. A revision dated [DATE] revealed the resident had a fall and therapy staff lowered the resident to the floor during therapy. R 14's [DATE] and [DATE] Fall Risk Evaluations revealed a fall risk score of eight, [DATE] scored 11, and on [DATE] scored nine. A score of 10 or above indicated a high risk for falls. The [DATE] to [DATE] Certified Nurse Aide (CNA) Task Bathing revealed R14 required physical help, supervision of one staff assistance, and at times could be independent with bathing (washing). Review of the [DATE] to [DATE] CNA Task for Transferring document indicated R14 required limited to extensive assistance for transferring with one to two staff assistance. R14's [DATE] Incident Investigation revealed at 08:15 AM on [DATE] CNA E left the facility for a task per Licensed Nurse (LN) H. LN H found R14 on his shower chair, bathing independently in his private room shower, and waiting for CNA E to return at approximately 08:,d+[DATE]:00 AM. CNA E admitted to leaving the resident unattended while bathing and did not let any other staff know to take over because she believed the resident could be left unattended. CNA E's [DATE] Incident Statement revealed when questioned by Administrative Nurse B, CNA E told Nurse B that she did not know R14 could not shower independently or be left alone. CNA E said LN H knew she left the facility for a task but did not notify her or any other staff that either resident was in the shower/whirlpool. CNA I's [DATE] Witness Statement revealed at approximately 08:15 AM R14 was found in his shower seated on his shower chair alone. LN H's [DATE] Witness Statement revealed at approximately 07:50 AM, LN H requested CNA E complete a task for her, and CNA E accepted and left the facility. Shortly after, LN H and CNA I completed vital signs and blood sugars, and found R14 alone in the shower, seated on his shower chair. He was not independent for showering and needed assistance. They assisted him into his wheelchair and assessed him. LN H noted that CNA E did not tell her she had any residents in the shower/whirlpool when LN H gave her the task. She noted that CNA E returned to the facility at approximately 08:45 AM. Observation of R14 on [DATE] at 09:35 PM revealed the resident seated in his wheelchair, ready to go to bed. CNA S and CNA Q assisted the resident from his wheelchair to bed with gait belt on, and the CNA's provided extensive assistance due to the resident's very unsteady/shaky gait. Interview with CNA S on [DATE] at 09:29 PM revealed R14 required one to two staff assistance for transfers, and at least one staff assistance for bathing. She stated, Staff always stay with the residents when bathing. Interview with Administrative Nurse B on [DATE] at 06:55 PM revealed she expected staff to stay with residents while in the whirlpool and shower and should ensure the resident had a call light near them. The facility's revised ,d+[DATE] Shower/Tub Bath policy revealed [staff] stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Review of [DATE] . Abuse, Neglect and Exploitation Policy and Procedure revealed the purpose of the components of this policy is to ensure that all residents of this facility will be free of neglectful treatment. The definition of Neglect means the failure of this facility and its employees to provide services to a resident that are necessary to avoid physical harm or pain. The facility failed to prevent an incident of neglect of R14 on [DATE] when CNA E left the resident in the shower alone without notifying other staff to ensure the appropriate assistance for approximately 30 minutes to an hour. - Review of R3's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Baseline Care Plan revealed R3 was alert and oriented and required the assistance of two staff for transfers and toileting with lift use as needed (PRN). Review of R3s [DATE] Incident Investigation revealed the phone rang, and CNA F answered the call. After a discussion on the phone, CNA F told CNA G to go to the resident's room, and when he arrived, the resident told the CNAs she needed to get her off of the commode because prior shift aides left her on the commode since approximately 07:,d+[DATE]:00PM, and she was unable to reach her call light, which was left on the left handrail of the resident's bed, behind her, where she could not reach it. R3 reported that she called the non-emergent police number because no staff had checked on her and she yelled for staff and no one responded. The two staff members assisted the resident off of the commode to her motorized chair, ensured she was able to reach her call light at approximately 11:00 PM/11:15 PM (approximately three hours after resident had been placed on the commode). R3 stated to CNA G that while on the commode her legs hurt, and her bottom went numb from being seated on the toilet for so long. The [DATE] Witness Statement for CNA G revealed he stated the phone rang and CNA F answered the call. After CNA F's discussion on the phone, she told CNA G to go to R3's room. When staff arrived to the resident's room, the resident told CNA F and CNA G they needed to get her off of the commode because the prior shifts aides left her on the commode for three hours and she was unable to reach her call light which was behind her (does not say how far). CNA G noted the call light was attached to the left handrail of the bed. He noted that the prior shift aides reported all residents were in bed, except for two other residents, and did not include R3. R3 told the staff she called the non-emergent police number to call the facility because no staff checked on her and she yelled for staff with no answer. She stated to staff that while on the commode her legs began to hurt, and her bottom was going numb from being left on the toilet so long. The [DATE] Witness Statement for CNA C revealed at approximately 07:,d+[DATE]:30 PM R3 pushed her call light, and she and CNA D moved the resident's commode to the end of her bed on the bottom left side. The staff transferred R3 to the commode, and clipped her call light on her bed, next to her and within reach. Staff instructed R3 to call when finished on the commode. The [DATE] Witness Statement for CNA D revealed she and CNA C assisted R3 to the commode after a visit with her family. CNA D tidied up the resident's room, and staff asked R3 if she needed anything else and she replied no. Her side table was by her side with her phone on it, and the resident's call light was on her bed next to her commode. Observation of R3 on [DATE] at 05:54 PM revealed the resident ate her dinner in her room, seated in her motorized wheelchair watching television. Observation of R3 on [DATE] at 02:35 PM revealed the resident in her room in an electric wheelchair with side table in front of her with personal laptop. The call light was in reach. Interview with R3 on [DATE] at 05:54 PM revealed she required two staff assistance for toileting on the commode. During a day last week, CNA C and D assisted her to the commode, and she then waited three hours, from approximately 08:00 PM to 11:30 PM on the commode for staff to assist her because her call light was not near her, at first she couldn't find it, but she noted it was on the bedrail behind her commode and she could not reach it. She usually just pushed her call light and they came eventually, but the staff forgot to make sure it was near her. She stated she, had to call the police department because my phone ran out of minutes, and I could only make emergency calls, and the police called the facility and notified them I was on the commode. She stated as a result of this incident her legs went numb and she was uncomfortable, but no skin issues. She also stated, sometimes she sat and watched television on the commode, but not more than an hour or so. Interview with CNA C on [DATE] at 06:15 PM revealed that last week, only her and CNA D were working the floor. This left her and CNA D for 33 residents, with approximately six to seven two assist residents, and the majority of the rest of the residents were one assist per CNA C. Around 07:00 PM, R3 used her call light, and CNA C and D helped her transfer to the commode. She then stated, she watched CNA D clip the call light onto the blanket at the end of the bed within reach of the resident, and her bedside table was right beside her with her cell phone, laptop and drinks. The commode was between the bed and wall, facing the television, with the call light clipped on the blankets on her bed to the left of her within reach. The oncoming shift arrived at 10:00 PM, and CNA C and D completed report at the nurse's station with CNA G and F. Interview with CNA Q on [DATE] at 04:49 PM revealed R3 required two staff assistance to transfer to the commode, and the CNAs should place her call light near her so she could get assistance when she done. Interview with CNA F on [DATE] at 06:06 PM revealed R3 told her that she had been on the commode for three hours when she and CNA G assisted her off the commode at approximately 11:00 PM the night of the incident, or maybe just after little after 11:00 PM. She stated, she thought it was odd that R3 had not called to be changed or toileted, but the prior shift CNAs C and D reported R3 was in bed, along with every other resident. She then stated, R3 had never called the police to get us before this incident and her call light was tied on the bedside rail, and not in reach of resident. R3 sat on the commode with her back to the bedside rail, facing the television. She said from experience that if R3's commode was not scooted back far enough; the call light wire did not reach. CNA F further indicated R3's cognition was intact, alert, and oriented, and she can tell you exactly what happened. Interview with LN M on [DATE] at 01:14 PM revealed staff left R3 seated on the commode for approximately two hours or more and her call light was not within reach. She did have her cell phone, but it did not have minutes. The 911 function still worked, so she used that because she could not call anyone else. She also stated R3's cognition was intact. Interview with Administrative Nurse B on [DATE] at 06:58 PM revealed R3 liked to sit on her commode for extended amounts of time, a few hours or more to watch television. R3 would call the front desk on her cell phone to get assistance off the commode. R3 called the non-emergent police line and told them she needed help off the commode and could not get ahold of facility staff. She added, when she talked to R3, she asked her why she did not call the facility, and R3 said she did not have the facility's number. She reported that CNA D and C said they clipped R3s call light to the end of the bed, and CNA G and F said the call light was found clipped to the bed rail. She stated, both places for the call light would be reachable for R3 since she was near the middle of the bed between the bed and wall on the commode. She continued, the CNAs for the night shift completed report at the nurse's station, some CNAs complete a visual report, but at a minimum verbal report. Administrative staff expected verbal report at the beginning of each shift. Usually, CNA G and F walked the building and visualized the residents, but she was not sure what happened on this particular night. Administrative Nurse B expected staff to ensure the placement of the call light so the resident could reach it. Review of [DATE] .Abuse, Neglect and Exploitation Policy and Procedure revealed the purpose of the components of this policy is to ensure that all residents of this facility will be free of neglectful treatment. The definition of Neglect means the failure of this facility and its employees to provide services to a resident that are necessary to avoid physical harm or pain. The facility failed to prevent the neglect of R3 on [DATE] when CNA C and CNA D failed to ensure the resident had her call light within reach when on the commode for toileting, which resulted in R3 being seated on her commode without assistance for approximately three hours. The deficient practice was determined to be past non-compliance as of [DATE] when residents/resident representatives were interviewed and notified with no additional concerns identified, staff involved were suspended pending further investigation, a QAPI meeting was scheduled for [DATE], and all applicable staff were re-educated on safe bathing.

The facility census totaled 28 residents, with 14 residents included in the sample and three residents reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to ensure cognitively impaired Resident (R) 2, identified as at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, and/or in combination with shear and/or friction), did not develop pressure ulcers while in the facility with appropriate repositioning, weekly skin assessments lacked the appropriate documentation for all pressure injuries or areas of skin concerns, staff did not follow wound treatment orders, and staff did not place the anti-pressure boots or float the residents heels as ordered. She developed one unstageable (full thickness tissue loss in which actual depth of the ulcer obscured by slough (soft dead tissue) and/or eschar (hard dead tissue in the wound bed) pressure injury, one deep tissue injury (DTI- full thickness injury to the soft tissue under the skin due to pressure usually over a boney prominence involving damage or death of subcutaneous fatty tissue) pressure injury, and two stage one (characterized by superficial reddening of the skin that when touched does not turn white and if pressure is not relieved, will progress into a pressure ulcer) pressure injuries. Findings included: - Review of R2's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/17/21 Admission Minimum Data Set (MDS) revealed the assessment was in progress. Review of the 04/17/21 Section C Cognitive Patterns of the Admission MDS revealed a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. Review of 04/09/21 Baseline Care Plan revealed R2 was at risk for skin breakdown with the following interventions: 05/11/21, discontinued 05/22/21 -- Staff would know the resident had a right gluteal wound, would cleanse with normal saline (NS), apply Santyl (debriding agent used to remove debris or infected/dead tissue from a wound) nickel thick with skin prep (skin protectant) to the outside borders, and cover with foam dressing or super absorbent calcium alginate dressing (a highly absorbent, biodegradable dressing derived from seaweed that maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue). 05/26/21- Staff would know the resident had a right heel wound, which required application of skin prep, staff to float heels or use heel protectors (anti-pressure), turn, and reposition every two hours. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 05/21/21- Ankle/heel boots (anti-pressure) bilaterally while in bed every shift for prevention of pressure ulcers. 05/27/21- Skin prep to bilateral heels, every shift, two times a day for intact blister to right heel as a preventative measure. 05/31/21- Cleanse right heel blister with normal saline, apply [MEDICATION(S)] (foam dressing) with Opti foam border, daily and as need (PRN) one time a day for blister treatment. 05/31/21- [MEDICATION(S)] Tablet (Vitamin C) 500 milligrams (mg) give one tablet by mouth in the morning for wound healing. 06/02/21- Weekly skin assessment by licensed nurse every Wednesday for skin monitoring. Review of 04/09/21 Braden Scale for Predicting Pressure Ulcer Risk assessment revealed a score of 15, which indicated R2 was at risk for pressure injuries/ulcers. The 04/09/21 Licensed Nurse Weekly Skin Assessment revealed R2 was admitted with upper mid vertebrae skin tear, left lateral ankle bruising, and the midback wound was covered with a dressing. The assessment lacked a description of the wounds on admission to the facility. The 04/10/21 Skin Evaluation Only assessment failed to identify R2's skin issues after the skin assessment on 04/09/21 which identified an open area to her back, but lacked a description of the wounds. Further review of the record revealed the facility failed to complete weekly skin assessments or skin evaluations for R2 from 04/11/21 to 05/08/21. Review of 05/03/21 to 06/01/21 CNA Task - Bed Mobility charting revealed R2 required extensive to total dependence on one to two staff for bed mobility. Review of the 05/09/21 Licensed Nurse Weekly Skin Assessment revealed a skin tear to R2's sacrum, wound measured 7.8 centimeters (cm) in length (L) x 1.5 cm in width (W), and an abrasion (scrape) wound to the right buttock which measured 0.8 cm L x 0.9 cm W x 0.1 cm depth (D) with a blister noted at the sacrum. The blister on the sacrum extended to the right buttock area and appeared discolored like a bruise. The assessment lacked any other descriptions of wounds. The 05/12/21 Licensed Nurse Weekly Skin Assessment revealed a right buttock shear (force generated when skin is moved against a fixed surface; any pressure injury accompanied by shear and friction will result in a debilitating tissue injury), which measured 9 cm L x 3 cm W x 0.2 cm D. The area to right gluteal area was an intact blister that opened up resulting in a skin tear/shearing appearance. Depth was noted as through the [MEDICATION(S)] layer at the edges with granulation tissue noted to borders and the center appeared very light blue to purple. The right lateral (outside) ankle had a stage 1 pressure ulcer, which measured 0.5 cm L x 0.5 cm W x 0.2 cm D, and the left lateral ankle had a pressure ulcer, which measured 0.5 cm L x 0.5 cm W x 0.2 cm D. The note lacked any other descriptions of wounds. Review of the 05/19/21 Weekly Wound Assessment Form revealed the wound on the right sacrum/buttock to be a full thickness, unstageable wound that measured 8 cm L x 6 cm W and had a depth unable to be determined, with 15% slough, 85% eschar, and moderate drainage with a reddened peri-wound. The assessment revealed the wound declined and lacked any other descriptions of wounds. The 05/21/21 Licensed Nurse Weekly Skin Assessment revealed an unstageable pressure wound to the right buttock, which started as a blister then later developed into a DTI, measured 8 cm L x 6 cm W and depth unable to determine. The resident's stage one pressure injury to the right lateral ankle measured 0.5 cm L x 0.5 cm W x 0.2 cm D, and a stage one to the left lateral ankle which measured 0.5 cm L x 0.5 cm W x 0.2cm D (from the boot the resident had to wear after the fracture). The note lacked any other descriptions of wounds. Review of 5/23/21 Weekly Pressure Ulcer Healing Assessment revealed the resident acquired the right upper gluteal wound identified on 05/12/21 in the facility. The pressure area had unstageable eschar to the right buttock, which measured 6 cm L x 5 cm W with scant drainage and moderate odor. The assessment lacked any other descriptions of wounds. The 05/26/21 Licensed Nurse Weekly Skin Assessment revealed the right buttock wound measured 9.5 cm L x 9 cm W, and unable to determine depth. The note lacked any other descriptions of wounds. The 05/26/21 Weekly Wound Assessment Form revealed the unstageable right heel wound measured 3.5 cm L x 3.5 cm W. The note lacked any other documentation or descriptions of wounds. The 05/26/21 Skin Evaluation Only revealed the right upper inner glute wound was unstageable and measured 29 cm L x 9 cm W x 0.5 cm D with slough in the wound bed, purulent exudate, tan/yellow drainage, and undermining. The right heel wound measured 3.5 cm L x 3.5 cm W and boggy (spongy, not firm). The note lacked any other documentation or descriptions of wounds. The 5/27/21 at 07:24 PM Nurses Note revealed the resident had a wound to the right buttock with the possibility of surgical debridement needed. The 06/01/21 at 02:41 PM Nurses Note revealed a treatment to the right heel area, which had an open area to the bottom front of area that measured 13 cm L x 10 cm W, had purple discoloration to the site, was soft to the touch, applied anti-pressure boots onto left foot, placed two pillows under bilateral lower extremities (BLE) to get the right heel up off the bed, rolled resident to left site, placed a small pillow between her knees and would turn/reposition R2 in one hour. An observation on 05/27/21 at 02:35 PM revealed R2 in bed, positioned on left side watching television, both heels noted on the bed surface with her anti-pressure boots observed in her recliner and not on her feet. At 03:08 PM Certified Nurse Aide (CNA) C and CNA Q were in the room, hands sanitized, gloves applied, pillow removed from the resident's right side, and checked for toileting. R2's right heel had a large fluid filled blister approximately 4-5 cm L x 3-4 cm W with clear/purple fluid within the blister and surrounding the dark purple area of the wound. The area to R2's sacrum wound had a large brownish yellow soft slough/eschar (dead) tissue hanging from resident's skin with undermining, and purulent drainage noted on gauze dressing that was removed. Licensed Nurse (LN) M measured the sacral wound at approximately 10.5 cm L x 9 cm W x 2.5 cm D. She then measured the right medial ankle stage one wound at 1 cm L x 2cm W, and the right heel blister measured 7 cm L x 9 cm W. CNA C and CNA Q placed the anti-pressure boots on R2 and positioned R2 on her right side with pillows. An observation on 06/01/21 at 12:35 PM revealed CNA O and Licensed Nurse (LN) P assisted R2 up to the wheelchair for lunch. The anti-pressure cushion was in place and anti-pressure boots were placed on R2's feet after she was up in the wheelchair. Further observation on 06/01/21 at 01:44 PM revealed CNA O, CNA J, and LN P pushed R2 back to the room in her wheelchair. LN P revealed the previous weekend the staff failed to place a dressing on R2's right heel. The facility faxed the doctor for orders and LN P discovered R2's anti-pressure boots were not on as care planned. During the observation R2 was moved to the bed with full lift, LN L removed R2's socks and observed a pressure wrap/dressing wrapped tightly around the right heel over the pressure injury. LN L revealed she did not know why R2 had a pressure dressing to the area and stated, it should not be there, and it could cause more damage to the already compromised area. LN L measured the right heel wound to be 10 cm L x 13 cm W with dark purple fluid filled blister which had ruptured with no drainage or odor noted. Interview with CNA N on 05/27/21 at 09:12 AM revealed R2 had a sore on her bottom, which the nurses addressed. CNA N assisted R2 with repositioning and stated the staff tried to reposition R2 every hour because the wounds were worse. CNA A confirmed R2 was found positioned on her back and without her anti-pressure boots in the past. Interview with CNA J on 05/27/21 at 09:53 AM revealed R2 had a bad pressure sore on her bottom that was pretty big, it started off really little, and now it was huge. CNA J revealed R2 required two staff assistance for repositioning every two hours, but that did not always happen. R2 had an air mattress, and she never refused to be turned or repositioned. Interview with CNA C on 05/27/21 at 03:12 PM revealed R2 was in bed without her pressure relieving boots and was unsure why R2 did not have her anti-pressure boots on until this afternoon. Interview with LN M on 05/27/21 at 01:14 PM revealed R2 had a pressure ulcer on her sacrum area which started around May 6th, and the wound had shown improvement. LN M revealed R2 required assistance with repositioning every two hours and was check and change for incontinence in bed. LN M revealed R2 only required skin prep as a treatment to her R heel and revealed the physician needed to be called as the wound needed immediate attention. Interview with LN L on 05/27/21 at 04:22 PM revealed the wound on R2's R heel was not there when she worked the 05/19/21. LN L revealed the facility applied skin prep to the wound and R2 was to wear the anti-pressure boots while in bed and that order had been in place since 05/09/21. LN L revealed the CNA's were educated by her at the first of the shift that the anti-pressure boots needed to be in place. LN L revealed she attempted to check on R2 as best she could to ensure the CNAs repositioned R2 appropriately. She also revealed the sacrum wound was about 3 cm L x 4 cm W when the wound nurse visited a week ago, and there was no necrotic tissue to the wound at that time. Interview with LN L on 06/01/21 at 02:13 PM revealed she was unsure why the pressure dressing was on the right heel and stated it should not have been. Interview with Wound Care Nurse K on 06/01/21 at 11:09 AM revealed she first saw R2 on 05/19/21, and she had a sacrum/right buttock pressure injury that was unstageable, had heavy drainage, and suggested a topical enzymatic debrider (a highly selective method of wound debridement that uses naturally occurring enzymes that break down dead tissue), calcium alginate, and bordered foam dressing as a treatment. Wound Nurse K revealed there was no other areas of concern or purulent drainage at the time of her assessment. She revealed the current interventions were a low air loss mattress, repositioning/turning every two hours, she suggested more frequent turning, and she did not discuss R2's feet at that time. Wound Nurse K revealed the facility nurses were expected to assess the wounds weekly and complete measurements of the wounds as she only came to the building every 4 weeks, unless otherwise indicated. Interview with Administrative Nurse B on 06/01/21 at 06:55 PM revealed she did the weekly wound measurements/descriptions which were sent to corporate, and the nurses completed the weekly skin assessments with measurements of all wounds in the Licensed Nurse Skin Assessment Weekly. Administrative Nurse B revealed the sacral and right heel wounds were facility acquired. She stated that R2 loved to lay on her back and staff were to reposition her every two hours. Staff also tried to reposition her even more frequently, every hour, and the moon boots should have been placed on both feet when she was in bed. Administrative Nurse B revealed she was unaware R2's boots were not placed on her until late in the day and was unsure why staff placed the Coban on her R heel as those were not the dressing orders. Interview with Provider R on 06/02/21 at 03:57 PM revealed he reviewed the resident's chart per the facility's request and the documentation made it seem that the facility had been completing pressure prevention for R2, but he had not talked to any other staff other than administrative staff. He further indicated he was not aware the staff were not repositioning frequently or not positioning off the pressure areas because he was told by the facility that staff turned R2 frequently, offloaded all pressure areas, and he was also told that the resident could not sleep on her back. Provider R was not aware of the right heel wound and thought staff offloaded appropriately with the anti-pressure boots. He then stated, his partner received notifications about this resident, but was unsure if his partner received notification about wound changes/needs and had been following since 05/19/21. He reviewed the charts, but had not seen the ulcers himself. Review of revised 06/06/19 Pressure Injury Prevention Policy revealed that residents admitted to the facility do not develop pressure injuries unless the individual's clinical condition demonstrates that the pressure injuries were unavoidable. Residents have pressure injuries will receive the necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing. Do not position the resident on his/her affected area. Turn and repositioning schedule of no less than once every two hours, elevating or floating heels off of bed surface, and any other intervention specific to resident need/weakness. Once a week, a licensed nurse shall perform a head to toe assessment on each resident identified with a Braden Score of 14 or below or as identified by the IDT for development of pressure injury. The facility failed to ensure R2 did not develop pressure ulcers while in the facility with appropriate repositioning, weekly skin assessments lacked the appropriate documentation for all pressure injuries or areas of skin concerns, staff did not follow wound treatment orders, and staff did not place the anti-pressure boots or float the residents heels as ordered. She developed one unstageable pressure injury, one DTI pressure injury, and two stage one pressure injuries.