Every finding on record at Heritage Health Care Rehabilitation & Skilled Nurs

The facility reported a census of 53 residents. Based on observation, interview and record review, the facility failed to ensure Resident (R) 3 remained free from abuse when he had an unwitnessed fall in his room and Licensed Nurse (LN) G instructed R3 to get onto his hands and knees and lift himself off the floor resulting in feelings of anger and embarrassment for R3.Findings included:- R3's Electronic Health Record (EHR) revealed diagnoses of unspecified sequelae of cerebral infarction (lingering, long-term effects or complications following a stroke [ischemic brain damage] when the specific nature of the aftereffects is not detailed), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R3's Admit Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment documented R3 utilized a wheelchair and walker for mobility. He was dependent on staff for toileting, lower body dressing and putting on footwear, required partial to moderate staff assistance with upper body dressing, personal and oral hygiene, and required supervision or touching assistance with bathing.The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/02/26 documented R3 required staff assistance with all activities of daily living (ADL).The Falls CAA, dated 02/02/26, documented that R3 had fallen at least once since admission and had taken antidepressant (medication used to treat depression) medication, a high-risk medication.The Psychotropic Drug Use CAA, dated 02/02/26, documented that R3 had taken an antidepressant.R3's Care Plan dated 02/19/26 documented R3 was at risk for falls related to weakness and receiving high risk medications. Interventions documented that staff would need to carry out all interventions to prevent R3 from falling.R3's Care Plan dated 02/19/26, documented that R3 had difficulty with personal hygiene, oral care, bathing, bed mobility, toilet use, transfers, dressing, ambulation and locomotion related to post hospital weakness. Interventions instructed staff to provide partial to moderate assistance to R3 with toilet use and repositioning and turning in bed.A Post-Fall Evaluation: Progress Note, documented on 02/12/26 at 02:48 AM, R3 had an unwitnessed fall in his room when trying to self-toilet. R3 fell while trying to transfer from his recliner to his bed.A Nursing: Progress Note, documented on 02/12/26 at 02:31 AM, R3 was sitting up on the floor leaning against the bed, and he had no shoes on and had slick socks on. Staff replaced his socks with gripper socks and donned house slippers on him. Staff then encouraged him to turn around and get on his knees and pull himself up off floor and into bed.An Official Statement, dated 02/12/26, documented Certified Medication Aide (CMA) R received shift report and heard LN G state that R3 had a fall overnight and LN G made R3 remain on the floor, to teach him a lesson, while she completed a few tasks. LN G then made R3 get off the floor without assistance.An Official Statement, dated 02/19/26, documented that R3 had told Administrative Staff A that LN G had instructed him to get into a prayer position and get himself off the floor. The statement further recorded R3 told Administrative Staff A that LN G was upset and argued with him about how many falls he had.On 03/03/26 at 12:17 PM, R3 was in the dining room eating lunch. Staff interacted with him well.On 03/03/26 at 01:50 PM, Certified Nurse Aide (CNA) N stated that if a resident was found on floor, she would make sure they were ok and would then notify the nurse. CNS N said staff should have assisted R3 and not have made him get up by himself.On 03/03/26 at 02:34 PM, Administrative Nurse E stated that she would have assisted R3 up from floor and then followed protocol including notifying the necessary people.On 03/03/26 at 03:05 PM, R3 reported that the nurse on 02/23/26 told him to get into a praying position and to pick himself up off the floor after his fall. He stated the nurse would not assist him and it made him feel angry and very embarrassed.On 03/04/26 at 10:00 AM, Administrative Staff A stated that LN G 's actions were inappropriate.The facility policy . Abuse, Neglect and Exploitation Policy and Procedure, dated 03/31/20, documented that facility staff would not use or allow others to use verbal, mental, sexual or physical abuse, corporal punishment or unvoluntary seclusion.The facility implemented corrective actions including abuse, neglect and exploitation training completed on of 02/21/26, prior to the onsite survey, therefore the deficient practice was deemed past noncompliance a G representing the actual psychosocial harm for R3.

The facility identified a census of 53 residents. Based on record review, observation, and interview, the facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics stored as overflow. Findings included:-In a facility reported incident, the facility reported that on 02/13/26 at approximately 02:00 PM, staff reported 12 hydrocodone (a potent semi-synthetic opioid analgesic and antitussive used to treat severe pain) were missing.The facility Facility Narcotic Dispensing Record for R1's hydrocodone medication documented that a count of 30 had been crossed out with a line and a count of 18 had been written in and initialed by two individuals and dated and times 02/12/26 at 11:00 PM. It was documented and initialed an amount given of one with the remaining amount of 17.Licensed Nurse (LN) H's Witness Statement, dated 02/16/26, documented that on 02/12/26 she was asked to pull a hydrocodone from the overflow medication, and she and Certified Medication Aide (CMA) R performed a count of the medication in the bottle pulled from the cabinet. There were 18 pills in the bottle, and the count sheet documented 30 pills. LN H then documented that she performed a count correction on the sheet by crossing out the 30 and writing 18, She noted that she became busy and forgot to notify administration of the error.CMA R's Witness Statement, dated 02/13/26, documented that she needed to replace R1's hydrocodone in the CMA medication cart and asked LN H to assist her in retrieving the medication from the overflow cabinet. CMA R documented that when they counted the bottle of pills on 02/12/26, there were only 18 in it and the count sheet said there were 30, CMA R documented that LN H said that the 30 count was another LN's handwriting and LN H changed the count to 18. CMA R documented that she forgot to report the error to the charge nurse until the next day, on 02/13/26.The facility's investigation, dated 02/13/26, documented on 02/12/26 at approximately 10:00 PM, LN H and CMA R pulled R1's hydrocodone from the overflow cabinet to move the medication into the medication cart. When LN H and CMA R counted the pills in the bottle it, there were 12 pills missing. The bottle and narcotic count sheet both stated a count of 30 but the bottle only had 18 pills at that time. This was reported to the Administrative Staff A on 02/13/26 at approximately 02:00 PM and an investigation was initiated. A full narcotic count on all medication storage in the facility was completed at that time with no other discrepancies identified. Residents were monitored for pain out of their normal, and none had been observed.During the investigation the following was revealed:-On 02/06/26, CMA S picked up the bottle of hydrocodone from a third-party pharmacy between 04:43-04:46 PM. This was confirmed with the pharmacist at the pharmacy. The medication was in a brown paper bag and stapled shut with the information sheet attached to the outside of the bag when it arrived at the facility. LN G opened the paper bag and was seen on camera footage locking the bottle up in the overflow cabinet. LN G then made out a narcotic count sheet but did not count the bottle at that time. On 02/06/26 at 06:33 PM, LN G and LN I counted the pills in the bottle and found the count to be correct. The contents of the bottle were not counted again until 02/12/26. Re-education on narcotic count, overflow, re-ordering of medications, and the pulling of medications for destruction was performed; and the overflow count form was changed, and the prescription number was added.Observed on 03/03/26 at 10:20 AM, the medication room near the east entrance was locked and the overflow narcotics were in a cabinet with a red breakaway lock on the cabinet and padlock. Administrative Nurse D and Administrative Nurse E demonstrated that the cabinet could not be opened without unlocking the padlock and the breakaway lock and administrative staff had to replace the breakaway lock.On 03/03/26 at 10:20 AM, CMA T stated that the overflow medications were kept in a medication room behind two locks. CMA T said that the nurses would count the overflow narcotics at shift change and then during the shift when the medications were used, the shift the CMA and nurse performed the count. She said that if the count was off, multiple re-counts were performed for verification and if the count was not correct then Administrative Nurse D and Administrative Staff A were immediately notified.On 10/20/25 at 10:30 AM, Administrative Nurse D and E stated that the overflow narcotics were kept behind two locks in the medication room, and the padlock on the narcotic cabinet had a red breakaway lock on it and if the tag was intact then a count was not needed, the nurses at shift change performed the count if needed, CMAs were not allowed to perform overflow narcotic counts.On 10/20/25 at 10:40 AM, Administrative Nurse D stated that if a CMA needed a narcotic refill on their cart, then two nurses performed the count and provided the medication to the CMA for the cart. Administrative Nurse D said that if the count was off then several re-count verifications were performed and if the count remained incorrect then she and Administrative Staff A were immediately notified along with the prescribing provider and the medical director, and the facility would get a new prescription to refill the medication so the resident would not be without. On 3/04/26 at 01:45 PM, Administrative Staff A stated that the facility contacted a contractor and had the locks to the medication rooms and cabinets replaced and that the facility contacted the facility pharmacy and paid to have the missing hydrocodone replaced and the facility paid for them.Review of the facility investigation revealed all corrective actions to the onsite survey therefore the deficient practice was deemed past noncompliance.The facility policy Controlled Substance Administration & Accountability, date 02/13/26, documented that it was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The policy also documented that the facility would have safeguards in place to prevent loss, diversion or accidental exposure.

The facility reported a census of 59 residents. Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the covers on three of the three dumpsters were kept closed. This deficient practice created a risk of attracting insects and/or rodents.Findings included:- During an initial environmental tour of the kitchen on 08/04/25 at 08:19 AM, observation revealed the lids to three of the three dumpsters outside of the kitchen were left open, with trash on the ground surrounding the dumpsters.On 08/04/25 at 09:15 AM, the lids of the dumpsters remained open.On 08/06/25 at 10:35 AM, Dietary Staff BB stated that staff were to keep the lids of the dumpsters closed at all times.The facility policy for Disposal of Garbage and Refuge undated, included: Dumpsters shall be kept covered when not being loaded. The surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attraction is minimal.

The facility reported a census of 59 residents, one main kitchen, and two kitchenettes. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for foodborne bacteria. This placed the residents at risk of foodborne illnesses.Findings included:- During an initial tour of the kitchen on 08/04/25 at 11:04 AM, the following areas of concern were noted:The microwave in the dining room was heavily soiled with dried-on food debris on the inside and outside of the microwave oven.The window area used to pass dirty dishes from the dining room to the kitchen had a heavy build-up of dried-on food and liquid on the frame of the window, the cove base underneath the window, and the trash can next to the window had dried-on food substance. The window area used to pass resident plates from the kitchen into the dining room had a heavy build-up of dried-on food and liquid. The stationary can opener had a build-up of a moist food substance on the base of the opener. The preparation table next to the stove, used to store pots and pans, had food debris on the bottom shelf. A three-tiered cart used to hold eggs, cheese, and clean plates during the preparation of breakfast had non-breakfast food debris on all three tiers. Two plastic containers used to hold individual packets of creamers and sugars had a build-up of grime on the lids. Three plastic containers used to hold flour, sugar, and breadcrumbs had a build-up of grime and a sticky substance on the lids. A large roast sat in a four-inch baking dish, thawing at room temperature. Observation of the three-door reach-in refrigerator revealed the following areas of concern:A one-half gallon of sour cream was opened and undated.A quart container of liquid eggs was opened and undated. A one-half-gallon container of peaches had an unidentified dried-on food substance. A one-gallon container of mayonnaise had an unidentified dried-on food substance.A nearly empty one-gallon container of mustard had an unidentified dried-on food substance and a heavy build-up of dried mustard around the lip of the container. A one-gallon container of salsa had spilled through the wire racks of the reach-in refrigerator onto three one-gallon containers of milk. The container of salsa had spilled onto the bottom shelf of the refrigerator and out onto the front bottom of the reach-in refrigerator. Observation of the snack area in the dining room revealed the following areas of concern:The front of the counter in front of the juice and coffee machines had dried-on food and liquid substance on four doors and one drawer. The three-tiered snack cart had a build-up of a sticky substance on two of the three tiers. All four wheels of the snack cart had a build-up of food debris and grime.Observation of the resident refrigerator/freezer in the kitchenette area of the dining room had the following areas of concern:A partial quart container of mixed fruit was opened and undated. A quart container of an unknown food-type substance was unlabeled. There were seven 20-ounce (oz) plastic bottles of soda opened and unlabeled. The freezer had four 12-oz cans of soda, which had exploded onto other items in the freezer. Two plastic jugs with a facility shake were undated and unlabeled. One opened quart of ice cream was undated and unlabeled. Two opened one-half-gallon containers of ice cream were undated and unlabeled. Two opened one-gallon containers of vanilla ice cream were undated and unlabeled. One plastic cup of an unknown food-type substance was undated and unlabeled. On 08/04/25 at 08:00 AM, Dietary Staff CC stated she had been thawing the roast on the countertop at room temperature instead of in the sink with cold water.On 08/06/25 at 10:35 AM, Dietary Staff BB confirmed the areas of concern would need to be corrected. Dietary Staff BB stated she would continue with the education of her staff during their monthly staff meetings.The facility policy for Sanitation, revised 10/2008, included: The kitchen and dining areas shall be kept clean and free from rubbish. Surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The facility policy for Food Safety Requirements, undated, included: Staff shall label and date foods kept in the refrigerator. Approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process. Thawing at room temperature is not acceptable.

The facility identified a census of 59 residents with two medication rooms, three medication carts, and two treatment carts. All five carts have a narcotic box. Based on observation, interview, and record review, the facility failed to adequately reconcile the medication cart for controlled substances. This placed the residents at risk for misappropriation. Findings include:- On 08/04/25 at 12:30 PM, the cart in the east hallway contained a lock box that contained controlled substances. Review of the controlled substance reconciliation log lacked evidence of a controlled substance reconciliation between two staff on 07/03/25 at 08:00 PM; only the day shift nurse signed off. The log lacked evidence that a reconciliation was completed on 08/04/25 at 06:00 AM shift. There were no signatures present. On 08/04/25 at 12:30 PM, Certified Medication Aide (CMA) S stated the narcotics should be counted and verified every time the cart changes hands. CMA S said the outgoing nurse, the on-coming nurse, and the CMA all sign for the accuracy of the controlled substances on the cart.On 08/06/25 at 02:19 PM, Administrative Nurse D stated the narcotic medications should be counted and adequately reconciled when the cart changes hands. The facility's policy Controlled Substance Administration and Accountability documented that two nurses account for all controlled substances and access keys at the end of each shift.

The facility reported a census of 59 residents, three medication carts, two treatment carts, and two medication rooms. Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled, stored, and secured adequately. This placed the affected residents at risk for ineffective medication regimens or diversion.Findings included:- During an observation on [DATE] at 12:30 PM in the east hall, a medication cart was unlocked and unattended. The cart contained various medications, including Talzenna (a cancer medication), Gabapentin (a medication to relieve nerve pain), and narcotics in a lock box. On [DATE] at 01:03 PM, the east treatment cart was observed. The top drawer contained Novolog (a short-acting insulin that lowers the level of glucose in the blood) that was opened on [DATE]. This would have expired on [DATE]. It also contained Tresiba (long-acting insulin) and Lantus (long-acting insulin) that were not dated when they were opened, so staff were unable to tell when they expired. On [DATE] at 12:30 PM, Certified Medication Aide (CMA) S stated the cart should always be locked when staff are not present with the cart.On [DATE] at 01:03 PM, Licensed Nurse (LN) I stated the insulin multi-use pens were to be dated when they were opened.On [DATE] at 02:19 PM, Administrative Nurse D stated she expected the staff to lock the cart if they were not in the cart. Administrative Nurse D stated the nurse should date the insulin pens when they are opened.The facility's policy Medication Storage dated 2025 documented that all medications and biologics are to be kept in locked compartments. Scheduled two medications are to be kept under a double lock.

The facility reported a census of 59 residents. The sample included 17 residents, including one resident reviewed for discharge. Based on interview and record review, the facility failed to provide the Ombudsman (a resident advocate) with a notice of transfer for Resident (R)67 and R69. This placed the residents at risk of impaired residents rights related to discharge. Findings included: -R69's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She was admitted to the facility on [DATE] with a goal to discharge to the community.The Return to Community Referral Care Area Assessment (CAA), dated 04/22/25, did not trigger.R69's Discharge MDS, dated 06/03/25, documented the resident had a planned discharge to the community.R69's Care Plan for discharge planning instructed staff to identify any resources the resident may need upon dismissal to home.R69's EMR revealed a Progress Note dated, which documented that the resident had been discharged from the facility, accompanied by family.R69's EMR lacked documentation that the Ombudsman was notified of the resident's discharge from the facility. The facility was unable to provide evidence; upon request, the Ombudsman was notified of the R69's discharge.On 08/06/25 at 12:14 PM, Social Services X stated the Ombudsman had not been notified of R69's discharge as required.The facility policy for Transfer Notification Policy, 09/2018, included: It is the policy of the facility to notify the resident, representative and the state ombudsman of an emergency transfer, such as transfers to an acute care facility.- R67's Electronic Medical Record (EMR) revealed a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R67's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating moderately impaired cognition. He entered the facility on 06/02/25 with his overall goal being to discharge to the community.The Discharge to Community Care Area Assessment (CAA), dated 06/06/25, did not trigger.R67's Discharge Return Anticipated MDS, dated 07/11/25, documented that he had been discharged to a critical access hospital.R67's Care Plan plan for CHF instructed staff to monitor the resident for shortness of breath (SOB).Review of R67's EMR revealed the resident had been discharged to the hospital on [DATE].R67's EMR lacked documentation of the Ombudsman (a resident advocate) being notified of the resident's discharge from the facility. The facility was unable to provide evidence; upon request, the Ombudsman was notified of the R69's discharge. On 08/06/25 at 12:14 PM, Social Services staff X stated the ombudsman had not been notified of the resident's discharge as required. The facility policy for Emergency Transfer Notification Policy, 09/2018, included: It is the policy of the facility to notify the resident, representative, and the state ombudsman of an emergency transfer, such as transfers to an acute care facility.

The facility reported a census of 59 residents. The sample included 17 residents, including four residents who were reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide the necessary ADL care for one sampled resident, Resident (R)8, who did not get showered. This deficient practice placed the affected resident at risk for impaired quality of life and poor hygiene.Findings included:- Review of the Electronic Health Record (EHR) revealed that R8's diagnoses included cutaneous abscess of right axilla (cavity containing pus and surrounded by inflamed tissue), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), end stage renal disease (ESRD- the kidneys are no longer able to adequately support the body's needs), periprosthetic fracture around internal prosthetic right knee joint (a break in the bone surrounding the knee replacement implant), pressure ulcer of sacral region Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R8's admission Minimum Data Set (MDS), dated 06/20/25, documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognitive impairment. He required a wheelchair and walker for mobility; he required set-up/clean-up assistance for eating, partial to moderate assistance for oral and personal hygiene, and was dependent on staff for bathing and all other ADLs.The Functional Abilities Care Area Assessment (CAA), dated 06/20/25, documented R8 required assistance in oral hygiene and was ADL dependent on staff for toileting hygiene and bathing.The Urinary Incontinence and Indwelling Catheter CAA, dated 06/20/25, noted that R8 was dependent on staff for toileting hygiene and was frequently incontinent.The Pressure Ulcer/Injury CAA, dated 06/20/25, triggered that R8 was at risk for developing pressure ulcers, and had one or more unhealed pressure ulcer(s) at Stage 2 or higher; he required ADL assistance for movement in bed. R8's Care Plan for ADLs, dated 06/29/25, instructed staff to provide partial/moderate assistance with bed mobility, oral and personal hygiene, supervision with set-up assistance for eating, and he was dependent on staff for toileting hygiene and wheelchair mobility. R8's EHR, under the bathing Tasks, lacked evidence that R8 received bathing in July 2025. There were no documented bathing refusals in July 2025.A review of the July Shower Sheets revealed R8 received one shower on 07/17/25, and no bathing refusals were recorded.Observation on 08/04/25 at 11:45 AM, staff transferred R8 from his bed to a wheelchair using a full-body mechanical lift.Observation on 08/05/25 at 01:48 AM, Certified Medication Aide (CMA) R prepared R8 for bathing and placed the lift sheet under him for transfer.Observation on 08/05/25 at 02:55 PM, R8 propelled himself about the hallway via a wheelchair. R8 reported that he received a shower.On 08/04/25 at 08:42 AM, R8 reported that he had only been allowed one shower since admission and was told by staff he would get a shower two weeks ago, but never did. He stated that he had requested showers but did not get them and had to give himself bed baths.On 08/05/25 at 12:54 PM, CMA R stated that bathing was attempted three times weekly for residents, though some residents prefer bathing twice a week. CMA R further stated that if a resident refused bathing, staff documented R, for refused, on the shower sheet, and then it was circled and signed by the resident. On 08/05/25 at 01:21 PM, Licensed Nurse (LN) G reported that residents were offered bathing at least twice a week; some preferred to bathe once a week. LN G also stated that if a resident refused, then the aide was supposed to notify the nurse to assess the reason for refusal. If the resident continued to refuse, then the refusal was recorded on the shower sheet and initialed or signed by the resident.On 08/05/25 at 01:30 PM, Administrative Nurse D stated that bathing was based on the resident's preference; if the resident refused, then it was recorded as refused on the shower sheet and in the EHR. Administrative Nurse D further stated that it was expected that the staff recorded the bathing or the bathing refusals.The facility policy Resident Showers, dated 2024, documented that it was the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues. It listed that residents would be provided showers as per resident request or facility schedule, and based upon resident safety.

The facility reported a census of 59 residents. The sample included 17 residents, with four residents reviewed for wounds. Based on observation, interview, and record review, the facility failed to provide the necessary wound care and services in accordance with professional standards of practice, including wound assessments at least weekly, including measurements and description, for Resident (R) 58 and R2. This placed R58 and R2 at risk for related complications and delayed healing.Findings included:-R58's Electronic Health Record (EHR) revealed a diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypothyroidism (a condition characterized by hyperactivity of the thyroid gland), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pressure ulcer Stage 3 (full-thickness pressure injury extending through the skin into the tissue below), cellulitis of left lower limb (skin infection caused by bacteria), foot drop right foot and foot drop left foot (inability or difficulty in moving the ankle and toes upward). R58’s admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The assessment documented R58 had impairment to her lower extremities and used a walker and wheelchair for mobility; she required supervision or touching assistance for oral, toileting, and personal hygiene, partial to moderate assistance for bathing and dressing activities of daily living (ADLs), and substantial to maximum assistance with putting on footwear. R58’s “Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA),” dated 07/06/25, recorded that R58 required ADL assistance for self-care and mobility activities. R58’s “Pressure Ulcer/Injury CAA,” dated 07/06/25, recorded R58 was at risk for developing pressure ulcers, and she had one or more unhealed pressure ulcer(s) at Stage 2 or higher. R58’s “Care Plan,” dated 07/11/25, recorded that she had a pressure ulcer on the first and second digit of the right foot. The care plan directed staff to monitor laboratory results for indications of malnutrition, nutritional intake, and skin redness (specifically over bony prominences). The plan directed staff to follow the wound care protocol and perform weekly skin assessments and skin care per facility guidelines, as needed. R58’s EHR revealed an order dated 07/03/25 for a Licensed Weekly Nurse Skin Assessment to be performed every Thursday night shift. R58’s EHR revealed no “Licensed Weekly Nurse Skin Assessment” performed on 07/03/25 or 07/10/25. R58’s “Licensed Weekly Nurse Skin Assessment” performed on 07/17/25 recorded that the foot was noted to have significant improvement with the dressing in place, clean/dry/intact (CDI), but recorded no measurements. R58’s “Licensed Weekly Nurse Skin Assessment” performed on 07/25/25 recorded that the dressing was intact to the foot with no drainage or heat palpated at the time, and no increased foul odor was present, and treatment was in place. There were no wound measurements recorded. R58’s “Licensed Weekly Nurse Skin Assessment” performed on 08/01/25 had no documentation recorded. On 08/04/25 at 04:03 PM, R58 was sitting in her recliner with her feet elevated, wearing sneakers, and reported she had a wound on one of her big toes that had been treated by staff. R58 reported that she did not want her shoes removed to allow wound observation. On 08/06/25 at 10:30 AM, Licensed Nurse (LN) H reported that wound assessments were supposed to include measurements, a visual description of the wound and surrounding tissue, any changes in the wound, drainage, and description of bandage appearance. On 08/06/25 at 03:05 PM, Administrative Nurse D stated there were no wound assessments for R58’s toe wound, only the “Licensed Weekly Nurse Skin Assessment.” Administrative Nurse D confirmed that the order start date for the “Licensed Weekly Nurse Skin Assessment” was 07/03/25 and further confirmed that the weekly assessments were not started by the nurses until 07/17/25. Administrative Nurse D further stated that there were no measurements of the wound in any of the assessments and that there was no documentation in the 08/01/25 assessment. The facility did not provide a policy related to pressure ulcer monitoring. -R2 's Electronic Medical Record (EMR) revealed a diagnosis of mild protein-calorie malnutrition and cachexia (a complex condition characterized by significant weight loss, muscle wasting, and overall weakness) R2’s 05/20/25 “5-day PPD Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS documented R2 had two Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure ulcers and one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer that were present on admission. R2’s Care Plan documented R2 was at risk for potential compromise to her skin integrity, initiated on 04/25/25. The plan directed staff to do weekly skin assessments per facility protocol. Staff were also to check the skin routinely with care. The care plan did not indicate a history or present skin concerns. The care plan did not indicate any preventative measures for pressure sores or skin conditions. R2’s Physician Order noted an order to apply a foam-padded Tegaderm (clear transparent dressing) in front of a padded Duoderm (wafer-type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids). Change every five days and/or as needed if soiled. Apply on the night shift to the coccyx (area over the tailbone) for prevention; dated 07/01/25. R2’s “Licensed Weekly Skin assessment dated [DATE], on admission, documented a coccyx wound that was a pressure ulcer. No measurements or wound descriptions were documented. R2’s “Licensed Weekly Skin assessment dated [DATE] documented a sacrum (area over the tailbone) wound that was a pressure ulcer. No measurements or wound descriptions were documented. R2’s “Skilled Evaluation” dated 07/30/25, documented a Stage 2 pressure ulcer that was present on admission. No measurements or wound descriptions were present. R2’s “Skilled Evaluation” dated 08/03/25, documented a Stage 2 pressure ulcer that was present on admission. No measurements or wound descriptions were present. R2's EMR lacked evidence of wound measurements, wound bed evaluation, and effectiveness of treatments. On 08/05/25 at 01:43 PM, Licensed Nurse (LN) H applied gloves. She removed R2’s brief and cleaned the area with a wipe. She stated it looked much better, and said she called the provider and got the wound treatment order changed from a Duoderm to a cream because it had closed that day. Observation of the area revealed it was blanchable and had no open area. LN H applied the cream and removed her gloves. On 08/05/25 at 01:43 PM, LN H stated she went into R2’s room earlier and removed the Duoderm to change the dressing. She noted the wound was closed and called the doctor to ask if he wanted to continue the Duoderm for prevention or discontinue it. LN H received the order to discontinue the Duoderm and apply a cream. LN H stated she was not aware how long R2’s bottom had had the pressure ulcer, but it had been there longer than two months. On 08/05/25 at 9:07 AM, Administrative Nurse D stated that R2 entered the facility with pressure areas on admission. Staff were to complete a “Licensed Weekly Skin Assessment and document measurements, the condition of the wound bed, and any changes weekly. Administrative Nurse D stated she was unable to tell from the documentation if it was healed and returned or if it was not healed. Admin Nurse D verified there were no measurements or descriptions of the wounds documented on the “Licensed Weekly Skin Assessments. The facility did not provide a policy related to pressure ulcer monitoring.

The facility reported a census of 59 residents. The sample included 17 residents. Based on interviews, record reviews and observation, the facility staff failed to implement sanitary storage of breathing treatment devices for Resident (R) 1, R18, and R3, who received nebulized (a device that changes liquid medication into a mist easily inhaled into the lungs) breathing treatments. This deficient practice had the potential to spread infections to the residents in the facility.Findings included:- Observed on 08/04/25 at 01:22 PM, R18 was wearing oxygen; the tubing and humidifier bottle were not dated. Her nebulizer equipment and tubing were sitting loosely on a chair, open to the air, and not dated. R18 reported that her nebulizer is left on her chair open to air regularly.Observed on 08/05/25 at 10:33 AM, R18's nebulizer equipment was sitting on her bedside table on paper towels. R18 reported she had her breathing treatment, and the staff had cleaned and set it on the paper towel to dry. The nebulizer tubing was attached to the machine sitting on the floor and chair; none of the equipment was dated.Observed on 08/05/25 at 11:17 AM, R18's nebulizer mask and treatment container were sitting on the bedside table loosely, not dated.Observed on 08/05/25 at 02:27 PM, R1's nebulizer tubing and mouthpiece sat on his bedside rolling table, attached to the machine with no dates.Observed on 08/06/25 at 09:09 AM, R1's nebulizer tubing and mouthpiece were attached to the machine and sitting on the bedside table with no dates.Observed on 08/06/2025 at 10:23 AM, R18's nebulizer items were still attached to the machine and sitting loosely on her chair.On 08/04/2025 at 01:22 PM, R18 reported that her nebulizer was regularly left on her chair loosely after treatments.On 08/06/2025 at 09:16 AM, Licensed Nurse (LN) G stated that nebulizers and oxygen tubing should have been dated, nebulizers should have been rinsed out and set on a paper towel to dry, and then stored in a bag until next use.On 08/06/2025 at 09:19 AM, R1 reported that his nebulizer had not been rinsed out since he had been there.On 08/06/25 at 01:19 PM, Administrative Nurse D stated that oxygen tubing and nebulizer treatment devices were to be dated and changed out weekly. Upon completion of nebulizer treatments, the delivery device was to be cleaned and placed on a paper towel to air dry.The facility policy Nebulizer Therapy, dated 2025, documented that care of the nebulizer equipment included that it would be cleaned after each use, parts would be disassembled after every treatment, the nebulizer cup and mouthpiece would be rinsed with sterile or distilled water, it would be placed an absorbent towel to air dry and once completely dried the nebulizer cup and mouthpiece would be stored in a zip lock bag.

The facility reported a census of 59 residents. The sample included 17 residents, including six residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses) for Resident (R) 6. This placed the resident at risk for uninformed treatment decisions.Findings included:- R6's Electronic Medical Record (EMR) documented the following diagnoses: panic disorder (an anxiety disorder) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R6's EMR documented the following physician's orders:Duloxetine (an antidepressant medication), 120 milligrams (mg), by mouth, every morning, for a diagnosis of depression, ordered 07/29/25. Risperidone (an antipsychotic medication), 1 mg, per percutaneous endoscopic gastrostomy (PEG- tube placed in the wall of the stomach), twice daily, for a diagnosis of resistant depression, ordered 10/28/24. Trazodone (an antidepressant medication), 100 mg, every day, for a diagnosis of insomnia (inability to sleep), ordered 05/07/25. R6's EMR lacked documentation of informed consent for R6's psychotropic and antipsychotic medications.On 08/06/25 at 07:33 AM, Administrative Nurse D stated it was the expectation for staff to obtain psychotropic drug consents before the medication was initiated. The facility policy for Use of Psychotropic Medications, undated, included: Prior to initiating or increasing a psychotropic medication, the resident, family, and/o /or resident representative must be informed of the benefits, risks, and alternatives for the medication.

The facility reported a census of 52 residents, with 17 sampled, including three residents reviewed for pressure ulcers/injuries. Based on observation, interview and record review, the facility failed to assess and provide preventive pressure ulcer treatment for two of the three residents reviewed. Resident (R) 109 developed unstageable pressure injuries on her bilateral heels, left lateral foot, and left anterior foot. The deficient practice placed R109 and any other resident with potential skin issues, at risk of further pressure injury development. Findings included: - Review of Resident (R)109's Physician Order Sheet, dated 12/06/23, included diagnoses of: fractured (broken bone) left femur (bone in thigh), cervical vertebrae (spinal bones in the neck) fracture, left foot drop (inability or difficulty in moving the ankle and toes upward), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Admission Minimum Data Set (MDS) dated [DATE] was in progress (not completed). The Baseline Care Plan, dated 12/06/23, instructed staff the resident was non-weight bearing on her left leg. The resident required assistance of one staff for bed mobility, transfer, and walking with a walker. The care plan indicated the resident had intact skin, no surgical wound, was not at risk for skin breakdown, and had no pressure ulcer/injury present. The resident required assist bars to turn over in bed. The Braden Score (an assessment scale of risk factors to predict pressure ulcer development) dated 12/07/23, revealed a score of 21, which indicated low risk (19-23 low risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, and less than 9 severe risk). An Admission Nursing Note dated 12/06/23, documented the resident had no noted skin issues with a little redness at times and was blanchable (the ability of skin to return to normal color after pressure is applied and then released). The note did not indicate the location of the redness. The medical record for R109 lacked documented skin assessment to address the specifics (to include location size and description) of the noted blanchable areas. The daily Skilled Nursing Evaluation Notes reviewed from 12/07/23 through 12/12/23, lacked documentation of the resident's pressure ulcer/injuries. The Skilled Nursing Evaluation Note dated 12/12/23 at 03:25 AM, indicated the resident had normal bilateral 2 plus pedal pulses (an assessment of blood flow in the feet) with brisk refill (time it takes for blood flow to resume after pressure is applied) in both extremities and the skin was pink with brisk refill of nail beds. The resident had a surgical wound to her left thigh. Observation on 12/12/23 at 07:59 AM, revealed Certified Nurse Aide (CNA) P and Q provided a bed bath to the resident. The resident's right and left heel lay directly on the bed, with no pressure relieving devices available. The resident's heels had blue, black areas; the left mid-lateral foot had two black areas; and one black area on the top of R109's left foot. Observation on 12/13/23 at 08:24 AM revealed the resident seated in her recliner with the footrest elevated and her heels resting directly on the footrest, lacking pressure relieving devices. Interview on 12/12/23 at 08:15 AM with Licensed Nurse (LN) G revealed she did not know the resident had pressure injuries and proceeded to measure the following areas on R109: 1. The resident's right foot heel had a red/purple non-blanching area with a width of 3.5 centimeters (cm) by 3.2 cm, with the top layer of nonintact skin suggestive of previous blistering, and the periwound (area around the wound) was red in color and non-blanching. 2. The left foot heel had a red/purple non-blanching area with a width of 5 cm by 3 cm, with the top layer of nonintact skin suggestive of previous blistering, and the periwound was red in color and non-blanching. 3. The left lateral foot contained two black/dark purple areas, which were near each other, which LN G measured as 2 cm by 1.5 cm and 1.5 cm by 2.5 cm. 4. The top of the left foot contained a black area which measured 1 cm by 1.3 cm. 5. The left lateral ankle contained a black area which measured 0.7 cm by 0.8 cm. 6. The left anterior foot contained a black area which measured 1 cm by 1 cm. Interview on 12/12/23 at 09:00 AM with LN G revealed she did not stage pressure ulcers and reported the skin issues to Administrative Nurse D and the physician. LN G said they obtained an order for skin prep (a medication gel that provides protection of the skin surface) and LN G applied the skin prep to the resident's pressure injuries at that time. Interview on 12/12/13/23 at 08:10 AM with LN H confirmed she did not complete a skin assessment of the resident's skin as the resident refused to lay in bed or get into her recliner upon admission. LN H stated she thought she notified the oncoming shift of the resident's need for a full skin assessment. Interview on 12/13/23 at 10:14 AM with Administrative Nurse D revealed she expected the admitting nurse to complete a full skin evaluation. Administrative Nurse D confirmed the oncoming licensed nurse did not complete the skin assessment for R109. Administrative Nurse D confirmed the facility could not determine when the pressure ulcer/injuries occurred and confirmed treatment and preventative measures were not in place until identification by the onsite surveyor on 12/12/23. Interview, on 12/13/23 at 10:30 AM with Corporate Nurse Consultant HH revealed they measured the wounds 12/13/23 at 10:00 AM and staged them all as unstageable, deep tissue injury. Administrative Nurse D confirmed the facility lacked an admitting skin assessment of R109 and lacked identification of the pressure ulcer/injuries to the residents right and left heels and areas on the residents left foot and ankle. Administrative Nurse D stated the resident did wear a brace to her left foot, and perhaps the brace contributed to the pressure injuries. Nurse Consultant HH stated the resident had weak pedal pulses, and perhaps vascular issues contributed to the pressure ulcer injuries. Interview on 12/14/23 at 09:00 AM with Medical Consultant II, revealed he expected the nursing staff to assess the resident for pressure ulcers and provide interventions for the prevention of pressure ulcers. The facility policy Pressure Injury Prevention and Management, implemented 01/07/23, instructed staff to provide treatment and services to heal pressure ulcer injury, prevent infection and the development of additional pressure ulcers. The facility failed to assess R109's skin upon admission or implement pressure injury preventative measures, after the resident admitted after surgical repair of a femur fracture and foot drop which resulted in the development of unstageable/deep tissue injuries to the residents right and left heel, anterior and lateral left foot.

The facility reported a census of 52 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria and the facility failed to utilize pasteurized eggs (gently heated in their shells, just enough to kill the bacteria) for soft cooked eggs for residents. Findings included: - During an initial tour on 12/12/23 at 08:01 AM, the following areas of concern were noted: 1. The reach-in freezers had food and frozen liquid debris on the bottom. 2. The refrigerator had food debris on the bottom. 3. A white wooden box used to hold the sugar, flour and brown sugar containers had a dusty, sticky substance covering the surface. 4. Three rolling carts each with three tiers had dried-on food debris and a build-up of food debris in the grooves of the handles of the cart. 5. A shelf directly above a food preparation table had a layer of food debris and dust. 6. A shelf holding plastic containers of sugar, creamer and artificial sweetener packets had a layer of food debris and dust over the sides. The tops of the plastic containers had coffee stains, dust, and food debris. 7. A covered trash can had dried food debris and dried-on splattered liquid debris on the container and lid. 8. Two plastic cutting boards were heavily grooved and discolored. 9. The U-shaped shelf over a food preparation table was heavily soiled with dust and food debris. 10. Observation in one refrigerator revealed two dozen unpasteurized eggs. Dietary Staff CC stated the facility had cooked and served to residents approximately 60-80 soft-cooked eggs (eggs served with the yolk of the egg runny) from unpasteurized eggs over the past 10 days. On 12/12/23 at 08:01 AM, Dietary Staff CC stated she had not realized the soft-cooked eggs she had been cooking and serving to residents for the past 10 days were not pasteurized. On 12/12/23 at 09:30 AM, Dietary Staff BB stated the facility will only serve hard eggs until the shipment of pasteurized eggs comes in a few days. On 12/14/23 at 09:53 AM, Dietary Staff BB stated the facility lacked a cleaning schedule for the kitchen. Staff were to ensure their work areas were clean before leaving their shifts. The facility policy for Use of Shell Eggs and Pasteurized Eggs and Procedure for Undercooked Eggs, dated 2011, included: Pasteurized eggs or egg products shall be used when eggs are served undercooked and for fried eggs. The facility lacked a policy for cleaning the kitchen. The facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria and failed to use pasteurized eggs in the cooking and serving of soft-cooked eggs to the residents to prevent food borne bacteria.

The facility reported a census of 52 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage 24 hours a day and excessively low weekend nursing staff. Findings included: - Review of the CASPER/PBJ Report Data revealed the following triggered areas: 1. Quarter four of 2022 (July 1 through September 30, 2022), lacked Licensed Nursing Staff on 07/02/22, 07/03/22, 07/04/22, and 07/09/22. 2. Quarter three of 2023 (April 1, 2023, through June 30, 2023) with excessively low weekend staffing. Review of the facility posting, schedule, and agency staffing invoices for Quarter four of 2022 (July 1 through September 30, 2022, revealed the facility had Licensed Nursing Staff on duty on 07/02/22, 07/03/22, 07/04/22, and 07/09/22. Review of the facility Agency staffing invoices, dated 04/01/2023 through 07/30/2023, demonstrated the Payroll Base Journal (PBJ) did not reflect the total nursing hours of direct care provided by agency nursing staff. These hours were confirmed by the Administrative Staff A and Consultant Staff HH. Review of the nursing schedule revealed the facility had licensed nurse staff on duty for 24 hours a day/seven days a week. Review of the schedule and staff posting for the weekends of April, May, and June of 2023, revealed the facility exceeded the state minimum requirement for direct care staff. The staffing pattern did not significantly vary from the scheduling from the weekdays with the per patient day hours of direct care by nursing staff ranging from 2.8 hours to 3.6 hours per patient day (PPD). On 12/12/23 at 02:30 PM, Administrative Staff A reported the facility had licensed nurse staffing 24 hours a day, seven days a week. He also reported the weekend staff PPD as noted above was able to meet the needs of the residents. Administrative Staff A confirmed the above findings and agreed the PBJ data was inaccurate. The facility policy Mandatory Submission of Uniform Format Staffing Information (PBJ), dated 01/05/23, documented .This facility will submit electronically submit to CMS complete and accurate direct care staffing information including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers for Medicare and Medicaid Services (CMS). The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff and RN coverage. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information for the facility.

The facility reported a census of 52 residents with 17 residents sampled, including two residents reviewed for indwelling urinary catheter (a tube inserted in the bladder to drain urine). Based on observation, interview and record review, the facility failed to follow appropriate infection control guidelines to prevent urinary tract infections (UTI) for one dependent Resident (R)14, regarding catheter care and failed to provide appropriate infection control techniques in the beauty shop, to prevent the spread of infections to the residents. Findings included: - Review of Resident (R)14's electronic medical record (EMR) included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She was dependent on staff for toileting and had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/10/23, documented the resident was dependent on staff for all her toileting needs. The care plan, dated 11/04/23, instructed staff to complete catheter care every shift. Review of the resident's EMR revealed the following physician's order, dated 11/03/23, Complete catheter cares every shift. On 12/12/23 at 02:23 PM, Certified Nurse Aide (CNA) NN and CNA OO entered the resident's room to provide catheter care. CNA NN performed peri-care (the cleansing of the genitals) and then proceeded to clean the catheter tubing. CNA NN used a clean wipe and wiped the tubing from approximately nine inches out going upward to the urinary meatus. On 12/12/23 at 02:23 PM, CNA NN stated that was the way she always performed catheter care as that was how she was taught to wipe the tubing from distal from the resident up to the resident's body. On 12/14/23 at 08:49 AM, Administrative Nurse D stated it was the expectation for staff to use appropriate procedure when providing catheter care to help prevent urinary tract infections (UTIs). The facility policy for Catheter Care, implemented 01/20/23, included: While performing catheter care obtain a new moistened cloth and starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. The facility failed to follow appropriate catheter care guidelines to help prevent urinary tract infections for this dependent resident with an indwelling urinary catheter. 36881 - On 12/11/23 at 03:36 PM, during a tour of the residents' beauty shop with Activity Staff Z the following concerns were identified: 1. A collection of various hair was built-up in the sink drain. 2. The countertop around the sink had various multiple hair clippings. 3. The top drawer of the sink counter held nail clippers with visible white debris, an unlabeled hair pick with hair in the teeth, and two unlabeled combs with hair in the teeth. On 12/11/23 at 03:36 PM, Activity Staff Z, verified the above findings and stated the beautician comes to the facility on e time a week and should clean the beauty and the personal care items before leaving. Personal care items should be labeled and not used between residents to prevent cross contamination and prevent infections. On 12/11/23 at 03:46 PM, Administrative Staff A, verified the above findings, and stated the beauty shop was used weekly. The beautician was responsible for cleaning the beauty shop equipment and personal care items used after use. The facility policy Cleaning of Beauty Shop and Hair Care Equipment dated 01/17/23, documentation included the beauty shop contained within the facility will be cleaned daily by housekeeping staff. The contracted beautician is responsible for cleaning all tools used during the beautician's contract including sinks, dryers, dryer filters, combs, brushes, and all personally owned equipment in the beauty shop. Combs and brushes will be washed in warm soapy water to remove grease and then soaked in disinfectant solution for at least 20 minutes. Fixtures and fittings, workstations etc. will be wiped clean daily to remove any hair cuttings. The facility failed to provide a sanitary environment to help prevent cross contaminations and infections for the residents of the facility that used the beauty shop.

The facility reported a census of 52 residents with 17 residents sampled, including two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)14, when staff failed to close the window blinds in the resident's room while performing catheter care. Findings included: - Review of Resident (R)14's electronic medical record (EMR) included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She was dependent on staff for toileting and had an indwelling urinary catheter (a closed sterile system with a catheter and retention balloon that is inserted into the bladder to drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/10/23, documented the resident was dependent on staff for all her toileting needs. The care plan, dated 11/04/23, instructed staff to complete catheter care every shift. Review of the resident's EMR revealed the following physician's order, dated 11/03/23, Complete catheter care every shift. On 12/12/23 at 02:23 PM, Certified Nurse Aide (CNA) NN and OO entered the resident's room to perform catheter care with the resident. The resident's bed was directly next to the windows. Part of the window blinds were fully open. Staff pulled the resident's gown up to her mid chest and removed her brief, exposing her to anyone outside of the window. During the cares, CNA OO opened the shared bathroom door which exposed the resident in bed with her genitals exposed to the two residents on the other side of the bathroom. On 12/12/23 at 02:23 PM, CNA NN stated she should have closed the blind before starting cares with the resident. CNA OO should have checked to make sure the other door of the shared bathroom was closed before opening the bathroom door from the resident's room and exposing her. On 12/12/23 at 02:23 PM, CNA OO stated the window blinds in the resident's room should have been closed before the staff began cares and they should not have opened the shared bathroom door wide until they knew if the bathroom door to the other resident room was closed. Staff need to always respect a resident's privacy. On 12/14/23 at 08:49 AM, Administrative Nurse D stated it was the expectation for staff to close the window blinds before giving resident care. Staff are also expected to not open doors which may cause the resident to be exposed while cares are being given. The facility policy for Catheter Care, implemented 01/20/23, included: It was the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The facility failed to show respect and dignity to this dependent resident while providing catheter care.

The facility reported a census of 52 residents with 17 residents sampled. Based on observation, interview and record review the facility failed to complete an individualized plan of care, regarding Activities of Daily Living (ADL) for one dependent Resident (R)46, regarding facial shaving. Findings included: - Review of Resident (R)46's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He required setup help of staff for personal hygiene and had no rejection of cares. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 08/19/23, did not trigger for further review. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of ten, indicating moderately impaired cognition. The resident had no rejection of cares. The care plan, dated 09/03/23, lacked staff instruction regarding ADLs for the resident, including facial shaving. Review of the resident's EMR, from 11/15/23 through 12/12/23, revealed the resident required independent to dependent staff assistance with personal hygiene. On 12/11/23 at 08:15 AM, the resident sat in his wheelchair in the dining room eating breakfast. He was unshaven. On 12/12/23 at 07:11 AM, the resident propelled himself in his wheelchair from his room to the dining room for breakfast. The resident remained unshaven. On 12/12/23 at 09:36 AM, the resident propelled himself in his wheelchair to the church service. He remained unshaven. On 12/13/23 at 08:25 AM, the resident remained unshaven. On 12/13/23 at 03:15 PM, the resident remained unshaven. On 12/14/23 at 08:31 AM, the resident ate breakfast in the dining room. He remained unshaven. On 12/13/23 at 03:06 PM, Certified Nurse Aide (CNA) OO stated the resident was cooperative with staff and did not refuse cares. The resident appeared as though he had not been shaven for a while. He likes to be clean shaven. On 12/13/23 at 01:09 PM, Certified Medication Aide (CMA) R stated residents are to be shaven on their shower days. CMA R stated she noticed the resident was unshaven. On 12/13/23 at 01:27 PM, Licensed Nurse (LN) I stated she noticed the resident was unshaven. He does not refuse cares of showers or shaving. On 12/14/23 at 08:49 AM, Administrative Nurse D stated ADLs should be included on all resident's care plans and confirmed this resident's care plan lacked staff instruction for ADLs, including facial shaving. The facility policy for Resident Centered Care Plan Process, updated 03/28/18, included: It is the policy of the facility to provide an individualized plan of care for all residents that is appropriate to their needs. The facility failed to provide an individualized plan of care for this dependent resident for staff instruction on completing the resident's ADL cares.

The facility reported a census of 52 residents with 17 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for two of the 17 residents. Resident (R)8 for decline in eating, and R4 for intervention for use of anipsychotic medication use. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 12/01/23, revealed diagnoses that included epilepsy (brain disorder characterized by repeated seizures), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and diabetic neuropathy ( damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated normal cognitive function. The resident had no swallowing or dental problems. The resident had a height of 59 inches and a weight of 174 pounds (lb). The resident required set-up assistance with eating. The Nutritional Status Care Area Assessment (CAA), dated 09/26/23, assessed the resident was on a regular diet with regular texture, regular liquid consistency and was a diabetic with insulin dependence. The Quarterly MDS dated [DATE], assessed the resident with difficulty/pain with swallowing. The resident's weight was 169 pounds with no/unknown weight loss. The Care Plan reviewed 09/28/23, instructed staff the resident was independent with eating with set-up help only. The resident was at risk for nutritional compromise related to diabetes, constipation and mechanically altered therapeutic diet. Staff to monitor diet as appropriate according to the resident's food preferences. The care plan lacked the further interventions attempted to prevent further weight loss for the resident. The Nutritional Risk assessment dated [DATE], assessed the resident was on a regular diet with no protein concerns. The resident was identified as a diabetic with use of insulin. The resident slowly improved her intake and ate well. The resident had 1+ edema and was at 176% of ideal body weight. The recommendation was to continue with the current nutritional care plan. On 11/20/23, the physician ordered a consistent carbohydrate diet with regular texture for the resident. A Dietary Progress Note dated 12/13/23, by the Registered Dietician, evaluated that the resident's weight was down in 30 days and recommended adding whole milk to each meal, super cereal at breakfast, fortified potatoes at lunch and offer ice cream at lunch and dinner. Staff instructed to encourage oral intake and provide food preferences. Observation, on 12/11/23 at 12:45 PM, revealed the resident seated in her wheelchair at the dining room table. The resident had a divided plate for her food. The resident's family member assisted the resident to eat, with the resident also attempting to feed herself. Observation, on 12/12/23 at 07:59AM, revealed the resident feeding herself in the dining room. The resident ate approximately 20% of sausage and eggs. Observation, on 12/12/23 at 12:35 PM, revealed the resident slowly feeding herself chicken nuggets with gravy, stuffing, and spinach casserole. The resident had a piece of frosted cake. On 12/12/23 at 12:51PM, The resident became distracted, and Certified Nurse Aide (CNA) O attempted to assist the resident and the resident resisted the assistance. On 12/12/23 at 01:42PM, the resident consumed approximately 10% of her meal. Interview, at that time with Administrative Staff E, revealed the resident resisted staff assistance since admission, and will usually eat with family assistance. Administrative Staff E confirmed the resident did have weight loss. Staff E stated the staff provided adapted silverware which the resident refused to use. Interview, on 12/12/23 at 02:16 PM, with CNA OO, revealed the resident has difficulty with her hands when trying to feed herself, and often resisted staff assistance. Interview, on 12/13/23 at 10:42 AM, with Dietary Staff BB, confirmed a Nutritional Evaluation was completed on 09/18/23, and no other assessment with the continued weight loss. Dietary Staff BB stated usually Administrative Nurse E, notifies the interdisciplinary team of the need for reevaluation, and she would contact the Registered Dietician. Dietary Staff BB confirmed she contacted the dietician on 12/13/23. Interview, on 12/13/23 at 1:06 PM, with Licensed Nurse LN I, revealed the resident had facial pain and swelling for a period in November due to a nasal bone fracture at which time she was provided a pureed diet and speech therapy assessed the resident for swallowing issue, of which the resident did not have any. The resident did have problems with her hands in holding utensils. LN, I stated if the resident did not eat at least 50% of a meal, she offered the resident a health shake and she will take strawberry flavored shakes at times. Interview, on 12/13/23 at 01:20PM, with administrative staff F, revealed she would expect nursing staff to update the care plan with interventions. Administrative Staff F stated the interdisciplinary team reviews residents with weight loss and they add interventions to the care plan also but did not know when the resident's last team review occurred. Interview, on 12/13/23 at 1:30PM, with Administrative Nurse F, revealed staff offered the resident health shakes but the resident often declined the shakes. Administrative Nurse F stated Administrative Nurse E, monitors the resident's weights. Administrative Nurse F stated she added interventions to the resident's care plan today. Interview, on 12/13/23 at 01:43 PM, with Dietary Consultant GG, confirmed the resident's weight loss, and believed the resident did not like health shakes, so she recommended fortified food. Interview on 12/14/23 at 09:00 AM, with Medical Consultant II, revealed he was aware of the resident's weight loss and they tried interventions to maintain her nutritional health. Interview, on 12/14/23 at 1:04 PM, with Administrative Nurse D, revealed she would expect staff to identify the resident's weight loss and ensure interventions were in place. The facility policy Activities of Daily Living dated 01/08/23, instructed staff to maintain individual objectives of the care plan and periodic review and evaluation. The facility failed to review and revise this resident's care plan to include nutritional interventions for this resident with weight loss who refused staff assistance with eating. 34056 - The Physician Order Sheet (POS), dated 11/01/23, documented Resident (R)4 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She had no delirium (a temporary mental state characterized by confusion, anxiety, incoherent speech, and hallucinations) or psychosis (any major mental disorder characterized by a gross impairment in reality testing) and had not received any of the medications listed on the MDS. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/12/23, did not trigger. The Entry MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. She received antipsychotic (medication used to treat psychosis) medication. The care plan, updated 10/29/23, lacked staff instruction of the resident receiving an antipsychotic medication and what interventions to try to assist the resident with any behaviors she might display. Review of the resident's electronic medical record (EMR) revealed the following physician's order, Assess for adverse side effects to antipsychotic medications, ordered on 10/25/23. On 12/11/23 at 11:28 AM, Administrative Nurse D stated antipsychotic medications should be included on the care plans. Nurses are able to add new medications to a hard copy care plan which was in each nurses station. The facility policy for Resident Centered Care Plan Process, updated 03/28/18, included: It is the policy of the facility to provide an individualized plan of care for all residents that is appropriate to their needs. The facility failed to review and revise the care plan to include the antipsychotic medication use for this dependent resident.

The facility reported a census of 52 residents with 17 residents sampled including four residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review the facility failed to provide appropriate assistance with personal hygiene needs for two dependent Residents (R)46 regarding facial shaving and R 21 regarding bathing. Findings included: - Review of Resident (R)46's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He required setup help of staff for personal hygiene and had no rejection of cares. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 08/19/23, did not trigger for further review. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of ten, indicating moderately impaired cognition. The resident had no rejection of cares. The care plan, dated 09/03/23, lacked staff instruction regarding ADLs for the resident. Review of the resident's EMR, from 11/15/23 through 12/12/23, revealed the resident required independent to dependent staff assistance with personal hygiene. On 12/11/23 at 08:15 AM, the resident sat in his wheelchair in the dining room eating breakfast. He was unshaven. On 12/12/23 at 07:11 AM, the resident propelled himself in his wheelchair from his room to the dining room for breakfast. The resident remained unshaven. On 12/12/23 at 09:36 AM, the resident propelled himself in his wheelchair to the church service. He remained unshaven. On 12/13/23 at 08:25 AM, the resident remained unshaven. On 12/13/23 at 03:15 PM, the resident remained unshaven. On 12/14/23 at 08:31 AM, the resident ate breakfast in the dining room. He remained unshaven. On 12/13/23 at 03:06 PM, Certified Nurse Aide (CNA) OO stated the resident was cooperative with staff and did not refuse cares. The resident appeared as though he had not been shaven for a while. He likes to be clean shaven. On 12/13/23 at 01:09 PM, Certified Medication Aide (CMA) R stated residents are to be shaven on their shower days. CMA R stated she noticed the resident was unshaven. On 12/13/23 at 01:27 PM, Licensed Nurse (LN) I stated she noticed the resident was unshaven. He does not refuse cares of showers or shaving. On 12/14/23 at 08:49 AM, Administrative Nurse D stated residents were to be shaven on their shower days and whenever they wanted. The facility policy for Activities of Daily Living, implemented 01/08/23, included: The facility will provide ADL cares for residents, including grooming. The facility failed to provide appropriate ADLs assistance for this dependent resident regarding facial shaving. 28560 - Review of Resident (R)21's Physician Order Sheet, revealed diagnoses that included collapsed vertebra (bones in spine) and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The resident preferences included very important for bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/29/23, revealed the resident required limited assistance with personal hygiene. The Quarterly MDS dated [DATE], revealed the resident had a BIMS score of 10, indicating moderate impairment of cognitive function. The Care Plan revised 11/15/23, revealed an entry dated 09/11/23 that the resident preferred morning showers two to six times a week. Review of the Bath Sheets revealed the resident received a shower on 11/08/23, 11/15/23, 11/22/23, 11/29/23 and 12/13/23. Interview, on 12/12/23 at 08:00 AM, with Certified Nurse Aide (CNA) O, revealed the resident was listed on the bath list for Wednesdays. Interview, on 12/12/23 at 11:00 AM, with CNA M, revealed the resident provided most of her own cares and the bath aide provided her showers. Interview, on 12/14/23 at 02:15 PM, with the resident revealed she would like a shower more frequently than once a week. Interview, on 12/14/23 at 02:30 PM, with Administrative Nurse D, revealed she would expect staff to provide bathing opportunities as the resident preferred them, but did not know how frequently that was for the resident. The facility policy Activities of Daily Living dated 01/08/23, revealed the facility will maintain individual objectives of the care plan. The facility failed to provide frequent bathing opportunities for this resident per her choice to ensure the resident maintained a sense of wellbeing.

The facility reported a census of 52 residents with seventeen selected for review which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff followed the care plan interventions for one Resident (R)8 of the four residents reviewed for accidents. R8 sustained two falls without the use of interventions with nonskid socks/slippers when in bed as care planned. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 12/01/23, revealed diagnoses that included epilepsy (brain disorder characterized by repeated seizures), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) congestive heart failure(a condition with low heart output and the body becomes congested with fluid) and diabetic neuropathy (damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated normal cognitive function. The resident required extensive assistance with sitting to standing and transfers. The resident did not attempt walking. The resident sustained two noninjury falls and one minor injury fall since admission. The Falls Care Area Assessment (CAA), dated 09/26/23, assessed the resident at risk for falls due to deconditioning (weakness) and gait/balance problems. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of 13 which indicated normal cognitive function. The resident required extensive assistance with sitting to standing and transfers. The resident did not attempt transfers. The resident sustained two non-injury falls and one fall with major injury since the previous MDS. The Care Plan reviewed 10/13/23, instructed staff to ensure the resident wore slippers or nonskid socks when in bed due to the resident attempting to get up on her own. The Fall Investigative Summary dated 10/21/23, revealed the resident was found in her room by staff at 05:50 AM, in a sitting position leaning against her bed. The resident lacked socks/slippers on her feet. The Fall Investigative Summary dated 11/27/23, revealed the resident was found laying on her left side on the floor by her bed without wearing socks/slippers. Observation, on 12/12/23 at 11:43 AM, revealed the resident positioned in bed. Certified Nurse Aide (CNA) N and CNA O prepared to transfer the resident from her bed to wheelchair. The resident's feet were bare. CNA N and O transferred the resident to her wheelchair and then onto the toilet. Observation, at 12/12/23 at 11:51 AM, revealed CNA M found the resident's nonskid socks and shoes in her room and placed them on the resident. Interview, on 12/12/23 at 11: 51 AM, with CNA M, revealed the resident often attempted to get herself up by herself. The resident required extensive assistance of two staff and should wear nonskid socks to bed. Interview, on 12/12/23 at 02:16 PM, with CNA OO, revealed the resident often tries to get herself out of bed and usually goes to bed after supper. CNA OO stated the resident should be checked on frequently and when she is sitting in her wheelchair, staff should position her so staff could view her from the nurses' station. Interview, on 12/14/23 at 01:00 PM with Administrative Nurse D, revealed she would expect staff to follow the care plan fall interventions and confirmed the resident lacked nonskid socks or slippers when in bed prior to the falls on 10/21/23 and 11/27/23. The facility policy Accidents and Supervision, dated 01/05/23, instructed staff to implement interventions to reduce hazards and risk and monitor the effectiveness of the care plan interventions and ensure they are implemented correctly and consistently. The facility failed to ensure staff placed nonskid socks/slipper on the resident when in bed as care planned to reduce risk of repeated falls.

The facility reported a census of 46 residents with 3 residents sampled for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure resident #1 (identified as a high risk for falls) remained free of an avoidable accident. Staff left the resident on the toilet, unattended, and the resident fell and sustained a hip fracture. Furthermore, the facility failed to provide planned interventions to prevent a fall for resident #3, experiencing a non-injury fall. Findings included: - [DIAGNOSES REDACTED].#1 included a pelvic fracture. [DIAGNOSES REDACTED]. An admission Minimum Data Set, dated dated [DATE] , scored the resident with a Brief Interview for Mental Status of 10/15, indicating moderately impaired cognition. The resident needed extensive assistance of 2 staff for transferring and toileting, with the resident unsteady in balance. The assessment identified the resident had falls in the past months prior to admission, and a fracture related to a fall in the 6 months prior to admission. However, the assessment indicated the resident had not experienced any falls since admission. The 5/14/16 Care Area Assessment for falls included: the resident was a high risk for falls with history of falls at home prior to hospitalization and admission to the nursing facility for rehabilitation secondary to a non-displaced fracture of the right pubis and right superior pubic ramus (pelvic fracture). The resident required extensive assist of 2 staff for stabilization to stand from sitting, ambulation with a walker, getting on and off of the toilet and all other transfers. The resident's family reported that he/she had several falls prior to this last fall resulting in a fractured pubis. The resident had not experienced any falls thus far since admission. The resident received an anti-anxiety and anti-depressant medication which could cause him/her to fall related to drowsiness. Additionally, the resident attempted to get up unassisted, instead of asking for assistance using the call light that staff leave within reach while the resident was in his/her room. Staff repeatedly cued the resident to use the call light. The resident's balance and gait were unsteady. The resident used a walker and staff assisted with use of a gait belt (belt used to help transfer a person from one place to another) for balance. The resident could be combative at times creating a potential for falling. The resident had confusion most of the time. The resident received physical and occupational therapy for strengthening, balance, transfers, gait and ADL's (activities of daily living). The 5/14/16 care plan instructed staff: 1.) Allow the resident to sit for a period while applying the gait belt, before staff assist the resident to rise to a standing position, due to an irregular heartbeat. 2.) PT/OT (physical and occupational therapy) to evaluate and provide muscle strengthening and improve balance, as goal was to return home. 3.) Repeatedly cue the resident to use the call light to meet whatever the resident needs or assistance with any transfers and ambulation. 4.) Check PA (personal alarm) every shift and assure working and placement, added on 6/3/16. 5.) Provide one or two staff assistance, depending on time of day, the resident needs more assistance in the AM and less in the afternoon/evenings, added on 7/13/16. 6.) PT reported the resident required minimal assistance of one staff with the roller walker, added on 7/19/16. 7.) Extensive assist of 1 staff for toilet use to help balance while the resident grabs hold of bars in the bathroom, to pull up his/her underwear and slacks after staff cleaned the resident. This care plan lacked information regarding the resident's need for staff attention throughout the toileting process and furthermore, lacked instruction to staff regarding the use of non-skid footwear. Review of the staff assessment for the residents risk for falls included: 5/8/16 Fall Risk assessment in the initial nursing assessment identified a history of 7 to 9 falls in prior months. A 5/11/16 IDT (interdisciplinary team) note included the staff passed by the resident's room and noticed the resident attempting to get him/herself out of bed. The resident's call light was not on. A 5/19/16 SNAR (skin, nutrition, at risk) note identified the resident at risk for falls, and noted the resident had no falls since admission. Review of the nursing documentation identified the following notes: On 7/11/16 at 8:10 AM staff documented the resident had a personal alarm in place and had been compliant today with requesting help. The documentation included the resident needed extensive assist of 1 staff for bed mobility and extensive assist of 2 staff today for unstable balance during transfers. The staff documented the staff use the walker in front of the resident during the transferring process. On 8/1/16 at 9:30 PM staff documented the resident was found on the floor in his/her bathroom. The CNA (certified nurse aide) had left the resident on the toilet to get a brief, and the resident reported to the CNA he/she needed to have a bowel movement. Staff left the room briefly to get a clean brief and returned. Upon return, staff noted the resident lying on the floor between the bathroom and the bedroom, with the resident's feet straight out on the floor, with normal socks (without non-skid pads) on the resident's feet. The nurse documented the staff assessed the resident for injury, noting skin tears to both arms, and able to bend both legs, with some groaning noted during the bending, which was normal for this resident. Staff assisted the resident to the bed with the resident unable to walk. After positioning the resident onto the bed, staff noted the resident's left leg had an outward rotation and staff called 911 for transport to the hospital. The staff documented, on 8/2/16 at 12:30 PM, the resident transferred and was admitted to the hospital for a fractured left hip. Review of the resident's physical therapy notes, dated 8/1/16 noted the resident had fair standing and transferring with minimum assistance and from a sitting to a standing position with minimum assistance. The resident continued to require a fair amount of assistance due to the resident's decreased safety awareness and decreased functional strength and mobility. The resident's last therapy treatment was 8/1/16. The 8/1/16 occupational discharge summary indicated the resident needed CGA (contact guard assistance) with toileting transfers. The resident's loss of balance during standing affected toileting ability and the resident demonstrated poor safety awareness. The resident's last therapy treatment was 8/1/16. On 8/8/16 at 3:50 PM, staff documented the resident returned to the facility with staples intact to the left hip area. On 8/18/16 at 8:50 AM, direct care staff M and N assisted the resident with arising, with 2 staff and a gait belt with maximum assistance needed to transfer the resident from the bed to the wheelchair, as the resident bears little weight. The resident had gripper socks on his/her feet, and lacked a personal alarm at that time. At 8:59 AM activity staff Z brought a personal alarm into the resident's room and clipped the alarm to the resident's shirt and placed the box into the resident's chair seat. Staff M reported the box had been beeping this AM, when staff assisted getting the resident out of bed, and staff took the PA to the nurse for battery replacement. On 8/18/16, intermittent observations from 9:10 AM to 10:30 AM, identified the resident remained in the dining room. At 11:30 AM the resident and his/her family member sat in the resident's room, with the personal alarm remaining clipped to the resident's shirt. Then at 12:45 PM the resident sat eating lunch with his/her family member, in the resident's room. A large group of family members visited the resident, seated in his/her wheelchair at 2:30 PM. At 4:00 PM, direct care staff O and P reported they toileted the resident using 2 staff, a gait belt and the grab bars in the bathroom, and then the resident went to therapy. At 6:40 PM direct care staff O and Q transferred the resident from the wheelchair to the bed. The resident required maximum assistance of staff for standing then cueing the resident to pivot to the bed. On 8/18/16 at 8:25 PM, administrative nursing staff B, reported they made changes to the resident's care plan on 7/19/16 regarding transferring and toileting status, indicating the resident changed from 2 person extensive assist to 1 person assist with toileting. On 8/18/16 at 9:35 AM, direct care staff M reported the resident did not require much different care now, than before the hospitalization . Staff reported the resident worked with therapy before the fall and since his/her return from the hospital. As far as transfers, toileting, etc. there really isn't any change. He/she was and continued to require 2 person extensive assist with transfers and toileting, and he/she was not using the walker for transferring now. On 8/18/16 at 10:50 AM, direct care staff N reported the resident walked to the bathroom on good days with the roller walker prior to his/her fall with maximum assistance of 2 staff with a gait belt. The staff reported they were not aware of the resident experiencing falls. However, the staff reported the resident sometimes stood up without assistance and tried to get up on his/her own. Staff reported the resident required an alarm since the original admission to the facility. The staff member further reported that resident's with alarms were not to be left alone on the toilet. On 8/18/16 3:30 PM direct care staff R reported they were not present but were on duty when the resident fell on [DATE]. The staff reported he/she was in another resident's room, when direct care staff S called on the cell phone and stated the resident fell and needed the nurse. The staff noted the resident laid on the floor, in the doorway of the bathroom and bedroom, and the resident had a lot of blood around him/her. Staff stated the resident's incontinent brief was up around the resident's waist, at that time. Direct care staff S reported on 8/18/16 at 3:45 PM, he/she had returned from break on 8/1/16, heard the resident's alarm and entered the resident's room. The resident attempted to stand and transfer from the bed, for toileting, and the staff assisted the resident with a gait belt and with the resident using the roller walker, ambulated the resident to the toilet. The resident stated to the staff of the need to pass a bowel movement, so the staff stepped into the bedroom, at which time the staff heard another resident yelling out. The staff reported they went to check immediately on the other resident, then returned to the resident's room. Upon entering the resident's room the staff observed the resident's feet on the bedroom floor and his/her head on the bathroom floor. The staff reported he/she was not told about not leaving the resident alone during the recent orientation process, however, reported being told that after the resident fell . On 8/18/16 at 4:15 PM direct care staff O reported during staff S's orientation the staff received training regarding alarm use and ensuring proper functioning and placement, the residents who have alarms should not be left alone on the toilet. Staff O reported the resident was a fall risk, prior to the fall and required 1 person assistance of staff, had an alarm and fall mat at the bedside. Review of direct care staff S's 7/13/16 CNA orientation checklist, signed by direct care staff R, indicated the staff received training regarding personal alarms, the purpose of, a list of residents with alarms, how to apply each type of alarm, and the importance of responding to alarms ASAP (as soon as possible). The orientation check list lacked documentation about supervision of the resident's who have personal alarms, while on the toilet. Administrative nursing staff D, reported on 8/18/16 at 5:30 PM, the resident had advanced to contact guard assistance with ambulation and transfers prior to the resident's fall, and determined during the investigation the aide was not negligent in the resident's care, as the aide left only due to attempting to prevent injury to another resident, then immediately returned, and that the accident was just an accident. The staff further reported the practice of not leaving a resident on the toilet alone was not added to the resident's care plan, however, the staff are all aware of this practice, via training with orientation and in-services. The facility undated policy for Fall Prevention, included each elder resident at the facility would receive adequate supervision and assistive devices to prevent accidents The High Risk Fall Prevention Protocol included the testing for balance included the resident with challenges with sitting and/or standing balance and used assistive devices for the physical assistance of one or two persons to transfer or ambulate. Additionally, the ambulatory elders would be encouraged to wear proper footwear, including non-skid slippers. The facility policy for Abuse, Neglect, and Exploitation, dated 10/12 directed care plans would be developed for each applicable resident that identified specific interventions for dealing with other challenging resident behaviors. Additionally, the policy defined neglect as failure of any employee to provide reasonable and necessary services to maintain the physical and mental health, safety or welfare of a resident. Review of the undated personal alarm policy, lacked information to direct staff that any resident with a personal alarm would not be left unattended on the toilet. The facility failed to ensure adequate supervision for this resident at risk for falls, when the staff left the resident on the toilet unattended, and the resident fell and experienced a hip fracture. - An admission Minimum Data Set, dated dated [DATE], identified resident #3 scored 4 of 15 on the Brief Interview for Mental Status assessment, indicating severely impaired cognition. The assessment further indicated the resident required total dependence of 2 staff for transfers, did not walk, and was dependent on staff for mobility with a w/c. The fall assessment included the resident had not fell prior to admission, but had a fall since admission, without injury. The quarterly Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status score of 5 of 15, indicating severely impaired cognition, and needed extensive assistance of 2 staff for transfers and toileting. The assessment reflected the resident had no falls. The 4/29/16 Care Area Assessment for falls included the resident had become very weak related to a recent hospitalization . The resident experienced limited range of motion in all extremities and osteoarthritis in his/her hands, wrists and knees bilaterally. The resident experienced one fall since admission, when the resident rolled out of bed due to an air mattress. Staff removed the air mattress was removed and implemented the use of a low bed. The care plan, dated 5/19/16 included: 1.) Check the resident for safety often. 2.) PT/OT (physical and occupational therapy) to evaluate and treat, 5/19/16. 3.) Bed changed to a baffle air mattress with low bed on 5/19/16. 4.) Assist of 2 staff with repositioning every 2 hours and prn (as needed), on 5/19/16. 5.) On 5/26/16, staff added the resident needed an alarm due to the resident getting up without assistance. 6.) On 6/17/16 staff noted the resident required 2 staff assistance for toileting or the sit to stand lift for toileting. 7.) On 7/14/16, PT 4 times weekly to improve the resident ' s functional strength, endurance and mobility, balance, gait, transfers and to maximize safe and independent function. 8.) 8/10/16, Use gait belt with all transfers. Two assist with transfers. Use walker if resident is able. Strength varies throughout the day. Review of nursing notes, dated 7/21/16 at 6:38 PM, identified the resident experienced a fall in the west shower room at 5:45 PM. The staff documented the CNA alerted the nurse of the resident being on the floor. Upon assessment, the nurse found the resident laying on the floor in front of the toilet, on his/her right side with his/her right hand under the resident. The resident ' s knees were bent and his/her feet were against the west wall, with the resident ' s head pointing east. The resident lacked any apparent signs of injury. The CNA (certified nurse aide) reported that he/she was transferring the resident when the resident ' s knees gave out, with the resident reporting mild knee pain to the bilateral knees. The resident was assisted to sit upright, then to stand for transfer into the wheelchair. The CNA further reported the resident did not fall hard, that first the resident went down to his/her knees, then staff assisted the resident to lay onto his/her right side. A note in the nursing documentation identified the intervention following the fall included to use 2 staff for transfers. However, review of the care plan identified the resident was already care planned for 2 staff for transfer. Observation, on 8/18/16 at 9:05 AM, identified the resident resting well in bed. The resident rested in a low bed with a fall mat at the bedside. Intermittent observations until 10:30 AM identified the resident remained resting quietly in bed. At 10:55 AM, on 8/18/16 the resident sat at the nail care table in the lobby area, visiting with activity staff Z and having his/her nails trimmed At 11:40 AM on 8/18/16 the resident rang for assistance with toileting. Administrative nursing staff D propelled the resident to the main shower room and assisted the resident with a gait belt. Direct care staff N and staff D then assisted the resident to the toilet. On 8/18/16 at 4:23 PM, direct care staff O and P assisted the resident with check and changing of an incontinent brief, then assisted the resident to a sitting position on the edge of the bed, placed the resident's shoes on the resident ' s feet and used a gait belt to transfer the resident into the wheelchair. Staff transferred a pressure sensitive alarm (which sounded when standing the resident up, and then when sitting the resident down), into the wheelchair and propelled the resident to supper. Staff O reported this is the normal routine and the resident needed 2 persons for transfer, due to weakness. On 8/18/16 at 9:25 AM direct care staff M reported the resident required extensive assistance of 2 staff for transfers, had a lot of anxiety and some dementia evidenced by confusion and seeing things not there. The resident required the use of a gait belt for transfers, and the resident grabs the bars in the bathroom to assist in transferring onto the toilet. The resident is currently receiving therapy and propels self with his/her feet in the wheelchair for mobility. Staff believed the intervention following the fall was a low bed and a fall mat. Licensed nursing staff I, reported on 8/18/16 at 1:53 PM when a resident falls, the nurse is to assess (the environmental area, as well as a head to toe assessment for any bodily injury, including ROM (range of motion), check the resident ' s vital signs, rendering first aide, if needed. If needed, then staff would send the resident to the hospital. After caring for the resident the nurse then would assess for the reason of the fall to determine an appropriate intervention. The intervention included was staff education to do 2 person assists with transfers. On 8/18/16 at 4:45 PM administrative nursing staff D reported the care plans are very difficult to keep up with and thought the resident had been a 1 person between the therapy and the time of the fall. The facility policy for Fall Prevention, undated, included each elder resident at the facility would receive adequate supervision and assistive devices to prevent accidents. The High Risk Fall Prevention Protocol included the testing for balance, and included any resident with challenges from sitting and/or standing balance and used assistive devices for the physical assistance of one or two persons to transfer or ambulate. The facility failed to ensure appropriate transferring assistance for this resident, who fell to his/her needs, during a one person assisted toileting, with the residents care plan reflecting the resident as a 2 person assist.

The facility reported a census of 50 residents with 23 residents in the sample. Based on interview, observation, and record review the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer and received the necessary treatment and services to promote healing for 1 of 3 residents reviewed who acquired a stage 4 pressure wound in the facility. (#65) Findings Included: - Review of resident # 65's annual MDS (Minimum Data Set) dated 6/2/2014 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident did not reject cares during the 7 day observation period. He/she required total assistance of 2 or more staff for bed mobility, transfers, dressing, and toileting, extensive assist of 2 or more staff with bathing and supervised set up assist with eating. He/she was non ambulatory, had functional limitations to both lower extremities and used a wheelchair for mobility, and was frequently incontinent of urine and bowel. He/she had a [DIAGNOSES REDACTED]. The following skin and ulcer treatments in place; pressure reducing device for chair and bed, turning/repositioning program, and nutrition/hydration intervention. Review of the quarterly MDS (Minimum Data Set) dated 02/25/2015 revealed a BIMS score of 15,which indicated intact cognition. The resident did not reject cares during the 7 day observation period. The resident required extensive assistance of two staff with bed mobility and extensive assist of one staff with transfers, dressing, and toileting, limited assistance of one staff with personal hygiene and was not ambulatory. He/she required physical assist of one staff with bathing, had functional limitation to both lower extremities and used a wheelchair for mobility. He/she experienced occasional urinary incontinence, and was frequently incontinent of bowel. The resident had a [DIAGNOSES REDACTED]. The stage 4 pressure ulcer was at a lesser stage on the prior assessment. The following skin and ulcer treatments were in place; pressure reducing device for chair and bed, turning/repositioning program, nutrition/hydration intervention, pressure ulcer care, and application of non-surgical dressings. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 6/2/2014 revealed the resident was dependent since his/her spinal cord surgery for [REDACTED]. Review of the Pressure Ulcer CAA dated 6/2/2014 revealed the resident was at risk for development of pressure ulcers due to [MEDICAL CONDITION], immobility, and being wheelchair bound. He/she worked with physical therapy and occupational therapy on balance, strength, and to decrease risk for falls and to improve balance for functional transfers. He/she was totally dependent on 2-3 staff to reposition when in bed and chair at least every 2 hours. He/she would attempt to help but was weak from [MEDICAL CONDITION] ( treatment of [REDACTED]. The resident was frequently incontinent of urine and bowel . Staff were to keep the resident as clean and dry as possible and nursing staff were to check his/her skin daily during cares as well as complete weekly skin checks. Review of Braden Scale Assessments (assessment used to determine the risk for development of a pressure ulcer) revealed the following; 5/28/2014- score of 15, which indicated moderate risk. Review of the Braden Scale results indicated the resident had some sensory impairment which limited the ability to feel or voice pain or discomfort which would result in a score of 14, a high risk. The Braden Scale was marked/scored incorrectly and recorded the resident was at moderate risk. Had the assessment been scored correctly, the resident would be been identified at high risk. Braden Skin Risk Assessments on 6/9/2014, 6/23/2014, 9/4/2014, 11/12/2014, 12/11/2014 and 2/25/2015 revealed the resident was a high risk for the development of pressure ulcers. Braden Skin Risk Assessments on 7/28/2014 and 8/25/2014 revealed the resident was a moderate risk for the development of pressure ulcers. Review of the resident's revised care plan dated 11/13/2014 revealed the resident had actual skin impairment due to immobility and decreased sensitivity. The resident needed assistance of bed rails and a trapeze bar for self-turning. The care plan directed staff to apply bed rails and the trapeze and ensure they were in place at all times, set the air mattress at 120, ensure the resident repositioned frequently and his/her skin remained clean and dry. The resident used a cushioned bedside commode (9/24/2014) and staff were to encourage the resident to sit on the bedside commode for no more than 10 minutes 1-2 times daily (9/29/2014). The staff were to follow facility protocols for the treatment of [REDACTED]. The resident was to avoid remaining in his/her wheelchair for longer than one hour to one and a half hours at a time. The care plan revealed the resident was noncompliant with a turning routine, would refuse to lay down at times, and received education by staff. The staff assisted him/her to reposition, left the room and returned to find him/her lying on his/her wound (1/6/2015) The resident agreed to transfer to the left out of his/her bed or chair to prevent injury to the wound on the right buttock, but at times was non- compliant. The resident verbalized he/she understood that transferring to the left was the best option for his/her wound (3/17/2015). The resident elected to attempt maggot therapy ( a type of debridement therapy using maggots) and the wound clinic placed maggots on the resident's wound on 3/23/2015 and then removed on 3/29/2015. Treatment to the right buttock/hip was santyl (an ointment that cleans wounds to clear the way for healthy tissue) and gauze changed twice daily. The resident went to the wound center for supplemental wound care (1/21/2015). Review of an investigation dated 1/2/2015 revealed the resident turned on his/her call to get out of bed at around 6:30 A.M. on 1/2/2015. Direct care staff FF observed the resident soaked from shoulders to knees and the resident reported staff did not check on him/her since 1230 A.M. Staff FF stated he/she could tell the resident was left in that condition for some time because the urine around him/her was dried in a ring around his/her body. The resident reported the night shift staff came into his/her room, told him/her he/she was having a bowel movement, and would return when he/she finished with the bowel movement. The resident stated he/she fell asleep and no one returned to his/her room until 6:30 A.M. when staff FF answered his/her call light. Review of weekly pressure ulcer assessments revealed the following: 10/24/2014- stage 2 pressure ulcer to the right buttock, which measured 3.0 cm x 1.9 cm x 0.2 cm. 11/17/2014- stage 3 pressure ulcer to the right buttock, which measured 2.9 cm x 1.6 cm x 0.1 cm. 1/27/2015- stage 4 pressure ulcer to the right buttock, which measured 1.8 cm x 1.9 cm x 1.0 cm. 4/25/2015- stage 4 pressure ulcer to the right buttock, which measured 3.0 cm x 2.5 cm x 4.0 cm. Review of psychotherapy progress note dated 3/12/2015 revealed the resident felt his/her wounds were getting better and he/she was compliant with the physician and wound clinic orders. Facility staff commented the resident displayed no behaviors. Review of a dietitian note dated 4/4/2015 at 8:56 A.M. revealed the resident had a stage 4 to the right buttock. Recommended Juven (nutritional supplement) twice daily due to the presence of a stage 4 to help with wound healing until the wound resolved. Review of a dietitian note dated 4/21/2015 at 3:27 P.M. revealed the resident continued with a stage 4 wound, which showed slow improvement. Recommendation was to consider Juven twice daily to help with healing. Review of physician orders [REDACTED]. Weekly skin assessments every night shift on Saturdays, effective 10/2/2014 Turn and reposition every 2 hours each shift, and awaken the resident in the night per his/her request for repositioning, effective 1/3/2015 Wound center consult, effective 1/21/2015 Offload wound at all times, tilt to the left when sitting, effective 1/26/2015 Staff to change dressing to the right buttock at least 10 hours between dressing changes, effective 3/23/2015. Cleanse wound to the right buttock and apply Santyl, loosely packed gauze, skin prep around wound bed, cover with dry gauze and secure with tape twice daily, effective 3/30/2015. During an observation on 4/28/2015 at 4:09 P.M. the resident sat in his/her wheelchair with feet placed on foot pedals, pressure cushion on the seat, and a pillow placed behind the back of the resident. A low air loss mattress was on the bed with a trapeze bar in place, mattress set on 120, and a cushioned bedside commode placed next to the bed. During an observation on 4/29/2015 at 6:39 A.M. the resident was lying on his/her left side flat in the bed with his/her eyes closed on a low air loss mattress set at 120. A pillow was behind the resident's back and an incontinent changing pad was under the resident's buttocks. A trapeze bar was within the resident's reach. At 7:50 A.M. the resident removed the pillow from behind his/her back, used the trapeze to reposition more on his/her back, however remained slightly on the left side. The resident then raised the head of bed to approximately 45 degrees. At 7:57 A.M. the resident asked direct care staff AA to move the blanket from the bottom of his/her bed due to blanket being wrapped around his/her feet. At 8:05 A.M. direct care staff AA assisted the resident with dressing his/her lower extremities. Observed a dressing to the right buttock with a brown discoloration covering approximately 3 in (inches) x 1 in of dressing closest to the resident's rectum and a small amount of reddish/brown drainage to the center of the dressing and on the resident's brief. A significant change in repositioning occurred with assistance of 2 staff at 8:10 A.M. During an observation on 4/29/2015 at 8:29 A.M. licensed nursing staff F changed the resident's right buttock dressing. The resident was lying on his/her left side when staff F removed the dressing. The dressing had a large amount of pink/reddish drainage on the area of gauze against the resident's skin. The wound was circular with blanchable redness surrounding the wound, some swelling at 2-3 o'clock, and a denuded (raw) area from 2-6 o'clock. A white stringy substance appeared throughout the wound bed. Staff F cleansed the wound with wound cleanser, santyl applied to the wound bed, staff loosely packed the area with dry gauze, skin prep applied around the wound, covered with dry gauze, and secured with tape. Direct care staff AA provided pericare. At 8:53 A.M. direct care staff AA and EE assisted the resident to a seated position on the bedside. Staff AA asked the resident how he/she wanted to transfer and he/she stated the left. Staff AA positioned the wheelchair on the right and the resident again requested to transfer on the left. Staff AA placed the slideboard under the resident's left upper leg, slid him/her to the foot of the bed using an incontinence changing cloth. The resident slid from the bed to his/her wheelchair with limited assistance of one staff. During an observation on 4/29/2015 at 2:07 P.M. the resident sat outside in his/her wheelchair eating lunch with a family member with a chair cushion in place. There was foam padding placed between the resident's knees. The resident was served turkey with gravy, stuffing, brussel sprouts, and peaches. He/she ate 90% (percent) of turkey with gravy, 20% of stuffing, 100% of brussel sprouts, and 100% of peaches. At 3:28 P.M. the resident requested assistance getting into his/her bed. Direct care staff X and Y responded to the resident's call light and assisted the resident into bed using a slideboard for transfer on the resident's left side. During an interview on 4/29/2015 at 8:15 A.M. the resident reported he/she was made aware of the pressure ulcer to his/her right buttock by a staff member during pericare several months ago. The resident reported when he/she first admitted , he/she was completely paralyzed and he/she could not tell when he/she was soiled. The resident believed the wound developed due to staff not assisting him/her with turning, repositioning and incontinence care. The resident stated he/she set his/her alarm on his/her cell phone for once nightly to request staff assist with repositioning and incontinence care. During an interview on 4/29/2015 at 2:17 P.M. a family member reported he/she believed the pressure wound occurred due to pressure from lack of repositioning and wet briefs with urine and bowel. The family member reported he/she would be surprised if the resident ever told staff he/she did not want to reposition. The family member reported staff did not always change the dressing as often as they should and did not always pack the wound as ordered. He/she reported during maggot therapy staff were to check the dressing every 2 hours and the staff went once from 10:00 P.M. until 5:00 A.M. without checking, per the resident's report to the family member. During an interview on 4/29/2015 at 2:39 P.M. the resident reported he/she placed the foam padding between his/her knees to keep his/her legs from turning inward. The resident reported approximately three months ago staff left him/her in his/her bed soiled with urine and bowel soaked up to his/her arms. The resident requested repositioning and was told by staff he/she was having a bowel movement and staff would return when finished. The resident fell back to sleep and was left soiled until 6:30 A.M., (approximately 6 hours), when another staff member answered his/her call light. During an interview on 4/29/2015 at 1:49 P.M. direct care staff AA reported he/she had no idea when the resident's right buttock wound developed. He/she stated the resident reported to him/her the evening and night shift staff did not reposition him/her until the end of their shift. Staff AA reported asking the night staff if they repositioned the resident and staff reported repositioning him/her at 5:00 A.M. only. Staff AA reported interventions prior to his/her right buttock wound included repositioning every 2 hours, limiting time on the bedside commode, keep his/her bottom off mattress by keeping on side, and a low air loss mattress, which staff AA was unsure of the correct setting. He/she was unsure if any other interventions were put in place once the right buttock wound developed. Staff AA stated every morning he/she worked with the resident, he/she observed bowel and wound drainage on the dressing. He/she did inform the nurse of the soiled dressing. Staff AA reported he/she believed the wound to the right buttock developed from staff not repositioning the resident timely and him/her being left in a briefs with urine and bowel. During an interview on 4/29/2015 at 3:54 P.M. direct care staff Y reported the resident had a pressure ulcer to his right buttock from sitting on it. Current interventions included repositioning every 2 hours, keeping off his/her right buttock, when in chair put pillow under the right side, and slide board for transfers. He/she was unaware of setting for low air loss mattress, but would ask nurse if needed. Staff Y reported the resident did not refuse interventions, and the resident was determined to heal his/her wound by calling for assistance to make sure staff repositioned and changed him/her. During an interview on 4/30/2015 at 9:52 A.M. licensed nursing staff G reported the resident had a wound to his/her right buttock and he/she believed the cause was pressure related from sitting in his/her wheelchair. Staff G reported the resident had a wheelchair cushion, low air loss mattress, turn/reposition every 2 hours, padded cushion on commode and staff encouraged him/her not to sit for long periods on the commode. Staff G was not aware of the low air loss mattress setting. Staff G stated the resident would sometimes refuse to turn when he/she was on the telephone or using his/her laptop. Staff G reported the resident went to the wound clinic every 2 weeks for wound care. Staff G reported he/she monitored residents daily to ensure repositioning and directed staff as indicated to provide cares. During an interview on 4/30/2015 at 10:35 A.M. administrative nurse C revealed the resident had a stage 4 right buttock pressure ulcer. He/she reported the wound developed on 10/24/2014 and was a stage 2. Interventions prior to development of the pressure ulcer included a low air loss mattress, padded bedside commode seat, new wheelchair and wheelchair cushion. New interventions since development of the pressure ulcer included the resident received a new low air loss mattress (1/31/2015), new cushion for wheelchair, educated on setting required for air mattress, observed transfers with slideboard to ensure wound protection, encouraged transfers on the left side, and educated on proper transfers. Staff C reported the licensed nurse was responsible for weekly skin assessments, weekly skin assessments by staff C and assessed daily through cares. Staff C believed the pressure ulcer developed because of the resident's comorbidities to [MEDICAL CONDITION], poor feeling to the lower extremities, and incontinence of bowel and urine. Staff C reported the current wound order was to cleanse the wound with normal saline, apply Santyl, lightly pack with gauze, cover, and tape twice daily at least 10 hours apart. Staff C reported the physician ordered dressing changes for 6:00 A.M. and 6:00 P.M. Staff informed the oncoming nurses of the time they changed the dressing during shift report and also by looking at the last dressing applied. Staff C reported staff re-educated the resident and encouraged compliance when the resident refused interventions to promote wound healing. Staff C reported staff informed the resident's primary care physician of the resident's wound status monthly by a telephone call and he/she was not aware whether he/she documented communication in the medical record. Staff C reported the resident went to the wound center every other week and the first visit occurred on January 27, 2015. Staff C stated the dietitian did not meet with the resident directly, but reviewed medical records. He/she said the dietitian first reviewed on 11/17/2014 with no recommendations made. On 4/4/2015 the dietitian recommendation Juven. Staff C reported he/she requested the dietary manager to follow up. Another recommendation by the dietitian on 4/21/2015 for Juven after it was not initiated on 4/4/2015. Staff C reported staff failed to follow up on the recommendation timely, however the resident's [MEDICATION NAME] (a protein in the blood) was okay. A decision was made to change Juven to [MEDICATION NAME] due to difficulty obtaining Juven and [MEDICATION NAME] was comparable. Staff C reported he/she was unaware if the order to offload the right buttock wound was on the care plan. During an interview on 4/30/2015 at 1:00 P.M. administrative nursing staff B reported the resident had a pressure ulcer to his/her left buttock area and was unsure when the wound developed. He/she reported the interventions prior to the development of the wound included an air mattress, wheelchair cushion, and he/she drank his/her own protein drink. Interventions after the pressure ulcer developed included treatment started, keep off area, ordered a special padded bedside commode, and educated on prolonged sitting on the bedside commode. Staff B reported if a resident refused interventions, staff educated the resident. He/she reported the resident was noncompliant with slide board transfers and used the trapeze instead of allowing staff to assist. The physician made rounds monthly and staff B was not aware if the resident's primary care physician observed the wound. Staff B stated the resident currently had a stage 4 and the wound was a stage 2 prior to going to the wound clinic. He/she believed the cause of the pressure ulcer may be related to noncompliance on the resident's part by sitting on the bedside commode for 45 minutes at time. Staff C reported recommendations made by the dietitian on 4/4/2015 and 4/21/2015 should have been initiated sooner. He/she was aware of the incident when the resident was left soiled in bed approximately 3 months ago, however he/she could not really prove anything. Staff B was unaware of an order to off load the right buttock at all times. During an interview on 4/30/2015 at 2:58 A.M. dietitian Q reported he/she had not met with the resident face to face. He/she reported a recommendation was made on 4/4/2015 for Juven to promote wound healing. The dietitian reported Juven was a nutritional supplement to promote tissue building in 2 weeks and help build and maintain lean body mass in 4 weeks. The dietitian reported Juven was effective in promotion of wound healing. On 4/21/2015 a second recommendation by the dietitian was made because he/she had a stage 4 to the buttock and normally the recommendation for Juven was the standard of practice and used for a stage 3 or 4 or multiple stages of wounds. The dietitian stated he/she did not see that staff initiated Juven, so he/she made the recommendation again. Staff Q reported when a dietitian made a recommendation a follow up should occur within 72 hours. Attempted to reach the wound clinic physician NN on 4/30/2015 at 3:09 P.M., and on 5/5/2015 at 8:18 A.M. Requested a return call with no response. Attempted to reach primary care physician MM on 4/30/2015 at 3:12 P.M., on 5/4/2015 at 9:22 A.M., and 5/4/2015 at 1:02 P.M., and on 5/5/2014 at 9:34 A.M. Requested a return call with no response. Review of the facility's revised policy on Pressure Ulcer Prevention dated 1/2015 revealed a resident without a pressure ulcer would not develop a pressure ulcer, a pressure ulcer would receive the necessary treatment and services to promote healing and prevent new pressure ulcers from developing. An assessment would include the ability to respond meaningfully to pressure-related discomfort (sensory perception), degree to which the skin was exposed to moisture, degree of physical activity, ability to change and control body position, usual food pattern, and friction and shear. Once a resident was identified as being at risk for development of pressure ulcers, the following information must be addressed; skin cleansing at the time of soiling and at routine intervals, turning and repositioning of no less than every 2 hours, and any other interventions specific to the resident's needs and weakness. The facility failed to ensure resident # 65, a resident who entered the facility without a pressure, had sensory impairment, and decreased mobility did not develop a pressure ulcer, failed to notify the physician in a timely manner for further direction when the pressure ulcer lacked progress in healing, and failed to provide physician ordered interventions in a timely manner to include Juven, a nutritional supplement, and offloading of the wound at all times. The resident's facility acquired stage 2 pressure ulcer worsened to a stage 4 pressure ulcer.

The facility reported a census of 50 residents with 23 residents in the sample. Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for pain management (#65), 1 of 2 residents reviewed for hospitalization s (#40), and 1 of 1 residents reviewed for palliative care (#30). Findings included: - Review of resident # 65's annual MDS (Minimum Data Set) dated 6/2/2014 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she did not reject cares during the 7 day observation period. The resident required total assistance of 2 or more staff for bed mobility, transfers, dressing, and toileting; extensive assist of 2 or more staff with bathing; and supervised set up assist with eating. The resident reported frequent pain rated as a 3 on a scale of 0-10 (zero being no pain and 10 being the worst pain imagined). He/she reported pain did not interfere with sleep at night or limit day to day activities. He/she was on a scheduled pain medication regimen, received pain medication as needed, and received non-medication interventions for pain management. Review of the quarterly MDS (Minimum Data Set) dated 02/25/2015 revealed a BIMS score of 15,which indicated intact cognition. He/she did not reject cares during the 7 day observation period. The resident required extensive assistance of two staff with bed mobility and extensive assist of one staff with transfers, dressing, and toileting. He/she reported occasional moderate pain, which did not interfere with sleep at night or limit day to day activities, was on a scheduled pain medication regimen, received pain medication as needed, and received non-medication interventions for pain. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 6/2/2014 revealed the resident was mostly dependent since [MEDICATION NAME] vertebrae (middle section of back bones) 1-6 spinal cord surgery for [REDACTED].>cancer. He/she required total assist of 2 staff for repositioning, bed mobility, transfers, dressing, and toileting. The resident attempted to do as much personal hygiene as he/she was able, however was limited by fatigue and back pain. Review of the CAAs revealed the Pain CAA did not trigger and none of the CAAs which triggered addressed pain. Review of a new admission assessment dated [DATE] revealed the resident reported frequent pain in the past 5 days, which he/she rated at a 8 on a scale of 0-10. The resident reported 3 as an acceptable level of pain, reported pain interfered with sleep at night and limited his/her day to day activities. The resident reported that rest effectively relieved the pain, and he/she received scheduled pain medications and as needed pain medications. Review of the care plan dated 6/19/2014 revealed the resident experienced chronic pain related [MEDICAL CONDITION] in his/her back. The care plan directed staff to administer [MEDICATION NAME] as ordered, to give [MEDICATION NAME] medication 1/2 hour before treatments or care, evaluate the effectiveness of pain interventions, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results. The care plan also directed staff to evaluate the impact on functional ability and cognition, monitor/document for side effects of pain medication, observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (a state of unease or dissatisfaction), nausea, vomiting, dizziness, falls, and report occurrences to physician. Staff were to monitor/record/report to nurse any signs or symptoms of non-verbal pain. Staff were to notify the physician if interventions were unsuccessful or if current complaints of pain were a significant change from the resident's past experience of pain. Staff revised the care plan on 4/8/2015 and directed staff to offer non medicinal pain interventions to include repositioning, massage, stretching exercises, and room comfort. Review of the resident's restorative program dated 1/29/2015 included active assistance of stretching both long quadriceps (a group of muscles on the thigh) x 20 repetitions and the Nustep (exercise equipment) for 20 minutes a day, working up to to a higher level of 4 plus. Review of a nursing note dated 4/17/2015 revealed the resident's [MEDICATION NAME] ER (extended release) was not delivered due to waiting on a hard prescription from the doctor's office. Facility staff phoned the physician's office twice on 4/13/2015 with no response. Review of current physician orders [REDACTED]. [MEDICATION NAME] 5 mg (milligrams) by mouth, give 1-4 tablets every 3 hours as needed for pain, effective 5/27/2014 [MEDICATION NAME] 10 mg, give 0.5 mg tablet by mouth every six hours as needed for pain, effective 5/27/2014 Assess and rate pain 1-10 scale or Wong Baker every day and night shift on Thursdays and Sundays, effective 6/2/14 Ice to muscle for 10 minutes for pain, effective 8/1/2014 [MEDICATION NAME] ER 10 mg by mouth twice daily for pain, effective 04/02/15 Review of the April 2015 MAR (Medication Administration Record) revealed the resident received [MEDICATION NAME] on 4/4 and 4/28/2015, [MEDICATION NAME] on 4/24/15, and [MEDICATION NAME] on 4/5, 4/7, 4/25, 4/26,4/27, and 4/28/15. The resident rated his/her pain at a 6 on 4/5/15, and a 2 on 4/12/15, 4/16 and 4/19/2015. Review of progress notes for April 2015 revealed the following: 4/25/2015- [MEDICATION NAME] 5-325 mg administered with effective results and [MEDICATION NAME] 5 mg, 2 tablets administered for low back pain rated at a 6. The documentation lacked follow up results. 4/26/ - [MEDICATION NAME] 5 mg administered for discomfort to buttocks and back rated at a 6. The documentation lacked follow up results. [MEDICATION NAME] 5 mg administered and the resident did not awaken to ask about his/her pain level, resting in bed at the time with no signs or symptoms of pain, eyes closed. Pain documented at a 0 out of 10 per his/her body language. 4/27/2015- [MEDICATION NAME] 5 mg for complaints of pain to back/right hip rated at a 7 with effective results. 4/28/2015- [MEDICATION NAME] 5 mg administered for all over pain rated at a 6. The resident's pain decreased to 2 out of 10. [MEDICATION NAME] 10 mg 0.5 tablet administered with effective results. 4/30/2015- [MEDICATION NAME] 5 mg administered for back pain rated at a 5. The documentation lacked follow up results. [MEDICATION NAME] 10 mg 0.5 mg administered for back pain. The effectiveness was unknown as the resident was out of the facility. During an observation on 4/29/2015 at 3:28 P.M. direct care staff X and Y responded to the resident's call light. The resident requested assistance with getting into bed. The resident verbalized pain as staff Y lifted his/her legs into the bed. During an interview on 4/28/2015 at 4:19 P.M. the resident reported he/she experienced chronic and constant pain from his/her waist down to both feet and muscle spasms due to a spinal cord injury. He/she rated the pain a 5 or 6 and described the pain as a tingling and burning sensation mostly in the legs. The resident reported the facility was out of [MEDICATION NAME] ER for a week now and substituted [MEDICATION NAME], which was not as effective. The resident reported therapy massaged and stretched his/her calf muscles when he/she received skilled therapy in the past. He/she reported massages helped relieve pain for brief periods and stretching of the lower legs relieved pain to his/her hips for longer periods. The resident reported he/she was no longer on therapy services and no longer received massages or stretching. He/she reported the staff did not offer stretching exercises, massages, room comfort, ice or repositioning to manage his/her pain and the lack of [MEDICATION NAME] ER made it harder for him/her to work on the Nustep (exercise equipment) due to increased pain to his/her lower legs. During an interview on 4/29/2015 at 2:39 P.M. the resident reported he/she was not sure what his/her restorative program was, but he/she tried to go to the therapy room to work on the Nustep machine to strengthen his/her legs daily. The resident reported since he/she was not receiving his/her [MEDICATION NAME] ER, he/she was unable to perform the Nustep exercise daily and could not perform the exercise as long due to increased pain. During an interview on 4/29/2015 at 1:45 P.M. direct care staff AA reported the resident complained of pain to his/her back and legs usually after he/she worked in the therapy room on his/her own and he/she would report the pain to the charge nurse. Staff AA reported he/she stretched the resident's legs in the past week per the resident's request. Staff AA was unaware of whether the stretching helped. There were no other interventions tried to his/her knowledge and staff AA was not aware of any other non-medication interventions to manager the resident's pain. Staff AA said he/she had access to the resident's care plan using the kardex (mini care plan) or care plan book located in the nurse's station. During an interview on 4/29/2015 at 2:10 P.M. staff Y reported the resident complained of back pain at times, especially during showers when washing or towel drying his/her back. Staff Y was not aware of any other complaints of pain to his/her knowledge. Staff Y reported interventions to manage pain included; turn every 2 hours and as needed pain medications. There were no other non- medication interventions to manage the resident's pain to his/her knowledge. Staff Y reported care plans were available on the kardex. During an interview on 4/30/2015 at 10:30 A.M. direct care staff L stated he/she phoned the physician's office on 4/13/2015 for a hard script of [MEDICATION NAME] ER. Staff L reported there was one week remaining of the medication. He/she then went to the physician's office on 4/23/15 to obtain the hard script and he/she was told it was sent out as a mail order. Staff L asked the physician's office nurse if they could receive an emergency script and was told to use the resident's as needed [MEDICATION NAME] until the [MEDICATION NAME] ER was available. Staff L phoned the mail order pharmacy and was told they could not fill the script due to lack of DEA (Drug Enforcement Administration) number and the script was destroyed. Staff L reported the [MEDICATION NAME] ER remained unavailable this date, and he/she administered [MEDICATION NAME] 5 mg 2 tablets as a substitute. He/she reported the resident last received OxycotinER on [DATE]. Staff L reported he/she informed the charge nurse on 4/13/2015 prior to the resident running out of [MEDICATION NAME] ER, on 4/23/2015 when he/she went to the physician's office, and charge nurse G was aware the resident continued to be out of [MEDICATION NAME] ER. During an interview on 4/30/2015 at 9:33 A.M. licensed nursing staff G reported when the resident first admitted he/she had a lot of pain and was doing therapy. The resident started asking for more as needed pain medications in the past month and he/she believed it was because of increased exercising on the Nustep. Staff G was aware the resident was out of his/her [MEDICATION NAME] ER and acknowledged there was no order to substitute [MEDICATION NAME] ER with [MEDICATION NAME] two 5 mg tablets. Staff G reported he/she would usually assess pain by asking him/her to rate pain prior to administering as needed pain medications. Staff G reported non-medication interventions used included ice and repositioning. He/she was not aware of any other interventions that were effective in managing the resident's pain. Staff G was not aware of whether the staff offered the resident pain medication prior to him/her exercising on the Nustep. During an interview on 4/30/2014 at 12:31 P.M. administrative nursing staff B reported he/she expected the nurse to call the physician if a resident was out of a medication and if the doctor was not available the nurse was expected to call the on call doctor for a prescription. Staff B reported the process to ensure a resident did not run out of medication was to phone the physician for a prescription when there was a 3 day supply remaining. Staff B reported he/she was made aware of the resident running out of [MEDICATION NAME] ER approximately 2 hours ago. Staff B reported if the resident had pain the nurse should obtain an order for [REDACTED]. The charge nurse was responsible for ensuring staff carried out non-medication interventions. Staff B reported the restorative program, which included stretching of the resident's quadriceps muscles may be beneficial in managing pain. During an interview on 4/30/2015 at 1:44 P.M. pharmacist R reported he/she was a consultant pharmacist for the facility and was able to fill a prescription for the facility. The resident typically used a different pharmacy, however he/she was able to fill a narcotic medication with a prescription. During an interview on 4/30/2015 at 2:50 P.M. pharmacist BB reported the pharmacy last filled the resident's [MEDICATION NAME] on [DATE] for 28 tablets and he/she would have to have a prescription to refill. Staff BB reported the facility did not provide a prescription or request a refill at this time. Attempted to reach primary care physician MM on 4/30/2015 at 3:12 P.M., on 5/4/2015 at 9:22 A.M., and 5/4/2015 at 1:02 P.M., and on 5/5/2014 at 9:34 A.M. Requested a return call with no response. Review of the facility's revised Pain policy dated 4/2007 revealed the physician and staff would identify individuals who had pain, were at risk for having pain, review treatments to include non medication treatments, order appropriate non medication and medication interventions to address pain, and the staff reassessed pain and consequences of pain at regular intervals; at least once a shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The facility failed to ensure resident # 65 received pain medication, as ordered by the physician, to ensure optimum (favorable outcome) control of the resident's pain. - Review of resident # 40's admission MDS (Minimum Data Set) dated 1/1/2015 revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. He/she did not reject care during the 7 day observation period. The resident required total assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and bathing and was dependent on one staff assistance with personal hygiene and eating. He/she was non- ambulatory, had functional limitation in range of motion to one side of upper and lower body, and used a wheelchair for mobility. Review of the Cognitive CAA (Care Area Assessment) dated 1/1/2015 revealed a BIMs score was 3, which indicated severe cognitive impairment. He/she was alert and oriented most of the time with intermittent confusion and poor short term memory. Staff reminded the resident of the day and time when assisting with cares and provided a calendar in his/her room to help with orientation of time. Review of the Nutrition CAA dated 1/1/2015 revealed the resident had a [DIAGNOSES REDACTED]. A peg tube ( a tube passed into the stomach through the abdominal wall to provide a means of feeding) was inserted in November 2014. He/she had diarrhea due to the amount of liquid feedings he/she received per the peg tube daily. The peg tube feeding was decreased to 5 cans daily and he/she tolerated it well. The resident received nothing by mouth except for ice chips, needed total assistance with the peg tub feedings, and received speech therapy. Review of the Feeding Tube CAA dated 1/1/2015 noted he/she had a [DIAGNOSES REDACTED]. He/she had a peg tube inserted in November 2014 and had diarrhea due to the amount of feedings. The feeding was decreased to 5 cans a day and the resident tolerated the feeding well. He/she received nothing by mouth except for ice chips, required total assistance with the peg tube feedings, and received speech therapy. Review of the care plan dated 1/5/2015 revealed the resident had a history of [REDACTED]. The care plan directed staff to monitor and report signs or symptoms of complications to the physician regarding UTI's, monitor labs, monitor/document resident's abilities for ADLs (activities of daily living), and assist resident as needed, monitor and report neurological deficits, note orders for physical and occupational therapy, administer [MEDICATION NAME] (a medication used to inhibit blood clots) for [MEDICAL CONDITION], provide the family, resident and caregiver education regarding medications, and speech therapy to evaluate and treat for communication as he/she did have some difficulty with speech and was hard to understand at times. Review of blood sugars per accucheck revealed the following blood sugars greater than 400: 12/19/2014 at 5:36 blood sugar was 496. The medical record lacked documentation of physician notification. 12/19/2014 at 8:27 A.M. blood sugar was 570. The medical record lacked documentation of physician notification. 12/21/2015 at 12:46 P.M. blood sugar was 505. The physician was notified and the resident was sent to the emergency room for elevated blood sugar. 12/26/2014 at 12:18 P.M. blood sugar was 437. The medical record lacked documentation of physician notification. 12/26/2014 at 5:35 P.M. blood sugar was 410. The medical record lacked documentation of physician notification. 12/29/2014 at 4:54 P.M. blood sugar was 418. The medical record lacked documentation of physician notification. 12/31/2014 at 8:57 P.M. blood sugar was 503. The medical record lacked documentation of physician notification. 1/1/2015 at 1:05 PM blood sugar was 427. The physician was faxed results with no response documented. 1/2/2015 at 8:03 A.M. blood sugar was 444. The medical record lacked documentation of physician notification. 1/3/2015 at 12:29 P.M. blood sugar was 479. The physician was faxed results with no response documented. 1/4/2015 at 8:27 A.M. blood sugar was 497. The physician was faxed results and no response documented. 1/7/2015 at 7:44 A.M. blood sugar was 577. The medical record lacked documentation of physician notification. 1/7/2015 at 1:38 P.M. blood sugar was 474. The medical record lacked documentation of physician notification. 1/7/2015 at 5:01 P.M. blood sugar was 420. The medical record lacked documentation of physician notification. 1/8/2015 at 5:41 A.M. blood sugar was 523. The resident's peg tube feeding was held. The medical record lacked documentation of physician notification. 1/8/2015 at 8:13 A.M. blood sugar was 470. The medical record lacked documentation of physician notification. 1/8/2015 at 5:02 P.M. blood sugar was 509. The medical record lacked documentation of physician notification. Review of a nursing progress note dated 1/8/2015 at 3:36 P.M. tube feeding was held for a blood sugar was 499. Blood sugar scheduled to be checked at 4:00 P.M. The nurse would reassess at the time since the resident was due for insulin at 4:30 P.M. The medical record lacked physician notification. Review of a progress noted dated 1/8/2015 at 5:35 P.M. revealed the resident's blood sugar at 4:30 P.M. was 509. The nurse administered 35 units of his/her regular insulin and 10 units per the sliding scale. The nurse gave approximately 100 ml (milliliters) of [MEDICATION NAME] (nutritional supplement) since Glucerna (nutritional supplement) was not available. Review of physician orders [REDACTED]. [MEDICATION NAME] Solution Cartridge 100 UNIT/ML, Inject 35 unit subcutaneously five times a day for diabetes, effective 12/24/2014 [MEDICATION NAME] Solution 100 UNIT/ML, Inject as per sliding scale: if blood sugar was 150.0 - 199.0 = inject 2 units; if blood sugar 200.0 - 249.0 = inject 4 units; if blood sugar 250.0 - 299.0 = inject 6 units; if blood sugar 300.0 - 349.0 = inject 8 units; if blood sugar 350.0 - 400.0 = inject 10 units and if over 400 give 12 units and call primary care physician, effective 12/25/2014 [MEDICATION NAME] Solution 100 UNIT/ML (milliliters), inject 65 unit subcutaneously two times a day for diabetes, effective 1/5/15 During an interview on 4/30/2015 at 8:34 A.M. licensed nursing staff G reported the resident was admitted with a peg tube, was a brittle diabetic, and had a [MEDICAL CONDITION]. He/she reported the resident's blood sugar ran high a lot and stated the staff should notify the physician if the resident's blood sugar was greater than 400. He/she reported sometimes the staff would fax the blood sugar results to the physician and did not always receive a response. Staff G reported he/she expected a response within a couple of hours, however the resident consistently ran high and was on a sliding scale for insulin, so he/she watched his/her blood sugars. During an interview on 4/30/2015 at 12:00 P.M. licensed nursing staff E reported staff should document blood sugars on the MAR (medication administration record), which had a progress note attached to the results. He/she reported staff were trying to get the resident admitted back to the hospital because his/her blood sugars were too high. During an interview on 4/30/2015 at 12:02 P.M. administrative nursing staff B reported the resident admitted to the facility following [MEDICAL CONDITION] was diabetic His/her blood sugars ran high. He/she reported when staff notified the physician, staff should call him/her. and not fax when blood sugars were greater than 400, and if the staff held the tube feedings, or they not given. He/she believed staff notified the physician when blood sugars ran high, but they may not have always notified him/her because the resident always ran high. The facility failed to monitor and notify the physician of resident #40's elevated blood sugars as ordered to maintain highest practicable physical well-being and avoid hospitalization . - Review of resident #30's quarterly MDS (minimum data set) dated 3/26/15 revealed a BIMS (brief interview for mental status) score of 01 which indicated severe cognitive impairment. The resident required extensive assistance of two persons with bed mobility, transfers, and toileting. The MDS revealed he/she required total dependence of two persons for dressing. The resident used a wheelchair for ambulation. Review of resident #30's significant change MDS (minimum data set) dated 4/9/15 revealed a BIMS (brief interview for mental status) score of 01 which indicated severe cognitive impairment. The resident required total dependence of two with bed mobility, transfers, dressing, and toilet use. The resident required total dependence of one person for locomotion on and off of the unit. The MDS revealed participation in religions activites or practices was of significant importance to the resident. Review of the psychosocial well-being CAA (care area assessment) dated 4/9/15 revealed the resident had behavior issues related to his/her dementia and he/she was not involved in activities related to his/her mental capacity, short attention span and yelling out. The resident ' s family visited daily and he/she watched or listened to TV in his/her room. The resident spent much of his/her time sleeping. Review of the resident's care plan, initiated 11/26/14, revealed comfort measures per family request, if he/she has infection please treat it. The care plan failed to include spiritual needs. Review of the Social service note dated 2/18/2015 at 7:21 PM revealed the resident did have periods of lethargy and difficulty arousing the resident for meals or activities, but other times he/she was awake and assisted feeding him/herself and preached sermons to those around him. His/her family had expressed they wanted his/her care to be comfort care. The family wanted staff to encourage the resident to eat and offer shakes, but if he/she refused not to force the issue regarding weight loss. His/her code status was a DNR (Do not resuscitate). Observation on 04/29/2015 at 10:54 AM revealed he/she was in bed with eyes closed and did not appear to be in any pain or discomfort. Interview with direct care staff DD on 2/29/14 at 4:45 PM revealed he/she would position the resident and make sure the resident was comfortable. Staff stated he/she reviewed the kardex on the computer to know what kind of care the resident needed. Interview with direct care staff CC on 4/30/2015 at 10:54 AM revealed staff used a Hoyer lift to transfer the resident. Staff CC described comfort care as care to make the resident comfortable closer to the end of life. Staff CC said the care plan did not identify comfort measures for this resident. Interview with licensed nursing staff G on 4/30/2015 at 12:13 PM revealed the staff were to provide comfort care. The family wanted to discontinue some of the resident's medication and did not want to the resident to receive tube feedings. Staff G revealed that he/she thought the care was no different than other residents' care. The resident did not get therapy. Staff G stated if the resident did not want to get up then he/she could stay in bed. The resident got PRN (as needed) [MEDICATION NAME] for pain but staff G reported the resident primarily had pain only associated with repositioning. Interview with administrative nursing staff B on 4/30/2015 at 3:54 PM revealed the resident had not exhibited any pain and the family did not want him/her to have life sustaining measures done. Staff B stated if the resident did not want to do anything then the staff was not make him/her. Staff B stated the care plan did not address any pain medication or spiritual measures for the resident. The staff stated that the resident was a minister when he/she was younger. A Comfort Care Policy was requested on 5/4/15, but had not been provided as of 5/5/15 The facility failed to identify and address the comfort care needs of the resident, including spiritual needs.