Every finding on record at Green Hills Health Care Center

Based on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to maintain dignity in dining for 2 of 4 residents (Resident #10 and #23) reviewed. The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #10 having BIMS (Brief Interview for Mental Status) of 10, indicating moderate cognitive impairment and had the following diagnoses: Alzheimer ' s Disease, Non-Alzheimer ' s Dementia, and history of stroke. The MDS also identified Resident #10 needing partial to moderate assistance with eating and no impairment of upper extremities. Review of Resident #10's Care Plan initiated on 8/12/24 indicated Resident #10 has potential for malnutrition as evidenced by nutritional screening tool with an intervention for Resident #10 to eat in the assisted dining room with no adaptive devices. Review of Resident #10's Dietary/Nutrition Profile dated 10/29/24 indicated the resident's diet included puree texture with thin liquids. Resident #10's Oral Status indicated holding food in mouth/cheeks or residual food in mouth after meals. Interventions included encourage fluid intakes at meals, snacks and all nursing cares to continue with other nutritional interventions in place. 2. The MDS dated [DATE] identified Resident #23 having BIMS of 7, indicating severe cognitive impairment and had the following diagnoses: Senile Degeneration of Brain, Stage 3 Chronic Kidney Disease, and Diabetes Mellitus. The MDS also identified Resident #23 needing partial to moderate assistance with eating and no impairment of upper extremities. Review of Resident 23's Care Plan initiated on 9/4/24 indicated Resident #23 has potential for malnutrition as evidenced by nutritional screening tool with an intervention for Resident #23 to eat in the assisted dining room where I need assistance, one on one with encouragement and cues. Review of Resident #23's Dietary/Nutrition Profile dated 11/18/24 indicated Resident #23's diet included a regular diet with thin liquids and use of foam silverware and two handled cups. The Dietary/Nutrition Profile also indicated Resident #23 eats in the assisted dining room where she receives partial assistance as needed. Observation on 11/20/24 at 10:03 AM revealed a small room across the hall from the facility's opening dining room. This room was labeled on the door with Assisted Dining, inside a square table. Observation of the assisted dining room on 11/20/24 at 5:16PM, revealed a CNA sitting with three residents including Resident #10 and Resident #23. Resident #23 had not received her meal, Resident #10 eating independently as well as the third Resident eating independently with CNA ' s supervision. During observation on 11/21/24 at 12:18 PM, Resident #23 stated she liked the other dining room, it's bigger and a lot nicer. Resident #23 stated I don't like being put in this room, I feel like I'm being discarded. Interview on 11/20/24 at 5:04 PM, Resident #10 stated she does not like the room that she eats meals in, four people sit at that table and they do not talk much and would like to visit with more residents while eating her meals. Resident #10 stated she does not need assistance to eat. Interview on 11/20/24 at 2:46 PM, Staff D, CNA revealed there are four residents that eat in the assisted dining room. Only one of the residents needs staff to fully assist them with eating, the other three are only supervised and able to feed themselves. The CNA supervising the assisted dining has three residents at a time. In the past they had done assisted dining in an area of the open dining room. At that time there were eight or nine residents that assisted or supervised. Since the number has gone down they moved back to the small assisted dining room. Staff D, had the understanding they were fed separate from the other residents for dignity. Interview on 11/20/24 at 2:51 PM, Staff F, RN, stated the residents needing assistance were moved to the separate assisted dining room due to residents with higher cognition had complained about the residents needing assistance being in the open dining room. Interview on 11/21/24 at 11:18 AM, Staff G, CNA, stated only one of the four residents that eat in the assisted dining room needs full physical assistance, the other three need supervision and or prompting. The assisted feeding residents started in the assisted dining room, then were moved to the open dining room because there were more residents needing assistance. They have now been moved back to the current assisted dining room because there wasn't as many residents needing assistance. In an interview on 11/21/24 at 2:35 PM, the Director of Nursing stated when the resident is evaluated and determined to need monitoring or assistance and/or the resident ' s family requests assistance or monitoring, the resident is placed in the assisted dining room for meals. When there were more residents that needed assistance or monitoring, they were in the big dining room, and had moved these residents to the small assisted dining room for dignity. Review of facility provided Stewardship of Resident Rights Policy, revision date 1/20/20, stated the following: 1. Respect for Individuality: We acknowledge and respect the uniqueness of each resident, including their beliefs, values, and cultural background. We will provide person-centered care that honors their individual preferences and choices to the fullest extent possible. 2. Non-Discrimination: We will not discriminate against any resident based on race, color, religion, gender, sexual orientation, national origin, age, disability, or any other protected status. All residents will receive equal access to services, care, and facilities without any form of discrimination.

Based on observation, policy review, and staff interview, staff failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 44 residents. Findings include: On 11/20/24 with meal service starting at 11:10 AM, Staff A, Food & Beverage Coordinator put on a glove, with the gloved hand opened a drawer, and with the same gloved hand touched tater tots, placed tater tots on a pan and into the oven. While preparing residents' plates, Staff A frequently leaned over the plates sitting on the shelf of the steam table with his apron touching the top surface side of the plates where food was placed. Staff A applied gloves, with gloved hands sliced a cucumber on a cutting board and with same gloved hands touched the cucumber slices. Staff A proceeded to wipe the cutting board with a dry cloth that was sitting on the counter, then placed green beans on the cutting board to cut into smaller pieces. Throughout the meal service, Staff A rested his bare hands on the cutting board and then placed food on the cutting board. Staff A got a drink from his personal cup, sitting beside the stove, and then continued to serve more plates, not washing his hands. The 2 scoops used to serve mashed potatoes were completely in the mashed potato container, including the handles, touching the mashed potatoes, Staff A removed the scoops with his bare hand and continued to serve the mashed potatoes with the scoops. The serving scoop, including the handle, fell into the broccoli, Staff A used tongs to remove the scoop by the handle of the scoop, then used the tongs to scoop cooked broccoli from a pan to the serving container. Staff B, Dietary Aide, after pouring drinks into 2 handled cups, moved the cups by holding the cups from the top, placing fingers around the top edge of the cups and then placed the cups on a tray to be served to a resident. Facility policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revised 1/10/22, documented employees must wash their hands after drinking, before coming in contact with any food surfaces, after handling soiled utensils and during food preparation, as often as necessary to prevent cross contamination when changing tasks and gloves are considered single-use items and must be discarded after completing the task for which they are used. Interview on 11/20/24 at 2:26 PM, the Director of Dietary Services stated expectation for gloves to be a 1-time usage. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on resident record review, staff interview, and facility policy review the facility failed to develop and implement a base line care plan to include a resident's use of a high-risk medication for 1 resident (Resident #35) of 5 residents reviewed for base line care plans. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) for Resident #35, dated 11/8/24, included diagnoses of transient cerebral ischemic attack (stroke) long term use of anticoagulants (blood thinner medication). The MDS documented the resident was receiving an anticoagulant. Resident #35's Order Summary Report documented a physician's order for Warfarin Sodium (blood thinner medication with high-risk for bleeding) 5 milligrams (mg) every Monday, Tuesday, Wednesday, Thursday, Saturday, and Sunday and 2.5 mg. on Friday. Resident #35's New Resident Initial Care Plan/Resident Summary dated 11/5/24, lacked inclusion of the anticoagulant and monitoring for side effects. Facility policy MDS Assessment and Care Plan Procedure, reviewed/revised 11/1/2020, documented the admitting registered nurse will develop and implement a baseline care plan for each resident within 48 hours and the care plan will include initial goals based on orders and physician orders. Interview on 11/21/24 at 10:04 AM, the Director of Nursing stated her expectation for anticoagulant medication and monitoring to be included in the baseline care plan.

Based on resident record review, staff interview, and facility policy review the facility failed to develop and implement a comprehensive person-centered care plan to include a resident's pressure ulcer and treatment for 1 resident (Resident #22) of 12 residents reviewed for care plans. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) for Resident #22, dated 10/8/24, included diagnoses of stroke and Parkinson's. The MDS documented the resident had a Stage 2 (partial-thickness skin loss with exposed dermis) and Stage 3 (full-thickness skin loss) pressure ulcer. Resident #22's Skin Evaluation dated 10/2/24 documented a new skin issue of an unstageable (obscured full-thickness skin and tissue lose) pressure ulceration to the right heel present and measuring approximately 1.5 centimeters(cm) X 0.5 cm., with site moist with eschar tissue (dead tissue) present. Resident #22's Care Plan lacked inclusion of the pressure ulcer and treatment until 11/19/24. Facility policy MDS Assessment and Care Plan Procedure reviewed/revised 11/1/20 documented the resident's care plan will address pressure ulcers. Interview on 11/21/24 at 10:04 AM, the Director of Nursing stated would expect a pressure ulcer and treatment to be included in the care plan timely.

Based on observation, resident record review, resident and staff interview, and facility policy review the facility failed to followed a physician's order for 1 resident (Resident #22) of 12 residents reviewed. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) for Resident #22, dated 10/8/24, included diagnoses of stroke and Parkinson's. The MDS documented the resident had a Stage 2 (partial-thickness skin loss with exposed dermis) and Stage 3 (full-thickness skin loss) pressure ulcer. Resident #22's Skin Evaluation dated 10/2/24 documented a new skin issue of an unstageable (obscured full-thickness skin and tissue lose) pressure ulceration to the right heel present and measuring approximately 1.5 centimeters(cm) X 0.5 cm., with site moist with eschar tissue (dead tissue) present. Resident #22's Physician Order Summary dated, 11/20/24, documented an order to apply prevalon boots (padded boots to prevent pressure to areas) to both lower extremities at all times due to pressure injury, every day and night shift with starting order date of 9/30/24. Observations on the following dates: 11/19/24 at 11:19 AM, 11/20/24 at 8:23 AM, and 11/21/24 at 9:20 AM, resident up in wheelchair with prevalon boot on right foot and gripper sock only on left foot. Interview on 11/20/24 at 4:03 PM, Resident #22 stated the staff talked about a boot for both heels but have never had one for the left foot, only for the right foot, and staff thought maybe hospice was going to provide the other boot. Interview on 11/21/24 at 9:30 AM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA stated always just 1 boot on the resident's right foot and have never put a boot on the left foot. Facility policy, Physician Orders Procedure reviewed/revised 719/24, documented it is the policy of the facility that all physician orders are followed as written. Interview on 11/21/24 at 10:04 AM, the Director of Nursing stated expectation was to follow physician's order.

Based on record review, facility provided documents, and policy review the facility failed to ensure residents received care to prevent hospitalization by administering incorrect medications to 1 of 1 (Resident #8) resident reviewed. The facility reported a census of 44. Findings include: Review Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS indicated the following diagnosis: Hypertension, Hyperlipidemia, Non-Alzheimer ' s Dementia, and Depression. Review of Functional Abilities and Goals assessment dated [DATE], indicated Resident #8 was dependent on assistance with toileting, showering, dressing, and transferring. Review of Resident #8's Census report indicated hospitalization on [DATE] and returning to the facility on [DATE]. Review of Resident #8's Progress Notes revealed the following: On 9/1/24 at 3:09 PM: Notified at 1:00 PM by Medication Aide on duty that resident had possibly received the wrong medications. Upon assessment- this RN confirmed that the resident did receive another resident's medication instead of her own. Medications received included Losartan 50mg, Aspirin 325mg, Cetrizine 5mg, Mag Ox 400mg, Namenda 10mg, Metoprolol 25mg, Montelukast 10mg, Vitamin D3 5000 units, and Verapamil 240mg. Most pertinent was 50mg of Losartin, 25mg of short-acting metoprolol and 240mg Verapamil SR. Vital signs upon assessment: 119/81-52-97.0-19-97% RA. Phone call to on call provider and reviewed situation with him including what medications the resident was given vs. what should have been given. Will go ahead and place a one time order for Celexa 20mg by mouth and then resume medication as scheduled/ordered. Will monitor vital signs closely for an adverse effect. ARNP called and also updated on situation. Will monitor vital signs for the next 24 hours for any changes- Vital signs will be monitored every hour x 6 hours and then move to every 2 hours until 2:00 PM on 9/2/24. On 9/1/24 at 3:25 PM: Verbal order given by physician that if Resident #8 does become bradycardia with a defined parameters of heart rate below 50-then send to ED for further evaluation. On 9/2/24 at 1:04 AM: Resident admitted to hospital- diagnosis: accidental drug ingestion and bradycardia. Review of Hospital Admission documents dated 9/1/24 revealed at 1:00 PM on 9/1/24 Resident #8 was given the incorrect medications by staff at her care center. She received all of another resident's medication. The full list included: Losartan 50mg, Aspirin 325mg, Cetrizine 5mg, Mag Ox 400mg, Namenda 10mg, Metoprolol 25mg, Montelukast 10mg, Vitamin D3 5000 units, and Verapamil 240mg. Most pertinent was 50mg of Losartin, 25mg of short-acting metoprolol and 240mg Verapamil SR. Resident #8's vital signs were monitored closely throughout the day, on the evening of 9/1/24 Resident #8 developed bradycardia, heart rate had been between 41 and 48 beats per minute and her blood pressure had been 112-130/57-63. Review of Hospital Progress Note dated 9/2/24 at 10:38 AM indicated Resident #8's bradycardia due to meds. No symptoms, no pauses, no heart block. Resident #8 planned to discharge tomorrow (9/3/24) back to her Long Term Care facility. On 9/3/24 at 2:13PM, the Facility's Investigation indicated the following statement made by Staff H, CMA: I tried to give (another resident) his pills, but he refused. I put his pills in the med cart and would reapproach him later. I got Resident #8's pills ready, but she was still sleeping. So I put her meds back in the cart and went to break. Later, when I came back, Resident #8 was up and in her room. So, I went to give her the pills and took her blood pressure. I realized I grabbed the wrong pills when I opened the med cart and noticed Resident #8's pills were still in the med cart. I went to report to the charge nurse and told her what happened. Review of Oral Medication Administration Procedure Policy revised 4/20/18 indicated the following: 1. All medications are kept locked in the medication cart in labeled cards. 2. Utilize five rights of medications administration: right time, right resident, right medication, right route and right dosage.

Based on observation, resident record review, resident and staff interview, and facility policy review the facility failed to complete physician treatment orders that were documented as completed for 1 resident (Resident #22) of 12 residents reviewed. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) for Resident #22, dated 10/8/24, included diagnoses of stroke and Parkinson's. The MDS documented the resident had a Stage 2 (partial-thickness skin loss with exposed dermis) and Stage 3 (full-thickness skin loss) pressure ulcer. Resident #22's Skin Evaluation dated 10/2/24 documented a new skin issue of an unstageable (obscured full-thickness skin and tissue lose) pressure ulceration to the right heel present and measuring approximately 1.5 centimeters(cm) X 0.5 cm., with site moist with eschar tissue (dead tissue) present. Resident #22's Physician Order Summary dated, 11/20/24, documented an order to apply prevalon boots (padded boots to prevent pressure to areas) to both lower extremities at all times due to pressure injury, every day and night shift with starting order date of 9/30/24. Observations on the following dates: 11/19/24 at 11:19 AM, 11/20/24 at 8:23 AM, and 11/21/24 at 9:20 AM, resident up in wheelchair with prevalon boot on right foot and gripper sock only on left foot. Review of Resident #22's Treatment Administration Record (TAR) for 10/1 to 31/24 and 11/1to 21/24, order for apply prevalon boots to both lower extremities, documented/signed as completed every day. Interview on 11/20/24 at 4:03 PM, Resident #22 stated the staff talked about a boot for both heels but have never had one for the left foot, only for the right foot, and staff thought maybe hospice was going to provide the other boot. Interview on 11/21/24 at 9:30 AM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA stated always just 1 boot on the resident's right foot and have never put a boot on the left foot. Interview on 11/21/24 at 9:45 AM, Staff E, Registered Nurse stated she signed Resident#22's TAR today for order of apply prevalon boots bilateral as completed. Staff E acknowledged the order stated prevalon boots to bilateral lower extremities at all time, the resident only had a boot on 1 foot and should have boots on both feet per order. Facility policy, Physician Orders Procedure reviewed/revised 719/24, documented it is the policy of the facility that all physician orders are followed as written. Interview on 11/21/24 at 10:04 AM, the Director of Nursing stated expectation to not sign as completed for an order not completed.

Based on clinical record reviews, facility policy review, and staff interviews, the facility failed to administer medication as ordered for a resident with no bowel movement (BM) for 4 days for one of one resident reviewed (Resident #17). The facility reported a census of 44 residents. Findings include: 1. Resident #17's Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of a fracture of the T 11-12 vertebrae (lower back) and depression. The MDS identified Resident #17 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. The MDS documented that Resident #17 had constipation. The MDS listed a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. Resident #17's hospital Discharge Summary related to her stay from 9/27/22 - 9/29/22, documented a discharge diagnosis of nausea and vomiting, secondary to constipation. The Discharge Summary included that Resident #17 received an enema. The Hospital Course indicated that Resident #17 admitted to the hospital due to nausea, vomiting, and constipation secondary to pain medications used for a recent compression fracture. Resident #17 required manual disimpaction (physical removal of stool from colon). Following this the physician started her on a bowel regimen of enemas until the resolution of her constipation. The document included the following medication orders: a. Bisacodyl 10 milligrams (MG) suppository. Place one suppository rectally as needed every day. b. Polyethylene glycol 17 gram (G) packet. Give 17 G by mouth every day c. senna-docusate 8.6-50 MG tablet. Give two tablets every day by mouth. Resident #17's History and Physical dated 9/27/22 identified that she had three hospitalization s in the month of September 2022. The first hospitalization resulted from a fall that resulted in compression fractures and the start of oral hydrocodone (pain medication). The second hospitalization occurred due to nausea and vomiting that resulted in the discontinuation of hydrocodone and the initiation of a fentanyl patch. The three stay happened due to nausea, vomiting, and constipation due to pain medications. The summary listed that Resident #17 did not have a BM for four days. Her computed tomography (CT) scan displayed significant stool burden (constipation). Resident #17 received an enema with manual disimpaction, which improved her symptoms significantly. Resident #17 discharged back to the nursing home. Once she returned to the nursing home, nausea and vomiting started again. At this time Resident #17 returned to the hospital, where she got admitted until 9/29/22. Resident #17's Elimination2 record reviewed on 11/21/22 at 9:09 AM, listed a BM on 11/17/22 at 9:51 AM. The record identified no further BMs documented thru 11/21/22, four days since last BM. Resident #17's November 2022 Medication Administration Record (MAR) documented the following physician orders, with no documentation of medications administered or results: a. Milk of Magnesia (MOM) (laxative) 30 milliliters(ml) as needed (PRN) one time daily b. Bisacodyl rectal suppository (PRN) every one day c. Enema rectal (PRN) every one day On 11/21/22 at 11:00 AM Staff A, Licensed Practical Nurse, confirmed the BM action form listed Resident #17 on day 4 without a BM. The form indicated that Resident #17 did not receive any PRN BM medications in the past seven days. Staff A explained the procedure as the night shift nurse fills out the BM Action Form with the resident's name for no BM, how many days, and passes it on to the day nurse. The facility's BM Action Form protocol: administer MOM on the 2nd day without BM and document results on BM Action Form and MAR and third day without BM nurse will complete an assessment of the abdomen, plus administer suppository and document results on BM Action Form and in MAR. Review of resident progress notes dated 11/17/22 - 11/21/22, lacked documentation of assessment of resident's abdomen and any interventions for no BM protocol. Facility policy titled, Bowel Management Action Policy revised 11/21/22, documented: that the night nurse will initiate a checklist for each resident who is 2 days or greater without a BM. The oncoming nurses will receive the BM checklist and follow protocols accordingly when to give bowel promotion medication. On 11/21/22 at 4:14 PM, the Director of Nursing (DON) confirmed the resident did not receive any PRN medication for the lack of a BM for 4 days. The DON explained that she expected them to follow the BM action form, administer the PRN medication as ordered, assess the resident, and then document in the progress notes.

Based on observation, facility policy review and staff interview, the facility failed to ensure the medication room was secure from unauthorized personnel. The facility census was 41 residents. Findings include: 1. During interview on 6/7/18 at 10:00 a.m., the Administrator and Director of Nursing (DON), stated on the evening of 12/13/17 pharmacy delivered narcotics to the facility that included a card of 30 [MEDICATION NAME]. Staff A, registered nurse, RN signed for the medication and placed the medication on the counter in the medication room, not under double lock. Staff B, certified nurse aide, CNA entered the medication room unsupervised during the evening while the narcotics were on the counter. Staff B should not have been in the medication room. Observation of the hallway camera video from the evening of 12/13/17 showed the narcotics delivered at 7:54 p.m. Staff A received the narcotics and took the narcotics into the medication room and shut the door. At 8:52 p.m. Staff D, certified medication aide opened the medication room door and went inside. Staff B arrived at the doorway of the medication room and went in and left. At 8:56 p.m., Staff D left the medication room and left the door open. At 8:59 p.m., Staff B went in a store room and came out with a box and looked in the medication room and observed Staff D in the lounge area doing a blood sugar. Staff D was out of view of the medication room. There were no other staff in the area to view Staff B go in the medication room. Staff B turned around and went in the medication room unsupervised and came out at 9:01 p.m. without anyone on duty seeing her, still holding the box and exited. Facility policy for delivery and receipt of routine deliveries directed staff to immediately log controlled substances into the facility's controlled medication inventory system and store controlled substances in compliance with applicable law. Facility policy for storage and expiration of medications, biologicals, syringes and needles directed staff to store Schedule II controlled substances and other medications deemed by the facility to be at risk for abuse or diversion in a separate compartment within the locked medication cart and should have a different key or access device. On 6/7/18 at 10:13 a.m. observation with DON in attendance showed the emergency kit in the locked willow storage room, in an unlocked cupboard. (not under double lock). On 6/11/18 at 2:09 p.m., Staff C confirmed the cupboard containing the emergency kit was not locked. An inventory listing of medications in the emergency kit identified the kit contained the following narcotics: [MEDICATION NAME], [MEDICATION NAME]/APAP and [MEDICATION NAME]. On 6/11/18 at 1:08 p.m., the Administrator stated following the missing [MEDICATION NAME], the facility inserviced staff, placed cameras in the medication rooms and automatic door closures on medication room doors and conducted monthly pharmacy audits.

Based on clinical record review, facility policy review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #11) The facility census was 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. A History and Physical dated 11/10/17, documented the resident was very difficult to control diabetes and had a lot of lability (unpredictable) in his blood sugars. Reportedly, became hypoglycemic while driving and sustained a motor vehicle accident, had multiple fractures secondary to the motor vehicle accident including facial fractures. Hospital course was otherwise complicated by difficult control of blood sugars, but otherwise improved and was deemed appropriate for transfer to a nursing facility. A Physician order [REDACTED].>400 Notify MD (physician). The Resident vital sign report dated 4/4/18 at 5:07 a.m., documented the residents blood sugar was 55. Clinical record review failed to indicate the facility notified the physician of the low blood sugar. The Resident vital sign report dated 4/10/18 at 12:50 a.m., documented the residents blood sugar was 48. Nurse notes dated 4/10/18 at 12:56 a.m., documented staff called the nurse to the room stating the resident was acting as if their blood sugar was low. Nurse obtain a blood sugar that measured 48 and gave juice and pudding fed by staff. Will continue to monitor. Clinical record review failed to indicate the facility notified the physician of the low blood sugar. The Resident vital sign report dated 5/3/18 at 12:25 a.m., documented the residents blood sugar was 62. Clinical record review failed to indicate the facility failed to notify the physician of the low blood sugar. The resident vital sign report dated 5/12/18 at 7:02 a.m., documented the residents blood sugar was 52. Nurse notes dated 5/12/18 at 7:09 a.m., documented the blood sugar checked at 6:35 a.m., resulted in a blood sugar reading of 52. The resident was symptomatic. [DIAGNOSES REDACTED] protocol followed. Blood sugar at this time 104. Will continue to monitor. Nurse notes dated 5/14/18 ( 2 days later) at 12:28 p.m., documented new order received to discontinue bedtime [MEDICATION NAME], continue to check blood sugar at bedtime and call if >400. Nurse notes dated 5/16/18 at 12:12 p.m., (4 days later) documented new order for [MEDICATION NAME] to be administered at 8:00 a.m. instead of 6:00 a.m. During interview on 5/30/18 at 1:40 p.m., the MDS coordinator confirmed the facility failed to notify the physician of the elevated and low blood sugars as directed and it was expected that nurses follow physician orders [REDACTED]. The Medication Policy with a revision dated 5/30/18, added Physician orders [REDACTED].

Based on record review, observation and staff interview, Resident Bill of Rights and facility policy the facility failed to assure residents were free of restraint use for one of one resident(s) reviewed who was restrained by staff (Resident #1). The facility reported a census of 46 residents, and a total of 7 residents were reviewed. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 8/1/16, Resident #1 experienced severely impaired cognition, required extensive assistance of 2 staff for bed mobility, and dressing, and was dependent upon 3 staff for transfers and locomotion on and off the unit. The MDS documented the resident had not ambulated (walked) in their room or the corridor. The resident's Care Plan with a goal date of 11/11/16, revealed the resident displayed impaired mobility, was at high risk for falls and required 2 staff and a mechanical lift (Hoyer) for transfers. A new intervention dated 6/16/16 directed staff: do not leave the resident unattended while in the wheelchair and call extra staff from the other side (health care center) to supervise the resident if staff are needed in another room. A new intervention dated 8/7/16 directed staff to check and change Resident #1 first when the arrival of the day shift to prevent restlessness and see whether or not the resident required care for an incontinence episode. The facility investigation dated 8/19/16 at 5:45 a.m. revealed Staff B, certified nursing assistant (CNA), discovered Resident #1 in a wheelchair with a transfer belt around his/her waist and secured around the back of the wheelchair. During an interview on 10/6/16 at 11:14 a.m., Staff B stated Staff A, CNA, asked which residents night shift had to get up. Staff B informed Staff A when the day shift staff arrive, they begin to assist residents that require 2 staff for assistance. After talking with Staff A, Staff B returned to another area of the facility. Staff B reported on 8/19/16 between 5:00 - 6:00 a.m., Staff B and Staff C, RN entered the memory care unit and observed Staff A sitting behind the nurses' desk with her foot elevated. Resident #1 was in his/her wheelchair near a table in front of the nurses' desk. Staff B observed a gait belt placed around Resident #1's abdomen and clipped behind the wheelchair. Staff B removed the gait belt and placed it on the nurses' desk. In an interview on 10/5/16 at 1:46 p.m., Staff A stated she saw a belt with a clip she had never seen before in Resident #1's wheelchair and thought it was used for positioning. She reported she placed it around the residents abdomen and chair. I was trying to help day shift and I don't know what I was thinking, I just put it around him/her. In another interview on 10/6/16 (no time identified), Staff A reported the resident was in the chair with the gait belt around her for between 15 - 30 minutes. On 10/5/16 at 8:15 a.m. the Administrator stated no restraints were to be used in the facility. The Abuse Prevention Policy dated 8/26/16 identified the facility is obligated to insure residents were free from verbal, mental, physical and sexual abuse. The policy revealed physical abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. The Resident Bill of Rights revealed each resident has the right to be from physical, verbal, sexual or mental abuse, corporal punishment, involuntary seclusion, and any physical restraints or psychoactive drugs administered for the purpose of discipline or convenience and not required to treat the resident's medical symptoms.

Based on observation, clinical record review, Nurse Practitioner (NP) and staff interview and facility policy review, the facility failed to properly assess a resident skin issue which warranted a thorough assessment (Resident #2). The facility identified a census of 47 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 3/23/16, Resident #2 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, rarely made self understood or understood others, with continuous inattention and disorganized thinking and required extensive assistance of staff with eating. A Care Plan printed 4/11/16 at 4:35:19 p.m., indicated the resident had problems that included a self care deficient as evidenced by (AEB) needing extensive assistance with activities of daily living (ADLS) and increased assistance with eating, Impaired cognitive deficit and psychosocial well being related to dementia AEB forgetfulness and Impaired skin integrity related to dementia, ischemic changes and poor circulation to the bilateral lower extremities. The interventions included the following: a. Check the resident at the beginning of each shift and at least every hour from 10 p.m. to 6 a.m. to determine the resident's needs were met. b. Assist the resident with dressing and undressing every day. The resident ' s care plan dated 6/1/16 documented no hot liquids in his/her room without lids; and lids should be placed on all hot (liquid) cups. A CNA Certified Nursing Assistant) Check Worksheet, completed by Staff F documented on 5/30/16 at 7 p.m., Resident #2 had a reddened area on his/her thighs. Resident #2 ' s record lacked any nursing assessment on 5/30/16 after Staff F documented the initial red areas on Resident #2. A CNA (Certified Nursing Assistant) Body Check Worksheet dated 5/31/16, indicated the resident had reddened areas with blisters, 3 closed and 1 open dated 5/31/16. The Summary Investigation Report revealed Resident #2 had comprised skin integrity on 5/31/16 at 6:30 a.m. as follows: 1). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had a red/warm area on the middle inner right thigh with the skin intact with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A non-stageable, 25 centimeter (cm) by (x) 11 cm area, with no depth, no undermining/tunneling, no drainage, wound edges intact, surrounding skin intact, no infection, wound bed red and no pain. 2). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had an open blister on the middle inner right thigh with the skin intact with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A full thickness area that measured 4 cm x 1.5 cm, with no depth, no undermining/tunneling, a scant amount of serosanguineous drainage, wound edges intact, surrounding skin intact and pink/red in color, no infection, wound bed moist and pink and no pain. 3). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had a blister (#1) on the middle inner right thigh with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A non stageable blister area that measured 1 cm x 2 cm, with no depth, no undermining/tunneling, no drainage, wound edges intact, surrounding skin intact and pink/red in color, no infection, wound bed white and no pain. 4). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had a blister (#2) on the middle inner right thigh with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A non stageable blister area that measured 2.8 cm, with no depth, no undermining/tunneling, no drainage, wound edges intact, surrounding skin intact and pink/red in color, no infection, wound bed dry and no pain. 5). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had a blister (#3) on the middle inner right thigh with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A non stageable blister area that measured 4.8 cm x 1.5 cm, with no depth, no undermining/tunneling, no drainage, wound edges intact, surrounding skin intact and pink/red in color, no infection, wound bed dry and no pain. 6). A Weekly Non-Pressure Ulcer Healing Assessment form (not initially dated), indicated the resident had a red/warm area on the left inner thigh with the skin intact with an onset date of 5/31/16 with no further documentation available. The next entry included the following: a. 6/1/16 - A non-stageable, 5 cm x 1.5 cm area, with no depth, no undermining/tunneling, no drainage, wound edges intact, surrounding skin intact, no infection, wound bed red and dry and no pain. Review of the facilities Clinical Notes Report form the following entries: a. 5/31/16 at 7:54 a.m. - A large red area on the inner right with several intact blisters and a smaller area on the left inner thigh. The Resident denied pain/itch, no odor or drainage notes. Placed the Resident on the NP list for evaluation. (documented by Staff A, Registered Nurse (RN) b. 5/31/16 at 12:14 p.m. - A large red/pinkish colored area noted on the right inner thigh. Area no warm to touch and non-raised. The resident denied any pain when area palpated. Noted near pubic area/inner groin area a large narrow fluid filled blister. The blister had been intact at that time. The NP had been notified and would address the following day when at the facility. (documented by Staff B, Licensed Practical Nurse (LPN) c. 6/1/16 at 12:47 a.m. - The right inner thigh blister had been beginning to open. The resident denied pain at the site. He/she had been on the NP list tomorrow for evaluation. (documented by Staff C, RN) During an interview with Staff F, CNA on 6/8/16 at 12:28 p.m., she reported working with Resident #2 on 5/30/16 from 2-10:00 p.m. and gave the resident a shower that night after supper. Staff F reported she noticed a red area on the resident ' s right thigh about the size of a fist. Staff F reported she completed a CNA Body Check Worksheet During an interview 6/8/16 at 9:15 a.m., Staff D, CNA confirmed he/she worked the 10 p.m. to 10 a.m. shift which started 5/30/16 and ended 5/31/16. The staff member indicated he/she checked the resident through the night however he/she remained dry. At approximately 5 a.m. the staff member assisted the resident to the bathroom and observed 4 blisters described as baseball sized on the resident's thighs on the inner aspect surrounded by approximately a grapefruit sized area of redness. When the staff member asked the resident what happened he/she stated the area had been a mole he/she had all of his/her life. The staff member informed Staff A and asked the staff member to assess the resident. Staff A came to the area, popped his/he head in the bathroom, then entered the bathroom but failed to assess the area and told Staff D he/she would place the resident on the NP list. During an interview 6/7/16 at 1:10 p.m., Staff E, CNA confirmed he/she worked 5/31/16 from 6:30 a.m. to 2:30 a.m. and had been informed by Staff D to look at the Resident's leg. The staff member entered the resident's room as he/she sat on the toilet and observed 4 blistered areas on the resident's right thigh approximately pea sized and a grapefruit size area of redness surround the blisters. The resident denied any pain. The staff member indicated she filled out a skin sheet and handed the form into Staff B. The staff member also indicated she knew Staff D informed Staff A about the skin issues. During an interview 6/8/16 at 11:15 a.m., Staff B confirmed he/she worked 5/31/16 from 7 a.m. until 1 p.m. and received report from Staff A who failed to inform him/her about the resident's skin condition. As Staff B had been preparing to pass medications that morning a CNA approached him/her and said he/she might want to check the resident's thigh as the area had been red and blistered. Staff B then asked Staff A about the skin issue and Staff A said, oh yeah, I am glad you reminded me, Staff D reported the condition to him/her and the resident had a blister but he/she would chart on the area and place the resident on the list to be seen by the NP. Later Staff B assessed the area and called the NP. The staff member described the area as a good sized square, reddened/hot pink area on the resident's right inner thigh with a long fluid filled blister that ran along the pubic area. The staff member indicated the resident had dementia but when the staff member palpated the area the resident did not express pain. The staff member indicated he/she did not see where Staff A placed the Resident on the list for the NP to assess and followed through according to the facilities policy and procedure. During an interview 6/8/16 at 9:40 a.m., the Administrator confirmed he/she would have expected Staff A to assess and intervene when the Resident's skin issue had been reported and the staff member failed to follow the appropriate steps according to the facilities policy and procedure. During an interview 6/8/16 at 10:53 a.m., a Nurse Practitioner (NP) confirmed he/she would have expected the facility staff to assess and intervene with any reported skin issue/condition change immediately. The NP also confirmed the resident's skin condition as a thermal burn which would have progressively worsened. According to NP ' s documentation dated 6/1/16, Resident #1 had been seen for large blisters on his/her right inner thigh with an unknown origin. The physician documented the resident ' s skin appeared burn but there had not been an incident where the resident had hot liquids. The resident denied having any pain. During an interview 6/8/16 at 9:40 a.m., the Administrator confirmed the policy and procedure documented below pertained to all skin issues not just pressure ulcers. According to a Pressure Sore Prevention and Management Procedure form revised 3/31/16, the policy and interpretation and implementation included the following: a. At any time during a CNA shift if a CNA observed any skin issues such as a bruise, skin tear, ulcer and etc they would fill out a Body Check Form and give the form to the charge nurse by the end of the shift. b. The Charge Nurse who identified the pressure sore (skin integrity) would have been responsible for documenting in the clinical notes. c. The Charge Nurse would have notified the following : a. Physician or NP and treatment orders initiated. b. Update the communication book and share during the shift report. c. Skin Nurse.

Based on observations and staff interview, the facility failed to maintain the appropriate food temperature to ensure the preservation of appeal and palatability for 1 out of the 3 residents reviewed with pureed diets. The facility reported a census of 43 residents. Findings include: An observation on 3/29/16 at 10:40 a.m. revealed the Dietary Supervisor prepared 3 pureed meals, heated the food in a microwave, checked the temperature and stored the food in a warmer. When asked, the chef stated he would recheck the temperature before he served the food. An observation on 3/29/16 at 11:30 a.m., revealed the Supervisor retrieved a meal from the food warmer, plated a meal that included pureed ham balls and corn casserole, and set it on the shelf to be served. The Supervisor failed to recheck the temperature. Per the surveyor's request, staff returned the meal and checked the temperature, which measured 115 degrees Fahrenheit (F). The food preparation and service policy revealed the danger zone of 41 through 135 degrees Fahrenheit can be conducive to the rapid growth and development of pathogenic microorganisms. Potentially hazardous foods include meats. The policy directed staff to reheat previously cooked food to an internal temperature of 165 degrees F, and to reheat mechanically altered hot foods to above 141 degrees F. The document dated 3/30/16 listed Resident #12 as one of three people with pureed diets. On 3/28/16 at 2:00 p.m., 2 residents who wished to remain anonymous stated: a. There are times the food has had to be reheated due to not being warm enough. b. The room trays are delivered almost cold. In an interview on 3/30/16 at 1:20 p.m., the Dietician stated pureed foods are reheated to 165 degrees F and then stored in the warmer. She stated staff should recheck food temperatures prior to serving them. An interview on 3/31/16 at 10:00 a.m. with the Administrator revealed she expected staff to maintain food they hold and serve at 135 degrees F or above.

Based on observation, record review and staff interviews, the facility failed to maintain sanitary conditions in an attempt to prevent food borne illnesses. The facility reported a census of 43 residents. Findings include: An observation during the initial kitchen tour on 3/28/16 at 9:10 a.m., revealed a greasy, brownish black residue built up on portions of the griddle's surface, and the back and sides of the griddle/stove appliance. An observation on 3/29/16 at 11:00 a.m. revealed the Dietary Supervisor/Chef repeatedly wiped the thermometer used to check food temperatures with a stained wash cloth that laid on the counter next to the microwave. Observation revealed he failed to sanitize or change the cloth before he used it to wipe the thermometer, or in between the subsequent times he wiped the thermometer. An observation on 3/29/16 at 11:00 a.m. revealed multiple silver pots and pans with an accumulation of carbon and/or crust built up on the interior bottoms. The substance on the the griddle's surface and the back and side of the griddle/stove appliance remained unchanged. On a subsequent kitchen tour with the Dietician on 3/30/16 at 9:00 a.m., the appearance of the multiple silver pots and pans and the griddle/stove appliance remained unchanged. 2 cutting boards, one with green stains and the other with brown stains, showed excessive wear and were stored among the rest of the clean cutting boards. According to the Dietician, staff had already washed the cutting boards. The Sanitization Policy directed: a. Keep all kitchens clean. b. Maintain in good repair all utensils, counters, shelves and equipment so they can be used and cleaned properly. c. Wash all equipment, food contact surfaces and utensils to remove or completely loosen soils by using the manual or mechanical means necessary. Sanitize the same by using hot water and/or chemical sanitizing solutions. During an interview on 3/30/16 at 1:30 p.m., the Dietician stated the cleaning schedule ran from Monday through Sunday and after staff initialed the sheet it was thrown away. The Dietician provided a Monday through Sunday cleaning schedule that had not been dated. When asked, she stated she wondered if the cleaning had been done thoroughly enough. She also stated that if the carbon and residue accumulated quickly enough to look the way that it currently did, she would have to look at having it done more frequently.

Based on record review, staff interviews, and facility medication administration procedure, the facility failed to follow professional standards for medication administration for 1 of 10 residents reviewed (Resident #2). The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 3/9/16, identified Resident #2 with severely impaired cognition. The MDS identified the resident had [DIAGNOSES REDACTED]. The March 2016 Treatments sheet and the February 2016 Physician order [REDACTED]. a. [MEDICATION NAME] (used to treat pain and inflammation) 1% Gel topical to the resident's right wrist three times daily for pain/discomfort (start date 3/17/15). b. [MEDICATION NAME] 1% Gel topical to the resident's back at 6:00 a.m. daily (start date 10/21/15). c. [MEDICATION NAME] 1% Gel topical to the resident's right shoulder twice daily for pain (start date 11/16/15). Record review revealed none of the [MEDICATION NAME] 1% Gel orders directed staff how much (the dose) of the gel to apply. During an interview 3/30/16 at 11:10 a.m., Staff B, LPN (Licensed Practical Nurse), stated she had always administered a 4 gram line of the [MEDICATION NAME] Gel because that is the dose other residents had received. Staff B stated she called the physician and had the [MEDICATION NAME] orders clarified on 3/29/16. A Physician's Telephone Orders Audit sheet, signed by the provider on 3/30/16, directed staff to discontinue [MEDICATION NAME] 1% Gel to the resident's right wrist. The orders directed staff to administer [MEDICATION NAME] 1% Gel 2 grams to the resident's right shoulder twice daily for pain and 4 grams to the resident's back daily at 6:00 a.m. During an interview 3/31/16 at 12:40 p.m., the DON (Director of Nursing) stated she had not been able to find a procedure for topical medication administration. The DON stated she expected staff to follow the 5 rights of medication administration when applying topical medications. The facility Oral Medication Administration Procedure, dated 2/27/15, directed staff to follow the 5 rights of medication administration that included the right time, right resident, right medication, right route, and right dose.

Based on observation, clinical record review and staff interviews, the facility failed to do the initial and subsequent assessments and document the progress of a facility acquired pressure ulcer for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 43 residents. Findings include: The 12/29/15 Minimum Data Set (MDS) assessment documented diabetes, [MEDICAL CONDITION], Non-Alzheimer's Dementia and heart failure as [DIAGNOSES REDACTED]. The MDS also documented the resident had been frequently incontinent of bowel and bladder and completely dependent on staff for all activities of daily living (ADLs). The 1/11/16 Care Plan documented that Resident #5 had impaired skin integrity related to a history of open areas to the buttocks and left calf had recently healed. The Care Plan dated 1/28/16 documented [MEDICATION NAME] ointment (skin impairment prevention and/or treatment) should be applied to Resident #5's buttocks every shift and as needed. The 3/30/16 Care Plan documented a small open area to Resident #5's left buttock that required the continued use of [MEDICATION NAME]. Additionally, the resident needed to be repositioned every 2 hours. An observation on 3/29/16 at 7:28 a.m., revealed Staff C, Certified Nursing Assistant (CNA) and Staff G, CNA, assisted Resident #5 to the toilet. Further observation revealed an open, reddened, circular shaped lesion on Resident #5's left buttock approximately 1 ½ to 2 cm in diameter. The clinical notes report dated 2/24/16 documented Stage 2 pressure ulcers on Resident #5's buttocks had been healed. The facility's 3/16/16 skin condition report documented Resident #5 required the preventative application of [MEDICATION NAME] every shift. The weekly pressure ulcer assessment dated [DATE] documented the initial assessment of a Stage 2 pressure ulcer that measured 0.4 centimeter (cm). The clinical notes report dated 3/30/16 documented a newly identified Stage 2 pressure ulcer that measured 0.4 cm on Resident #5's left buttock. The Pressure Sore Prevention and Management Procedure directed staff when they identify a skin problem, document it and alert the charge nurse. The procedure directed the charge nurse to chart the skin problem in the communication book, notify the doctor for orders and share the information during shift report. The procedure directed the skin nurse to complete weekly skin assessments, document them and inform the physician of the area's progress every two weeks. An interview on 3/30/16 at 1:45 p.m. with Staff A, Registered Nurse/Wound Nurse (RN) revealed that she had not been informed of the wound on Resident #5's left buttock. The RN stated Resident #5 had been afflicted with skin issues since admission. An interview with Staff A on 3/30/16 at 2:00 p.m., revealed she had just measured the pressure ulcer on Resident #5's left buttock and notified the provider. She stated the wound measured 0.4 cm. An interview on 3/30/16 at 2:05 p.m. with the Director of Nursing (DON) revealed that newly identified pressure ulcers needed to be reported before the end of shift. The DON stated that Staff A had just been informed about the pressure ulcer on Resident #5's left buttock on the afternoon of 3/30/16. An interview on 3/30/16 at 2:30 p.m. with Staff C, CNA, revealed she did not report the wound to the nurse that day because she had seen that particular wound on Resident #5's left buttock for approximately 2 weeks prior to the 3/29/16 observation. During an interview on 3/30/16 at 4:25 p.m., the DON reported documentation expectations of nurses regarding a newly identified pressure ulcer include: a. Contact the doctor for orders. b. Appropriate staff execute the orders. c. Document assessment in the nurses' notes. d. Record the initial assessment on the skin sheet. e. Add subsequent weekly assessments to the skin sheet to track progress.

Based on record review and interviews the facility administrative staff failed to report an allegation involving mistreatment, neglect, or abuse to the Department of Inspections and Appeals within 24 hours. Resident #4 reported to the facility he/she was transferred from wheelchair to bed roughly by facility staff. Census was reported as 44 residents. Findings include: A quarterly Minimum Date Assessment ((MDS) dated [DATE] revealed Resident #4 ' s Brief Interview for Mental Status score of 15 indicated an intact cognitive status. According to the MDS Resident #4, required extensive assistance of two staff members for transfers and total dependence of one staff member for locomotion off the unit. Resident #4 ' s MDS listed upper and lower extremity impairment to one side and only able to stabilize with staff assistance for moving from the toilet, surface to surface transfers, walking and moving from a seated to standing position. Resident #4 utilized a walker and wheelchair for mobility. The MDS reported [DIAGNOSES REDACTED]. The plan of care dated 9/10/15 for Resident #4 noted a problem of impaired skin integrity related to potential for significant bruising due to the administration of [MEDICATION NAME] (an anticoagulant drug taken to prevent the blood from clotting). Resident #4 was at high risk for bruising. Interventions to protect Resident #4 from bruising dated 11/9/15 included the use of geri-sleeves, derma-savers, staff monitoring of skin issue and padding of the arms of the commode and wheelchair. The intervention dated 12/15/15 directed the use of a soft posey belt for transfers. Two staff members are directed to assist Resident #4 with toileting and transfers. Review of an Incident Report dated 12/24/15 at 8:00 a.m. revealed a large bruise occurred post transfer on Resident #4's right upper arm. Additional comments identified staff education on transferring of residents. Review of an emergency physician history and physical dated 12/26/15 at 1:30 p.m. revealed Resident #4 was transferred to the emergency room for evaluation of a large bruise on the right upper arm that Resident #4 stated occurred during a transfer. Resident#4's right upper extremity was assessed as an extensive area of hematoma (localized collection of blood outside the blood vessels) centered at the level of the right elbow and extensive ecchymosis (bruising) around the hematoma. According to the history and physical report Resident #4 informed the hospital staff the bruise occurred during a transfer when staff failed to use a gait belt transfer assistive device and grabbed his/her arms in a sometimes rough manner as described by Resident #4. The report identified Resident #4 complained of pain in the area of the bruise. The report noted treatment for [REDACTED]. Review of a hospital history and physical dated 12/31/15 revealed Resident #4 was admitted to the hospital for [DIAGNOSES REDACTED]. The assessment revealed extensive ecchymosis from the right shoulder to the right wrist area. The right upper arm was quite swollen, very firm and tender. Unable to palpate a strong radial pulse on the right side. Review of an undated facility Summary Investigation Report revealed Resident #4 stated on 12/23/15 he/she was assisted to bed by two Certified Nursing Assistants (CNA ' s) and they did not use the gait belt but grabbed his/her arm and were slightly rough while transferring her. The report summarized an investigation into the incident and the resident ' s allegation. During an interview on 2/12/16 at 9:30 a.m. the Administrator stated when administrative staff was notified on 12/24/15 of Resident #4's allegation of rough treatment a full investigation was initiated. The facility collected Staff statements and according to the facility an evaluation of the evidence determined the allegation was not substantiated. The Administrator stated she used the facility's algorithm for reporting major injuries and determined a report to department of inspections and Appeals was not warranted. During an interview with the Administrator on 2/17/16 at 9:30 a.m. identified the facility failed to report the allegation of abuse to the Department of Inspections and Appeals because the allegation could not be proven per the facility investigation of Resident#4 ' s injury.

Based on clinical record review, staff and resident interviews, the facility failed to complete three of four resident restorative plans as directed. (Resident #4, #5 & #6) The facility census was 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. A Restorative Care Program sheet dated 5/9/14, indicated the resident required restorative exercises three times a week. The Program directed staff to complete bilateral lower extremity exercises and to encourage the resident to walk to all meals. Review of the 2015 Restorative Care Flow Record revealed the resident received August 2015 exercises 7 times out of 18 opportunities and received no October 2015 exercises. 2. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. A Restorative Care Program dated 4/9/14, indicated the resident required restorative exercises three times a week. The program directed the staff to complete upper and lower extremities three times a week per the program. Review of the 2015 Restorative Care Flow Record revealed the resident received August 2015 exercises 6 times out of 18 opportunities and received no October 2015 exercises. 3. The MDS assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. A Restorative Care Program dated 10/2/15, directed staff to complete the resident's restorative program 5 times a week, with the use of the NuSTep, exercise bands and walking exercises. Review of the October 2015 Restorative Care Flow Record revealed the resident received exercises 6 times out of 30 opportunities. During interview on 11/2/15 at 4:00 p.m., the resident stated they were not getting their restorative exercise as planned. During interview on 11/3/15 at 11:20 a.m., the Director of Nursing stated staff assigned to complete the Restorative Program had an injury in August 2015 which prevented them from completing the prescribed restorative program for residents. The Director of Nursing stated resident walking programs were completed daily but not the other parts of the programs as they did not have the staff to complete the programs.

Based on clinical record review and staff interviews, the facility failed to include all interventions for identified care problems for 1 of 6 residents reviewed. (Resident #4) The facility identified a census of 35 residents. Findings include: Review of a Minimum Data Set (MDS) assessment form dated 6/11/15, Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident was severely cognitively impaired and required extensive assistance of staff with eating. According to a Care Plan Report with a date range from 6/1/15 until 8/19/15, the resident experienced a self-care deficit related to dementia. The care plan directed staff to provide meals in the Memory Care Unit and monitor to make sure he/she continues to feed themselves. Review of a Steps Following a Skin Tear Procedure form dated 6/16/15 and following a coffee spill, staff were directed to have lids on all liquids The Care Plan Report failed to identify the above stated intervention.

Based on observation, clinical record review, staff interviews and facility policy review, the facility failed to properly assess and intervene when 1 of 6 residents experienced and incident and/or a condition change (Resident #4). The facility identified a census of 35 residents. Findings include: Review of a Minimum Data Set (MDS) assessment form dated 6/11/15, Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident was severely cognitively impaired and required extensive assistance of staff with eating. According to a Care Plan Report with a date range from 6/1/15 until 8/19/15, the resident experienced a self-care deficit related to dementia. The care plan directed staff to provide meals in the Memory Care Unit and monitor to make sure he/she continues to feed themselves. Review of a Clinical Notes entry dated 6/18/15 at 2:25 p.m., included the following information: Another resident's family member reported to staff today on 6/16/15 he/she witnessed the resident had spilled coffee on his/her lap. Visited with the staff member present at the time of the incident and the staff member reported she observed the resident had spilled coffee onto the left side of his/her lap but the staff member felt the coffee was cold at the time. Staff reported they took the resident to the bathroom and checked the area and at the time noted no redness, warmth or blistering. Two nurses checked the area today and again no redness, blistering or warmth noted. For the intervention the resident required lids on all liquids served include a lid. Review of the Steps Following a Skin Tear Procedure form dated 6/16/15, a summary of the investigation and care plan revision section identified the following information: Another resident's family member reported he/she observed the resident spilled coffee on his/her legs. The staff members reported the resident spilled coffee on himself/herself landing on the groin area. The staff member reported she felt the coffee had been cold due to the time of the incident. Staff reported they assisted the resident and checked the area where the coffee had spilled, but observed no redness, blistering and/or warmth. Two nurses checked the area and no redness/warmth and blistering noted. An observation on 8/19/15 at 9:30 a.m., revealed the resident positioned at the dining room table with a glasses of uncovered water and juice. During an interview 8/20/15 at 11:50 a.m., Staff C, Certified Medication Aide (CMA) indicated she approached the resident on the day of the incident, noticed his/her pants were wet, took the resident to the bathroom, pulled down his/her pants and found no redness, burns, blisters and/or warmth. The staff member confirmed she failed to report the incident to the nurse. During an interview 8/20/15 at 11:36 a.m., Staff E, Certified Nursing Assistant (CNA) indicated she vaguely remembered the incident but felt it had been reported to the nurse that day with an assessment completed. The staff member confirmed she had toileted the resident and changed his/her pants but there had been no redness,[MEDICAL CONDITION] the skin had not been hot to the touch. During a staff interview 8/20/15 at 10:15 a.m., Staff A, Registered Nurse (RN) indicated she and Staff B, Licensed Practical Nurse (LPN) assessed the area after the fact and thought no assessment had been completed at the time because the CNA and CMA failed to report the incident to the nurse. During an interview on 8/20/15 at 1:43 p.m., Staff B confirmed a family member reported the incident to the nurses on 6/18/15 however the incident occurred on 6/16/15 and when she and Staff A assessed the area they found no injuries. The staff indicated it was facility policy to immediately report such an incident to the nurse for an assessment and to monitor. During an interview on 8/20/15 at 1:55 p.m., the Administrator confirmed she would have expected staff to immediately report the incident to the nurses as considered an incident. During an interview on 8/20/15 at 2:01 p.m., Staff D, CNA confirmed the facility policy directed staff to report an incident to the nurse even if no injuries occurred. Review of an Incident Report Policy/Procedure form revised 9/05, directed the staff to complete an I Incident Report regarding the following: a. Extensive scratches, abrasions, rashes, excoriations or burns. b. Anything out of the ordinary.

Based on clinical record and interviews, the facility failed to provide adequate supervision with transfers to prevent accidents for one (1) of seven (7) residents reviewed (Resident #6). Record review determined Resident #6 required the assistance of two staff for transfers. Staff interview revealed on 7/5/14, Resident #6 lost his/her balance when a staff member attempted to transfer the resident by him/her(self). Resident #6 re-injured his/her recent hip prosthesis when the staff failed to provide a safe transfer. A concern was identified for adequate supervision for Resident #1. The facility reported a census of 46 residents of which 7 resided in the secure memory care unit. Findings include: 1.The Hospital Transfer Report dated 7/1/14 documented [DIAGNOSES REDACTED]. The Physician's Progress Notes dated 7/1/14 at 12:42 p.m. documented the resident had a small uni-cortical crack about 2 inches above the tip of the right femoral prosthesis (hip replacement) and the resident would be transferred to the nursing home to continue protective mobilization. The note identified Resident #6 had 50% weight-bearing on the right leg with fall precautions carried out. The note also documented if the resident were to fall there would be a significant chance of a femur shaft fracture. According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #6 required two staff assistance with bed mobility, transfers, toilet use, and when dressing. The assessment identified Resident #6 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, when moving on/off the toilet and during surface to surface transfers. The Clinical Notes dated 7/1/14 at 4:32 p.m., documented the nursing home received a medical predictability document which indicated " This is a statement of medical predictability. The weight bearing status of this resident is restricted. When the weight bearing status restriction is lifted this would let the resident receive therapies under Medicare Part A if qualify. The physician estimated that this could be as soon as 7/11/14. " The physician signed the form and a copy had been given to the therapy staff. The New Resident Admit/Initial Care Plan dated 7/1/14 identified Resident #6 could ambulate and transfer with only 50% weight-bearing on the right leg and assistance of 2 staff. The care plan documented the resident was at risk for falls and required a personal alarm at all times. The care plan noted the resident wears glasses. (The care plan did not address the resident's legal blindness in both eyes.) The Incident Report dated 7/6/14, completed by Staff A, he documented the resident had been transferred from his/her wheelchair by Staff C. The staff put a gait belt on him/her and asked the resident to grab the bar by the toilet in the shower room. The resident missed the grab bar and when he/she started to fall, Staff C caught him/her and assisted the resident back to the wheelchair. During an interview with Staff A on 8/7/14 at 2:10 p.m., he reviewed the Incident/Accident Report he completed and acknowledged he incorrectly documented the " date " of incident as 7/6/14, instead of when it occurred on 7/5/14. He reviewed the clinical documentation in the electronic medical record and confirmed he failed to document the incident in the resident's record. The Clinical Notes entry dated 7/6/14 (incorrectly date, should read 7/5/14) at 5:40 a.m., completed by Staff E, registered nurse (RN) documented the resident transferred to the hospital per ambulance on 7/5/14 at 2200 (10:00 p.m.) due to continued complaints of pain after an incident which occurred during an attempt to transfer the resident from the wheelchair to a shower chair at some undocumented time. The electronic clinical record contained no further documentation regarding the resident's status after transfer to the hospital. During interview on 8/12/14 at 2:20 PM Staff C stated she and another CNA had planned to transfer the resident from the wheelchair to the shower chair when the other staff member got called to assist in the memory care unit. Staff C stated the resident had refused a shower for three days but consented to take a shower after discussion with his/her spouse. Staff C stated she thought it would be okay to assist the resident to stand holding the safety bar on the wall, pull down the resident's slacks, replace the wheelchair with the shower chair and have the resident sit down. Staff C demonstrated where she placed the resident's wheelchair at a 90 degree angle to the horizontal grab bar, assisted the resident to grip the bar with the left hand, placed a gait belt around the resident's waist and while she stood to the left of the resident she assisted the resident to stand and cued the resident to grip the bar with the right hand. Staff C stated the resident missed gripping the bar and "flailed" (lost balance) to the right and twisted. She lifted up on the gait belt and assisted the resident to sit in the wheelchair. Staff C stated the resident immediately hollered out in pain. Staff A responded immediately and administered pain medication to the resident. The other CNA then returned to the shower room and they transferred the resident to bed. Staff C stated she knew the resident's care plan directed to transfer the resident with 2 assistants but did not think standing the resident up constituted the transfer. She had cared for the resident for two days and knew he/she stood well in his/her own bathroom so she thought the resident would be okay to stand up with her assistance. Staff C stated she could not say for sure if the resident maintained touch-toe weight bearing on the right leg as the incident happened so quickly. Staff C had been unaware of the resident's legal blindness until asked by the surveyor and stated that may have been the reason he/she did not grip the grab bar as he/she could not see it. The right hip X-ray report dated 7/5/14 at 2327 (11:27 PM) documented a new intertrochanteric fracture of the right femur surrounding a bipolar prosthesis with significant anterior distraction of the anterior fracture fragment by 4 to 5 centimeters anteriorly. The Full Operative Report dated 7/7/14 documented the resident underwent [REDACTED]. The postoperative [DIAGNOSES REDACTED]. During interview on 8/7/14 at 1:35 PM the physical therapist stated she evaluated the resident on 7/1/14 for physical therapy (PT). The resident had a central vision deficit from macular degeneration and a postural disability related to Parkinson's disease. During the evaluation the PT therapist stated the resident "lunged" to the right side when assisted to stand from a seated position and required extensive assistance of a certified nursing assistant (CNA) and herself to keep weight off the resident ' s right leg. The PT therapist stated she assessed Resident #6 as a high fall risk and at risk for further injury. The PT reported the occupational therapist (OT) was also aware the resident had a small crack in the head of the femur and she wrote a PT/OT recommendation to caregivers which identified Resident #6 required two (2) staff assistance with a front-wheeled walker (FWW) for transfers. The form also documented the resident to only touch toes of the right foot to the floor and that the resident loses his/her balance easily. The PT stated she provided the form and reviewed the instructions with a nurse and a certified nurse aide (CNA) and then placed the recommendation in the CNA communication book with the initial care plan for Resident #6. The PT stated too much weight-bearing and or foot-planted twisting on the right leg could easily cause a fracture of the femur and or dislocation of the hip prosthesis. 2. The Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED].#1. The same MDS documented the resident required extensive assistance for completion of transfer and bed mobility, non-ambulatory and limitations in functional range of motion of one arm and one leg. The Care Plan Report effective 4/28/11 identified the resident with impaired physical mobility and directed staff apply a pressure alarm at all times when in bed or chair and to check the functioning of the alarm every shift. An Incident/Accident Report dated 6/22/14 at 2210 (10:10 PM) documented the resident found on the floor of his/her room. the Clinical Notes Report completed by Staff dated 6/23/14 at 1:32 AM documented a CNA found the resident on the floor during check of resident alarms. The note documented the resident's coccyx, left buttock and both elbows were reddened. During interview on 8/12/14 at 2:20 PM Staff F, CNA, stated she found the resident lying on the floor of his/her room in a fetal position in front of the television about 3 feet from the bed when she had entered the room to check the resident's alarm. She could not say how the long the resident lay on the floor but stated the resident's hip and elbows were reddened. During interview on 8/12/14 at 3:25 PM Staff E, RN, stated the resident's alarm did not sound, but when she and Staff F put the resident back to bed they checked the alarm and it functioned. Staff E stated she did not know if she noted the alarm malfunction on the incident report because the instructions attached to the incident report stated to not document fault or equipment failure. During interview on 8/12/14 at 1:15 PM the director of nursing stated she had been aware the resident's alarm did not sound on 6/22/14. She stated she signed the incident report 6/23/14 which would indicate she did review it.