Every finding on record at Henderson County Ret Center

Based on record review and interview the facility failed to follow an Antibiotic Stewardship program. This failure has the potential to affect all 41 residents who currently reside in the facility. Findings Include: CMS form 671 signed by V1, Administrator, on 05/08/24 documents there are 41 residents living in the facility. On 5/8/24 at 10:30 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated that the facility utilizes the McGreer Criteria which are written definitions of what constitutes an infection. The Facility's Infection Control Monitoring Logs for January, February, March, and April 2024 listed all of the residents who had been on antibiotics for infections, there was no documentation of monitoring of signs and symptoms of infections prior to antibiotic use, or any documentation of any evidence-based criteria used to define any of the infections prior to antibiotic use. On 5/8/24 at 10:40 AM V6 (Registered Nurse/ Assisted Director of Nursing) stated We need to train our nurses on McGreer Criteria for identifying what is an infection and what does not meet the criteria. The Facility's Antibiotic Stewardship policy dated 4/7/2020 documents The facility will develop an Antibiotic Stewardship Program that promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. A collaborative effort between the resident/resident representative, interdisciplinary team, practitioners, Medical Director, pharmacist and leadership team is essential for success of the Antibiotic Stewardship Program. The Facility's Antibiotic Stewardship policy also documents when the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes Resident signs and symptoms, assessment/vital signs, interview the resident for symptoms. The Nurse will document all assessment findings in the electronic medical record. The Facility's Antibiotic Stewardship policy also documents The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including documentation related to antibiotic selection and use.

Based on observation, interview, and record review the facility failed to perform hand hygiene during resident cares for two of 12 residents (R36 and R40) reviewed for infection control in a sample of 18. Findings include: 1) R36's current Care Plan, documents that R36 has an indwelling urinary catheter and that R36 requires staff assistance with all cares. On 05/08/24 at 8:30 am, R36 was sitting on the commode in R36's bathroom and V4 (Certified Nursing Assistant/CNA) was performing indwelling urinary catheter care. While wearing the same soiled gloves V4 (CNA) then completed the following tasks: set up two wash basins to cleanse R36 of stool; emptied R36's indwelling urinary catheter drainage bag (leg bag) of urine into the commode; washed and wiped bowel/stool off R36's buttocks; pulled up R36's pants; and assisted R36 to the wheelchair. V4 then removed V4's soiled gloves. V4 did not perform hand hygiene or change gloves during R36's cares. On 05/08/24 08:35 am, V4 (Certified Nursing Assistant/CNA) stated, I should have changed gloves after I did catheter care and before cleaning bowel from (R36's) rectum. On 5/8/24 at, V2 (Director of Nursing) stated, The Nurses and CNA's (Certified Nursing Assistant's) should be performing hand hygiene during all cares, especially when they go from a contaminated area to clean. Facility Catheter Care, Urinary Policy, undated, documents: the purpose of this procedure is to prevent catheter-associated urinary tract infections; place equipment on the bedside stand; wash and dry hands thoroughly or use antimicrobial hand gel; put on gloves, thoroughly rinse perineal area including the penis/scrotum; thoroughly rinse perineal area in same order, using fresh and clean washcloth; gently dry perineum; rinse washcloth or use a clean one and apply soap or skin cleansing agent; wash and rinse the rectal area thoroughly, including under the scrotum, anus and buttocks and dry; discard any disposable items into the designated containers; remove gloves and discard into designated container; wash and dry hands thoroughly or use antimicrobial hand gel; reposition and make resident comfortable; clean the bedside stand if used; and wash and dry your hands thoroughly. 34542 2) On 5/8/2024, at 10:05 a.m., V6/Certified Nursing Assistant, during indwelling catheter care donned gloves. V6 then without changing gloves, proceeded to transfer R40, using a sit to stand lift, to R40's bed. V6 pulled down R40's pants and incontinence brief. V6 then adjusted the empty trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's catheter tubing. V6 placed the dirty rag in a plastic trash bag on R40's bed; grabbed a clean, wet, soapy, wash rag and wiped R40's genital area. V6 placed the dirty rag in the plastic trash bag on R40's bed. V6 grabbed the clean wet rag and rinsed R40's catheter tubing and R40's genital. V6 placed rag in the trash bag; grabbed a dry towel and dried R40's genital and catheter tubing. V6 placed the towel in the trash bag; adjusted R40's catheter tubing; pulled up R40's incontinence brief and pants. On 5/8/24, at 10:10 am., V6 confirmed V6 should have, but did not, change gloves during catheter care when going from dirty to clean. On 5/8/24, V2/Director of Nursing confirmed the expectation that V6 should have changed gloves, during catheter care when going from dirty to clean.

Based on record review and interview the facility failed to ensure a prophylactic antibiotic was monitored for effectiveness and not prescribed in excessive duration for one of five residents (R8) reviewed for unnecessary medications in the sample of 18. Findings include: A Health Status Note dated 03/4/22 documents R8 received a new order for Cephalexin 250 milligrams for frequent UTIs (urinary tract infection). This order has no end date. A Consultant Pharmacist Communication to Physician signed by V8, Consultant Pharmacist, on 03/10/23 documents, Antibiotic use without symptoms - Cephalexin. Under the drug usage guidelines use antibiotics routinely or indefinitely without symptoms is discouraged due to increased risk for potential side effects and the development of antibiotic resistance. V5, R8's physician, responded, Prophylaxis, UTI recurrent. An identical Communication was written by V8 on 01/10/24 regarding R8's Cephalexin. V5 responded, Recurrent UTI/need for PPX (prophylaxis). R8's medical record documents as of 05/08/24 she is still receiving Cephalexin 250 milligrams daily as a prophylactic medication to prevent UTIs. R8 was diagnosed and treated for UTIs on 08/30/23, 11/25/23, 01/26/24, 04/30/24 and 05/06/24. On 05/08/24 at 12:35 PM V2, Director of Nursing, confirmed R8 has been diagnosed and treated for five UTIs since 08/30/23. V2 stated there is no system in place to monitor the effectiveness of the antibiotic prescribed to R8. V2 confirmed R8 has been on a daily dose of Cephalexin since 03/04/22. On 05/08/24 at 2:34 PM, V5, R8's physician confirmed R8 has received a prophylactic dose of antibiotic for over two years. Policy dated 01/18/23 titled Suspected Urinary Tract Infection Policy and Procedure documents, Residents of long-term care facilities (LTCF) tend to have risk factors for the development of urinary tract infections (UTI), making UTIs one of the most common infections presenting in nursing facility residents. However, overuse and/or unnecessary treatment with antibiotics can lead to bacterial resistance and unwanted side effects.

Based on observation, interview and record review the facility failed to provide informed consent for an antipsychotic medication, failed to identify target behaviors and failed to identify an appropriate supporting diagnosis for one resident (R22) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 15. Findings include: Facility Policy/Psychotropic Medication Policy dated 1/16/19 documents: Prior to the administration of a psychotropic medication, the following includes a process for the IDT (Interdisciplinary Team) and resident/resident representative to participate in the care process: The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. Antipsychotic Medication: Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. Antipsychotic medications may be indicated if: Behavioral symptoms present a danger to the resident or others; Expressions or indications of distress that are significant distress to the resident; If not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which present a danger or significant distress to the resident. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. A Psychotropic Drug Assessment will be completed on admission, quarterly, an irregularity identified in the pharmacist's medication regimen review and with significant changes of condition. Consent: Provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment. The goals of psychotropic medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will also include the classification of psychotropic drug(s) to be monitored for side effects daily. On 5/2/23 and 5/3/23 R22 was observed sitting in his room and also sleeping/napping in bed after lunch. On 5/2/23 R22 was sitting in his room in a wheelchair. After being greeted, R22 began talking about people and events in a rambling but calm manner. R22 was able to answer simple questions, however, could not stay focused on topic and would continue to ramble. Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23 and consent signed on 3/13/23 indicates Abilify was increased to 3mg on that date. Neither consent indicates a diagnosis, indication for use, specific side effects or target behaviors. Current POS (Physician's Order Summary) indicates R22 has orders for Abilify (antipsychotic) 3mg (milligrams) daily related to Severe Unspecified Dementia with Mood Disturbance, Severe Recurrent Major Depressive Disorder with Psychotic Symptoms. CNA (Certified Nurse Assistant) Behavior Monitoring indicates: February 2023 Rejection of care/twice; yelling/9 times; abusive language 6 times, March 2023 Rejection of care/once; yelling/10 times; abusive language twice; wandering/once, April 2023 Yelling/twice; abusive language/once and May 2023 No behaviors. R22's Current Care Plan indicates R22 has a behavior problem related to Dementia. R22 is alert with confusion; known to yell out at staff during cares and has been known to refuse care and medications. R22 can become verbally aggressive with staff during cares. R22 will often watch television and yell out at the television; will have conversations with himself at times. [NAME] has been known to have hallucinations/delusions with paranoid behaviors. R22's Care Plan also indicates (R22) uses psychotropic medications related to Major Depressive Disorder with psychotic features. R22's Care Plan does not identify what type/category of psychotropic (antipsychotic) R22 receives or target behaviors. Progress Note dated 4/5/23 at 4:47am indicates R22 usually sleeps well and engages in confused conversation at times. Progress Note dated 4/13/23 at 11:41am indicates R22 was alone in his room after breakfast, staff overheard R22 talking and swearing at (someone) however no one else was in the room. Note indicates behavior was discussed with spouse who stated, I just don't think that medicine is doing him a bit of good anymore. Physician Note dated 3/13/23 indicates R22 has diagnosis of Dementia without behavioral disturbance and behavior is cooperative. Note indicates to Avoid medications on Beer's List. (The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beer's List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults [AGE] years and older. The Beer's List includes the antipsychotic Abilify). Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23. Consent does not indicate an indication for use, diagnosis, side effects or target behaviors. On 5/3/23 at 3:10pm V2, DON (Director of Nursing) stated prior to starting the Abilify, R22 was having multiple episodes per day of yelling at the TV, yelling at self and seemed distressed. V2 stated that R22 was referred to Behavioral Health Services and they recommended to start R22 on Abilify. V2 stated the Behavioral Health practitioner told her There was all this evidence that Abilify is not even an antipsychotic until it reaches a certain dosage. V2 stated we did increase the dosage once and (R22's) wife wanted us to increase it more because she believed it was helping although his behaviors did return.

Based on observation, interview and record review, the facility failed to change oxygen tubing and humidification bottle as ordered for one resident (R4) out of one resident reviewed for oxygen administration in a sample of 15. Findings include: The facilities Oxygen Administration policy undated, documents 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Equipment and Supplies: 2. Nasal cannula, nasal catheter, or mask (as ordered) 3. Humidifier bottle. On 05/02/23 at 10:10 AM, R4's oxygen tubing was dated 10/29 and the humidification bottle was dated 10/22. R4's medical record documents R4 received oxygen via nasal cannula on 1/6/23 and 2/6/23. R4's physician orders dated 11/26/22 documents Change oxygen/nebulizer tubing weekly while in use. On 5/2/23 at 11:10 AM, V4, Infection Preventionist, verified she documented R4 as being on oxygen on 1/6/23 and 2/6/23 and stated I would have documented that she was on oxygen because that's what she was on at the time. (R4) does wear her oxygen from time to time because she believes it makes her feel better. On 5/2/23 at 11:15 AM, V2, Director of Nursing (DON), verified oxygen tubing and humidifier bottle date and stated It's supposed to be changed weekly. I'm not sure why it hasn't been changed since October.

Based on observation, interview and record review, the facility failed to immediately report inner thigh bruising to the Abuse coordinator for one of 12 residents (R26) reviewed for abuse in the sample of 16. Findings include: Facility Policy/Abuse (undated) documents: It is the policy of this facility that injuries of unknown source are reported per Federal and State Law. The facility will ensure all violations involving injuries of unknown source are reported immediately. Internal Reporting: Employees must report any 'abuse' or 'suspicion of abuse' immediately to the Administrator. R26's current Physician order [REDACTED]. R26's orders indicate R26 has behaviors of being demanding, resistive to care and can be physically aggressive. On 2/23/21 at 10:00am, R26 was assisted to the toilet by V11 and V12 CNAs (Certified Nurse Assistants). At that time a large, crescent shaped solid dark red and purple bruise was noted on R26's left inner thigh. A blue, green, purple and blue bruise approximately palm sized - was noted on R26's right out hip. At that time V11, CNA stated that she had seen R26's bruises on shower day. CNA Documentation dated 2/21/21 indicates R26 received a shower on that day. On 2/23/21 at 2:30pm, V2 (DON/Director of Nursing) and V3 (ADON/Assistant Director of Nursing) assisted R26 to the toilet. At that time a scattered light blue/green bruise was also noted on R26's right inner thigh that was not seen earlier due to R26's positioning on the toilet. Both left and right inner thigh bruises were located on the same area of R26's inner thighs. R26's current Physician order [REDACTED]. That order was changed to right outer thigh on 2/24/21. R26's medical record did not document orders indicate monitoring of inner thigh bruises. On 2/24/21 at 10:00am V7, LPN (Licensed Practical Nurse) stated that she had been told about R26's bruises by the night shift nurse during the morning of 2/23/21 and observed the bruises on R26 at that time. V7 did acknowledge that bruises on a residents inner thighs would be suspicious and unlikely to be obtained during a fall out of bed. V7 stated that suspicious bruises are reported to V2, DON. No documentation of the R26's inner thigh bruises were found or presented. On 2/23/21 at 2:30pm V2, DON, stated that she was notified of R26's fall on 2/23/21 and told about the bruise on R26's outer hip. V2 stated that she was notified in the morning that R26 had two bruises. V2 stated that she normally reports bruises to V1, Administrator, however she didn't tell V1 until later that day. Incident Investigation Report dated 2/23/21 at 6:00pm indicates that when V7, LPN arrived for her shift at 5:00am on 2/23/21 and V7 found and reported to V2, DON that R26 also had a bruise on right inner thigh. Report indicates that upon further investigation R26 actually had three areas of bruising - bruising to bilateral inner thighs and a right outer hip bruise. Investigation dated 2/24/21 indicates three nurses were reprimanded due to Staff reporting (R26's bruises) to those three nurse's with no follow up documentation or incident report initiated to V2, DON. The Investigation Witness Statement indicates V13, CNA reported R26's bruises to V15, RN (Registered Nurse) on 2/22/21. Investigation of bruises of unknown origin not reported to the V1, Abuse Coordinator until 2/23/21 and not reported to the State Agency until 2/23/21 at 6:00pm.

Based on observation, interview, and record review, the facility failed to prevent a pressure ulcer from developing and worsening, failed to identify a pressure ulcer, and failed to follow a physician prescribed treatment for one of two residents (R29) reviewed for pressure ulcers in the sample of 24. This failure resulted in R29's wound worsening from a Stage II pressure ulcer to Unstageable. Findings include: The facility's Prevention of Pressure Ulcers policy, dated 2/27/19, documents, Pressure ulcers are usually formed when a resident remains the the same position for an extended period of time causing increased pressure or a decrease of circulation to that area and subsequent destruction of tissue. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. According to the National Pressure Ulcer Advisory Panel: Prevention and Treatment of Pressure Ulcers Quick Guide, dated 2014, A pressure ulcer is 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. Category/Stage II: Partial Thickness Skin Loss: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum filled blister. Unstageable: Depth Unknown: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. According to Merck Manual Professional Version, Pressure Ulcers, dated (YEAR), Direct ulcer care. Appropriate ulcer care involves cleaning, debridement, and dressings. Debridement is necessary to remove necrotic tissue. Necrotic tissue serves as a medium for bacterial growth and blocks normal wound healing. Dressings are helpful for protecting the wound and facilitating the healing process (Dressings should be used for stage I pressure ulcers that are subject to friction or incontinence and for all other pressure ulcers. R29's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 4/11/19, documents that R29 is at a high risk for developing pressure ulcers. R29's Incident note, dated 3/12/19, documents, CNA (Certified Nursing Assistant) noticed a blister with light bruising at R29's right great toe. CNA states she is sure it was not there this morning. Area measures 1 cm (centimeter) x 1 cm. R29's physician's orders [REDACTED]. great toe. This order was obtained on 3/19/19. R29's MDS (Minimum Data Set), dated 3/13/19, documents in Section M Skin Conditions that R19 does not have any pressure ulcers. R29's Pressure ulcer Care plan, dated 4/12/19, has no documentation of revision to R29's care plan to address R29's pressure ulcer nor were new interventions implemented when the area was discovered. R29's Nurse's note, dated 3/17/19, documents that R29's right greater toe has a broken blister with a reddish center. R29's Skin/Wound Note, dated 3/29/19, documents that R29 continues to have an open area related to the blister on R29's right great toe. The noted also documents that R29's treatment order continues to be a [MEDICATION NAME] spot on R29's right great toe until it is resolved. R29's Electronic Census documents that R29 was discharged to the hospital on [DATE]. R29's Readmission assessment, dated 4/11/19, documents that R29 has a blister to his right great toe that measures 2 cm x 2 cm x 1 cm. The assessment also documents that a Stage II pressure ulcer may present as an intact or open/ruptured serum/filled blister, and an Unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 04/15/19 at 11:11 AM, R29 had a circular shaped wound covered approximately 75% with eschar (dark brown/black tissue) on the end of R29's right big toe. The wound had no dressing covering it. V8 (Certified Nursing Assistant) stated that R29's wound has been present for over six weeks and confirmed that no dressing was in place. On 04/17/19 at 11:34 AM V2 (Director of Nursing) removed R29's socks where R29's area to his right great toe was uncovered with no dressing. V2 confirmed that R29 had a round eschar area covering the end of R29's toe and that there was no dressing in place to R29's toe. V2 stated she wasn't aware that R29 still had an area to the end of his toe. On 04/17/19 at 01:20 PM, V2 stated that R29 had a blister that developed on the end of his right great toe from the pressure of the toe rubbing against his foot board. On 04/17/19 at 02:20 PM, V9 (Wound Nurse) stated, When R29's wound was discovered 3/12/19 it was a fluid filled blister. When the blister popped we got the order for a [MEDICATION NAME] dressing. Then he went into the hospital. When I assessed the wound when he returned from the hospital hard and scabbed. I measured it when he returned with having depth even though it was scabbed. I was not aware that a blister is considered a pressure ulcer. We continued the [MEDICATION NAME] treatment when he returned so the treatment should be in place at all times. On 04/17/19 at 02:36 PM, V9 removed R29's blanket to expose R29's feet. R29 had no dressing on his right great toe. R29 had a round area on the end of his right great toe with approximately 75% of the wound covered in eschar. V9 stated, The eschar was not there when I initially assessed this wound is was just a scab like area with no eschar present. The wound has worsened, and it is now necrotic and Unstageable. On 4/18/19 at 12:15 p.m., V10 (R29's Physician) stated that if a treatment is not being utilized it will contribute to the wound worsening.

Based on interview and record review the facility failed to develop a comprehensive care plan to address identified risks for side rail use for eight of eight residents (R1, R7, R15, R20, R24, R27, R29, and R34) reviewed for side rail use in the sample of 24. Findings include: The facility's Bed Rail Policy (undated) documents, Resident care plans include use of the bed rails as assessed with [REDACTED]. 1. R1's Side Rail assessment dated [DATE] documents R1 has a history of falls, has visual deficits, has problems with balance or poor trunk control, receives medications that would require safety precautions. 2. R15's Side Rail assessment dated [DATE] documents R15 is unable to get in and out of bed, has a history or falls, has a history of falls from bed, has visual deficits, has fluctuations in levels of consciousness or a cognitive deficit, has problems with balance or poor trunk control, and receives medications that would require safety precautions. 3. R20's Side Rail assessment dated [DATE] documents R20 has a history of falls, has a history of falls from bed, has visual deficits ([MEDICAL CONDITION]), has fluctuations in levels of consciousness/cognitive deficit, and has problems with balance and trunk control. 4. R29's Side rail assessment, dated 3/11/19, documents that R29 has a history of falls, visual defects, fluctuations in levels of consciousness/cognitive defect, and has problems with balance and trunk control. 5. R34's Side rail assessment, dated 3/25/19, documents that R34 has a history of falls, visual defects, fluctuations in levels of consciousness/cognitive defect, and has problems with balance and trunk control. 6. R7's Side Rail assessment dated [DATE] documents R7 has a history of falls, has a history of falls from bed, has visual deficits ([MEDICAL CONDITION]), has fluctuations in levels of consciousness/cognitive deficit, and has problems with balance and trunk control. 7. R24's Side Rail assessment dated [DATE] documents R24 has a history of falls, has fluctuations in levels of consciousness/cognitive deficit related to forgetfulness and confusion, and has problems with balance and trunk control. 8. R27's Side Rail assessment dated [DATE] documents R27 has a history of falls, has fluctuations in levels of consciousness/cognitive deficit, has problems with balance and trunk control related to weakness, requires assistance needed with transfers, and receives medications that would require safety precautions (Opioid, Antipsychotic). R1, R7, R15, R20, R24, R27, R29, and R34's current Care Plans do not address risks with the use of side rails as identified on their Side Rail Evaluations. On 04/17/19 at 09:25 AM, V2 (Director Of Nursing) stated, (R1, R7, R15, R20, R24, R27, R29, and R34) do not have care plans to address risks associated with the use of their side rails.

Based on observation, interview, and record review the facility failed to accurately complete side rail assessments identifying residents being at risk for entrapment with the use of side rails and failed to implement alternatives prior to the installation of side rails for eight of eight residents (R1, R7, R15, R20, R24, R27, R29, and R34) reviewed for side rail use in the sample of 24. Findings include: The facility's Bed Rail Policy (undated) documents, It is the policy of this facility to identify risks and hazards commonly associated with bed rail use. Individual bed rail evaluations will include data collection analysis and determination of potential alternative to bed rail use. The facility's priority is to ensure safe and appropriate bed rail use. Issues that often result in bed rails use include memory disorders, impaired mobility, risk for injury, and sleep disturbances. Individuals with agitation, [MEDICAL CONDITION], confusion, pain, uncontrolled body movements, and eliminations issues are at risk for entrapment and/or suffering serious injury from a fall. 1. On 04/15/19 at 10:11 AM and 04/16/19 at 11:11 AM, R1's bed had bilateral half side rails in the raised position. R1 stated, I only use the side rail on the left side of my bed. I do not use the side rail on the right side of my bed. I have had the side rails since I was admitted here. R1's Current physician's orders [REDACTED]. R1's Fall Scale assessment dated [DATE] documents R1 is at a high risk for falls. R1's Side Rail assessment dated [DATE] documents R1 has a history of falls, has visual deficits, has problems with balance or poor trunk control, receives medications that would require safety precautions. This same assessment documents that R1 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). 2. On 04/16/19 at 11:12 AM, R15 was lying in bed with bilateral half side rails in the raised position. V5 (Certified Nursing Assistant/CNA) turned and re-positioned R15 in bed, and R15 did not use the side rails during the re-positioning. V5 stated, (R15) has right sided weakness and cannot use the left side rail. R15's current [DIAGNOSES REDACTED]. R15's Side Rail assessment dated [DATE] documents R15 is unable to get in and out of bed, has a history or falls, has a history of falls from bed, has visual deficits, has fluctuations in levels of consciousness or a cognitive deficit, has problems with balance or poor trunk control, and receives medications that would require safety precautions. This same assessment documents R15 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). R15's Fall Scale assessment dated [DATE] documents R15 is a high risk for falls. R15's Minimum Data Set (MDS) Assessment Section C Cognitive Patterns dated 3-29-19 documents R15's BIMS (Brief Interview of Mental Status) score at a 3, indicating R15 is severely cognitively impaired. This same MDS Section G Functional Status documents R15 requires extensive assistance of two staff physical assist for bed mobility, transfers, and toilet use. 3. On 04/15/19 at 10:27 AM, R20 was lying in bed with bilateral half side rails in the raised position. R20's current [DIAGNOSES REDACTED]. R20's Side Rail assessment dated [DATE] documents R20 has a history of falls, has a history of falls from bed, has visual deficits ([MEDICAL CONDITION]), has fluctuations in levels of consciousness/cognitive deficit, and has problems with balance and trunk control. This same assessment documents R20 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). R20's MDS Assessment Section C dated 3-4-19, documents R20's BIMS score a 3 indicating R20 is severely cognitively impaired. This same assessment Section G Functional Status documents R20 requires extensive assistance of one staff physical assist for bed mobility, transfers, and toilet use. R20's Fall Scale assessment dated [DATE] documents R20 is a high risk for falls. 4. On 04/15/19 at 09:48 AM, R29 had bilateral 1/2 side rails attached and upright on R29's bed. R29's Side rail assessment, dated 3/11/19, documents that R29 has a history of falls, visual defects, fluctuations in levels of consciousness/cognitive defect, and has problems with balance and trunk control. R29's assessment also documents that R29 does not have any risks associated with the use bilateral half side rails (even though risks were identified on the assessment, as listed above). 5. On 04/15/19 at 01:48 PM, R34 had a grab bar upright and attached to the right side of R34's bed R34's Side rail assessment, dated 3/25/19, documents that R34 has a history of falls, visual defects, fluctuations in levels of consciousness/cognitive defect, and has problems with balance and trunk control. R34's assessment also documents that R34 does not have any risks associated with the use of a grab bar (even though risks were identified on the assessment, as listed above). 6. On 4/15/19 at 10:12 AM, R7 had bilateral half side rails on R7's bed in the upright position. R7's Side Rail assessment dated [DATE] documents R7 has a history of falls, has a history of falls from bed, has visual deficits ([MEDICAL CONDITION]), has fluctuations in levels of consciousness/cognitive deficit, and has problems with balance and trunk control. This same assessment documents R7 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). 7. On 4/15/19 at 9:00 AM, R24's bed contained bilateral half side rails in the upright position. R24's Side Rail assessment dated [DATE] documents R24 has a history of falls, has fluctuations in levels of consciousness/cognitive deficit related to forgetfulness and confusion, and has problems with balance and trunk control. This same assessment documents R24 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). 8. On 4/15/19 at 10:36 AM, R27's bed contained bilateral half side rails. The right rail was in the upright position and the left rail was in the down position. R27's Side Rail assessment dated [DATE] documents R27 has a history of falls, has fluctuations in levels of consciousness/cognitive deficit, has problems with balance and trunk control related to weakness, requires assistance needed with transfers, and receives medications that would require safety precautions (Opioid, Antipsychotic). This same assessment documents R27 does not have any risks associated with the use of bilateral half side rails (even though risks were identified on the assessment, as listed above). R1, R7, R15, R20, R24, R27, R29, and R34's Medical Records do not contain documentation of any alternatives tried prior to the installation of side rails. On 04/17/19 at 09:25 AM, V2 (Director Of Nursing) stated, (R1, R7, R15, R20, R24, R27, R29, and R34's) side rail assessments were coded incorrectly as being 'not at risk' with the use of side rails, and should have been coded that (R1, R7, R15, R20, R24, R27, R29, and R34) are 'at risk' with the use of side rails. (R1, R7, R15, R20, R24, R27, R29, and R34) have not had any alternatives tried prior to the installation/implementation of side rails.

Based on observation, interview, and record review, the facility failed to keep an indwelling urinary drainage bag and tubing off of the bed and floor, and keep it below the level of the bladder for one of one resident (R29) reviewed for indwelling urinary catheters in the sample of 24. Findings include: The facility's Urinary Catheter Care policy, dated 9/2014, documents, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag: Be sure the catheter tubing and drainage bag are kept off the floor. The policy also documents, For a male resident: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. R29's Care plan, dated 4/12/19, documents that R29 has an indwelling urinary catheter due to genitalia swelling. The care plan also documents the intervention to position the indwelling urinary catheter drainage bag and tubing below the level of the bladder. On 04/15/19 at 11:11 AM R29 had dark yellow urine present in his indwelling urinary catheter drainage bag and tubing. V8 (Certified Nursing Assistant) removed R29's indwelling urinary catheter drainage bag from side of R29's bed holding the bag at the level of her chest while R29 was lying in bed. Dark yellow urine refluxed in the tubing. Then, V8 handed the drainage bag to V7 (Certified Nursing Assistant) who pulled it thru R29's pant leg above the level of R29's bladder. Once the drainage bag was thru R29's pant leg, V7 laid it on R29's bed. V7 and V8 positioned R29 to a sitting positing on the side of his bed and placed the drainage bag on floor. Using a stand aid, V7 and V8 stood R29 while the drainage bag remained on the floor. Once R29 was standing V8 attached the drainage bag to the stand aid and transferred R29 to his high back reclining wheel chair. Once he was in his wheel chair, V8 placed the drainage bag on the floor while positioning R29 in his wheel chair. On 04/15/19 at 11:24 AM, V7 and V8 confirmed that they held R29's indwelling urinary drainage bag above the level of R29's bladder, and that it was placed on the bed and floor.

Based on observation, interview, and record review the facility failed to implement an active/passive range of motion restorative program for one of three residents (R20) reviewed for limitations in range of motion in the sample of 24. Findings include: The facility's Resident Mobility and Range of Motion policy dated 07/2017 documents, Residents will not experience an avoidable reduction in range of motion. Residents with limitations will receive treatment and services to increase and or prevent a further decrease in range of motion. Residents with limitations will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. On 04/15/19 at 10:46 AM, V7 CNA (Certified Nursing Assistant) and V8 (CNA) assisted R20 to the side of the bed and then assisted R20 from the bed to the toilet. R20's right arm was flaccid during these transfers. R20's current [DIAGNOSES REDACTED]. R20's Minimum Data Set Assessment Section G Functional Status dated 3-4-19 documents R20 has a limitation in range of motion to one side of the upper extremity. This same Assessment Section O Restorative Nursing Programs documents R20 does not receive a restorative program or range of motion program for R20's limitation to the upper extremity. On 04/16/19 at 11:14 AM, V4 (Minimum Data Set Coordinator) stated, (R20) has a limitation and does not have full range of motion to the right arm due to her [MEDICAL CONDITION]. A restorative program of range of motion was not implemented for (R20's) limitation. A range of motion program should have been implemented. On 04/16/19 at 11:21 AM, V5 (CNA) stated, (R20) does not get a range of motion program. We (facility staff) just have (R20) do as much as possible for herself.

Based on observation, interview, and record review, the facility failed to revise a care plan with advanced directives and for the development of a pressure ulcer for two of 15 residents (R29, R34) reviewed for care plans in the sample of 24. Findings include: The facility's Comprehensive Person-Centered Care Plans policy, dated 12/2016, documents, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 1. R29's Incident note, dated 3/12/19, documents, CNA (Certified Nursing Assistant) noticed a blister with light bruising at R29's right great toe. CNA states she is sure it was not there this morning. Area measures 1 cm (centimeter) x 1 cm. R29's Readmission assessment, dated 4/11/19, documents that R29 has a blister to his right great toe that measures 2 cm x 2 cm x 1 cm. The assessment also documents that a Stage II pressure ulcer may present as an intact or open/ruptured serum/filled blister, and an unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 04/17/19 at 11:34 AM, V2 (Director of Nursing) removed R29's socks and confirmed that R29 had a round eschar (dark brown/black tissue) area covering the end of R29's toe. R29's wound was an unstageable pressure ulcer based on it's characteristics. On 04/17/19 at 01:20 PM, V2 stated that R29 had a blister that developed on R29's right great toe from the pressure of his toe rubbing against his foot board. R29's Pressure ulcer Care plan, dated 4/12/19, has no documentation of revision to R29's care plan to address R29's pressure ulcer nor were new interventions implemented On 04/18/19 at 11:08 AM, V4 (Minimum Data Set Coordinator) confirmed that R29's pressure ulcer was not identified on R29's care plan nor was the care plan revised with new interventions. 2. The facility's Advance Directive policy, no date available, documents, Resident wishes will be communicated to the staff via the care plan and to the resident physician. R34's physician's orders [REDACTED]. R34's POLST (Practitioner Order For Life-Sustaining Treatment) form, dated 8/7/18, documents that R34 is a DNR. R34's Advanced Directive Care plan, dated 4/26/17, documents that R34 is a full code. On 04/18/19 at 11:08 AM, V4 (Minimum Data Set Coordinator) confirmed that R34's advanced directives were not revised on R34's care plan.

Based on observation, interview, and record review the facility failed to have a clinical indication for the use of a restraint for one of one resident (R30) reviewed for restraints in a sample of 24. Findings include: The facility's Use of Restraints Policy and Procedure dated 2/27/19 documents, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's condition and this restricts his/her typical ability to change position or place, that device is considered a restraint. Examples of devices that are/may be considered physical include leg restraints, arm restraints, hand mitts, soft mitts, soft ties or vest, wheelchair safety bars, (high back wheelchair), and lap cushions and trays that the resident cannot remove. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Placing a resident in a chair that prevents the resident from rising. R30's progress notes dated 9/8/17 document, (V2/Director of Nursing/DON) called (V6/R30's POA/ Power of Attorney) expressing concern of (R30's) frequent falls. We discussed options, and together decided that a low pedal (high back wheelchair) with tray will be a good choice to protect (R30). R30's progress notes dated 9/16/17 document, (R30) continually attempting to ambulate unassisted, smacking hand on desk and removing safety alarms. R30's progress notes dated 9/26/17 document, (R30) was attempting to pull off tray that is connected to (high back wheelchair). (R30) is angry and agitated. R30's fall plan of care revised 3/22/19, documents, (R30) is a high risk for falls. (R30) is often confused. She lacks safety awareness, has poor standing balance, and very poor impulse control. (R30) is unaware of her safety limits. She is unaware that she is unable to ambulate independently safely. (High back wheelchair) with lap tray when up. R30's current Restraint plan of care documents R30 needs assistance with tray removal. R30's current MDS (Minimum Data Set) assessment Section P Physical Restraint dated 3/18/19, documents R30 uses a chair that prevents rising daily. R30's Physical Restraint assessment dated [DATE] documents under Reason for Restraint, agitated behavior, frequent falls, attempts transfer. On 4/17/19 at 2:00 PM, R30 was sitting in her (high back wheelchair) with the tray attached. On 4/16/19 at 10:38 AM, V2 stated, (R30) cannot remove the tray from her wheelchair herself. On 4/17/19 at 10:02 AM, V2 stated, (R30) has the low (high back wheelchair) with tray to prevent falls.

Based on interview and record review, the facility failed to document a [DIAGNOSES REDACTED]. Findings include: The facility's [MEDICAL CONDITION] Medication Policy, undated, documents, Prior to the administration of a [MEDICAL CONDITION] medication, the following includes a process for the IDT (Interdisciplinary team) and resident/resident representative to participate in the care process: 1. The indication for any [MEDICAL CONDITION] medication will be thoroughly documented in the clinical record to include an appropriate supporting [DIAGNOSES REDACTED]. The medical record must show documentation of adequate indication and diagnosed condition. The policy also documents, A [MEDICAL CONDITION] Drug Assessment will be completed on admission, quarterly, a new medication or renewal order, an irregularity identified in the pharmacist's medication regimen review and with changes of condition (significant change of condition, new, persistent or recurrently symptom/problem, worsening of an existing problem, unexplained decline in function or cognition). The policy also documents, Baseline Tardive Dyskinesia assessment will be completed with re-assessment every six months and as needed for antipsychotic medications. R1's Medication Review Report, dated 4/1-4/30/18, documents that R1 had an order for [REDACTED]. R1's Care plan, dated 3/28/18, documents that R1 is receiving [MEDICATION NAME] for the [DIAGNOSES REDACTED]. R1's Medical records have no documentation of a [DIAGNOSES REDACTED]. The medical record also has no documentation of a completed [MEDICAL CONDITION] assessment nor an AIMS assessment. On 6/11/18 at 2:15 p.m., V3 (Licensed Practical Nurse) stated that R1 didn't have any behaviors, and she only remembered him yelling out at times. On 6/11/18 at 2:20 p.m., V4 (Registered Nurse) stated, (R1) didn't have any behaviors. On 6/12/18 at 10:10 a.m., V2 (Director of Nursing) stated, (R1) doesn't have any behaviors. He periodically yells out, but I don't feel that was justifiable for him to be receiving an antipsychotic. I don't feel like his [DIAGNOSES REDACTED]. V2 also stated that a [MEDICAL CONDITION] assessment nor an AIMS was completed for R1.

Based on observation, interview, and record review, the facility failed to assess for entrapment risks for the use of side rails for one resident(R30)of 8 residents reviewed for side rails in a total sample of 14. FINDINGS INCLUDE: R30's Careplan, dated 3/5/18, documents, SIDERAIL: Bilateral half rails up for safety during care provisions to promote independence with bed mobility. R30's Electronic Medical Record, dated 3/2018, does not have any assessments that include risk for entrapment. On 3/21/18, at 8:30 A.M., and 3/22/18 at 10:30 A.M. R30 was lying in bed with bilateral siderails up and the bed was against the wall. On 3/22/18,at 1:30 P.M., V2 (Director of Nurses) confirmed that R30 always has two half rails up at all times. V2 also confirmed that the Siderail Assessment has no assessment for entrapment. That is one of the new regulations, and I just missed that piece of it.

Based on observation, interview, and record review, the facility failed to ensure that a physical restraint used for one resident (R30) was for the treatment of [REDACTED]. FINDINGS INCLUDE: The Use of Restraint Policy dated 11/10 states Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a) Treat the medical symptom.' The Restraint-Physical (Initial Evaluation dated 3/18/2017 states (R30) has confusion at times. Has a significant history of self transferring despite potential outcomes. Has a history of falls and falls with fractures. (R30) can be resistive with cares is very impatient with staff. (R30) can be verbally aggressive towards staff. 03/21/18 9:00 A.M. and 3/22/18 at 1:00 P.M. R30 was in a in reclined cushion chair, foot pedals and lap tray. On 3/22/18 V2(Director of Nurses) stated We use the foot pedals because (R30) will drag her feet when we push her chair. V2 also stated (R30) has had several falls, I didn't know of any other interventions. I thought the restraint was the lesser of two evils of a fall with major injury versus a restraint.

Based on observation, interview and record review the facility failed to perform a physical restraint assessment for one resident (R30) of two residents, reviewed for physical restraints, in a total sample of 14. FINDINGS INCLUDE: The facility policy, entitled Use of Restraints, dated 11/2010, document, Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. R30's Careplan, dated 10/03/17, documents, Low pedal (reclining cushion chair) with lap tray to be on when up. On 3/22/2018, V2 (Director of Nursing) provided an undated document, entitled Seating/Wheeled Mobility Letter of Medical Necessity Power Wheelchair/Chairs And or Any Custom Wheelchair (i.e., any wheelchair with a custom seating system) as the pre-restraining assessment. The assessment was signed by V6 (Physical Therapy Assistant.) The [DIAGNOSES REDACTED]. Additionally, this document list: Presenting problem: Long history of unsteadiness, falling backwards and impulsivity causing high fall risk and prone to serious injury. The Seating/Wheelchair Mobility Letter of Medical Necessity Power Wheelchair/Chairs And or Any Custom Wheelchair (i.e any wheelchair with a custom seating system) shows the following areas not completed: Cardio-Respiratory , Tone/ Strength, Explain whey the consumer's need for prolonged sitting tolerance type seat, lap tray and/ or spinal orthotic need for prolong sitting tolerance, postural support to permit functional activities, or pressure reduction cannot be met adequately by a planar type seat, lap tray and/or spinal orthotic, Therapeutic Objectives/Benefits of Prescribed Equipment, Skin Condition/Integrity, Equipment Prescription. This same assessment shows that V6 (Physical Therapy Assistant) assessed R30 for a reclining cushion chair. The lap tray and foot pedals were not on the assessment. 03/21/18, at 9:00 A.M., and 3/22/18, at 1:00 P.M., R30 was observed in a in reclined cushion chair, with foot pedals and lap tray. On 03/21/18, V2 (Director of Nurses) confirmed the assessment was not complete, not dated, and did not include lap tray and foot pedals. V2 stated, The lap tray and foot pedals should have been on that.

Based on record review and interview the facility failed to determine if a resident had a living will/advanced directives, upon admission, for one resident (R135) of 14 residents reviewed for code status in a total sample of 14. FINDINGS INCLUDE: The facility policy, entitled Cardiopulmonary Resuscitation (CPR) Policy, undated, document, It is the policy of this facility will provide basic life support, including CPR (Cardiopulmonary Resuscitation) when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. R135's Admission Notes documents that R135 was admitted to facility via family car after a fall at home. On [DATE], at 9:45 A.M., V3 (Registered Nurse) confirmed no advanced directives in R135's medical record. On [DATE], at 9:55 A.M., V2 (Director of Nursing) confirmed no advanced directives in R135's medical record. V2 stated, It's not there, we missed it. On [DATE], at 11:00 A.M., R135 stated, I have a living will and should have a doctor's order for no CPR; I don't want tubes or life support, none of it. On [DATE], at 9:45 A.M., V3 (Registered Nurse) confirmed if V3 found a resident with no heartbeat and no breathing, if there was no information available, I would initiate CPR immediately. On [DATE], at 9:50 A.M., V4 (Licensed Practical Nurse) confirmed if V4 found a resident with no heartbeat an no breathing, if there was no information available,I would initiate CPR immediately. On [DATE], at 11:15 A.M., V2 confirmed if V2 found a resident with no heartbeat and no breathing, if there was no information available, I would initiate CPR immediately. V2 also stated, I would expect that all the nurses that work here would initiate CPR if they (the nurse) did not have the DNR (Do not Resuscitate) order available.

Based on record review, and interview, the facility failed to immediately report an allegation of verbal abuse to the Administrator and failed to submit an initial and final alleged abuse investigation report to the State Agency for one resident (R5) of three residents reviewed for abuse in a sample of six. Findings include: R5's online medical record documents: R5's [DIAGNOSES REDACTED]. Minimum Data Set (MDS) document R5's Brief Interview for Mental Status (BIMS) as 3 (indicating R5 is not cognitively intact); R5's Care Plan, dated 4-10-2017, documents, (R5) will yell out. Asks repetitive questions. Caregivers to provide opportunity for positive interaction, attention. Approach/Speak (to R5) in a calm manner. Facility document, provided by E2 (Director of Nursing), entitled Employee Counseling Report, dated 8-18-2017, documents, (E3/Certified Nursing Assistant) was reported to have been sitting at the assisted dining room feeder table, assisting residents to eat their meals on Wednesday, 8/16/17, while filling out a job application. A resident (R5) repeated herself to get (E3's) attention, and was reportedly ignored by (E3). The resident finally yelled to get (E3's) attention, and (E3) was heard saying (to R5) 'Jesus [***] ing Christ, I'm not in the mood to talk' sternly; FINAL WRITTEN WARNING WITH RECOMMENDATION OF 3 DAY(S) SUSPENSION; DESCRIPTION OF REASON(S) FOR ACTION (BE AS SPECIFIC AS POSSIBLE): 1) It is a well known rule that there is to be no distractions while feeding residents a meal. This is a great time to sit down and talk with residents, give them some conversation and attention, and ensure their well being. Filling out a job application needs to be done on your own time. 2) Never ignore a resident. Never cuss at a resident, and never speak sternly to a resident. You speak kindly to these residents whether you're 'in the mood to talk' or not. If you are unable to do so, you shouldn't be working the floor. On 8-24-2017, at 11:10 a.m., E6 (Certified Nursing Assistant/transportation aide), confirmed: sitting with E3 in the assisted dining room on Wednesday 8-16-2017; E3 was filling out a job application; R5 tried to get E3's attention and with no success, R5 yelled; E3 then firmly stated to R5, Jesus [***] ing Christ, I am not in the mood to talk to you right now!, while giving a dirty look to R5. E6 stated at that time that E6 reported the incident to E2 (Director of Nursing) on 8-18-17. On 8-24-2017, at 11:30 a.m., E2 confirmed the following: E2's investigation and subsequent suspension for E3's interaction with R5; E6 should have reported the allegation right away; and the allegation should have been reported to the State Agency, but never was.

Based on record review, and interview, the facility staff failed to follow their facility Abuse Prevention Program Policy by not internally reporting a verbal abuse allegation immediately, and by not reporting said allegation to the State Agency, for one resident (R5) of three residents reviewed for verbal abuse in a sample of 6. Findings include: Facility Policy, entitled Abuse Prevention Program, not dated, documents, Any individual observing or suspecting resident abuse of any kind must immediately report such incident to the administrator ; and (State Agency) shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. As soon as possible but not to exceed 24 hours if the events that cause the reasonable suspicion do not result in serious bodily injury. On 8-24-2017, at 11:10 a.m., E6 (Certified Nursing Assistant) confirmed: On Wednesday 8-16-2017, witnessing E3 (Certified Nursing Assistant) state, in a stern manner, to R5, Jesus [***] ing Christ, I am not in the mood to talk to you right now!; and not reporting the abuse allegation until two days later-Friday 8-18-2017. On 8-24-2017, at 11:30 a.m., E2 (Director of Nursing), confirmed: On 8-18-2017, E6 reported an allegation of verbal abuse against R5 that E6 witnessed on 8-16-2017; and the allegation, which resulted in a 3-day suspension of E3, was not reported to the State Agency.

Based on observation, record review, and interview, the facility failed to reposition and provide incontinence care for two of three residents (R4,R5) reviewed for pressure sores in the sample of ten. R4 developed multiple stage two pressure ulcers. Findings include: 1. On 03/5/12 at 9:45 a.m., R4 was sitting in her wheelchair in the main dining room during activities. R4 had a lap restraint in place. After the activity, R4 was wheeled to the assistive dining room table at 11:10 a.m.. At 11:25 a.m.on 03/05/12, R4 was still in the assistive dining room while E3(CNA/Certified Nursing Assistant) was bringing in other residents into the dining room to eat lunch that was being served at 11:30 a.m.. E3 stated that R4 was not checked for incontinence before bringing R4 to the dining room. E3 stated she did not have time to check R4. E3 stated that R4 was transferred with a mechanical lift from bed to wheelchair between 6:30 - 7:00 a.m. and had not been transferred out of the wheelchair since that time. At 11:30 a.m. on 03/5/12, E3 (CNA) took R4 from the dining room to R4's room. E3 and E4(CNA) transferred R4 from R4's wheelchair to R4's bed with a mechanical lift. R4 was found to be incontinent of bowel and bladder. R4 had an open area on the upper left buttocks and a large purple area on the lower, left buttocks with a light red center. E5 (Licensed Practical Nurse) measured the areas on 03/05/12 at 11:45 a.m.. The open area on the upper, left buttocks measured 1 cm (centimeter) x 1 cm x 1 cm, and the lower left buttocks purple area measured 4 cm x 4 cm. E5 stated that the the open area and the purple area were new areas and called R4's physician for new orders. A physician order [REDACTED]. Nursing notes dated 01/13/12, document that R4 has a history of pressure sores. On 01/13/12 nursing notes, document that R4 developed a centimeter red/purple area on the left buttocks, and on 01/16/12, a 2 centimeter open area was found on the left buttocks. On 03/07/12 at 10:00 a.m., Z1 (Family member) stated that R4 just had a pressure sore on her bottom back in January, 2012 and now R4 has another one. Z1 stated that, "they must not be keeping her clean and she sits a lot in the chair." R4's care plan dated 1/25/12, documents for staff to turn and reposition R4 at least every two hours as necessary, keep R4 clean and dry, check R4's body daily.This care plan notes that R4 is transferred with assist of two staff and a mechanical lift. R4's Minimum (MDS) data set [DATE] documents R4 is at risk for pressure sores, is non-ambulatory, and requires assist of two staff for transfers and Activities of Daily Living. The facility Intensive Skin Care Protocol and Policy Statement documents to inspect skin frequently for signs of pressure, turn and reposition every two hours, and if a reddened area is noted then the turning schedule should be shortened to one hour. Residents in chairs, recliner chairs, or wheelchairs are to have a change of postioning every two hours or more, such as standing or ambulating. 2. According to the current physician progress notes [REDACTED]. The Minimum (MDS) data set [DATE] documents that R5 is at moderate risk for developing pressure sores. It documents that R5 is incontinent of bowel and bladder at times. The Pressure Ulcer Potential assessment dated [DATE] documents that R5 scores a 10 which should be considered low risk according to this assessment. The physician order [REDACTED]. The care plan dated 1/22/12 document that R5 has potential for poor skin integrity related to fragile skin left inner buttock area. The approaches are: Preventive protection to Left inner buttock-[MEDICATION NAME] or mepflex foam with borders daily and as needed as tolerated. Check area two times a week during bath. The care plan is not updated with any approaches to relieve the pressure from R5's buttock to promote healing. On 3/5/12 at 9:00AM, R5 was seated reclined asleep in the recliner in her room. R5 stayed in this position until lunch when she was assisted to a straight chair around 11:00 AM. At 12:00PM, R5 was assisted back to her recliner in her room where she stayed until the evening meal. On 3/6/12 at 8:30 AM, E6 (treatment Nurse) did the treatment as ordered to R5's left buttock. R5's left and right buttock had dark brown discoloration on both sides approximately 10cm by 10cm. R5 reclined in the recliner until noon and again after lunch, all afternoon. On 3/7/12, R5 reclined in the recliner in her room asleep from morning till lunch and after lunch all afternoon. On 3/7/12 at 11:00 AM, E4 (CNA) stated that R5 likes to recline in the recliner and sleep all day. E4 stated that R5 will go to activities once in a while. E4 stated that no one has told her to assist R5 to a different position, just to place her back into the recliner after meals. E4 stated that she thought that R5 would probably lie in the bed if she asked R5 to. On 3/7/12 at 12:30 PM, R5 was laying in bed asleep on her right side. E4 stated that R5 was agreeable to lay in bed to rest to relieve the pressure off her buttock.